Effectiveness of a modified behavioural activation treatment training program for primary medical staff to manage depressive symptoms among rural elderly in Hunan Province, China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Depression is a major global health problem, with high prevalence rates of depressive symptoms observed among the elderly population in China, particularly exacerbating in rural areas. Due to a lack of professional mental health training and inadequate psychotherapy capacity within primary medical staff, rural elderly individuals grappling with depressive symptoms often encounter challenges in receiving timely diagnosis and treatment. In this landscape, the modified behavioural activation treatment (MBAT) emerges as a promising approach due to its practicality, ease of therapist training and application, patient acceptability, and broad applicability. However, existing evidence for MBAT mainly hails from developed countries, leaving a gap in its adaptation and implementation within rural China. This study aims to develop an MBAT training programme for primary medical staff to manage depressive symptoms among rural elderly and evaluate its effectiveness.

METHODS AND ANALYSIS

A cluster randomised controlled trial will be conducted in 10 randomly selected township hospitals in Lengshuijiang and Lianyuan, Hunan Province. We aim to recruit 150 participants, with 5 township hospitals selected for each group, each consisting of 15 participants. The intervention group will implement the MBAT training programme, while the control group will receive usual care training programme. Depressive symptoms, psychosocial functioning, quality of life and satisfaction will be measured at baseline, immediately post-intervention, and at 3 and 6 months post-intervention. Effectiveness will be assessed using linear or generalised linear mixed models.

ETHICS AND DISSEMINATION

This study has obtained approval from the Institutional Review Board of the Third Xiangya Hospital, Centre South University (No.: 2022-S261). Results will be disseminated through publication in international peer-reviewed journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300074544.

Predictive modeling of antidepressant efficacy based on cognitive neuropsychological theory

BACKGROUND

We aimed to develop a clinical predictive model based on the cognitive neuropsychological (CNP) theory and machine-learning to examine SSRI efficacy in the treatment of MDD.

METHODS

Baseline assessments including clinical symptoms (HAMD, HAMA, BDI, and TEPS scores), negative biases (NEO-PI-R-N and NCPBQ scores), sociodemographic characteristics (social support and SES), and a 5-min eye-opening resting-state EEG were completed by 69 participants with first-episode major depressive disorder (MDD) and 36 healthy controls. The clinical symptoms and negative bias were again assessed after an 8-week treatment of depression with selective serotonin reuptake inhibitors (SSRIs). A multi-modality machine-learning model was developed to predict the effectiveness of SSRI antidepressants.

RESULTS

At baseline, we observed significant differences between MDD patients and healthy controls in terms of social support, clinical symptoms, and negative bias characteristics (p < 0.001). A negative association was found (p < 0.05) between neuroticism and alpha asymmetry in both the central and central-parietal areas, as well as between negative cognitive processing bias and alpha asymmetry in the parietal region. Compared to responders, non-responders exhibited less negative cognitive processing bias and greater alpha asymmetry in both central and central-parietal regions. Importantly, we developed a multi-modality machine-learning model with 83 % specificity using the above salient features.

CONCLUSIONS

Research results support the CNP theory of depression treatment. To some extent, the multimodal clinical model constructed based on the CNP theory effectively predicted the efficacy of this treatment in this population.

LIMITATIONS

Small sample and only focus on the mechanisms of delayed-onset SSRI treatment.

Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents

LAY ABSTRACT

Depression is common among autistic youth and has a significant negative impact on quality of life and day-to-day functioning. Despite great need for efficacious treatments, there are currently limited research-supported interventions for depression symptoms in autistic young people. This study tested a novel, behavior-based approach or psychotherapy for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A) with 15 youth (11-16 years old). BA-A is an individually delivered 12-session therapy that was developed for and to meet the needs of autistic youth with depression. Results found that autistic youth and their caregivers were able to participate in BA-A therapy sessions, and clinicians were able to deliver BA-A in accordance with the treatment manual. Notably, results demonstrated that autistic youth depression symptoms significantly improved after participating in BA-A. Furthermore, anxiety symptoms and social skills significantly improved following BA-A.

A Digital Behavioral Activation Intervention (JuNEX) for Pregnant Women With Subclinical Depression Symptoms: Explorative Co-Design Study

BACKGROUND

Digital interventions are gaining increasing interest due to their structured nature, ready availability, and self-administered capabilities. Perinatal women have expressed a desire for such interventions. In this regard, behavioral activation interventions may be particularly suitable for digital administration.

OBJECTIVE

This study aims to exploratorily investigate and compare the feasibility of the internet-based self-help guided versus unguided version of the Brief Behavioral Activation Treatment for Depression-Revised, an empirically supported in-person behavioral activation protocol, targeting pregnant women with subclinical depression symptoms. A user-centered design is used, whereby data are collected with the intent of evaluating how to adjust the intervention in line with pregnant women's needs. Usability and user engagement were evaluated.

METHODS

A total of 11 Italian pregnant women with subclinical depressive symptoms based on the Patient Health Questionnaire-9 (scoring<15) participated in this study; of them, 6 (55%) women were randomly assigned to the guided group (age: mean 32.17, SD 4.36 years) and 5 (45%) to the unguided group (age: mean 31, SD 4.95 years). The Moodle platform was used to deliver the interventions in an e-learning format. It consisted of 6 core modules and 3 optional modules; the latter aimed at revising the content of the former. In the guided group, each woman had weekly chats with their assigned human guide to support them in the homework revisions. The intervention content included text, pictures, and videos. Semistructured interviews were conducted, and descriptive statistics were analyzed.

RESULTS

Collectively, the data suggest that the guided intervention was better accepted than the unguided one. However, the high rates of dropout (at T6: guided group: 3/6, 50%; unguided: 4/5, 80%) suggest that a digital replica of Behavioral Activation Treatment for Depression-Revised may not be feasible in an e-learning format. The reduced usability of the platform used was reported, and homework was perceived as too time-consuming and effort-intensive. Moreover, the 6 core modules were deemed sufficient for the intervention's goals, suggesting that the 3 optional modules could be eliminated. Nevertheless, participants from both groups expressed satisfaction with the content and found it relevant to their pregnancy experiences.

CONCLUSIONS

Overall, the findings have emphasized both the intervention's merits and shortcomings. Results highlight the unsuitability of replicating an in-person protocol digitally as well as of the use of nonprofessional tools for the implementation of self-help interventions, ultimately making the intervention not feasible. Pregnant women have nonetheless expressed a desire to receive psychological support and commented on the possibilities of digital psychosocial supports, particularly those that are app-based. The information collected and the issues identified here are important to guide the development and co-design of a more refined platform for the intervention deployment and to tailor the intervention's content to pregnant women's needs.

Threat, safety, safeness and social safeness 30 years on: Fundamental dimensions and distinctions for mental health and well-being

In 1993, the British Journal of Clinical Psychology published my paper titled 'Defence and safety: Their function in social behaviour and psychopathology'. The paper highlights that to understand people's sensitivity to threat, we also need to understand their ability to identify what is safe. This paper offers an update on these concepts, highlighting distinctions that were implicit but not clearly defined at the time. Hence, the paper seeks to clarify distinctions between: (i) threat detection and response, (ii) safety and safety seeking, (iii) safeness and (iv) their social and non-social functions and forms. Threat detection and response are to prevent or minimize harm (e.g., run from a predator or fire). Safety checking relates to monitoring for the absence and avoidance of threat, while safety seeking links to the destination of the defensive behaviour (e.g., running home). Safety seeking also relates to maintaining vigilance to the appearance of potential harms and doing things believed to avoid harm. Threat-defending and safety checking and seeking are regulated primarily through evolved threat processing systems that monitor the nature, presence, controllability and/or absence of threat (e.g., amygdala and sympathetic nervous system). Safeness uses different monitoring systems via different psychophysiological systems (e.g., prefrontal cortex, parasympathetic system) for the presence of internal and external resources that support threat-coping, risk-taking, resource exploration. Creating brain states that recruit safeness processing can impact how standard evidence-based therapies (e.g., exposure, distress tolerance and reappraisal) are experienced and produce long-term change.

