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Garey L, Thai JM, Zvolensky MJ, Smits JAJ. Exercise and Smoking Cessation. Curr Top Behav Neurosci 2024. [PMID: 39090290 DOI: 10.1007/7854_2024_497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Smoking is a public health crisis, leading to a multitude of health complications. Exercise is associated with numerous health benefits and is accepted by health professionals and smokers as a potentially effective smoking cessation aid. This chapter discusses the extant literature on the relation between exercise and smoking, including cross-sectional studies, experiments, and randomized clinical trials. There is robust evidence for exercise's efficacy in reducing cigarette craving, tobacco withdrawal symptoms, and negative affect. Further, exercise-based interventions appear to boost short-term abstinence yet may fall short of facilitating long-term abstinence. Methodological limitations of extant work are reviewed. We conclude with a discussion of the next steps in this line of work to fine-tune exercise interventions and their application for smoking cessation.
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Affiliation(s)
- Lorra Garey
- Department of Psychology, University of Houston, Houston, TX, USA.
- HEALTH Institute, University of Houston, Houston, TX, USA.
| | - Jessica M Thai
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA
- HEALTH Institute, University of Houston, Houston, TX, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jasper A J Smits
- Department of Psychology, The University of Texas at Austin, Austin, TX, USA
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2
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Kökönyei G, Kovács LN, Szabó J, Urbán R. Emotion Regulation Predicts Depressive Symptoms in Adolescents: A Prospective Study. J Youth Adolesc 2024; 53:142-158. [PMID: 37985558 PMCID: PMC10761508 DOI: 10.1007/s10964-023-01894-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
Emotion regulation as a proximal factor has been linked with depressive symptoms. However, studies have mainly focused on a limited number of strategies and have mostly been cross-sectional in design. This is particularly evident when examining the protective effects of adaptive strategies. This study aimed to investigate the prospective relationship between putatively adaptive and maladaptive emotion regulation strategies and depressive symptoms among adolescents. Additionally, a person-oriented approach was applied to identify latent classes of adolescents based on their depressive symptoms and compared these classes in terms of their adaptive and maladaptive strategies. Two waves of data from a prospective study, which included 1371 youth (mean age: 15.66 years; SD = 0.49 years; 55.1% girls), were analysed. The two points of data collection were spaced approximately half a year apart. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale, and putatively adaptive and maladaptive emotion regulation strategies were assessed with the Cognitive Emotion Regulation Questionnaire. Seven strategies (acceptance, positive refocusing, positive reappraisal, putting into perspective, self-blame, rumination, and catastrophizing) were categorised into adaptive and maladaptive factors using exploratory structural equation modeling. After controlling for gender, age, and depressive symptoms at Time 1, both maladaptive and adaptive emotion regulation strategies at Time 1 predicted depressive symptoms at Time 2. Three subgroups emerged based on the intensity of depressive symptoms across the waves: the stable low, stable moderate, and stable high depressive symptom groups. The use of maladaptive emotion regulation strategies (such as rumination, self-blame, and catastrophizing) at Time 1 was more pronounced in the stable moderate and high symptom groups compared to the stable low depressive symptom group. The comparable prospective associations between putatively adaptive and maladaptive strategies with symptoms suggest the need to identify factors that may mitigate the negative impact of maladaptive emotion regulation and/or promote adaptive emotion regulation to buffer the effects of everyday stressors.
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Affiliation(s)
- Gyöngyi Kökönyei
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.
- NAP3.0-SE Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
- Department of Pharmacodynamics, Faculty of Pharmacy, Semmelweis University, Budapest, Hungary.
| | - Lilla Nóra Kovács
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Judit Szabó
- National Institute of Criminology, Budapest, Hungary
| | - Róbert Urbán
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
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3
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Thapar A, Eyre O, Patel V, Brent D. Depression in young people. Lancet 2022; 400:617-631. [PMID: 35940184 DOI: 10.1016/s0140-6736(22)01012-1] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 02/06/2023]
Abstract
Depression rates in young people have risen sharply in the past decade, especially in females, which is of concern because adolescence is a period of rapid social, emotional, and cognitive development and key life transitions. Adverse outcomes associated with depression in young people include depression recurrence; the onset of other psychiatric disorders; and wider, protracted impairments in interpersonal, social, educational, and occupational functioning. Thus, prevention and early intervention for depression in young people are priorities. Preventive and early intervention strategies typically target predisposing factors, antecedents, and symptoms of depression. Young people who have a family history of depression, exposure to social stressors (eg, bullying, discordant relationships, or stressful life events), and belong to certain subgroups (eg, having a chronic physical health problem or being a sexual minority) are at especially high risk of depression. Clinical antecedents include depressive symptoms, anxiety, and irritability. Evidence favours indicated prevention and targeted prevention to universal prevention. Emerging school-based and community-based social interventions show some promise. Depression is highly heterogeneous; therefore, a stepwise treatment approach is recommended, starting with brief psychosocial interventions, then a specific psychological therapy, and then an antidepressant medication.
