Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Effect of Fluid and Caffeine Management on Quality of Life in Older Women with Overactive Bladder in Rural Korea: A Pilot Study

Purpose

This study aimed to investigate the effectiveness of the simplified intervention, consisting of fluid and caffeine management alone in older women with overactive bladder symptoms.

Patients and Methods

A quasi-experimental pretest-posttest design was used. Rural, community-dwelling older women were recruited at four senior centers in South Korea. Of the 63 participants initially enrolled, 34 met the inclusion criteria. One group (n = 15) used fluid and caffeine management alone (FM), and the other group (n = 12) used a combination of fluid and caffeine management and pelvic floor muscle training (FM+PFMT). Urinary symptom-specific health-related quality of life was measured using the Korean version of KHQ. Sleep quality was measured using the Pittsburgh Sleep Quality Index. After the intervention, participants were assessed 4 and 8 weeks. A linear mixed model was used for the analysis.

Results

The mean age of the participants was 74.44 ± 5.67 years. Among the nine domains of KHQ, impact on life and physical limitations decreased significantly in both groups, without significant between-group differences. Sleep/energy increased in both groups, and the scores in the FM+PFMT group were significantly improved. The number of micturition episodes per day and the quality of sleep did not differ significantly between the two groups.

Conclusion

A simplified intervention, consisting of fluid and caffeine management alone can be considered as the first-line intervention to improve health-related quality of life in rural, community-dwelling, older women with overactive bladder symptoms. Healthcare providers should consider providing a relatively simple, but equally effective intervention to maximize the adherence and effectiveness.

Perceived Negative Effects of Tic Management Strategies in Adults With Tic Disorders

Behavior therapy is a well-established and empirically supported treatment for tic disorders (TDs). However, concerns have been expressed about the negative effects of behavioral interventions, such as tic worsening, tic substitution, and excessive effort. This study explored perceived negative effects of tic management strategies in adults with TDs and predictors of these experiences. Participants (N = 72) completed semi-structured interviews 11 years after receiving behavior therapy or supportive therapy in a randomized clinical trial. We examined responses to interview questions about managing tics and predictors of reported negative effects. Most participants did not experience tic worsening (84%) or tic substitution (75%) from tic management strategies. The majority felt they could manage tics while participating in their environment (87%) and did not report life interference from tic management (77%). About half (45%) felt less present when managing tics. Treatment non-responders in the original trial were more likely to report negative effects of tic management strategies. No differences in reported negative consequences were found between those who received behavior therapy versus supportive therapy, suggesting that behavior therapy specifically does not lead to such adverse effects. These findings could reduce misconceptions about behavior therapy for TDs and enhance its acceptability and utilization.

Psychological therapies for depression in older adults residing in long-term care settings

BACKGROUND

Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

OBJECTIVES

To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions

ABSTRACT

The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

Body-Focused Repetitive Behavior Disorders in Children and Adolescents: Clinical Characteristics and Treatment Outcomes in a Naturalistic Setting

Body-focused repetitive behavior disorders, including trichotillomania (hair-pulling disorder) and excoriation (skin picking) disorder, typically emerge in early adolescence, but little is known about the clinical characteristics and treatment outcomes of these disorders in young people, particularly in real-world clinical settings. Participants were 63 children and adolescents (51 girls; age range 9-17) with a diagnosis of trichotillomania (n = 33) and/or skin-picking disorder (n = 33) attending a specialist outpatient clinic in Stockholm, Sweden. Demographic and clinical characteristics were gathered at the initial assessment. Of the 63 assessed youths, 56 received manual-based behavior therapy mainly focusing on habit reversal training, which was combined with medication when deemed appropriate. The mean clinician-reported trichotillomania and skin-picking disorder symptom severity at baseline (n = 63) was in the moderate range. We observed high rates of psychiatric comorbidity (63.5%) and use of psychiatric medication (54.8%). For the 56 individuals undertaking treatment at the clinic, mixed-effects regression models showed a significant decrease in symptom severity from baseline to posttreatment, with gains maintained up to the 12-month follow-up. Substantial and durable improvements were also seen on self-reported symptoms, self-reported depression, and global functioning. Specialist care should be made more widely available to improve the prognosis and quality of life of young people with trichotillomania and skin-picking disorder.

Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

Therapeutic exercises for idiopathic scoliosis in adolescents

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.

OBJECTIVES

To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.

MAIN RESULTS

We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (-MD 3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI 0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.

AUTHORS' CONCLUSIONS

The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.

Effects of a mobile health intervention on health-related outcomes in Japanese office workers: a pilot study

OBJECTIVES

The purpose of the current study was to explore the effects of a mobile health (mHealth) intervention based on the Persuasive System Design (PSD) model on health-related outcomes among office workers.

MATERIAL AND METHODS

The authors conducted a trial that consisted of a 4-week baseline and an 8-week intervention period by reference to 23 office workers in a private research company. The mHealth application was developed to improve these workers' daily step count, decrease their sedentary time, and increase their sleep duration in accordance with the PSD model. The app features included at least 1 principal factor from each of the 4 main categories of the PSD model (primary task support, dialogue support, system credibility support, and social support). The objective health-related variables were measured using a smartwatch (Fitbit Luxe) that was synchronized with the application using the Fitbit Web Application Programming Interface. Subjects used the app, which included self-monitoring, personalized messages, education, and a competition system for users, during the intervention period.

RESULTS

Sedentary time exhibited a significant decrease (a median reduction of 14 min/day, p < 0.05) during the intervention period. No significant differences in daily step count and sleep duration were observed between the baseline and intervention periods.

CONCLUSIONS

This study suggests that the mHealth intervention based on the PSD model was useful for reducing sedentary time among office workers. Given that many previous studies on this topic have not been based on any theories, future studies should investigate the impact of structured selection behavior change theories on health-related outcomes among office workers. Int J Occup Med Environ Health. 2024;37(2).

Overvaluation of shape/weight at posttreatment predicts relapse at 12-month follow-up after successful behaviorally-based treatment of binge-eating disorder

OBJECTIVE

To test whether overvaluation of shape/weight at the end of treatment prospectively predicts relapse at 12-month follow-up in patients with binge-eating disorder (BED).

METHOD

Participants were 129 patients with BED who achieved abstinence from binge eating after 6 months of behaviorally-based weight-loss treatments in a clinical trial. Independent assessments conducted at posttreatment and at 12-month follow-up included the Eating Disorder Examination interview, the Beck Depression Inventory, and weight measurements.

RESULTS

Of the 129 participants who attained abstinence from binge-eating at posttreatment, 46 (36%) were categorized with clinical overvaluation and 83 (64%) with subclinical overvaluation; 115 (89%) were re-assessed at 12-month follow-up. Participants with overvaluation at posttreatment were significantly more likely than those without to relapse at 12-months to non-abstinence from binge eating (54% vs. 28%) and to diagnosis-level binge-eating frequency of once weekly or greater (31% vs. 13%). Overvaluation at posttreatment predicted significantly higher eating-disorder psychopathology and depression scores at 12-month follow-up but were unrelated to weight and weight changes. Treatment groups did not have main or interaction effects; posttreatment overvaluation effects were observed regardless of treatment and of covarying for posttreatment value of dependent variables.

CONCLUSIONS

Our findings suggest that overvaluation of shape/weight at the end of treatment predicts relapse and heightened eating-disorder psychopathology and depression scores 1 year later in patients who achieved abstinence from binge eating with behaviorally-based treatments. Overvaluation of shape/weight has significant clinical implications and warrants consideration as a diagnostic specifier for BED as it provides important prospective prognostic information.

