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Vrijsen JN, Grafton B, Koster EHW, Lau J, Wittekind CE, Bar-Haim Y, Becker ES, Brotman MA, Joormann J, Lazarov A, MacLeod C, Manning V, Pettit JW, Rinck M, Salemink E, Woud ML, Hallion LS, Wiers RW. Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward. Behav Res Ther 2024; 179:104557. [PMID: 38797055 DOI: 10.1016/j.brat.2024.104557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/17/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.
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Affiliation(s)
- Janna N Vrijsen
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; Depression Expertise Center, Pro Persona Mental Health Care, Nijmegen, the Netherlands.
| | - Ben Grafton
- Centre for the Advancement of Research on Emotion, School of Psychological Science, University of Western Australia, Australia
| | - Ernst H W Koster
- Department of Experimental-Clinical and Health Psychology, Ghent University, Belgium
| | - Jennifer Lau
- Youth Resilience Unit, Queen Mary University of London, UK
| | - Charlotte E Wittekind
- Department of Psychology, Clinical Psychology and Psychotherapy, LMU Munich, Germany
| | - Yair Bar-Haim
- School of Psychological Sciences, Tel-Aviv University, Tel Aviv-Yafo, Israel; School of Neuroscience, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Eni S Becker
- Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands
| | - Melissa A Brotman
- Emotion and Development Branch, National Institute of Mental Health Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Jutta Joormann
- Department of Psychology, Yale University, New Haven, Conneticut, USA
| | - Amit Lazarov
- School of Neuroscience, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Colin MacLeod
- Centre for the Advancement of Research on Emotion, School of Psychological Science, University of Western Australia, Australia
| | - Victoria Manning
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia; Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Jeremy W Pettit
- Department of Psychology and Center for Children and Families, Florida International University, Miami, FL, USA
| | - Mike Rinck
- Emotion and Development Branch, National Institute of Mental Health Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Elske Salemink
- Department of Clinical Psychology, Faculty of Social and Behavioural Sciences, Utrecht University, the Netherlands
| | - Marcella L Woud
- Clinical Psychology and Experimental Psychopathology, Georg-Elias-Mueller-Institute of Psychology, University of Göttingen, Göttingen, Germany; Mental Health Research and Treatment Center, Ruhr-University Bochum, Bochum, Germany
| | | | - Reinout W Wiers
- Addiction Development and Psychopathology (ADAPT) Lab, Department of Psychology, and Centre for Urban Mental Health, University of Amsterdam, Amsterdam, the Netherlands
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Egan SJ, Greene D, Callaghan T, Raghav S, Funk J, Badenbach T, Talam S, Kemp G, McEvoy P, Ehring T, Kopf-Beck J. Worry and rumination as a transdiagnostic target in young people: a co-produced systematic review and meta-analysis. Cogn Behav Ther 2024:1-24. [PMID: 38923912 DOI: 10.1080/16506073.2024.2369936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
PROTOCOL REGISTRATION PROSPERO (CRD42023408899).
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Affiliation(s)
- Sarah J Egan
- enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
- Discipline of Psychology, Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Danyelle Greene
- Australian Institute for Business and Economics, University of Queensland, Brisbane, Australia
| | - Thomas Callaghan
- Discipline of Psychology, Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | | | - Julia Funk
- Department of Psychology, LMU Munich, Munchen, Germany
| | | | | | - Georgia Kemp
- Independent Lived Experience Expert Consultant, UK
| | - Peter McEvoy
- enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
- Discipline of Psychology, Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Thomas Ehring
- Department of Psychology, LMU Munich, Munchen, Germany
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Sicouri G, Daniel E, Salemink E, Mackinnon A, Allsop A, Hudson J. Codesigned online cognitive bias modification of interpretations for anxiety and depression in children: study protocol of a randomised controlled trial. BMJ Open 2024; 14:e078652. [PMID: 38589253 PMCID: PMC11015299 DOI: 10.1136/bmjopen-2023-078652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 03/06/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Previous research has shown that cognitive bias modification of interpretations (CBM-I) may be a promising intervention for anxiety in youth; however, results are mixed. Given the high comorbidity between anxiety and depression in youth, it is surprising that no child studies have targeted biases associated with both. This study aims to evaluate the effectiveness and acceptability of an online CBM-I intervention (Mindmaster) for children with symptom scores of anxiety or depression above a borderline or clinical threshold. The intervention has been codesigned with children, parents and mental health professionals to promote user engagement. METHODS AND ANALYSIS The study is a randomised controlled trial, with two parallel arms. Participants are 143 children aged 8-10 years with scores of anxiety and/or depressive symptoms above a borderline or clinical threshold. They will be allocated to either the intervention group or the waitlist control group. The intervention consists of 2 weeks of online CBM-I training, with four sessions (10-15 min) per week. Outcome assessments will be conducted at baseline, 4 weeks after baseline (post-training/post-waitlist) and 8 weeks after baseline (follow-up) for the intervention group only. The primary outcome is interpretation bias. Secondary outcomes are anxiety and depressive symptoms and life interference. Analyses will be conducted within an intention-to-treat framework using mixed models for repeated measures. ETHICS AND DISSEMINATION The study was approved by the University of New South Wales Human Research Ethics Committee (HC220758). Findings will be reported to (1) participating families; (2) presented at scientific conferences and (3) disseminated to peer-review publications. Data will be available from the corresponding author on request. TRIAL REGISTRATION NUMBER ACTRN12622001493730.
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Affiliation(s)
- Gemma Sicouri
- Black Dog Institute, Sydney, New South Wales, Australia
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Emily Daniel
- Black Dog Institute, Sydney, New South Wales, Australia
| | - Elske Salemink
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | | | | | - Jennifer Hudson
- Black Dog Institute, Sydney, New South Wales, Australia
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
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Sicouri G, Daniel EK, Spoelma MJ, Salemink E, McDermott EA, Hudson JL. Cognitive bias modification of interpretations for anxiety and depression in children and adolescents: A meta-analysis. JCPP ADVANCES 2024; 4:e12207. [PMID: 38486951 PMCID: PMC10933640 DOI: 10.1002/jcv2.12207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/19/2023] [Indexed: 03/17/2024] Open
Abstract
Background Evidence suggests that cognitive bias modification of interpretations (CBM-I) is effective in modifying interpretation biases and has a small effect on reducing anxiety in children and adolescents. However, most evidence to date is based on studies which report anxiety or general distress using ad-hoc Likert-type or Visual Analogue Scales, which are useful but do not reliably index symptoms of clinical importance. This meta-analysis aimed to establish the effects of CBM-I for children and adolescents on both anxiety and depression using psychometrically validated symptom measures, as well as state negative affect and negative and positive interpretation bias. Methods We identified studies through a systematic search. To be eligible for inclusion, studies needed to target interpretation biases, not combine CBM-I with another intervention, randomly allocate participants to CBM-I or a control condition, assess a mental health outcome (i.e., anxiety or depression symptoms using validated measures or state measures of negative affect) and/or interpretation bias and have a mean age less than 18 years. Results We identified 36 studies for inclusion in the meta-analysis. CBM-I had a small and non-significant unadjusted effect on anxiety symptoms (g = 0.16), no effect on depression symptoms (g = -0.03), and small and non-significant unadjusted effects on state negative affect both at post-training (g = 0.16) and following a stressor task (g = 0.23). In line with previous findings, CBM-I had moderate to large unadjusted effects on negative and positive interpretations (g = 0.78 and g = 0.52). No significant moderators were identified. Conclusions CBM-I is effective at modifying interpretation bias, however there were no effects on mental health outcomes. The substantial variability across studies and paucity of studies using validated symptom measures highlight the need to establish randomized controlled trial protocols that evaluate CBM-I in clinical youth samples to determine its future as a clinical intervention.
