Cardiac rehabilitation for children and young people (CardioActive): protocol for a single-blind randomised feasibility and acceptability study of a centre-based cardiac rehabilitation programme versus usual care in 11-16 years with heart conditions

BACKGROUND

Congenital heart conditions are among the most common non-communicable diseases in children and young people (CYP), affecting 13.9 million CYP globally. While survival rates are increasing, support for young people adjusting to life with a heart condition is lacking. Furthermore, one in three CYP with heart conditions also experiences anxiety, depression or adjustment disorder, for which little support is offered. While adults are offered cardiac rehabilitation (CR) to support their mental and physical health, this is not offered for CYP.One way to overcome this is to evaluate a CR programme comprising exercise with mental health support (CardioActive; CA) for CYP with heart conditions. The exercise and mental health components are informed by the metacognitive model, which has been shown to be effective in treating anxiety and depression in CYP and associated with improving psychological outcomes in adult CR.

METHOD AND ANALYSIS

The study is a single-blind parallel randomised feasibility trial comparing a CR programme (CA) plus usual care against usual care alone with 100 CYP (50 per arm) aged 11-16 diagnosed with a heart condition. CA will include six group exercise, lifestyle and mental health modules. Usual care consists of routine outpatient management. Participants will be assessed at three time points: baseline, 3-month (post-treatment) and 6-month follow-up. Primary outcomes are feasibility and acceptability (ie, referral rates, recruitment and retention rates, attendance at the intervention, rate of return and level of completion of follow-up data). Coprimary symptom outcomes (Strength and Difficulties Questionnaire and Paediatric Quality of Life) and a range of secondary outcomes will be administered at each time point. A nested qualitative study will investigate CYP, parents and healthcare staff views of CR and its components, and staff's experience of delivering CA. Preliminary health economic data will be collected to inform future cost-effectiveness analyses. Descriptive data on study processes and clinical outcomes will be reported. Data analysis will follow intention to treat. Qualitative data will be analysed using thematic analysis and the theoretical framework of acceptability.

ETHICS AND DISSEMINATION

Ethical approval was granted on 14 February 2023 by the Greater Manchester East Research Ethics Committee (22/NW/0367). The results will be disseminated through peer-reviewed journals, conference presentations and local dissemination.

TRIAL REGISTRATION NUMBER

ISRCTN50031147; NCT05968521.

Risk factors for Internet Gaming Disorder: Testing the contribution of metacognitions, stress, and coping

Engaging in online gaming is often considered as an avoidance strategy to cope with stress. This study aimed to test whether metacognitions make a unique contribution and which of them is/are the most salient to explaining Internet Gaming Disorder (IGD) tendency after controlling for age, gender, and stress. We further explored the structure of relationships between these variables by testing a metacognitively mediated stress-IGD model. A convenience sample of 1255 Chinese young adults with gaming experience (age ranged from 18 to 27; 57.0% females) completed an anonymous online questionnaire in June 2021. Each metacognitions subscale was positively correlated with IGD tendency, whilst cognitive confidence and positive beliefs about worry were identified as the most salient dimensions among metacognitions for IGD tendency after controlling for demographics and stress. The mediation path model showed acceptable fit after implementing minor modifications. The bootstrapping results showed that the effect of stress on IGD tendency was fully mediated, with metacognitions and escape motivation as independent mediators. In the model, the paths from both positive metacognitions and uncontrollability/danger metacognitions to escape motivation (and in turn IGD) remained significant, whilst the path between cognitive confidence and IGD also remained significant. The findings suggest revisions to the stress-coping model consistent with self-regulatory executive function theory, and advance our understanding of the potential risk factors linking stress to problematic gaming. Enhancing individuals' capacity for metacognitive regulation may be an effective approach for future IGD preventive interventions among Chinese young gamers.

Prevalence of post-traumatic stress and tests of metacognition as a PTSD risk marker in patients with coronary heart disease and elevated HADS scores: analysis of data from the PATHWAY RCT's in UK cardiac rehabilitation

Introduction

Anxiety and depression in coronary heart disease (CHD) are associated with poorer health outcomes, greater healthcare use and reduced quality of life. Post-traumatic stress symptoms may be a particular concern as they are associated with increased mortality at follow-up. We examined prevalence of PTSD in patients with elevated anxiety/depression scores referred for cardiac rehabilitation (CR) across seven NHS sites in North-West England. We tested a possible mechanism (metacognition) linking CHD to PTSD symptom severity as implicated in the metacognitive model.

Methods

Data was collected at baseline as part of the NIHR funded PATHWAY trial of metacognitive therapy for anxiety and depression in CHD. Patients (n = 572) with at least mild symptoms of anxiety and depression under routine screening (assessed with the Hospital Anxiety and Depression Scale) and attending CR were eligible for the study. A battery of questionnaires, including assessment of demographic variables, PTSD symptoms (using the IES-R) and metacognitive beliefs was administered prior to random allocation and intervention delivery.

Results

Rates of PTSD were high, with 48% of patients meeting threshold for PTSD and a further 15% partial PTSD. All five metacognition subscales were positively associated with PTSD vs. no PTSD, with beliefs about the uncontrollability and danger of worry and beliefs about need to control thoughts being most strongly related. For every unit increase in uncontrollability and danger metacognitions the odds of being in the PTSD group increased 30%, whilst the odds of partial PTSD increased 16%. Stepwise regression analysis using the metacognitive subscales along with demographic and health-related covariates found that uncontrollability/danger and need for control metacognitions explained unique variation in PTSD symptom severity, with unique contributions also for age, sex, and number of comorbidities.

Conclusion

PTSD symptoms appeared highly prevalent in the current CR sample. Metacognitive beliefs were individually associated with symptom severity with the strongest positive relationship observed for beliefs about uncontrollability and dangerousness of worry, followed by need to control thoughts. The results highlight the importance in assessing PTSD in CR patients and add support to implementing metacognitive therapy in CHD to target particular metacognition risk factors in anxiety, depression and PTSD.

A framework for implementing Patient and Public Involvement in mental health research: The PATHWAY research programme benchmarked against NIHR standards

BACKGROUND

Patient and Public Involvement (PPI) in research has become a key component recommended by research commissioners, grant award bodies and specified in government policies. Despite the increased call for PPI, few studies have demonstrated how to implement PPI within large-scale research studies.

OBJECTIVE

The aim of the current study was to provide a case example of the implementation of a patient advisory group in a large-scale mental health research programme (PATHWAY) and to benchmark this against UK standards.

METHOD

A PPI group was incorporated throughout the PATHWAY research programme, from grant development to dissemination. The group attended regular meetings and supported participant recruitment, evaluated patient-facing documents, supported the piloting of the research intervention and co-developed the dissemination and impact strategy. The implementation of PPI throughout the project was benchmarked against the UK standards for PPI.

RESULTS

The inclusion of PPI in the PATHWAY project provided tangible changes to the research project (i.e., improving study documents, co-developing dissemination materials) but also proved to be a beneficial experience to PPI members through the development of new skills and the opportunity to provide a patient voice in research. We show how PPI was involved across seven study phases and provide examples of implementation of the six UK standards. The study did not include PPI in data analysis but met all the UK standards for PPI. Challenges regarding practical components (i.e., meeting frequency, language use), increasing diversity and PPI members' knowledge of research were highlighted as areas for further improvement.

CONCLUSIONS

We provide a case example of how PPI can be implemented throughout a research lifecycle and we note the barriers faced and make suggestions for PPI in future implementation and research.

PATIENT AND PUBLIC CONTRIBUTION

PPI members were involved throughout the lifecycle of the research programme. The PPI lead was a co-author on the manuscript and contributed to report writing.

Improving access to psychological therapies: Analysis of effects associated with remote provision during COVID-19

BACKGROUND

COVID-19 had an immediate impact on the way Improving Access to Psychological Therapy (IAPT) services in the United Kingdom were delivered, requiring services to move to remote therapy. While remote therapy has been shown to be effective, little is known about the effects associated with moving to remote therapy delivered during COVID-19 within IAPT services.

OBJECTIVE

The objective of the study was to assess the characteristics of those undergoing remote therapy and test the effects associated with the effect of remote delivery on anxiety and depression symptoms compared with in-person therapy before lockdown.

METHODS

We conducted a retrospective, cross-sectional benchmark comparison of remote therapy across four IAPT services in Greater Manchester. Routinely collected measures of anxiety (GAD-7) and depression (PHQ-9) were used to compare effects across the two time periods. A mixed-effects model was conducted to assess within and between group changes in anxiety and depression, while controlling for pre-specified confounders.

FINDINGS

Remote therapy did not appear to impact on service provision, with the number of sessions offered and attended being similar to those prior to COVID-19. Both face-to-face (pre-COVID-19) and remote therapy (during COVID-19) were associated with variable improvements in anxiety and depression with no significant difference between them. However, remote therapy was associated with a more rapid decrease in symptoms in comparison with face-to-face treatment. Mean improvement in symptoms was small and increased as number of sessions/time increased and analysis of rates of improvement indicated that both face-to-face and remote therapy might need more time to reach target cut-off points on measures.

CONCLUSIONS

Both face-to-face and remote therapies delivered under IAPT were associated with improvements in symptoms with no apparent difference apart from the finding that remote therapy was associated with more rapid change.

CLINICAL IMPLICATIONS

Remote therapy delivery in IAPT does not appear to confer a disadvantage over face-to-face contact, but at a group mean level the magnitude of improvement associated with both treatments was small. Remote therapy provision may widen patient access to and engagement with psychological services.

