A meta-analysis of relapse rates in cognitive-behavioral therapy for anxiety disorders

Brain stimulation enhances dispositional mindfulness in PTSD: an exploratory sham-controlled rTMS trial

Objective

Post-traumatic stress disorder (PTSD) is characterized by hypervigilance, intrusive thoughts, negative mood, and avoidant behaviors. Therapies involving mindfulness have been shown to reduce PTSD symptoms and modulate brain function. Pharmacological and brain stimulation interventions are also effective for treating PTSD. Non-invasive repeated transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex (DLPFC) has been shown to regulate mood and improve PTSD symptoms.

Methods

This is a retrospective chart analysis of data collected pre-treatment, post-treatment, and at three-month follow-up in a single-site, double-blind, sham-controlled trial of right DLPFC rTMS. 31 participants diagnosed with PTSD were recruited for this pilot study. Over two weeks, 19 participants received ten sessions of either 1 Hz or 10 Hz stimulation, and nine received sham treatment.

Results

Participants in the rTMS group had a significant reduction in total Five Facet Mindfulness Questionnaire (FFMQ) scores from baseline to post-treatment, this difference was no longer observed when a false discovery rate (FDR) correction was applied. However, a significant improvement was observed in the rTMS group from baseline to the three-month follow-up in total FFMQ score and nonreactivity. This change in mindfulness scores suggests a potential delay in onset of benefits.

Conclusions

Based on our preliminary data, rTMS may improve levels of dispositional mindfulness and its specific subcomponents. Future studies could investigate brain stimulation to assess its utility for improving mindfulness and related health outcomes to reduce suffering related to PTSD. Moreover, application of this neurostimulation modality for improving mental illness and well-being more generally merits further exploration.

Clinical trial registration

https://clinicaltrials.gov/study, identifier NCT01806168.

Ready for translation: non-invasive auricular vagus nerve stimulation inhibits psychophysiological indices of stimulus-specific fear and facilitates responding to repeated exposure in phobic individuals

Recent laboratory research showed that vagus nerve stimulation promotes fear extinction, the inhibitory core mechanism of exposure treatment, presumably via activation of the noradrenergic brain system. However, a translation of this stimulation technique to clinical practice is lacking. We therefore investigated the potential of vagal stimulation to inhibit excessive fear responses and facilitate responding to in-vivo and laboratory exposure in individuals with specific phobia. Spider-phobic participants were subjected to three standardized in-vivo exposures towards a living tarantula, complemented by an exposure in vitro (between exposure in vivo I and II). Transcutaneous auricular vagus nerve stimulation (taVNS) was applied during in-vitro exposure, presenting pictures of the exposed tarantula, other spiders and neutral tools in the laboratory. Fear was assessed by self-reports and behavioral avoidance (in-vivo exposures), and amygdala-mediated autonomic and behavioral fear components (exposure in vitro). Vagal stimulation facilitated the reduction of behavioral avoidance across repeated in-vivo exposures. During laboratory exposure, taVNS inhibited fear tachycardia and corrugator muscle activity specifically in response to pictures of the previously exposed tarantula - an effect that became stronger with increasing stimulation duration. Psychophysiological indices of noradrenergic transmission in the basolateral amygdala were elevated during taVNS and correlated to subsequent attenuation of behavioral avoidance. Our results suggest, that taVNS exerts stimulus-specific and dose-dependent inhibition of multiple automatic response components of excessive fear, highlighting taVNS as a valuable adjunct to exposure-based treatment. A translational mechanism of action is supported, proposing that taVNS exhibits its effects by noradrenergic activation of fear extinction circuitry, particularly targeting the basolateral amygdala.

Difficult to Treat Anxiety: A neurocomputational framework

Anxiety disorders, affecting approximately one in nine individuals globally, impose significant socioeconomic and health burdens, with many individuals failing to achieve symptom remission despite standard treatments. Difficult-to-Treat Anxiety (DTA) encompasses a broad spectrum of persistent anxiety disorders that remain refractory to conventional interventions, necessitating a shift from rigid response-based criteria to a mechanistically driven framework integrating computational psychiatry and systems neuroscience. Central to DTA is dysregulated approach-avoidance decision-making, where heightened punishment sensitivity, inflexible belief updating, and uncertainty misestimation drive persistent avoidance behaviors and reinforce maladaptive anxiety cycles. Computational modeling of reinforcement learning tasks reveals exaggerated Pavlovian biases and impaired exploratory learning, while predictive processing models highlight overestimation of threat and rigidity in safety learning, perpetuating chronic anxiety. Neural dysfunction in default mode and negative affective networks, characterized by hyperstable attractor states in the amygdala and impaired top-down regulation by the prefrontal cortex, further sustains maladaptive anxiety states. Novel interventions targeting these dysfunctions-such as neuromodulation, precision pharmacotherapy, and personalized digital therapeutics-offer potential breakthroughs in managing DTA. This review synthesizes current evidence on computational, neural, and behavioral mechanisms underlying DTA, proposing an integrative, process-targeted approach to assessment and treatment. Future research must refine biomarker-driven subtyping and individualized interventions, moving beyond trial-and-error approaches toward mechanistically informed, precision psychiatry for persistent anxiety disorders.