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Affiliation(s)
- Gemma Sicouri
- Black Dog InstituteUniversity of New South WalesSydneyNew South WalesAustralia
- School of PsychologyUniversity of New South WalesSydneyNew South WalesAustralia
| | - Emily K. Daniel
- Black Dog InstituteUniversity of New South WalesSydneyNew South WalesAustralia
| | - Michael J. Spoelma
- Black Dog InstituteUniversity of New South WalesSydneyNew South WalesAustralia
- Discipline of Psychiatry and Mental HealthSchool of Clinical MedicineFaculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Elske Salemink
- Department of Clinical PsychologyUtrecht UniversityUtrechtthe Netherlands
| | - Emma A. McDermott
- Black Dog InstituteUniversity of New South WalesSydneyNew South WalesAustralia
| | - Jennifer L. Hudson
- Black Dog InstituteUniversity of New South WalesSydneyNew South WalesAustralia
- School of PsychologyUniversity of New South WalesSydneyNew South WalesAustralia
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Rapee RM, Creswell C, Kendall PC, Pine DS, Waters AM. Anxiety disorders in children and adolescents: A summary and overview of the literature. Behav Res Ther 2023; 168:104376. [PMID: 37499294 DOI: 10.1016/j.brat.2023.104376] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.
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Affiliation(s)
- Ronald M Rapee
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia.
| | - Cathy Creswell
- Departments of Psychiatry and Experimental Psychology, University of Oxford, Oxford, UK
| | - Philip C Kendall
- Department of Psychology, Temple University, Child and Adolescent Anxiety Disorders Clinic, USA
| | - Daniel S Pine
- National Institute of Mental Health Intramural Research Program (NIMH-IRP), USA
| | - Allison M Waters
- School of Applied Psychology, Griffith University, Brisbane, Australia
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Ghosh A, Agnihotri J, Bhalotia S, Sati BK, Agarwal L, A A, Tandon S, Meena K, Raj S, Azad Y, Gupta S, Gupta N. Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study. JMIR Serious Games 2023; 11:e37105. [PMID: 37133923 DOI: 10.2196/37105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/11/2022] [Accepted: 03/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring. OBJECTIVE In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm. METHODS We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged. RESULTS We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users. CONCLUSIONS These games may help improve the effectiveness and engagement levels of computerized interventions for depression.
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Affiliation(s)
- Arka Ghosh
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Jagriti Agnihotri
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Sradha Bhalotia
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Bharat Kumar Sati
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Latika Agarwal
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Akash A
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Swastika Tandon
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Komal Meena
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Shreyash Raj
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Yatin Azad
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Silky Gupta
- Department of Cognitive Science, Indian Institute of Technology Kanpur, Kanpur, India
| | - Nitin Gupta
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
- Department of Cognitive Science, Indian Institute of Technology Kanpur, Kanpur, India
- Mehta Family Center for Engineering in Medicine, Indian Institute of Technology Kanpur, Kanpur, India
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Mavragani A, Ranganath V. An Emotional Bias Modification for Children With Attention-Deficit/Hyperactivity Disorder: Co-design Study. JMIR Form Res 2022; 6:e36390. [PMID: 36485019 PMCID: PMC9789490 DOI: 10.2196/36390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 10/23/2022] [Accepted: 11/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is one of the common neurodevelopment disorders. Children with ADHD typically have difficulties with emotional regulation. Previous studies have investigated the assessment for underlying emotional biases using the visual probe task. However, one of the significant limitations of the visual probe task is that it is demanding and repetitive over time. Previous studies have examined the use of gamification methods in addressing the limitations of the emotional bias visual probe task. There has also been increased recognition of the potential of participatory action research methods and how it could help to make the conceptualized interventions more relevant. OBJECTIVE The primary aim of this study was to collate health care professionals' perspectives on the limitations of the existing visual probe task and to determine if gamification elements were viable to be incorporated into an emotional bias modification task. METHODS A co-design workshop was conducted. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore, were invited to participate. Considering the COVID-19 pandemic and the restrictions, a web-based workshop was conducted. There were 3 main phases in the workshops. First, participants were asked to identify limitations and suggest potential methods to overcome some of the identified limitations. Second, participants were shown examples of existing gaming interventions in published literature and commercial stores. They were also asked to comment on the advantages and limitations of these interventions. Finally, participants were asked if gamification techniques would be appropriate. RESULTS Overall, 4 health care professionals consented and participated. Several limitations were identified regarding the conventional emotional bias intervention. These included the nature of the task parameters, included stimulus set, and factors that could have an impact on the accuracy of responding to the task. After examining the existing ADHD games, participants raised concerns about the evidence base of some of the apps. They articulated that any developed ADHD game ought to identify the specific skill set that was targeted clearly. Regarding gamification strategies, participants preferred economic and performance-based gamification approaches. CONCLUSIONS This study has managed to elucidate health care professionals' perspectives toward refining a conventional emotional bias intervention for children with ADHD. In view of the repetitiveness of the conventional task, the suggested gamification techniques might help in influencing task adherence and reduce the attrition rates.
