Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial

BACKGROUND

Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative.

OBJECTIVE

This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program's impact on secondary psychosocial outcomes and explore potential change mechanisms.

METHODS

Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences.

RESULTS

Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=-0.68, 95% CI -1.00 to -0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size.

CONCLUSIONS

Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/44210.

The ethical imperative to honor autistic clients' autonomy in mental health treatment

Autistic adolescents and adults commonly experience mental health concerns; however, mental health clinicians may hold implicit stigmatizing views of autism that contribute to case conceptualization and treatment goal setting that align more with caregivers' than clients' goals. This impingement on client autonomy is concerning, problematic, and potentially harmful for autistic clients who are of an age to set their own treatment agenda regardless of co-occurring intellectual disability and/or language delays. An application of the shared decision-making framework, an evidence-based tool for promoting client autonomy, can help to avoid these challenges in treatment. In this perspective, we use a case vignette as an anchor for discussing the imperative of honoring autistic clients' autonomy in mental health treatment and guiding shared decision-making to reduce stigma, promote autonomy, and increase collaborative care for autistic clients in mental health treatment.

Autonomy and loneliness - longitudinal within- and between-person associations among Swedish older adults

OBJECTIVES

Loneliness is an important risk factor for mental and physical health over the life span. Little is known about psychosocial predictors and consequences of loneliness apart from social network characteristics. One important factor that may both prevent from, but also be affected by loneliness, is perceived autonomy.

METHOD

In the present study, we investigated the longitudinal association of loneliness and autonomy over four years among participants of the Swedish Health, Aging and Retirement Transitions in Sweden (HEARTS) study (n = 5718, age 60-66 at baseline). We used a latent curve model with structured residuals, which distinguishes within- and between-person associations and includes cross-lagged parameters.

RESULTS

Higher levels of autonomy at baseline were associated with lower levels of loneliness, and increases in autonomy were associated with decreases in loneliness. When individuals felt more autonomous than usual, they also reported less loneliness. However, the cross-lagged paths were not significant, which means that autonomy did not predict loneliness over time on the within-person level, and loneliness did not predict autonomy over time.

CONCLUSION

Our findings show that higher autonomy was related to lower loneliness on different analytical levels, but the direction of effects is unclear. More research is needed to understand the development of this association over the life span.

Investigating the impact of eating norms and collective autonomy support vs. collective control on unhealthy eating and its internalization

Our eating behaviors are highly influenced by those of individuals surrounding us and the groups we belong to. The first goal of this experiment was to determine how social norms that encourage (pro-) vs. discourage (anti-) unhealthy eating influence people’s intentions and motivations to eat unhealthily. Since these norms can be conveyed by one’s group in a manner that either promotes group members’ autonomy (i.e., collective autonomy support), or pressures them into eating certain foods (i.e., collective control), the experiment also tests which of these types of messages promotes the highest conformity to group norms. Hence, the second goal of this experiment was to investigate this synergetic effect of pro- vs anti-unhealthy eating norms and of collective autonomy support vs. collective control on participants’ unhealthy eating intentions and their motivations for unhealthy eating. An experimental study (N = 341) using a 2 (eating norm: pro-unhealthy eating norm vs. anti-unhealthy eating norm) x 3 (type of group support: collective autonomy support vs. collective control vs. no support) design was conducted. Results showed that pro-unhealthy eating norms increased participants’ intentions to eat salty and fatty food, but also their amotivation (i.e., lack of motivation) for unhealthy eating relative to anti-unhealthy eating norms. In addition, when pro-unhealthy eating was encouraged in a controlling (vs. in an autonomy supportive) manner, participants reported higher intentions to eat tofu tacos. Finally, when pro-unhealthy eating was promoted by supporting group members’ autonomy, participants reported higher integrated regulation, i.e., a highly internalized motivation, for unhealthy eating. These results demonstrate that eating norms do not impact all types of unhealthy food consumption in the same manner, and that collective control may be motivating in uncertain contexts; furthermore, when individuals’ autonomy is supported and promoted by other group members, they are more susceptible to integrate unhealthy eating in their life.