The relationship between childhood trauma and social anxiety in college students: the mediating role of evaluation fear

BACKGROUND

Social anxiety has become a common psychological problem that seriously affects the mental health of contemporary youth. Although numerous studies have shown that childhood trauma is closely related to social anxiety in adulthood, the mediating role of evaluation of fear in this relationship remains unclear. This study aims to explore the relationships among childhood trauma, evaluation fear, and social anxiety among college students and their internal pathways.

METHODS

In September 2023, a sample of 559 Chinese university students aged 18-22 years (mean age = 20.20, SD = 1.211; 229 males and 330 females) completed the Childhood Trauma Questionnaire, Liebowitz Social Anxiety Scale, Fear of Positive Evaluation Scale, and Brief Fear of Negative Evaluation Scale. Correlation analyses were conducted to explore the initial relationships among the main variables. Structural equation modeling was performed to examine the parallel mediating effects of fear of positive and negative evaluation on the relationship between childhood trauma and social anxiety.

RESULTS

Significant correlations were found among childhood trauma, social anxiety, fear of negative evaluation, and fear of positive evaluation. Childhood trauma significantly and positively predicted both fear of positive evaluation (β = 0.40, p < 0.001) and fear of negative evaluation (β = 0.31, p < 0.001). Fear of positive and negative evaluation also positively predicted social anxiety (β = 0.45, p < 0.001; β = 0.43, p < 0.001, respectively). The parallel mediation effects of fear of positive and negative evaluation on the relationship between childhood trauma and social anxiety were significant (effect size: 0.309, 95% CI = [0.240, 0.380]), with the mediation effects accounting for 60.78% of the total effect.

CONCLUSION

Fear of positive and negative evaluation plays a mediating role in the impact of childhood trauma on social anxiety. This finding provides a new perspective for understanding the formation mechanism of social anxiety and offers a scientific basis for developing effective intervention strategies.

Fear and safety learning in anxiety- and stress-related disorders: An updated meta-analysis

Fear learning processes are believed to play a crucial role in the development and maintenance of anxiety and stress-related disorders. To integrate results across different studies, we conducted a systematic meta-analysis following PRISMA guidelines to examine differences in fear conditioning during fear acquisition, extinction, and extinction recall between individuals with anxiety-related or stress-related disorders and healthy participants. This analysis updates the work of Duits et al. (2015) while also refining distinctions between physiological and behavioral outcomes and examining extinction recall. Our meta-analysis encompasses 77 studies published from 1986 to 2022, involving 2052 patients with anxiety disorders, obsessive-compulsive disorder, or post-traumatic stress disorder, and 3258 healthy controls. The results indicate significant differences in fear acquisition, extinction, and recall between the two groups. Specifically, during acquisition patients exhibited heightened physiological and behavioral responses to the CS- and reported increased affect ratings for the CS+ . During extinction and extinction recall, patients continue to show heightened threat expectancy and negative affect ratings towards the CS- and increased affect ratings towards the CS+ . No differences were found in CS+ /CS- differentiation between groups. These findings imply that individuals with anxiety and stress-related disorders may exhibit amplified responses to safety cues and stronger reactions to threat cues during fear conditioning, lasting through extinction and extinction recall. These changes may lead to increased sensitivity in detecting fear and slower extinction process, resulting in more enduring anxiety responses. We discuss these results in the context of existing literature on fear and safety learning and consider potential underlying mechanisms.

Intermittent theta burst stimulation of the left dorsolateral prefrontal cortex has no additional effect on the efficacy of virtual reality exposure therapy for acrophobia. A randomized double-blind placebo-controlled study

Anxiety disorders are among the most common mental disorders. Treatment guidelines recommend pharmacotherapy and cognitive behavioral therapy as standard treatment. Although cognitive behavioral therapy is an effective therapeutic approach, not all patients benefit sufficiently from it. In recent years, non-invasive brain stimulation techniques, such as transcranial magnetic stimulation, have been investigated as promising adjuncts in the treatment of affective disorders. The aim of this study is to investigate whether a combination of intermittent theta burst stimulation (iTBS) and virtual reality exposure therapy leads to a significantly greater reduction in acrophobia than virtual reality exposure with sham stimulation. In this randomized double-blind placebo-controlled study, 43 participants with acrophobia received verum or sham iTBS over the left dorsolateral prefrontal cortex prior to two sessions of virtual reality exposure therapy. Stimulation of the left dorsolateral prefrontal cortex with iTBS was motivated by an experimental study showing a positive effect on extinction memory retention. Acrophobic symptoms were assessed using questionnaires and two behavioral approach tasks one week before, after treatment and six months after the second diagnostic session. The results showed that two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms, with an overall remission rate of 79 %. However, there was no additional effect of iTBS of the left dorsolateral prefrontal cortex on the therapeutic effects. Further research is needed to determine how exactly a combination of transcranial magnetic stimulation and exposure therapy should be designed to enhance efficacy.