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Affiliation(s)
| | - Vallabhajosyula Ranganath
- Anatomy, Office of Medical Education, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Salemink E, de Jong SRC, Notebaert L, MacLeod C, Van Bockstaele B. Gamification of cognitive bias modification for interpretations in anxiety increases training engagement and enjoyment. J Behav Ther Exp Psychiatry 2022; 76:101727. [PMID: 35217211 DOI: 10.1016/j.jbtep.2022.101727] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/29/2021] [Accepted: 02/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Interpretation bias plays a crucial role in anxiety. To test the causal role and potential clinical benefits, training procedures were developed to experimentally change interpretation bias. However, these procedures are monotonous and plain, which could negatively affect motivation and adherence. The aim of this study was to make the interpretation training more engaging and enjoyable, without compromising its effectiveness, through gamification. METHODS The training was gamified by including extrinsically and intrinsically motivating elements such as points, scores, time-pressure, fun and adaptive elements (training at an individually challenging level). A 2 (Type: Gamified vs. Standard) x 2 (Training Valence: Positive vs. Placebo) between-subjects design was used with random allocation of 79 above-average anxious individuals. Post-training, we assessed the liking and recommendation of the training task, interpretation bias (Recognition task and the Scrambled Sentence Task) and anxiety. RESULTS Participants experienced the gamified training tasks as more engaging and enjoyable than the standard tasks, although it was not recommend more to fellow-students. Both positive training conditions (gamified and standard) were successful in eliciting a positive interpretation bias when assessed with the Recognition task, while only the standard positive training impacted on interpretations when assessed with the Scrambled Sentence Task. No differential effects were observed on anxiety. LIMITATIONS The study involved only a single-session training and participants were selected for high trait (and not social) anxiety. CONCLUSIONS The gamified training was evaluated more positively by the participants, while maintaining the effectiveness of eliciting positive interpretations when assessed with the Recognition task. This suggests that gamification might be a promising new approach.
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Affiliation(s)
- Elske Salemink
- Department of Psychology, University of Amsterdam, P.O. Box 80140, 3508, TC, Utrecht, the Netherlands; Department of Clinical Psychology, Utrecht University, the Netherlands.
| | - Suzanne R C de Jong
- Department of Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1018, BT, Amsterdam, the Netherlands.
| | - Lies Notebaert
- School of Psychological Science, University of Western Australia, 35 Stirling Highway, WA 6009, Crawley, Australia.
| | - Colin MacLeod
- School of Psychological Science, University of Western Australia, 35 Stirling Highway, WA 6009, Crawley, Australia.
| | - Bram Van Bockstaele
- School of Psychological Science, University of Western Australia, 35 Stirling Highway, WA 6009, Crawley, Australia; Research Institute of Child Development and Education, University of Amsterdam, Nieuwe Achtergracht 129-B, 1018, WT, Amsterdam, the Netherlands.
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Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms. Behav Res Ther 2022; 157:104180. [PMID: 36037642 DOI: 10.1016/j.brat.2022.104180] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/29/2022] [Accepted: 08/08/2022] [Indexed: 12/15/2022]
Abstract
This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I2 = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I2 = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.
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Eilert N, Wogan R, Leen A, Richards D. Internet-Delivered Interventions for Depression and Anxiety Symptoms in Children and Young People: Systematic Review and Meta-analysis. JMIR Pediatr Parent 2022; 5:e33551. [PMID: 35551071 PMCID: PMC9136650 DOI: 10.2196/33551] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/23/2022] [Accepted: 02/07/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Mental health difficulties in children and adolescents are highly prevalent; however, only a minority receive adequate mental health care. Internet-delivered interventions offer a promising opportunity to increase access to mental health treatment. Research has demonstrated their effectiveness as a treatment for depression and anxiety in adults. This work provides an up-to-date examination of the available intervention options and their effectiveness for children and young people (CYP). OBJECTIVE In this systematic review and meta-analysis, we aimed to determine the evidence available for the effectiveness of internet-delivered interventions for treating anxiety and depression in CYP. METHODS Systematic literature searches were conducted throughout November 2020 using PubMed, PsycINFO, and EBSCO academic search complete electronic databases to find outcome trials of internet-delivered interventions treating symptoms of anxiety and/or depression in CYP by being either directly delivered to the CYP or delivered via their parents. Studies were eligible for meta-analysis if they were randomized controlled trials. Risk of bias and publication biases were evaluated, and Hedges g between group effect sizes evaluating intervention effects after treatment were calculated. Meta-analyses used random-effects models as per protocol. RESULTS A total of 23 studies met the eligibility criteria for the systematic review, of which 16 were included in the meta-analyses, including 977 participants in internet-delivered treatment conditions and 1008 participants in control conditions across 21 comparisons. Random-effects models detected a significant small effect for anxiety symptoms (across 20 comparisons; Hedges g=-0.25, 95% CI -0.38 to -0.12; P<.001) and a small but not significant effect for depression (across 13 comparisons; Hedges g=-0.27, 95% CI -0.55 to 0.01; P=.06) in favor of internet-delivered interventions compared with control groups. Regarding secondary outcomes, there was a small effect of treatment across 9 comparisons for impaired functioning (Hedges g=0.52, 95% CI 0.24-0.80; P<.001), and 5 comparisons of quality of life showed no effect (Hedges g=-0.01, 95% CI -0.23 to 0.21; P=.94). CONCLUSIONS The results show that the potential of internet-delivered interventions for young people with symptoms of anxiety or depression has not been tapped into to date. This review highlights an opportunity for the development of population-specific interventions and their research to expand our current knowledge and build an empirical base for digital interventions for CYP. TRIAL REGISTRATION PROSPERO CRD42020220171; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220171.
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Affiliation(s)
- Nora Eilert
- e-Mental Health Group, School of Psychology, University of Dublin Trinity College, Dublin, Ireland.,SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Rebecca Wogan
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Aisling Leen
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Derek Richards
- e-Mental Health Group, School of Psychology, University of Dublin Trinity College, Dublin, Ireland.,SilverCloud Science, SilverCloud Health, Dublin, Ireland
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Du JY, Hallford DJ, Grant JB. Characteristics of episodic future thinking in anxiety: A systematic review and meta-analysis. Clin Psychol Rev 2022; 95:102162. [DOI: 10.1016/j.cpr.2022.102162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 12/12/2022]
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Henricks LA, Lange WG, Luijten M, Becker ES. A New Social Picture Task to Assess Interpretation Bias related to social fears in adolescents. Res Child Adolesc Psychopathol 2022; 50:1067-1080. [PMID: 35435540 PMCID: PMC9013980 DOI: 10.1007/s10802-022-00915-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 12/02/2022]
Abstract
This pre-registered study focused on developing a new social picture task to assess interpretation bias related to social fears in adolescents. Using such a pictorial task may increase ecological validity and readily trigger emotional processes compared to more traditional verbal tasks that are often used. In the picture task, ambiguous social pictures were presented, followed by a positive and negative interpretation. In this study, we examined how the new task relates to an already existing interpretation bias task and how the new pictorial task relates to social fears in adolescents. The sample consisted of 329 adolescents aged 12 to 18 years. Interpretation bias was assessed with the newly developed pictorial task and with more traditional verbal vignettes. Social fears were measured with self-report questionnaires. The results suggest that the pictorial task was able to assess interpretation bias comparable to the verbal vignettes, suggesting appropriate convergent validity. Interpretation bias assessed with the picture task was linked to higher levels of fear of negative evaluation, the core symptom of social anxiety, but not to social anxiety symptoms in general. The verbal task was linked to both social fears and thus still seems the preferred method to investigate interpretation bias related to social fears in adolescents. However, we do believe that with further improvement of the pictorial task, it could be a useful addition to the research field.
