Predictors of relapse and recurrence following cognitive behavioural therapy for anxiety-related disorders: a systematic review

Intermittent theta burst stimulation of the left dorsolateral prefrontal cortex has no additional effect on the efficacy of virtual reality exposure therapy for acrophobia. A randomized double-blind placebo-controlled study

Anxiety disorders are among the most common mental disorders. Treatment guidelines recommend pharmacotherapy and cognitive behavioral therapy as standard treatment. Although cognitive behavioral therapy is an effective therapeutic approach, not all patients benefit sufficiently from it. In recent years, non-invasive brain stimulation techniques, such as transcranial magnetic stimulation, have been investigated as promising adjuncts in the treatment of affective disorders. The aim of this study is to investigate whether a combination of intermittent theta burst stimulation (iTBS) and virtual reality exposure therapy leads to a significantly greater reduction in acrophobia than virtual reality exposure with sham stimulation. In this randomized double-blind placebo-controlled study, 43 participants with acrophobia received verum or sham iTBS over the left dorsolateral prefrontal cortex prior to two sessions of virtual reality exposure therapy. Stimulation of the left dorsolateral prefrontal cortex with iTBS was motivated by an experimental study showing a positive effect on extinction memory retention. Acrophobic symptoms were assessed using questionnaires and two behavioral approach tasks one week before, after treatment and six months after the second diagnostic session. The results showed that two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms, with an overall remission rate of 79 %. However, there was no additional effect of iTBS of the left dorsolateral prefrontal cortex on the therapeutic effects. Further research is needed to determine how exactly a combination of transcranial magnetic stimulation and exposure therapy should be designed to enhance efficacy.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.

Status after Hospital Discharge: An Observational Study of the Progression of Patients' Mental Health Symptoms Six Weeks after Hospital Discharge

(1) Background: Transitioning from mental health inpatient care to community care is often a vulnerable time in the treatment process where additional risks and anxiety may arise. We collected data for this study as part of a pragmatic cluster-randomized, longitudinal approach in Alberta. As the first phase of the ongoing innovative supportive program, this paper assessed the progression of mental health symptoms in patients six weeks after hospital discharge. Factors that may contribute to the presence or absence of anxiety and depression symptoms, as well as well-being, following return to the community were investigated. This provides evidence and baseline data for future phases of the project. (2) Methods: An observational study design was adopted for this study. Data on a variety of sociodemographic and clinical factors were collected at discharge and six weeks after via REDCap. Anxiety, depression, and well-being symptoms were assessed using the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the World Health Organization-Five Well-Being Index (WHO-5), respectively. Descriptive, chi-square, independent t-tests, and multivariate regression analyses were conducted. (3) Result: The survey was completed by 88 out of 306 participants (28.8% response rate). The chi-square/Fisher exact test and independent t-test revealed no significant change in the mental health conditions from baseline to six weeks after discharge. It was found that the only significant factor predicting symptoms six weeks after discharge from inpatient treatment was the baseline symptoms in all three logistic regression models. It was four times more likely for those who experienced anxiety and depression at baseline to experience anxiety and depression symptoms six weeks after discharge (OR = 4.27; 95% CI: 1.38-13.20) (OR = 4.04; 95% CI: 1.25-13.05). Those with poor baseline well-being were almost 12 times more likely to experience poor well-being six weeks after discharge (OR = 11.75; 95% CI: 3.21-42.99). (4) Conclusions: Study results found no significant change in mental health conditions in the short term following hospital discharge. It is essential that researchers and policymakers collaborate in order to implement effective interventions to support and maintain the mental health conditions of patients following discharge.

Impaired learning, memory, and extinction in posttraumatic stress disorder: translational meta-analysis of clinical and preclinical studies