Process of change and efficacy of acceptance and commitment therapy (ACT) for anxiety and depression symptoms in adolescents: A meta-analysis of randomized controlled trials

INTRODUCTION

Recent literature suggests that acceptance and commitment therapy (ACT) may be an effective approach for treating symptoms of depression and anxiety symptoms in adolescents. This review meta-analyzes the efficacy of ACT on adolescent depression and anxiety, emphasizing the role of process variables (i.e., psychological flexibility).

METHODS

We systematically searched MedLine, PsycInfo and Scopus for randomized controlled trials (RCT) investigating the effect of ACT on anxiety/depression in adolescents. Studies were combined using the inverse variance method in a random effects model. Additional subgroup and meta-regression analyses were performed, and risk of bias was assessed. The review was pre-registered (PROSPERO registration number: CRD42023483300).

RESULTS

Our review included 27 RCTs with a total of 2860 participants. ACT did not outperform CBT but was significantly more effective than other active controls (e.g., treatment as usual) for depression symptoms and inactive controls for all outcomes. ACT was more effective than inactive controls for all outcomes. Improvements in psychological flexibility significantly predicted reductions in between-group depression and anxiety. Younger age and a higher percentage of women predicted better outcomes for some outcomes.

LIMITATIONS

It should be noted that this results may be limited by the fact that all included studies were rated as having a high risk of bias. This is mainly due to the self-reported nature of the measures and the lack of crucial methodological information (e.g., process of randomization and allocation, treatment fidelity assessment).

CONCLUSION

Our findings support ACT's efficacy for adolescents, particularly in treating depression symptoms. The proposed mechanism of change (psychological flexibility) plays a significant role in the improvements. ACT is comparable in efficacy to CBT, suggesting its potential as an alternative to traditional cognitive-behavioral approaches.

A systematic review of the effects of rumination-focused cognitive behavioral therapy in reducing depressive symptoms

There is still potential room for improving the effectiveness of standard Cognitive Behavioral Therapy (CBT) in preventing the onset of depression, achieving full remission, and preventing relapse or recurrence of depression. Standard CBT seems less effective in reducing depressive rumination, a key risk factor leading to the onset and persistence of depression. To improve treatment efficacy for depression, rumination-focused cognitive behavioral therapy (RFCBT) was developed, which was modified from CBT and specifically targeted to manage rumination. This systematic review aimed to assess the effects of RFCBT by evaluating whether RFCBT could contribute to reducing depressive symptoms pre-post intervention. A literature search was conducted up to April 30, 2024, across four English-language databases, including PubMed, Web of Science, Google Scholar, and Embase. The search terms employed were: (depress* OR mood OR affect OR rumination) AND ("Rumination Focused Cognitive behavio* Therapy" OR RFCBT). Among the initial 328 studies identified, 12 met the inclusion criteria, of which 10 were randomized controlled trials. Intervention characteristics and results were narratively synthesized to address the review aims. This review found preliminary evidence that the RFCBT could eliminate depressive symptoms post-intervention, and might prevent individuals from developing depression, alleviate depressive symptoms, and prevent relapse of depression, as well as reduce rumination. RFCBT could be promoted to treat depressive symptoms, especially for those with a high tendency toward rumination. However, more studies with rigorous designs are required to confirm its efficacy across different stages of depression. Future studies could compare RFCBT with other psychotherapies, dismantle the psychological therapies to identify their effective components, and explore which specific groups of people might benefit most from this intervention.

State of the Science: Disgust and the Anxiety Disorders

Anxiety disorders have long been conceptualized as disorders of fear, while other emotions have largely been overlooked. However, an emerging literature has increasingly implicated disgust in certain anxiety-related disorders, including obsessive-compulsive disorder, specific phobias (e.g., spider phobia), health anxiety, and posttraumatic stress disorder. Roughly two decades of research has accumulated evidence identifying various mechanisms linking disgust-related phenomena to these disorders. In the present "State of the Science" review, we sought to summarize the current state of the literature with respect to disgust-related mechanisms in anxiety disorders, including trait-level vulnerabilities (e.g., disgust proneness), cognitive processes (e.g., biases of attention and memory), and associated learning mechanisms (e.g., evaluative conditioning). Research in these areas has revealed important ways in which disgust differs from fear-related phenomena, which have important treatment implications. From there, we sought to summarize research on laboratory interventions that attempt to target and attenuate disgust, as well as the early research on formal cognitive-behavioral treatments that integrate disgust-related interventions for anxiety disorders. Although the past two decades of research have revealed important insights related to the role of disgust in psychopathology, much remains to be learned in this area. We propose some future directions, emphasizing the importance of a guiding framework that highlights studying disgust-related mechanisms across different levels of analysis.

