Trauma Memory Characteristics and Neurocognitive Performance in Youth Exposed to Single-Event Trauma

Cognitive models of posttraumatic stress disorder (PTSD) highlight characteristics of trauma memories, such as disorganisation, as key mechanisms in the aetiology of the disorder. However, studies investigating trauma memory in youth have provided inconsistent findings. Research has highlighted that PTSD in youth may be accompanied by difficulties in neurocognitive functioning, potentially impacting ability to recall the trauma memory. The present study sought to investigate both trauma memory characteristics and neurocognitive functioning in youth aged 8-17 years. Youths exposed to single-event trauma, with (N = 29, Mage = 13.6, 21 female) and without (N = 40, Mage = 13.3, 21 female) a diagnosis of PTSD, completed self-report measures of trauma memory, a narrative memory task and a set of neurocognitive tests two to six months post-trauma. A group of non trauma-exposed youths (N = 36, Mage = 13.9, 27 female) were compared on narrative and neurocognitive tasks. Results indicated that trauma memories in youth with, versus without, PTSD were more sensory-laden, temporally disrupted, difficult to verbally access, and formed a more 'central' part of their identity. Greater differences were observed for self-reported memory characteristics compared to narrative characteristics. No between group differences in neurocognitive function were observed. Self-reported trauma memory characteristics highlight an important factor in the aetiology of PTSD. The observed lack of significant differences in neurocognitive ability potentially suggests that cognitive factors represent a more relevant treatment target than neurocognitive factors in single-event PTSD. Further research to understand the cognitive factors represented by self-reported trauma memory characteristics is recommended.

Improving access to psychological intervention in low-middle income settings: Results from a waitlist-controlled, proof-of-concept trial of the MemFlex intervention for trauma-exposed Afghan youth

BACKGROUND

Low-intensity interventions targeting a range of mental health issues offer a scalable approach for young trauma survivors in low-middle income countries.

AIMS

Here, we present results from a proof-of-concept, randomized, waitlist-controlled trial evaluating MemFlex, an autobiographical memory-based intervention, for trauma-exposed Afghan youth residing in Iran. MemFlex seeks to reduce the negative and overgeneral memory biases which maintain and predict poor mental health.

MATERIALS AND METHODS

Young people aged 12-18 years (N = 40) with parents who had experienced forced migration from Afghanistan were recruited from high schools in Karaj City in Iran. All had experienced a traumatic event in the last year. Participants were randomized to receive four weeks of a group-based delivery of MemFlex or Waitlist. Our primary cognitive outcome was autobiographical memory flexibility, that is, the ability to deliberately retrieve any memory type on demand. Primary clinical outcome was emotional distress, measured on the Farsi version of the Hopkins Symptom Checklist.

RESULTS

Results indicated that MemFlex participants demonstrated large effect sizes for pre-to-post improvement in memory flexibility (d = 2.04) and emotional distress (d = 1.23). These improvements were significantly larger than Waitlist (ds < .49), and were maintained at three-month follow-up.

DISCUSSION

Positive benefits were observed for completion of MemFlex, and future comparison against an active intervention appears warranted.

CONCLUSION

Further evaluation of MemFlex in this context may offer a low-cost, and low-resource intervention to improve access to psychological intervention for young migrants in low-middle income countries.

A deep learning quantification of patient specificity as a predictor of session attendance and treatment response to internet-enabled cognitive behavioural therapy for common mental health disorders

BACKGROUND

Increasing an individual's ability to focus on concrete, specific detail, thus reducing the tendency toward overly broad, decontextualised generalisations about the self and world, is a target within cognitive behavioural therapy (CBT). However, empirical investigation of the impact of within-treatment specificity on treatment outcomes is scarce. We evaluated whether the specificity of patient dialogue predicted a) end-of-treatment symptoms and b) session completion for CBT for common mental health issues.

METHODS

This preregistered (https://osf.io/agr4t) study trained a deep learning model to score the specificity of patient dialogue in transcripts from 353,614 internet-enabled CBT sessions for common mental health disorders, delivered on behalf of UK NHS services. Data were from obtained from 65,030 participants (n = 47,308 female, n = 241 unstated) aged 18-94 years (M = 34.69, SD = 12.35). Depressive disorders were the most common (39.1 %) primary diagnosis. Primary outcome was end-of-treatment score on the Patient Health Questionnaire-9 (PHQ-9). Secondary outcome was number of sessions attended.

RESULTS

Linear mixed-effects models demonstrated that increased patient specificity significantly predicted lower post-treatment symptoms on the PHQ-9, although the size and direction of the effect varied depending on the type of therapeutic activity being completed. Effect sizes were consistently small. Higher patient specificity was associated with completing a greater number of sessions.

LIMITATIONS

We are unable to infer causation from our data.

CONCLUSIONS

Although effect sizes were small, an effect of specificity was observed across common mental health disorders. Further studies are needed to explore whether encouraging patient specificity during CBT may provide an enhancement of treatment attendance and treatment effects.

Hot metacognition: poorer metacognitive efficiency following acute but not traumatic stress

Aberrations to metacognition-the ability to reflect on and evaluate self-performance-are a feature of poor mental health. Theoretical models of post-traumatic stress disorder propose that following severe stress or trauma, maladaptive metacognitive evaluations and appraisals of the event drive the development of symptoms. Empirical research is required in order to reveal whether disruptions to metacognition cause or contribute to symptom development in line with theoretical accounts, or are simply a consequence of ongoing psychopathology. In two experiments, using hierarchical Bayesian modelling of metacognition measured in a memory recognition task, we assessed whether distortions to metacognition occur at a state-level after an acute stress induction, and/or at a trait-level in a sample of individuals experiencing intrusive memories following traumatic stress. Results from experiment 1, an in-person laboratory-based experiment, demonstrated that heightened psychological responses to the stress induction were associated with poorer metacognitive efficiency, despite there being no overall change in metacognitive efficiency from pre- to post-stress (N = 27). Conversely, in experiment 2, an online experiment using the same metamemory task, we did not find evidence of metacognitive alterations in a transdiagnostic sample of patients with intrusive memory symptomatology following traumatic stress (N = 36, compared to 44 matched controls). Our results indicate a relationship between state-level psychological responses to stress and metacognitive alterations. The lack of evidence for pre- to post-stress differences in metamemory illustrates the importance for future studies to reveal the direction of this relationship, and consequently the duration of stress-associated metacognitive impairments and their impact on mental health.

Work Engagement and Well-being Study (SWELL): a randomised controlled feasibility trial evaluating the effects of mindfulness versus light physical exercise at work

BACKGROUND

Mindfulness-based programmes (MBPs) are increasingly offered at work, often in online self-guided format. However, the evidence on MBPs' effect on work performance (WP) is inconsistent.

OBJECTIVE

This pragmatic randomised controlled feasibility trial assessed procedural uncertainties, intervention acceptability and preliminary effect sizes of an MBP on WP, relative to an alternative intervention.

METHODS

241 employees from eight employers were randomised (1:1) to complete a 4-week, self-guided, online MBP or a light physical exercise programme (LE)(active control). Feasibility and acceptability measures were of primary interest. WP at postintervention (PostInt) was the primary outcome for preliminary assessment of effect sizes. Secondary outcomes assessed mental health (MH) and cognitive processes hypothesised to be targeted by the MBP. Outcomes were collected at baseline, PostInt and 12-week follow-up (12wFUP). Prospective trial protocol: NCT04631302.

FINDINGS

87% of randomised participants started the course. Courses had high acceptability. Retention rates were typical for online trials (64% PostInt; 30% 12wFUP). MBP, compared with the LE control, offered negligible benefits for WP (PostInt (d=0.06, 95% CI -0.19 to 0.32); 12wFUP (d=0.02, 95% CI -0.30 to 0.26)). Both interventions improved MH outcomes (ds=-0.40 to 0.58, 95% CI -0.32 to 0.18); between-group differences were small (ds=-0.09 to 0.04, 95% CI -0.15 to 0.17).

