Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood

Experiential Avoidance and Bordering Psychological Constructs as Predictors of the Onset, Relapse and Maintenance of Anxiety Disorders: One or Many?

To investigate (a) the incremental predictive validity of experiential avoidance over and above bordering psychological constructs (i.e., rumination, worry, neuroticism and anxiety sensitivity) in predicting onset, relapse and maintenance of anxiety disorders; and (b) whether these related constructs can be represented by a single, higher-order latent factor with similar predictive power as the separate psychological constructs while offering a more parsimonious predictive model. Longitudinal cohort study with repeated assessments after 4 years in a sample of 2157 adults aged 18-65, consisting of 1614 persons with past or current anxiety disorder (Panic Disorder with or without Agoraphobia, Social Anxiety Disorder, Generalized Anxiety Disorder, Agoraphobia without panic) according to the Composite Interview Diagnostic Instrument (CIDI) and 543 controls. Experiential avoidance (Acceptance and Action Questionnaire-I) manifested substantial overlap with bordering cognitive constructs. Experiential avoidance and anxiety sensitivity both uniquely predicted maintenance of anxiety disorders and neuroticism uniquely predicted relapse of anxiety disorders, over and above the effect of the other cognitive constructs. Moreover, a latent factor of psychological vulnerability loaded strongly on each of these psychological constructs. This latent factor predicted onset, maintenance and relapse of anxiety disorders. The tendency to frequently experience strong negative emotions, to evaluate these experiences as aversive and to engage in avoidant coping strategies may constitute a transdiagnostic factor predictive of anxiety disorders. Further developing and testing of interventions targeting transdiagnostic construct underlying anxiety and mood disorders seem warranted.

Home practice in Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction: A systematic review and meta-analysis of participants' mindfulness practice and its association with outcomes

Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) emphasize the importance of mindfulness practice at home as an integral part of the program. However, the extent to which participants complete their assigned practice is not yet clear, nor is it clear whether this practice is associated with positive outcomes.

For this systematic review and meta-analysis, searches were performed using Scopus and PubMed for studies published through to the end of 2015, reporting on formal home practice of mindfulness by MBSR or MBCT participants.

Across 43 studies (N = 1427), the pooled estimate for participants' home practice was 64% of the assigned amount, equating to about 30 minutes per day, six days per week [95% CI 60–69%]. There was substantial heterogeneity associated with this estimate. Across 28 studies (N = 898), there was a small but significant association between participants’ self-reported home practice and intervention outcomes (r = 0·26, 95% CI 0·19,–0·34).

MBSR and MBCT participants report completing substantial formal mindfulness practice at home over the eight-week intervention, albeit less than assigned amounts. There is a small but significant association between the extent of formal practice and positive intervention outcomes for a wide range of participants.

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Standard mindfulness interventions assign significant home practice.

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This meta-analysis estimated participants' typical practice completion.

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Average mindfulness home practice time equated to 30 min per day, 6 days per week.

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The extent of practice positively correlated with intervention outcomes.

Misophonia: A new mental disorder?

Misophonia, a phenomenon first described in the audiology literature, is characterized by intense emotional reactions (e.g., anger, rage, anxiety, disgust) in response to highly specific sounds, particularly sounds of human origin such as oral or nasal noises made by other people (e.g., chewing, sniffing, slurping, lip smacking). Misophonia is not listed in any of the contemporary psychiatric classification systems. Some investigators have argued that misophonia should be regarded as a new mental disorder, falling within the spectrum of obsessive-compulsive related disorders. Other researchers have disputed this claim. The purpose of this article is to critically examine the proposition that misophonia should be classified as a new mental disorder. The clinical and research literature on misophonia was examined and considered in the context of the broader literature on what constitutes a mental disorder. There have been growing concerns that diagnostic systems such as DSM-5 tend to over-pathologize ordinary quirks and eccentricities. Accordingly, solid evidence is required for proposing a new psychiatric disorder. The available evidence suggests that (a) misophonia meets many of the general criteria for a mental disorder and has some evidence of clinical utility as a diagnostic construct, but (b) the nature and boundaries of the syndrome are unclear; for example, in some cases misophonia might be simply one feature of a broader pattern of sensory intolerance, and (c) considerably more research is required, particularly work concerning diagnostic validity, before misophonia, defined as either as a disorder or as a key feature of some broader syndrome of sensory intolerance, should be considered as a diagnostic construct in the psychiatric nomenclature. A research roadmap is proposed for the systematic evaluation as to whether misophonia should be considered for future editions of DSM or ICD.

Effects of Home-Delivered Cognitive Behavioral Therapy (CBT) for Depression on Anxiety Symptoms among Rural, Ethnically Diverse Older Adults

BACKGROUND

We examined the effects of home-delivered cognitive-behavioral therapy (CBT) for depression on anxiety symptoms in an ethnically diverse, low resource, and medically frail sample of rural, older adults.

METHOD

This was a secondary analysis of a randomized clincial trial with 134 rural-dwelling adults 65 years and older with decreased quality of life and elevated psychological symptomatology. Anxiety symptoms were assessed with the anxiety and phobic anxiety subscales of the Symptom Checklist-90-Revised (SCL-90-R).

RESULTS

Compared to a minimal support control condition, CBT for depression resulted in significantly greater improvements in symptoms of anxiety and phobic anxiety from pre-treatment to post-treatment.

CONCLUSION

Home-delivered CBT for depression can be an effective treatment for anxiety in a hard-to-reach older populations.

CLINICAL IMPLICATIONS

Additional research should explore integrated anxiety and depression protocols and other treatment modalities, including bibliotherapy or telehealth models of CBT, to reduce costs associated with its in home delivery. Flexibility in administration and adaptations to the CBT protocol may be necessary for use with vulnerable, rural older adults.