A Pilot Study Comparing a Community of Practice Program with and without Concurrent Ketamine-Assisted Therapy

The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) has increased among healthcare providers, while the effectiveness of conventional treatments remains limited. Ketamine-assisted therapy offers a promising alternative; however, few have integrated ketamine with a group-based therapeutic modality. We report a retrospective, secondary analysis of a 12-week pilot of a Community of Practice (CoP) oriented group therapy program with optional, adjunct ketamine for depression, anxiety, and PTSD in a sample of 57 healthcare providers. All participants moved through the treatment as one group, with 38 electing to also receive three adjunct ketamine sessions in addition to the weekly CoP. Symptoms were assessed at baseline and pilot completion with the PHQ-9 for depression, GAD-7 for anxiety, and PCL-5 for PTSD. We observed significant reductions in the mean change among all participants, suggesting that benefit was derived from the CoP component, with or without ketamine as an adjunct. PHQ-9 scores decreased by 6.79 (95% CI: 5.09-8.49, p < .001), GAD-7 scores decreased by 5.57 (CI: 4.12-7.00, p < .001), and PCL-5 scores decreased by 14.83 (CI: 10.27-19.38, p < .001). Reductions were larger, but statistically nonsignificant, among those receiving ketamine. Further research is required to assess the impact of ketamine as an adjunct in group-based therapies.

Getting stress-related disorders under control: the untapped potential of neurofeedback

Stress-related disorders are among the biggest global health challenges. Despite significant progress in understanding their neurocognitive basis, the promise of applying insights from fundamental research to prevention and treatment remains largely unfulfilled. We argue that neurofeedback - a method for training voluntary control over brain activity - has the potential to fill this translational gap. We provide a contemporary perspective on neurofeedback as endogenous neuromodulation that can target complex brain network dynamics, is transferable to real-world scenarios outside a laboratory or treatment facility, can be trained prospectively, and is individually adaptable. This makes neurofeedback a prime candidate for a personalized preventive neuroscience-based intervention strategy that focuses on the ecological momentary neuromodulation of stress-related brain networks in response to actual stressors in real life.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

An investigation of the role of estradiol in fear reduction during a single session of exposure therapy

Research suggests that estradiol may moderate fear extinction. It is unclear whether these results generalize to exposure therapy. The aim of the current study was to determine whether estradiol moderates outcomes in exposure therapy among women with anxiety disorders. Participants were 35 women with a primary diagnosis of an anxiety disorder who participated in the study as part of routine care at an anxiety specialty clinic. Endogenous estradiol was assessed via saliva. They provided subjective distress ratings before (pre) and after (post) an exposure session, as well as after a brief delay (recall). Contrary to predictions, there were no significant differences in exposure outcomes between the high and low estradiol groups. However, among participants with primary obsessive-compulsive disorder (OCD), results were partially consistent with the hypotheses. Women with lower estradiol initially demonstrated more improvement in subjective distress from pre- to post-exposure, but after the delay, significantly greater distress (attenuated extinction recall). Results suggest that women with lower estradiol may respond less favorably to exposure therapy for OCD relative to women with higher estradiol. These findings await replication in larger samples with longer recall delays. Should replication occur, these results may inform the use of estradiol to augment exposure therapy.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.

The Bergen 4-day treatment for social anxiety disorder: a pilot study

BACKGROUND

Few studies have examined the use of concentrated and intensified cognitive behaviour therapy for treating social anxiety disorder (SAD). The aim of this study was to examine the feasibility of the Bergen 4-Day Treatment (B4DT) for treating SAD.

METHODS

This study adopted an open trial design without a control group. Thirty consecutively referred patients who were diagnosed with SAD were treated and assessed at pre-treatment, at post-treatment, and at the 3-month follow-up. The Liebowitz Social Anxiety Scale was used to assess symptoms of SAD; the Generalized Anxiety Disorder-7 scale was used to assess anxiety symptoms; and the Patient Health Questionnaire-9 was used to assess symptoms of anxiety and depression. The Client Satisfaction Questionnaire-8 was administered posttreatment.