Effectiveness of physical and mental health interventions for young people with heart conditions: protocol for a systematic review and meta-analysis

INTRODUCTION

Cardiovascular disease is among the most common of non-communicable diseases, affecting 13.9 million children and young people (CYP) globally. Survival rates for CYP with heart conditions are rising, however, support for adjusting to life with a heart condition is lacking, as such it is unsurprising that one in three suffer from anxiety, depression or adjustment disorder. The proposed review aims to identify and assess the effectiveness of physical and mental health interventions across physical and mental health outcomes in young people with cardiac conditions using narrative synthesis and meta-analysis if appropriate.

METHODS AND ANALYSIS

Embase, Medline, PubMed, PsycINFO, Cochrane Databases, Web of Science and reference lists of relevant publications will be searched from 1980 to June 2022 for articles published in English or Italian. Screening, data extraction, intervention coding and risk of bias will be performed by two independent reviewers using an extraction checklist. Intervention content and features will be identified and reported using the Template for Intervention Description and Replication checklist. A narrative review of the included studies will be conducted. If possible and appropriate, a random-effects model meta-analysis will be conducted to calculate the pooled within-group and between-group effect sizes for the primary outcome measures. If sufficient data are available, a subgroup meta-analysis will investigate whether specific intervention types are associated with different levels of intervention effectiveness.

ETHICS AND DISSEMINATION

This systematic review does not directly involve the use of human beings, therefore, there is no requirement for ethical approval. Findings will be disseminated through peer-reviewed publication and in various media, such as conferences, congresses or symposia.

PROSPERO REGISTRATION NUMBER

CRD42022330582.

The Effectiveness of Metacognitive Therapy Compared to Behavioral Activation for Severely Depressed Outpatients: A Single-Center Randomized Trial

INTRODUCTION

Major depressive disorder (MDD) is a highly prevalent and disabling disorder. This study examines two psychotherapy methods for MDD, behavioral activation (BA), and metacognitive therapy (MCT), when applied as outpatient treatments to severely affected patients.

METHODS

The study was conducted in a tertiary outpatient treatment center. Patients with a primary diagnosis of MDD (N = 122) were included in the intention-to-treat sample (55.7% female, mean age 41.9 years). Participants received one individual and one group session weekly for 6 months (M). Assessments took place at baseline, pretreatment, mid-treatment (3 M), post-treatment (6 M), and follow-up (12 M). The primary outcome was depressive symptomatology assessed by the Hamilton Rating Scale for Depression at 12 M follow-up. Secondary outcomes included general symptom severity, psychosocial functioning, and quality of life.

RESULTS

Linear mixed models indicated a change in depressive symptoms (F(2, 83.495) = 12.253, p < 0.001) but no between-group effect (F(1, 97.352) = 0.183, p = 0.670). Within-group effect sizes were medium for MCT (post-treatment: d = 0.610; follow-up: d = 0.692) and small to medium for BA (post-treatment: d = 0.636, follow-up: d = 0.326). In secondary outcomes, there were improvements (p ≤ 0.040) with medium to large within-group effect sizes (d ≥ 0.501) but no between-group effects (p ≥ 0.304). Response and remission rates did not differ between conditions at follow-up (response MCT: 12.9%, BA: 13.3%, remission MCT: 9.7%, BA: 10.0%). The deterioration rate was lower in MCT than in BA (χ21 = 5.466, p = 0.019, NTT = 7.4).

DISCUSSION

Both MCT and BA showed symptom reductions. Remission and response rates were lower than in previous studies, highlighting the need for further improvements in adapting/implementing treatments for severely affected patients with MDD.

Metacognitive therapy home-based self-help for anxiety and depression in cardiovascular disease patients in the UK: A single-blind randomised controlled trial

BACKGROUND

Anxiety and depression in cardiac rehabilitation (CR) are associated with greater morbidity, mortality, and increased healthcare costs. Current psychological interventions within CR have small effects based on low-quality studies of clinic-based interventions with limited access to home-based psychological support. We tested the effectiveness of adding self-help metacognitive therapy (Home-MCT) to CR in reducing anxiety and depression in a randomised controlled trial (RCT).

METHODS AND FINDINGS

We ran a single-blind, multi-centre, two-arm RCT. A total of 240 CR patients were recruited from 5 NHS-Trusts across North West England between April 20, 2017 and April 6, 2020. Patients were randomly allocated to Home-MCT+CR (n = 118, 49.2%) or usual CR alone (n = 122, 50.8%). Randomisation was 1:1 via randomised blocks within hospital site, balancing arms on sex and baseline Hospital Anxiety and Depression Scale (HADS) scores. The primary outcome was the HADS total score at posttreatment (4-month follow-up). Follow-up data collection occurred between August 7, 2017 and July 20, 2020. Analysis was by intention to treat. The 4-month outcome favoured the MCT intervention group demonstrating significantly lower end of treatment scores (HADS total: adjusted mean difference = -2.64 [-4.49 to -0.78], p = 0.005, standardised mean difference (SMD) = 0.38). Sensitivity analysis using multiple imputation (MI) of missing values supported these findings. Most secondary outcomes also favoured Home-MCT+CR, especially in reduction of post-traumatic stress symptoms (SMD = 0.51). There were 23 participants (19%) lost to follow-up in Home-MCT+CR and 4 participants (3%) lost to follow-up in CR alone. No serious adverse events were reported. The main limitation is the absence of longer term (e.g., 12-month) follow-up data.

CONCLUSION

Self-help home-based MCT was effective in reducing total anxiety/depression in patients undergoing CR. Improvement occurred across most psychological measures. Home-MCT was a promising addition to cardiac rehabilitation and may offer improved access to effective psychological treatment in cardiovascular disease (CVD) patients.

TRIAL REGISTRATION

NCT03999359.

New and Interesting Fungi. 5

Nine new genera, 17 new species, nine new combinations, seven epitypes, three lectotypes, one neotype, and 14 interesting new host and / or geographical records are introduced in this study. New genera: Neobarrmaelia (based on Neobarrmaelia hyphaenes), Neobryochiton (based on Neobryochiton narthecii), Neocamarographium (based on Neocamarographium carpini), Nothocladosporium (based on Nothocladosporium syzygii), Nothopseudocercospora (based on Nothopseudocercospora dictamni), Paracamarographium (based on Paracamarographium koreanum), Pseudohormonema (based on Pseudohormonema sordidus), Quasiphoma (based on Quasiphoma hyphaenes), Rapidomyces (based on Rapidomyces narthecii). New species: Ascocorticium sorbicola (on leaves of Sorbus aucuparia, Belgium), Dactylaria retrophylli (on leaves of Retrophyllum rospigliosii, Colombia), Dactylellina miltoniae (on twigs of Miltonia clowesii, Colombia), Exophiala eucalyptigena (on dead leaves of Eucalyptus viminalis subsp. viminalis supporting Idolothrips spectrum, Australia), Idriellomyces syzygii (on leaves of Syzygium chordatum, South Africa), Microcera lichenicola (on Parmelia sulcata, Netherlands), Neobarrmaelia hyphaenes (on leaves of Hyphaene sp., South Africa), Neobryochiton narthecii (on dead leaves of Narthecium ossifragum, Netherlands), Niesslia pseudoexilis (on dead leaf of Quercus petraea, Serbia), Nothocladosporium syzygii (on leaves of Syzygium chordatum, South Africa), Nothotrimmatostroma corymbiae (on leaves of Corymbia henryi, South Africa), Phaeosphaeria hyphaenes (on leaves of Hyphaene sp., South Africa), Pseudohormonema sordidus (on a from human pacemaker, USA), Quasiphoma hyphaenes (on leaves of Hyphaene sp., South Africa), Rapidomyces narthecii (on dead leaves of Narthecium ossifragum, Netherlands), Reticulascus parahennebertii (on dead culm of Juncus inflexus, Netherlands), Scytalidium philadelphianum (from compressed air in a factory, USA). New combinations: Neobarrmaelia serenoae, Nothopseudocercospora dictamni, Dothiora viticola, Floricola sulcata, Neocamarographium carpini, Paracamarographium koreanum, Rhexocercosporidium bellocense, Russula lilacina. Epitypes: Elsinoe corni (on leaves of Cornus florida, USA), Leptopeltis litigiosa (on dead leaf fronds of Pteridium aquilinum, Netherlands), Nothopseudocercospora dictamni (on living leaves of Dictamnus albus, Russia), Ramularia arvensis (on leaves of Potentilla reptans, Netherlands), Rhexocercosporidium bellocense (on leaves of Verbascum sp., Germany), Rhopographus filicinus (on dead leaf fronds of Pteridium aquilinum, Netherlands), Septoria robiniae (on leaves of Robinia pseudoacacia, Belgium). Lectotypes: Leptopeltis litigiosa (on Pteridium aquilinum, France), Rhopographus filicinus (on dead leaf fronds of Pteridium aquilinum, Netherlands), Septoria robiniae (on leaves of Robinia pseudoacacia, Belgium). Neotype: Camarographium stephensii (on dead leaf fronds of Pteridium aquilinum, Netherlands). Citation: Crous PW, Begoude BAD, Boers J, Braun U, Declercq B, Dijksterhuis J, Elliott TF, Garay-Rodriguez GA, Jurjević Ž, Kruse J, Linde CC, Loyd A, Mound L, Osieck ER, Rivera-Vargas LI, Quimbita AM, Rodas CA, Roux J, Schumacher RK, Starink-Willemse M, Thangavel R, Trappe JM, van Iperen AL, Van Steenwinkel C, Wells A, Wingfield MJ, Yilmaz N, Groenewald JZ (2022) New and Interesting Fungi. 5. Fungal Systematics and Evolution 10: 19-90. doi: 10.3114/fuse.2022.10.02.