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Affiliation(s)
- Anita Thapar
- Wolfson Centre for Young People's Mental Health and Child and Adolescent Psychiatry Section, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK.
| | - Olga Eyre
- Wolfson Centre for Young People's Mental Health and Child and Adolescent Psychiatry Section, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - David Brent
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
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4
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Gupta RS, Dickey L, Kujawa A. Neural markers of emotion regulation difficulties moderate effects of COVID-19 stressors on adolescent depression. Depress Anxiety 2022; 39:515-523. [PMID: 35604282 PMCID: PMC9246973 DOI: 10.1002/da.23268] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/31/2022] [Accepted: 05/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Stressful events, such as those imposed by the COVID-19 pandemic, are associated with depression risk, raising questions about processes that make some people more susceptible to the effects of stress on mental health than others. Emotion regulation may be a key process, but methods for objectively measuring emotion regulation abilities in youth are limited. We leveraged event-related potential (ERP) measures and a longitudinal study of adolescents oversampled for depression and depression risk to examine emotion regulation difficulties as prospective predictors of depressive symptoms in response to pandemic-related stress. METHODS Before the pandemic, adolescents with (n = 28) and without (n = 34) clinical depression (N = 62 total) completed an explicit emotion regulation task while ERP data were recorded and measures of depressive symptoms. Adolescents were re-contacted during the pandemic to report on COVID-19 related stressful events and depressive symptoms (n = 48). RESULTS Adolescents who had never experienced a depressive episode showed an increase in depressive symptoms during the pandemic, but adolescents who were clinically depressed before the pandemic did not exhibit significant changes in symptoms. Neural markers of emotion regulation abilities interacted with pandemic-related stressful events to predict depressive symptoms during the pandemic, such that stressors predicted increases in depressive symptoms only for adolescents with greater difficulty modulating responses to negative images before the pandemic. CONCLUSIONS Results provide insight into adolescent mental health during the COVID-19 pandemic and highlight the role of emotion regulatory brain function in risk and resilience for depression.
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Affiliation(s)
- Resh S Gupta
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, California, USA
| | - Lindsay Dickey
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Autumn Kujawa
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
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5
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Doom JR, Rozenman M, Fox KR, Phu T, Subar AR, Seok D, Rivera KM. The Transdiagnostic Origins of Anxiety and Depression During the Pediatric Period: Linking NIMH Research Domain Criteria (RDoC) Constructs to Ecological Systems. Dev Psychopathol 2021; 33:1599-1619. [PMID: 35281333 PMCID: PMC8916713 DOI: 10.1017/s0954579421000559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the last decade, an abundance of research has utilized the NIMH Research Domain Criteria (RDoC) framework to examine mechanisms underlying anxiety and depression in youth. However, relatively little work has examined how these mechanistic intrapersonal processes intersect with context during childhood and adolescence. The current paper covers reviews and meta-analyses that have linked RDoC-relevant constructs to ecological systems in internalizing problems in youth. Specifically, cognitive, biological, and affective factors within the RDoC framework were examined. Based on these reviews and some of the original empirical research they cover, we highlight the integral role of ecological factors to the RDoC framework in predicting onset and maintenance of internalizing problems in youth. Specific recommendations are provided for researchers using the RDoC framework to inform future research integrating ecological systems and development. We advocate for future research and research funding to focus on better integration of the environment and development into the RDoC framework.