RESULTS

Overall, patients reported a high level of satisfaction with the B4DT. Large effect sizes were observed for symptoms of SAD (d = 1.94-2.66) and for the secondary outcomes, i.e., generalized anxiety (d = 0.86-0.99) and depression (d = 0.62-0.83). The remission rate was 55.2% at follow-up, while the treatment response rate was 89.7%.

CONCLUSIONS

The B4DT is a promising treatment approach for patients with SAD. In the future, controlled trials should be performed to compare the efficacy of this treatment approach with standard outpatient treatment. Practical consequences, policy implications, and suggestions for future research are discussed herein.

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

Safety, feasibility, tolerability, and clinical effects of repeated psilocybin dosing combined with non-directive support in the treatment of obsessive-compulsive disorder: protocol for a randomized, waitlist-controlled trial with blinded ratings

Background

To date, few randomized controlled trials of psilocybin with non-directive support exist for obsessive-compulsive disorder (OCD). Results and participant feedback from an interim analysis of an ongoing single-dose trial (NCT03356483) converged on the possibility of administering a higher fixed dose and/or more doses of psilocybin in future trials for presumably greater benefits.

Objectives

This trial aims to evaluate the safety, feasibility, tolerability, and clinical effects of two doses of psilocybin paired with non-directive support in the treatment of OCD. This trial also seeks to examine whether two doses of psilocybin lead to greater OCD symptom reduction than a single dose, and to elucidate psychological mechanisms underlying the effects of psilocybin on OCD.

Design

A randomized (1:1), waitlist-controlled design with blinded ratings will be used to examine the effects of two doses of oral psilocybin paired with non-directive support vs. waitlist control on OCD symptoms. An adaptive dose selection strategy will be implemented (i.e., first dose: 25 mg; second dose: 25 or 30 mg).

Methods and analysis

This single-site trial will enroll 30 adult participants with treatment-refractory OCD. Aside from safety, feasibility, and tolerability metrics, primary outcomes include OCD symptoms assessed on the Yale-Brown Obsessive-Compulsive Scale - Second Edition (Y-BOCS-II). A blinded independent rater will assess primary outcomes at baseline and the primary endpoint at the end of the second dosing week. Participants will be followed up to 12 months post-second dosing. Participants randomized to waitlist will be rescreened after 7 weeks post-randomization, and begin their delayed treatment phase thereafter if still eligible.

Ethics

Written informed consent will be obtained from participants. The institutional review board has approved this trial (protocol v. 1.7; HIC #2000032623).

Discussion

This study seeks to advance our ability to treat refractory OCD, and catalyze future research seeking to optimize the process of psilocybin treatment for OCD through understanding relevant psychological mechanisms.Clinical trial registration: ClinicalTrials.gov, identifier NCT05370911.

Resting respiratory sinus arrythmia and cognitive reappraisal moderate the link between political climate stress and anxiety symptoms in Latina and Black mothers

Guided by the Family Stress Model for minority families, the present study examined the potential buffering effect of resting respiratory sinus arrythmia (RRSA), cognitive reappraisal, and mindfulness on the association between political climate stress (PCS) and anxiety symptoms in a sample of Latina and Black mothers. Participants were 100 mothers living in the southeastern United States. Mothers reported on PCS, cognitive reappraisal, mindfulness, and symptoms of anxiety. RRSA were measured during a resting task. Moderation analyses tested the influence of these three factors (RRSA, cognitive reappraisal, mindfulness) on the relation between PCS and anxiety. Results showed that the relation between PCS and anxiety symptoms was strongest at low levels of RRSA and cognitive reappraisal. At high levels of these two factors, there was no association between PCS and anxiety symptoms. Mothers with high levels of RRSA and cognitive reappraisal may be able to interact with and evaluate environmental stimuli in such a way that allows for adaptive adjustment, buffering against the negative impact of PCS. RRSA and cognitive reappraisal may be important targets of interventions designed to address the rising rates of anxiety symptoms in Latina and Black mothers.

Identifying active ingredients in cognitive-behavioral therapies: What if we didn't?

Identifying active ingredients of psychological interventions is a major goal of psychotherapy researchers that is often justified by the promise that it will lead to improved patient outcomes. Much of this "active ingredients" research is conducted within randomized controlled trials (RCTs) with patient populations, putting it in Phase T2 of the clinical-translational spectrum. I argue that RCTs in patient populations are very "messy laboratories" in which to conduct active ingredient work and that T0 and T1 research provide more controlled contexts. However, I call attention to the long road from identifying active ingredients of CBTs, whether in T0, T1, or T2 research, to improving outcomes. Dissemination and implementation research (T3 and T4 approaches) may be conceptually closer to improving outcomes. Given how common and disabling mental health symptoms are, I argue that if researchers want to improve patient outcomes, these research programs must receive more attention including work on the uptake of psychological interventions as well as work on optimal ordering of existing interventions.