Basic psychological need satisfaction and frustration in major depressive disorder

Basic psychological needs theory postulates that a social environment that satisfies individuals' three basic psychological needs of autonomy, competence, and relatedness leads to optimal growth and well-being. On the other hand, the frustration of these needs is associated with ill-being and depressive symptoms foremost investigated in non-clinical samples; yet, there is a paucity of research on need frustration in clinical samples. Survey data were compared between adult individuals with major depressive disorder (MDD; n = 115; 48.69% female; 38.46 years, SD = 10.46) with those of a non-depressed comparison sample (n = 201; 53.23% female; 30.16 years, SD = 12.81). Need profiles were examined with a linear mixed model (LMM). Individuals with depression reported higher levels of frustration and lower levels of satisfaction in relation to the three basic psychological needs when compared to non-depressed adults. The difference between depressed and non-depressed groups was significantly larger for frustration than satisfaction regarding the needs for relatedness and competence. LMM correlation parameters confirmed the expected positive correlation between the three needs. This is the first study showing substantial differences in need-based experiences between depressed and non-depressed adults. The results confirm basic assumptions of the self-determination theory and have preliminary implications in tailoring therapy for depression.

Family group decision-making for children at risk of abuse or neglect: A systematic review

Background

Capturing the scale of child maltreatment is difficult, but few would argue that it is anything less than a global problem which can affect victims' health and well-being throughout their life. Systems of detection, investigation and intervention for maltreated children are the subject of continued review and debate.

Objectives

To assess the effectiveness of the formal use of family group decision-making (FGDM) in terms of child safety, permanence (of child's living situation), child and family well-being, and client satisfaction with the decision-making process.

Search Methods

Both published and unpublished manuscripts were considered eligible for this review. Library staff from Scholarly Information (Brownless Biomedical Library) University of Melbourne, conducted 14 systematic bibliographic searches. Reviewers also checked the reference lists of all relevant articles obtained, and reference lists from previously published reviews. Researchers also hand-searched 10 relevant journals.

Selection Criteria

Study samples of children and young people, aged 0-18 years, who have been the subject of a child maltreatment investigation, were eligible for this review. Studies had to have used random assignment to create treatment and control groups; or, parallel cohorts in which groups were assessed at the same point in time. Any form of FGDM, used in the course of a child maltreatment investigation or service, was considered an eligible intervention if it involved: a concerted effort to convene family, extended family, and community members; and professionals; and involved a planned meeting with the intention of working collaboratively to develop a plan for the safety well-being of children; with a focus on family-centred decision-making.

Data Collection and Analysis

Two review authors independently extracted the necessary data from each study report, using the software application Covidence. Covidence highlighted discrepancies between data extracted by separate reviewers, further analysis was conducted until a consensus was reached on what data were to be included in the review. Two authors also independently conducted analyses of study bias.

Main Results

Eighteen eligible study reports were found, providing findings from 15 studies, involving 18 study samples. Four were randomised controlled trials (RCTs; N = 941) the remainder employed quasi-experimental designs with parallel cohorts. Three of the quasi-experimental studies used prospective evaluations of nonrandomly assigned comparison groups (N = 4,368); the rest analysed pre-existing survey data, child protection case files or court data (N = 91,786). The total number of children studied was 97,095. The longest postintervention follow-up period was 3 years. Only four studies were conducted outside the United States; two in Canada and one in Sweden and one in the Netherlands. The review authors judged there to be a moderate or high risk of bias, in most of the bias categories considered. Only one study referenced a study protocol. Eleven of the fifteen studies were found to have a high likelihood of selection bias (73%). Baseline imbalance bias was deemed to be unlikely in just two studies, and highly likely in nine (60%). Confounding variables were judged to be highly likely in four studies (27%), and contamination bias was judged highly likely in five studies (33%). Researcher allegiance was rated as a high risk in three studies (20%) where the authors argued for the benefits of FGDM within the article, but without supporting references to an appropriate evidence base. Bias from differential diagnostic activity, and funding source bias, were less evident across the evidence reviewed. This review combines findings for eight FGDM outcome measures. Findings from RCTs were available for four outcomes, but none of these, combined in meta-analysis or otherwise, were statistically significant. Combining findings from the quasi-experimental studies provided one statistically significant finding, for the reunification of families, favouring FGDM. Ten effect sizes, from nine quasi-experimental studies, were synthesised to examine effects on the reunification of children with their family or the effect on maintaining in-home care; in short, the effect FGDM has on keeping families together. There was a high level of heterogeneity between the studies (I 2 = 92%). The overall effect, based on the combination of these studies was positive, small, but statistically significant: odds ratio (OR), 1.69 (confidence interval [CI], 1.03, 2.78). Holinshead's (2017) RCT also measured the maintenance on in-home care and reported a similar result: OR, 1.54 (CI, -0.19, 0.66) not statistically significant. The overall effect for continued maltreatment from meta-analysis of five quasi-experimental studies, favoured the FGDM group, but was not statistically significant: OR, 0.73 (CI, 0.48, 1.11). The overall combined effect for continued maltreatment, reported in RCTs, favoured the control group. But it was not statistically significant: OR, 1.29 (CI, 0.85, 1.98). Five effect sizes, from nonrandomised studies, were synthesised to examine the effect of FGDM on the number of kinship placements. The overall positive effect based on the combination of these studies was negligible: OR, 1.31 (CI, 0.94, 1.82). Meta-analysis was not possible with other outcomes. FGDM's role in expediting case processing and case closures was investigated in six studies, three of which reported findings favouring FGDM, and three which favoured the comparison group. Children's placement stability was reported in two studies: an RCT's findings favoured the control, while a quasi-experimental study's findings favoured FGDM. Three studies reported findings for service user satisfaction: one had only 30 participants, one reported a statistically significant positive effect for FGDM, the other found no difference between FGDM and a control. Engagement with support services was reported in two studies; neither reported statistically significant findings.