Current evidence-based treatments for post-traumatic stress disorder (PTSD) are efficacious in only part of PTSD patients. Therefore, novel neurobiologically informed approaches are urgently needed. Clinical and translational neuroscience point to altered learning and memory processes as key in (models of) PTSD psychopathology. We extended this notion by clarifying at a meta-level (i) the role of information valence, i.e. neutral versus emotional/fearful, and (ii) comparability, as far as applicable, between clinical and preclinical phenotypes. We hypothesized that cross-species, neutral versus emotional/fearful information processing is, respectively, impaired and enhanced in PTSD. This preregistered meta-analysis involved a literature search on PTSD+Learning/Memory+Behavior, performed in PubMed. First, the effect of information valence was estimated with a random-effects meta-regression. The sources of variation were explored with a random forest-based analysis. The analyses included 92 clinical (N = 6732 humans) and 182 preclinical (N = 6834 animals) studies. A general impairment of learning, memory and extinction processes was observed in PTSD patients, regardless of information valence. Impaired neutral learning/memory and fear extinction were also present in animal models of PTSD. Yet, PTSD models enhanced fear/trauma memory in preclinical studies and PTSD impaired emotional memory in patients. Clinical data on fear/trauma memory was limited. Mnemonic phase and valence explained most variation in rodents but not humans. Impaired neutral learning/memory and fear extinction show stable cross-species PTSD phenotypes. These could be targeted for novel PTSD treatments, using information gained from neurobiological animal studies. We argue that apparent cross-species discrepancies in emotional/fearful memory deserve further in-depth study; until then, animal models targeting this phenotype should be applied with utmost care.

Relationship between Baseline Physical Activity and Generalized Anxiety Disorder and Major Depressive Disorder Treatment Outcomes

OBJECTIVES

Generalized anxiety disorder and major depressive disorder often benefit from medication and psychotherapy. Our aim was to determine whether a correlation exists between patient baseline physical activity and response to treatment.

METHODS

This was a retrospective study that included adult patients with anxiety and depression who received outpatient care for their conditions by providers in the Department of Psychiatry and Psychology of the Mayo Clinic in Jacksonville, Florida. Statistical analyses were used to analyze whether Rapid Assessment of Physical Activity scores as a measure of baseline exercise correlated to changes in Patient Health Questionnaire-9 (PHQ-9) scores or Generalized Anxiety Disorder-7-item scale (GAD-7) scores during treatment for anxiety or depression. Factors including age, sex, smoking status, and caffeine intake also were analyzed.

RESULTS

When comparing change in GAD-7 or PHQ-9 scores from baseline to follow-up during treatment for anxiety or depression, there was no significant difference based on Rapid Assessment of Physical Activity scores. Caffeine intake had a direct correlation with PHQ-9 scores from baseline to 12 to 24 weeks but no correlation with GAD-7 scores.

CONCLUSIONS

Overall, the amount of physical activity a patient participates in before anxiety or depression treatment does not appear to affect improvement outcomes. Caffeine intake may improve depression severity scores; however, further research is needed to assess whether this could be a part of future treatment plans.

Association between the COVID-19 pandemic and psychiatric symptoms in people with preexisting obsessive-compulsive, eating, anxiety, and mood disorders: a systematic review and meta-analysis of before-after studies

AIM

To determine whether the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in psychiatric symptoms in people with preexisting obsessive-compulsive, eating, anxiety, and mood disorders compared to their prepandemic levels.

METHODS

We searched MEDLINE, CINAHL, PsycINFO, and Embase from inception until February 16, 2022. Studies were included if they reported prepandemic and during-pandemic psychiatric symptoms, using validated scales, in people with preexisting mood, anxiety, eating, or obsessive-compulsive disorders. Two reviewers independently screened studies, extracted data, and assessed evidence certainty. Random-effects meta-analyses were conducted. Effect sizes were reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

Eighteen studies from 10 countries were included. Of the 4465 included participants, 68% were female and the average age was 43 years. Mood and obsessive-compulsive disorders were the most studied disorders. During-pandemic psychiatric measurements were usually collected during nationwide lockdown. Obsessive-compulsive symptoms worsened among people with obsessive-compulsive and related disorders, with a moderate effect size (N = 474 [six studies], SMD = -0.45 [95% CI, -0.82 to -0.08], I2  = 83%; very low certainty). We found a small association between the COVID-19 pandemic and reduced anxiety symptoms in people with mood, anxiety, obsessive-compulsive, and eating disorders (N = 3738 [six studies], SMD = 0.11 [95% CI, 0.02-0.19], I2  = 63%; very low certainty). No change in loneliness, depressive, or problematic eating symptoms was found.

CONCLUSION

People with obsessive-compulsive and related disorders may benefit from additional monitoring during the COVID-19 pandemic and possibly future pandemics. Other psychiatric symptoms were stable in people with the specific disorders studied. Overall, evidence certainty was very low.