Molecular Solid Tumor Algorithm – Simplified Patient-Centric/Cost-Effective Approach by Pathologists

Introduction/Objective

The process from the time the patient is diagnosed with cancer and receives their first treatment is complex and time-consuming. It requires adherence to national comprehensive cancer network (NCCN) guidelines; is challenged with limited tissue, how and when to order tests, and reimbursement timelines with pre- authorizations. We evaluated the role of the pathologists, who are an integral part of patient care, along with oncologists and surgeons.

Methods/Case Report

254 cases from various types of solid tumors (paraffin-embedded blocks) were collected from several pathology departments. Tests (two panels NGS-DNA/RNA expression, FISH, PD-L1, and IHC) were ordered as early as on the day of diagnosis to as late as 18 months following the diagnosis. Cancer cases reviewed were Colo-Rectal (72), Lung (48), Breast (24), Gastric (10), CNS (8), Melanoma (4), Head/Neck (20), GU (16), Sarcomas (8), Thyroid (6), Hepatic (8), Female Genital Tract (7) and Unknown Primary (23).

Results (if a Case Study enter NA)

We evaluated pathology reports, identified blocks, reviewed H&E slides, utilized NCCN guidelines in collaboration with oncologists. Tests were ordered using established billing criteria. Following tests were performed: PD-L1 (190 - 75%), FISH (50 - 20%), and NGS – two simple panel approach (215 - 85%). Using the aforesaid methods, our NGS results were successful in &gt;95%. We were able to identify actionable and prognostic mutations in &gt;80% of tumors.

Conclusion

Our algorithm has been designed considering NCCN guidelines and are updated frequently with new therapeutic targets and actionable mutations. The emphasis is to conserve diagnostic tissue and ensure timely ordering of tests as medically necessary. This can be adopted by pathologists in conjunction with clinical information, pathology reports, and be used as a part of diagnostic workups to reduce delays in treatment, avoid tissue loss, utilize current billing (inpatient/outpatient) practices, pre-authorization and eventually improving patient care as well as reduce overall healthcare costs.

Discrete choice experiment to investigate preferences for psychological intervention in cardiac rehabilitation

OBJECTIVE

Cardiac rehabilitation (CR) is offered to people who recently experienced a cardiac event, and often comprises of exercise, education and psychological care. This stated preference study aimed to investigate preferences for attributes of a psychological therapy intervention in CR.

METHODS

A discrete choice experiment (DCE) was conducted and recruited a general population sample and a trial sample. DCE attributes included the modality (group or individual), healthcare professional providing care, information provided prior to therapy, location and the cost to the National Health Service (NHS). Participants were asked to choose between two hypothetical designs of therapy, with a separate opt-out included. A mixed logit model was used to analyse preferences. Cost to the NHS was used to estimate willingness to pay (WTP) for aspects of the intervention design.

RESULTS

Three hundred and four participants completed the DCE (general public sample (n=262, mean age 47, 48% female) and trial sample (n=42, mean age 66, 45% female)). A preference for receiving psychological therapy was demonstrated by both samples (general population WTP £1081; 95% CI £957 to £1206). The general population appeared to favour individual therapy (WTP £213; 95% CI £160 to £266), delivered by a CR professional (WTP £48; 9% % CI £4 to £93) and with a lower cost (β=-0.002; p&lt;0.001). Participants preferred to avoid options where no information was received prior to starting therapy (WTP -£106; 95% CI -£153 to -£59). Results for the location attribute were variable and challenging to interpret.

CONCLUSIONS

The study demonstrates a preference for psychological therapy as part of a programme of CR, as participants were more likely to opt-in to therapy. Results indicate that some aspects of the delivery which may be important to participants can be tailored to design a psychological therapy. Preference heterogeneity is an issue which may prevent a 'one-size-fits-all' approach to psychological therapy in CR.

Impact of cardiac resynchronisation therapy in patients with cardiac sarcoidosis

Background

Implantation of a device is usually required in cardiac sarcoidosis (CS) patients presenting with advanced conduction abnormalities or ventricular arrhythmias. A cardiac resynchronisation therapy (CRT) device is often chosen in patients with concomitant left ventricular systolic impairment. The role of CRT in CS is not well established.

Purpose

To describe the cohort of CS patients with CRT device in situ in our hospital focusing on the short-term effect in serial echocardiography and long-term outcomes on morbidity and mortality.

Methods

All consecutive CS patients with a CRT device in situ were identified in our CS database (2005–2022). A confident CS diagnosis was provided after review of all relevant clinical and imaging baseline data in our CS multi-disciplinary meeting and a consensus decision for CRT-D implantation was made based on international guidelines. All patients were followed up for at least 6 months with serial echocardiography. Serial data regarding symptoms, rhythm disturbance and echocardiographic parameters were obtained and comparisons were performed using Wilcoxon signed rank test.

Results

A total of 51 CS patients with CRT-D were identified (mean age: 57±10 years old). Patients were male predominant (64.7%) and Caucasian in origin (86.2%). Extra-cardiac sarcoidosis was confirmed histologically in 33 (64.7%) patients. The prevalence of smoking, diabetes, hypertension and ischaemic heart disease was 27.5%, 21.6%, 49.0% and 7.8% respectively. At the time of device implantation or during follow-up, 43 (84.3%) patients were found to have active cardiac sarcoidosis on cardiac PET.

Post CRT implantation there was a significant difference in LV ejection fraction (35.9±15.0% vs 42.2±14.1%, p&lt;0.001), LV end-systolic diameter (4.90±1.46 cm vs 4.62±1.32 cm, p=0.012) and LV end-diastolic diameter (5.99±1.18 cm vs 5.66±1.06 cm, p&lt;0.001). No significant changes were observed in the right ventricular function (p=0.09) and severity of mitral regurgitation (p=0.40). There was one patient who experienced acute heart failure decompensation admission within six months of CRT-D implantation. The New York Heart Association (NYHA) class improved in 26 patients (51.0%), worsened in 4 (7.8%) patients and remained the same in 21 (41.2%) patients at 6 months post CRT-implantation. During the mean follow up of 47.6 months, the composite end-point of death and cardiac transplantation was reached in 9 (17.6%) patients (8 deaths and 1 cardiac transplantation). 5 patients had major complications including a large haematoma, a small atrio-septal defect, haemothorax, device associated endocarditis and lead fracture. Minor wound infections were seen in 3 patients and 4 patients received inappropriate shock or anti-tachycardia pacing.

Conclusions

CRT in cardiac sarcoidosis patients is associated with short-term improvement in LV remodelling and functional status but over a four year follow up, morbidity and mortality are common.

Funding Acknowledgement

Type of funding sources: None.

Youth Metacognitive Therapy (YoMeta): protocol for a single-blind randomised feasibility trial of a transdiagnostic intervention versus treatment as usual in 11–16-year-olds with common mental health problems

Background

Mental health disorders in children and young people (CYP) are increasing but the provision of current evidence-based treatment for common mental health problems is limited. Treatment effects vary widely with no clear superiority of a single treatment approach. Further evaluation of contemporary and effective treatments in CYP is needed. Metacognitive therapy (MCT) has shown enhanced efficacy over ‘gold standard’ approaches in adult mental health, but so far has not been evaluated in a randomised trial of CYP. As such, we aim to assess the acceptability and feasibility of group-MCT for CYP with common mental health problems in comparison to usual treatment within Child and Adolescent Mental Health Services (CAMHS).

Method

YoMeta is a multicentre, two-arm, single-blind randomised feasibility trial comparing group-MCT to usual care in CYP with common mental health problems in CAMHS. CYP (target sample n = 100) with a common mental health problem will be recruited across at least three CAMHS services in the UK. Participants in the intervention arm will receive up to eight sessions of group-MCT delivered by a CAMHS mental health practitioner. The control arm will receive usual care in CAMHS which includes individual or group-based therapy. Feasibility will be assessed by the success of recruitment, retention, and data quality. Acceptability of the intervention will be assessed by the number of sessions attended and through qualitative interviews aimed at exploring CYP acceptability and understanding of the intervention. Symptoms of psychological distress will be assessed using the Revised Children Anxiety and Depression Scale (RCADS) at 20 weeks. We will also assess psychological well-being, symptoms of depression, metacognitive beliefs, quality of life, and measures to support economic evaluation (health status and health and social care use). Qualitative interviews will be conducted to understand practitioner’s views on training and delivery of group-MCT.

Discussion

The trial is designed to evaluate the acceptability and feasibility of group-MCT for CYP with common mental health problems. Group-MCT may aid in improving access to treatment, reduce waiting times, and improve outcomes for CYP with common mental health disorders. The study will provide important information and data to evaluate future research potential and confirm sample size estimation for a definitive large-scale RCT to test the effectiveness and cost-effectiveness of group-MCT in CYP.

Trial registration

NCT05260060; ISCTRN18335255

The network structure of dysfunctional metacognition: Analysis of the MCQ-30

The Metacognitive Control System (MCS) model gives central importance to maladaptive metacognition in psychological vulnerability and disorder. The metacognitions questionnaire 30 (MCQ-30) is widely used to assess such metacognitions and to establish their effects. Previous studies consistently demonstrate that the MCQ-30 consists of five latent factors, with some factors showing wide-ranging positive associations with symptoms and some demonstrating more specific symptom links. Questions remain concerning relationships between MCQ-items (or domains) and the most central of these outside of the latent-factor model. In the present study we set out to explore the internal structure of the MCQ-30 using network analysis and estimated two graphical Gaussian models, one with items- and one with domains, in an unselected sample (N = 1080). The robustness and stability of the networks, as well as the node predictability were assessed. Among our observations was that the items of the MCQ-30 appeared to cluster in meaningful substructures, corresponding to metacognitive theory. Furthermore, "need for control" was the most centrally placed domain, suggesting it plays an important role in the network and that its activation has a strong influence on other nodes. The theoretical and clinical implications of the current findings are discussed in light of the metacognitive model of psychological disorder.