Efficacy of a Transdiagnostic internet-based treatment for emotional disorders with a specific component to address positive affect: Study protocol for a randomized controlled trial

BACKGROUND

Emotional disorders (ED) are among the most prevalent mental disorders. However, less than 50% of people suffering from ED receive the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which tries to address the underlying processes common to ED. Most of these programs focus primarily on down-regulating negative affectivity, rather than increasing strengths and up-regulating positive affectivity. The data suggest the existence of disturbances in positive affectivity in these disorders, and so new interventions focusing on these problems are greatly needed. It is also essential to provide assistance to all the people in need. Information and Communication Technologies can be very useful. This study aims to evaluate the efficacy of a transdiagnostic Internet-based treatment for ED in a community sample. The protocol includes traditional CBT components, as well as a specific component to address positive affect. We intend to test this protocol, including this specific component or not, versus a waiting list control group. Moreover, we aim to test the differential effect of this specific component, and study the effectiveness (in terms of patients' acceptance) of using a self-applied Internet-based program. This paper presents the study protocol.

METHODS

The study is a randomized controlled trial. 207 participants will be randomly assigned to: a)Transdiagnostic Internet-based protocol (TIBP), b)Transdiagnostic Internet-based protocol + positive affect component (TIBP + PA), or c)a Waiting List control group (WL). Primary outcomes measures will be the BDI-II, the BAI, and the PANAS. Secondary outcomes will include diagnosis-specific measures of the principal disorder. Participants' treatment acceptance will also be measured. Participants will be assessed at pre-, post-treatment, and 3- and 12- month follow-ups. The data will be analyzed based on the Intention-to-treat principle. Per protocol analyses will also be performed.

DISCUSSION

To the best of our knowledge, this is the first study of a transdiagnostic Internet-based treatment for ED with a specific component to up-regulate positive affectivity. This intervention could contribute to improve the efficiency and effectiveness of current treatment programs for ED, promote the dissemination of EBTs, and help to decrease the high prevalence of ED.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02578758 . Registered 15 October 2015.

A test of the core process account of psychopathology in a heterogenous clinical sample of anxiety and depression: A case of the blind men and the elephant?

Many cognitive and behavioral processes, such as selective attention to threat, self-focused attention, safety-seeking behaviors, worry and thought suppression, have their foundations in research on anxiety disorders. Yet, they are now known to be transdiagnostic, i.e. shared across a wide range of psychological disorders. A more pertinent clinical and theoretical question is whether these processes are themselves distinct, or whether they reflect a shared 'core' process that maintains psychopathology. The current study utilized a treatment-seeking clinical adult sample of 313 individuals with a range of anxiety disorders and/or depression who had completed self-report measures of widely ranging processes: affect control, rumination, worry, escape/avoidance, and safety-seeking behaviors. We found that only the first factor extracted from a principal components analysis of the items of these measures was associated with symptoms of anxiety and depression. Our findings supported the 'core process' account that had its origins in the field of anxiety disorders, and we discuss the implications for theory, clinical practice and future research across psychological disorders.

Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis

Research evaluating transdiagnostic CBT (tCBT) demonstrates its efficacy. Some evidence suggests equivalence between tCBT and diagnosis-specific CBT (dxCBT), however more investigations are necessary to clarify any difference in efficacy. This meta-analysis was conducted to compare tCBT and dxCBT, and to investigate the differential impact of comorbidity on effect sizes. Pre and post scores from primary anxiety measures in 83 treatment conditions, taken from studies primarily targeting anxiety disorders, were summarised and compared. Meta-regression analyses were then used to test the effects of comorbidity. DxCBT and tCBT meta-effects were found to be large, where g=0.951, 95% CI: 0.874-1.027, and g=1.059, 95% CI: 0.876-1.242, respectively. While statistically different (p=0.008), overlap of confidence intervals indicated a lack of clinical significance. Furthermore, no relationship between comorbidity rate and tCBT outcome was observed. These results were discussed in the context of previous findings in the transdiagnostic CBT literature.

A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias - One size fits all

BACKGROUND AND OBJECTIVES

Many individuals with anxiety disorders do not receive professional treatment. Internet interventions have shown to be effective in the treatment of anxiety. The present randomized controlled trial was designed to examine the effectiveness of a short-term (4-week) Internet intervention in treating panic disorder, agoraphobia, social anxiety disorder, and specific phobias ('ConfID'). We addressed the questions of whether this transdiagnostic program would affect these disorders to varying degrees and whether there would be moderators of effectiveness.

METHODS

Adults who were recruited in online forums for anxiety underwent an online baseline assessment (N = 179) and were randomized either to the intervention group (ConfID) or the control group (care as usual). Online post-assessment took place 4 weeks later. The primary outcome was assessed with the Beck Anxiety Inventory (BAI); the secondary outcomes targeted the disorder-specific symptoms, depression, and somatization.

RESULTS

Participants in the intervention group showed a significantly stronger anxiety reduction compared to participants receiving care as usual (small-to-medium effect size between groups in intention-to-treat analysis). The treatment effect was similar for the different disorders and was moderated by participants' attitudes towards Internet interventions. Secondary outcomes yielded effect sizes in the medium range.

LIMITATIONS

Moderate treatment adherence, lack of measures beyond online self-reports, and unavailability of long-term results.

CONCLUSIONS

The study provides further evidence that transdiagnostic Internet interventions are promising in reducing the existing treatment gap in individuals with panic disorder and phobias. Results extend previous findings by showing that significant effects can also be reached by comprehensive short-term programs and that the effects might be moderated by participants' attitudes towards Internet interventions.