Automated VR therapy for improving positive self-beliefs and psychological well-being in young patients with psychosis: a proof of concept evaluation of Phoenix VR self-confidence therapy

BACKGROUND

Low self-confidence in patients with psychosis is common. This can lead to higher symptom severity, withdrawal from activities, and low psychological well-being. There are effective psychological techniques to improve positive self-beliefs but these are seldom provided in psychosis services. With young people with lived experience of psychosis we developed a scalable automated VR therapy to enhance positive-self beliefs.

AIMS

The aim was to conduct a proof of concept clinical test of whether the new VR self-confidence therapy (Phoenix) may increase positive self-beliefs and psychological well-being.

METHOD

Twelve young patients with non-affective psychosis and with low levels of positive self-beliefs participated. Over 6 weeks, patients were provided with a stand-alone VR headset so that they could use Phoenix at home and were offered weekly psychologist meetings. The outcome measures were the Oxford Positive Self Scale (OxPos), Brief Core Schema Scale, and Warwick-Edinburgh Well-being Scale (WEMWBS). Satisfaction, adverse events and side-effects were assessed.

RESULTS

Eleven patients provided outcome data. There were very large end-of-treatment improvements in positive self-beliefs (OxPos mean difference = 32.3; 95% CI: 17.3, 47.3; Cohen's d=3.0) and psychological well-being (WEMWBS mean difference = 11.2; 95% CI: 8.0, 14.3; Cohen's d=1.5). Patients rated the quality of the VR therapy as: excellent (n=9), good (n=2), fair (n=0), poor (n=0). An average of 5.3 (SD=1.4) appointments were attended.

CONCLUSIONS

Uptake of the VR intervention was high, satisfaction was high, and side-effects extremely few. There were promising indications of large improvements in positive self-beliefs and psychological well-being. A randomized controlled clinical evaluation is warranted.

A feasibility and pilot additive randomised control trial of attachment security priming during behavioural activation

BACKGROUND

There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes.

AIMS

This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming.

METHOD

This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates.

RESULTS

All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes.

CONCLUSIONS

Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Feasibility and acceptability of a community health worker administered behavioral activation intervention for postpartum depression: a single arm pilot study from India

Introduction

Women in India experience high rates of postpartum depression (PPD), with minimal availability of screening or treatment. India has an extensive network of community health workers, known as accredited social health activists (ASHAs). While they are knowledgeable about most maternal-child health problems, they have minimal knowledge about PPD. We trained ASHAs to deliver a simple home-based intervention, behavioral activation (BA), which involves individuals in activities that are sources of positive reinforcement to counter depression. The research questions guiding this study were as follows: 1) What are the feasibility and acceptability of ASHAs screening for and delivering a brief behavioral activation intervention addressing PPD among women in Belagavi, South India? 2) What impact did the brief behavioral activation intervention have on PPD?

Methods

The mixed methods evaluation used interviews with participants and interventionists, and depression scores were assessed before and after the evaluation. After a 2-day training with 17 ASHAs that focused on understanding PPD, screening using the Edinburgh Postnatal Depression Scale (EPDS), and implementing the BA protocol, ASHAs and researcher supervisors screened the mothers 6-12 weeks postpartum presenting at pediatric immunization clinics. Mothers who screened positive were invited to participate in an ASHA-led 5-week BA intervention, with ASHAs visiting the mothers' homes. We assessed post-intervention EPDS scores and conducted satisfaction assessments and individual interviews.

Results

All 26 women who screened positive on the EPDS agreed to be enrolled in the study. All participants had a significant reduction (p < 0.001) in PPD scores. Both ASHAs and mothers had high enthusiasm for the intervention methods and activities.

Discussion

This ASHA-delivered BA intervention was found to be feasible, acceptable, and effective in treating PPD in rural Indian mothers. This corroborates literature that demonstrates the efficacy of a BA intervention among individuals with generalized depression in South Asia. In communities with minimal mental health resources, interventions led by trained community workers have the potential to address PPD.

L-Carnitine in the Treatment of Psychiatric and Neurological Manifestations: A Systematic Review

OBJECTIVE

L-carnitine (LC), a vital nutritional supplement, plays a crucial role in myocardial health and exhibits significant cardioprotective effects. LC, being the principal constituent of clinical-grade supplements, finds extensive application in the recovery and treatment of diverse cardiovascular and cerebrovascular disorders. However, controversies persist regarding the utilization of LC in nervous system diseases, with varying effects observed across numerous mental and neurological disorders. This article primarily aims to gather and analyze database information to comprehensively summarize the therapeutic potential of LC in patients suffering from nervous system diseases while providing valuable references for further research.

METHODS

A comprehensive search was conducted in PubMed, Web Of Science, Embase, Ovid Medline, Cochrane Library and Clinicaltrials.gov databases. The literature pertaining to the impact of LC supplementation on neurological or psychiatric disorders in patients was reviewed up until November 2023. No language or temporal restrictions were imposed on the search.

RESULTS

A total of 1479 articles were retrieved, and after the removal of duplicates through both automated and manual exclusion processes, 962 articles remained. Subsequently, a meticulous re-screening led to the identification of 60 relevant articles. Among these, there were 12 publications focusing on hepatic encephalopathy (HE), while neurodegenerative diseases (NDs) and peripheral nervous system diseases (PNSDs) were represented by 9 and 6 articles, respectively. Additionally, stroke was addressed in five publications, whereas Raynaud's syndrome (RS) and cognitive disorder (CD) each had three dedicated studies. Furthermore, migraine, depression, and amyotrophic lateral sclerosis (ALS) each accounted for two publications. Lastly, one article was found for other symptoms under investigation.

CONCLUSION

In summary, LC has demonstrated favorable therapeutic effects in the management of HE, Alzheimer's disease (AD), carpal tunnel syndrome (CTS), CD, migraine, neurofibromatosis (NF), PNSDs, RS, and stroke. However, its efficacy appears to be relatively limited in conditions such as ALS, ataxia, attention deficit hyperactivity disorder (ADHD), depression, chronic fatigue syndrome (CFS), Down syndrome (DS), and sciatica.

Examining the Efficacy of Extended Reality-Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial

BACKGROUND

Major depressive disorder (MDD) is a global concern with increasing prevalence. While many evidence-based psychotherapies (EBPs) have been identified to treat MDD, there are numerous barriers to patients accessing them. Virtual reality (VR) has been used as a treatment enhancement for a variety of mental health disorders, but few studies have examined its clinical use in treating MDD. Behavioral activation (BA) is a simple yet effective and established first-line EBP for MDD that has the potential to be easily enhanced and adapted with VR technology. A previous report by our group explored the feasibility and acceptability of VR-enhanced BA in a small clinical proof-of-concept pilot. This study examines the clinical efficacy of a more immersive extended reality (XR)-enhanced BA (XR-BA) prototype. This is the first clinical efficacy test of an XR-BA protocol.

OBJECTIVE

This study examined whether XR-BA was feasible and efficacious in treating MDD in an ambulatory telemedicine clinic.

METHODS

A nonblinded between-subject randomized controlled trial compared XR-BA to traditional BA delivered via telehealth. The study used a previously established, brief 3-week, 4-session BA EBP intervention. The experimental XR-BA participants were directed to use a Meta Quest 2 (Reality Labs) VR headset to engage in simulated pleasant or mastery activities and were compared to a control arm, which used only real-life mastery or pleasant activities as between-session homework. The Patient Health Questionnaire (PHQ)-9 was the primary outcome measure. Independent-sample and paired-sample t tests (2-tailed) were used to determine statistical significance and confirmed using structural equation modeling.