Abstract 2746: Preclinical activity and manufacturing feasibility of genetically modified PDCD-1 knockout (KO) tumor-infiltrating lymphocyte (TIL) cell therapy

Background: Adoptive cell therapy with autologous TIL has demonstrated an objective response rate (ORR) of 36% in the post-immune checkpoint inhibitor (ICI) setting in patients (pts) with advanced/unresectable melanoma (Sarnaik JCO 2021), while in ICI-naïve pts who received early-line combination of TIL and pembrolizumab, the ORR was 60%, with a 30% CR rate (O’Malley SITC 2021). Although effective, anti-PD-1 therapy is limited by poor penetration into the tumor, internalization, and endocytic clearance, in contrast with TIL, which overcome this inherent limitation. PDCD-1 gene inactivation (PD-1 KO) may enhance TIL cell therapy efficacy in the post-ICI setting and abrogate the need for systemic anti-PD-1 therapy in ICI-naïve pts. In preclinical studies, PD-1 KO TIL maintain robust effector function and phenotypic markers indicative of functional TIL (Ritthipichai ESMO 2020). We describe preclinical activity, clinical-scale manufacturing process development, and characterization of IOV-4001, an autologous PD-1 KO TIL cell product.

Methods: hIL-2 NOG mice engrafted with melanoma tumor cells received adoptive transfer of autologous PD-1 KO TIL (developed with TALEN® gene editing technology in collaboration with Cellectis), mock TIL (electroporation without TALEN), mock TIL + anti-PD-1 antibody, or no adoptive transfer (n=14 each). Tumor size was measured 2×/wk for 39 days. A 22-day clinical-scale manufacturing process was established, including pre-rapid expansion protocol (pre-REP), activation, electroporation, resting, and REP, for the generation of PD-1 KO TIL. Final PD-1 KO TIL product was characterized for total viable cells (TVC), purity (% viability), identity (% CD45+CD3+), and function (PD-1 KO efficiency).

Results: Day 39 mean ± SEM tumor size (mm2) for mice treated with PD-1 KO TIL (6 ± 2.8) showed superior tumor control relative to mock TIL (26 ± 8.5, P&lt;0.05), mock TIL + anti-PD-1 (33 ± 8.8, P&lt;0.01), and no adoptive TIL transfer (112 ± 8.4, P&lt;0.0001). Product attributes from 6 clinical-scale manufacturing runs for PD-1 KO TIL were acceptable, with a median (range) TVC, purity, and identity of 8.3 × 109 (0.9×109-35.7×109), 94% (91%-99%), and 99% (98%-99%), respectively. Median (range) PD-1 KO efficiency was 48% (31%-84%). PD-1 KO TIL function and phenotype (differentiation, memory, activation, and exhaustion) were comparable to mock TIL.

Conclusions: Anti-tumor activity of PD-1 KO TIL was superior to mock TIL suggesting that endogenous PD-1 inhibition may confer a functional advantage to the TIL over an antibody combination. PD-1 KO TIL clinical manufacturing was feasible and the TIL product quality attributes and phenotype were acceptable; importantly, lack of complete PD-1 KO may spare other PD-1-dependent in vivo cellular functions. Together, these data support clinical investigation of IOV-4001, an autologous PD-1 KO TIL cell therapy.

Citation Format: Arvind Natarajan, Anand Veerapathran, Adrian Wells, Kenneth Onimus, Marcus Machin, Seth Wardell, Jamie L. Blauvelt, Madan Jagasia, Rafael Cubas. Preclinical activity and manufacturing feasibility of genetically modified PDCD-1 knockout (KO) tumor-infiltrating lymphocyte (TIL) cell therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2746.

Metacognitive therapy self-help for anxiety-depression: Single-blind randomized feasibility trial in cardiovascular disease

Background: One in three cardiovascular disease (CVD) patients experience significant anxiety and depression. Current psychological interventions have limited efficacy in reducing such symptoms and are offered as a face-to-face intervention that may be a barrier to accessing treatment. We evaluated the feasibility and acceptability of delivering assisted home-based self-help metacognitive therapy (home-MCT) to cardiac rehabilitation (CR) patients experiencing anxiety and depression. Method: One hundred eight CR patients with elevated anxiety and/or depression were recruited to a single-blind randomized feasibility trial across two United Kingdom National Health Service Trusts and were randomized to usual CR or usual CR plus home-MCT. The feasibility and acceptability of adding home-MCT to CR was based on credibility or expectancy ratings, recruitment rate, drop-outs, number of CR and home-MCT modules completed, and ability of outcome measures to discriminate between patients. The study was used to refine the sample size estimate for a full-scale trial. The quality of telephone support calls delivered by CR staff trained in MCT was assessed. Results: Home-MCT was found to be feasible and acceptable for the current CR patients with anxiety and depression. Recruitment and retention of participants was high, and attendance at CR was similar for both groups. Completion of home-MCT was high, but the quality of telephone support calls delivered was lower than expected. Conclusions: Home-MCT was acceptable and feasible to deliver to CR patients experiencing anxiety and depression, and the feasibility of conducting a full-scale trial of the intervention was established. Home-MCT may provide additional treatment options for cardiac patients experiencing psychological distress.

Metacognition, cognition and social anxiety: A test of temporal and reciprocal relationships

Cognitive models of social anxiety give prominence to dysfunctional schemas about the social self as the key underlying factors in maladaptive self-processing strategies and social anxiety symptoms. In contrast, the metacognitive model argues that beliefs about cognition represent a central belief domain underlying psychopathology and cognitive schemas as products of a thinking style regulated by metacognition. The present study therefore evaluated the temporal and reciprocal relations between metacognitive beliefs, social self-beliefs, and social anxiety symptoms to shed light on possible causal relationships among them. Eight hundred and sixty-eight individuals gathered at convenience participated in a four-wave online survey with each measurement wave 6 weeks apart. Using autoregressive cross-lagged panel models, we found significant temporal and reciprocal relations between metacognition, social self-beliefs (schemas), and social anxiety. Whilst social self-beliefs prospectively predicted social anxiety this relationship was reciprocal. Metacognitive beliefs prospectively predicted both social interaction anxiety and social self-beliefs, but this was not reciprocal. The results are consistent with metacognitive beliefs causing social anxiety and social self-beliefs and imply that negative social self-beliefs might be a product of metacognition. The clinical implications are that metacognitive beliefs should be the central target in treatments of social anxiety.

Evaluating Metacognitive Therapy to Improve Treatment of Anxiety and Depression in Cardiovascular Disease: The NIHR Funded PATHWAY Research Programme

BACKGROUND

Anxiety and depression contribute to poorer physical and mental health outcomes in cardiac patients. Psychological treatments are not routinely offered in cardiac care and have mixed and small effects. We conducted a series of studies under the PATHWAY research programme aimed at understanding and improving mental health outcomes for patients undergoing cardiac rehabilitation (CR) through provision of metacognitive therapy (MCT).

METHODS

PATHWAY was a series of feasibility trials, single-blind, multicenter, randomized controlled trials (RCTs), qualitative, stated preferences for therapy and health economics studies.

FINDINGS

Patients felt their psychological needs were not met in CR and their narratives of distress could be parsimoniously explained by the metacognitive model. Patients reported they would prefer therapy over no therapy as part of CR, which included delivery by a cardiac professional. Two feasibility studies demonstrated that RCTs of group-based and self-help MCT were acceptable, could be embedded in CR services, and that RCTs of these interventions were feasible. A definitive RCT of group-MCT within CR (n = 332) demonstrated significantly greater reductions in the severity of anxiety and depression, exceeding CR alone, with gains maintained at 12 month follow-up (SMD HADS total score = 0.52 at 4 months and 0.33 at 12 months). A definitive trial of self-help MCT is ongoing.

CONCLUSION

There is a need to better meet the psychological needs of CR patients. Embedding MCT into CR demonstrated high acceptability and improved efficacy on psychological outcomes. Results support roll-out of MCT in CR with evaluation of national implementation.

REGISTRATION

URL: NCT02420431; ISRCTN74643496; NCT03129282.

Metacognitive therapy and work-focused interventions for patients on sick leave due to anxiety and depression: study protocol for a randomised controlled wait-list trial

Background

Common mental disorders such as depression and anxiety are major contributors to the global burden of disease. Affected individuals suffer reduced quality of life, impaired functioning and reduced capacity to work. Maintaining employment is an important determinant for health and wellbeing, and the economic impact of depression and anxiety is a significant societal expense. Treatments providing effective symptom reduction and helping patients return to work (RTW) would thus have substantial public health benefits. The present study will explore the effectiveness of metacognitive therapy (MCT) and work-focused interventions on reducing symptoms and increasing RTW rates for patients on sick leave due to depression and anxiety.

Methods

The study is a randomised controlled wait-list trial (RCT; N = 240). The intervention group will receive protocol-based MCT and work-focused interventions immediately after inclusion. The control condition is a wait-list control group. All patients will receive up to 12 weekly sessions. The study context is a Norwegian outpatient clinic part of a national programme aimed at reducing sick leave. The co-primary outcomes are change in RTW and symptoms of depression and anxiety at the end of treatment. In addition to self-report, sick leave will also be collected from national registries from 2 years prior to intervention to 4 years after intervention. Symptoms of depression and anxiety will be collected by self-report at pre- and post-treatment and at 6 and 12 months follow-up after treatment. A cost-effectiveness analysis will use total cost and quality-adjusted life-years as the secondary outcomes.

Discussion

There is broad consensus on the importance of identifying treatment that effectively reduces depression and anxiety symptoms and aids RTW. This study is an important contribution to the field as it is the first RCT on MCT and work-focused interventions for patients on sick leave due to anxiety and depression.