Introversion, Extraversion, and Worsening of Chronic Pain Impact during Social Isolation: A Mediation Analysis

COVID-19 social distancing mandates increased social isolation, resulting in changes in pain severity and interference among individuals with chronic pain. Differences in personality (e.g., introversion/extraversion) may modulate responses to social isolation. We examined the influence of introversion on reported social distancing-related increases in pain interference and assessed for mediators of this relationship. Individuals with chronic pain (n = 150) completed validated questionnaires 4-8 weeks after implementation of social distancing mandates. Introversion/extraversion was measured using a subscale of the Myers-Briggs Type Indicator and changes in pain and psychosocial variables were calculated by comparing participants' recalled and current scores. Association between introversion/extraversion and other variables were assessed using linear regression. A parallel mediation was used to examine mediators of the association between introversion and change in pain interference. Higher introversion was associated with a decrease in pain interference after social distancing (Rho = - .194, p = .017). Parallel mediation analysis revealed that the relationship between introversion/extraversion and change in pain interference was mediated by changes in sleep disturbance and depression, such that higher introversion was associated with less isolation-induced sleep disruption and depression, and thereby less worsening of pain interference. These findings suggest that personality factors such as introversion/extraversion should be considered when personalizing treatment of chronic pain.

Maintenance Psychotherapies for Older Adults: A Scoping Review

BACKGROUND/OBJECTIVE

Given the chronicity of depression and anxiety disorders in late life, maintenance treatments may have a role in preserving healthy functioning. This study aims to understand the state of the science on maintenance psychotherapies for Black, Asian, and Latinx older adults.

DESIGN

Scoping review.

METHODS

A priori protocol was prospectively published. Four databases were searched up to December 1, 2021. Eligible studies were conducted in the United States or Puerto Rico and focused on maintenance psychotherapies treating depression, anxiety, or both in adults 60+. Due to the underrepresentation of Black, Asian, and Latinx participants, studies were included irrespective of the participant's racial or ethnic background.

RESULTS

A total of 3,623 unique studies were retrieved, and eight studies were included. Two studies represented randomized clinical trials, and six were studies of post hoc analyses. All studies were from the same research team, had similar maintenance treatments, and focused on depression. Studies included racially homogenous samples (94-98% White). The primary outcome was the recurrence of a major depressive episode. Across studies, maintenance psychotherapy shows promise in preventing the recurrence of depression in some older adults.

CONCLUSION

Expanding the scope of knowledge from achieving optimal functioning to sustaining those changes in older adults is a significant public health challenge given symptom recurrence. The small body of knowledge on maintenance psychotherapies shows a promising direction in maintaining healthy functioning following recovery from depression. However, opportunities remain to expand the evidence of maintenance psychotherapies with a more significant commitment to the inclusion of diverse populations.

Brain glucose metabolism on [18F]-FDG PET/CT: a dynamic biomarker predicting depression and anxiety in cancer patients

Objectives

To explore the correlation between the incidence rates of depression and anxiety and cerebral glucose metabolism in cancer patients.

Methods

The experiment subjects consisted of patients with lung cancer, head and neck tumor, stomach cancer, intestinal cancer, breast cancer and healthy individuals. A total of 240 tumor patients and 39 healthy individuals were included. All subjects were evaluated by the Hamilton depression scale (HAMD) and Manifest anxiety scale (MAS), and were examined by whole body Positron Emission Tomography/Computed Tomography (PET/CT) with 18F-fluorodeoxyglucose (FDG). Demographic, baseline clinical characteristics, brain glucose metabolic changes, emotional disorder scores and their relations were statistically analyzed.

Results

The incidence rates of depression and anxiety in patients with lung cancer were higher than those in patients with other tumors, and Standard uptake values (SUVs) and metabolic volume in bilateral frontal lobe, bilateral temporal lobe, bilateral caudate nucleus, bilateral hippocampus, left cingulate gyrus were lower than those in patients with other tumors. We also found that poor pathological differentiation, and advanced TNM stage independently associated with depression and anxiety risk. SUVs in the bilateral frontal lobe, bilateral temporal lobe, bilateral caudate nucleus, bilateral hippocampus, left cingulate gyrus were negatively correlated with HAMD and MAS scores.

Conclusion

This study revealed the correlation between brain glucose metabolism and emotional disorders in cancer patients. The changes in brain glucose metabolism were expected to play a major role in emotional disorders in cancer patients as psychobiological markers. These findings indicated that functional imaging can be applied for psychological assessment of cancer patients as an innovative method.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE)

BACKGROUND

Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness.

METHODS

A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment.

DISCUSSION

The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach.

TRIAL REGISTRATION

ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.