RESULTS

Overall, 26 participants with MDD were randomized to receive either XR-BA (n=13, 50%) or traditional BA (n=13, 50%). The mean age of the 26 participants (n=6, 23% male; n=19, 73% female; n=1, 4% nonbinary or third gender) was 50.3 (SD 17.3) years. No adverse events were reported in either group, and no substantial differences in dropout rates or homework completion were observed. XR-BA was found to be statistically noninferior to traditional BA (t18.6=-0.28; P=.78). Both the XR-BA (t9=2.5; P=.04) and traditional BA (t10=2.3; P=.04) arms showed a statistically significant decrease in PHQ-9 and clinical severity from the beginning of session 1 to the beginning of session 4. There was a significant decrease in PHQ-8 to PHQ-9 scores between the phone intake and the beginning of session 1 for the XR-BA group (t11=2.6; P=.03) but not the traditional BA group (t11=1.4; P=.20).

CONCLUSIONS

This study confirmed previous findings that XR-BA may be a feasible, non-inferior, and acceptable enhancement to traditional BA. Additionally, there was evidence that supports the potential of XR to enhance expectation or placebo effects. Further research is needed to examine the potential of XR to improve access, outcomes, and barriers to MDD care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05525390; https://clinicaltrials.gov/study/NCT05525390.

Testing a brief, self-guided values affirmation for behavioral activation intervention during COVID-19

This pilot study tested a single-session digital values affirmation for behavioral activation (VABA) intervention. Hypotheses predicted the VABA intervention would be more effective than an active control condition in improving mood, decreasing COVID-19 fear/worry and depressive symptoms, and promoting positively reinforcing behaviors during early weeks of the COVID-19 pandemic. Participants were a diverse sample of undergraduate students (N = 296) under a state-wide lockdown. Students were randomized to either VABA, a 10-min values clarification and affirmation task, or Control, a time- and attention-matched task. Positive and negative affects were assessed pre- and post-intervention. At next-day follow-up, positive and negative affects were reassessed, as well as past 24-h behavioral activation and depressive symptoms. Within-group increases in positive affect were observed in both conditions (VABA d = 0.39; Control d = 0.19). However, VABA produced a significantly larger increase than Control (F[2] = 3.856, p = .022, d = 0.22). At 24-h follow-up, behavioral activation, which was significantly higher in VABA versus Control (t[294] = -5.584, p < .001, d = 0.65), predicted fewer depressive symptoms (R2 change = .019, β = -.134, p = .003). VABA is an ultra-brief intervention that appears to have acute effects on mood-enhancement and behavioral activation.

Behavioral Activation: Values-Aligned Activity Engagement as a Transdiagnostic Intervention for Common Geriatric Conditions

Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.

Less bang for my buck: Diminished anticipated enjoyment contributes to dysphoria-linked deficit in activity behavioural engagement choice

This study experimentally investigated the role of anticipated enjoyment and effort in mediating dysphoria-related deficit in activity engagement behavioural choice. Using a novel activity information processing task (about a fictional "new" Nintendo Wii sports game called "Tornado Ball"), N = 249 participants (n = 95 High Dysphoria; n = 154 Low Dysphoria) were presented information about the benefits (enjoyable features) and costs (mental and physical effort barriers) as product reviews from another player. The order of cost vs. benefit information was manipulated such that participants either heard cost information before benefit information, or vice versa. They then rated what their anticipated enjoyment and effort will be if they were to play Tornado Ball, before being given the opportunity to choose to try it themselves or not. The High Dysphoria group reported lower anticipated enjoyment (but not higher effort) relative to the Low Dysphoria group, but only when cost information was presented first. Importantly, a moderated mediation showed that the High Dysphoria group reported lower tendency to choose activity engagement (game play) as a function of having lower anticipated enjoyment, but only when cost information was presented first. The present finding indicate that reduced anticipated enjoyment may causally contribute to dysphoria-linked deficits in activity engagement behavioural choice.

Behavioral activation for family caregiver connectedness: Adaptation of an evidenced based intervention

Informal caregivers of older adults with chronic illness have unique barriers to social connection. As the older adult population increases, individualized interventions are urgently needed to address the social disconnection experienced across generations of informal caregivers. Adapting an evidenced-based intervention to target social connectedness and leverage technology-mediated communication may be a promising approach. This article describes the adaptation of the Brief Behavioral Activation Treatment for Depression-Revised intervention using elements of the Framework for Reporting Adaptations and Modifications-Enhanced. Facilitating the comprehensive documentation of modifications made, we discuss the (a) rationale for modifications, (b) timing and approach to modifications, (c) nature of context and content modifications, and (d) fidelity in modifications. The Behavioral Activation for Family Caregiver Connectedness intervention addresses unique barriers to caregiver social connection with individualized value-based plans. Modifications to content and delivery reflect the goal of improving intervention fit in the context of social connectedness experienced by informal caregivers.

Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach

BACKGROUND

While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes.

METHODS

We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores.

RESULTS

Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression.

CONCLUSIONS

An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.

Effects of the COVID-19 pandemic on anhedonia, reward exposure and responsiveness, and sleep in college students

Objective: The COVID-19 pandemic's effects on college student mental health and its underlying mechanisms are not fully understood. Although necessary, physical distancing abruptly restricts interaction with environmental rewards and disrupts sleep patterns, both of which may contribute to psychological symptoms (eg, depression and anhedonia). This study explored differences in psychological symptoms, reward exposure and responsiveness, and sleep before versus during the pandemic. Methods: Eighty-seven college students completed baseline questionnaires and a one-week daily diary paradigm. The sample was divided into two groups based on data collection before (pre-) or after (post-COVID-19) implementation of state-wide COVID-19 physical distancing measures. Results: Findings highlight higher anhedonia, decrements in exposure to social, professional, and exercise related rewards, lower aniticipatory reward responsiveness, and lower sleep efficiency among college students during the initial months of the pandemic. Conclusions: Findings suggest anhedonia, reward system functioning, and sleep may be important targets to mitigate against college student mental health sequelae during COVID-19.

Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trial

BACKGROUND

Older adults were more likely to be socially isolated during the COVID-19 pandemic, with increased risk of depression and loneliness. We aimed to investigate whether a behavioural activation intervention delivered via telephone could mitigate depression and loneliness in at-risk older people during the COVID-19 pandemic.

METHODS

BASIL+ (Behavioural Activation in Social Isolation) was a pragmatic randomised controlled trial conducted among patients recruited from general practices in England and Wales, and was designed to assess the effectiveness of behavioural activation in mitigating depression and loneliness among older people during the COVID-19 pandemic. Eligible participants were aged 65 years and older, socially isolated, with a score of 5 or higher on the Patient Health Questionnaire-9 (PHQ-9), and had multiple long-term conditions. Participants were allocated in a 1:1 ratio to the intervention (behavioural activation) or control groups by use of simple randomisation without stratification. Behavioural activation was delivered by telephone; participants were offered up to eight weekly sessions with trained BASIL+ Support Workers. Behavioural activation was adapted to maintain social connections and encourage socially reinforcing activities. Participants in the control group received usual care with existing COVID-19 wellbeing resources. The primary clinical outcome was self-reported depression severity, assessed by the PHQ-9, at 3 months. Outcomes were assessed masked to allocation and analysis was by treatment allocation. This trial is registered with the ISRCTN registry (ISRCTN63034289).

FINDINGS

Between Feb 8, 2021, and Feb 28, 2022, 449 eligible participants were identified and 435 from 26 general practices were recruited and randomly assigned (1:1) to the behavioural activation intervention (n=218) or to the control group (usual care with signposting; n=217). The mean age of participants was 75·7 years (SD 6·7); 270 (62·1%) of 435 participants were female, and 418 (96·1%) were White. Participants in the intervention group attended an average of 5·2 (SD 2·9) of eight remote behavioural activation sessions. The adjusted mean difference in PHQ-9 scores between the control and intervention groups at 3 months was -1·65 (95% CI -2·54 to -0·75, p=0·0003). No adverse events were reported that were attributable to the behavioural activation intervention.

INTERPRETATION

Behavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups.

FUNDING

UK National Institute for Health and Care Research.

Group-based behaviour therapy improves self-care, glycaemic control and distress in adults with type 1 diabetes

AIMS

Psychological interventions have had modest effects on HbA1c in adults with Type 1 diabetes (T1D). We evaluated a novel behaviour therapy (BT) group program aiming to improve diabetes self-care and reduce HbA1c and distress. Core features were the application of a functional-analytic model, behavioural self-management training, and personally selected T1D self-care behaviours as treatment targets.