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Sfärlea A, Lukas L, Schulte-Körne G, Platt B. The KOALA-study: study protocol for a comprehensive study of cognitive biases in adolescent anorexia nervosa patients compared to healthy and clinical controls. J Eat Disord 2021; 9:139. [PMID: 34715933 PMCID: PMC8555351 DOI: 10.1186/s40337-021-00494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/08/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Anorexia nervosa (AN) is characterized by dysfunctional cognitions including cognitive biases at various levels of information processing. However, less is known about the specificity of these biases, i.e., if they occur for eating-disorder-related information alone or also for non-eating-disorder-related emotional information in AN patients (content-specificity) and if they are unique to individuals with AN or are also shown by individuals with other mental disorders (disorder-specificity). METHODS The present study systematically assesses cognitive biases in 12-18-year-old female adolescents with AN on three levels of information processing (attention, interpretation, and memory) and with regard to two types of information content (eating-disorder-related, i.e., stimuli related to body weight and shape, and non-eating-disorder-related). To address not only content- but also disorder-specificity, adolescents with AN will be compared not only to a healthy control group but also to a clinical control group (adolescents with major depression or particular anxiety disorders). Cognitive biases are assessed within a single experimental paradigm based on the Scrambled Sentences Task. During the task eye movements are recorded in order to assess attention biases while interpretation biases are derived from the behavioural outcome. An incidental free recall test afterwards assesses memory biases. We expect adolescents with AN to show more pronounced negative cognitive biases on all three levels of information processing and for both types of content compared to healthy adolescents. In addition, we expect the specificity of biases to translate into differential results for the two types of content: AN patients are expected to show stronger biases for disorder-related stimuli but similar or less pronounced biases for non-disorder-related stimuli compared to the clinical control group. DISCUSSION This is the first study to comprehensively assess cognitive biases in adolescents with AN. It will have essential implications not only for cognitive-behavioural models of AN but also for subsequent studies aiming to modify cognitive biases in this population, thereby addressing important maintaining factors already at an early stage of the disorder.
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Affiliation(s)
- Anca Sfärlea
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Ludwig-Maximilians-University Munich, Pettenkoferstr. 8a, 80336, Munich, Germany.
| | - Linda Lukas
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Ludwig-Maximilians-University Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Ludwig-Maximilians-University Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Belinda Platt
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Ludwig-Maximilians-University Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
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Pile V, Williamson G, Saunders A, Holmes EA, Lau JYF. Harnessing emotional mental imagery to reduce anxiety and depression in young people: an integrative review of progress and promise. Lancet Psychiatry 2021; 8:836-852. [PMID: 34419188 DOI: 10.1016/s2215-0366(21)00195-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/23/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022]
Abstract
Emotional mental imagery is a powerful part of our mental landscape. Given its capacity to depict, process, and generate emotional events, mental imagery could have an important role in psychological therapies. This Series paper explores whether harnessing emotional mental imagery is meaningful to young people; ways in which interventions use emotional mental imagery; contextual and individual factors influencing intervention effectiveness; and mechanisms underpinning imagery techniques. We completed a systematic review of imagery interventions and consulted young people with lived experience (n=10) and leading international experts (n=7). The systematic search identified 86 papers covering a diverse range of imagery interventions. Across the seven categories of techniques reviewed, imagery rescripting for aversive memories, techniques targeting positive imagery, and imagery-enhanced protocols indicated the most potential. The report suggests that harnessing emotional mental imagery in psychological interventions could be a promising approach to reduce anxiety and depression and that mental health science could inform the development of new interventions and help to maximise intervention effectiveness.
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Affiliation(s)
- Victoria Pile
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Psychology, Royal Holloway, University of London, Egham, UK.
| | - Grace Williamson
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Aleks Saunders
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emily A Holmes
- Department of Psychology, Uppsala University, Uppsala, Sweden; Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jennifer Y F Lau
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Díaz-García A, Franke M, Herrero R, Ebert DD, Botella C. Theoretical adequacy, methodological quality and efficacy of online interventions targeting resilience: a systematic review and meta-analysis. Eur J Public Health 2021; 31:i11-i18. [PMID: 34240159 PMCID: PMC8266533 DOI: 10.1093/eurpub/ckaa255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is a growing interest in the promotion of mental health, and concepts as resilience are re-emerging and taking relevance. In addition, Information and Communication Technologies can provide potential benefits in the field of mental health, and the treatment of mental disorders in particular. This study aims to synthesize the evidence of internet-based resilience interventions, analyzing the theoretical adequacy, methodological quality and efficacy. METHODS A systematic search was performed. The eligibility criteria stated for this article were: randomized controlled trials targeted at adults or adolescents and including any psychological intervention focussing on resilience in its rationale or design. Studies with direct (e.g. resilience scales) and proximal resilience measures (e.g. scales on well-being) were included. Risk of bias was assessed for each trial using Cochrane's Collaboration Tool. Two reviewers worked independently in order to identify potential articles. A total of 11 articles were selected. A random-effects pooling model using the Hartung-Knapp-Sidik-Jonkman method based on direct and proximal resilience measures at post-test was used. RESULTS The overall effects of online resilience training compared to control groups at post-test were not significant; the effect size concerning the improvement of resilience was g=0.12 (95% CI: -0.14 to 0.38). In addition, a potential association between the type of outcome and the effect size could be revealed. CONCLUSIONS The results of the present meta-analysis showed that the overall effect of online resilience trainings was not significant. Nonetheless, a tendency for a higher benefit for resilience was found in the studies with a clear assessment theory, indicating some promising effects. REGISTRATION NUMBER PROSPERO CRD42018083339.