PUBLIC SIGNIFICANCE

Although effective treatments are available for binge-eating disorder, relapse following successful treatments is not uncommon. Almost nothing is known about what predicts relapse following treatments for binge-eating disorder. Our study found that overvaluation of shape/weight (i.e., body image concerns that overly impact self-worth) at posttreatment prospectively predicted relapse and higher eating-disorder psychopathology and depression 1 year later in patients who achieved binge-eating abstinence with behaviorally based treatments.

CLINICALTRIALS

gov registration: NCT00829283. (Treatment of obesity and binge eating: Behavioral weight loss vs. stepped care.).

Characterising individual variability in associations between self-monitoring and weight change during and after a behavioral weight management program

Objective

Greater self-monitoring of caloric intake and weight has been associated with success at both initial weight loss and long-term maintenance. Given the existence of wide variability in weight loss outcomes and the key role of self-monitoring within behavioral weight management interventions, this study examined individual variability in associations between self-monitoring and weight change and whether demographic factors could predict who may best benefit from self-monitoring.

Methods

Participants were 72 adults with overweight or obesity (mean ± SD, age = 50.6 ± 10.3; body mass index = 31.2 ± 4.5 kg/m2; 71%Female; 83%White) enrolled in a 12-week weight loss program followed by a 40-week observational maintenance period. Participants were encouraged to self-monitor caloric intake and weight daily and to report these data via a study website each week. Multilevel mixed models were used to estimate week-to-week associations between self-monitoring and weight change, by individual and linear regressions and ANOVAs were used to explore demographic differences in these associations.

Results

Most participants (68%) demonstrated statistically significant negative associations between self-monitoring of either caloric intake or weight and weight change. Of these, 76% benefited from self-monitoring both caloric intake and weight, 18% from self-monitoring caloric intake only, and 6% from self-weighing only. The magnitude of associations between self-monitoring and weight change did not significantly differ by age, gender, race/ethnicity, education, or income, all ps > 0.05.

Conclusions

Differences in the effectiveness of self-monitoring for weight loss were not observed by demographic characteristics. Future research should examine if other factors may predict the effectiveness of self-monitoring.

Behavioral Parent Training for School-Aged Children With ADHD: A Systematic Review of Randomized Control Trials

BACKGROUND

All guidelines for the treatment of ADHD in children include behavioral parent training in combination with other strategies. In the past, several systematic reviews have been carried out that were either outdated or not sufficiently specific to ADHD. We wanted to conduct a new review focusing on a specific ADHD population of school age (4-12 years) and on behavioral and cognitive programs. We aimed to test our hypothesis that behavioral parent training would improve parents' difficulties, children's symptomatology, and the quality of life of families with ADHD.

METHODS

PUBMED, PsychInfo, Web of Science, ERIC, and Cochrane databases were searched for original articles on randomized control trials on behavioral parent training group for children with ADHD aged from 4 to 12 years until July 2023.

RESULTS

A total of 20 studies were included in the systematic review. The results were divided into four categories: parent data, child data collected by parents, teachers, or researchers. A qualitative analysis revealed for parents, effects on parental stress, feelings of parental efficacy, and negative parental educational behavior. As regard children, only effects are noted for parental assessment, on ADHD symptomatology, externalized disorders, and social skills.

CONCLUSION

Despite the heterogeneity or small number of studies in some categories, BPTs have positive effects on both parents and children. There are no convincing results to support the generalization of progress. This would seem to indicate that it remains essential to consider actions specific to each problematic environment for the child.

Predicting high-risk periods for weight regain following initial weight loss

OBJECTIVE

The aim of this study was to develop a predictive algorithm of "high-risk" periods for weight regain after weight loss.

METHODS

Longitudinal mixed-effects models and random forest regression were used to select predictors and develop an algorithm to predict weight regain on a week-to-week basis, using weekly questionnaire and self-monitoring data (including daily e-scale data) collected over 40 weeks from 46 adults who lost ≥5% of baseline weight during an initial 12-week intervention (Study 1). The algorithm was evaluated in 22 adults who completed the same Study 1 intervention but lost <5% of baseline weight and in 30 adults recruited for a separate 30-week study (Study 2).

RESULTS

The final algorithm retained the frequency of self-monitoring caloric intake and weight plus self-report ratings of hunger and the importance of weight-management goals compared with competing life demands. In the initial training data set, the algorithm predicted weight regain the following week with a sensitivity of 75.6% and a specificity of 45.8%; performance was similar (sensitivity: 81%-82%, specificity: 30%-33%) in testing data sets.

CONCLUSIONS

Weight regain can be predicted on a proximal, week-to-week level. Future work should investigate the clinical utility of adaptive interventions for weight-loss maintenance and develop more sophisticated predictive models of weight regain.

New Therapy for a New Normal: Comparing Telehealth and in-Person Time-Limited Parent-Child Interaction Therapy

Telehealth treatment for child disruptive behavior has the potential to overcome multiple barriers to access (e.g., transportation, therapist availability). Traditional Parent-Child Interaction Therapy (PCIT) has demonstrated efficacy via telehealth in randomized controlled trials. The current study extends this research by examining community-based effectiveness of time-limited (i.e., 18 week) telehealth PCIT, comparing intake and posttreatment child behavior and caregiver skills for both telehealth and in-person PCIT. Participants included predominantly racially, ethnically, linguistically, and socioeconomically diverse children aged 2 to 8 years, and their caregivers. Dyads (N = 380) received either telehealth (IPCIT) or in-person PCIT.Propensity score analyses were conducted to address potential selection bias due to the nonrandomized sample. Regression analyses revealed no difference between IPCIT and in-person treatment for child disruptive behaviors or compliance outcomes. However, caregivers who received IPCIT demonstrated fewer positive statements and greater corrective/directive statements at posttreatment than caregivers who received in-person treatment.This research demonstrated that time-limited IPCIT can effectively improve child disruptive behavior among a socioeconomically, linguistically, and culturally diverse population, and represents the largest sample to date demonstrating the effectiveness of PCIT via telehealth. Future research is warranted to document intervention sustainability on a more system-wide level, and balance prioritizing caregiver skill acquisition over family-derived treatment goals.

Utilization of Counseling Services by Pediatric Patients With Obesity Using MarketScan Data (2017-2019)

The United States has implemented policy efforts for public and private insurance to cover counseling services related to the treatment of obesity. However, no research has yet studied counseling service utilization among pediatric patients with obesity. We used 3 years (2017-2019) of IBM MarketScan Commercial Claims and Encounters Database and IBM MarketScan Multi-State Medicaid Data to examine such utilization patterns. We found the proportion of patients receiving any counseling services to be low among both privately insured (7.06%-7.97%) and Medicaid patients (9.51%-11.61%) within 6 months from diagnosis of obesity. This underutilization is concerning as many pediatric patients go undiagnosed, as evidenced in this research. Among the utilized services, nutrition counseling and face-to-face counseling were utilized the most by privately and Medicaid-insured patients over 6- and 12-month follow-ups. Our study underscores the need for implementing policies and programs to promote the utilization of counseling services among pediatric patients.

From direct contingencies to derived relations: the ever-developing nature of theory and practice in behavior analysis

Purpose

To illustrate the processes of development within the behavioral theory and the corresponding expansion of the areas in which it is applied, especially the advancement (conceptual developments) of the functional analysis of language inspired by Relational Frame Theory (RFT) research.

Views

Classical and operant conditioning are well-established behavioral learning processes, discovered and described at the beginning of the twentieth century. They provide the tools for analyzing, establishing and modifying the functions of stimuli and responses of the organisms through manipulation of the environment. Although B. F. Skinner provided grounds for the functional analysis of complex behaviors such as language, it was not until the beginning of the twenty-first century that RFT was introduced. From this moment behavior analysts could use behavioral principles to explain how stimulus functions may change without direct learning. The practical application of the growing knowledge about Arbitrarily Applicable Relational Responding (AARR), a basic generalized operant described within RFT, allows us to analyze, explain and change behaviors that had hitherto been beyond the scope of behavioral therapy. The continued growth and development of behavior theory and practice holds the promise for an expansion of its application to new areas and populations in need. One such development is the functional analysis of verbal behavior e.g., relational frames, ROE (relating-orienting-evoking).