METHODS

Participants with T1D, 2-consecutive HbA1c ≥ 8.5 %(69 mmol/mol) and/or diabetes-related emotional/behavioural difficulties who had received specialist multidisciplinary input for ≥2 years completed 6-sessions of BT over 9-weeks. Outcomes were assessed at baseline, on completing 5-consecutive weekly sessions (post-) and at session 6, 1-month after (follow-up).

RESULTS

Of 66 participants mean age 37.9 years, mean age at T1D diagnosis 22.0 years, and median T1D duration 14 years, 54 completed BT. HbA1c improved from baseline to follow-up (9.7 ± 1.9 %-8.8 ± 1.3 %, p < 0.001), as did diabetes distress (DD: total score 49.2 ± 7.8 baseline, 38.9 ± 14.7 post- and 32.8 ± 11.7 follow-up, p < 0.001). All DD subscales of emotional burden, and physician, regimen, and interpersonal distress, improved (p < 0.001). Consistent results were observed for patients on multiple daily injections and continuous subcutaneous insulin infusion therapy.

CONCLUSIONS

BT based on a functional-analytic and behavioural self-management model holds promise as an effective means of improving HbA1c and reducing DD in adults with T1D.

Exploring the relevance of a psychology-based resilience app (JoyPop™) for Indigenous youth

BACKGROUND

Despite facing challenges to mental wellness from ongoing multifold trauma, Indigenous youth continue to galvanize their resilience. One pathway undertaken is embracing technology. The JoyPop™ youth resilience mobile application (app) was invited by Six Nations of the Grand River (SN) leadership to consider its use with their reserve youth.

OBJECTIVE

This study explored the feasibility of JoyPop™ research from the SN community adult perspective for appropriateness and relevance to SN youth, as a precursor to a user-experience study with community youth.

METHODS

Semi-structured, online interviews with 19 adult community members (26 % male) about JoyPop™ were conducted with nominated stakeholders from SN. Based on a standard presentation of the app, comments were solicited about app features, design, and relevance to Haudenosaunee culture. Interviews were transcribed, coded in a double-blind fashion, and analyzed for themes.

RESULTS

Most offered positive feedback, with some level of support for each feature of JoyPop™. Themes were identified (Need for Indigenous Design, Incorporation of Indigenous Culture, Appreciation of Ease, Flexibility and Personalization), stemming from comments of appraisal and suggestions for adaptations (e.g., incorporating more cultural elements, localized resources, simplification of app).

CONCLUSIONS

The JoyPop™ app was viewed as positive and relevant, based on feedback from adults within SN. Adaptations were identified by adults to better fit SN youth needs, and research with SN youth is pending before implementation of adaptations. Research with other communities is encouraged to expand the reach of technology interventions, to holistically support Indigenous youth mental health in a culturally relevant way.

Living with depression and diabetes: A qualitative study in Bangladesh and Pakistan

Diabetes and depression are both serious health conditions. While their relationship is bidirectional and each condition adversely affects outcomes for the other, they are treated separately. In low and middle income countries, such as Bangladesh and Pakistan, health systems are already stretched and the integration of diabetes and depression care is rarely a priority. Within this context through interviews with patients, healthcare workers and policy makers the study explored: lived experiences of people living with depression and diabetes, current practice in mental health and diabetes care and barriers and perspectives on integrating a brief psychological therapy into diabetes care. The findings of the study included: differing patient and practitioner understandings of distress/depression, high levels of stigma for mental health and a lack of awareness and training on treating depression. While it was apparent there is a need for more holistic care and the concept of a brief psychological intervention appeared acceptable to participants, many logistical barriers to integrating a mental health intervention into diabetes care were identified. The study highlights the importance of context and of recognising drivers and understandings of distress when planning for more integrated mental and physical health services, and specifically when adapting and implementing a new intervention into existing services.

Effect of Behavioral Activation for Women with Postnatal Depression: A Systematic Review and Meta-Analysis

Evidence shows that behavioral activation (BA), a simple form of psychological therapy, is as effective as the more complex psychological therapy-cognitive behavioral therapy (CBT)-in treating general depression. However, it remains unclear whether BA when compared with treatment-as-usual (TAU) has greater contributions in reducing postnatal depression. This systematic review compared the effect of BA versus TAU in reducing depression symptoms among postnatal women. Five databases (MEDLINE, Embase, Emcare, Cochrane Library, and PsycINFO) were searched. Risk of bias was assessed using the Cochrane Collaboration's 'risk-of-bias 2 tool'. A random-effects meta-analysis was conducted to examine the effect of BA on postnatal depression. Of 2844 initial studies, only two randomized control trials (RCTs) met the inclusion criteria. The overall quality of evidence of these two RCTs was low. When compared to TAU, meta-analysis showed that BA was associated with reduced depression symptoms in postnatal women (standard mean difference -0.56; 95% confidence interval -0.76 to -0.37). This review suggests that BA might be more effective than TAU for alleviating postnatal depression. However, due to concerns about evidence quality, these findings should be interpreted cautiously.

Exposure traced in daily life: improvements in ecologically assessed social and physical activity following exposure-based psychotherapy for anxiety disorders

BACKGROUND

Although exposure-based cognitive-behavioral therapy for anxiety disorders has frequently been proven effective, only few studies examined whether it improves everyday behavioral outcomes such as social and physical activity.

METHODS

126 participants (85 patients with panic disorder, agoraphobia, social anxiety disorder, or specific phobias, and 41 controls without mental disorders) completed smartphone-based ambulatory ratings (activities, social interactions, mood, physical symptoms) and motion sensor-based indices of physical activity (steps, time spent moving, metabolic activity) at baseline, during, and after exposure-based treatment.

RESULTS

Prior to treatment, patients showed reduced mood and physical activity relative to healthy controls. Over the course of therapy, mood ratings, interactions with strangers and indices of physical activity improved, while reported physical symptoms decreased. Overall results did not differ between patients with primary panic disorder/agoraphobia and social anxiety disorder. Higher depression scores at baseline were associated with larger changes in reported symptoms and mood ratings, but smaller changes in physical activity CONCLUSIONS: Exposure-based treatment initiates increased physical activity, more frequent interaction with strangers, and improvements in everyday mood. The current approach provides objective and fine-graded process and outcome measures that may help to further improve treatments and possibly reduce relapse.

"Therapy without a therapist?" The experiences of adolescents and their parents of online behavioural activation for depression with and without therapist support

Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression.Trial registration number: ClinicalTrials.gov Identifier NCT04117789, Date of registration: 07 October 2019.

Does reward processing moderate or mediate the link between childhood adversity and psychopathology: A longitudinal study

Childhood adversity is common and associated with elevated risk for transdiagnostic psychopathology. Reward processing has been implicated in the link between adversity and psychopathology, but whether it serves as a mediator or moderator is unclear. This study examined whether alterations in behavioral and neural reward processing function as a mechanism or moderator of psychopathology outcomes following adversity experiences, including threat (i.e., trauma) and deprivation. A longitudinal community sample of 10-15-year-old youths was assessed across two waves (Wave 1: n = 228; Wave 2: n = 206). Wave 1 assessed adverse experiences, psychopathology symptoms, reward processing on a monetary incentive delay task, and resting-state fMRI. At Wave 2, psychopathology symptoms were reassessed. Greater threat experiences were associated with blunted behavioral reward sensitivity, which, in turn, predicted increases in depression symptoms over time and mediated the prospective association between threat and depression symptoms. In contrast, reward sensitivity moderated the association between deprivation experiences and prospective externalizing symptoms such that the positive association of deprivation with increasing externalizing symptoms was absent for children with high levels of reward sensitivity.

Brief scales for the measurement of target variables and processes of change in cognitive behaviour therapy for major depression, panic disorder and social anxiety disorder

BACKGROUND

The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.

AIMS

To develop 13 brief versions (3-6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.

METHOD

Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293).