Trial registration

ClinicalTrials.gov NCT03301922. Registered on October 4, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05822-4.

Metacognitive Beliefs and Suicidal Ideation: An Experience Sampling Study

The current study aimed to examine the relationship between metacognitive beliefs about suicidal ideation and the content and process of suicidal ideation. This was to examine the potential contribution of the Self-Regulatory Executive Function (S-REF) model (Wells and Matthew, 2015) to suicidal ideation. Twenty-seven participants completed both trait and state-level measures of suicidal ideation, negative affect, defeat, hopelessness, entrapment and metacognitive beliefs. Experience Sampling Methodology (ESM) was adopted to measure state-level measurements with participants invited to complete an online diary up to seven times a day for six days. Multi-level modelling enabled a detailed examination of the relationships between metacognitive beliefs and suicidal ideation. Positive (β = 0.241, p < 0.001) and negative (β = 0.167, p < 0.001) metacognitive beliefs about suicidal ideation were positively associated with concurrent suicidal ideation even when known cognitive correlates of suicide were controlled for. The results have important clinical implications for the assessment, formulation and treatment of suicidal ideation. Novel meta-cognitive treatments targeting beliefs about suicidal ideation are now indicated. A limited range of characteristics reported by participants affects the generalizability of findings. Future research is recommended to advance understanding of metacognition and suicide but results demonstrate an important contribution of the S-REF model.

101 Expansion of tumor-infiltrating lymphocytes (TIL) using static bag for the clinical manufacturing rapid expansion protocol (REP) process

Background

Lifileucel (LN-144) and LN-145, adoptive cell therapies using autologous tumor-infiltrating lymphocytes (TIL), have demonstrated encouraging efficacy with acceptable safety in a variety of tumor types.1–4 The lifileucel Gen 2 clinical manufacturing process uses gas-permeable rapid expansion (G-Rex®, Wilson Wolf, Saint Paul, MN) bioreactors for TIL expansion.5 Static gas-permeable cell culture bags (EXP-Pak™, Charter Medical, Winston-Salem, NC) are alternate bioreactors that have been used for clinical manufacturing of T cells.6 In this study, TIL product characteristics were compared after expansion at small- and full-scale using EXP-Pak bags and G-Rex bioreactors.

Methods

Cryopreserved pre-REP TIL were cultured with OKT-3 and irradiated peripheral blood mononuclear cells in either small-scale (G-Rex 5M flasks or EXP-50 bags) or full-scale (G-Rex 500MCS or EXP-5L bags) conditions. The same culture media formulation was used throughout the process. Final harvested TIL products were characterized for the following quality attributes: total viable cells (TVC), purity (% viability), identity (% CD45+CD3+), and activity (IFN-gamma release). Additional characterization was performed to determine the TIL differentiation, central and effector memory subsets, activation, exhaustion status, and impurities using multi-color flow cytometry. The T-cell receptor (TCR) repertoires of the final products were assessed for unique CDR3 (uCDR3) counts and shared clones using RNA-seq.

Results

The median (range) TVC from 6 small-scale runs of G-Rex condition was 90.8×109 (26.9×109–98.6×109) cells, and the corresponding TVC of EXP-Pak bag condition was 119×109 (63.2×109–141×109) cells. Full-scale runs (n=3) yielded similar TVC for G-Rex and EXP-Pak bag conditions. Both conditions had comparable purity, identity, and activity (table 1). 91–99% of TCR Vbeta clones of EXP-Pak bag TIL were present in G-Rex (table 2). Cell proliferation, cell cycle, and mitochondrial function of TIL generated from EXP-Pak bags and G-Rex flask methodologies will be presented.

Conclusions

The final TIL product generated in the EXP-Pak bag condition did not differ from cells produced in the G-Rex flask functionally or phenotypically and demonstrated similar growth profiles. These data support further evaluation of EXP-Pak bags for potential use in clinical and potential commercial TIL cell therapy manufacturing applications.

Acknowledgements

This study and analysis were funded by Iovance Biotherapeutics, Inc. (San Carlos, CA, USA). Editorial support was provided by Amanda Kelly (Iovance).

References

Sarnaik AA, et al. J Clin Oncol. 2021; doi: 10.1200/JCO.21.00612.

Thomas SS, et al. J Clin Oncol. 2021;39 (suppl; abstract 9537).

Jazaeri A, et al. J Clin Oncol. 2019;37 (suppl; abstract 2538).

Jimeno A, et al. J Immunother Cancer. 2020;8 (suppl; abstract A378).

Wardell S, et al. J Immunother Cancer. 2019;7 (suppl 1; abstract P226).

BioProcess International. 2014 [white paper]. https://bioprocessintl.com/sponsored-content/efficacy-utility-new-exp-pak-closed-system-disposable-cell-expansion-bags-designed-cell-therapy-applications/Accessed July 23, 2021.

Abstract 101 Table 1

Summary of final TIL product attributes

Abstract 101 Table 2

Common uCDR3 clones and% overlap of TCR clones

176 Successful generation of tumor-infiltrating lymphocyte (TIL) product from renal cell carcinoma (RCC) tumors for adoptive cell therapy

Background

Patients with RCC may achieve remission with immune-checkpoint inhibitors (ICI); however, most patients will progress. Adoptive cell therapy with autologous TIL allows for expansion of T-cells from tumor tissue leading to a polyclonal T-cell product with a diverse T-cell receptor repertoire capable of recognizing an array of tumor antigens. TIL therapy with centrally manufactured lifileucel demonstrated a 36% overall response rate in patients with ICI-refractory melanoma.1 We present our preclinical experience of TIL production in RCC.

Methods

This study was approved by the DF/HCC Institutional Review Board. Fresh tumor samples (≥1.5-cm) were harvested from consented patients undergoing resection for RCC. TIL were manufactured using pre-rapid expansion (1/10th scale) and rapid expansion (1/100th scale) protocol for 22 days. Characterization (total viable cells [TVC],% viability, identity, and potency) was performed on the final TIL product. TIL purity, differentiation, memory, activation, and exhaustion status were characterized using multi-color flow cytometry.

Results

Baseline characteristics of 11 recruited patients are shown in table 1. Clear cell was the most common histology (73%). Two patients had previously treated metastatic disease with samples harvested from the lung and adrenal gland; one patient had prior cryoablation with adjacent local recurrence. The remainder were treatment-naïve primary nephrectomy samples. Eight products (73%) showed acceptable TIL product attributes (table 2). Median (range) TVC, viability, and identity (CD45+CD3+%) for the final TIL product were 74×109 (18×109–133×109), 95% (86%–97%), and 98% (94%–99%), respectively. Median (range) percentage of CD4+ cells was 69% (21%–97%) and CD8+ cells was 27% (2%–72%). The non–T-cell population, including B cells, monocytes, and NK cells, was <7%. The final TIL product was functional, and responded to polyclonal bead stimulation; the median (range) IFNg and granzyme B were 8834 (3319–12,957) pg/mL and 34,329 (15,565–65,521) pg/mL, respectively. Acceptable TIL product was generated from both metastatic lesions and primary tumor samples. Of the 3 tumor samples that did not demonstrate acceptable TIL product attributes, one (ID 1) was from a patient treated with a CXCR4 inhibitor <1 month before resection, another (ID 4) was from a patient previously treated with ocrelizumab (CD20-directed cytolytic antibody) for multiple sclerosis, and the final (ID 8) was harvested from the cryoablated tumor nodule rather than the adjacent recurrent tumor.

Abstract 176 Table 1

Baseline demographics and tumor characteristics

Abstract 176 Table 2

Summary of product attributes. 1, No CD3+ subset. 2, Product not available to test

Conclusions

These feasibility data suggest that TIL can be successfully expanded ex vivo from RCC samples (including pre-treated and metastatic tumors) and support potential clinical investigation of TIL in patients with RCC.

References

Sarnaik AA, Hamid O, Khushalani NI, Lewis KD, Medina T, Kluger HM, Thomas SS, Domingo-Musibay E, Pavlick AC, Whitman ED, Martin-Algarra S, Corrie P, Curti BD, Oláh J, Lutzky J, Weber JS, Larkin JMG, Shi W, Takamura T, Jagasia M, Qin H, Wu X, Chartier C, Graf Finckenstein F, Fardis M, Kirkwood JM, Chesney JA. Lifileucel, a Tumor-Infiltrating Lymphocyte Therapy, in Metastatic Melanoma. J Clin Oncol 2021 May 12:JCO2100612. doi: 10.1200/JCO.21.00612. Epub ahead of print. PMID: 33979178.

Ethics Approval

This study was approved by the DF/HCC Institutional Review Board protocol # 06-105.

Metacognitive therapy versus cognitive-behavioral therapy in adults with generalized anxiety disorder: A 9-year follow-up study

OBJECTIVE

Metacognitive therapy (MCT) and cognitive-behavior therapy (CBT) are effective treatments for generalized anxiety disorder. In this study, we followed-up patients who had previously participated in a randomized controlled trial of MCT compared against CBT.

METHOD

We collected 9-year follow-up data on 39 out of 60 original patients (i.e., 65% response rate).

RESULTS

At 9 years, the recovery rates were 57% for MCT and 38% for CBT (completer analysis). Following MCT, 43% maintained their recovery status and a further 14% achieved recovery. Following CBT, the sustained recovery rate was 13%, while a further 25% achieved recovery. Patients in the MCT condition showed significantly more improvement with respect to symptoms of worry and anxiety. In the CBT group, 23.1% were re-diagnosed with generalized anxiety disorder (GAD) compared with 9.5% in the MCT group.

CONCLUSIONS

This follow-up study showed a continuation of gains in both treatments at long-term follow-up, but with outcomes continuing to favor MCT and strengthening its comparative superiority.