Adaptive functions of self-focused attention: Insight and depressive and anxiety symptoms

Maladaptive forms of self-focus, such as rumination, are considered transdiagnostic factors that contribute to depressive and anxiety symptoms. However, no or few studies have explored the possibility that adaptive forms of self-focus can also be a common factor that is negatively associated with depressive and anxiety symptoms. To test this possibility, we first examined the psychometric properties of a scale measuring adaptive forms of self-focus (the Self-Reflection and Insight Scale) on Japanese undergraduates (n=117). We replicated the two-factor structure of the scale: (a) self-reflection, which is a tendency to focus purposefully on self for self-regulation, and (b) insight, which is a sense of clear self-understanding. Second, we tested our specific hypothesis that these two factors negatively predict a common factor of depressive and anxiety symptoms. The results of structural equation modeling showed that insight (but not self-reflection) has a significant negative association with a latent variable that explains both depressive and anxiety symptoms. Furthermore, this common-factor model explained the data better than a control model in which insight predicts depressive and anxiety symptoms individually. These results suggest that (lack of) insight plays an important role in psychological (mal)adjustment as a shared process in depressive and anxiety symptoms.

Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care

BACKGROUND

Disorder-specific and transdiagnostic internet cognitive behaviour therapy (iCBT) programs are effective for anxiety and depression, but no studies have compared their effectiveness in primary care.

METHODS

Patient characteristics, adherence and effectiveness of Transdiagnostic iCBT (n=1005) were compared to disorder-specific programs for generalized anxiety disorder (GAD) (n=738) and depression (n=366) in a naturalistic non-randomised comparison study. Patients completed their iCBT program in primary care. The PHQ-9 (depression), GAD-7 (generalized anxiety), K-10 (distress), and the WHODAS-II (disability) were measured at pre- and post-treatment.

RESULTS

Patients in the Transdiagnostic program had higher comorbidity rates and baseline distress. All programs were associated with medium to large within-group effect sizes for improving anxiety, depression and distress between pre- and post-treatment (d's=0.64-1.39). Controlling for baseline group differences in severity, we found small effect sizes favoring the Transdiagnostic program over the GAD program in reducing PHQ-9 (d=0.44, 95%CI: 0.34-0.53), K-10 (d=0.21, 95%CI: 0.16-0.35) and WHODAS scores (d=0.20, 95%CI: 0.10-0.29), and small effect sizes favoring the Transdiagnostic program over the Depression program in reducing GAD-7 scores (d=0.48, 95%CI: 0.36-0.60). A smaller proportion of patients completed the Transdiagnostic program (44.9%) compared to the depression (51.6%) and GAD (49.2%) programs, which was attributable to baseline differences in age and symptom severity.

CONCLUSIONS

Both Transdiagnostic iCBT and disorder-specific iCBT programs are effective in primary care, but there appears to be small effects favoring Transdiagnostic iCBT. Methods to increase adherence are needed to optimize the benefits to patients, and these findings await replication in a RCT.

The contribution of clinical and psychosocial factors to fatigue in 182 patients with inflammatory bowel disease: a cross-sectional study

BACKGROUND

Fatigue is a frequently reported and predominant symptom experienced by patients with inflammatory bowel disease (IBD) and its impact has been associated with poorer quality of life (QoL). The complex interplay between disease-related variables and potentially modifiable psychosocial factors in IBD-fatigue has yet to be unravelled.

AIM

To evaluate the contribution of clinical, sociodemographic and psychosocial factors to the severity and impact of IBD-fatigue and QoL.

METHOD

In a cross-sectional study, 182 patients with IBD were recruited from three tertiary referral hospitals' out-patient clinics in London. Fatigue was assessed utilising the Inflammatory Bowel Disease-Fatigue Scale (IBD-F), the Multidimensional Fatigue Inventory (MFI); and QoL by the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients completed self-report questionnaires evaluating emotional, cognitive and behavioural factors potentially correlated with fatigue. Sociodemographic data were collected. Disease-related and laboratory data were retrieved from patients' hospital electronic medical records.

RESULT

In hierarchical regression models, disease activity was the only clinical factor consistently associated with severity and impact of fatigue and QoL (P = 0.01). More negative fatigue perceptions were significantly associated with greater IBD-F1 scores (P = 0.01). When controlling for clinical factors (disease activity and anti-TNF therapy), negative perceptions of fatigue, and all-or-nothing and avoidance behaviours explained an additional 41% of the variance in fatigue impact (IBD-F2).

CONCLUSIONS

Apart from disease activity, emotional and behavioural factors and patients' negative fatigue perceptions may be key factors to be addressed. Further exploration of these factors in longitudinal and intervention studies may help to develop effective models of fatigue management.

Cognitive behavioral therapy increases amygdala connectivity with the cognitive control network in both MDD and PTSD

Background

Both major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) are characterized by alterations in intrinsic functional connectivity. Here we investigated changes in intrinsic functional connectivity across these disorders as a function of cognitive behavioral therapy (CBT), an effective treatment in both disorders.

Methods

53 unmedicated right-handed participants were included in a longitudinal study. Patients were diagnosed with PTSD (n = 18) and MDD (n = 17) with a structured diagnostic interview and treated with 12 sessions of manualized CBT over a 12-week period. Patients received an MRI scan (Siemens 3 T Trio) before and after treatment. Longitudinal functional principal components analysis (LFPCA) was performed on functional connectivity of the bilateral amygdala with the fronto-parietal network. A matched healthy control group (n = 18) was also scanned twice for comparison.

Results

LFPCA identified four eigenimages or principal components (PCs) that contributed significantly to the longitudinal change in connectivity. The second PC differentiated CBT-treated patients from controls in having significantly increased connectivity of the amygdala with the fronto-parietal network following CBT.