CONCLUSION

The trial is feasible; interventions are acceptable. Results provide little support for a later phase trial comparing an MBP to a light exercise control. To inform future trials, we summarise procedural challenges.

CLINICAL IMPLICATIONS

Results suggest MBPs are unlikely to improve WP relative to light physical exercise. Although the MBP improved MH, other active interventions may be just as efficacious.

TRIAL REGISTRATION NUMBER

NCT04631302.

Patterns of emotion-network dynamics are orthogonal to mood disorder status: An experience sampling investigation

Individuals differ markedly in how they experience the ebb and flow of emotions. In this study, we used daily experience sampling to examine whether these differences reflect the nature and presence of mood disorders or whether they can better be characterized as distinct dynamic emotion profiles that cut-across diagnostic boundaries. We followed 105 individuals in 2019-2020 with diagnoses of major depression, remitted major depression, bipolar disorder, or no history of disorder, over 14 days (n = 6,543 experience-sampling assessments). We applied group iterative multiple model estimation, using both diagnosis-based and data-driven methods to investigate similarities in unfolding within-person emotion-network time-courses. Results did not support diagnosis-based subgroupings but rather revealed two significant data-driven subgroups based on dynamic emotion patterns. These data-driven subgroups did not significantly differ in terms of clinical features or demographics, but did differ on key emotion metrics-instability, granularity, and inertia. These data-driven subgroupings, agnostic to diagnostic status, provide insights into the nature of idiographic emotion-network dynamics that cut-across clinical diagnostic divisions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

BACKGROUND

Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators.

METHODS

This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954.

FINDINGS

We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms.

INTERPRETATION

This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress.

FUNDING

Swiss National Science Foundation.

A core component of psychological therapy causes adaptive changes in computational learning mechanisms

BACKGROUND

Cognitive distancing is an emotion regulation strategy commonly used in psychological treatment of various mental health disorders, but its therapeutic mechanisms are unknown.

METHODS

935 participants completed an online reinforcement learning task involving choices between pairs of symbols with differing reward contingencies. Half (49.1%) of the sample was randomised to a cognitive self-distancing intervention and were trained to regulate or 'take a step back' from their emotional response to feedback throughout. Established computational (Q-learning) models were then fit to individuals' choices to derive reinforcement learning parameters capturing clarity of choice values (inverse temperature) and their sensitivity to positive and negative feedback (learning rates).

RESULTS

Cognitive distancing improved task performance, including when participants were later tested on novel combinations of symbols without feedback. Group differences in computational model-derived parameters revealed that cognitive distancing resulted in clearer representations of option values (estimated 0.17 higher inverse temperatures). Simultaneously, distancing caused increased sensitivity to negative feedback (estimated 19% higher loss learning rates). Exploratory analyses suggested this resulted from an evolving shift in strategy by distanced participants: initially, choices were more determined by expected value differences between symbols, but as the task progressed, they became more sensitive to negative feedback, with evidence for a difference strongest by the end of training.

CONCLUSIONS

Adaptive effects on the computations that underlie learning from reward and loss may explain the therapeutic benefits of cognitive distancing. Over time and with practice, cognitive distancing may improve symptoms of mental health disorders by promoting more effective engagement with negative information.

Affective working memory in depression

Depressed individuals show a wide range of difficulties in executive functioning (including working memory), which can be a significant burden on everyday mental processes. Theoretical models of depression have proposed these difficulties to be especially pronounced in affective contexts. However, evidence investigating affective working memory (WM) capacity in depressed individuals has shown mixed results. The preregistered study used a complex span task, which has been shown to be sensitive to difficulties with WM capacity in affective relative to neutral contexts in other clinical groups, to explore affective WM capacity in clinical depression. Affective WM capacity was compared between individuals with current depression (n = 24), individuals in remission from depression (n = 25), and healthy controls (n = 30). The results showed that, overall, WM capacity was more impaired in the context of negative distractor images, relative to neutral images. Furthermore, those with a lifetime history of depression (individuals with current depression and individuals remitted from depression), performed worse on the task, compared to healthy controls. However, there was no support for the greater disruption of WM capacity in affective compared to neutral contexts in those with a lifetime history of depression. These findings' implications for current models of depression are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

From basic science to clinical practice: Can cognitive behavioural therapy tasks be augmented with enhanced episodic specificity?

Individuals with depression typically remember their past in a generalised manner, at the cost of retrieving specific event memories. This may impair engagement with cognitive behavioural therapy (CBT) tasks that use concrete episodic information to challenge maladaptive beliefs, potentially limiting their therapeutic benefit. Study 1 demonstrated that an episodic specificity induction increased detail and specificity of autobiographical memory in people with major depression, relative to control conditions (N = 88). We therefore examined whether the induction enhanced the efficacy of CBT tasks that depend on episodic memory - cognitive reappraisal (Study 2, N = 30), evidence gathering (Study 2, N = 30), and planning behavioural experiments (Study 3a, N = 30). Across all three tasks, there were no significant differences in emotion- or belief-change between the specificity and control conditions. Although the induction temporarily enhanced specificity in depressed individuals, it did not significantly augment the efficacy of CBT tasks theorised to benefit from the use of specific mnemonic information.

Reduced social risk-taking in depression

Evolutionary models of depression posit that depressed mood represents an adaptive response to unacceptably low social status, motivating the inhibition of social risk-taking in favor of submissive behaviors which reduce the likelihood of social exclusion. We tested the hypothesis of reduced social risk taking using a novel adaptation of the Balloon Analogue Risk Task (BART) in participants with major depressive disorder (MDD; n = 27) and never-depressed comparison participants (n = 35). The BART requires participants to pump up virtual balloons. The more the balloon is pumped up, the more money a participant gains on that trial. However, more pumps also increase the risk the balloon will burst such that all money is lost. Prior to performing the BART, participants took part in a team induction in small groups in order to prime social-group membership. Participants then completed two conditions of the BART: an Individual condition where they risked only their own money, and a Social condition, where they risked the money of their social group. The groups did not differ in their performance in the individual condition (Cohen's d = 0.07). However, the MDD group risked fewer pumps in the Social condition than the never-depressed group (d = 0.57). The study supports the notion of an aversion to social risk-taking in depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

More than meets the eye: emotional stimuli enhance boundary extension effects for both depressed and never-depressed individuals

Boundary extension is a memory phenomenon in which an individual reports seeing more of a scene than they actually did. We provide the first examination of boundary extension in individuals diagnosed with depression, hypothesising that an overemphasis on pre-existing schema may enhance boundary extension effects on emotional photographs. The relationship between boundary extension and overgeneralisation in autobiographical memory was also explored. Individuals with (n = 42) and without (n = 41) Major Depressive Disorder completed a camera paradigm task utilising positive, negative, and neutral stimuli. Across all participants, positive (d = 0.37) and negative (d = 0.66) stimuli were extended more than neutral stimuli. This effect did not differ between depressed and never-depressed participants. Across all participants, images containing objects were extended more than images containing faces. An association was also evident between extension effects in memory for perceptual space and extensions of autobiographical memory across time.