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6
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Ingul JM, Martinsen K, Adolfsen F, Sund AM, Ytreland K, Bania EV, Lisøy C, Rasmussen LMP, Haug IM, Patras J, Collins LM, Kendall PC, Neumer SP. Inside the Clockwork of the ECHO Factorial Trial: A Conceptual Model With Proposed Mediators for Prevention of Emotional Problems in Children. Front Psychol 2021; 12:703224. [PMID: 34234731 PMCID: PMC8255930 DOI: 10.3389/fpsyg.2021.703224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
Having interventions that are not only evidence-based and effective but also cost-effective and efficient is important for the prevention and treatment of child and adolescent emotional problems. A randomized clinical trial (RCT) tests the total interventions effect but does not address specific components of the intervention. In this article the hypothesis and a conceptual model of the ECHO study are presented and discussed. The ECHO intervention consists of three different components each containing two levels of intervention. By using a cluster randomized factorial design, children aged 8-12 at 40 schools across Norway will be randomized to eight different experimental conditions investigating the optimal balance between effect, cost-effectiveness, and efficiency. The article presents the design and the different components being tested and discusses how optimalization can be reached through this innovative design. The article also discusses how interventions can be improved by investigating and understanding the mechanisms of change within psychological interventions. For each of the three components in the study we consider the mediators that could be active within the intervention and how the study investigates such mediation. The results will contribute to a better understanding of how psychological interventions work and how we intend to optimize the EMOTION intervention.
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Affiliation(s)
- Jo Magne Ingul
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristin Martinsen
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway.,Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Frode Adolfsen
- Faculty of Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare North, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Mari Sund
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,St Olav's University Hospital, Trondheim, Norway
| | - Kristin Ytreland
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Valmyr Bania
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Carina Lisøy
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway.,Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Lene-Mari Potulski Rasmussen
- Faculty of Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare North, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ida Mari Haug
- Faculty of Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare North, UiT The Arctic University of Norway, Tromsø, Norway
| | - Joshua Patras
- Faculty of Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare North, UiT The Arctic University of Norway, Tromsø, Norway
| | - Linda M Collins
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York, NY, United States
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, United States
| | - Simon Peter Neumer
- Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.,Faculty of Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare North, UiT The Arctic University of Norway, Tromsø, Norway
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7
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Emotion regulation deficits mediate childhood sexual abuse effects on stress sensitization and depression outcomes. Dev Psychopathol 2020; 34:157-170. [PMID: 33023709 DOI: 10.1017/s095457942000098x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Child sexual abuse (CSA) is a notable risk factor for depressive disorders. Though multiply determined, increased sensitivity to stress (stress sensitization) and difficulty managing distress (emotion regulation) may reflect two pathways by which CSA confers depression risk. However, it remains unclear whether stress sensitization and emotion regulation deficits contribute to depression risk independently or in a sequential manner. That is, the frequent use of maladaptive emotion regulation responses and insufficient use of those that attenuate distress (adaptive emotion regulation) may lead to stress sensitization. We tested competing models of CSA, stress sensitization, and emotion regulation to predict depression symptoms and depressive affects in daily life among adults with and without histories of CSA. Results supported a sequential mediation: CSA predicted greater maladaptive repertoires that, in turn, exacerbated the effects of stress on depression symptoms. Maladaptive responses also exacerbated the effects of daily life stress on contemporaneous negative affect (NA) levels and their increase over time. Independent of stress sensitization, emotion regulation deficits also mediated CSA effects on both depressive outcomes, though the effect of maladaptive strategies was specific to NA, and adaptive responses to positive affect. Our findings suggest that emotion regulation deficits and stress sensitization play key intervening roles between CSA and risk for depression.
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8
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Greimel E, Feldmann L, Piechaczek C, Oort F, Bartling J, Schulte-Rüther M, Schulte-Körne G. Study protocol for a randomised-controlled study on emotion regulation training for adolescents with major depression: the KONNI study. BMJ Open 2020; 10:e036093. [PMID: 32912977 PMCID: PMC7485251 DOI: 10.1136/bmjopen-2019-036093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Major depression (MD) often has its onset during adolescence and is associated with significant morbidity and mortality. One important factor for the development and maintenance of adolescent MD are disturbances in emotion regulation and the underlying neural processes. Cognitive reappraisal (CR) is a particular adaptive emotion regulation strategy. Previously, it has been shown in healthy adults that a task-based training in CR is efficient to reduce negative affect, and that these effects translate into everyday life.This randomised controlled trial examines for the first time whether a task-based training in CR proves effective in MD adolescents. Specifically, we will investigate whether the CR training improves the ability to downregulate negative affect in MD individuals as assessed by behavioural and neurobiological indices, and whether training effects generalise outside the laboratory. METHODS AND ANALYSIS Adolescents with MD will be randomly allocated to a group that either receives a task-based training in CR or a control training. Both involve four training sessions over a time period of 2 weeks. In the CR training, participants will be instructed to downregulate negative affective responses to negative pictures via CR, while the control training involves picture viewing. During the training sessions, the Late Positive Potential, gaze fixations on negative picture aspects and affective responses to pictures will be collected. Before and after the training programmes, and at a 2-week follow-up, overall negative and positive affect, rumination and perceived stress will be assessed as primary outcomes. Analyses of variance will be conducted to test the effectiveness of the CR training with regard to both primary outcomes and task-based behavioural and neurobiological parameters. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Medical Faculty of the LMU Munich, Germany. The results will be published in peer-reviewed journals and disseminated through conferences, social media and public events. TRIAL REGISTRATION DETAILS ClinicalTrials.gov NCT03957850, registered 21st May 2019; URL: https://clinicaltrials.gov/ct2/show/NCT03957850.