Limitations

Analysis of CBT-induced amygdala connectivity changes was restricted to the a priori determined fronto-parietal network. Future studies are needed to determine the generalizability of these findings, given the small and predominantly female sample.

Conclusion

We found evidence for the hypothesis that CBT treatment is associated with changes in connectivity between the amygdala and the fronto-parietal network. CBT may work by strengthening connections between the amygdala and brain regions that are involved in cognitive control, potentially providing enhanced top-down control of affective processes that are dysregulated in both MDD and PTSD.

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CBT treatment effects found in functional connectivity for combined MDD and PTSD patients.

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Novel longitudinal dimension reduction method characterizes direction of changes.

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Study shows CBT increases amygdala connectivity with the fronto-parietal network.

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CBT mechanism may be to enhance cognitive control region connectivity.

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A post-hoc whole brain voxel-wise analysis independently confirmed the findings.

Complaint-Directed Mini-Interventions for Depressive Complaints: A Randomized Controlled Trial of Unguided Web-Based Self-Help Interventions

Background

Prevention of depression is important due to the substantial burden of disease associated with it. To this end, we developed a novel, brief, and low-threshold Web-based self-help approach for depressive complaints called complaint-directed mini-interventions (CDMIs). These CDMIs focus on highly prevalent complaints that are demonstrably associated with depression and have a substantial economic impact: stress, sleep problems, and worry.

Objective

The aim was to evaluate the effectiveness of the Web-based self-help CDMIs in a sample of adults with mild-to-moderate depressive symptoms compared to a wait-list control group.

Methods

A two-armed randomized controlled trial was conducted. An open recruitment strategy was used. Participants were randomized to either the Web-based CDMIs or the no-intervention wait-list control group. The CDMIs are online, unguided, self-help interventions, largely based on cognitive behavioral techniques, which consist of 3 to 4 modules with up to 6 exercises per module. Participants are free to choose between the modules and exercises. Assessments, using self-report questionnaires, took place at baseline and at 3 and 6 months after baseline. The control group was given access to the intervention following the 3-month assessment. The primary goal of the CDMIs is to reduce depressive complaints. The primary outcome of the study was a reduction in depressive complaints as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). Secondary outcomes included reductions in stress, worry, sleep problems, and anxiety complaints, and improvements in well-being. Data were analyzed using linear mixed models.

Results

In total, 329 participants enrolled in the trial, of which 165 were randomized to the intervention group and 164 to the control group. Approximately three-quarters of the intervention group actually created an account. Of these participants, 91.3% (116/127) logged into their chosen CDMI at least once during the 3-month intervention period (median 3, range 0-166). After 3 months, there was a significant reduction in depressive symptomatology for participants in the intervention group compared to participants in the wait-list control group (reduction in depression: mean –4.47, 95% CI –6.54 to –2.40; Cohen d=–0.70). Furthermore, significant effects were observed for sleep problems, worry, anxiety, and well-being, with effect sizes ranging from –0.29 to –0.40. The intervention did not significantly reduce stress. At 6-month follow-up, the improvements in the intervention group were generally sustained.

Conclusions

This study shows that the online self-help CDMIs have a positive impact on various mental health outcomes. Future research should focus on which specific strategies may boost adherence, and increase the reach of the CDMIs among people with low socioeconomic status.

ClinicalTrial

Netherlands Trial Register (NTR): NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM)

Acquisition of CS-US contingencies during Pavlovian fear conditioning and extinction in social anxiety disorder and posttraumatic stress disorder

BACKGROUND

Fear-based disorders, like social anxiety disorder (SAD) and posttraumatic stress disorder (PTSD), are characterized by an exaggerated fear response and avoidance to trigger cues, suggesting a transdiagnostic mechanism of psychopathology. Current theories suggest that abnormalities in conditioned fear is a primary contributor to the pathophysiology of these disorders. The primary goal of this study was to compare acquisition of conditioned stimulus (CS) and aversive unconditioned stimulus (US) contingencies during fear learning and extinction in individuals with SAD and PTSD.

METHODS

In a standard Pavlovian fear conditioning-extinction paradigm we measured subjective US expectancy ratings to different CSs in patients with SAD (n=16) compared to patients with PTSD (n=13) and healthy controls (n=15) RESULTS: Both patient groups (SAD, PTSD) acquired differential conditioning between a CS that predicted US (CS+) and a CS that never predicted the US (CS-), however, both groups reported an increased expectancy that the US would occur following the CS-. Additionally, the PTSD group overestimated that the US would occur in general. Neither patient group showed evidence of successful extinction of the CS+-US contingency nor differentiated their expectation of US occurrence between the CS+ and CS- during extinction learning.

LIMITATIONS

Group sample sizes were small and we did not include a trauma-exposed group without PTSD CONCLUSIONS: Both SAD and PTSD generalize expectations of an aversive outcome across CSs, even when a CS never signals an aversive outcome and PTSD may tend to over-expect threat. Fear learning and extinction abnormalities may be a core feature underlying shared symptoms across fear-based disorders.