Affective Control Training (AffeCT) reduces negative affect in depressed individuals

Depression is the leading cause of disability worldwide, with prevalence rates rising. Despite the scale of the problem, available pharmacological and psychological interventions only have limited efficacy. The National Institute of Health's Science of Behaviour Change framework proposes to address this issue by capitalising on insights from basic science to identify mechanisms that can be targeted by novel interventions. The current study evaluated the potential of a computerized programme aimed at improving affective control, a mechanistic target involved in both risk and maintenance of depression. In a first phase the cognitive profiles of 48 depressed individuals (mean age: 39 years, 75 % female) were compared to cognitive functioning in 16 never-depressed individuals (mean age: 31 years, 56 % female). The sole index of functioning that differed between diagnostic groups was reaction time across negative and positively valanced trials on an affective Stroop task (d = 0.58). This index was then used to evaluate an affective control training (AffeCT) against a placebo training. Results showed no significant changes on tasks that showed no differences with never-depressed individuals in Phase I. However, compared to placebo training, AffeCT led to significantly greater improvement in the target index, affective Stroop performance (d = 1.17). Importantly, AffeCT led to greater reductions in negative affect as measured by the Positive Affect and Negative Affect Schedule compared to the placebo training (d = 0.98). This proof-of-concept study shows promising benefits of AffeCT on depressed individuals' affect, but not depressive symptoms. It further supports the utility of the Science of Behaviour Change framework, highlighting the need for determining meaningful assays of target mechanisms when evaluating novel interventions.

Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Complex PTSD is characterised by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships. Complex PTSD has been adopted as a new diagnosis in the ICD-11. Individuals with complex PTSD typically have sustained or multiple exposures to trauma, such as childhood abuse and domestic or community violence. The disorder has a 1-8% population prevalence and up to 50% prevalence in mental health facilities. Progress in diagnostics, assessment, and differentiation from post-traumatic stress disorder and borderline personality disorder is reported, along with assessment and treatment of children and adolescents. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions.

Protocol for the Work Engagement and Well-being Study (SWELL): a randomised controlled feasibility trial evaluating the effects of mindfulness versus light physical exercise at work

INTRODUCTION

Mental ill health is a major cause of disability. Workplaces are attractive for preventative interventions since most adults work; meanwhile, employers are interested in improving employees' well-being and productivity. Mindfulness-based programmes are increasingly popular in occupational settings. However, there is inconsistent evidence whether mindfulness interventions improve work performance and how effective mindfulness-based programmes are, compared with other interventions, in preventing mental ill health.

METHODS AND ANALYSIS

In this online randomised controlled feasibility trial, an anticipated 240 employees will be randomised to either a 4-week light physical exercise course or a mindfulness course of the same duration (1:1 allocation). The primary outcome is work performance, measured using the Work Role Functioning Questionnaire. We aim to evaluate the acceptability, feasibility and procedural uncertainties of a randomised controlled trial in a workplace, calculate an effect size estimate to inform power calculations for a larger trial, and explore whether improved executive function and/or enhanced mental health could be potential mechanisms underlying the effect of mindfulness on work performance. Outcomes will be collected at baseline, postintervention and 12-week follow-up.

ETHICS AND DISSEMINATION

Approval has been obtained from Cambridge Psychology Research Ethics Committee. (PRE.2020072). Results will be published in peer-reviewed journals. A lay summary will be disseminated to a wider audience including participating employers.

TRIAL REGISTRATION NUMBER

NCT04631302.

Autobiographical memory style and clinical outcomes following mindfulness-based cognitive therapy (MBCT): An individual patient data meta-analysis

The ability to retrieve specific, single-incident autobiographical memories has been consistently posited as a predictor of recurrent depression. Elucidating the role of autobiographical memory specificity in patient-response to depressive treatments may improve treatment efficacy and facilitate use of science-driven interventions. We used recent methodological advances in individual patient data meta-analysis to determine a) whether memory specificity is improved following mindfulness-based cognitive therapy (MBCT), relative to control interventions, and b) whether pre-treatment memory specificity moderates treatment response. All bar one study evaluated MBCT for relapse prevention for depression. Our initial analysis therefore focussed on MBCT datasets only(n = 708), then were repeated including the additional dataset(n = 880). Memory specificity did not significantly differ from baseline to post-treatment for either MBCT and Control interventions. There was no evidence that baseline memory specificity predicted treatment response in terms of symptom-levels, or risk of relapse. Findings raise important questions regarding the role of memory specificity in depressive treatments.

The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds

BACKGROUND

The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC.

METHOD

Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC.

RESULTS

In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures.

CONCLUSIONS

The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.

Converging evidence for enduring perceptions of low social status in individuals in remission from depression

BACKGROUND

The risk of depressive relapse and recurrence is associated with social risk factors that may be amplified by a submissive socio-cognitive profile.

METHODS

In Study 1 we aimed to identify perceptions of low social status in a community sample (N = 613) with a self-reported history of mental health difficulties (n = 232) and, more specifically in Study 2 (N = 122), in individuals in clinical remission from depression (n = 18), relative to a never-depressed control group (n = 64), and relative to a group experiencing a current depressive episode (n = 40).

RESULTS

In Study 1, a total of 225 of the 232 participants in the self-reported mental health difficulties group opted to provide further information regarding their mental health history, of whom 153 (68%) reported a history of anxiety, 168 (74.7%) reported a history of depression, and 13 (5.8%) reported an unspecified mental health history. Elevated depressive symptoms were associated with perceptions of low social status which significantly differed between individuals with and without a self-reported history of mental health difficulties. In Study 2 we found enduring perceptions of low social status in remitted depressed individuals.

LIMITATIONS

We were unable to discern between historical or current clinical diagnosis in the community sample of Study 1, as we were reliant on self-report. We were unable to explore the effects of medication or causal relationships between depressive symptoms and social status as the studies were cross-sectional in nature.

CONCLUSIONS

These findings suggest that evolutionarily rooted socio-cognitive profiles could impact affiliative processes and may confer increased vulnerability to future depressive episodes.

Validation of the Child version of the Perseverative Thinking Questionnaire of repetitive negative thinking in young people with diagnosed depressive and anxiety disorders

This paper sought to provide the first validation of a transdiagnostic measure of repetitive negative thinking – the Perseverative Thinking Questionnaire‐Child version (PTQ‐C) – in young people diagnosed with anxiety and depressive disorders. Participants (N = 114) were 11‐ to 17‐year‐olds with complex and comorbid presentations seeking treatment through Child and Adolescent Mental Health Services. Confirmatory factor analyses best supported a three‐factor model for the PTQ‐C; however, hypotheses of both perfect and close fit were rejected, and a subsequent bifactor model suggested minimal unique variance for each subscale. Results demonstrated good internal consistency, convergent validity and divergent validity for the total score and three PTQ‐S subscales: core characteristics, perceived unproductiveness, and consumed mental capacity of negative repetitive thinking. PTQ‐C scores did not account for additional variance in anxiety symptoms once worry was considered, indicating that retention of a content‐specific measure may be warranted in clinical samples. Findings emphasize the importance of validating clinically relevant measures which were developed with subclinical populations in samples with diagnosed mental health disorders.

Population Prevalence of the Posttraumatic Stress Disorder Subtype for Young Children in Nationwide Surveys of the British General Population and of Children in Care

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating condition that when left untreated can have severe lifelong consequences for psychological, social, and occupational functioning. Initial conceptualizations of PTSD were centered on adult presentations. However, the instantiation of developmentally appropriate PTSD in young children (PTSD-YC) criteria, tailored to preschool (6 years old and younger) children, represents an important step toward identifying more young children experiencing distress. This study explored population-level prevalence of PTSD-YC indexed via an alternative algorithm for DSM-IV PTSD (AA-PTSD).

METHOD

Representative population data were used to test whether application of AA-PTSD criteria, relative to the DSM-IV PTSD algorithm, increased identification of 5- to 6-year-old children with clinical needs in both the general population (n = 3,202) and among looked after children (ie, in Britain, foster children are called looked after children [more commonly referred to as children in care].) (n = 137), in whom the risk of mental health issues is greater.

RESULTS

Notably, no 5- to 6-year-old children in the general population sample were diagnosed with PTSD using adult-based DSM-IV criteria. In contrast, AA-PTSD prevalence was 0.4% overall, rising to 5.4% in trauma-exposed children. In looked after children, overall PTSD prevalence rose from 1.2% when applying adult-based DSM-IV criteria to 14% when using AA-PTSD criteria. Of trauma-exposed looked after children, 2.7% met criteria for DSM-IV PTSD compared with 57.0% when applying AA-PTSD criteria. In both samples, use of the alternative algorithm to index PTSD-YC criteria markedly increased identification of children experiencing functional impairment owing to symptoms.