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Affiliation(s)
- Ellen Greimel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Hospital of the Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Lisa Feldmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Hospital of the Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Charlotte Piechaczek
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Hospital of the Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Frans Oort
- Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands
| | - Jürgen Bartling
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Hospital of the Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Martin Schulte-Rüther
- Translational Brain Medicine in Psychiatry and Neurology, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, RWTH Aachen University, Aachen, Germany
- JARA-Brain, Aachen, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Hospital of the Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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9
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Loevaas MES, Lydersen S, Sund AM, Neumer SP, Martinsen KD, Holen S, Patras J, Adolfsen F, Rasmussen LMP, Reinfjell T. A 12-month follow-up of a transdiagnostic indicated prevention of internalizing symptoms in school-aged children: the results from the EMOTION study. Child Adolesc Psychiatry Ment Health 2020; 14:15. [PMID: 32336987 PMCID: PMC7178617 DOI: 10.1186/s13034-020-00322-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 04/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Anxious and depressive symptoms in youth are highly prevalent, are often comorbid and have a high rate of relapse. Preventive interventions are promising, but follow-up results are lacking. The transdiagnostic EMOTION program is an indicated preventive cognitive behavioral therapy (CBT) intervention targeting children aged 8-12 years. METHODS The present study investigates the 12 months follow-up effects of the EMOTION intervention in a cluster randomized controlled trial (RCT) with 795 children that included both child self-reports and parental reports. RESULTS Mixed model analyses showed a larger decrease of symptoms in the intervention group than in the control group for child self-reported anxious symptoms (The Multidimensional Anxiety Scale for Children (MASC) difference 4.56, CI 1.83 to 7.29, p = .001). Parental reports for both anxious (MASC difference 2.50, CI .26 to 4.74, p = .029) and depressive (The Mood and Feelings Questionnaire-short form (SMFQ) difference 1.55, CI .83 to 2.26, p ≤ .001) symptoms in children also showed a reduction. No statistically significant difference was found for child self-reported depressive symptoms (SMFQ difference .69, CI - .22 to 1.60, p = .139). CONCLUSION The transdiagnostic EMOTION program has shown the potential for long-term reductions in symptoms of both anxiety and depression in school-aged children. However, results regarding depressive symptoms must be considered preliminary as only parental report indicated effect.Trial registration The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov Identifier; NCT02340637.
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Affiliation(s)
- M. E. S. Loevaas
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
| | - S. Lydersen
- Medical Faculty, Department of Mental Health, Regional Center for Child and Youth Mental Health and Child Welfare, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - A. M. Sund
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
- Medical Faculty, Department of Mental Health, Regional Center for Child and Youth Mental Health and Child Welfare, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - S-P. Neumer
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - K. D. Martinsen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - S. Holen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - J. Patras
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - F. Adolfsen
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - L-M. P. Rasmussen
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - T. Reinfjell
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
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10
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Greimel E, Piechaczek C, Schulte-Rüther M, Feldmann L, Schulte-Körne G. The role of attentional deployment during distancing in adolescents with major depression. Behav Res Ther 2020; 126:103554. [PMID: 32036305 DOI: 10.1016/j.brat.2020.103554] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/23/2019] [Accepted: 01/13/2020] [Indexed: 01/18/2023]
Abstract
Individuals with major depression (MD) show deficits in cognitive reappraisal. It is yet unexplored how the act of directing visual attention away from/towards emotional aspects impacts on cognitive reappraisal in MD. Thus, we examined the role of attentional deployment during cognitive reappraisal (specifially during distancing) in adolescent MD. 36 MD adolescents and 37 healthy controls (12-18 years) performed a cognitive reappraisal task during which they a) down-regulated self-reported negative affective responses to negative pictures via distancing, or b) simply attended to the pictures. During the task, attentional focus was systematically varied by directing participants' gaze to emotional vs. non-emotional picture aspects. The validity of this experimental manipulation was checked by continuous eye-tracking during the task. Across groups and gaze focus conditions, distancing diminished negative affective responses to the pictures. Regulation success significantly differed between groups dependent on gaze focus: MD adolescents showed relatively less regulation success than controls in the emotional gaze focus condition, while the reverse was true for the non-emotional gaze focus condition. The results suggest that in MD adolescents, an emotional context might interfere with emotion regulatory aims. The findings can provide an important starting point for the development of innovative training regimes that target deficient reappraisal processes in adolescents suffering from MD.