Personality, Psychopathology, and Psychotherapy: A Pre-specified Analysis Protocol for Confirmatory Research on Personality-Psychopathology Associations in Psychotherapy Outpatients

The role of personality trait variation in psychopathology and its influence on the outcome of psychotherapy is a burgeoning field. However, thus far most findings were based on controlled clinical trials that may only poorly represent real-world clinical settings due to highly selective samples mostly restricted to patients with major depression undergoing antidepressive medication. Focusing on personality and psychopathology in a representative naturalistic sample of psychotherapy patients is therefore worthwhile. Moreover, up to date hardly any confirmatory research has been conducted in this field. Strictly confirmatory research implies two major requirements: firstly, specific hypotheses, including expected effect sizes and statistical approaches to data analysis, must be detailed prior to inspection of the data, and secondly, corresponding protocols have to be published online and freely available. Here, we introduce a longitudinal naturalistic study aimed at examining, firstly, the prospective impact of baseline personality traits on the outcome of psychotherapy over a 6-month observation period; secondly, the stability and change in personality traits over time; thirdly, the association between longitudinal change in psychopathology and personality; fourthly, the agreement between self-reports and informant rating of personality; and fifthly, the predictive validity of personality self-reports compared to corresponding informant ratings. For it, we comprehensively state a priori hypotheses, predict the expected effect sizes and detail the statistical analyses that we intend to conduct to test these predictions. Such a stringent confirmatory design increases the transparency and objectivity of psychopathological research, which is necessary to reduce the rate of false-positive findings and to increase the yield of scientific research.

Transdiagnostic Cognitive Behavioral Therapy Versus Treatment as Usual in Adult Patients With Emotional Disorders in the Primary Care Setting (PsicAP Study): Protocol for a Randomized Controlled Trial

Background

Demand for primary care (PC) services in Spain exceeds available resources. Part of this strong demand is due to the high prevalence of emotional disorders (EDs)—anxiety, depression, and somatic symptom disorders—and related comorbidities such as pain or chronic illnesses. EDs are often under- or misdiagnosed by general practitioners (GPs) and, consequently, treatment is frequently inadequate.

Objective

We aim to compare the short- and long-term effectiveness of group-delivered transdiagnostic cognitive behavioral therapy (TD-CBT) versus treatment as usual (TAU) in the treatment of EDs in the PC setting in Spain. We also aim to compare the effect of these treatments on disability, quality of life, cognitive-emotional factors, and treatment satisfaction.

Methods

Here we present the study design of a two-arm, single-blind, randomized controlled trial (N=1126) to compare TAU to TD-CBT for EDs. TAU will consist primarily of pharmacological treatment and practical advice from the GP while TD-CBT will be administered in seven 90-minute group sessions held over a period ranging from 12 to 14 weeks. Psychological assessments are carried out at baseline (ie, pretreatment); posttreatment; and at 3-, 6-, and 12-month follow-up. The study is conducted in approximately 26 PC centers from the National Health System in Spain.

Results

This study was initiated in December 2013 and will remain open to new participants until recruitment and follow-up has been completed. We expect all posttreatment evaluations to be completed by December 2017, and follow-up will end in December 2018.

Conclusions

We expect the TD-CBT group to have better results compared to TAU on all posttreatment measures and that this improvement will be maintained during follow-up. This project could serve as a model for use in other areas or services of the National Health System in Spain and even in other countries.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 58437086; http://www.isrctn.com/ISRCTN58437086 (Archived by WebCite at http://www.webcitation.org/6mbYjQSn3)

The relevance of uncertainty and goal conflict to mental disorders, their prevention and management: a unifying approach

Intolerance of Uncertainty (IU) has been shown to underlie a range of disorders. Technological advances have produced a decline in our development of an ability to wait in the face of uncertainty. The paper provides an update on empirical, theoretical and neural research in IU. Einstein's extended trandiagnostic model of IU is described. This model is based on control theory. The research update and IU model propose specific tools which can be implemented within transdiagnostic treatment approaches.

The effects of cognitive and behavioural therapies for anxiety disorders on depression: a meta-analysis

BACKGROUND

The effects of cognitive behavioural therapy of anxiety disorders on depression has been examined in previous meta-analyses, suggesting that these treatments have considerable effects on depression. In the current meta-analysis we examined whether the effects of treatments of anxiety disorders on depression differ across generalized anxiety disorder (GAD), social anxiety disorder (SAD) and panic disorder (PD). We also compared the effects of these treatments with the effects of cognitive and behavioural therapies of major depression (MDD).

METHOD

We searched PubMed, PsycINFO, EMBASE and the Cochrane database, and included 47 trials on anxiety disorders and 34 trials on MDD.

RESULTS

Baseline depression severity was somewhat lower in anxiety disorders than in MDD, but still mild to moderate in most studies. Baseline severity differed across the three anxiety disorders. The effect sizes found for treatment of the anxiety disorders ranged from g = 0.47 for PD, g = 0.68 for GAD and g = 0.69 for SAD. Differences between these effect sizes and those found in the treatment of MDD (g = 0.81) were not significant in most analyses and we found few indications that the effects differed across anxiety disorders. We did find that within-group effect sizes resulted in significantly (p < 0.001) larger effect sizes for depression (g = 1.50) than anxiety disorders (g = 0.73-0.91). Risk of bias was considerable in the majority of studies.

CONCLUSIONS

Patients participating in trials of cognitive behavioural therapy for anxiety disorders have high levels of depression. These treatments have considerable effects on depression, and these effects are comparable to those of treatment of primary MDD.

A systematic review of anxiety amongst people with Multiple Sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a chronic neurological disease, which poses significant psychological challenges. The purpose of this systematic review was to identify factors that are associated with anxiety in people with MS (PwMS). It aimed to examine the strength of evidence for factors associated with anxiety symptoms and identify limitations of existing studies.

METHOD AND RESULTS

One hundred and thirty one studies met inclusion criteria and were included in the review. A narrative synthesis was then conducted. Anxiety was found to be associated with a variety of demographic, physical, psychological, cognitive and social factors. A consistent finding was that anxiety was strongly associated with both high level of disability and low quality of life. A strong association between anxiety and depression was also found.

CONCLUSION

Implications for these results are discussed and a preliminary model of understanding anxiety in the context of MS is outlined. Given the overlap between anxiety and depression, a transdiagnostic treatment approach is suggested. In light of the shortcomings of extant studies, suggestions for future research are offered.