CONCLUSION

Results demonstrate the utility of the PTSD-YC diagnosis beyond at-risk and treatment-seeking samples. Use of PTSD-YC criteria substantially improves identification of 5- to 6-year-old children burdened by PTSD at the population level.

Proof of Concept for the Autobiographical Memory Flexibility (MemFlex) Intervention for Posttraumatic Stress Disorder

Autobiographical memory distortions are a key feature of posttraumatic stress disorder (PTSD). In this proof-of-concept randomized controlled trial (N = 43), we evaluated an autobiographical memory flexibility intervention, MemFlex. We aimed to determine whether the mechanism-focused intervention, which aims to improve autobiographical memory processes, may also affect other cognitive predictors of PTSD and potentially reduce PTSD symptoms in Iranian trauma survivors diagnosed with PTSD. Results indicated significant, moderate to large between-groups effect sizes in favor of MemFlex, relative to wait-list control, for the targeted cognitive mechanism of autobiographical memory flexibility and PTSD symptoms. A large, significant effect was also observed on maladaptive posttraumatic cognitions-a strong predictor of PTSD prognosis, which is a key target of high-intensity cognitive therapies for PTSD. Findings support future completion of a scaled-up trial to evaluate treatment efficacy of MemFlex for PTSD to determine whether MemFlex may offer a culturally adaptive, low-cost, low-intensity intervention able to improve cognitive mechanisms of PTSD.

A randomized, controlled proof-of-concept trial evaluating durable effects of memory flexibility training (MemFlex) on autobiographical memory distortions and on relapse of recurrent major depressive disorder over 12 months

Low-intensity psychological interventions that target cognitive risk factors for depressive relapse may improve access to relapse prevention programs and thereby reduce subsequent risk. This study provides the first evaluation of an autobiographical memory-based intervention for relapse prevention, to establish whether memory-training programs that are efficacious for acute depression may also aid those currently in remission. We also provide the longest follow-up to-date of the effects of autobiographical memory training on autobiographical memory processes themselves. This pre-registered randomized-controlled proof-of-concept trial (N = 74) compared an autobiographical Memory Flexibility (MemFlex) intervention to Psychoeducation about cognitive-behavioral mechanisms which maintain depression. Both interventions were primarily self-guided, and delivered via paper workbooks completed over four weeks. The key cognitive outcome was ability to retrieve and alternate between specific and general autobiographical memories. Co-primary clinical outcomes were time until depressive relapse and depression-free days in the twelve-months following intervention. Results indicated a small-moderate effect size (d = 0.35) in favor of MemFlex for the cognitive outcome. A small Hazard Ratio (1.08) was observed for time until depressive relapse, along with a negligible effect size for depression-free days (d = 0.11). Although MemFlex produced long-term improvement in memory retrieval skills, there was little support for MemFlex as a relapse prevention program for depression.

Prevalence and predictive value of ICD-11 post-traumatic stress disorder and Complex PTSD diagnoses in children and adolescents exposed to a single-event trauma

BACKGROUND

The 11th edition of the International Classification of Diseases (ICD-11) made a number of significant changes to the diagnostic criteria for post-traumatic stress disorder (PTSD). We sought to determine the prevalence and 3-month predictive values of the new ICD-11 PTSD criteria relative to ICD-10 PTSD, in children and adolescents following a single traumatic event. ICD-11 also introduced a diagnosis of Complex PTSD (CPTSD), proposed to typically result from prolonged, chronic exposure to traumatic experiences, although the CPTSD diagnostic criteria do not require a repeated experience of trauma. We therefore explored whether children and adolescents demonstrate ICD-11 CPTSD features following exposure to a single-incident trauma.

METHOD

Data were analysed from a prospective cohort study of youth aged 8-17 years who had attended an emergency department following a single trauma. Assessments of PTSD, CPTSD, depressive and anxiety symptoms were performed at two to four weeks (n = 226) and nine weeks (n = 208) post-trauma, allowing us to calculate and compare the prevalence and predictive value of ICD-10 and ICD-11 PTSD criteria, along with CPTSD. Predictive abilities of different diagnostic thresholds were undertaken using positive/negative predictive values, sensitivity/specificity statistics and logistic regressions.

RESULTS

At Week 9, 15 participants (7%) were identified as experiencing ICD-11 PTSD, compared to 23 (11%) experiencing ICD-10 PTSD. There was no significant difference in comorbidity rates between ICD-10 and ICD-11 PTSD diagnoses. Ninety per cent of participants with ICD-11 PTSD also met criteria for at least one CPTSD feature. Five participants met full CPTSD criteria.

CONCLUSIONS

Reduced prevalence of PTSD associated with the use of ICD-11 criteria is likely to reduce identification of PTSD relative to using ICD-10 criteria but not relative to DSM-4 and DSM-5 criteria. Diagnosis of CPTSD is likely to be infrequent following single-incident trauma.

Efficacy and moderators of efficacy of trauma-focused cognitive behavioural therapies in children and adolescents: protocol for an individual participant data meta-analysis from randomised trials

INTRODUCTION

Trauma-focused cognitive behavioural therapies are the first-line treatment for posttraumatic stress disorder (PTSD) in children and adolescents. Nevertheless, open questions remain with respect to efficacy: why does this first-line treatment not work for everyone? For whom does it work best? Individual clinical trials often do not provide sufficient statistical power to examine and substantiate moderating factors. To overcome the issue of limited power, an individual participant data meta-analysis of randomised trials evaluating forms of trauma-focused cognitive behavioural therapy in children and adolescents aged 6-18 years will be conducted.

METHODS AND ANALYSIS

We will update the National Institute for Health and Care Excellence guideline literature search from 2018 with an electronic search in the databases PsycINFO, MEDLINE, Embase, Cochrane Central Register of Controlled Trials and CINAHL with the terms (trauma* OR stress*) AND (cognitive therap* OR psychotherap*) AND (trial* OR review*). Electronic searches will be supplemented by a comprehensive grey literature search in archives and trial registries. Only randomised trials that used any manualised psychological treatment-that is a trauma-focused cognitive behavioural therapy for children and adolescents-will be included. The primary outcome variable will be child-reported posttraumatic stress symptoms (PTSS) post-treatment. Proxy-reports (teacher, parent and caregiver) will be analysed separately. Secondary outcomes will include follow-up assessments of PTSS, PTSD diagnosis and symptoms of comorbid disorders such as depression, anxiety-related and externalising problems. Random-effects models applying restricted maximum likelihood estimation will be used for all analyses. We will use the Revised Cochrane Risk of Bias tool to measure risk of bias.

ETHICS AND DISSEMINATION

Contributing study authors need to have permission to share anonymised data. Contributing studies will be required to remove patient identifiers before providing their data. Results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019151954.

The current state of memory Specificity Training (MeST) for emotional disorders

Memory Specificity Training (MeST) is an intervention developed from basic science that has found clinical utility. MeST uses cued recall exercises to target the difficulty that some people with emotional disorders have in recalling personally experienced events. MeST is simple enough to be delivered alongside traditional interventions or online by artificial intelligence. Currently, research indicates MeST's effects are immediate but short-lived, and there is limited research indicating its superiority over established interventions. Future investigations must establish the dosage and specific components of MeST that are necessary for clinically significant effects. Further, it must establish the secondary processes (e.g., problem-solving) that mediate between MeST-driven improvements in memory and symptoms. Similar interventions that build upon the idea of training autobiographical memory specificity are also emerging and warrant further investigation.