RESULTS

In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of -0.53 to -0.21. Correlations with the original process scales were substantial (r=.83-.96), internal consistency was mostly adequate (α=0.65-0.86), and change scores were moderate to large (|d|=0.51-1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.

CONCLUSIONS

Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond

BACKGROUND

Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.

AIMS

In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment.

METHOD

The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.

CONCLUSION

Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Mechanisms of change in Behavioral Activation: Adapting depression treatment for autistic people

Despite high rates of co-occurring depression, few studies have developed or adapted treatments targeting depressive symptoms for autistic adults. Behavioral activation is widely accepted as an empirically-supported approach for treating depression in other populations. Careful attention to the mechanisms targeted by behavioral activation is an essential step toward adapting behavioral activation protocols for use with autistic adults. We consider the mechanisms targeted by behavioral activation and provide a framework for research to explore the facilitators and barriers to the use of behavioral activation to treat depression in autistic adults. Drawing upon clinical experience and extant literature, the suggestions presented are aimed at highlighting considerations for clinicians wanting to use behavioral activation programs in their clinical practices with autistic adults and to promote the research needed to establish behavioral activation as an evidence-based practice for treating depression in adults on the autism spectrum.

The Oxford Positive Self Scale: psychometric development of an assessment of cognitions associated with psychological well-being

BACKGROUND

Developing, elaborating, and consolidating positive views of the self is a plausible route to increased psychological well-being. We set out to provide an assessment of positive self-beliefs that could be used in research and clinical practice.

METHODS

A non-probability online survey was conducted with 2500 UK adults, quota sampled to match the population for age, gender, ethnicity, income, and region. Exploratory factor analysis of a 94-item pool - generated with guidance from people with lived experience of mental health difficulties - was conducted to develop the Oxford Positive Self Scale (OxPos). The item pool was further reduced using regularised structural equation modelling (SEM) before confirmatory factor analysis. Optimal cut-off scores were developed using receiver operating characteristic curves. Additional validations were carried out with two further general population cohorts (n = 1399; n = 1693).

RESULTS

A 24-item scale was developed with an excellent model fit [robust χ2 = 995.676; df = 246; CFI = 0.956; TLI = 0.951; RMSEA = 0.049 (0.047, 0.052); SRMR = 0.031]. The scale comprises four factors: mastery; strength; enjoyment; and character. SEM indicated that the scale explains 68.6% of variance in psychological well-being. The OxPos score was negatively correlated with depression (r = -0.49), anxious avoidance (r = -0.34), paranoia (r = -0.23), hallucinations (r = -0.20), and negative self-beliefs (r = -0.50), and positively correlated with psychological well-being (r = 0.79), self-esteem (r = 0.67), and positive social comparison (r = 0.72). Internal reliability and test-retest reliability were excellent. Cut-offs by age and gender were generated. A short-form was developed, explaining 96% of the full-scale variance.

CONCLUSIONS

The new open access scale provides a psychometrically robust assessment of positive cognitions that are strongly connected to psychological well-being.

A Process Evaluation of Intervention Delivery for a Cancer Survivorship Rehabilitation Clinical Trial Conducted during the COVID-19 Pandemic

The purpose of the present study was to conduct a process evaluation of intervention delivery for a randomized controlled trial (RCT) conducted during the COVID-19 pandemic (NCT03915548). The RCT tested the effects of a telephone-delivered behavioral intervention on changes in breast cancer survivors' satisfaction with social roles and activities, as compared to an attention control condition. This process evaluation examined (a) fidelity monitoring scores; (b) participants' perceived benefit ratings for gaining confidence, reducing distress, adjusting habits and routines, setting goals, and increasing exercise; and (c) field notes, email communications, and transcripts of coach supervision and debriefing sessions. The behavioral and attention control conditions were delivered with a high degree of fidelity (global quality rating score for the BA/PS condition was M = 4.6 (SD = 0.6) and M = 4.9 (SD = 0.3) for the attention control condition, where "5" is the highest rating). The behavioral intervention participants perceived greater benefits than the control participants pertaining to goal setting, t(248) = 5.73, p = <0.0001, adjusting habits and routines, t(248) = 2.94, p = 0.0036, and increasing exercise, t(248) = 4.66, p = <0.0001. Moreover, coaches' perceptions regarding the behavioral intervention's therapeutic aspects aligned with the study's a priori conceptual model including the use of a structured process to set small, observable goals and facilitate the independent use of problem-solving skills. However, coaches also noted that aspects of the attention control condition, including the perceived relevance of the educational content and opportunities for social support, may have made it more therapeutically potent than intended. The pandemic may have affected the activity goals behavioral intervention participants could set as well as augmented the relevancy of social support provided in both conditions.

Longitudinal associations between academic competence-building and depression symptoms in early adolescence

The longitudinal associations between academic competence-building and depression symptoms were investigated among 741 early adolescents in Singapore. Extending from past studies on academic achievement and depression, the current research tested two competing hypotheses - the academic incompetence hypothesis versus the adjustment erosion hypothesis using a 3-wave longitudinal study over an academic year. The former hypothesis suggests that prior deficits in academic competence-building lead to subsequent depression symptoms, whereas the latter posits that previous depression leads to subsequent deficits in competence-building. Longitudinal associations between a higher-order competence-building factor (operationalized using multiple constituent motivational variables) and depression were examined using a random intercept cross-lagged panel model. Results indicated that within-individual decreases in competence-building prospectively predicted subsequent within-individual increases in depression symptoms, but the opposite effect was not observed. Within-individual fluctuations in competence-building also predicted end-of-year grades and teacher-reported adjustment problems. Overall, the current findings were consistent with the academic incompetence hypothesis, suggesting that interventions aimed at sustaining academic competence-building could offer protection against the worsening of depression. These results clarified the within-individual developmental dynamics between academic competence-building and depression symptoms in adolescents over time.

Refocusing of Attention on Positive Events Using Monitoring-Based Feedback and Microinterventions for Patients With Chronic Musculoskeletal Pain in the PerPAIN Randomized Controlled Trial: Protocol for a Microrandomized Trial

BACKGROUND

Chronic musculoskeletal pain (CMSP) affects between 13% and 47% of the population, with a global growth rate of 20.3% within the last 15 years, suggesting that there is a high need for effective treatments. Pain diaries have long been a common tool in nonpharmacological pain treatment for monitoring and providing feedback on patients' symptoms in daily life. More recently, positive refocusing techniques have come to be used, promoting pain-free episodes and positive outcomes rather than focusing on managing the pain.

OBJECTIVE

This study aims to evaluate the feasibility (ie, acceptability, intervention adherence, and fidelity) and initial signals of efficacy of the PerPAIN app, an ecological momentary intervention for patients with CMSP. The app comprises digitalized monitoring using the experience sampling method (ESM) and feedback. In addition, the patients receive 3 microinterventions targeted at refocusing of attention on positive events.

METHODS

In a microrandomized trial, we will recruit 35 patients with CMSP who will be offered the app for 12 weeks. Participants will be prompted to fill out 4 ESM monitoring questionnaires a day assessing information on their current context and the proximal outcome variables: absence of pain, positive mood, and subjective activity. Participants will be randomized daily and weekly to receive no feedback, verbal feedback, or visual feedback on proximal outcomes assessed by the ESM. In addition, the app will encourage participants to complete 3 microinterventions based on positive psychology and cognitive behavioral therapy techniques. These microinterventions are prompts to report joyful moments and everyday successes or to plan pleasant activities. After familiarizing themselves with each microintervention individually, participants will be randomized daily to receive 1 of the 3 exercises or none. We will assess whether the 2 feedback types and the 3 microinterventions increase proximal outcomes at the following time point. The microrandomized trial is part of the PerPAIN randomized controlled trial (German Clinical Trials Register DRKS00022792) investigating a personalized treatment approach to enhance treatment outcomes in CMSP.

RESULTS

Approval was granted by the Ethics Committee II of the University of Heidelberg on August 4, 2020. Recruitment for the microrandomized trial began in May 2021 and is ongoing at the time of submission. By October 10, 2022, a total of 24 participants had been enrolled in the microrandomized trial.