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges' g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58-1.05, depression: g = .79, 95% CI: .59-1.00) and medium on quality of life (g = .56, 95% CI: .37-.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.

Treatment for Anhedonia: A Neuroscience Driven Approach

Anhedonia, or loss of interest or pleasure in usual activities, is characteristic of depression, some types of anxiety, as well as substance abuse and schizophrenia. Anhedonia is a predictor of poor long-term outcomes, including suicide, and poor treatment response. Because extant psychological and pharmacological treatments are relatively ineffective for anhedonia, there is an unmet therapeutic need for this high-risk symptom. Current psychological and drug treatments for anxiety and depression focus largely on reducing excesses in negative affect rather than improving deficits in positive affect. Recent advances in affective neuroscience posit that anhedonia is associated with deficits in the appetitive reward system, specifically the anticipation, consumption, and learning of reward. In this paper, we review the evidence for positive affect as a symptom cluster, and its neural underpinnings, and introduce a novel psychological treatment for anxiety and depression that targets appetitive responding. First, we review anhedonia in relation to positive and negative valence systems and current treatment approaches. Second, we discuss the evidence linking anhedonia to biological, experiential, and behavioral deficits in the reward subsystems. Third, we describe the therapeutic approach for Positive Affect Treatment (PAT), an intervention designed to specifically target deficits in reward sensitivity.

Relationships Between Refraining From Catastrophic Thinking, Repetitive Negative Thinking, and Psychological Distress

Skills to refrain from catastrophic thinking were negatively related to worry and a wide range of psychological distress. Repetitive negative thinking (including worry) is proposed as a common etiological factor for a wide range of psychological distress. Therefore, reduced repetitive negative thinking would mediate the negative relation between refraining from catastrophic thinking and psychological distress (depression, social anxiety, phobia, generalized anxiety, and obsessions and compulsions). As an overlap between five indices of psychological distress was expected, we first computed latent factors underlying them, which were then predicted by refraining from catastrophic thinking and repetitive negative thinking. Cross-sectional questionnaire data from 125 nonclinical voluntarily participating students ( M age = 19.0 years, SD = 3.6; 54% women) supported the predictions: refraining from catastrophic thinking was negatively correlated with depression, social anxiety, phobia, generalized anxiety, and obsession and compulsion. Repetitive negative thinking mediated the negative relationship between refraining from catastrophic thinking and latent factors underlying psychological distress (Fear and Distress). Refraining from catastrophic thinking may be negatively correlated with psychological distress due to its negative relation to repetitive negative thinking.

The potential of low-intensity and online interventions for depression in low- and middle-income countries

The World Health Organization (WHO) reports that low- and middle-income countries (LMICs) are confronted with a serious 'mental health gap', indicating an enormous disparity between the number of individuals in need of mental health care and the availability of professionals to provide such care (WHO in 2010). Traditional forms of mental health services (i.e. face-to-face, individualised assessments and interventions) are therefore not feasible. We propose three strategies for addressing this mental health gap: delivery of evidence-based, low-intensity interventions by non-specialists, the use of transdiagnostic treatment protocols, and strategic deployment of technology to facilitate access and uptake. We urge researchers from all over the world to conduct feasibility studies and randomised controlled studies on the effect of low-intensity interventions and technology supported (e.g. online) interventions in LMICs, preferably using an active control condition as comparison, to ensure we disseminate effective treatments in LMICs.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for Social Anxiety Disorder and comorbid disorders: A randomized controlled trial

Disorder-specific (DS-CBT) and transdiagnostic (TD-CBT) cognitive behaviour therapy have both been used to treat social anxiety disorder (SAD). This study compared internet-delivered DS-CBT and TD-CBT for SAD across clinician-guided (CG-CBT) and self-guided (SG-CBT) formats. Participants with SAD (n=233) were randomly allocated to receive internet-delivered TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of SAD (Cohen's d≥1.01; avg. reduction≥30%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d≥1.25; avg. reduction≥39%), generalised anxiety disorder (Cohen's d≥0.86; avg. reduction≥36%) and panic disorder (Cohen's d≥0.53; avg. reduction≥25%) were found immediately post-treatment and were maintained or further improved to 24-month follow-up. No marked differences were observed between TD-CBT and DS-CBT or CG-CBT and SG-CBT highlighting the potential of each for the treatment of SAD and comorbid disorders.

Smartphone-Based Psychotherapeutic Micro-Interventions to Improve Mood in a Real-World Setting

BACKGROUND

Using mobile communication technology as new personalized approach to treat mental disorders or to more generally improve quality of life is highly promising. Knowledge about intervention components that target key psychopathological processes in terms of transdiagnostic psychotherapy approaches is urgently needed. We explored the use of smartphone-based micro-interventions based on psychotherapeutic techniques, guided by short video-clips, to elicit mood changes.

METHOD

As part of a larger neurofeedback study, all subjects-after being randomly assigned to an experimental or control neurofeedback condition-underwent daily smartphone-based micro-interventions for 13 consecutive days. They were free to choose out of provided techniques, including viscerosensory attention, emotional imagery, facial expression, and contemplative repetition. Changes in mood were assessed in real world using the Multidimensional Mood State Questionnaire (scales: good-bad, GB; awake-tired, AT; and calm-nervous, CN).