Recurrence of anxiety disorders and its predictors in the general population

BACKGROUND

Anxiety disorders frequently recur in clinical populations, but the risk of recurrence of anxiety disorders is largely unknown in the general population. In this study, recurrence of anxiety and its predictors were studied in a large cohort of the adult general population.

METHODS

Baseline, 3-year and 6-year follow-up data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). Respondents (N = 468) who had been in remission for at least a year prior to baseline were included. Recurrence was assessed at 3 and 6 years after baseline, using the Composite International Diagnostic Interview version 3.0. Cumulative recurrence rates were estimated using the number of years since remission of the last anxiety disorder. Furthermore, Cox regression analyses were conducted to investigate predictors of recurrence, using a broad range of putative predictors.

RESULTS

The estimated cumulative recurrence rate was 2.1% at 1 year, 6.6% at 5 years, 10.6% at 10 years, and 16.2% at 20 years. Univariate regression analyses predicted a shorter time to recurrence for several variables, of which younger age at interview, parental psychopathology, neuroticism and a current depressive disorder remained significant in the, age and gender-adjusted, multivariable regression analysis.

CONCLUSIONS

Recurrence of anxiety disorders in the general population is common and the risk of recurrence extends over a lengthy period of time. In clinical practice, alertness to recurrence, monitoring of symptoms, and quick access to health care in case of recurrence are needed.

Machine learning based approaches for clinical and non-clinical depression recognition and depression relapse prediction using audiovisual and EEG modalities: A comprehensive review

Mental disorders are rapidly increasing each year and have become a major challenge affecting the social and financial well-being of individuals. There is a need for phenotypic characterization of psychiatric disorders with biomarkers to provide a rich signature for Major Depressive Disorder, improving the understanding of the pathophysiological mechanisms underlying these mental disorders. This comprehensive review focuses on depression and relapse detection modalities such as self-questionnaires, audiovisuals, and EEG, highlighting noteworthy publications in the last ten years. The article concentrates on the literature that adopts machine learning by audiovisual and EEG signals. It also outlines preprocessing, feature extraction, and public datasets for depression detection. The review concludes with recommendations that will help improve the reliability of developed models and the determinism of computational intelligence-based systems in psychiatry. To the best of our knowledge, this survey is the first comprehensive review on depression and relapse prediction by self-questionnaires, audiovisual, and EEG-based approaches. The findings of this review will serve as a useful and structured starting point for researchers studying clinical and non-clinical depression recognition and relapse through machine learning-based approaches.

HDAC1-mediated regulation of GABA signaling within the lateral septum facilitates long-lasting social fear extinction in male mice

Social anxiety disorder (SAD) is caused by traumatic social experiences. It is characterized by intense fear and avoidance of social contexts, which can be robustly mimicked by the social fear conditioning (SFC) paradigm. The extinction phase of the SFC paradigm is akin to exposure therapy for SAD and requires learning to disassociate the trauma with the social context. Learning-induced acetylation of histones is critical for extinction memory formation and its endurance. Although class I histone deacetylases (HDACs) regulate the abovementioned learning process, there is a lack of clarity in isoforms and spatial specificity in HDAC function in social learning. Utilizing the SFC paradigm, we functionally characterized the role of HDAC1, specifically in the lateral septum (LS), in regulating the formation of long-term social fear extinction memory. We measured a local increase in activity-inducing HDAC1 phosphorylation at serine residues of social fear-conditioned (SFC⁺) mice in response to the extinction of social fear. We also found that LS-HDAC1 function negatively correlates with acute social fear extinction learning using pharmacological and viral approaches. Further, inhibition of LS-HDAC1 enhanced the expression of the GABA-A receptor β1 subunit (Gabrb1) in SFC⁺ mice, and activation of GABA-A receptors facilitated acute extinction learning. Finally, the facilitation of extinction learning by HDAC1 inhibition or GABA-A receptor activation within the LS led to the formation of long-lasting extinction memory, which persisted even 30 days after extinction. Our results show that HDAC1-mediated regulation of GABA signaling in the LS is crucial for the formation of long-lasting social fear extinction memory.

An interdisciplinary multimodal integrative healthcare program for somatic symptom disorder, with predominant (spinal) pain

OBJECTIVE

Although multimodal interventions are generally recommended in patients with long-term somatic symptom disorders (SSD), available evidence is limited. The current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for patients with SSD and predominant (spinal) pain.