Fractured Pasts: The Structure of the Life Story in Sexual-Trauma Survivors With Posttraumatic Stress Disorder

We examined the organization of past and future affective autobiographical knowledge in sexual-trauma survivors compared with control participants. Participants (N = 113) divided their past (and future) life into chapters (e.g., “college,” “marriage”), then characterized each chapter using positive or negative attributes. Sexual-trauma survivors (n = 27) endorsed a greater proportion of negative attributes, demonstrated greater affective compartmentalization (separation of positive and negative attributes into different chapters), and showed reduced redundancy (consistent endorsement across chapters) of positive attributes relative to control participants (n = 23). Groups did not differ on negative redundancy for past life structure or any metrics for future life structure. In a secondary analysis, we compared life structures for the sexual-trauma group and for individuals with chronic depression but no sexual-trauma history (n = 30) and matched control participants (n = 56), which revealed significantly greater negative redundancy in the depressed group. The distinct life structure presented by sexual-trauma survivors may reflect efforts to constrain the impact of trauma on an individual’s self-identity.

Emotional complexity across the life story: Elevated negative emodiversity and diminished positive emodiversity in sufferers of recurrent depression

BACKGROUND

Greater diversity in the experience of negative and positive emotions - emodiversity - is associated with better mental health outcomes in the general population (Quoidbach et al. 2014). However, conceptual accounts of depression suggest this might differ in clinical depression. In this study, the diversity of negative and positive emotion experiences as remembered by a recurrently depressed sample and a never-depressed control group were compared.

METHODS

Emodiversity was assessed using a life structure card sort task which allowed for the assessment of memory for emotional experience over the life course. Depressed (n=34) and non-depressed (n=34) participants completed the card sort task, from which emodiversity metrics were calculated for negative and positive emotion experience.

RESULTS

Depressed individuals showed recollections of enhanced emodiversity across negative emotion but reduced emodiversity across positive emotion, relative to never-depressed individuals.

LIMITATIONS

This study involved a relatively small sample size.

DISCUSSION

This study indicates that greater diversity of negative emotion experience, which has been interpreted as a protective factor against depressed mood in community samples (Quoidbach et al., 2014), instead characterises the remembered experience of recurrent clinical depression. The finding that positive emodiversity is adaptive in depression suggests that therapeutic outcomes may be improved by facilitating exposure to a diverse range of positive emotions. These findings indicate that the relationship between emotion diversity and mental health is more complex than hitherto assumed.

Compartmentalization of self-representations in female survivors of sexual abuse and assault, with posttraumatic stress disorder (PTSD)

BACKGROUND

This study examined the structure of the self-concept in a sample of sexual trauma survivors with posttraumatic stress disorder (PTSD) compared to healthy controls using a self-descriptive card-sorting task. We explored whether individuals with PTSD possess a highly affectively-compartmentalized self-structure, whereby positive and negative self-attributes are sectioned off into separate components of self-concept (e.g. self as an employee, lover, mother). We also examined redundancy (i.e. overlap) of positive and negative self-attributes across the different components of self-concept.

METHOD

Participants generated a set of self-aspects that reflected their own life (e.g. 'self at work'). They were then asked to describe their self-aspects using list of positive or negative attributes.

RESULTS

Results revealed that, relative to the control group, the PTSD group used a greater proportion of negative attributes and had a more compartmentalized self-structure. However, there were no significant differences between the PTSD and control groups in positive or negative redundancy. Sensitivity analyses demonstrated that the key findings were not accounted for by comorbid diagnosis of depression.

CONCLUSION

Findings indicated that the self-structure is organized differently in those with PTSD, relative to those with depression or good mental health.

Negative and positive emotional complexity in the autobiographical representations of sexual trauma survivors

This study examined the diversity of experienced positive and negative emotions - emodiversity - within two existing datasets involving female survivors of sexual abuse and assault, who all met criteria for chronic Posttraumatic Stress Disorder (PTSD) as well as a diversity of comorbid diagnoses. Study 1 investigated the structure of the self-concept and Study 2 explored the organization of past autobiographical knowledge. In each study, we measured emodiversity for positive and negative emotion constructs in the trauma sample, relative to healthy control participants with no history of sexual trauma or PTSD. Results confirmed our hypotheses that individuals with a severe sexual trauma history and resultant PTSD would show elevated negative emodiversity and reduced positive diversity across both the structure of the self-concept and the structure of the life narrative, relative to control participants. The current results differ from community studies where greater negative emodiversity is associated with better mental health but mirror those from a prior study with individuals with Major Depressive Disorder. This suggests that valence-based differences in emodiversity may result from chronic emotional disturbance.

Memory category fluency, memory specificity, and the fading affect bias for positive and negative autobiographical events: Performance on a good day-bad day task in healthy and depressed individuals

In mentally healthy individuals, autobiographical memory is typically biased toward positive events, which may help to maintain psychological well-being. Our aim was to assess a range of important positive memory biases in the mentally healthy and explore the possibility that these biases are mitigated in those with mental health problems. We administered a novel recall paradigm that required recollection of multiple good and bad past events (the Good Day–Bad Day task) to healthy and depressed individuals. This allowed us to explore differences in memory category fluency (i.e., the ability to generate integrated sets of associated events) for positive and negative memories, along with memory specificity, and fading affect bias—a greater reduction in the intensity of memory-related affect over time for negative versus positive events. We found that healthy participants demonstrated superior category fluency for positive relative to negative events but that this effect was absent in depressed participants. Healthy participants exhibited a strong fading affect bias that was significantly mitigated, although still present, in depression. Finally, memory specificity was reduced in depression for both positive and negative memories. Findings demonstrate that the positive bias associated with mental health is maintained by multiple autobiographical memory processes and that depression is as much a function of the absence of these positive biases as it is the presence of negative biases. Results provide important guidance for developing new treatments for improving mental health.

Role of autobiographical memory in patient response to cognitive behavioural therapies for depression: protocol of an individual patient data meta-analysis

INTRODUCTION

Cognitive behavioural therapies (CBTs) are one of the most effective treatments for major depression. However, ~50% of individuals do not adequately respond to intervention and of those who do remit from a depressive episode, over 50% will experience later relapse. Identification of patient-level factors which moderate treatment response may ultimately help to identify cognitive barriers that could be targeted to improve treatment efficacy. This individual patient data meta-analysis explores one such potential moderator-the ability to retrieve specific, detailed memories of the autobiographical past-as cognitive-based therapeutic techniques draw heavily on the ability to use specific autobiographical information to challenge the dysfunctional beliefs which drive depression.

METHODS AND ANALYSIS

We have formed a collaborative network which will contribute known datasets. This will be supplemented by datasets identified through literature searches in Medline, PsycInfo, Web of Science, the Cochrane Central Register of Controlled Trials and WHO trials database between December 2018 and February 2019. Inclusion criteria are delivery of a cognitive or cognitive behavioural therapy for major depression, and measurement of autobiographical memory retrieval at preintervention. Primary outcomes are depressive symptoms and clinician-rated diagnostic status at postintervention, along with autobiographical memory specificity at postintervention. Secondary outcomes will consider each of these variables at follow-up. All analyses will be completed using random-effects models employing restricted maximum likelihood estimation. Risk of bias in included studies will be measured using the Revised Cochrane Risk of Bias Tool.

ETHICS AND DISSEMINATION

The findings will be published in a peer-reviewed journal. Study results will contribute to better understanding of the role of autobiographical memory in patient response to CBTs, and may help to inform personalised medicine approaches to treatment of depression.

PROSPERO REGISTRATION NUMBER

CRD42018109673.