CONCLUSIONS

This trial will provide evidence on the feasibility of the PerPAIN app and the initial signals of efficacy of the different intervention components. In the next step, the intervention would need to be further refined and investigated in a definitive trial. This ecological momentary intervention presents a potential method for offering low-level accessible treatment to a wide range of people, which could have substantial implications for public health by reducing disease burden of chronic pain in the population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43376.

Effect of Daily Life Reward Loop Functioning on the Course of Depression

Engagement in activities increases positive affect (Reward Path 1), which subsequently reinforces motivation (Reward Path 2), and hence future engagement in activities (Reward Path 3). Strong connections between these three reward loop components are considered adaptive, and might be disturbed in depression. Although some ecological nomentary assessment (EMA) studies have investigated the cross-sectional association between separate reward paths and individuals' level of depression, no EMA study has looked into the association between individuals' reward loop strength and depressive symptom course. The present EMA study assessed reward loop functioning (5x/day, 28 days) of 46 outpatients starting depression treatment at secondary mental health services and monitored with the Inventory of Depressive Symptomatology-Self-Report (IDS-SR) during a 7-month period. Results of multilevel regression analyses showed significant within-person associations for Reward Path 1 (b = 0.21, p < .001), Reward Path 2 (b = 0.43, p < .001), and Reward Path 3 (b = 0.20, p < .001). Stronger average reward loops (i.e., within-person mean of all reward paths) did not relate to participants' improvement in depressive symptoms over time. Path-specific results revealed that Reward Paths 1 and 2 may have partly opposite effects on depressive symptom course. Together, our findings suggest that reward processes in daily life might be best studied separately and that further investigation is warranted to explore under what circumstances strong paths are adaptive or not.

Efficacy and safety of combination behavioral activation for smoking cessation and varenicline for treating tobacco dependence among individuals with current or past major depressive disorder: A 2 × 2 factorial, randomized, placebo-controlled trial

BACKGROUND AND AIMS

Treatment of depression-related psychological factors related to smoking behavior may improve rates of cessation among adults with major depressive disorder (MDD). This study measured the efficacy and safety of 12 weeks of behavioral activation for smoking cessation (BASC), varenicline and their combination.

DESIGN, SETTING, PARTICIPANTS

This study used a randomized, placebo-controlled, 2 × 2 factorial design comparing BASC versus standard behavioral treatment (ST) and varenicline versus placebo, taking place in research clinics at two urban universities in the United States. Participants comprised 300 hundred adult smokers with current or past MDD.

INTERVENTIONS

BASC integrated behavioral activation therapy and ST to increase engagement in rewarding activities by reducing avoidance, withdrawal and inactivity associated with depression. ST was based on the 2008 PHS Clinical Practice Guideline. Both treatments consisted of eight 45-min sessions delivered between weeks 1 and 12. Varenicline and placebo were administered for 12 weeks between weeks 2 and 14.

MEASUREMENTS

Primary outcomes were bioverified intent-to-treat (ITT) 7-day point-prevalence abstinence at 27 weeks and adverse events (AEs).

FINDINGS

No significant interaction was detected between behavioral treatment and pharmacotherapy at 27 weeks (χ2 (1)  = 0.19, P = 0.67). BASC and ST did not differ (χ2 (1)  = 0.43, P = 0.51). Significant differences in ITT abstinence rates (χ2 (1)  = 4.84, P = 0.03) emerged among pharmacotherapy arms (16.2% for varenicline, 7.5% for placebo), with results favoring varenicline over placebo (rate ratio = 2.16, 95% confidence interval = 1.08, 4.30). All significant differences in AE rates after start of medication were higher for placebo than varenicline.

CONCLUSION

A randomized trial in smokers with major depressive disorder found that varenicline improved smoking abstinence versus placebo at 27 weeks without elevating rates of adverse events. Behavioral activation for smoking cessation did not outperform standard behavioral treatment, with or without adjunctive varenicline therapy.

Physical and Extracurricular Activity in Adolescents With and Without ADHD: Examining Group Differences and the Role of Cognitive Disengagement Syndrome Symptoms

OBJECTIVE

This study examined extracurricular and physical activity related to ADHD (diagnosis and symptoms) and cognitive disengagement syndrome (CDS) symptoms.

METHODS

Participants were 302 adolescents (ages 12-14) with and without ADHD and primary caregivers. ADHD diagnosis was determined with parent interview. Questionnaires provided information on parent-reported demographic characteristics, ADHD symptoms, and extracurricular activity involvement; and adolescent-reported ADHD and CDS symptoms and indices of physical activity.

RESULTS

Although ADHD diagnosis and symptom dimensions were correlated with less extracurricular and physical activity involvement, CDS symptoms were most often independently associated with these outcomes. Females and adolescents from lower income homes also often had less involvement in extracurricular and physical activity.

CONCLUSIONS

Findings point to the need for more research in this area, careful assessment of risk factors (i.e., CDS symptoms, economic burden), and interventions that address inactivity in adolescents with ADHD, including those that address inequity related to income and sex.

Randomized control trial of a culturally adapted behavioral activation therapy for Muslim patients with depression in Pakistan

BACKGROUND

Behavioral activation therapy (BA) is as effective as cognitive behavior therapy (CBT) in treating depression and can be delivered by practitioners with much less psychological training, making it particularly suitable for low resource settings. BA that is culturally adapted for Muslims (BA-M) is a culturally adapted form of BA that has been found acceptable and feasible for Muslims with depression in the United Kingdom and Turkey; however, this is the first time that its efficacy has been determined through a definitive randomized controlled trial.

AIM

To compare the effectiveness of BA-M with CBT for Muslim patients with depression in Pakistan.

METHODS

One hundred and eight patients were randomized 1:1 to treatment arms in a parallel-group randomized controlled trial in hospital or community sites in Lahore, Pakistan. Recruitment followed self-referral or referrals from clinicians, consultants or relevant professionals at each site. Four measures were recorded by blinded assessors: The patient health questionnaire-9 (PHQ-9); the BA for depression scale short form (BADS-SF); symptom checklist-revised and the World Health Organization Quality-of-Life Brief Scale. All measures were recorded at baseline and post treatment; PHQ-9 and BADS-SF were also recorded at each session and at three month follow up. The primary analysis was to regress the PHQ-9 score after therapy upon the PHQ-9 score before therapy (baseline) and the type of therapy given, that is, analysis of covariance. In addition, analysis using PHQ-9 scores collected at each therapy session was employed in a 2-level regression model.

RESULTS

Patients in the BA-M arm experienced greater improvement in PHQ-9 score of 1.95 units compared to the CBT arm after adjusting for baseline values (P = 0.006) The key reason behind this improvement was that patients were retained in therapy longer under BA-M, in which patients were retained for an average 0.75 sessions more than CBT patients (P = 0.013). Patients also showed significant differences on physical (P < 0.001), psychological (P = 0.004) and social (P = 0.047) domains of Quality of Life (QoL) at post treatment level, indicating an increased QoL in the BA-M group as compared to the treatment as usual group. Some baseline differences were noted in both groups for BA scores and two domains of QoL scale: Physical and environment, which might have influenced the results, though the BA-M group showed more improvement at completion of therapy.

CONCLUSION

Results proved the efficacy of BA-M in reducing symptoms for depressed patients in Pakistan, indicating BA-M is a promising treatment modality for depression in future, particularly in low resource settings.

Investigating the role of action-contingent expectancy biases in dysphoria-linked activity engagement behavioural choice

Reduced tendency to engage in potentially rewarding activities is a hallmark of depression. The present study investigated the role of future expectancy biases in depression-linked behavioural choice, in participants varying in self-reported depression symptoms (dysphoria). A novel laboratory paradigm was developed to test the hypotheses that the degree to which higher dysphoria is associated with reduced tendency to engage in a potentially rewarding activity is dependent on the presence of negative biases in the expected outcomes of activity engagement. Specifically, two types of expectancy biases were distinguished: a) the expected likelihood of a negative rather than positive outcome, and b) the expected emotional impact of either outcome. N = 176 undergraduate students with varied levels of dysphoria were given the opportunity to choose to engage in a coin-tossing game that could result in a win or loss monetary outcome in terms of charity donations, and then rated both types of expectancies. Results indicated that higher dysphoria was associated with more negative expectations concerning the likelihood of objective outcomes and the emotional impact of such outcomes, and as hypothesised, such negative expectancy biases mediated indirect associations between dysphoria and behavioural choice.