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Affiliation(s)
- E Greimel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - C Piechaczek
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - M Schulte-Rüther
- Translational Brain Medicine in Psychiatry and Neurology, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, RWTH Aachen University, Germany; JARA-Brain, Aachen, Germany
| | - L Feldmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - G Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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11
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Daches S, Yaroslavsky I, Kovacs M. The persistence of hedonically-based mood repair among young offspring at high- and low-risk for depression. Cogn Emot 2019; 34:568-580. [PMID: 31482752 DOI: 10.1080/02699931.2019.1660622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of the present study was to examine whether offspring at high and low familial risk for depression differ in the immediate and more lasting behavioural and physiological effects of hedonically-based mood repair. Participants (9- to 22-year olds) included never-depressed offspring at high familial depression risk (high-risk, n = 64), offspring with similar familial background and personal depression histories (high-risk/DEP, n = 25), and never-depressed offspring at low familial risk (controls, n = 62). Offspring provided affect ratings at baseline, after sad mood induction, immediately following hedonically-based mood repair, and at subsequent, post-repair epochs. Physiological reactivity, indexed via respiratory sinus arrhythmia (RSA), was assessed during the protocol. Following mood induction and mood repair, high- and low-risk (control) offspring reported comparable changes in levels of sadness and RSA. However, sadness increased among high-risk offspring following the post-repair epoch, whereas low-risk offspring maintained mood repair benefits. High-risk/DEP offspring also reported higher levels of sadness following the post-repair epoch than did low-risk offspring. Change in RSA did not differ across the three offspring groups. Self-ratings confirm that one source of difficulty associated with depression risk is diminished ability to maintain hedonically-based mood repair gains, which were not apparent at the physiological level.
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Affiliation(s)
- Shimrit Daches
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Ilya Yaroslavsky
- Department of Psychology, Cleveland State University, Cleveland, OH, USA
| | - Maria Kovacs
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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12
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Rothenberg WA, Di Giunta L, Lansford JE, Lunetti C, Fiasconaro I, Basili E, Thartori E, Favini A, Pastorelli C, Eisenberg N, Amico FD, Rosa M, Cirimele F. Daily Associations between Emotions and Aggressive and Depressive Symptoms in Adolescence: The Mediating and Moderating Role of Emotion Dysregulation. J Youth Adolesc 2019; 48:2207-2221. [PMID: 31302795 DOI: 10.1007/s10964-019-01071-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
Nearly half of adolescents experience depressive or aggressive symptoms that impair their functioning at some point in adolescence. Experiencing intense difficult emotions and difficulties regulating such emotions may lead to these depressive and aggressive symptoms. However, existing work largely investigates how adolescent emotions at a single time point predict adolescent depressive or aggressive symptoms months or years later. New investigations are needed to capture the dynamic, changing nature of adolescents' daily experiences of emotions and symptoms of mental distress. Such investigations would further understanding of how emotions affect mental health in adolescents' everyday lives. Answering this call, the present study investigated how emotion dysregulation moderated and mediated daily associations between sadness and depressive symptoms and between anger and aggression utilizing ecological momentary assessment in a community sample of 103 Italian adolescents (Mage = 16.77, SD = 0.78, range: 15-18 years old; 47% female). The results revealed that if an adolescent experienced higher-than-usual sadness or anger on a particular day, then they also experienced higher than usual depressive or aggressive symptoms, respectively. Emotion dysregulation mediated and moderated these associations. Adolescents with higher anger had greater difficulties regulating their anger, which led to higher aggressive symptoms (a mediating effect). If adolescents' sadness was higher than usual on a given day, their depressive symptoms were more severe than usual if they also had higher than usual difficulties regulating sadness (a moderating effect). These findings contribute to our understanding of how emotions impact mental distress on a daily basis for adolescents, emphasize the importance of examining specific adolescent emotions, and shed new light on how emotional regulatory capacities influence emotions and mental health in adolescents' everyday lives.