The impact of affective information on working memory: A pair of meta-analytic reviews of behavioral and neuroimaging evidence

Everyday life is defined by goal states that are continuously reprioritized based on available, often affective information. To pursue these goals, individuals need to process and maintain goal-relevant information, while ignoring potentially salient information that distracts resources from these goals. Empirically, this ability has typically been operationalized as working memory (WM) capacity. A growing body of research is investigating the impact of information’s affective salience on WM capacity. In the present review we address this question by exploring the potential differential impact of affective compared with neutral information on WM, and the underlying neural substrates. One-hundred and 65 studies (N = 7,433) were included in the meta-analysis. Results showed negligible to small (d̂ = −.07–.20) effects of affective information on behavioral measures of WM in healthy individuals (n = 4,936) that varied as a function of valence and task-relevance. Heterogeneity analyses were significant, demonstrating the need to identify further study-specific factors and individual differences that moderate affective WM. At the neural level (33 studies; n = 683), processing affective versus neutral material during WM tasks was associated with more frequent recruitment of the vlPFC, the amygdala, and the temporo-occipital cortex. In contrast to healthy individuals, across behavioral studies those suffering from mental health problems (n = 2,041) showed impaired WM accuracy (d̂ = −0.21) in the presence of affective material. These findings highlight the importance of integrating behavioral and neural levels of analysis. Finally, these findings suggest that affective WM capacity may be a transdiagnostic mechanism associated with poor mental health.

The behavioral and neuroimaging meta-analyses showed that in psychologically healthy individuals there was limited support for behavioral working memory (WM) performance to be affected by affective information, whereas at the neural level WM in the presence of affective relative to neutral information was associated with differential recruitment of the salience network and the fronto-parietal control network. These findings highlight the importance of combining behavioral and neuroimaging research syntheses. Second, in individuals with mental health problems WM was significantly impaired by affective material. This suggests that WM performance on tasks including affective compared with neutral information may be a sensitive and transdiagnostic cognitive marker of mental health status.

Misremembrance of Things Past: Depression Is Associated With Difficulties in the Recollection of Both Specific and Categoric Autobiographical Memories

Impaired retrieval of specific, autobiographical memories of personally experienced events is characteristic of major depressive disorder (MDD). However, findings in subclinical samples suggest that the reduced specificity phenomenon may reflect a broader impairment in the deliberate retrieval of all autobiographical memory types. This experiment (N = 68) explored this possibility by requiring individuals with and without MDD to complete a cued-recall task that required retrieval of specific, single-incident memories to a block of cues; retrieval of categoric, general memories to a block of cues; and to alternate between retrieval of specific and general memories for a block of cues. Results demonstrated that relative to never-depressed controls, individuals with MDD experience reduced recall of both specific (d = 0.48) and general memories (d = 1.00) along with reduced flexibility in alternating between specific and general memories (d = 0.90). Findings support further development of autobiographical memory–based interventions that target a range of retrieval deficits rather than specificity alone.

A randomised controlled trial of memory flexibility training (MemFlex) to enhance memory flexibility and reduce depressive symptomatology in individuals with major depressive disorder

Successful navigation within the autobiographical memory store is integral to daily cognition. Impairment in the flexibility of memory retrieval can thereby have a detrimental impact on mental health. This randomised controlled phase II exploratory trial (N = 60) evaluated the potential of a novel intervention drawn from basic science - an autobiographical Memory Flexibility (MemFlex) training programme - which sought to ameliorate memory difficulties and improve symptoms of Major Depressive Disorder. MemFlex was compared to Psychoeducation (an evidence-based low-intensity intervention) to determine the likely range of effects on a primary cognitive target of memory flexibility at post-intervention, and co-primary clinical targets of self-reported depressive symptoms and diagnostic status at three-month follow-up. These effect sizes could subsequently be used to estimate sample size for a fully-powered trial. Results demonstrated small-moderate, though as expected statistically non-significant, effect sizes in favour of MemFlex for memory flexibility (d = 0.34, p = .20), and loss of diagnosis (OR = 0.65, p = .48), along with the secondary outcome of depression-free days (d = 0.36, p = .18). A smaller effect size was observed for between-group difference in self-reported depressive symptoms (d = 0.24, p = .35). Effect sizes in favour of MemFlex in this early-stage trial suggest that fully-powered evaluation of MemFlex may be warranted as an avenue to improving low-intensity treatment of depression.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT02371291.

Prevalence of auditory pseudohallucinations in adult survivors of physical and sexual trauma with chronic post-traumatic stress disorder (PTSD)

Auditory Verbal Hallucinations (AVHs) are commonly associated with psychosis but are also reported in post-traumatic stress disorder (PTSD). Hearing voices after the experience of stress has been conceptualised as a dissociative experience. Brewin and Patel's (2010) seminal study reported that hearing voices is relatively common in PTSD, as hearing voices was associated with PTSD in half and two thirds of military veterans and survivors of civilian trauma, respectively. The authors conceptualised these voices as "auditory pseudohallucinations." To build upon this work, we administered Brewin and Patel's' interview to adult survivors (n = 40) of physical and sexual trauma with chronic PTSD, and healthy controls (n = 39). In contrast to previous findings, only 5% (n = 2) of our PTSD sample reported recently hearing a voice that was consistent with an auditory pseudohallucination, with no reports in our control group. Thus, no support was provided for auditory pseudohallucinations as a significant symptom in this population.

The HARMONIC trial: study protocol for a randomised controlled feasibility trial of Shaping Healthy Minds-a modular transdiagnostic intervention for mood, stressor-related and anxiety disorders in adults

INTRODUCTION

Anxiety, mood and trauma-related disorders are common, affecting up to 20% of adults. Many of these individuals will experience symptoms of more than one disorder as diagnostically defined. However, most psychological treatments focus on individual disorders and are less effective for those who experience comorbid disorders. The Healthy and Resilient Mind Programme: Building Blocks for Mental Wellbeing (HARMONIC) trial introduces a novel transdiagnostic intervention (Shaping Healthy Minds (SHM)), which synthesises several evidence-based treatment techniques to address the gap in effective interventions for people with complex and comorbid difficulties. This early phase trial aims to estimate the efficacy and feasibility of the transdiagnostic intervention in preparation for a later-phase randomised controlled trial, and to explore mechanisms of change.

METHODS/ANALYSIS

We outline a patient-level two-arm randomised controlled trial (HARMONIC) that compares SHM to treatment-as-usual for individuals aged >18 years (n=50) with comorbid mood, anxiety, obsessive-compulsive or trauma/stressor disorders diagnoses, recruited from outpatient psychological services within the UK National Health Service (NHS). The co-primary outcomes will be 3-month follow-up scores on self-report measures of depressive symptoms, anxiety symptoms, and disability and functional impairment. Secondary outcomes include changes in symptoms linked to individual disorders. We will assess the feasibility and acceptability of SHM, the utility of proposed outcome measures, and refine the treatment manuals in preparation for a later-phase trial.

ETHICS AND DISSEMINATION

This trial protocol has been approved by the Health Research Authority of the NHS of the UK (East of England, Reference: 16/EE/0095). We anticipate that trial findings will inform future revisions of clinical guidelines for numerous forms of mood, anxiety and stressor-related disorders. Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations, clinical workshops and a trial website.

TRIAL REGISTRATION

NCT03143634; Pre-results.

A cluster randomized controlled platform trial comparing group MEmory specificity training (MEST) to group psychoeducation and supportive counselling (PSC) in the treatment of recurrent depression

Impaired ability to recall specific autobiographical memories is characteristic of depression, which when reversed, may have therapeutic benefits. This cluster-randomized controlled pilot trial investigated efficacy and aspects of acceptability, and feasibility of MEmory Specificity Training (MEST) relative to Psychoeducation and Supportive Counselling (PSC) for Major Depressive Disorder (N = 62). A key aim of this study was to determine a range of effect size estimates to inform a later phase trial. Assessments were completed at baseline, post-treatment and 3-month follow-up. The cognitive process outcome was memory specificity. The primary clinical outcome was symptoms on the Beck Depression Inventory-II at 3-month follow-up. The MEST group demonstrated greater improvement in memory specificity relative to PSC at post-intervention (d = 0.88) and follow-up (d = 0.74), relative to PSC. Both groups experienced a reduction in depressive symptoms at 3-month follow-up (d = 0.67). However, there was no support for a greater improvement in depressive symptoms at 3 months following MEST relative to PSC (d = -0.04). Although MEST generated changes on memory specificity and improved depressive symptoms, results provide no indication that MEST is superior to PSC in the resolution of self-reported depressive symptoms. Implications for later-phase definitive trials of MEST are discussed.