Conclusions

It seems useful to add advancements proposed by RFT to the behavioral toolbox with which we could effectively describe, explain and change behavior with precision, scope and depth.

Working Mechanisms of Exposure and Response Prevention in the Treatment of Tourette Syndrome and Tic Disorders Revisited: No Evidence for within-Session Habituation to Premonitory Urges

BACKGROUND

Exposure and response prevention (ERP) has been shown to be an effective treatment for Tourette syndrome (TS) and chronic tic disorders (CTD). ERP is based on voluntary tic suppression in combination with prolonged exposure to premonitory urges preceding tics. A prevailing hypothesis of the working mechanism underlying ERP in tics is habituation to the premonitory urges as a result of prolonged exposure. However, results so far are equivocal. This study aims to further explore the relation between urges and ERP in tics, by investigating the course of premonitory urges during ERP sessions.

METHODS

Using a data-driven approach, within-session habituation to premonitory urge intensity was investigated. In total, 29 TS patients rated urge intensity at seven timepoints during ten 1 h ERP sessions.

RESULTS/CONCLUSIONS

Latent growth modeling showed an increase in urge intensity during the first 15 min of each session followed by a plateau in the remaining 45 min of the session. This does not support the idea of within-session habituation to premonitory urges as a working mechanism of ERP. Other potential underlying working mechanisms are discussed and should be tested in future research.

Bladder training compared to bladder training associated with pelvic floor muscle training for overactive bladder symptoms in women: A randomized clinical trial

AIMS

To compare the effects of bladder training (BT) versus BT with pelvic floor muscle training (PFMT) in women with overactive bladder (OAB) symptoms.

METHODS

Randomized controlled clinical trial including women with OAB symptoms, randomized into two groups: BT versus BT + PFMT. For 12 consecutive weeks, the women received home BT. The BT + PFMT performed supervised PFMT, once/week, associated at home PFMT protocol. Primary outcomes were urinary urgency, daytime voiding frequency, nocturia and urgency urinary incontinence assisted by both 3-day bladder diary and International Consultation on Incontinence OAB (ICIQ-OAB) questionnaire. Secondary outcomes were 24-h pad test and Patient Global Impression of Improvement. T-test, analysis of variance, Mann-Whitney (SPSS 20.0) and power/effect size (G-power) were applied in data analyses.

RESULTS

Sixty-three women were included (B = 31; BT + PFMT = 32). There was no significant statistical difference between groups in terms of urinary symptoms: daytime frequency (BT: pre: 11.59 [±5.80], post: 9.10 [±4.05]; BT + PFMT: pre: 10.67 [±3.73], post: 8.08 [±3.38]) p = 0.75; nocturia: (BT: pre: 1.46 [±0.91], post: 0.82 [±0.82]; BT + PFMT: pre: 1.80 [±2.26], post: 0.82 [±1.15]) p = 0.70; urinary urgency (BT: pre: 3.22 [±4.70], post: 4.49 [±4.32]; BT + PFMT: pre: 6.87 [±5.60], post: 6.15 [±4.52]) p = 0.10; ICIQ-OAB total score: (BT: pre: 9.16 [±2.55], post: 6.32 [±3.77]; (BT + PFMT: pre: 9.75 [±2.06], post: 5.06 [±3.44] p = 0.30.

CONCLUSIONS

Supervised PFMT added to BT did not provide further improvements than isolated BT in women with OAB symptoms.

Improvements in cardiovascular disease risk factors associated with modest weight loss following treatment in patients with binge-eating disorder and obesity

BACKGROUND

Modest weight losses may be associated with improvements in cardiovascular disease risk factors (CVDRF) in patients with obesity. The effects of weight losses on CVDRF in persons with binge-eating disorder (BED) are unknown. This study prospectively examined changes in CVDRF among patients receiving behaviorally-based weight-loss treatment (BBWLT) who attained modest weight losses (≥5 to <10% and ≥10%).

METHOD

Of 191 participants, CVDRF variables were re-assessed in 168 participants at posttreatment and in 151 at 12-month follow-up. Participants who attained ≥5 to <10% weight loss were compared to those who did not on CVDRFs (total cholesterol, HDL, LDL, triglycerides, HbA1C, mean plasma glucose, heart rate, and systolic/diastolic blood pressure); similar comparisons were completed for those who attained ≥10% weight loss.

RESULTS

At posttreatment, ≥5 to <10% weight loss (N = 42; 25.0%) was associated with significant improvements in HbA1c and mean plasma glucose, whereas ≥10% weight loss (N = 40, 23.8%) was associated with significant improvements in total cholesterol, triglycerides, HbA1c, mean plasma glucose, and heart rate. At 12-month follow-up, ≥5 to <10% weight loss (N = 17; 11.1%) was related to significant improvements on HDL, triglycerides, HbA1c, and mean plasma glucose, whereas ≥10% weight loss (N = 40, 26.0%) was associated with significant improvements on all the CVDRF variables (except blood pressure).

CONCLUSIONS

Modest weight loss is associated with significant improvements in CVDRFs in patients with BED and obesity following treatment and at 12-month follow-up. Future work should examine whether improvements in CVDRF are attributable to weight loss per se and/or to other related lifestyle changes.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with binge-eating disorder and obesity who attain modest weight loss following treatment exhibit improvements in various measures of cardiovascular disease risk compared to those who do not. While weight loss has been challenging for individuals with binge-eating disorder, clinicians should inform patients of the potential health benefits of modest weight loss. Future research should investigate whether weight loss itself and/or related behavioral lifestyle changes drive improved cardiovascular disease risk factors.

EFFECTS OF REHABILITATION PROGRAM FOCUSED ON IMPROVING REAL-LIFE DAILY ACTIVITIES OF PATIENTS WITH MILD COGNITIVE IMPAIRMENTS OR DEMENTIA AND THEIR CAREGIVERS

Objective

To evaluate the effectiveness of a dyadic outpatient rehabilitation program focused on improving the real-life daily activities of patients with mild cognitive impairments or dementia and their caregivers.

Design

Retrospective study.

Subjects

Eight patients with mild cognitive impairments or dementia and their caregivers.

Methods

The rehabilitation program comprised eight 1-hour sessions by occupational therapists with patients and his/her caregivers. Patients were assessed for motor function, cognitive function, and quality of life, and their caregivers were assessed for depression and caregiver burden. Participants were assessed at pre-program and post-program, and 3-month follow-up.

Results

The scores of caregiver-assessed Quality of life in Alzheimer's disease scale in patients significantly improved at post-program (median [interquartile range], 30.0 [7.0]) compared with pre-program (27.0 [2.8], effect size = 0.77, p = 0.029). In caregivers, the Zarit Caregiver Burden Interview scores decreased significantly at post-program (16.5 [13.0]) compared with pre-program (22.0 [17.5], effect size = 0.72, p = 0.042). There were no significant differences in other assessments.

Conclusions

The rehabilitation program focused on real daily activities and demonstrated to improve patients' quality of life and caregivers' depression and caring burden through patient-caregiver interaction. Future enhanced follow-up systems are warranted.

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Twelve-month follow-up: Comparative efficacy of cognitive therapy, behavior therapy, and cognitive behavior therapy for patients with insomnia

OBJECTIVE

Treatments that alleviate insomnia over the long term are critical. We evaluated the relative long-term efficacy of cognitive therapy (CT), behavior therapy (BT), and cognitive behavior therapy (CBT) for insomnia.