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Affiliation(s)
- W Andrew Rothenberg
- Duke University Center for Child & Family Policy, Durham, NC, USA. .,University of Miami Miller School of Medicine, Mailman Center for Child Development, Miami, FL, USA.
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13
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Kaiser RH, Peterson E, Kang MS, Van Der Feen J, Aguirre B, Clegg R, Goer F, Esposito EC, Auerbach RP, Pizzagalli DA. Frontoinsular Network Markers of Current and Future Adolescent Mood Health. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2019; 4:715-725. [PMID: 31155512 DOI: 10.1016/j.bpsc.2019.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/12/2019] [Accepted: 03/31/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Adolescence is a developmental period in which depression and related mood syndromes often emerge, but few objective markers exist to guide diagnosis or predict symptoms. One potential mood marker is the functioning of frontoinsular networks, which undergo substantial development in adolescence and have been implicated in adult depression. To test this hypothesis, we used task-based neuroimaging to evaluate whether frontoinsular network dysfunction was linked to current and prospective mood health in adolescents. METHODS Adolescents (n = 40, 13-19 years of age) reporting varying levels of depressive symptom severity performed an emotional working memory task with neuroimaging. Next, teens completed a 2-week follow-up consisting of a daily diary report of negative affect and final report of depressive symptoms (n = 28 adherent). Analyses tested associations between task-related functional connectivity in frontoinsular networks and baseline or prospective measures of mood health over 2-week follow-up. RESULTS Frontoinsular task response was associated with higher current depression severity (p = .049, ηp2 = .12), increases in future depression severity (p = .018, ηp2 = .23), and more intense and labile negative affect in daily life (ps = .015 to .040, ηp2 = .22 to .30). In particular, hypoconnectivity between insula and lateral prefrontal regions of the frontoparietal network was related to both baseline and prospective mood health, and hyperconnectivity between insula and midline or temporal regions of the default network was related to prospective mood health. CONCLUSIONS These findings indicate that frontoinsular imbalances are related to both current depression and changes in mood health in the near future and suggest that frontoinsular markers may hold promise as translational tools for risk prediction.
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Affiliation(s)
- Roselinde H Kaiser
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado.
| | - Elena Peterson
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado
| | - Min Su Kang
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts
| | - Julie Van Der Feen
- Adolescent Partial Hospitalization Program, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Blaise Aguirre
- Three East Girls Intensive and Step-Down Program, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Rachel Clegg
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts
| | - Franziska Goer
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts
| | - Erika C Esposito
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts
| | - Randy P Auerbach
- Department of Psychiatry, Columbia University, New York, New York; Division of Clinical Developmental Neuroscience, Sackler Institute, New York, New York
| | - Diego A Pizzagalli
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts; McLean Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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14
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Gilbert K, Luking K, Pagliaccio D, Luby JL, Barch DM. Dampening Positive Affect and Neural Reward Responding in Healthy Children: Implications for Affective Inflexibility. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2019; 48:120-130. [PMID: 27819484 PMCID: PMC5420488 DOI: 10.1080/15374416.2016.1233502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Blunted reward processing is evident in and may contribute to the onset of major depressive disorder. However, it is unclear what mechanisms contribute to the development of blunted reward-response prior to depression onset. The current study examined how individual differences in the tendency to dampen positive affect, an affect regulation strategy that decreases positive affect, are associated with reward responding and related brain activation in 39 healthy children (ages 7-10; 51% female; 79% White). To do this, we examined neural responses to winning a reward (candy) within the context of a previous loss, win, or neutral outcome. Whole-brain regression analyses revealed that self-reported tendencies to engage in dampening were associated with blunted striatum and thalamic activation during a winning outcome when following a previous loss outcome, as compared to when following a neutral outcome. This finding was above and beyond the influence of current depressive symptoms. However, tendencies to dampen positive affect were not associated with neural activity during the second of 2 consecutive win outcomes, and thus did not support the notion that dampening is associated with an inability to maintain reward responding. In youth, tendencies to dampen positive affect may be associated with less ability to flexibly upregulate neural reward responding following a loss, possibly leading to the development of affective inflexibility and increased vulnerability to depression. Dampening positive affect may be one mechanism that contributes to aberrant neural reward responding via affective inflexibility and may be a target for prevention in youth.