An interdisciplinary multimodal integrative healthcare program for depressive and anxiety disorders

Objective

Although multimodal interventions are recommended in patients with severe depressive and/or anxiety disorders, available evidence is scarce. Therefore, the current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, for patients with (comorbid) depressive and/or anxiety disorders.

Methods

Participants were 3,900 patients diagnosed with a depressive and/or anxiety disorder. The primary outcome was Health-Related Quality of Life (HRQoL) measured with the Research and Development-36 (RAND-36). Secondary outcomes included: (1) current psychological and physical symptoms measured with the Brief Symptom Inventory (BSI) and (2) symptoms of depression, anxiety, and stress measured with the Depression Anxiety Stress Scale (DASS). The healthcare program consisted of two active treatment phases: main 20-week program and a subsequent continuation-phase intervention (i.e., 12-month relapse prevention program). Mixed linear models were used to examine the effects of the healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of 12-month relapse prevention program (T3).

Results

Results showed significant improvements from T0 to T2 for the primary variable (i.e., RAND-36) and secondary variables (i.e., BSI/DASS). During the 12-month relapse prevention program, further significant improvements were mainly observed for secondary variables (i.e., BSI/DASS) and to a lesser extent for the primary variable (i.e., RAND-36). At the end of the relapse prevention program (i.e., T3), 63% of patients achieved remission of depressive symptoms (i.e., DASS depression score ≤ 9) and 67% of patients achieved remission of anxiety symptoms (i.e., DASS anxiety score ≤ 7).

Conclusion

An interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, seems effective for patients suffering from depressive and/or anxiety disorders with regard to HRQoL and symptoms of psychopathology. As reimbursement and funding for interdisciplinary multimodal interventions in this patient group has been under pressure in recent years, this study could add important evidence by reporting on routinely collected outcome data from a large patient group. Future studies should further investigate the long-term stability of treatment outcomes after interdisciplinary multimodal interventions for patients suffering from depressive and/or anxiety disorders.

Safety, tolerability, and clinical and neural effects of single-dose psilocybin in obsessive-compulsive disorder: protocol for a randomized, double-blind, placebo-controlled, non-crossover trial

Background

Psilocybin may help treat obsessive-compulsive disorder (OCD). To date, only one open-label study of psilocybin for OCD exists, necessitating further investigation with a randomized controlled design. The neural correlates of psilocybin's effects on OCD have also not been studied.

Objectives

This first-of-its-kind trial aims to evaluate the feasibility, safety, and tolerability of psilocybin in the treatment of OCD, provide preliminary evidence on the effects of psilocybin on OCD symptoms, and elucidate neural mechanisms that may mediate psilocybin's effects on OCD.

Design

We use a randomized (1:1), double-blind, placebo-controlled, non-crossover design to examine the clinical and neural effects of either a single dose of oral psilocybin (0.25 mg/kg) or active placebo-control agent (250 mg of niacin) on OCD symptoms.

Methods and analysis

We are enrolling 30 adult participants at a single site in Connecticut, USA who have failed at least one trial of standard care treatment (medication/psychotherapy) for OCD. All participants will also receive unstructured, non-directive psychological support during visits. Aside from safety, primary outcomes include OCD symptoms over the past 24 h, assessed by the Acute Yale-Brown Obsessive-Compulsive Scale and Visual Analog Scale ratings. These are collected by blinded, independent raters at baseline and the primary endpoint of 48 h post-dosing. Total follow-up is 12 weeks post-dosing. Resting state neuroimaging data will be collected at baseline and primary endpoint. Participants randomized to placebo will be offered the chance to return for an open-label dose of 0.25 mg/kg.

Ethics statement

All participants will be required to provide written informed consent. The trial (protocol v. 5.2) was approved by the institutional review board (HIC #2000020355) and registered with ClinicalTrials.gov (NCT03356483).

Discussion

This study may represent an advance in our ability to treat refractory OCD, and pave the way for future studies of neurobiological mechanisms of OCD that may respond to psilocybin.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE)

BACKGROUND

Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness.

METHODS

A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment.

DISCUSSION

The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach.

TRIAL REGISTRATION

ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.

Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: a randomized controlled trial

Background

Improving children's access to mental health services need more innovative solutions, especially in low- and middle-income countries. School-based psychosocial interventions delivered by lay counselors may be an efficient way to improve children's access to mental health services. But few studies were conducted to examine the effectiveness of these interventions. Therefore, this study is to evaluate the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) in a group format delivered by lay counselors to children with trauma-related symptoms in China.