RESULTS

Twenty-seven men participated on at least 11 days and were thus included in the analyses. Altogether, they underwent 335, generally well-tolerated, micro-intervention sessions, with viscerosensory attention (178 sessions, 53.13%) and contemplative repetition (68 sessions, 20.30%) being the most frequently applied techniques. Mixed models indicated that subjects showed better mood [GB: b = 0.464, 95%confidence interval (CI) [0.068, 0.860], t (613.3) = 2.298, p = 0.022] and became more awake [AT: b = 0.514, 95%CI [0.103, 0.925], t (612.4) = 2.456, p = 0.014] and calmer [CN: b = 0.685, 95%CI [0.360, 1.010], t (612.3) = 4.137, p < 0.001] from pre- to post-micro-intervention. These mood improvements from pre- to post-micro-intervention were associated with changes in mood from the 1st day until the last day with regard to GB mood (r = 0.614, 95%CI [0.297, 0.809], p < 0.001), but not AT mood (r = 0.279, 95%CI [-0.122, 0.602], p = 0.167) and CN mood (r = 0.277, 95%CI [0.124, 0.601], p = 0.170).

DISCUSSION

Our findings provide evidence for the applicability of smartphone-based micro-interventions eliciting short-term mood changes, based on techniques used in psychotherapeutic approaches, such as mindfulness-based psychotherapy, transcendental meditation, and other contemplative therapies. The results encourage exploring these techniques' capability to improve mood in randomized controlled studies and patients. Smartphone-based micro-interventions are promising to modify mood in real-world settings, complementing other psychotherapeutic interventions, in line with the precision medicine approach. The here presented data were collected within a randomized trial, registered at ClinicalTrials.gov (Identifier: NCT01921088) https://clinicaltrials.gov/ct2/show/NCT01921088.

The Effects of Waiting for Treatment: A Meta-Analysis of Waitlist Control Groups in Randomized Controlled Trials for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent mental disorder. However, little is known about how SAD changes in subjects who do not receive treatment. Waitlist control groups (WLCGs) are frequently included in randomized controlled trials (RCTs) on the treatment of mental disorders. Data from WLCGs are of value as they provide information on the untreated short-term course of a disorder and may serve as disorder-specific norms of change (benchmarks) against which treatment outcomes of SAD can be compared. Thus, we performed a meta-analysis focusing on the effects occurring in WLCGs of RCTs for SAD. Our study was conducted along the PRISMA guidelines. Thirty RCTs (total n = 2460) comprising 30 WLCGs and 47 treatment groups were included. Mean waiting time was 10.6 weeks. The pooled effect of waiting on SAD measures was g = 0.128 (95% CI: 0.057-0.199). Effects regarding other forms of anxiety, depression and functioning were of similarly small size. In contrast, change in the treatment groups was large, both within (g = 0.887) and between groups (g = 0.860). Our results show that for SAD, changes occurring in WLCGs of RCTs are small. The findings may serve as benchmarks in pilot studies of a new treatment or as an additional comparison in studies comparing two active treatments. For psychotherapy research in general, the small effect sizes found in WLCGs confirm that testing a treatment against a waiting list is not a very strict test. Further research on WLCGs in specific mental disorders is required, for example examining the expectancies of patients randomized to waiting. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

In clinical practice, patients suffering from a mental disorder often have to wait for treatment. By analyzing data from waitlist control groups we can gain estimates of symptom change that occur during waiting. It could be seen that waiting for treatment only results in a negligible effect. Thus, in the short-term (i.e., 10.6 weeks) time is no healer in social anxiety disorder. Our results are similar to previous meta-analyses on the effects of waiting in other disorders, e.g., depression and posttraumatic stress disorder.

Transdiagnostic computerised cognitive behavioural therapy for depression and anxiety: A systematic review and meta-analysis

An increasing number of computerised transdiagnostic cognitive behavioural therapy programs (TD-cCBT) have been developed in the past decade, but there are no meta-analyses to explore the efficacy of these programs, nor moderators of the effects. The current meta-analysis focused on studies evaluating TD-cCBT interventions to examine their effects on anxiety, depression and quality of life (QOL). Results from 17 RCTs showed computerised TD-cCBT outperformed control conditions on all outcome measures at post-treatment, with large effect sizes for depression (g's=.84), and medium effect sizes for anxiety (g=.78) and QOL (g=.48). RCT quality was generally good, although heterogeneity was moderate to high. Further analyses revealed that studies comparing TD-cCBT to waitlist controls had the largest differences (g=.93) compared to active (g=.59) and usual care control groups (g=.37) on anxiety outcomes, but there was no influence of control group subtype on depression outcomes. Treatment length, symptom target (mixed versus anxiety only), treatment design (standardised versus tailored), and therapist experience (students versus qualified therapists) did not influence the results. Preliminary evidence from 4 comparisons with disorder-specific treatments suggests transdiagnostic treatments are as effective for reducing anxiety, and there may be small but superior outcomes for TD-cCBT programs for reducing depression (g=.21) and improving QOL (g=.21) compared to disorder-specific cCBT. These findings show that TD-cCBT programs are efficacious, and have comparable effects to disorder-specific cCBT programs.

Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial

BACKGROUND

In view of the high co-occurrence of depression and insomnia, a novel way to reduce the risk of escalating depression might be to offer an insomnia intervention. We aimed to assess whether an online self-help insomnia program could reduce depression symptoms.

METHODS

We did this randomised controlled trial at the Australian National University in Canberra, Australia. Internet users (aged 18-64 years) with insomnia and depression symptoms, but who did not meet criteria for major depressive disorder, were randomly assigned (1:1), via computer-generated randomisation, to receive SHUTi, a 6 week, modular, online insomnia program based on cognitive behavioural therapy for insomnia, or HealthWatch, an interactive, attention-matched, internet-based placebo control program. Randomisation was stratified by age and sex. Telephone-based interviewers, statisticians, and chief investigators were masked to group allocation. The primary outcome was depression symptoms at 6 months, as measured with the Patient Health Questionnaire (PHQ-9). The primary analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000121965.