METHOD

Patients (N = 188, 62.2% female, 81.1% White, 6.5% Hispanic or Latinx, Mage = 47.4 years) with insomnia were randomized to eight sessions of CT, BT, or CBT for insomnia. Assessments at pretreatment and 12-month follow-up measured insomnia severity, insomnia response/remission, sleep diary parameters, and daytime functioning.

RESULTS

Patients in all three treatment groups improved on insomnia severity, sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, work and social adjustment, and mental health (ps < .05). Moreover, in each treatment group, a substantial proportion of patients achieved remission and response. CBT was associated with larger improvements in insomnia severity relative to CT as well as greater remission and improvements in physical health, relative to CT and BT (ps < .05). For patients with a psychiatric comorbidity, CBT was associated with greater improvements in work and social adjustment and mental health, relative to CT (ps < 0.05). CT was not associated with change in time in bed, and none of the treatment conditions were associated with change in daytime fatigue (ps > .05).

CONCLUSIONS

These encouraging results suggest that therapists may be able to offer CBT, BT, or CT to improve nighttime and daytime symptoms of insomnia over the long-term, with CBT offering a relative advantage for select outcomes and subgroups. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A phenotypic approach to obesity treatment

Obesity is a chronic disease that increases morbidity and mortality and adversely affects quality of life. The rapid rise of obesity has outpaced the development and deployment of effective therapeutic interventions, thereby creating a global health crisis. The presentation, complications, and response to obesity treatments vary, yet lifestyle modification, which is the foundational therapeutic intervention for obesity, is often "one size fits all." The concept of personalized medicine uses genetic and phenotypic information as a guide for disease prevention, diagnosis, and treatment and has been successfully applied in diseases such as cancer, but not in obesity. As we gain insight into the pathophysiologic mechanisms of obesity and its phenotypic expression, specific pathways can be targeted to yield a greater, more sustained therapeutic impact in an individual patient with obesity. A phenotype-based pharmacologic treatment approach utilizing objective measures to classify patients into predominant obesity mechanism groups resulted in greater weight loss (compared with a non-phenotype-based approach) in a recent study by Acosta and colleagues. In this review, we discuss the application of lifestyle modifications, behavior therapy and pharmacotherapy using the obesity phenotype-based approach as a framework.

Cognitive-behavioral therapy for binge-eating disorder for non-responders to initial acute treatments: Randomized controlled trial

OBJECTIVE

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but many patients who receive "evidence-based" interventions do not derive sufficient benefit. Given the dearth of controlled research examining treatments for patients who fail to respond to initial interventions, this study tested the efficacy of cognitive-behavioral therapy (CBT) for patients with BED who do not respond to initial acute treatments.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested 16-weeks of therapist-led CBT for non-responders to initial treatment (naltrexone/bupropion and/or behavioral therapy) for BED with obesity. Thirty-one patients (mean age 46.3 years, 77.4% women, 80.6% White, mean BMI 38.99 kg/m2 ) who were non-responders to initial acute treatments were randomized to CBT (N = 18) or no-CBT (N = 13), in addition to continuing double-blinded pharmacotherapy. Independent assessments were performed at baseline, throughout treatment, and posttreatment; 83.9% completed posttreatment assessments.

RESULTS

Intention-to-treat remission rates were significantly higher for CBT (61.1%; N = 11/18) than no-CBT (7.7%; N = 1/13). Mixed models of binge-eating frequency (assessed using complementary methods) converged revealing a significant interaction between CBT and time and a significant main effect of CBT. Binge-eating frequency decreased significantly with CBT but did not change significantly with no-CBT. Since only four patients received behavioral treatment during the acute treatments, we performed "sensitivity-type" analyses restricted to the 27 patients who received pharmacotherapy during the acute treatment and found the same pattern of findings for CBT versus no-CBT.

CONCLUSIONS

Adult patients with BED who fail to respond to initial pharmacological treatments should be offered CBT.

PUBLIC SIGNIFICANCE

Even with leading evidence-based treatments for binge-eating disorder, many patients do not derive sufficient benefit. Almost no controlled research has examined treatments for patients who fail to respond to initial interventions. This study found that that cognitive-behavioral therapy was effective for patients with binge-eating disorder who did not respond to initial interventions, with 61% achieving abstinence.

Self-guided Online Medical Hypnosis Program Improves Dry Nights in Children With Nocturnal Enuresis in a Prospective Single-Center Pilot Study

Bedwetting is a common condition in children. We evaluated the effectiveness of medical hypnosis as a first-line therapy in children with primary monosymptomatic nocturnal enuresis (PMNE). The study enrolled children in a prospective single-center pilot clinical trial consisting of 1 month diary of dry nights prior to using the commercially available hypnosis intervention (www.keepingthebeddry.com), followed by 3 consecutive months diary following intervention. Seventeen children aged 8 to 15 years old were enrolled and 12 recorded at least 1 month data after the hypnosis intervention. The median dry nights prior to intervention was 8 (0-17) days and improved to 15.5 (7-28) days by the third month post-intervention (P = .0033). All patients who completed the study showed an improvement. Self-guided medical hypnosis therapy showed significant improvement in dry nights without any side effects and any identifiable risk to patients. It should be considered for use in children as first-line therapy for PMNE.

The CBIT+TMS Trial: study protocol for a two-phase randomized controlled trial testing neuromodulation to augment behavior therapy for youth with chronic tics

Background

Comprehensive Behavioral Intervention for Tics (CBIT) is a first-line treatment for tic disorders that aims to improve controllability over tics that an individual finds distressing or impairing. However, it is only effective for approximately half of patients. Supplementary motor area (SMA)-directed neurocircuitry plays a strong role in motor inhibition, and activity in this region is thought to contribute to tic expression. Targeted modulation of SMA using transcranial magnetic stimulation (TMS) may increase CBIT efficacy by improving patient ability to implement tic controllability behaviors.

Methods

The CBIT+TMS trial is a two-phase, milestone driven early-stage randomized controlled trial. The trial will test whether augmenting CBIT with inhibitory, noninvasive stimulation of SMA with TMS modifies activity in SMA-mediated circuits and enhances tic controllability in youth ages 12-21 years with chronic tics. Phase 1 will directly compare two rTMS augmentation strategies (1Hz rTMS vs. cTBS) vs. sham in N = 60 participants. Quantifiable, a priori "Go/No Go Criteria" guide the decision to proceed to Phase 2 and selection of the optimal TMS regimen. Phase 2 will compare the optimal regimen vs. sham and test the link between neural target engagement and clinical outcomes in a new sample of N = 60 participants.

Discussion

This clinical trial is one of few to date testing TMS augmentation of therapy in a pediatric sample. Results will provide insight into whether TMS is a potentially viable strategy for enhancing CBIT efficacy and reveal potential neural and behavioral mechanisms of change.

Trial registration

ClinicalTrials.gov Identifier: NCT04578912.

Obsessions And Compulsions: A Lifespan Perspective

Freud traced the origin of the obsessional neurosis, which he considered a model condition for psychoanalytic inquiry, to a fixation in the anal phase of psychosexual development. Although many analysts have raised doubts about his account, and while the Sullivanian and Lacanian traditions have proposed alternatives, no approach has accounted for what Freud observed as the dizzying variety of obsessive presentations, which seem to defy a singular explanation. The broader research community has moved on, meanwhile, to genetic, neurological, and cognitive-behavioral explanations of what we now call obsessive-compulsive disorder. I argue that we can best account for the variety of obsessive presentations and meaningfully contribute to this interdisciplinary dialogue by framing obsessive-compulsive symptoms as the result of a disorder of volition, an exaggerated sense of willpower, not tied to any one developmental phase or bodily zone. Such a disorder evolves through the lifespan processes of introjection, identification, and repudiation in relation to an anxious/critical parent or an unpredictable environment. I trace these processes through three major developmental milestones. The implication is that, by looking in depth at how the obsessive person internalizes relationships, psychoanalysis can make a unique contribution to a conversation beyond its own borders.