Methods

A total of 234 children (aged 9-12 years) with full or subthreshold posttraumatic stress disorder (PTSD) were randomly assigned to group-based TF-CBT or treatment as usual (TAU). In the intervention group, 118 children received 10-12 sessions of group-based TF-CBT delivered by lay counselors for 9 consecutive weeks. In the TAU group, 116 children received the usual school services provided by psychology teachers. The primary outcome was the reduction in PTSD severity, which was assessed with the UCLA PTSD reaction index for DSM-5 (PTSD-RI-5). The secondary outcomes included the reduction in PTSD severity and the remission of PTSD, both of which were measured with the PTSD checklist-5 (PCL-5). Secondary outcomes also included the reduction in depression severity and the reduction in generalized anxiety severity. Blinded assessments were collected at baseline, posttreatment (primary endpoint), and 3-month follow-up. This trial is registered with Chinese Clinical Trial Registry, ChiCTR1900027131.

Findings

At posttreatment, the intervention group scored significantly lower than the TAU group on PTSD-RI-5 PTSD (30.98 vs. 39.22; adjusted mean difference [AMD], -7.35; 95% CI, -11.66 to -3.04), PCL-5 PTSD (28.78 vs. 38.04; AMD, -8.49; 95% CI, -13.23 to -3.75), depression (5.52 vs. 7.96; AMD, -1.63; 95% CI, -2.50 to -0.76), and generalized anxiety (7.23 vs. 8.64; AMD, -1.21; 95% CI, -2.20 to -0.23). The remission of PCL-5 PTSD was also significantly higher in the intervention group (42.86% vs. 13.54%, χ ²  = 13.10, P < 0.001). These two groups showed a similar level of symptoms at the 3-month follow-up.

Interpretation

The group-based TF-CBT can significantly alleviate PTSD, depression, and generalized anxiety right after treatment in Chinese children who suffer from different types of trauma. But the long-term effects of this intervention need to be further tested. This intervention can be delivered by trained lay counselors in low- and middle-income countries.

Funding

None.

Anxiety Disorders: A Review

Importance

Anxiety disorders have a lifetime prevalence of approximately 34% in the US, are often chronic, and significantly impair quality of life and functioning.

Observations

Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors. Generalized anxiety disorder (6.2% lifetime prevalence), social anxiety disorder (13% lifetime prevalence), and panic disorder (5.2% lifetime prevalence) with or without agoraphobia are common anxiety disorders seen in primary care. Anxiety disorders are associated with physical symptoms, such as palpitations, shortness of breath, and dizziness. Brief screening measures applied in primary care, such as the Generalized Anxiety Disorder-7, can aid in diagnosis of anxiety disorders (sensitivity, 57.6% to 93.9%; specificity, 61% to 97%). Providing information about symptoms, diagnosis, and evidence-based treatments is a first step in helping patients with anxiety. First-line treatments include pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs, eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, eg, venlafaxine extended release) remain first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder. Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo (eg, generalized anxiety disorder: standardized mean difference [SMD], -0.55 [95% CI, -0.64 to -0.46]; social anxiety disorder: SMD, -0.67 [95% CI, -0.76 to -0.58]; panic disorder: SMD, -0.30 [95% CI, -0.37 to -0.23]). Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders compared with psychological or pill placebo (eg, generalized anxiety disorder: Hedges g = 1.01 [large effect size] [95% CI, 0.44 to 1.57]; social anxiety disorder: Hedges g = 0.41 [small to medium effect] [95% CI, 0.25 to 0.57]; panic disorder: Hedges g = 0.39 [small to medium effect[ [95% CI, 0.12 to 0.65]), including in primary care. When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care.

Conclusions and Relevance

Anxiety disorders affect approximately 34% of adults during their lifetime in the US and are associated with significant distress and impairment. First-line treatments for anxiety disorders include cognitive behavioral therapy, SSRIs such as sertraline, and SNRIs such as venlafaxine extended release.

Long-term outcomes of cognitive behavioural therapy for social anxiety disorder: A meta-analysis of randomised controlled trials

Cognitive Behavioural Therapy (CBT) is effective in treating Social Anxiety Disorder (SAD). However, less is known about whether gains achieved in disorder-specific and secondary outcomes (e.g., depression, general anxiety, quality of life, and self-esteem) are maintained 12 months or longer. A systematic literature search yielded 25 relevant studies that administered CBT to participants with SAD. Multivariate meta-analyses of post-treatment assessments, found that CBT was superior to control conditions in reducing social anxiety (g =.74), depression (g =.52), general anxiety (g =.69) and improving quality of life (g =.39). The within-groups effect sizes revealed that 12 months or more after CBT treatment, symptoms continued to improve for social anxiety (g_av =.23) and quality of life (g_av =.17), and gains were maintained for depressive (g_av =.06) and general anxiety symptoms (g_av =.03). However, meta-analyses of long-term outcomes lack comparison groups. Moderation was non-significant for the treatment model, format, number of sessions, treatment duration, or inclusion of booster sessions. Future research may investigate what drives improvement after treatment cessation and how CBT affects other co-occurring symptomatology. Taken together, CBT produces many benefits for SAD and individuals with co-occurring symptoms can benefit from extant SAD-focused treatments.