METHOD

The healthcare program consisted of two active treatment phases: main 20-week program and a 12-month relapse prevention program. Participants were 4453 patients diagnosed with SSD. The primary outcome was health-related quality of life (HRQoL) assessed using the RAND-36 (i.e., mental/physical component summary) and secondary outcomes included physical and psychological symptoms assessed using the Brief Symptom Inventory (BSI) and RAND-36 subscales. Mixed linear models were used to examine the effects of the multimodal healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of relapse prevention program (T3).

RESULTS

Significant improvements were found from T0 to T2 for all primary variables (i.e., mental/physical component summary) and secondary variables (i.e., BSI/RAND-36 subscales), which were maintained until the end of the relapse prevention program (T3).

CONCLUSION

An interdisciplinary multimodal integrative treatment for SSD is effective for improving HRQoL and reducing physical and psychological symptoms.

Patients' symptoms and strengths as predictors of long-term outcomes of CBT for generalized anxiety disorder - A three-level, multi-predictor analysis

Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual's symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients' strengths for clinical practice.

Possible substance use disorders among first responders during the COVID-19 era: a quasi-experimental study of personal and residential vulnerability

Background: During the COVID-19 pandemic possible substance use disorders (SUD) were exacerbated from increased stress and isolation. Experiences of symptomology differ widely by occupations.Objectives: The objectives were to determine if there is a temporal relationship between COVID-19 vulnerability and possible SUDs among first responders, and to examine the association with neighborhood vulnerability.Methods: We conducted an analysis with two distinct cohorts dependent on time of entry: 1) First responders that began counseling prior to COVID-19 and 2) First responders that began counseling after the start of COVID-19. Data were collected at intake from first responders seeking mental health services between 2017 and 2021 at an organization in Dallas/Fort Worth, Texas. The study sample included 195 mostly male (75%) first responders (51% law enforcement officers; 49% emergency medical technicians/firefighters). Bivariate models tested unadjusted relationships between covariates and possible SUD. Adjusted models consisted of a two-level multivariable logistic regression models.Results: Nearly 40% (n = 77) screened positive for a possible SUD. Those beginning counseling after COVID-19 did not have higher odds of SUDs. For every unit increase in neighborhood Severe COVID-19 Health Risk Index at a first responder's residential location there was an increase in the odds of a possible SUD (AOR = 3.14, 95% CI: 1.47, 6.75).Conclusions: Our study highlights the degree to which personal and residential vulnerability to COVID-19 impacted first responders. The increased occupational stress of this population, and an established pattern of maladaptive coping, elucidates the need for preventative and clinical approaches to strengthen the resilience of this population.

Lifestyle medicine for anxiety symptoms: A meta-analysis of randomized controlled trials

BACKGROUND

Lifestyle medicine (LM) is gaining increasing attention as a treatment option for anxiety, but the current state of evidence has not yet been systematically examined.

METHODS

Six electronic databases were systematically searched from inception to February 2022. Randomized controlled trials (RCTs) comparing the effects of multicomponent LM interventions on anxiety symptoms with either care-as-usual, waitlist, no intervention, or attention control group on anxiety symptoms were identified.

RESULTS

A total of 53 RCTs with 18,894 participants were included for qualitative synthesis, in which 45 RCTs with data available were included for meta-analysis. Multicomponent LM intervention was significantly more effective than the control groups in reducing anxiety symptoms at immediate posttreatment (d = 0.19, p < .001) and at short-term follow-up (d = 0.29, p < .001). However, no significant difference at medium-term was found (p = .14), whereas more studies are needed to study the long-term effects. The subgroup analyses suggested that baseline anxiety symptoms was a significant moderator, suggesting that those with moderate level of baseline anxiety symptoms appeared to have greater improvements (d = 0.66, p < .05).

LIMITATIONS

Minimal anxiety symptoms at baseline contributed to the floor effect and influenced the degree of improvement. The included RCTs had a high risk of bias in general with potential publication bias detected.

CONCLUSION

The findings of this meta-analysis provided support for the positive effects of multicomponent LM interventions for anxiety symptoms. Future research is needed to determine the long-term effects of multicimponent LM and the optimal baseline anxiety severity.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

Durability of treatment effects following internet-delivered cognitive behavioural therapy for depression and anxiety delivered within a routine care setting

OBJECTIVE

To investigate post-treatment relapse and remission rates 3, 6 and 9 months after completion of an acute phase of a clinician-supported internet-delivered cognitive-behavioural therapy (iCBT) for anxiety and depressive symptoms, within a routine care setting.