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Affiliation(s)
- Amanda Díaz-García
- Department of Psychology and Sociology, Universidad de Zaragoza (Campus de Teruel), Teruel
| | - Marvin Franke
- Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen Nuremberg, Erlangen, Germany
| | - Rocio Herrero
- CIBER Pathophysiology of Obesity and Nutrition (CB06/03), Carlos III Institute of Health, Madrid, Spain
- Department of Personality, Evaluation and Psychological Treatments, Universidad de Valencia, Valencia, Spain
| | - David Daniel Ebert
- Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen Nuremberg, Erlangen, Germany
| | - Cristina Botella
- CIBER Pathophysiology of Obesity and Nutrition (CB06/03), Carlos III Institute of Health, Madrid, Spain
- Universitat Jaume I, Castellón, Spain
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O'Connor CE, Everaert J, Fitzgerald A. Interpreting ambiguous emotional information: Convergence among interpretation bias measures and unique relations with depression severity. J Clin Psychol 2021; 77:2529-2544. [PMID: 34101175 DOI: 10.1002/jclp.23186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/07/2021] [Accepted: 05/08/2021] [Indexed: 12/30/2022]
Abstract
This study aimed to examine the convergence among interpretation bias measures and their associations with depressive symptom severity. Research into interpretation biases employs measures of interpretation bias interchangeably, however, little is known about the relationship between these measures. Participants (N = 82 unselected undergraduate students; 59 female) completed four computer-based interpretation bias tasks in a cross-sectional design study. Indirect measures, based on participants' reaction times, were not correlated with each other and had poor split-half reliability. Direct measures were more strongly correlated with depressive symptoms than indirect measures, but only the Scrambled Sentences Task explained a reliable unique portion of the variance in depressive symptoms. Interpretation bias tasks may not measure the same cognitive process and may differ in the extent to which they are a cognitive marker of depression-linked interpretation bias. These findings help to improve the measurement of and theory underlying interpretation bias and depressive symptoms.
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Affiliation(s)
| | - Jonas Everaert
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
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Ji JL, Baee S, Zhang D, Calicho-Mamani CP, Meyer MJ, Funk D, Portnow S, Barnes L, Teachman BA. Multi-session online interpretation bias training for anxiety in a community sample. Behav Res Ther 2021; 142:103864. [PMID: 33966880 DOI: 10.1016/j.brat.2021.103864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 03/23/2021] [Accepted: 04/06/2021] [Indexed: 11/25/2022]
Abstract
The present study assessed target engagement, preliminary efficacy, and feasibility as primary outcomes of a free multi-session online cognitive bias modification of interpretation (CBM-I) intervention for anxiety in a large community sample. High trait anxious participants (N = 807) were randomly assigned to a CBM-I condition: 1) Positive training (90% positive-10% negative); 2) 50% positive-50% negative training; or 3) no-training control. Further, half of each CBM-I condition was randomized to either an anxious imagery prime or a neutral imagery prime. Due to attrition, results from six out of eight sessions were analyzed using structural equation modeling of latent growth curves. Results for the intent-to-treat sample indicate that for target engagement, consistent with predictions, decreases in negative interpretations over time were significantly greater among those receiving positive CBM-I training compared to no-training or 50-50 training, and vice-versa for increases in positive interpretations. For intervention efficacy, the decrease in anxiety symptoms over time was significantly greater among those receiving positive CBM-I training compared to no-training. Interaction effects with imagery prime were more variable with a general pattern of stronger results for those completing the anxious imagery prime. Findings indicate that online CBM-I positive training is feasible and shows some promising results, although attrition rates were very high for later training sessions.
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Affiliation(s)
- Julie L Ji
- School of Psychological Science, University of Western Australia, Australia; Department of Psychology, University of Virginia, Virginia, United States.
| | - Sonia Baee
- School of Engineering, University of Virginia, Virginia, United States
| | - Diheng Zhang
- Department of Psychology, University of Virginia, Virginia, United States; Department of Psychology, University of Arizona, United States
| | | | - M Joseph Meyer
- Department of Psychology, University of Virginia, Virginia, United States
| | | | - Samuel Portnow
- Department of Psychology, University of Virginia, Virginia, United States
| | - Laura Barnes
- School of Engineering, University of Virginia, Virginia, United States
| | - Bethany A Teachman
- Department of Psychology, University of Virginia, Virginia, United States
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Emerging Domain-Based Treatments for Pediatric Anxiety Disorders. Biol Psychiatry 2021; 89:716-725. [PMID: 33451677 DOI: 10.1016/j.biopsych.2020.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 12/25/2022]
Abstract
Domain-specific cognitive training treatments for pediatric anxiety disorders rely on accurate and reliable identification of specific underlying deficits and biases in neurocognitive functions. Once identified, such biases can serve as specific targets for therapeutic intervention. Clinical translations typically reflect mechanized training protocols designed to rectify the identified biases. Here, we review and synthesize research on key neurocognitive processes that emerge as potential targets for specialized cognitive training interventions in pediatric anxiety disorders in the domains of attention, interpretation, error monitoring, working memory, and fear learning. For each domain, we describe the current status of target establishment (i.e., an association between pediatric anxiety and a specific neurocognitive process), and then review extant translational efforts regarding these targets and the evidence supporting their clinical utility in youths. We then localize each of the domains within the path leading to efficacious, evidence-supported treatments for pediatric anxiety, providing a roadmap for future research. The review indicates that specific cognitive targets in pediatric anxiety have been established in all the reviewed domains except for fear learning, where a clear target is yet to be elucidated. In contrast, evidence for clinical efficacy emerged only in the threat-related attention domain, with some preliminary findings in the domains of interpretation and working memory. The path to clinical translation in the domain of error monitoring is yet unclear. Implications and potential avenues for future research and translation are discussed.
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Mental Imagery and its Relevance for Psychopathology and Psychological Treatment in Children and Adolescents: a Systematic Review. Int J Cogn Ther 2020. [DOI: 10.1007/s41811-020-00092-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AbstractThis review provides an overview of the current state of research concerning the role of mental imagery (MI) in mental disorders and evaluates treatment methods for changing MI in childhood. A systematic literature search using PubMed/Medline, Web of Science, and PsycINFO from 1872 to September 2020 was conducted. Fourteen studies were identified investigating MI, and fourteen studies were included referring to interventions for changing MI. Data from the included studies was entered into a data extraction sheet. The methodological quality was then evaluated. MI in childhood is vivid, frequent, and has a significant influence on cognitions and behavior in posttraumatic stress disorder (PTSD), social anxiety disorder (SAD), and depression. The imagery’s perspective might mediate the effect of MI on the intensity of anxiety. Imagery rescripting, emotive imagery, imagery rehearsal therapy, and rational-emotive therapy with imagery were found to have significant effects on symptoms of anxiety disorders and nightmares. In childhood, MI seems to contribute to the maintenance of SAD, PTSD, and depression. If adapted to the developmental stages of children, interventions targeting MI are effective in the treatment of mental disorders.