Authors' Conclusions

The current evidence base, in this field, is insufficient to draw conclusions about the effectiveness of FGDM. These models of child protection decision-making may help bring about better outcomes for children at risk, or they may increase the risk of further maltreatment. Further research of rigour, designed to avoid the potential biases of previous evaluations, is needed.

COVID-19 and forced alcohol abstinence in India: The dilemmas around ethics and rights

In response to the COVID-19 pandemic, as with other countries across the world, the Central and State Governments of India initiated several measures to slow down the spread of the virus and to 'flatten the curve'. One such measure was a 'total lockdown' for several weeks across the country. A complex and unexpected outcome of the lockdown which has medical, ethical, economic, and social dimensions is related to alcohol consumption. The lockdown and consequent acute non-availability of alcohol resulted in people with alcohol dependence going into withdrawals, black marketing of alcohol, and in extreme cases suicide resulting from the alleged frustration of not having access to alcohol. The health dilemmas around this situation are biological (e.g. pushing people into risky situations-potentially fatal alcohol withdrawal, consumption of illicit or other non-consumable alcohol) and psychosocial (e.g. isolation increasing the risk of relapses, loss of control over the decision to abstain which can be detrimental to recovery, restriction of access to services for alcohol problems). The legal and rights-related dilemmas are centred around whether States have the right to impinge on individual autonomy on the grounds of public health, the capacity of the health systems to provide appropriate services to cope with those who will struggle with the unavailability of alcohol, the constitutionality of the Central government's impinging on jurisdiction of states under the guise of a health emergency caused by the pandemic, and the ability of the State to make unbiased decisions about this issue when it is highly dependent on the revenue from the sale of alcohol and associated industries. The way forward could be a pragmatic and utilitarian approach involving continued access to alcohol, while observing all physical distancing norms necessary during the pandemic, for those who want to continue drinking; and implementing innovative measures such as tele-counselling for those who wish not to return back to drinking.

Game-based interventions for neuropsychological assessment, training and rehabilitation: Which game-elements to use? A systematic review

Game-based interventions (GBI) have been used to promote health-related outcomes, including cognitive functions. Criteria for game-elements (GE) selection are insufficiently characterized in terms of their adequacy to patients' clinical conditions or targeted cognitive outcomes. This study aimed to identify GE applied in GBI for cognitive assessment, training or rehabilitation. A systematic review of literature was conducted. Papers involving video games were included if: (1) presenting empirical and original data; (2) using video games for cognitive intervention; and (3) considering attention, working memory or inhibitory control as outcomes of interest. Ninety-one papers were included. A significant difference between the number of GE reported in the assessed papers and those composing video games was found (p < .001). The two most frequently used GE were: score system (79.2% of the interventions using video games; for assessment, 43.8%; for training, 93.5%; and for rehabilitation, 83.3%) and narrative context (79.2% of interventions; for assessment, 93.8%; for training, 73.9% and for rehabilitation, 66.7%). Usability assessment was significantly associated with six of the seven GE analyzed (p-values between p ≤ 0.001 and p. = 027). The use of GE that act as extrinsic motivation promotors (e.g., numeric feedback system) may jeopardize patients' long-term adherence to interventions, mainly if associated with progressive difficulty-increase of gaming experience. Lack of precise description of GE and absence of a theoretical framework supporting GE selection are important limitations of the available clinical literature.