Behavioral Interventions for Children and Adults with Tic Disorder

Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study

BACKGROUND

Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations.

AIM

To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses.

DESIGN

A pre-/post-intervention study.

SETTINGS/PARTICIPANTS

In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations.

RESULTS

Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit.

CONCLUSION

A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.

Treatment characteristics among patients with binge-eating disorder: an electronic health records analysis

OBJECTIVES

Treatment for adults diagnosed with binge-eating disorder (BED) includes psychotherapy and/or pharmacotherapy and aims to reduce the frequency of binge-eating episodes and disordered eating, improve metabolic-related issues and reduce weight, and address mood symptoms. Data describing real-world treatment patterns are lacking; therefore, this study aims to characterize real-world treatment patterns among patients with BED.

METHODS

This retrospective study identified adult patients with BED using natural language processing of clinical notes from the Optum electronic health record database from 2009 to 2015. Treatment patterns were examined during the 12 months preceding the BED recognition date and during a follow-up period after BED recognition (1-3 years for most patients).

RESULTS

Among 1042 patients, 384 were categorized as the BED cohort and 658, who met less stringent criteria, were categorized as probable BED. In the BED cohort, mean ± SD age was 45.2 ± 13.4 years and 81.8% were women (probable BED, 45.9 ± 12.8 years, 80.2%). A greater percentage of patients in the BED cohort were prescribed pharmacotherapy (70.6% [probable BED, 66.9%]) than received/discussed psychotherapy (53.1% [probable BED, 39.2%]) at baseline. In the BED cohort, 54.4% of patients were prescribed antidepressants (probable BED, 52.4%), 25.3% stimulants (probable BED, 20.1%), and 34.4% nonspecific psychotherapy (probable BED, 24.6%) at baseline, with no substantive differences observed during follow-up. Low percentages of patients in the BED cohort received/discussed cognitive behavioral therapy at baseline (12.5% [probable BED, 9.0%) or during follow-up (13.0% [probable BED, 8.8%). Among patients with ≥1 psychotherapy visit, the mean ± SD number of visits in the BED cohort was 1.2 ± 5.9 at baseline (probable BED, 1.7 ± 7.3) and 2.2 ± 7.7 during follow-up (probable BED, 2.6 ± 7.7).

CONCLUSION

This cohort of patients with BED was treated more frequently with pharmacotherapy than psychotherapy. These data may help inform strategies for reducing differences between real-world treatment patterns and evidence-based recommendations.

Predictors of Engagement Barriers for Adolescent ADHD Treatment

OBJECTIVE

The purpose of this study was to understand patient characteristics that predict engagement barriers during behavior therapy for ADHD.

METHOD

Participants were 121 adolescents with ADHD and parents who received evidence-based behavior therapy for ADHD. Multiple regression examined relationships between six independent variables and frequency of barriers.

RESULTS

ODD comorbidity and parental ADHD predicted higher frequency of overall barriers. With respect to barriers subtypes, these variables also predicted higher frequencies of cognitive, teen, early-treatment and mid-treatment barriers. Late-treatment, ODD predicted higher frequency of barriers, while minority status predicted lower barriers.

CONCLUSIONS

Adolescents diagnosed with ADHD and comorbid ODD, or who have parents that are also diagnosed with ADHD, are at greatest risk for engagement barriers during behavior therapy. During all phases of treatment, this patient subgroup would benefit from enhancements to standard behavior therapy that focus on therapeutic engagement-particularly targeting teen beliefs about treatment.

Lifestyle Intervention in NAFLD: Long-Term Diabetes Incidence in Subjects Treated by Web- and Group-Based Programs

BACKGROUND

Behavioral programs are needed for prevention and treatment of NAFLD and the effectiveness of a web-based intervention (WBI) is similar to a standard group-based intervention (GBI) on liver disease biomarkers.

OBJECTIVE

We aimed to test the long-term effectiveness of both programs on diabetes incidence, a common outcome in NAFLD progression.

METHODS

546 NAFLD individuals (212 WBI, 334 GBI) were followed up to 60 months with regular 6- to 12-month hospital visits. The two cohorts differed in several socio-demographic and clinical data. In the course of the years, the average BMI similarly decreased in both cohorts, by 5% or more in 24.4% and by 10% or more in 16.5% of cases available at follow-up. After excluding 183 cases with diabetes at entry, diabetes was newly diagnosed in 48 cases during follow-up (31 (16.6% of cases without diabetes at entry) in the GBI cohort vs. 17 (9.7%) in WBI; p = 0.073). Time to diabetes was similar in the two cohorts (mean, 31 ± 18 months since enrollment). At multivariable regression analysis, incident diabetes was significantly associated with prediabetes (odds ratio (OR) 4.40; 95% confidence interval (CI) 1.97-9.81; p < 0.001), percent weight change (OR 0.57; 95% CI 0.41-0.79; p < 0.001) and higher education (OR 0.49; 95% CI 0.27-0.86; p = 0.014), with no effect of other baseline socio-demographic, behavioral and clinical data, and of the type of intervention. The importance of weight change on incident diabetes were confirmed in a sensitivity analysis limited to individuals who completed the follow-up.

CONCLUSION

In individuals with NAFLD, WBI is as effective as GBI on the pending long-term risk of diabetes, via similar results on weight change.

Feeding/Eating problems in children: Who does (not) benefit after behavior therapy? A retrospective chart review

Background

Treating disordered feeding at a young age reduces risks of future feeding problems, but not all children profit equally; can we define predictors of a worse prognosis?

Objectives

In 252 children, with a mean age of 4; 7 years (SD = 3 years; range 5 months to 17; 10 years), who had undergone behavioral day treatment in the past, several variables were investigated, retrieved from initial consultation (t1) and re-assessed at follow-up (t2).

Method

Logistic regressions were carried out with sex, gastro-intestinal problems, refusal of the first nutrition, syndrome/intellectual disability, Down's syndrome, autism spectrum disorder, comorbidity of medical diseases (other than gastro-intestinal problems), restrictive caloric food intake and selective food intake, as the predictor variables from t1, and age-appropriate food intake at t2 as the dependent variable. The potential role of sensory processing problems was reviewed at t2.

Results

About 73% had improved towards an age-appropriate food intake. Sex (boys), syndrome/intellectual disability, and a lack of varied nutritional intake at t1 were predictors of a worse prognosis. We found a small, but significant correlation between current selective eating patterns and general sensory processing problems.

Conclusion

Feeding disordered children, especially boys, with intellectual disabilities or selective eating patterns are at risk for not achieving an age-adequate food intake at a later age, despite behavioral treatment.

Preliminary Results of an Interdisciplinary Behavioral Program to Improve Access to Preventative Dental Care for Adults With Intellectual and Developmental Disabilities

Adults with intellectual and developmental disabilities (AIDD) experience significant oral health disparities, partially due to perceived behavioral issues. This article describes the preliminary outcomes of a developing interdisciplinary (dental, medical, behavioral) program involving a behavioral intervention for AIDD previously receiving preventative dental care with sedation, general anesthesia, or protective stabilization (SAS). After a baseline assessment, a board-certified behavior analyst implemented increasingly complex behavioral interventions during simulated dental visits. Prior to COVID-19 pandemic-related restrictions, there were 32 active participants; 15 (46.9%) successfully completed a focused, real dental exam with simple behavioral interventions and 17 (53.1%) remain in treatment. These preliminary results suggest that many AIDD previously receiving SAS may participate in a preventative dental exam with minimal behavioral supports, if given the opportunity.