Metacognitive Beliefs Uniquely Contribute to Interpersonal Problems: A Test Controlling for Adult Attachment, Big-5 Personality Traits, Anxiety, and Depression

Interpersonal difficulties are common across psychological disorders and are a legitimate target of treatment. Psychotherapeutic models differ in their understanding of interpersonal problems and how these problems are formulated and treated. It has been suggested that they are both the cause and effect of emotional distress symptoms, that they result from early attachment experiences, and that they are related to personality dimensions. However, the metacognitive model of psychopathology predicts that emotion disorder symptoms and interpersonal problems are linked to a common set of factors involving dysfunctional metacognition. In support of this view, metacognitive therapy has substantially reduced interpersonal problems in patients with anxiety and depression even though interpersonal problems are not directly targeted, indicating a role for metacognitive change. Nevertheless, the relationship between interpersonal problems and metacognitive beliefs remains underexplored, and the statistical control of emotion symptoms, personality, and attachment is important in substantiating any metacognition effects. The aim of the present study was therefore to test metacognitive beliefs as statistical predictors of interpersonal problems while controlling for anxiety/depression, adult attachment, and the Big-5 personality dimensions. In a cross-sectional study, 296 participants completed a battery of self-report questionnaires. We found that positive- and negative-metacognitive beliefs, cognitive confidence, and cognitive self-consciousness accounted for significant and unique variance in interpersonal problems together with avoidant attachment and conscientiousness when the overlap between all predictors was controlled. These findings support the notion that metacognitive beliefs are relevant to interpersonal problems with the potential implication that metacognitive therapy could have particularly broad effects on both emotion disorder symptoms and interpersonal problems.

Metacognition, rumination and suicidal ideation: An experience sampling test of the self-regulatory executive function model

A relationship between rumination and suicidal ideation is well-evidenced. A role for thought suppression has also been suggested but under-explored. The present study assessed the relative contribution of rumination and a range of thought control strategies in the understanding of suicidal ideation, within the theoretical framework of the self-regulatory executive function (S-REF) model (Wells & Matthews, 2015). Twenty-four participants who had experienced suicidal ideation in the last two months completed trait-level measures of metacognitive beliefs and momentary sampling measures of thought control strategy use, rumination and suicidal ideation over six days. Maladaptive thought control strategy use (worry and punishment), alongside rumination, predicted suicidal ideation. Adaptive strategies (distraction, social control and reappraisal) emerged as negative predictors. Metacognitive beliefs about the need to control thoughts predicted the use of punishment- but not worry-based thought control strategies. Thought control strategy use is as important in the development of suicidal ideation as rumination. The S-REF model represents a promising new approach to understanding these processes in the development of suicidal ideation.

Delivery preferences for psychological intervention in cardiac rehabilitation: a pilot discrete choice experiment

Background

Cardiac rehabilitation (CR) is a programme of care offered to people who recently experienced a cardiac event. There is a growing focus on home-based formats of CR and a lack of evidence on preferences for psychological care in CR. This pilot study aimed to investigate preferences for delivery attributes of a psychological therapy intervention in CR patients with symptoms of anxiety and/or depression.

Methods

A discrete choice experiment (DCE) was conducted and recruited participants from a feasibility trial. Participants were asked to choose between two hypothetical interventions, described using five attributes; intervention type (home or centre-based), information provided, therapy manual format, cost to the National Health Service (NHS) and waiting time. A separate opt-out was included. A conditional logit using maximum likelihood estimation was used to analyse preferences. The NHS cost was used to estimate willingness to pay for aspects of the intervention delivery.

Results

35 responses were received (39% response rate). Results indicated that participants would prefer to receive any form of therapy compared with no therapy. Statistically significant results were limited, but included participants being keen to avoid not receiving information prior to therapy (β=−0.270; p=0.03) and preferring a lower cost to the NHS (β=−0.001; p=0.00). No significant results were identified for the type of psychological intervention, format of therapy/exercises and programme start time. Coefficients indicated preferences were stronger for home-based therapy compared with centre-based, but this was not significant.

Conclusions

The pilot study demonstrates the feasibility of a DCE in this group, it identifies potential attributes and levels, and estimates the sample sizes needed for a full study. Preliminary evidence indicated that sampled participants tended to prefer home-based psychological therapy in CR and wanted to receive information before initiating therapy. Results are limited due to the pilot design and further research is needed.

Cardiac rehabilitation patients experiences and understanding of group metacognitive therapy: a qualitative study

OBJECTIVE

Depression and anxiety are up to three times more prevalent in cardiac patients than the general population and are linked to increased risks of future cardiac events and mortality. Psychological interventions for cardiac patients vary in content and are often associated with weak outcomes. A recent treatment, metacognitive therapy (MCT) has been shown to be highly effective at treating psychological distress in mental health settings. This is the first study to explore qualitatively, cardiac rehabilitation (CR) patients' experiences and understanding of group MCT with the aim of examining aspects of treatment that patients experienced as helpful.

METHODS

In-depth qualitative interviews were conducted with 24 purposively sampled CR patients following group MCT. Data were analysed using thematic analysis.

RESULTS

Two main themes were identified: (1) general therapy factors that were seen largely as beneficial, where patients highlighted interaction with other CR patients and CR staff delivery of treatment and their knowledge of cardiology; (2) group MCT-specific factors that were seen as beneficial encompassed patients' understanding of the intervention and use of particular group MCT techniques. Most patients viewed MCT in a manner consistent with the metacognitive model. All the patients who completed group MCT were positive about it and described self-perceived changes in their thinking and well-being. A minority of patients gave specific reasons for not finding the treatment helpful.

CONCLUSION

CR patients with anxiety and depression symptoms valued specific group MCT techniques, the opportunity to learn about other patients, and the knowledge of CR staff. The data supports the transferability of treatment to a CR context and advantages that this might bring.

Improving the Effectiveness of Psychological Interventions for Depression and Anxiety in Cardiac Rehabilitation: PATHWAY-A Single-Blind, Parallel, Randomized, Controlled Trial of Group Metacognitive Therapy

Supplemental Digital Content is available in the text.

Depression and anxiety in cardiovascular disease are significant, contributing to poor prognosis. Unfortunately, current psychological treatments offer mixed, usually small improvements in these symptoms. The present trial tested for the first time the effects of group metacognitive therapy (MCT; 6 sessions) on anxiety and depressive symptoms when delivered alongside cardiac rehabilitation (CR).

Covid-19, Lockdown and Self-Isolation: Evaluation of Deliberate Self-Harm Admissions

Background: COVID 19 is still presenting a clear and dynamic global threat. The United Kingdom remains one of the hardest hit countries from the pandemic. In January 2021 parliament announced that the UK will be entering a full national lockdown. This paper explores what effect lockdown measures had on rates of deliberate self-harm presentations to one NHS trust in Manchester UK. Methods: This paper compared the number of cases of deliberate self-harm which presented to the emergency department of Manchester Royal Infirmary for March-May in 2018, 2019 and 2020. This was achieved by utilising coding from emergency department data and reviewing hospital records surrounding each case. Results: 2018 recorded a total of 101 admissions as a result of DSH with all causes admissions of 8,514 making the proportions of admissions due to self-harm 1.19%. In 2019, 9,038 patients were admitted, of these, 130 (1.44%) were identified as DSH. In 2020 the total number of admissions fell to 5,676 with 118 admitted due to self-harm, representing 2.08% of admissions. The absolute number of admissions remained stable however the proportion of admissions due to self-harm was significantly higher in 2020 (p < 0.001). Other significant findings include a higher proportion of male admissions compared to females in 2020 (58.5%) and a decrease in the normal of cases relating to paracetamol overdose in 2020. Discussion: The findings demonstrated by this study do not indicate that lockdown is an absolute risk for DSH behaviours however it does illustrate the stable nature of these cases despite and dramatic decline in all cause admissions. The rate of increase of deliberate self-harm accelerated significantly between March and May in 2020. Steps must be taken to avoid a similar situation following the 2021 lockdown and beyond - focus on improving access to certain virtual services may help to achieve this goal.

DESIGN OPTIMIZATION OF THE HOLOS-QUAD MICRO-REACTOR CONCEPT

The Holos-Quad micro-reactor concept is proposed by HolosGen LLC to generate 22 MWt with a lifetime of approximately 8 effective full power years (EFPYs) for civilian applications. The design is based on a very innovative high-temperature gas-cooled reactor concept using four Subcritical Power Modules (SPMs) that fit into one commercial 40-foot transport ISO container. A rigorous design approach was employed in order to ensure that all input parameters were fully investigated and the best solutions possible were considered. The first step of this approach consisted of properly defining the Holos-Quad design problem by identifying the design objectives, the operational constraints, and the input parameters. In the second step, a sensitivity analysis was performed to enable a preliminary investigation of the input parameters to identify the correlations among input and output variables. Finally, the design optimization was performed in the third step, employing a genetic algorithm to effectively explore the highly constrained input parameters and find global optimal solutions. The multi-objective optimization identified various core solutions that would be optimum solutions for different types of applications. For applications where economics matters less and the ease of transportation matters more, a core weight of ~15 tons could achieve a lifetime of ~3.5 EFPYs. For applications where economics matters more and the ease of transportation matters less, a lifetime of 8.3 EFPYs could be achieved with a total core weight of ~26.7 tons.