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Affiliation(s)
- Kirsten Gilbert
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri
| | - Katherine Luking
- Department of Psychology, Stony Brook University, Stony Brook, New York
| | - David Pagliaccio
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Joan L. Luby
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri
| | - Deanna M. Barch
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri
- Department of Psychology, Washington University in St. Louis, St. Louis, Missouri
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15
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Loevaas MES, Sund AM, Patras J, Martinsen K, Hjemdal O, Neumer SP, Holen S, Reinfjell T. Emotion regulation and its relation to symptoms of anxiety and depression in children aged 8-12 years: does parental gender play a differentiating role? BMC Psychol 2018; 6:42. [PMID: 30126444 PMCID: PMC6102894 DOI: 10.1186/s40359-018-0255-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 08/10/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Symptoms of anxiety and depression are prevalent and highly comorbid in children, contributing to considerable impairment even at a subclinical level. Difficulties with emotion regulation are potentially related to both anxious and depressive symptoms. Research looking at maternal contributions to children's mental health dominates the literature but ignores the potentially important contributions of fathers. METHOD The present study is part of the Coping Kids study in Norway, a randomized controlled study of a new indicated preventive intervention for children, EMOTION. EMOTION aims to reduce levels of anxious and depressive symptoms in children aged 8-12 years. Using cross sectional data and multiple regression analyses, we investigated the relations between anxious and depressive symptoms and emotion regulation in n = 602 children. Symptoms were reported by the child, mothers and fathers. Emotion regulation was reported by mothers and fathers. RESULTS Symptoms of anxiety, as reported by parents, were associated with poorer emotion regulation. This association was also demonstrated for depressive symptoms as reported by both parents and children. When analyzing same gender reports, parental gender did not differentiate the relationship between anxiety symptoms and emotion regulation. For depressive symptoms, we did find a differentiating effect of parental gender, as the association with dysregulation of emotion was stronger in paternal reports, and the association with adaptive emotion regulation was stronger in maternal reports. When using reports from the opposite parent, the emotion regulation difficulties were still associated with depressive and anxiety symptoms, however exhibiting somewhat different emotional regulation profiles. CONCLUSION Problems with emotion regulation probably coexists with elevated levels of internalizing symptoms in children. In future research, both caregivers should be included. TRIAL REGISTRATION The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov; Protocol ID 228846/H10 .
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Affiliation(s)
- M. E. S. Loevaas
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
| | - A. M. Sund
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
- Regional Center for Child and Youth Mental Health and Child Welfare, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - J. Patras
- RKBU – North, Health Sciences Faculty, UiT The Arctic University of Norway, Tromso, Norway
| | - K. Martinsen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - O. Hjemdal
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - S.-P. Neumer
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - S. Holen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - T. Reinfjell
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
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16
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Whalen DJ, Gilbert KE, Barch DM, Luby JL, Belden AC. Variation in common preschool sleep problems as an early predictor for depression and anxiety symptom severity across time. J Child Psychol Psychiatry 2017; 58:151-159. [PMID: 27616560 PMCID: PMC5247335 DOI: 10.1111/jcpp.12639] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Child and adolescent psychopathology has been linked to increased sleep problems, but there has been less investigation of this relationship in younger samples with early-onset psychopathology. This study examined three specific but commonly observed aspects of sleep behaviors in young children - (i) Sleep onset latency, (ii) Refusal to sleep alone, and (iii) Nighttime awakenings - measured during preschool, and investigated whether these sleep problems predicted anxiety and/or depression across the next 6 years until school age (ages 9-13). METHODS Data were analyzed from N = 292 participants from a prospective longitudinal study of preschool-age children (ages 3-6). At baseline, parent-reported clinical interviews of psychiatric symptoms, as well as sleep problems were conducted using the Preschool-Age Psychiatric Assessment (PAPA). Follow-up clinical interviews were also conducted annually through school age using the Childhood and Adolescent Psychiatric Assessment (CAPA). RESULTS Parent-reported sleep onset latency and refusal to sleep alone were significant independent predictors of MDD and anxiety severity, but not ADHD severity across time, even after controlling for family income-to-needs ratio and maternal internalizing psychopathology. In exploratory analyses using only healthy preschoolers, parent-reported sleep onset latency and refusal to sleep alone also predicted anxiety severity. CONCLUSIONS We demonstrate that specific, yet relatively common sleep problems predict diagnostic severity of depression and anxiety across time, but not ADHD. Increased clinical attention to and screening for sleep onset latency and refusal to sleep alone during preschool may be warranted.