Parents of minor children lose less weight during a behavioral weight loss intervention: Findings from the Rural LEAP trial

Objective

The transition to parenthood is associated with worsening health behaviors, yet the impact of parental status on successful weight loss has rarely been examined. The purpose of this study was to examine the effect of parental status of minor children on weight loss and behavioral adherence in a rural community-based weight loss intervention.

Methods

Five hundred and twenty-eight adults (age 21-75 years, body mass index [BMI] 30-45 kg/m2) were enrolled in a group-based weight loss intervention consisting of 16 weekly sessions delivered in face-to-face group sessions at Cooperative Extension Service (CES) offices. Participants who were parents with at least one minor child (≤18 years old) in the home were compared to participants with no minor children in the home. Measures included percent weight loss, session attendance, adherence to self-monitoring, and achieving calorie and physical activity goals.

Results

Compared to participants without minor children, parents with minor children lost significantly less weight (7.5% vs. 6.2%, respectively; p = 0.01), and were less likely to lose ≥5% of baseline weight (59.2% vs. 70.2%, respectively; p = 0.02). In addition, parents with minor children attended significantly fewer sessions, had lower adherence to self-monitoring, and met calorie and step goals less often (all ps < 0.001). The association between parental status and percent weight loss was not significantly moderated by gender of the parent.

Conclusions

Parents of minor children had greater difficulty adhering to intervention goals and lost less weight than participants without minor children. Future research should investigate whether tailoring intervention to meet the unique needs of parents can enhance outcomes, especially given the large segment of the population represented by this group.

The complex association of barriers and interest in internet-delivered cognitive behavior therapy for depression and anxiety: informing e-health policies through exploratory path analysis

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) provides critical remote access to mental health care to at-risk populations. However, to our knowledge, no investigation has been conducted to understand complex pathways through which barriers to care (i.e. structural, attitudinal and technological) correlate with patient interest in ICBT.

AIM

The objective of this study is to develop and test a pathway analysis framework using structural equation modeling to understand direct and mediating associations of barriers to care with interest in ICBT.

METHODS

This cross-sectional observational study was conducted among adult (>18 years) urban and rural residents (n = 200) in Saskatchewan, Canada. An online survey assessed interest in ICBT, barriers to ICBT, demographics, and depression and anxiety symptoms. Utilizing structural equation modeling, a path analysis framework was developed.

RESULTS

Path analysis results showed how associations between complex barriers and demographic variables correlate with interest in ICBT. For instance, the negative association of perceived financial concerns and life chaos on interest in ICBT was mediated by perceived access to care.

CONCLUSION

The findings identify specific barriers that could be addressed through targeted population health interventions to improve uptake of ICBT.

Evaluating the feasibility and potential efficacy of a brief eTherapy for binge-eating disorder: A pilot study

OBJECTIVE

For those with binge-eating disorder (BED), access to evidence-based, face-to-face treatment is often constrained by clinician availability and high treatment costs. Emerging evidence suggests online therapy (eTherapy) may navigate these barriers and reduce binge-eating symptomatology; however, less evaluation has been done in those with BED, particularly with briefer programs targeting early change. This study investigated the feasibility and potential efficacy of a brief, supported eTherapy in those with BED or subthreshold BED.

METHOD

Participants were 19 women with BED who completed a four-session eTherapy. This was a single-arm, pre-post intervention study, with participants completing weekly content and attending telehealth sessions. Key outcomes were assessed by the Eating Disorder Examination Questionnaire-Short (EDE-QS): objective binge episode days, loss of control over eating days, and eating disorder (ED) psychopathology via a total EDE-QS score.

RESULTS

Generalized and linear mixed models showed significantly reduced loss of control over eating days and ED psychopathology. Program feasibility was high, with strong program adherence and a below average attrition rate.

DISCUSSION

Pilot results support the feasibility and potential efficacy of a brief, behavioral-focused eTherapy program in reducing ED pathology in those with BED. Future research should further investigate findings in an adequately powered randomized controlled trial.

PUBLIC SIGNIFICANCE

This study suggests that a brief, behavioral-focused online therapy, guided by non-expert clinicians, can be successfully administered to those with binge-eating disorder (BED) and may be efficacious at reducing eating disorder and other related symptomatology. Brief eTherapies that are effective, accessible, and rapidly available may facilitate earlier intervention in illness and improve treatment outcomes for individuals who experience this common and distressing disorder.

24-Month follow-up of randomized controlled trial of guided-self-help for loss-of-control eating after bariatric surgery

BACKGROUND

Loss-of-control (LOC)-eating postoperatively predicts suboptimal longer-term outcomes following bariatric surgery. This study examined longer-term effects through 24-month follow-ups after completing treatments in a randomized controlled trial testing guided-self-help treatments (cognitive-behavioral therapy [gshCBT] and behavioral weight-loss [gshBWL]) and control (CON) delivered postoperatively for LOC-eating.

METHODS

140 patients with LOC-eating 6 months after bariatric surgery were randomized (5:5:2 ratio) to 3-months of gshCBT (n = 56), gshBWL (n = 60), or CON (n = 24) delivered by trained allied-health clinicians. Independent assessments were performed throughout/after treatments and at 6-, 12-, 18-, and 24-month follow-ups; 83% of patients were assessed at 24-month follow-up.

RESULTS

Intention-to-treat analyses comparing the three groups (gshCBT vs. gshBWL vs. CON) in LOC-eating abstinence at posttreatment (30%, 27%, 38%), 12-month follow-up (34%, 32%, 42%), and 24-month follow-up (45%, 32%, 38%) revealed no significant differences. Mixed-models revealed significantly reduced LOC-eating frequency through posttreatment, no significant changes in LOC-eating frequency during follow-up, and no differences between the three groups. Weight reduced significantly, albeit modestly, through posttreatment but increased significantly and substantially during follow-ups, with no differences between groups.

CONCLUSIONS

Overall, the 12-week scalable guided-self-help treatments did not differ from each other or control, were associated with significantly reduced frequency of LOC-eating and modest weight loss at posttreatment but were followed by significant weight gain during the 24-month follow-up. Weight gain was substantial and nearly universal whereas the frequency of LOC-eating did not change over time (i.e., LOC-eating reductions and abstinence rates were well maintained through 24-moth follow-ups). Patients with postoperative LOC-eating require more intensive adjunctive treatments.

PUBLIC SIGNIFICANCE

Loss-of-control (LOC) eating postoperatively predicts poorer bariatric surgery outcomes and the longer-term effects of postoperative adjunctive postoperative interventions for LOC eating are unknown. In this 24-month follow-up of a controlled study of scalable guided-self-help treatments and a control condition, improvements in LOC-eating frequency, eating-disorder psychopathology, and depression during treatment were maintained well, with no differences between the three groups. Proportion of patients achieving abstinence from LOC-eating at the 24-month follow-up ranged from 38% to 45% across the three groups. In contrast, weight increased significantly during the 24-month follow-ups, with no differences between the three groups. Findings suggest LOC-eating following bariatric surgery might represent a "marker" for a subgroup of patients that are at risk for substantial weight gains over time. LOC eating following bariatric surgery is challenging to treat with low-intensity scalable treatments and may require more intensive specialist treatments.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019

OBJECTIVE

To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019.

METHOD

This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD.

RESULTS

The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%.