METHOD

Secondary analysis from a 12-month pragmatic randomized-controlled trial delivered within the Improving Access to Psychological Therapies (IAPT) programme in England. Participants in the intervention arm were included if they met criteria for reliable recovery from depression (PHQ-9) and anxiety (GAD-7) at post-treatment assessment. Survival analysis was used to assess durability of treatment effects and determine predictors to relapse at 3-, 6- and 9-month follow-up. Hazard ratios predicting time-to-relapse were estimated with semi-parametric Cox proportional hazards model.

RESULTS

Of the 241 participants in the intervention arm, 89 participants met the criteria for reliable recovery from depression and anxiety at the post-treatment assessment. Of these 89 eligible cases, 29.2% relapsed within the 9-month period, with 70.8% remaining in remission at 9 months post-treatment. Of those who relapsed, 53.8% experienced a relapse of depression and anxiety; 7.7% experienced a relapse of depression only; and 38.4% experienced a relapse of anxiety only. Younger age, having a long-term condition, and residual symptoms of anxiety at end-of-treatment were all significant predictors of relapse.

CONCLUSIONS

This study is the first to explore the remission and relapse rates after an acute phase of iCBT treatment, within a routine, stepped-care setting. The results add to the scarce literature on the durability of the effects of iCBT treatment in routine care settings, where patients are not typically followed up after receiving a completed course of treatment.

Disentangling the mediating role of modifying interpretation bias on emotional distress using a novel cognitive bias modification program

BACKGROUND

Negative interpretation bias is a potential risk factor for emotional disorders. In this study, we tested a clinically inspired 4-session online Cognitive Bias Modification-Interpretation (CBM-I_Clin) program to modify negative interpretation biases.

METHODS

We randomized one hundred and twenty-one volunteer young adults (Mean age = 21.6 years, SD = 3.5; 85 % women) with varying levels of emotional distress to either an experimental or waitlist control group. Mediation analyses were used to disentangle the associations between the intervention, changes in interpretation biases (assessed by both a self-report and an experimental task), and changes in measures of cognitive vulnerability and symptoms of depression and anxiety.

RESULTS

The results showed that the CBM-I_Clin could change negative interpretation biases. Also, it had a direct effect on the change in negative memory bias, an indirect effect on the change in depression symptoms via the change in interpretation bias, and both direct and indirect effects on the change in self-reported dysfunctional attitudes.

LIMITATIONS

The study included a non-clinical sample of participants and it did not control for some potential confounding factors (e.g., attentional disorders). Furthermore, participants' engagement during the sessions at home was not supervised.

CONCLUSIONS

The CBM-I_Clin is a potential tool to prevent and intervene in emotional disorders in young adults and could complement other traditional CBM procedures or clinical interventions.

The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management

The clinical construct of "anxiety neurosis" was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM-III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive-behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

A meta-analysis of relapse rates in cognitive-behavioral therapy for anxiety disorders

Cognitive-behavioral therapy (CBT) is a first-line treatment for anxiety and related disorders, with large pre- to post-treatment effect sizes. Rates of relapse, or the likelihood that a state of remission will be maintained once treatment is withdrawn, have been relatively neglected in CBT outcome studies. The present meta-analysis aimed to determine the overall rate of relapse in CBT for anxiety and related disorders. A secondary aim was to assess whether demographic, clinical, and methodological factors were associated with rates of relapse in CBT. Articles were identified from prior CBT meta-analyses and review papers and from literature searches using the PsycINFO and Medline electronic databases, with 17 full-length articles retained for meta-analysis (total N = 337 patients). Results showed an overall relapse rate of 14 %, which did not significantly differ between diagnoses. The way in which relapse was defined was significantly associated with relapse rates; when relapse was defined as meeting diagnostic criteria, estimates were lower than when alternative definitions were used. The findings indicate that relapse following symptom remission occurs in a minority of patients, suggesting that future treatment development and refinement efforts should focus on improving relapse prevention skills and interventions to minimize risk of relapse.

Is Continued Improvement After Automated Virtual Reality Exposure Therapy for Spider Phobia Explained by Subsequent in-vivo Exposure? A First Test of the Lowered Threshold Hypothesis

Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent in-vivo exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants (n = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of in-vivo exposures since last assessment. Number of in-vivo exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent in-vivo exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit in-virtuo to in-vivo transitioning components.