NEUTRONIC BENCHMARK ON HOLOS-QUAD MICRO-REACTOR CONCEPT

The Holos-Quad micro-reactor concept is proposed by HolosGen LLC for civilian applications to generate 22 MWt with a lifetime of approximately 8 effective full power years (EFPYs). The design is based on a very innovative high-temperature gas-cooled reactor concept using four Subcritical Power Modules (SPMs) that fit into one commercial 40-foot transport ISO container. Neutronics benchmarks were developed based on a preliminary version of the Holos-Quad design to confirm feasibility of the neutronics design of this non-traditional high temperature gas-cooled (HTGR)-type micro-reactor concept. Calculations were performed using Monte Carlo codes (SERPENT and OpenMC) as well as the PROTEUS high-fidelity deterministic code for two exercises based on a unit cell model and a full core model. The results obtained showed good agreement with all of the evaluated parameters for the unit cell problem and the full core problem. SERPENT and OpenMC display consistently good agreement in eigenvalue within 150 pcm for the unit cell benchmark and less than 270 pcm for the full core benchmark. PROTEUS eigenvalues showed relatively larger differences but still reasonable agreement with the SERPENT solutions. For the depletion benchmark, the observed eigenvalue differences between SERPENT and OpenMC were within 300 pcm throughout the depletion up to 100 GWd/MT, ensuring that the two codes used equivalent input parameters such as the recoverable heat values for fission reactions. This benchmark exercise confirms the neutronic feasibility and core performance of the preliminary Holos-Quad design.

Validation of a Chinese version of the short form of Metacognitions Questionnaire (MCQ-30)

BACKGROUND

This study investigated the psychometric properties of a Chinese version of the short form of Metacognitions Questionnaire (MCQ-30), which is an effective tool to assess metacognitive beliefs that have been linked to mental disturbance/disorder. We also tested whether metacognition factors would correlate with Internet gaming disorder (IGD) tendency.

METHODS

Six hundred and eighty Chinese university students (Mean age=19.72, SD=1.38; 31.9% male) voluntarily completed an anonymous online questionnaire. Using standard translation procedures, the MCQ-30 items were translated from English into Chinese language and then back-translated. Depression, anxiety, and IGD tendency were assessed by validated scales.

RESULTS

Confirmatory factor analysis (CFA) results supported the five-factor structure of the MCQ-30, with satisfactory model fit and good reliability. Criterion-related validity was also supported by significant positive correlations between the five factors and depression/anxiety symptoms. All of the five metacognition factors were also significantly correlated with IGD tendency, with positive beliefs about worry and cognitive confidence being the most salient factor after controlling for gender and age.

LIMITATIONS

This study did not examine the test-retest reliability of this scale, and the generalizability of the findings to other age groups remains unclear.

CONCLUSIONS

This study showed satisfactory psychometric properties of a Chinese version of the MCQ-30 and is the first to demonstrate a positive association between specific metacognition factors and IGD tendency among Chinese people. The latter finding supports an application of metacognitive therapy to the treatment of behavioral addictions, including IGD.

Treatment of a heart base tumor and chylothorax with endovascular stent, stereotactic body radiation therapy, and a tyrosine kinase inhibitor in a dog

An 8-year-old 28-kg male castrated rough collie was evaluated for persistent chylothorax secondary to right atrial mass. Cardiac ultrasound and computed tomography revealed a right atrial intra- and extraluminal mass with partial obstruction of the cranial vena cava and secondary chylothorax. Vascular stent placement was elected to alleviate cranial vena cava obstruction and secondary chylothorax. An 18 mm × 180 mm self-expanding stent was deployed in the region of the stricture, spanning the cranial vena cava and right atrium. An intrathoracic drainage catheter and subcutaneous port were placed within the right hemithorax, and antiplatelet therapy was initiated. Four weeks later, the dog underwent stereotactic body radiation therapy. Three months following treatment, the dog was diagnosed with supraventricular tachycardia and received antiarrhythmic therapy and antiangiogenic/antiproliferative medication (Palladia™). Subsequent evaluations confirmed the resolution of arrhythmia and pleural effusion. Combined vascular stent placement and stereotactic body radiation therapy for the treatment of a right atrial intraluminal and extraluminal mass leading to cranial vena cava compression and subsequent chylothorax may lead to long-term survival. A good outcome was achieved in this patient due to resolution of pleural effusion, as well as cytoreduction and presumably delayed progression of tumor growth.

Protocol for the economic evaluation of metacognitive therapy for cardiac rehabilitation participants with symptoms of anxiety and/or depression

INTRODUCTION

Cardiac rehabilitation (CR) is offered to reduce the risk of further cardiac events and to improve patients' health and quality of life following a cardiac event. Psychological care is a common component of CR as symptoms of depression and/or anxiety are more prevalent in this population, however evidence for the cost-effectiveness of current interventions is limited. Metacognitive therapy (MCT), is a recent treatment development that is effective in treating anxiety and depression in mental health settings and is being evaluated in CR patients. This protocol describes the planned approach to the economic evaluation of MCT for CR patients.

METHODS AND ANALYSIS

The economic evaluation work will consist of a within-trial analysis and an economic model. The PATHWAY Group MCT study has been prospectively designed to collect comprehensive self-reported resource use and health outcome data, including the EQ-5D, within a randomised controlled trial study design (UK Clinical Trials Gateway). A within-trial economic evaluation and economic model will compare the cost-effectiveness of MCT plus usual care (UC) to UC, from a health and social care perspective in the UK. The within-trial analysis will use intention-to-treat and estimate total costs and quality-adjusted life-years (QALYs) for the trial follow-up. Single imputation will be used to impute missing baseline variables. Multiple imputation will be used to impute values missing at follow-up. Items of resource use will be multiplied by published national healthcare costs. Regression analysis will be used to estimate net costs and net QALYs and these estimates will be bootstrapped to generate 10 000 net pairs of costs and QALYs to inform the probability of cost-effectiveness. A decision analytical economic model will be developed to synthesise trial data with the published literature over a longer time frame. Sensitivity analysis will explore uncertainty. Guidance of the methods for economic models will be followed and dissemination will adhere to reporting guidelines.

ETHICS AND DISSEMINATION

The economic evaluation includes a within-trial analysis. The trial which included the collection of this data was reviewed and approved by Ethics. Ethics approval was obtained by the Preston Research Ethics Committee (project ID 156862). The modelling analysis is not applicable for Ethics as it will use data from the trial (secondary analysis) and the published literature. Results of the main trial and economic evaluation will be published in the peer-reviewed National Institute for Health Research (NIHR) journals library (Programme Grants for Applied Research), submitted to a peer-reviewed journal and presented at appropriate conferences.

TRIAL REGISTRATION NUMBER

ISRCTN74643496; Pre-results.

Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: A systematic review

Anxiety and depression are common among patients with chronic physical illnesses and have a significant impact on morbidity, quality of life, and health service utilisation. Psychological treatment of anxiety and depression has small to moderate efficacy in this group and is not commonly based on a model of causal mechanisms. A novel approach to understanding and improving mental health outcomes in physical illnesses is needed. One approach may be to explore the role of metacognitive beliefs which are reliably associated with anxiety and depression in individuals with mental health difficulties. The current systematic review aimed to evaluate the contribution of metacognitive beliefs to anxiety and depression across physical illnesses. Systematic searches were conducted on Web of Science, PsychINFO, MEDLINE, Embase, and CINAHL of studies published between 1997 and January 2019. 13 eligible studies were identified that in sum comprised 2851 participants. Metacognitive beliefs were found to have reliable, moderate, positive and significant associations with anxiety and depression symptoms across a range of physical illnesses. There appeared to be commonality and some specificity in the relationships. Negative metacognitive beliefs concerned with uncontrollability and danger of worry were associated with both anxiety and depression across all physical illnesses assessed, whilst more specific associations emerged for individual medical conditions where positive beliefs about worry, cognitive confidence and cognitive self-consciousness were unique correlates. Negative metacognitive beliefs of uncontrollability and danger significantly and positively predicted symptoms of anxiety and depression after controlling for factors including age, gender, disease factors and cognition (illness perceptions and intolerance of uncertainty). The results suggest that the metacognitive model of psychological disorder is applicable to psychological symptoms of anxiety and depression across a range of chronic medical conditions, implying that metacognitive therapy might be helpful in improving outcomes in multiple morbidities that involve poor mental and medical health.

Utilising Patient and Public Involvement in Stated Preference Research in Health: Learning from the Existing Literature and a Case Study

Publications reporting discrete choice experiments of healthcare interventions rarely discuss whether patient and public involvement (PPI) activities have been conducted. This paper presents examples from the existing literature and a detailed case study from the National Institute for Health Research-funded PATHWAY programme that comprehensively included PPI activities at multiple stages of preference research. Reflecting on these examples, as well as the wider PPI literature, we describe the different stages at which it is possible to effectively incorporate PPI across preference research, including the design, recruitment and dissemination of projects. Benefits of PPI activities include gaining practical insights from a wider perspective, which can positively impact experiment design as well as survey materials. Further benefits included advice around recruitment and reaching a greater audience with dissemination activities, amongst others. There are challenges associated with PPI activities; examples include time, cost and outlining expectations. Overall, although we acknowledge practical difficulties associated with PPI, this work highlights that it is possible for preference researchers to implement PPI across preference research. Further research systematically comparing methods related to PPI in preference research and their associated impact on the methods and results of studies would strengthen the literature.

Abstract A05: Expansion of tumor-infiltrating lymphocytes (TIL) using Iovance's Gen 2 process from advanced bladder cancer for adoptive immunotherapy

Background: Patients with advanced bladder cancer have limited therapeutic options, apart from cisplatin-based chemotherapy and use of immune checkpoint inhibitors (ICI). Median survival for patients with metastatic disease is 15 to 18 months. Hence there is a need for more effective therapies. Adoptive cell therapy using tumor-infiltrating lymphocytes (TIL) has demonstrated durable and complete responses with long-term survival of &gt; 10 years in patients with metastatic melanoma. Previous attempts to generate TIL from bladder cancer showed some success; however, the process required an extended manufacturing time (35–50+ days). Iovance has developed a second-generation GMP manufacturing process (Gen 2) with a significantly reduced time to expand functional TIL from melanoma, cervical, and head and neck tumors. The goal of this study was to determine the feasibility of generating TIL from patient-derived bladder cancer tumor specimens using the 22-day Iovance Gen 2 manufacturing process.