CONCLUSION

There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Cognitive changes in health locus of control attributions after behavioral analysis in patients with panic disorder and/or agoraphobia

Patients with Panic Disorder and / or Agoraphobia (PD +/- Ag) attribute their mental health more to external factors and less to internal, while after behavior treatment (BT) their external attributions decrease and internal attributions increase. We examined whether these cognitive changes observed at the end of BT, begin earlier. Forty patients with PD +/- Ag were assessed on the Multidimensional Health Locus of Control Scale, before and after the diagnostic and psychoeducational sessions that precede the clinical implementation of BT. Decreased health attributions to significant others (t = 4.22, p < 0.01), and an increase trend to self (t = -0.78, p = 0.43) were observed, which are compatible with the active role patients need to adopt in the clinical application of BT.

Effect of Aromatherapy with Essential oil of Lavandula Angustifolia Mill- Citrus Bergamia and Mindfulness-Based Intervention on Sexual Function, Anxiety, and Depression in Postmenopausal Women: A Randomized Controlled Trial with Factorial Design

BACKGROUND

Due to the importance of psychological support for women during menopause as a period with a high prevalence of mental health problems, this study aimed to evaluate the effect of the essential oil of lavender-Bergamot (La-Ber) and Mindfulness-Based Intervention (MBI) on sexual function, anxiety (primary outcome), and depression score (secondary outcome) in postmenopausal women with sexual dysfunction.

MATERIALS AND METHODS

This controlled randomized trial with a factorial design was performed on 132 postmenopausal women. Participants were randomly allocated into four equal groups: Aromatherapy-Routine Care (Aroma-RC), MBI-Placebo (MBI-P), Aromatherapy-MBI (Aroma-MBI), or Routine Care-Placebo (RC-P). Two to three drops of La-Ber or a similar placebo were inhaled three times a day for 8 weeks. Eight sessions of MBI intervention were conducted. At the end of the intervention and eight weeks afterward, the outcomes were assessed.

RESULTS

The sexual function score improved significantly in Aroma-MBI (adjusted Mean Difference [aMD]: 2.4, 95% CI: 0.01 to 4.80) and MBI-P (aMD: 2.6, 95% CI: 0.2 to 5.1) groups compared to the RC-P group. The anxiety score was reduced in the Aroma-RC group at the end of the intervention (aMD: -4.12, 95% CI: -7.41 to -0.72; p = 0.020) and eight weeks later as well as in the Aroma-MBI group. In terms of depression, the mean score of depression was significantly lower than the RC-P group in the Aroma-RC group at the end of the intervention (p = 0.011).

CONCLUSIONS

MBI and aromatherapy seem effective on sexual function and menopausal anxiety. MBI improves sexual function, while aromatherapy ameliorated anxiety and depression.

Integrative review about somatic care improvement tools for people with autistic syndrome disorder

PURPOSE

Perform an integrative literature review on ways to improve somatic care access for people with autistic spectrum disorders (PASD).

DESIGN AND METHODS

Integrative review as described by Whittemore and Kanfl methodology has been chosen by the author to concatenate knowledge about somatic care situation and existing processes that could improve its access for PASD. The PRISMA diagram was applied for its synthetic and visual modeling of the research process.

FINDINGS

Barriers that reduce somatic care access were discussed by five of the six selected articles, which suggest fields of improvement by using bio-psycho-sensorial profiling tools for PASD, healthcare preparation protocols, or visual pathway tools to prevent behavioral disorders.

PRACTICE IMPLICATIONS

Somatic care access for people with autism is improved by the tools presented in this review.

Optimizing relapse prevention and changing habits (REACH+) in anorexia nervosa

INTRODUCTION

Relapse rates in anorexia nervosa (AN) are high, even after full weight restoration. This study aims to develop a relapse prevention treatment that specifically addresses persistent maladaptive behaviors (habits). Relapse Prevention and Changing Habits (REACH+) aims to support patients in developing routines that promote weight maintenance, encourage health, and challenge habits that perpetuate illness. The clinical trial design uses the Multiphase Optimization STrategy (MOST) framework to efficiently identify which components of treatment contribute to positive outcomes.

METHODS

Participants will be 60 adults with AN who have achieved weight restoration in an inpatient setting. Treatment will consist of 6 months of outpatient telehealth sessions. REACH+ consists of behavior, cognitive, and motivation components, as well as food monitoring and a skill consolidation phase. A specialized online platform extends therapy between sessions. Participants will be randomly assigned to different versions of each component in a fractional factorial design. Outcomes will focus on maintenance of remission, measured by rate of weight loss and end-of-trial status. Interventions that contribute to remission will be included in an optimized treatment package, suitable for a large-scale clinical trial of relapse prevention in AN.

Change in eating-disorder psychopathology network structure in patients with binge-eating disorder: Findings from treatment trial with 12-month follow-up

OBJECTIVE

Effective treatments exist for binge-eating disorder (BED), although roughly 50% of patients fail to attain binge-eating abstinence. Evidence on how to refine treatments is lacking. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for the identification of the most strongly connected symptoms, which could inform intervention targets. This study assessed how BED symptom centrality changed with behaviorally based weight-loss treatments (BBWLTs).

METHODS

Participants were 191 adult patients (71% female, 79% White) with BED with comorbid obesity participating in a randomized controlled trial testing 6-month BBWLTs for BED. Independent assessments of BED symptoms were performed at pretreatment, posttreatment, and 12 months after treatment. Strength centrality indicated how strongly and frequently symptoms were associated with each other in the network. Significant changes in centrality between timepoints were determined using permutation tests.

RESULTS

At pretreatment, overvaluation of shape/weight and preoccupation with shape/weight and food/eating had the highest strength centrality. At posttreatment and 12-month follow-up, dissatisfaction with shape/weight had the highest centrality, which significantly increased from pretreatment.

CONCLUSIONS

The relations among symptoms of BED are not static and change over time with treatment. BBWLTs do not appear to reduce connectivity of overvaluation of shape/weight (the most central BED symptom prior to treatment), but instead increase connectivity of dissatisfaction with shape/weight with other symptoms following treatment. The observed network structure of symptoms following BBWLTs resembles network analyses of people without eating disorders. Findings highlight the importance of understanding how treatments impact symptom relationships, not just symptom intensities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of transition from face-to-face to telehealth on behavioral obesity treatment during the COVID-19 pandemic

OBJECTIVE

This study evaluated whether the transition of a face-to-face behavioral intervention to videoconferencing-based telehealth delivery during the COVID-19 pandemic resulted in significantly smaller weight losses than those typically observed in gold-standard, face-to-face programs.

METHODS

Participants were 160 adults with obesity (mean [SD] age = 49.2 [11.9] years, BMI = 36.1 [4.2] kg/m² ) enrolled in two cohorts of a 16-week comprehensive weight-management program. Cohort 1 began in person and transitioned to telehealth (Zoom) delivery during week 11 of the intervention because of COVID-19; Cohort 2 was conducted completely remotely. A noninferiority approach (using a clinically relevant noninferiority margin of 2.5%) was used to assess whether the weight losses observed were inferior to the 8% losses from baseline typically produced by gold-standard, face-to-face lifestyle interventions.

RESULTS

From baseline to postintervention, participants lost an average of 7.4 [4.9] kg, representing a reduction of 7.2% [4.6%]. This magnitude of weight change was significantly greater than 5.5% (t[159] = 4.7, p < 0.001), and, thus, was within the proposed noninferiority margin.

CONCLUSIONS

These findings demonstrate that the results of behavioral weight-management interventions are robust, whether delivered in person or remotely, and that individuals can achieve clinically meaningful benefits from behavioral treatment even during a global pandemic. Pragmatic "lessons learned," including modified trial recruitment techniques, are discussed.