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

Neural Predictors of Improvement With Cognitive Behavioral Therapy for Adolescents With Depression: An Examination of Reward Responsiveness and Emotion Regulation

Earlier depression onsets are associated with more debilitating courses and poorer life quality, highlighting the importance of effective early intervention. Many youths fail to improve with evidence-based treatments for depression, likely due in part to heterogeneity within the disorder. Multi-method assessment of individual differences in positive and negative emotion processing could improve predictions of treatment outcomes. The current study examined self-report and neurophysiological measures of reward responsiveness and emotion regulation as predictors of response to cognitive-behavioral therapy (CBT). Adolescents (14-18 years) with depression (N = 70) completed monetary reward and emotion regulation tasks while electroencephalogram (EEG) was recorded, and self-report measures of reward responsiveness, emotion regulation, and depressive symptoms at intake. Adolescents then completed a 16-session group CBT program, with depressive symptoms and clinician-rated improvement assessed across treatment. Lower reward positivity amplitudes, reflecting reduced neural reward responsiveness, predicted lower depressive symptoms with treatment. Larger late positive potential residuals during reappraisal, potentially reflecting difficulty with emotion regulation, predicted greater clinician-rated improvement. Self-report measures were not significant predictors. Results support the clinical utility of EEG measures, with impairments in positive and negative emotion processing predicting greater change with interventions that target these processes.

Scope, Characteristics, Behavior Change Techniques, and Quality of Conversational Agents for Mental Health and Well-Being: Systematic Assessment of Apps

BACKGROUND

Mental disorders cause substantial health-related burden worldwide. Mobile health interventions are increasingly being used to promote mental health and well-being, as they could improve access to treatment and reduce associated costs. Behavior change is an important feature of interventions aimed at improving mental health and well-being. There is a need to discern the active components that can promote behavior change in such interventions and ultimately improve users' mental health.

OBJECTIVE

This study systematically identified mental health conversational agents (CAs) currently available in app stores and assessed the behavior change techniques (BCTs) used. We further described their main features, technical aspects, and quality in terms of engagement, functionality, esthetics, and information using the Mobile Application Rating Scale.

METHODS

The search, selection, and assessment of apps were adapted from a systematic review methodology and included a search, 2 rounds of selection, and an evaluation following predefined criteria. We conducted a systematic app search of Apple's App Store and Google Play using 42matters. Apps with CAs in English that uploaded or updated from January 2020 and provided interventions aimed at improving mental health and well-being and the assessment or management of mental disorders were tested by at least 2 reviewers. The BCT taxonomy v1, a comprehensive list of 93 BCTs, was used to identify the specific behavior change components in CAs.

RESULTS

We found 18 app-based mental health CAs. Most CAs had <1000 user ratings on both app stores (12/18, 67%) and targeted several conditions such as stress, anxiety, and depression (13/18, 72%). All CAs addressed >1 mental disorder. Most CAs (14/18, 78%) used cognitive behavioral therapy (CBT). Half (9/18, 50%) of the CAs identified were rule based (ie, only offered predetermined answers) and the other half (9/18, 50%) were artificial intelligence enhanced (ie, included open-ended questions). CAs used 48 different BCTs and included on average 15 (SD 8.77; range 4-30) BCTs. The most common BCTs were 3.3 "Social support (emotional)," 4.1 "Instructions for how to perform a behavior," 11.2 "Reduce negative emotions," and 6.1 "Demonstration of the behavior." One-third (5/14, 36%) of the CAs claiming to be CBT based did not include core CBT concepts.

CONCLUSIONS

Mental health CAs mostly targeted various mental health issues such as stress, anxiety, and depression, reflecting a broad intervention focus. The most common BCTs identified serve to promote the self-management of mental disorders with few therapeutic elements. CA developers should consider the quality of information, user confidentiality, access, and emergency management when designing mental health CAs. Future research should assess the role of artificial intelligence in promoting behavior change within CAs and determine the choice of BCTs in evidence-based psychotherapies to enable systematic, consistent, and transparent development and evaluation of effective digital mental health interventions.

Longitudinal Associations Between Reward Responsiveness and Depression Across Adolescence

OBJECTIVE

Lower neural response to reward predicts subsequent depression during adolescence. Both pubertal development and biological sex have important effects on reward system development and depression during this period. However, relations among these variables across the transition from childhood to adolescence are not well characterized.

METHOD

Depressive symptoms, pubertal status, and the reward positivity (RewP) event-related potential component, a neural indicator of reward responsivity, were assessed in 609 community-recruited youth at 9, 12, and 15 years of age. Structural equation modeling was used to examine concurrent and prospective relations within and between depression and reward responsiveness as well as the influence of pubertal status and biological sex on these variables across assessments.

RESULTS

Stability paths for depression, the RewP, and pubertal status were significant across assessments. Compared with male participants, female participants reported more advanced pubertal status at all assessments, a smaller RewP at age 9, and higher levels of depression at age 15. More advanced pubertal status was associated with a larger RewP at age 15. Most importantly, there were bidirectional prospective effects between the RewP and depression from ages 12 to 15; a lower RewP at age 12 predicted increases in depression at age 15, whereas increased depression at age 12 predicted a lower RewP at age 15.

CONCLUSION

These findings indicate that there are bidirectional prospective effects between reward responsiveness and depression that emerge between ages 12 and 15. This may be a crucial time for studying bidirectional reward responsiveness-depression associations across time.

A low-intensity behavioral intervention for depression in older adults delivered by lay coaches: proof-of-concept trial

OBJECTIVES

A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial.

METHOD

In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (M = 66.83 years old, SD = 10.39) with depression (PHQ ≥ 10). Patient outcomes were change in pre- to post-treatment depressive symptoms, disability, and the target mechanism of increased activity.

RESULTS

Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]).

CONCLUSION

It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

Relationship of cortisol and alpha amylase to behavioral engagement under three levels of negative evaluative psychosocial stress

Despite that behavioral engagement is integral to mental health, surprisingly little is known about the relationship of psychosocial stress and behavioral engagement. The current study developed an observer-rated measure of behavioral engagement for lab-based stress inductions, then examined its relationship with stress-responsive biomarkers and affect. Young adults (N = 109, Mage=19.4, SDage=1.59, 57% female) completed one of three Trier Social Stress Test (TSST) conditions-non-stressful Control, Intermediate, or an Explicit Negative Evaluative-and at four timepoints provided self-reports of positive and negative affect and saliva samples for cortisol and salivary alpha-amylase (sAA). Trained study staff (experimenters and TSST judges) completed a programmed questionnaire measure of the novel behavioral engagement measure after the participants completed the TSST. Psychometric review and EFA of the behavioral engagement items resulted in a final 8-item measure with good interrater reliability and well-fitting 2-factor structure, capturing Persistence (4 items; loadings=.41-.89), and Quality of Speech (4 items; loadings=.53-.92). Results indicated that the relationship of positive affect growth and biomarker level to behavioral engagement varied substantially as a function of context: As negative evaluation level strengthened, behavioral engagement became more tightly associated with relative preservation of positive affect. For both cortisol and sAA, the relationship between biomarker levels (but not reactivity) and behavioral engagement varied significantly by condition, such that under milder conditions and elevated levels of biomarkers, engagement was greater, but under Explicit Negative Evaluation, and elevated levels of biomarkers, engagement was less, suggesting behavioral withdrawal. Findings reveal the critical role of context-especially negative evaluation-in the relationship of biomarkers with behavioral engagement.

COVID-19 anxiety and mental health among university students during the early phases of the U.S. pandemic

OBJECTIVE

This study examined the impact of COVID-19 in the early stages of the pandemic on university students in the U.S. by: (1) characterizing COVID-19-related disruptions; (2) evaluating health anxiety, obsessive-compulsive (OC), depression, and stress symptoms; and (3) analyzing the unique role of COVID-19 anxiety on mental health outcomes, after accounting for relevant variables.