Satisfaction of basic psychological needs following a mild traumatic brain injury and relationships with post-concussion symptoms, anxiety, and depression

PURPOSE

Self-determination theory proposes that the satisfaction of basic psychological needs (competence, autonomy, and relatedness) is essential to psychological well-being. This study aims to explore the acute impact of a mild traumatic brain injury on the perception of need satisfaction as well as to better understand which variables among post-concussion symptoms and mood are associated with the satisfaction of these psychological needs.

MATERIAL AND METHODS

A total of 179 adults with mild traumatic brain injury were included. The Basic Psychological Needs Satisfaction Scale (BPNS) was completed retrospectively to assess need satisfaction pre-injury and after the injury to assess need satisfaction post-injury. The Rivermead Post Concussion Symptoms Questionnaire as well as the Hospital Anxiety and Depression Scale were also completed post injury.

RESULTS

A significant difference between the perception of need satisfaction pre- and post- was found on the total BPNS score, with lower scores on the post-injury evaluation (less satisfaction). Moreover, higher levels of depression and anxiety were associated with less satisfaction.

CONCLUSIONS

These results suggest that sustaining a mild traumatic brain injury may have a negative impact on the satisfaction of competence, autonomy, and relatedness needs. To conclude, it is recommended that these concepts be included in psychological intervention programs following mild traumatic brain injury.Implications for rehabilitationA significant decrease in psychological need satisfaction is highlighted following mild traumatic brain injury.It is recommended that the needs of autonomy, competence, and relatedness in intervention programs following mild traumatic brain injury needs to be addressed.The more mild traumatic brain injury patients are anxious and depressed the more likely it is that they will present a diminished satisfaction of needs, expressed by a lower level of perception of their autonomy, competence, and relatedness. Thus, integrative intervention for anxiety as well as depression following mild traumatic brain injury is also recommended.

Helpful and Hindering Events in Internet-Delivered Cognitive Behavioural Treatment for Generalized Anxiety

Background: Anxiety disorders are a highly prevalent cause of impairment globally with generalized anxiety disorder (GAD) sharing many features with other anxiety disorders. Aims: The present study investigated the helpful and hindering events and impacts for individuals with generalized anxiety who engaged with a supported 6-week online intervention based on cognitive behavioural therapy (iCBT). Method: Participants (n = 36) completed the Helpful and Hindering Aspects of Therapy (HAT) for each session. A descriptive-interpretative framework was used to analyse the data. Results: Helpful events were identified by participants as CBT techniques including psychoeducation, monitoring, cognitive restructuring and relaxation, and found supporter interaction, mindfulness and reading personal stories helpful. The associated impacts were identified as support and validation; behavioural change/applying coping strategies; clarification, awareness, and insight; reassurance/relief; and self-efficacy/empowerment. Hindering events were identified as treatment content/form; and amount of work/technical issues, which led to impacts such as frustration/irritation; increased anxiety; and isolation. Conclusion: The implications of the results, potential future directions of research and limitations of the study are discussed.

Changes in Psychological Need Fulfillment Over the Course of Treatment for Major Depressive Disorder

Self-determination theory (Ryan & Deci, 2017) maintains that the psychological needs for autonomy, competence, and relatedness are essential qualities of experience that individuals require to thrive. The present research examined the role of psychological need fulfillment in a clinical sample undergoing treatment for major depressive disorder. Fifty-one patients with a SCID-IV diagnosis for major depressive disorder were randomly assigned to 16 weeks of cognitive behavioral therapy or antidepressant medication. Depressive symptoms, cognitive errors, dysfunctional attitudes, and psychological need fulfillment were assessed at four time points (pre-treatment, week 4, week 8, and week 16). Psychological need fulfillment increased over the course of treatment and did not differ significantly between treatment conditions. Furthermore, increases in psychological need fulfillment were associated with decreases in depression severity over and above the effects of time, cognitive errors, and dysfunctional attitudes. Given the incremental predictive validity of need fulfillment, a better understanding of its role in the treatment for depression may prove beneficial to mental health researchers and practitioners.