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Sfärlea A, Buhl C, Loechner J, Neumüller J, Asperud Thomsen L, Starman K, Salemink E, Schulte-Körne G, Platt B. "I Am a Total…Loser" - The Role of Interpretation Biases in Youth Depression. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2020; 48:1337-1350. [PMID: 32654075 PMCID: PMC7445197 DOI: 10.1007/s10802-020-00670-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Negative interpretation biases have been found to characterize adults with depression and to be involved in the development and maintenance of the disorder. However, less is known about their role in youth depression. The present study investigated i) whether negative interpretation biases characterize children and adolescents with depression and ii) to what extent these biases are more pronounced in currently depressed youth compared to youth at risk for depression (as some negative interpretation biases have been found already in high-risk youth before disorder onset). After a negative mood induction interpretation biases were assessed with two experimental tasks: Ambiguous Scenarios Task (AST) and Scrambled Sentences Task (SST) in three groups of 9-14-year-olds: children and adolescents with a diagnosis of major depression (n = 32), children and adolescents with a high risk for depression (children of depressed parents; n = 48), as well as low-risk children and adolescents (n = 42). Depressed youth exhibited substantially more negative interpretation biases than both high-risk and low-risk groups (as assessed with both tasks), while the high-risk group showed more negative interpretation biases than the low-risk group only as assessed via the SST. The results indicate that the negative interpretation biases that are to some extent already present in high-risk populations before disorder onset are strongly amplified in currently depressed youth. The different findings for the two tasks suggest that more implicit interpretation biases (assessed with the SST) might represent cognitive vulnerabilities for depression whereas more explicit interpretation biases (assessed with the AST) may arise as a consequence of depressive symptomatology.
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Affiliation(s)
- Anca Sfärlea
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Christina Buhl
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Johanna Loechner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
- Department of Clinical Psychology and Psychotherapy, LMU Munich, Munich, Germany
| | - Jakob Neumüller
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Laura Asperud Thomsen
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Kornelija Starman
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Elske Salemink
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
| | - Belinda Platt
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, 80336 Munich, Germany
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21
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Ji JL, Meyer MJ, Teachman BA. Facilitating Episodic Simulation in Anxiety: Role of Sensory Scaffolding and Scenario Modality. Int J Cogn Ther 2020. [DOI: 10.1007/s41811-020-00070-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AbstractCognitive bias modification of interpretation style (CBM-I) is a family of cognitive training programs that seek to reduce anxious thinking by training people to assign relatively more positive meanings to ambiguous situations. CBM-I’s effects may be enhanced by encouraging more vivid imagery-based episodic simulation of events and by increasing engagement with the training materials. This study investigated the role of sensory scaffolding (whether pictures, or pictures + sound were added) and verbal scenario modality (whether scenarios were delivered visually or aurally) on episodic simulation (Vivid; Plausible; Changing Perspective ratings) and user engagement (Relatable, Comprehensible, Enjoyable ratings). Amazon Mechanical Turk workers (N = 187) with varied anxiety symptom severity read or listened to brief scenarios that varied by sensory scaffolding and verbal scenario modality. Results were somewhat mixed. Generally, picture scaffolding tended to facilitate both episodic simulation and user engagement (relative to no scaffolding), irrespective of scenario modality and anxiety level.
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Schmidt NB, Vereenooghe L. Inclusiveness of cognitive bias modification research toward children and young people with neurodevelopmental disorders: A systematic review. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2020; 68:86-101. [PMID: 35309701 PMCID: PMC8928859 DOI: 10.1080/20473869.2020.1720156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 06/14/2023]
Abstract
Cognitive bias modification (CBM) is increasingly used to target cognitive biases related to internalising or externalising problems, which are common in neurodevelopmental disorders (NDD). This systematic review assesses the available evidence for using CBM in children and young people with NDD, in particular regarding ambiguous interpersonal information, and the extent of their exclusion from this type of intervention research. PsycINFO, PsycARTICLES, MEDLINE, Cochrane Central Register of Controlled Trials and Science Citation Index were consulted using MeSH terms and synonyms of "neurodevelopmental disorders", "mental health problems", "cognitive bias", "modification" and "review". Data extraction focused on the efficacy of CBM for NDD, how CBM was delivered, whether studies adopted exclusion criteria relating to NDD and the rationale for such criteria. The search identified 2270 records, of which twenty-nine studies assessed CBM for interpretations and were included in the qualitative synthesis. Three studies targeted bias in NDD, whereas a third of studies explicitly excluded participants based on NDD-related criteria: most frequently intellectual impairment, reading or learning difficulties and autism spectrum disorder (ASD). Only one study provided a rationale for excluding NDD which related to the reading demands of their intervention. There is tentative evidence for the feasibility of using CBM to reduce interpretation bias in children and young people with mild intellectual disability, ASD or attention-deficit/hyperactivity disorder (ADHD). We recommend that CBM research should consider including participants with NDD, use CBM tasks and adaptations that enable this group's inclusion, or provide a sufficient rationale for their exclusion.
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Affiliation(s)
- Nora B. Schmidt
- Faculty of Psychology and Sports Science, Bielefeld University, Bielefeld, Germany
| | - Leen Vereenooghe
- Faculty of Psychology and Sports Science, Bielefeld University, Bielefeld, Germany
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Zhang M, Ying J, Song G, Fung DSS, Smith H. Web-Based Cognitive Bias Modification Interventions for Psychiatric Disorders: Scoping Review. JMIR Ment Health 2019; 6:e11841. [PMID: 31651410 PMCID: PMC6915808 DOI: 10.2196/11841] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 06/06/2019] [Accepted: 08/26/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cognitive biases refer to automatic attentional or interpretational tendencies, which result in individuals with addictive disorders to automatically attend to substance-related stimuli and those with anxiety disorders to attend to threatening stimuli. To date, several studies have examined the efficacy of cognitive bias modification, and meta-analytical studies have synthesized the evidence for overall efficacy. The clinical utility of cognitive bias modification interventions has previously been limited to the confines of a laboratory, but recent advances in Web technologies can change this. OBJECTIVE This scoping review aimed to determine the scope of Web-based cognitive bias interventions and highlight their effectiveness. METHODS Databases (PubMed and MEDLINE, EMBASE, PsycINFO, ScienceDirect, and Cochrane Central) were searched from inception to December 5, 2017. The following search terminologies were used: ("attention bias" OR "cognitive bias" OR "approach bias" OR "avoidance bias" OR "interpretative bias") AND ("Internet" OR "Web" OR "Online"). The methods for this scoping review are based on the previously published protocol. For the synthesis of the evidence, a narrative synthesis was undertaken, as a meta-analysis was not appropriate, given the lack of reported effect sizes and the heterogeneity in the outcomes reported. RESULTS Of the 2674 unique articles identified, we identified 22 randomized controlled studies that met our inclusion criteria: alcohol use disorder (n=2), tobacco use disorder (n=2), depressive disorder (n=3), anxiety and depressive symptoms in adolescents (n=3), obsessive-compulsive disorder (OCD; n=2), social anxiety disorder (n=9), and anxiety disorder (n=1). The sample sizes of these studies ranged from 16 to 434 participants. There is preliminary evidence to suggest that Web-based interventions could reduce biases among adolescents with heightened symptoms of anxiety and depression and among individuals with OCD. CONCLUSIONS This is the first scoping review that mapped out the scope of cognitive bias modification interventions for psychiatric disorders. Web-based interventions have been applied predominantly for social anxiety and addictive disorders. Larger cohorts must be used in future studies to better determine the effectiveness of Web-based cognitive bias interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/10427.