PARTICIPANTS

Participants included 263 students (63.9% female).

METHODS

Data were collected online between March 19, 2020 and May 1, 2020.

RESULTS

Participants screened positive for health anxiety (6.5%), OC symptoms (48.7%), or depression (29.7%). COVID-19 anxiety was positively associated with mental health symptoms. After controlling for demographics and COVID-19 impact, COVID-19 anxiety accounted for significant variance in health anxiety, OC symptoms, and stress.

CONCLUSIONS

Findings demonstrate the vast impact of COVID-19 on mental health among university students and provide guidance for identifying mental health priorities in the context of public health crises.

Scaling up quality-assured psychotherapy: The role of therapist competence on perinatal depression and anxiety outcomes

OBJECTIVES

To examine: (1) the psychometric properties of two therapist competence measures-multiple choice questionnaire (MCQ) and standardized role-plays; (2) whether therapist competence differed between non-specialist (NSPs) and specialist (SPs) providers; and (3) the relations between therapist competence and patient outcomes among perinatal patients receiving brief psychotherapy.

METHODS

This study is embedded within the SUMMIT Trial-a large, ongoing psychotherapy trial for perinatal women with depressive and anxiety symptoms. We assessed the: (1) psychometric properties of therapist competence measures using Cronbach's alpha and inter-class correlation; (2) differences in therapist competence scores between n = 23 NSPs and n = 22 SPs using a two-sample t-test; and (3) relations between therapist competence measures and perinatal patient outcomes through a linear regression model.

RESULTS

Internal consistency for role-play was acceptable (α = 0.71), whereas MCQ was excellent (α = 0.97). Role-play showed good inter-rater reliability (ICC = 0.80) and scores were higher for SPs compared with NSPs (t(2,38) = -2.86, p = 0.0069) and associated with outcomes of anxiety (B = 1.52, SE = 0.60, p = 0.01) and depressive (B = 0.96, SE = 0.55, p = 0.08) symptom scores.

CONCLUSIONS

Our study highlights the importance of demonstrating psychological treatment skills through standardized role-plays over knowledge-based competence to predict perinatal patient outcomes. Using well-defined evidence-based tools is critical for deploying NSPs to provide high-quality psychotherapy and increase accessibility to psychological treatments for perinatal populations worldwide.

A smartphone-based serious game for depressive symptoms: Protocol for a pilot randomized controlled trial

Background

Depression is the most prevalent mental disorder, with detrimental effects on the patient's well-being, high disability, and a huge associated societal and economic cost. There are evidence-based treatments, but it is difficult to reach all people in need. Internet-based interventions, and more recently smartphone-based interventions, were explored to overcome barriers to access. Evidence shows them to be effective alternatives to traditional treatments. This paper presents the protocol of a pilot study whose primary aim is to investigate the efficacy of a smartphone-based serious game intervention for patients with mild to moderate depressive symptoms.

Methods

This randomized controlled pilot trial protocol foresees two arms design: 1/ smartphone- based serious game intervention (based on Cognitive Behavior Therapy with particular emphasis on Behavioral Activation and Physical Activity), 2/ waiting list control group. The study is expected to recruit 40 participants (18+), which will be randomly assigned to one of the experimental conditions. The duration of the intervention is two months. The primary outcome measure will be depressive symptomatology. Secondary outcomes will include other variables such as physical activity, resilience, anxiety, depression impairment, and positive and negative affect. Treatment expectation, satisfaction, usability, and game playability will also be measured. The data will be analyzed based on the intention-to-treat and per protocol analyses.

Discussion

The study aims to establish initial evidence for the efficacy of a smartphone-based serious game intervention, to serve as input for a larger-scale randomized control trial. The intervention exploits advanced smartphone capabilities, such as the use of a serious game as delivery mode, with the potential benefit of engagement and treatment adherence, and motion sensors to monitor and stimulate physical activity. As a secondary objective, the study aims to gather initial evidence on the user's expectations, satisfaction, usability and playability of the serious game as a treatment.

Effectiveness of cognitive behavioural therapy-based interventions for maternal perinatal depression: a systematic review and meta-analysis

BACKGROUND

Depression during the perinatal period (during pregnancy and the year after childbirth) is common and associated with a range of negative effects for mothers, infants, family members, and wider society. Although existing evidence suggests cognitive behavioral therapy (CBT) based interventions are effective for perinatal depression, less is known about the effect of CBT-based interventions on important secondary outcomes, and a number of potential clinical and methodological moderators have not been examined.

METHODS

A systematic review and meta-analysis primarily examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of depression. Secondary aims examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of anxiety, stress, parenting, perceived social support, and perceived parental competence; and explored clinical and methodological moderators potentially associated with effectiveness. A systematic search of electronic databases and other sources was performed up to November 2021. We included randomized controlled trials comparing CBT-based interventions for perinatal depression with control conditions allowing for the isolation of the effects of CBT.

RESULTS

In total, 31 studies (5291 participants) were included in the systematic review and 26 studies (4658 participants) were included in the meta-analysis. The overall effect size was medium (hedges g = - 0.53 [95% CI - 0.65 to - 0.40]); with high heterogeneity. Significant effects were also found for anxiety, individual stress, and perceived social support, however few studies examined secondary outcomes. Subgroup analysis identified type of control, type of CBT, and type of health professional as significant moderators of the main effect (symptoms of depression). Some concerns of risk of bias were present in the majority of studies and one study had a high risk of bias.

CONCLUSIONS

CBT-based interventions for depression during the perinatal period appear effective, however results should be interpreted with caution given high levels of heterogeneity and low quality of included studies. There is a need to further investigate possibly important clinical moderators of effect, including the type of health professional delivering interventions. Further, results indicate a need to establish a minimum core data set to improve the consistency of secondary outcome collection across trials and to design and conduct trials with longer-term follow-up periods.

TRIAL REGISTRATION

CRD42020152254 .

Functional role of frontal electroencephalogram alpha asymmetry in the resting state in patients with depression: A review

Depression is a psychological disorder that affects the general public worldwide. It is particularly important to make an objective and accurate diagnosis of depression, and the measurement methods of brain activity have gradually received increasing attention. Resting electroencephalogram (EEG) alpha asymmetry in patients with depression shows changes in activation of the alpha frequency band of the left and right frontal cortices. In this paper, we review the findings of the relationship between frontal EEG alpha asymmetry in the resting state and depression. Based on worldwide studies, we found the following: (1) Compared with individuals without depression, those with depression showed greater right frontal EEG alpha asymmetry in the resting state. However, the pattern of frontal EEG alpha asymmetry in the resting state in depressive individuals seemed to disappear with age; (2) Compared with individuals without maternal depression, those with maternal depression showed greater right frontal EEG alpha asymmetry in the resting state, which indicated that genetic or experience-based influences have an impact on frontal EEG alpha asymmetry at rest; and (3) Frontal EEG alpha asymmetry in the resting state was stable, and little or no change occurred after antidepressant treatment. Finally, we concluded that the contrasting results may be due to differences in methodology, clinical characteristics, and participant characteristics.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression

Background

To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity.

Method

150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator.

Discussion

Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression.

Trial registration

The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

The PATHS to Purpose: A New Framework Toward Understanding Purpose Development

Academic and lay interest has accrued over recent years with respect to how people develop a purpose in life. However, few theoretical models exist for understanding this developmental process as well as how to connect one’s overarching purpose in life to their daily feelings of purposefulness. The current article presents the PATHS (Purpose As Trait, Habit, and State) model, borrowing from clinical and personality development literatures. This framework allows researchers to consider purpose as a more enduring life direction (trait level), as an automatized routine acting in accordance with one’s goals (habit level), and as a more momentary reflection or feeling that one is engaged in purposeful pursuits (state level). Using this framework provides researchers with a valuable tool toward explaining how people progress toward purpose, via natural development or intervention, as well as the potential influences in this process.