Cognitive control processes in behavior therapy for youth with Tourette's disorder

BACKGROUND

Cognitive control processes are implicated in the behavioral treatment of Tourette's disorder (TD). However, the influence of these processes on treatment outcomes has received minimal attention. This study examined whether cognitive control processes and/or tic suppression predicted reductions in tic severity and treatment response to behavior therapy.

METHOD

Fifty-three youth with TD or a pervasive tic disorder participated in a randomized wait list-controlled trial of behavior therapy. Following a baseline assessment to evaluate psychiatric diagnoses, tic severity, and cognitive control processes (e.g., response selection, inhibition, and suppression), youth were randomly assigned to receive eight sessions of behavior therapy (n = 23) or a wait list of equal duration (n = 28). Youth receiving immediate treatment completed a post-treatment assessment to determine improvement in tic severity. Meanwhile, youth in the wait list condition completed another assessment to re-evaluate tic severity and cognitive control processes, and subsequently received 8 sessions of behavior therapy followed by a post-treatment assessment to determine improvement.

RESULTS

A multiple linear regression model found that pretreatment inhibition/switching on the Delis-Kaplan Executive Function System Color-Word Interference Test predicted reductions in tic severity after behavior therapy (β = -.36, t = -2.35, p = .025, ƞ2  = .15). However, other cognitive control processes and tic suppression did not predict treatment response and/or reductions in tic severity. Small nonsignificant effects were observed in cognitive control processes after behavior therapy.

CONCLUSION

Cognitive control processes may influence tic severity reductions in behavior therapy. Notably, even when other cognitive control processes are impaired and youth are initially unable to voluntarily suppress their tics, youth with TD can still benefit from behavior therapy. Findings offer implications for clinical practice and research for TD.

Sex-dependent influence of postweaning environmental enrichment in Angelman syndrome model mice

INTRODUCTION

Angelman syndrome (AS) is a rare neurodevelopmental disorder caused by mutation or loss of UBE3A and marked by intellectual disability, ataxia, autism-like symptoms, and other atypical behaviors. One route to treatment may lie in the role that environment plays early in postnatal life. Environmental enrichment (EE) is one manipulation that has shown therapeutic potential in preclinical models of many brain disorders, including neurodevelopmental disorders. Here, we examined whether postweaning EE can rescue behavioral phenotypes in Ube3a maternal deletion mice (AS mice), and whether any improvements are sex-dependent.

METHODS

Male and female mice (C57BL/6J Ube3atm1Alb mice and wild-type (WT) littermates; ≥10 mice/group) were randomly assigned to standard housing (SH) or EE at weaning. EE had a larger footprint, a running wheel, and a variety of toys that promoted foraging, burrowing, and climbing. Following 6 weeks of EE, animals were submitted to a battery of tests that reliably elicit behavioral deficits in AS mice, including rotarod, open field, marble burying, and forced swim; weights were also monitored.

RESULTS

In male AS-EE mice, we found complete restoration of motor coordination, marble burying, and forced swim behavior to the level of WT-SH mice. We also observed a complete normalization of exploratory distance traveled in the open field, but we found no rescue of vertical behavior or center time. AS-EE mice also had weights comparable to WT-SH mice. Intriguingly, in the female AS-EE mice, we found a failure of EE to rescue the same behavioral deficits relative to female WT-SH mice.

CONCLUSIONS

Environmental enrichment is an effective route to correcting the most penetrant phenotypes in male AS mice but not female AS mice. This finding has important implications for the translatability of early behavioral intervention for AS patients, most importantly the potential dependency of treatment response on sex.

Efficacy of cognitive therapy and behavior therapy for menopausal symptoms: a systematic review and meta-analysis

BACKGROUND

T long-term effects of cognitive therapy and behavior therapy (CTBT) for menopausal symptoms are unknown, and whether the effects are different between natural menopause and treatment-induced menopause are currently unclear. Therefore, we sought to conduct an accurate estimate of the efficacy of CTBT for menopausal symptoms.

METHODS

We conducted searches of Cochrane Library, EMBASE, PsycINFO, PubMed, and Web of Science databases for studies from 1 January 1977 to 1 November 2021. Randomized controlled trials (RCTs) comparing intervention groups to control groups for menopausal symptoms were included. Hedge's g was used as the standardized between-group effect size with a random-effects model.

RESULTS

We included 14 RCTs comprising 1618 patients with a mean sample size of 116. CTBT significantly outperformed control groups in terms of reducing hot flushes [g = 0.39, 95% confidence interval (CI) 0.23-0.55, I2 = 45], night sweats, depression (g = 0.50, 95% CI 0.34-0.66, I2 = 51), anxiety (g = 0.38, 95% CI 0.23-0.54, I2 = 49), fatigue, and quality of life. Egger's test indicated no publication bias.

CONCLUSIONS

CTBT is an effective psychological treatment for menopausal symptoms, with predominantly small to moderate effects. The efficacy is sustained long-term, although it declines somewhat over time. The efficacy was stronger for natural menopause symptoms, such as vasomotor symptoms, than for treatment-induced menopause symptoms. These findings provide support for treatment guidelines recommending CTBT as a treatment option for menopausal symptoms.

A Text Messaging-Enhanced Intervention for African American Patients With Heart Failure, Depression, and Anxiety (TXT COPE-HF): Protocol for a Pilot Feasibility Study

BACKGROUND

African Americans have a higher incidence rate of heart failure (HF) and an earlier age of HF onset compared to those of other racial and ethnic groups. Scientific literature suggests that by 2030, African Americans will have a 30% increased prevalence rate of HF coupled with depression. In addition to depression, anxiety is a predictor of worsening functional capacity, decreased quality of life, and increased hospital readmission rates. There is no consensus on the best way to treat patients with HF, depression, and anxiety. One promising type of treatment-cognitive behavioral therapy (CBT)-has been shown to significantly improve patients' quality of life and treatment compliance, but CBT has not been used with SMS text messaging reminders to enhance the effect of reducing symptoms of depression and anxiety in racial and ethnic minority patients with HF.

OBJECTIVE

The objectives of our study are to (1) adapt and modify the Creating Opportunities for Personal Empowerment (COPE) curriculum for delivery to patients with HF by using an SMS text messaging component to improve depression and anxiety symptoms, (2) administer the adapted intervention to 10 patients to examine the feasibility and acceptability of the approach and modify it as needed, and (3) examine trends in depression and anxiety symptoms postintervention. We hypothesize that patients will show an improvement in depression scores and anxiety symptoms postintervention.

METHODS

The study will comprise a mixed methods approach. We will use the eight steps of the ADAPT-ITT (assessment, decision, administration, production, topical expert, integration, training, and testing) model to adapt the intervention. The first step in this feasibility study will involve assembling individuals from the target population (n=10) to discuss questions on a specific topic. In phase 2, we will examine the feasibility and acceptability of the enhanced SMS text messaging intervention (TXT COPE-HF [Texting With COPE for Patients With HF]) and its preliminary effects with 10 participants. The Beck Depression Inventory will be used to assess depression, the State-Trait Anxiety Inventory will be used to assess anxiety, and the Healthy Beliefs and Lifestyle Behavior surveys will be used to assess participants' lifestyle beliefs and behavior changes. Changes will be compared from baseline to end point by using paired 2-tailed t tests. An exit focus group (n=10) will be held to examine facilitators and barriers to the SMS text messaging protocol.

RESULTS

The pilot feasibility study was funded by the Academy for Clinical Research and Scholarship. Institutional review board approval was obtained in April 2021. Data collection and analysis are expected to conclude by November 2021 and April 2022, respectively.

CONCLUSIONS

The study results will add to the literature on the effectiveness of an SMS text messaging CBT-enhanced intervention in reducing depression and anxiety among African American patients with HF.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/32550.

Corrigendum: A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD

[This corrects the article DOI: 10.3389/fpsyt.2022.794044.].