FINDINGS

Between April 30, 2013, and June 9, 2014, we randomly assigned 1149 participants to receive SHUTi (n=574) or HealthWatch (n=575), of whom 581 (51%) participants completed the study program assessments at 6 weeks and 504 (44%) participants completed 6 months' follow-up. SHUTi significantly lowered depression symptoms on the PHQ-9 at 6 weeks and 6 months compared with HealthWatch (F[degrees of freedom 2,640·1]=37·2, p<0·0001). Major depressive disorder was diagnosed in 22 (4%) participants at 6 months (n=9 in the SHUTi group and n=13 in the HealthWatch group), with no superior effect of SHUTi versus HealthWatch (Fisher's exact test=0·52; p=0·32). No adverse events were reported.

INTERPRETATION

Online cognitive behaviour therapy for insomnia treatment is a practical and effective way to reduce depression symptoms and could be capable of reducing depression at the population level by use of a fully automatised system with the potential for wide dissemination.

FUNDING

Australian National Health and Medical Research Council.

Japan Unified Protocol Clinical Trial for Depressive and Anxiety Disorders (JUNP study): study protocol for a randomized controlled trial

BACKGROUND

The unified protocol for the transdiagnostic treatment of emotional disorders is a promising treatment approach that could be applicable to a broad range of mental disorders, including depressive, anxiety, trauma-related, and obsessive-compulsive disorders. However, no randomized controlled trial has been conducted to verify the efficacy of the unified protocol on the heterogeneous clinical population with depressive and anxiety disorders.

METHODS/DESIGN

The trial was designed as a single-center, assessor-blinded, randomized, 20-week, parallel-group superiority study in order to compare the efficacy of the combination of unified protocol and treatment-as-usual versus waiting-list with treatment-as-usual for patients with depressive and/or anxiety disorders. The primary outcome was depression at 21 weeks, assessed by the 17-item version of the GRID-Hamilton Rating Scale for Depression. Estimated minimum sample size was 27 participants in each group. We will also examine the treatment mechanisms, treatment processes, and neuropsychological correlates.

DISCUSSION

The results of this study will clarify the efficacy of the unified protocol for depressive and anxiety disorders, and the treatment mechanism, process, and neurological correlates for the effectiveness of the unified protocol. If its efficacy can be confirmed, the unified protocol may be of high clinical value for Japan, a country in which cognitive behavioral treatment has not yet been widely adopted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02003261 (registered on December 2, 2013).

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems

BACKGROUND

Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings.

OBJECTIVE

This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning.

METHOD

Narrative review.

RESULTS AND CONCLUSIONS

Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

A transdiagnostic cognitive behaviour therapy-based intervention in a secondary-care mental health service

Due to the growing evidence base supporting the hypothesis of common processes across different mental health problems, transdiagnostic interventions are receiving increased research attention. Transdiagnostic approaches have the potential to produce better outcomes, to reduce waiting times and to increase cost-effectiveness in stretched mental health services. Research into transdiagnostic cognitive behaviour therapy (CBT) in group format has demonstrated positive results in participants with anxiety disorders, with some studies extending the inclusion criteria to secondary and comorbid symptoms. This study evaluates a transdiagnostic CBT-based intervention, delivered by a secondary-care mental health team and includes participants with a range of diagnoses typical of this population. The real-world setting and lack of exclusion criteria based upon diagnosis provides an ecologically valid evaluation of a transdiagnostic CBT-based intervention. The results suggest that the intervention was associated with reductions in self-reported symptomatology and improvements in social functioning of individuals who attended in a secondary-care mental health service.

Effectiveness of a transdiagnostic internet-based protocol for the treatment of emotional disorders versus treatment as usual in specialized care: study protocol for a randomized controlled trial

BACKGROUND

Emotional disorders (depression and anxiety disorders) are highly prevalent mental health problems. Although evidence showing the effectiveness of disorder-specific treatments exists, high comorbidity rates among emotional disorders limit the utility of these protocols. This has led some researchers to focus their interest on transdiagnostic interventions, a treatment perspective that might be more widely effective across these disorders. Also, the current way of delivering treatments makes it difficult provide assistance to all of the population in need. The use of the Internet in the delivery of evidence-based treatments may help to disseminate treatments among the population. In this study, we aim to test the effectiveness of EmotionRegulation, a new transdiagnostic Internet-based protocol for unipolar mood disorders, five anxiety disorders (panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder and anxiety disorder not otherwise specified), and obsessive-compulsive disorder in comparison to treatment as usual as provided in Spanish public specialized mental health care. We will also study its potential impact on basic temperament dimensions (neuroticism/behavioral inhibition and extraversion/behavioral activation). Expectations and opinions of patients about this protocol will also be studied.

METHODS/DESIGN

The study is a randomized controlled trial. 200 participants recruited in specialized care will be allocated to one of two treatment conditions: a) EmotionRegulation or b) treatment as usual. Primary outcome measures will be the BAI and the BDI-II. Secondary outcomes will include a specific measure of the principal disorder, and measures of neuroticism/behavioral inhibition and extraversion/behavioral activation. Patients will be assessed at baseline, post-treatment, and 3- and 12-month follow-ups. Intention to treat and per protocol analyses will be performed.

DISCUSSION

Although the effectiveness of face-to-face transdiagnostic protocols has been investigated in previous studies, the number of published transdiagnostic Internet-based programs is still quite low. To our knowledge, this is the first randomized controlled trial studying the effectiveness of a transdiagnostic Internet-based treatment for several emotional disorders in public specialized care. Combining both a transdiagnostic approach with an Internet-based therapy format may help to decrease the burden of mental disorders, reducing the difficulties associated with disorder-specific treatments and facilitating access to people in need of treatment. Strengths and limitations are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02345668 . Registered 27 July 2015.