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Affiliation(s)
| | | | - Deanna M. Barch
- Department of Psychiatry, Washington University,The Program in Neuroscience, Washington University,Department of Psychology, Washington University,Department of Radiology, Washington University
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17
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Kovacs M, Yaroslavsky I, Rottenberg J, George CJ, Kiss E, Halas K, Dochnal R, Benák I, Baji I, Vetró A, Makai A, Kapornai K. Maladaptive mood repair, atypical respiratory sinus arrhythmia, and risk of a recurrent major depressive episode among adolescents with prior major depression. Psychol Med 2016; 46:2109-2119. [PMID: 27198823 DOI: 10.1017/s003329171600057x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Because depressive illness is recurrent, recurrence prevention should be a mainstay for reducing its burden on society. One way to reach this goal is to identify malleable risk factors. The ability to attenuate sadness/dysphoria (mood repair) and parasympathetic nervous system functioning, indexed as respiratory sinus arrhythmia (RSA), are impaired during depression and after it has remitted. The present study therefore tested the hypothesis that these two constructs also may mirror risk factors for a recurrent major depressive episode (MDE). METHOD At time 1 (T1), 178 adolescents, whose last MDE had remitted, and their parents, reported on depression and mood repair; youths' RSA at rest and in response to sad mood induction also were assessed. MDE recurrence was monitored until time 2 (T2) up to 2 years later. Mood repair at T1 (modeled as a latent construct), and resting RSA and RSA response to sadness induction (RSA profile), served to predict onset of first recurrent MDE by T2. RESULTS Consistent with expectations, maladaptive mood repair predicted recurrent MDE, above and beyond T1 depression symptoms. Further, atypical RSA profiles at T1 were associated with high levels of maladaptive mood repair, which, in turn, predicted increased risk of recurrent MDE. Thus, maladaptive mood repair mediated the effects of atypical RSA on risk of MDE recurrence. CONCLUSIONS This study documented that a combination of behavioral and physiological risk factors predicted MDE recurrence in a previously clinically referred sample of adolescents with depression histories. Because mood repair and RSA are malleable, both could be targeted for modification to reduce the risk of recurrent depression in youths.
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Affiliation(s)
- M Kovacs
- University of Pittsburgh School of Medicine,Pittsburgh, PA,USA
| | | | | | - C J George
- University of Pittsburgh Medical Center,PA,USA
| | - E Kiss
- Szeged University,Hungary
| | | | | | | | - I Baji
- Szeged University,Hungary
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18
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Yaroslavsky I, Rottenberg J, Bylsma LM, Jennings JR, George C, Baji I, Benák I, Dochnal R, Halas K, Kapornai K, Kiss E, Makai A, Varga H, Vetró Á, Kovacs M. Parasympathetic nervous system activity predicts mood repair use and its effectiveness among adolescents with and without histories of major depression. JOURNAL OF ABNORMAL PSYCHOLOGY 2016; 125:323-36. [PMID: 26950752 DOI: 10.1037/abn0000149] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Depressive disorders that onset in the juvenile years have been linked to far-reaching adverse consequences, making it imperative to elucidate key mechanisms and contributory factors. Excessive use of regulatory responses that exacerbate sadness (maladaptive mood repair) or insufficient use of regulatory responses that reduce it (adaptive mood repair) may reflect behavioral mechanisms of depression risk. Cardiac vagal control, indexed by patterns of respiratory sinus arrhythmia (RSA), has received attention as a putative physiological risk factor for depression. Although mood repair and RSA are related, the nature of this relationship is not well characterized in the context of depression risk. Therefore, we tested alternative models of the relationships between RSA patterns (at rest and in response to a sad film), trait mood repair, and the effectiveness of a mood repair response in the laboratory (state mood repair) among adolescents with depression histories (n = 210) and emotionally healthy peers (n = 161). In our data, a mediation model best explained the association between the key constructs: Adolescents with normative RSA patterns exhibited lower levels of depression and trait maladaptive mood repair, and benefited more from instructed (state) mood repair in the laboratory. By contrast, adolescents with atypical RSA patterns exhibited higher levels of depression and dispositional maladaptive mood repair, which, in turn, mediated the relations of RSA patterns and depression symptoms. Atypical RSA patterns also predicted reduced benefits from laboratory mood repair.
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Affiliation(s)
| | | | - Lauren M Bylsma
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | | | - Charles George
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Ildikó Baji
- Department of Psychiatry, University of Szeged
| | | | | | - Kitti Halas
- Department of Psychiatry, University of Szeged
| | | | - Enikő Kiss
- Department of Psychiatry, University of Szeged
| | | | | | - Ágnes Vetró
- Department of Psychiatry, University of Szeged
| | - Maria Kovacs
- Department of Psychiatry, University of Pittsburgh School of Medicine
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