The Impact of Affective Context on Autobiographical Recollection in Depression

Across two studies we investigated the influence of contextual cues on autobiographical memory recall. In Study 1, participants (N = 37) with major depressive disorder, in episode or in varying degrees of remission, were administered a Negative Autobiographical Memory Task (NAMT) that required them to retrieve negatively valenced memories in response to positive cue words (a positive context). We reasoned that increased depression symptom severity would be associated with a reduced ability to override priming from this disadvantageous context. Consequently, we hypothesized that increased depressive severity would counterintuitively be associated with reduced negativity ratings for retrieved personal memories to positive cues on the NAMT. This hypothesis was supported. Study 2, using a community sample (N = 63), demonstrated that a similar reduction in memory negativity was observed in individuals with lower working memory capacity—an index of executive control. Implications for autobiographical memory and executive training paradigms for depression are discussed.

Impact of culture on autobiographical life structure in depression

OBJECTIVES

Distortions in autobiographical memory have been implicated in major depressive disorder (MDD). Those with MDD demonstrate a 'depressogenic' autobiographical life structure. Research has not examined how culture influences this process. We investigated whether Malay individuals (members of an interdependent culture) with MDD demonstrated a 'depressogenic' autobiographical life structure similar to that of British individuals (members of an independent culture) with MDD.

DESIGN

A 2 (Culture; Malay, British) × 2 (Mood; depressed, control) cross-sectional design using a card sort task and self-report measures was used.

METHODS

Malay individuals with MDD or no history of MDD completed the life-structure card-sorting task, which provided a novel method for investigating organizational structure of the life narrative. These data were compared to previously collected data in which British individuals with MDD or without MDD had completed the same task within the same experimental protocol.

RESULTS

Pan-culturally those with MDD had greater negativity (i.e., used more negative attributes), negative redundancy (i.e., used the same negative attributes repeatedly across life chapters) and negative emodiversity (i.e., had greater variety and relative abundance of negative attributes), and reduced positive redundancy (i.e., used the same positive attributes repeatedly across chapters) in their structuring relative to controls. While the British MDD group had greater compartmentalization (i.e., the negative and positive attributes were clustered separately across different chapters) than British controls, the Malay MDD group had lower levels of compartmentalization than Malay controls.

CONCLUSIONS

The findings suggest culture may shape aspects of the autobiographical life structure in MDD.

PRACTITIONER POINTS

The majority of the literature investigating depression pertains to individuals from European Western cultures, despite recognition that depression ranks as one of the most debilitating diseases worldwide. This raises questions as to whether current depression models and interventions can be applied universally or whether they are limited to European Western groups. The current study found that pan-culturally those with MDD had similar structuring of their life story relative to controls. However, there were some cultural differences that need to be considered (e.g., Malay individuals provided less detailed, less elaborate and less emotionally diverse life stories and while the British MDD group had greater compartmentalization than British controls, the Malay MDD group had lower levels of compartmentalization than Malay controls). Limitations of the study included group differences in gender and mood at the time of testing. Cultural differences in the number of attributes used may have influenced findings. Only the Malay group completed the individualism-collectivism measure.

Study protocol for a randomised, controlled platform trial estimating the effect of autobiographical Memory Flexibility training (MemFlex) on relapse of recurrent major depressive disorder

INTRODUCTION

Major depressive disorder (MDD) is a chronic condition. Although current treatment approaches are effective in reducing acute depressive symptoms, rates of relapse are high. Chronic and inflexible retrieval of autobiographical memories, and in particular a bias towards negative and overgeneral memories, is a reliable predictor of relapse. This randomised controlled single-blind trial will determine whether a therapist-guided self-help intervention to ameliorate autobiographical memory biases using Memory Flexibility training (MemFlex) will increase the experience of depression-free days, relative to a psychoeducation control condition, in the 12 months following intervention.

METHODS AND ANALYSIS

Individuals (aged 18 and above) with a diagnosis of recurrent MDD will be recruited when remitted from a major depressive episode. Participants will be randomly allocated to complete 4 weeks of a workbook providing either MemFlex training, or psychoeducation on factors that increase risk of relapse. Assessment of diagnostic status, self-report depressive symptoms, depression-free days and cognitive risk factors for depression will be completed post-intervention, and at 6 and 12 months follow-up. The cognitive target of MemFlex will be change in memory flexibility on the Autobiographical Memory Test- Alternating Instructions. The primary clinical endpoints will be the number of depression-free days in the 12 months following workbook completion, and time to depressive relapse.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the NHS National Research Ethics Committee (East of England, 11/H0305/1). Results from this study will provide a point-estimate of the effect of MemFlex on depressive relapse, which will be used to inform a fully powered trial evaluating the potential of MemFlex as an effective, low-cost and low-intensity option for reducing relapse of MDD.

TRIAL REGISTRATION NUMBER

NCT02614326.

Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal trauma

Individuals who experience repeated interpersonal trauma exposure often present with posttraumatic stress disorder (PTSD) with more complex features. There is currently no consensus regarding whether current evidence-based interventions for PTSD need to be tailored to better account for these complex features. However, one recommended adaptation is to adopt a phase-based or sequenced approach involving three phases, each with a distinct function. This paper describes the development of a 12-session Emotion- and Memory-Processing Group Programme, adapted from Cloitre's Skills Training in Affective and Interpersonal Regulation (STAIR) phase-based treatment protocol. A single case series provided a preliminary examination of the group-based intervention's efficacy for three groups of women with a history of repeated interpersonal trauma and PTSD with complex features (N = 15; age 19-46 years) at The Haven Sexual Assault Referral Centre in London. Results revealed significant reductions in: PTSD, complex features of PTSD, and depression, along with improvements in process measures of maladaptive cognitions and emotion processing. Results from this case series demonstrate that an Emotion- and Memory-Processing Group Programme holds promise for treating individuals with a history of interpersonal trauma in outpatient settings, and provides evidence to warrant the completion of a feasibility trial.

The devil's in the detail: Accessibility of specific personal memories supports rose-tinted self-generalizations in mental health and toxic self-generalizations in clinical depression

Models of memory propose that separate systems underpin the storage and recollection of specific events from our past (e.g., the first day at school), and of the generic structure of our experiences (e.g., how lonely I am), and that interplay between these systems serves to optimize everyday cognition. Specifically, it is proposed that memories of discrete events help define the circumstances (boundary conditions) in which our generalized knowledge applies, thereby enhancing accuracy of memory-dependent cognitive processes. However, in the domain of self-judgment, cognition is systematically biased, with a robust self-enhancement bias characterizing healthy individuals and a negativity bias characterizing the clinically depressed. We hypothesized that self-enhancement effects in the mentally healthy may partly rest on an impaired ability for specific memories to set appropriate boundary conditions on positive self-generalizations, while the opposite may be true for self-referred negative traits in the depressed. To assess this, we asked healthy and depressed individuals to think about the applicability of a trait to themselves, then to recall a specific memory that was inconsistent with that trait which would therefore index a boundary condition for its applicability. Healthy individuals showed faster recall only for specific positive memories following negative trait evaluations, while depressed individuals demonstrated faster recall only of specific negative memories following positive trait evaluations—the pattern expected given the respective self-enhancement and negativity biases. Results suggest that specific memories may serve to delimit self-generalizations in biased ways, and thus support systemic biases in trait judgments characteristic of healthy and depressed individuals.