Social Identities as Pathways into and out of Addiction

There exists a predominant identity loss and "redemption" narrative in the addiction literature describing how individuals move from a "substance user" identity to a "recovery" identity. However, other identity related pathways influencing onset, treatment seeking and recovery may exist, and the process through which social identities unrelated to substance use change over time is not well understood. This study was designed to provide a richer understanding of such social identities processes. Semi-structured interviews were conducted with 21 adults residing in a drug and alcohol therapeutic community (TC) and thematic analysis revealed two distinct identity-related pathways leading into and out of addiction. Some individuals experienced a loss of valued identities during addiction onset that were later renewed during recovery (consistent with the existing redemption narrative). However, a distinct identity gain pathway emerged for socially isolated individuals, who described the onset of their addiction in terms of a new valued social identity. Almost all participants described their TC experience in terms of belonging to a recovery community. Participants on the identity loss pathway aimed to renew their pre-addiction identities after treatment while those on the identity gain pathway aimed to build aspirational new identities involving study, work, or family roles. These findings help to explain how social factors are implicated in the course of addiction, and may act as either motivations for or barriers to recovery. The qualitative analysis yielded a testable model for future research in other samples and settings.

Treatment beliefs and preferences for psychological therapies for weight management

OBJECTIVE

Treatment beliefs and preferences for psychological therapies were investigated in 80 overweight individuals trying to manage their weight.

METHOD

Participants read 4 therapy descriptions: cognitive behavioral therapy (CBT), behavior therapy (BT), cognitive therapy (CT), and acceptance and commitment therapy (ACT). They ranked the treatments in order of preference, explained the reason for their preferred choice, and reported their beliefs about each approach.

RESULTS

Individual CBT (43.42%) and BT (31.58%), delivered face-to-face or technologically, were the most preferred treatment options, while ACT (17.12%) and CT (7.89%) were the least preferred. The main reasons cited among those who chose CBT and BT were perceived comprehensiveness and the practical nature of the approach, respectively. Treatment beliefs were strongly predicted by psychological need satisfaction as well as perceived ease and effort.

CONCLUSIONS

Further research should ascertain the stability of treatment beliefs and the efficacy of modifying the treatment context to meet individual needs.

Fostering self-endorsed motivation to change in patients with an eating disorder: the role of perceived autonomy support and psychological need satisfaction

OBJECTIVE

Although several studies have established the beneficial effects of self-endorsed forms of motivation for lasting therapeutic change, the way patients with an eating disorder can be encouraged to volitionally pursue change has received less attention. On the basis of Self-Determination Theory, this longitudinal study addressed the role of an autonomy-supportive environment and psychological need satisfaction in fostering self-endorsed motivation for change and subsequent weight gain.

METHOD

Female inpatients (n = 84) with mainly anorexia nervosa and bulimia nervosa filled out questionnaires at the onset of, during, and at the end of treatment regarding their perceived autonomy support from parents, staff members, and fellow patients, their psychological need satisfaction, and their reasons for undertaking change. Furthermore, the body mass index (BMI) of the patients at the onset and end of treatment was assessed by the staff. Path analyses were used to investigate the relations between these constructs.

RESULTS

At the start of treatment, perceived parental autonomy support related positively to self-endorsed motivation through psychological need satisfaction. Perceived staff and fellow patients autonomy support related to changes in self-endorsed motivation over the course of treatment through fostering change in psychological need satisfaction. Finally, relative increases in self-endorsed motivation related to relative increases in BMI throughout treatment in a subgroup of patients with anorexia nervosa.

DISCUSSION

These results point to the importance of an autonomy-supportive context for facilitating self-endorsed motivation.

Interpersonal motives in anorexia nervosa: the fear of losing one's autonomy

OBJECTIVE

This study examined the widely held but insufficiently studied hypothesis of autonomy disturbances in anorexia nervosa.

METHOD

A total sample of 112 participants comprising patients with acute anorexia nervosa (AN), women recovered from anorexia nervosa (REC), clinical controls (CC), and healthy controls (HC) completed measures of dependency and intimacy strivings, as well as measures of frustrations of these same strivings.

RESULTS

In comparison to HC and CC, AN showed a stronger motivation to avoid dependency and lower strivings for intimacy. Compared with HC, but not with CC, AN also showed stronger frustrations of the same motives. Whereas REC did not differ from AN regarding avoidance of dependency, they reported lower frustration of dependency avoidance (i.e., less actual experiences of dependency). Finally, REC reported higher intimacy motivation as well as better satisfaction of intimacy motivation as compared with AN.

CONCLUSIONS

The present findings suggest that a pronounced motive of avoiding dependency may be a vulnerability factor for anorexia nervosa that is disorder-specific and trait-like. Frustrations of this motive seem to be associated with psychopathology.