Methods: The TIL manufacturing process for the resected bladder tumor samples includes a pre-Rapid Expansion Protocol (pre-REP) and Rapid Expansion Protocol (REP) over 22 days. Pre-REP (1/10th scale) and REP (1/100th scale) was performed to align with the Iovance Gen 2 manufacturing process. During the pre-REP 1- to 3-mm size tumor fragments are placed in media containing IL-2 for 11 days. To further stimulate TIL growth, TIL are expanded using REP that includes irradiated PBMC feeders, IL-2, and anti-CD3 for 11 days. Release testing parameters (total viable cells, % viability, TIL phenotype) were tested on the harvested final product. TIL purity, differentiation, memory, activation, and exhaustion status were extensively characterized using multicolor flow cytometry. TIL functionality was determined by measuring IFNγ and Granzyme B release after restimulation.

Results: Four bladder tumor samples were obtained from Roswell Park Comprehensive Cancer Center (RPCCC). Total viable count of REP TIL harvested on Day 22 was 18.4 +/- 8.9 × 109 (numbers adjusted to full scale), with 92.7 +/- 2.5% viability at harvest. The phenotype of harvested TIL were 92.4 +/- 4.8% CD3+/CD45+ cells, and non-T cell population including B cells and NK cells were &lt; 4%. TIL expanded from bladder cancer samples secreted IFNγ and Granzyme B in response to anti-CD3/CD28/CD137 beads at similar levels to Iovance-manufactured melanoma TIL.

Conclusions: All four bladder carcinoma-derived TIL have demonstrated growth, phenotype, and function comparable to that for other tumor types (i.e., melanoma, cervical, HNSCC). TIL generation from bladder cancer samples is feasible and allows for the application of Iovance's Gen 2 manufacturing process for an autologous cellular infusion product to treat bladder cancer patients. An early-phase trial testing autologous TIL therapy in transitional cell cancer of the urothelium is being planned.

Citation Format: Qiang J. LI, Khurshid Guru, Amit Lugade, Elizabeth Brese, Kunle Odunsi, Anand Veerapathran, Kenneth Onimus, Adrian Wells, Cecile Chartier, Arvind Natarajan, Maria Fardis, Gurkamal Chatta. Expansion of tumor-infiltrating lymphocytes (TIL) using Iovance's Gen 2 process from advanced bladder cancer for adoptive immunotherapy [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2019 May 18-21; Denver, CO. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(15_Suppl):Abstract nr A05.

Metacognition in Cardiac Patients With Anxiety and Depression: Psychometric Performance of the Metacognitions Questionnaire 30 (MCQ-30)

The evaluation of effective psychological therapies for anxiety and depression in cardiac patients is a priority, and progress in this area depends on the suitability and validity of measures. Metacognitive Therapy is a treatment with established efficacy in mental health settings. It postulates that anxiety and depression are caused by dysfunctional metacognitions, such as those assessed with the Metacognitions Questionnaire 30 (MCQ-30), which impair effective regulation of repetitive negative thinking patterns. The aim of this study was to examine the psychometric properties of the MCQ-30 in a cardiac sample. A sample of 440 cardiac patients with co-morbid anxiety and/or depression symptoms completed the MCQ-30 and the Hospital Anxiety and Depression Scale. Confirmatory factor analysis (CFA) was used to test established factor structures of the MCQ-30: a correlated five-factor model and a bi-factor model. The five-factor model just failed to meet our minimum criteria for an acceptable fit on Comparative Fit Index (CFI) = 0.892 vs. criterion of ≥ 0.9; but was acceptable on the Root Mean Square Error of Approximation (RMSEA) = 0.061 vs. ≤ 0.08; whereas the bi-factor model just met those criteria (CFI = 0.913; RMSEA = 0.056). These findings suggest that the bi-factor solution may carry additional information beyond the five subscale scores alone. However, such a model needs to be evaluated further before widespread adoption could be recommended. Meantime we recommend cautious continued use of the five-factor model. Structural issues aside, all five subscales demonstrated good internal consistency (Cronbach alphas > 0.7) and similar relationships to HADS scores as in other patient populations. The MCQ-30 accounted for additional variance in anxiety and depression after controlling for age and gender.

Establishing the Feasibility of Group Metacognitive Therapy for Anxiety and Depression in Cardiac Rehabilitation: A Single-Blind Randomized Pilot Study

BACKGROUND

Anxiety and depression are common in cardiac rehabilitation (CR) patients. However, CR programs which incorporate psychological techniques achieve modest reductions in emotional distress. More efficacious interventions that can be easily integrated within services are required. A promising alternative to current psychological interventions is metacognitive therapy (MCT). The aim was to evaluate the acceptability and feasibility of delivering Group-MCT to CR patients experiencing symptoms of anxiety and depression.

METHOD AND RESULTS

Fifty-two CR patients with elevated anxiety and/or depression were recruited to a single-blind randomized feasibility trial across three UK National Health Service Trusts and randomized to usual CR or usual CR plus six weekly sessions of group-MCT. Acceptability and feasibility of adding group-MCT to CR was based on recruitment rates, withdrawal, and drop-out by the primary end-point of 4 months; number of MCT and CR sessions attended; completion of follow-up questionnaires; and ability of the outcome measures to discriminate between patients. The study was also used to re-estimate the required sample size for a full-scale trial. We also examined the extent by which non-specialists adhered to the Group-MCT protocol. Group-MCT was found to be feasible and acceptable for CR patients with anxiety and depression. Recruitment and retention of participants was high, and attendance rates at CR were similar for both groups.

CONCLUSION

The results suggest the addition of MCT to CR did not have a negative impact on retention and support a full-scale trial of Group-MCT for cardiac patients.

Metacognitive Therapy for Depression: A 3-Year Follow-Up Study Assessing Recovery, Relapse, Work Force Participation, and Quality of Life

A major challenge in the treatment of depression has been high relapse rates following treatment. The current study reports results from a 3-year follow-up of patients treated with metacognitive therapy (MCT). Thirty-four of the 39 patients enrolled in the original study attended assessment (participation rate of 87%). There were large reductions in symptoms of depression, anxiety, interpersonal problems, and worry, as well as metacognitive beliefs. Three patients fulfilled diagnostic criteria for axis-I disorders: one with depression and two with generalized anxiety disorder. Sixty percent had not experienced any new depressive episodes in the 3-year follow-up period, and the static relapse rates were low (11-15%). Recovery rates ranged from 69 to 97% depending upon the four different criteria used. Nevertheless, 26% had sought out treatment for depression or other psychological difficulties. Most patients (70%) had experienced negative life events in the follow-up period, but these events did not influence current depression severity. Return to work outcomes were encouraging, as eight out of 13 patients that had been on benefits were no longer receiving benefits. Life satisfaction ratings showed mean scores around 70 (on a 0-100 scale) and showed a moderate to strong negative correlation with depression severity. In conclusion, MCT appears to be promising with respect to long-term effect. Randomized controlled trials should investigate if the long-term effect of MCT surpasses that of other evidence-based treatments for depression.

Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health

The self-regulatory executive function (S-REF) model explains the role of strategic processes and metacognition in psychological disorder and was a major influence on the development of metacognitive therapy. The model identifies a universal style of perseverative negative processing termed the cognitive attentional syndrome (CAS), comprised of worry, rumination, and threat monitoring in the development of disorder. The CAS is linked to dysfunctional metacognitions that include beliefs and plans for regulating cognition. In this paper, I extend the theoretical foundations necessary to support further research on mechanisms linking metacognition to cognitive regulation and effective treatment. I propose a metacognitive control system (MCS) of the S-REF that can be usefully distinguished from cognition and is comprised of multiple structures, information, and processes. The MCS monitors and controls activity of the cognitive system and regulates the behavior of neural networks whose activities bias the way cognition is experienced. Metacognitive information involved in the regulation of on-line processing includes metacognitive beliefs, metacognitive procedural commands, and more transient cybernetic code. Separation of the cognitive and metacognitive systems and modeling their relationship presents major implications concerning what should be done in therapy and how it should be done. The paper concludes with an in-depth consideration of methods that strengthen the psychological basis of psychotherapy and aid in understanding and applying metacognitive therapy in particular. Finally, limitations of the model and implications for future research on self-awareness, self-regulation, and metacognition are discussed.

What Comes First Metacognition or Negative Emotion? A Test of Temporal Precedence

The Self-Regulatory Executive Function model predicts that emotional symptoms and metacognition can causally affect each other. Crucially, for the model metacognition must cause emotion disorder symptoms. Therefore, in time-series data involving repeated measurements, metacognitions should predict subsequent changes in emotion. 265 participants completed a questionnaire battery three times over a 2 month period. Structural equation modeling (SEM) using cross-lagged panel analysis tested the inter-relationships between metacognitive beliefs, anxiety and depression symptoms over time. The cross-lagged structural model was a significantly better fit than the autoregressive model. Metacognitive beliefs were found to predict subsequent symptoms of anxiety while symptoms of anxiety predicted later metacognition over different time courses. The metacognition factor representing uncontrollability and danger of thoughts appeared to be prominent in the effects observed. Metacognitions and depression were also positively related over time to a lesser degree, but in the cross-lagged model these temporal relationships were non-significant. This is likely due to low levels of depression within the sample and low variability over time. The findings for anxiety are consistent with the S-REF model and with experimental and prospective studies supporting metacognitive beliefs as a causal mechanism in psychological distress symptoms.