Beneficial effects of training in self-distancing and perspective broadening for people with a history of recurrent depression

Cognitive training designed to recalibrate maladaptive aspects of cognitive-affective processing associated with the presence of emotional disorder can deliver clinical benefits. This study examined the ability of an integrated training in self-distancing and perspective broadening (SD-PB) with respect to distressing experiences to deliver such benefits in individuals with a history of recurrent depression (≥3 prior episodes), currently in remission. Relative to an overcoming avoidance (OA) control condition, SD-PB: a) reduced distress to upsetting memories and to newly encountered events, both during training when explicitly instructed to apply SD-PB techniques, and after-training in the absence of explicit instructions; b) enhanced capacity to self-distance from and broaden perspectives on participants' experiences; c) reduced residual symptoms of depression. These data provide initial support for SD-PB as a low-intensity cognitive training providing a spectrum of cognitive and affective benefits for those with recurrent depression who are at elevated risk of future episodes.

A cluster-randomised, controlled trial of the impact of Cogmed Working Memory Training on both academic performance and regulation of social, emotional and behavioural challenges

BACKGROUND

We explored whether school-based Cogmed Working Memory Training (CWMT) may optimise both academic and psychological outcomes at school. Training of executive control skills may form a novel approach to enhancing processes that predict academic achievement, such as task-related attention, and thereby academic performance, but also has the potential to improve the regulation of emotion, social problems and behavioural difficulties.

METHODS

Primary school children (Mean age = 12 years, N = 148) were cluster-randomised to complete active CWMT, a nonadaptive/placebo version of CWMT, or no training.

RESULTS

No evidence was found for training effects on task-related attention when performing academic tasks, or performance on reading comprehension and mathematics tasks, or teacher-reported social, emotional and behavioural difficulties.

CONCLUSIONS

CWMT did not improve control of attention in the classroom, or regulation of social, emotional and behavioural difficulties.

The effects of autobiographical memory flexibility (MemFlex) training: An uncontrolled trial in individuals in remission from depression

BACKGROUND AND OBJECTIVES

Impaired cognitive processing is a key feature of depression. Biases in autobiographical memory retrieval (in favour of negative and over-general memories) directly impact depression symptoms, but also influence downstream cognitive factors implicated in the onset and maintenance of the disorder. We introduce a novel cognitive intervention, MemFlex, which aims to correct these biases in memory retrieval and thereby modify key downstream cognitive risk and maintenance factors: rumination, impaired problem solving, and cognitive avoidance.

METHOD

Thirty eight adults with remitted Major Depressive Disorder completed MemFlex in an uncontrolled clinical trial. This involved an orientation session, followed by self-guided completion of six workbook-based sessions over one-month. Assessments of cognitive performance and depression symptoms were completed at pre- and post-intervention.

RESULTS

Results demonstrated medium-sized effects of MemFlex in improving memory specificity and problem solving, and decreasing rumination, and a small effect in reducing cognitive avoidance. No significant change was observed in residual symptoms of depression.

LIMITATIONS

This study was an uncontrolled trial, and has provided initial evidence to support a larger-scale, randomized controlled trial.

CONCLUSIONS

These findings provide promising evidence for MemFlex as a cost-effective, low-intensity option for reducing cognitive risk associated with depression.

Memory Flexibility training (MemFlex) to reduce depressive symptomatology in individuals with major depressive disorder: study protocol for a randomised controlled trial

Background

Major depressive disorder (MDD) is associated with chronic biases in the allocation of attention and recollection of personal memories. Impaired flexibility in attention and autobiographical memory retrieval is seen to both maintain current symptoms and predict future depression. Development of innovative interventions to reduce maladaptive cognitive patterns and improve cognitive flexibility in the domain of memory may therefore advance current treatment approaches for depression. Memory specificity training and cognitive bias modification techniques have both shown some promise in improving cognitive flexibility. Here we outline plans for a trial of an innovative memory flexibility training programme, MemFlex, which advances current training techniques with the aim of improving flexibility of autobiographical memory retrieval. This trial seeks to estimate the efficacy of MemFlex, provide data on feasibility, and begin to explore mechanisms of change.

Methods/design

We plan a single-blind, randomised, controlled, patient-level trial in which 50 individuals with MDD will complete either psychoeducation (n = 25) or MemFlex (n = 25). After completing pre-treatment measures and an orientation session, participants complete eight workbook-based sessions at home. Participants will then be assessed at post-treatment and at 3 month follow-up. The co-primary outcomes are depressive symptoms and diagnostic status at 3 month follow-up. The secondary outcomes are memory flexibility at post-treatment and number of depression free days at 3 month follow-up. Other process outcomes and mediators of any treatment effects will also be explored.

Discussion

This trial will establish the efficacy of MemFlex in improving memory flexibility, and reducing depressive symptoms. Any effects on process measures related to relapse may also indicate whether MemFlex may be helpful in reducing vulnerability to future depressive episodes. The low-intensity and workbook-based format of the programme may improve access to psychological therapies, and, if encouraging, the results of this study will provide a platform for later-phase trials.

Trial registration

NCT02371291 (ClinicalTrials.gov), registered 9 February 2015.

The Prospective Role of Cognitive Appraisals and Social Support in Predicting Children's Posttraumatic Stress

Although both social support and cognitive appraisals are strong predictors of children's posttraumatic adjustment, understanding of the interplay between these factors is limited. We assessed whether cognitive appraisals mediated the relationship between social support and symptom development, as predicted by cognitive models of posttraumatic stress disorder (PTSD). Ninety seven children (Mean age = 12.08 years) were assessed at one month and six months following a single incident trauma. We administered self-report measures of cognitive appraisals, social support, and a diagnostic interview for PTSD. Results indicated that cognitive appraisals at one month post-trauma mediated the relationship between social support at one month post-trauma, and PTSD severity at follow-up. Differences in this relationship were observed between child-reported social support and parent-rated ability to provide support. Firm evidence was provided for the application of cognitive models of PTSD to children.

A comparison of MEmory Specificity Training (MEST) to education and support (ES) in the treatment of recurrent depression: study protocol for a cluster randomised controlled trial

Background

Depression is a debilitating mental health problem that tends to run a chronic, recurrent course. Even when effectively treated, relapse and recurrence rates remain high. Accordingly, interventions need to focus not only on symptom reduction, but also on reducing the risk of relapse by targeting depression-related disturbances that persist into remission. We are addressing this need by investigating the efficacy, acceptability and feasibility of a MEmory Specificity Training (MEST) programme, which directly targets an enduring cognitive marker of depression - reduced autobiographical memory specificity. Promising pilot data suggest that training memory specificity ameliorates this disturbance and reduces depressive symptoms. A larger, controlled trial is now needed to examine the efficacy of MEST. This trial compares MEST to an education and support (ES) group, with an embedded mechanism study.

Methods/Design

In a single blind, parallel cluster randomised controlled trial, 60 depressed individuals meeting diagnostic criteria for a current major depressive episode will be recruited from the community and clinical services. Using a block randomisation procedure, groups of 5 to 8 participants will receive five weekly sessions of MEST (n = 30) or education and support (n = 30). Participants will be assessed immediately post-treatment, and at 3- and 6-months post-treatment (MEST group only for 6-month follow-up). Depressive symptoms at 3-month follow-up will be the primary outcome. Secondary outcomes will be change in depressive status and memory specificity at post-treatment and 3-months. The 6-month follow-up of the MEST group will allow us to examine whether treatment gains are maintained. An explanatory question will examine variables mediating improvement in depression symptoms post-treatment and at 3-month follow-up.

Discussion

This trial will allow us to investigate the efficacy of MEST, whether treatment gains are maintained, and the mechanisms of change. Evidence will be gathered regarding whether this treatment is feasible and acceptable as a low-intensity intervention. If efficacy can be demonstrated, the results will support MEST as a treatment for depression and provide the foundation for a definitive trial.

Trial registration

NCT01882452 (ClinicalTrials.gov), registered on 18 June 2013.