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Affiliation(s)
- Melvyn Zhang
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Jiangbo Ying
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Guo Song
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Daniel S S Fung
- Department of Developmental Psychiatry, Institute of Mental Health, Singapore, Singapore
| | - Helen Smith
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Post-Craniopharyngioma and Cranial Nerve-VI Palsy Update on a MS Patient with Major Depression and Concurrent Neuroimmune Conditions. Brain Sci 2019; 9:brainsci9100281. [PMID: 31627490 PMCID: PMC6826476 DOI: 10.3390/brainsci9100281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/06/2019] [Accepted: 10/11/2019] [Indexed: 11/16/2022] Open
Abstract
We report the case of a male multiple sclerosis (MS) patient with type 2 diabetes (T2D), asthma, major depression (MD or major depressive disorder, MDD), and other chronic conditions, after his recent difficulties with craniopharyngioma and cranial nerve-VI (CN6) palsy. In addition, we show magnetic resonance image and spectroscopy (MRI, MRS), Humphrey's Visual Field (HVF), and retinal nerve fiber layer thickness (RNFLT) findings to explain the changes in the patient's health, and discuss the methods that helped/help him sustain productivity and euthymia despite long-standing problems and new CNS changes.
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Zhang M, Ying J, Song G, Fung DS, Smith H. Gamified Cognitive Bias Modification Interventions for Psychiatric Disorders: Review. JMIR Ment Health 2018; 5:e11640. [PMID: 30361194 PMCID: PMC6229516 DOI: 10.2196/11640] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/28/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Automatic biases, such as attentional biases and avoidance and interpretative biases, have been purported to be responsible for several psychiatric disorders. Gamification has been considered for cognitive bias modification, mainly to address the core issues of diminishing motivation to train over time, as bias modification intervention tasks tend to be highly repetitive. While a prior review has suggested how gamification strategies could be applied to such tasks, there remains a lack of systematic evaluation of gamified cognitive bias modification interventions in the literature. OBJECTIVE The objective of this review is to understand the overall effectiveness of a gamified approach for cognitive bias modification and inform future research that seeks to integrate gamification technologies into existing conventional bias modification interventions. METHODS To identify the relevant articles for our review, the following search terminologies were used: ("cognitive bias" OR "attention bias" OR "interpret* bias" OR "approach bias" OR "avoidance bias") AND ("training" OR "modification" OR "practice" OR "therapy") AND ("gamification" OR "game elements" OR "game" OR "gaming" OR "game mechanics"). PubMed, MEDLINE, PsycINFO, and Scopus databases were searched systematically for articles published after 2000. Articles were included if they described a gamified cognitive bias modification task and included participants with underlying psychopathological symptoms. Data were systematically extracted from the identified articles, and a qualitative synthesis was performed. RESULTS Four studies evaluated gamified cognitive bias modification interventions. Two studies included participants with anxiety symptoms, one with affective symptoms, and one with alcohol problems. The conventional visual probe task paradigm was used in 3 studies, and the attentional visual search task paradigm was used in the last study. We found gaming elements incorporated to include that of animations, sounds, feedback, and a point-scoring system for response time and difficulty. Of the 4 identified studies, only 2 reported their gamified interventions to be effective. CONCLUSIONS Our review is the first to systematically synthesize the evidence for gamified cognitive bias modification interventions. The results arising from our review should be considered in the future design and conceptualization of gamified cognitive bias modification interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/10154.
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Affiliation(s)
- Melvyn Zhang
- National Addiction Management Service, Institute of Mental Health, Singapore, Singapore
| | - Jiangbo Ying
- National Addiction Management Service, Institute of Mental Health, Singapore, Singapore
| | - Guo Song
- National Addiction Management Service, Institute of Mental Health, Singapore, Singapore
| | - Daniel Ss Fung
- Department of Developmental Psychiatry, Institute of Mental Health, Singapore, Singapore
| | - Helen Smith
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Zhang M, Ying J, Ho RC. Gamified Cognitive Bias Interventions for Psychiatric Disorders: Protocol of a Systematic Review. JMIR Res Protoc 2018; 7:e10154. [PMID: 30327292 PMCID: PMC6231833 DOI: 10.2196/10154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/23/2018] [Accepted: 07/31/2018] [Indexed: 12/31/2022] Open
Abstract
Background Cognitive bias modification has been increasingly studied in the past decade with reviews reporting the effectiveness of bias modification. Advances in electronic health and mobile health technologies have transformed how conventional cognitive bias modification is delivered. To date, gamification technologies and serious games have been widely evaluated in health care, and prior studies have reported the use of gamification for cognitive bias modification. However, no prior research, to date, has systematically evaluated the literature for gamified cognitive bias modification interventions. Objective The proposed systematic review aims to review how gamification has been applied to cognitive bias modification interventions. Methods A systematic review will be conducted. A search will be conducted on the respective databases till 2018. Selection of the studies will be determined by the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality assessment of the included studies will be assessed using the Cochrane Risk of Bias Tool. In addition, a narrative synthesis will be conducted. Results We expect that the review will be completed 12 months from the publication of this protocol. Conclusions The findings that arise from this review will be crucial as they will inform future research that seeks to integrate gamification technologies into existing conventional bias modification interventions. Registered Report Identifier RR1-10.2196/10154
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Affiliation(s)
- Melvyn Zhang
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Jiangbo Ying
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Roger Cm Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Zhang M, Ying J, Song G, Fung DS, Smith H. Web-Based Cognitive Bias Intervention for Psychiatric Disorders: Protocol for a Systematic Review. JMIR Res Protoc 2018; 7:e10427. [PMID: 30087091 PMCID: PMC6104442 DOI: 10.2196/10427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/12/2018] [Accepted: 06/20/2018] [Indexed: 01/29/2023] Open
Abstract
Background Traditional psychological therapies focus mainly on modification of individuals’ conscious decision-making process. Unconscious processes, such as cognitive biases, have been found accountable for various psychiatric psychopathologies, and advances in technologies have transformed how bias modification programs are being delivered. Objective The primary aim of this review is to synthesize evidence of Web-based cognitive bias modification intervention for bias reduction. The secondary aim is to determine the change in symptoms for individual psychiatric disorders following bias modification. Methods A systematic review will be conducted including only randomized trials. There will be no restrictions on participants included in the study. A search will be conducted on the respective databases until 2017. Selection of studies will be by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA-P) guidelines. Quality assessment of included studies will be conducted using the Cochrane Risk of Bias tool. A narrative synthesis of identified articles will then be conducted. A meta-analysis will be considered only if there are sufficient articles in a domain for statistical analysis. Ethical approval for this protocol and the planned systematic review was not required. Results We expect that the review will be completed 12 months from publication of this protocol. Conclusions This review is of importance given how technology has transformed delivery of conventional therapies. Findings from this review will guide future research involving technology and cognitive bias modification interventions. Trial Registration International Prospective Register for Systematic Reviews (PROSPERO): 2017 CRD42017074754; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=74754 (Archived by WebCite at http://www.webcitation.org/ 71AvSgZGn) Registered Report Identifier RR1-10.2196/10427
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Affiliation(s)
- Melvyn Zhang
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Jiangbo Ying
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Guo Song
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Daniel Ss Fung
- Department of Developmental Psychiatry, Institute of Mental Health, Singapore, Singapore
| | - Helen Smith
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Zhang M, Ying J, Song G, Fung DS, Smith H. Attention and Cognitive Bias Modification Apps: Review of the Literature and of Commercially Available Apps. JMIR Mhealth Uhealth 2018; 6:e10034. [PMID: 29793899 PMCID: PMC5992457 DOI: 10.2196/10034] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/19/2018] [Accepted: 05/10/2018] [Indexed: 01/12/2023] Open
Abstract
Background Automatic processes, such as attentional biases or interpretative biases, have been purported to be responsible for several psychiatric disorders. Recent reviews have highlighted that cognitive biases may be modifiable. Advances in eHealth and mHealth have been harnessed for the delivery of cognitive bias modification. While several studies have evaluated mHealth-based bias modification intervention, no review, to our knowledge, has synthesized the evidence for it. In addition, no review has looked at commercial apps and their functionalities and methods of bias modification. A review is essential in determining whether scientifically validated apps are available commercially and the proportion of commercial apps that have been evaluated scientifically. Objective The objective of this review was primarily to determine the proportion of attention or cognitive bias modification apps that have been evaluated scientifically and secondarily to determine whether the scientifically evaluated apps were commercially available. We also sought to identify commercially available bias modification apps and determine the functionalities of these apps, the methods used for attention or cognitive bias modification, and whether these apps had been evaluated scientifically. Methods To identify apps in the published literature, we searched PubMed, MEDLINE, PsycINFO, and Scopus for studies published from 2000 to April 17, 2018. The search terms used were “attention bias” OR “cognitive bias” AND “smartphone” OR “smartphone application” OR “smartphone app” OR “mobile phones” OR “mobile application” OR mobile app” OR “personal digital assistant.” To identify commercial apps, we conducted a manual cross-sectional search between September 15 and 25, 2017 in the Apple iTunes and Google Play app stores. The search terms used to identify the apps were “attention bias” and “cognitive bias.” We also conducted a manual search on the apps with published evaluations. Results The effectiveness of bias modification was reported in 7 of 8 trials that we identified in the published literature. Only 1 of the 8 previously evaluated apps was commercially available. The 17 commercial apps we identified tended to use either an attention visual search or gamified task. Only 1 commercial app had been evaluated in the published literature. Conclusions This is perhaps the first review to synthesize the evidence for published mHealth attention bias apps. Our review demonstrated that evidence for mHealth attention bias apps is inconclusive, and quite a few commercial apps have not been validated scientifically.
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Affiliation(s)
- Melvyn Zhang
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - JiangBo Ying
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Guo Song
- National Addictions Management Service, Institute of Mental Health, Singapore, Singapore
| | - Daniel Ss Fung
- Medical Board / Department of Development Psychiatry, Institute of Mental Health, Singapore, Singapore
| | - Helen Smith
- Department of Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Lisk SC, Pile V, Haller SPW, Kumari V, Lau JYF. Multisession Cognitive Bias Modification Targeting Multiple Biases in Adolescents with Elevated Social Anxiety. COGNITIVE THERAPY AND RESEARCH 2018; 42:581-597. [PMID: 30237649 PMCID: PMC6133013 DOI: 10.1007/s10608-018-9912-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Research studies applying cognitive bias modification of attention (CBM-A) and interpretations (CBM-I) training to reduce adolescent anxiety by targeting associated cognitive biases have found mixed results. This study presents a new multi-session, combined bias CBM package, which uses a mix of training techniques and stimuli to enhance user-engagement. We present preliminary data on its viability, acceptability and effectiveness on reducing symptoms and biases using an A–B case series design. 19 adolescents with elevated social anxiety reported on their social anxiety, real-life social behaviours, general anxiety, depression, and cognitive biases at pre/post time-points during a 2-week baseline phase and a 2-week intervention phase. Retention rate was high. Adolescents also reported finding the CBM training helpful, particularly CBM-I. Greater reductions in social anxiety, negative social behaviour, and general anxiety and depression, characterised the intervention but not baseline phase. There was a significant correlation between interpretation bias change and social anxiety symptom change. Our enhanced multi-session CBM programme delivered in a school-setting appeared viable and acceptable. Training-associated improvements in social anxiety will require further verification in a study with an active control condition/group.
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Affiliation(s)
- Stephen C Lisk
- 1Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF UK
| | - Victoria Pile
- 1Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF UK
| | - Simone P W Haller
- 2Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Veena Kumari
- 3Centre for Cognitive Neuroscience, College of Health and Life Sciences, Brunel University London, London, UK
| | - Jennifer Y F Lau
- 1Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF UK
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Vrijsen JN, Dainer-Best J, Witcraft SM, Papini S, Hertel P, Beevers CG, Becker ES, Smits JAJ. Effect of cognitive bias modification-memory on depressive symptoms and autobiographical memory bias: two independent studies in high-ruminating and dysphoric samples. Cogn Emot 2018. [DOI: 10.1080/02699931.2018.1450225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Janna N. Vrijsen
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Pro Persona Mental Health Care, Depression Expertise Center, Nijmegen, The Netherlands
| | - Justin Dainer-Best
- Department of Psychology & Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Sara M. Witcraft
- Department of Psychology & Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Santiago Papini
- Department of Psychology & Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Paula Hertel
- Department of Psychology, Trinity University, San Antonio, TX, USA
| | - Christopher G. Beevers
- Department of Psychology & Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Eni S. Becker
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Jasper A. J. Smits
- Department of Psychology & Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
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