The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda

OBJECTIVES

We reviewed the evidence regarding the effectiveness of schema therapy for anxiety disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD).

METHODS

This systematic review followed the recommendation of the PRISMA guidelines. A database search (PsycINFO, MEDLINE, EMBASE, WEB OF SCIENCE, and Academic Search Ultimate) was conducted to identify eligible studies up until 2 April 2021. The search included the keywords ('schema therap*' or 'schema group therap*' or 'schema mode therap*' or 'schema focused' or 'young's model') and ('anxiety disorder*' or 'anxiety-related disorder*' or 'agoraphobia' or 'health anxiety' or 'phobi*' or 'panic disorder' or 'obsessive compulsive disorder' or 'OCD' or 'posttraumatic stress' or 'post traumatic stress' or 'PTSD' or 'hypochondria' or 'axis 1'). Included studies were appraised on methodological quality according to the Psychotherapy Outcome study Methodology Rating Form.

RESULTS

We identified 41 studies that were eligible based on the topic. However, only six (comprising 316 anxiety, OCD, and PTSD patients) could be included despite lenient methodological inclusion/exclusion criteria. Results showed that schema therapy can lead to beneficial effects in disorder-specific symptoms and early maladaptive schemas. Yet, we also uncovered substantial methodological limitations in most studies.

CONCLUSIONS

Schema therapy is a promising treatment for anxiety, OCD, and PTSD. Yet, there is a systematic problem in the quality of research despite growing clinical interest and application. We therefore concluded with a research agenda presenting recommendations for future research that will be crucial for building a solid evidence-base for schema therapy in chronic anxiety, OCD, and PTSD.

PRACTITIONER POINTS

A systematic review on the effectiveness of schema therapy for anxiety disorders, OCD, and PTSD. Preliminary but limited evidence that schema therapy leads to beneficial effects in disorder-specific symptoms. Preliminary but limited evidence that schema therapy leads to beneficial effects in early maladaptive schemas in anxiety, OCD, and PTSD. More research of higher methodological quality is needed to provide more conclusive empirical support for the use of schema therapy for anxiety, OCD, and PTSD.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

Objectives

The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).

Methods

A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.

Results

Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.

Conclusions

In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.

Systematic review registration number

PROSPERO 2018: CRD42018103142.

Research Review: A meta-analysis of relapse rates in cognitive behavioral therapy for anxiety and related disorders in youth

BACKGROUND

Cognitive behavioral therapy (CBT) is an effective treatment for youth with anxiety and related disorders, with a 59% remission rate at post-treatment. Results of reviews and meta-analyses indicate that treatment gains are maintained across long-term follow-up, at least in terms of symptom improvement. Less is known about relapse, defined as patients who initially achieve remission status but then experience a return of symptoms after a follow-up period.

METHOD

The current study used meta-analysis to determine the overall rate of relapse in CBT for children and adolescents (age 18 years or younger) with anxiety and related disorders. Potential moderating factors of relapse rates, including demographic, methodological, and clinical/intervention characteristics, were also examined. Out of a pool of 78 abstracts, 13 full-text articles were retained for meta-analysis. An additional two articles were identified from other sources (total N = 535 patients).

RESULTS

Results showed an overall relapse rate of 10.5% (including comorbid autism spectrum disorder) and 8% (excluding comorbid autism spectrum disorder) across studies. Moderator analyses demonstrated that relapse rates were higher among younger and more racially diverse samples, as well as among patients with comorbid externalizing disorders and those taking psychiatric medications. There were no differences in relapse rates as a function of primary diagnosis.

CONCLUSIONS

Taken together, the findings indicate that relapse rates in CBT for anxious youth are relatively low, suggesting that treatment development and refinement efforts should focus on improving treatment response and remission rates for this population.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BACKGROUND

The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.

METHODS/DESIGN

We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.

STATISTICAL ANALYSIS

Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.

DISCUSSION

This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Mental Health in Australia: Psychological Distress Reported in Six Consecutive Cross-Sectional National Surveys From 2001 to 2018

PURPOSE

To examine Australian psychological distress trends from 2001 to 2017/18, including analysis by age, sex, location, and household income.

METHODS

Secondary analysis of the working age population (18-64 years) in six successive representative national health surveys. Measures were prevalence of psychological distress at very-high symptom level (defined by a Kessler Psychological Distress Scale (K10) score of 30 or more) and combined high/very-high level (K10 score of 22 or more). Very-high K10 scores are associated with mental health problems meeting diagnostic thresholds in past year.

RESULTS

From 2001 to 2017/18 Australian rates of K10 very-high distress rose significantly from 3.8 to 5.1% and combined high/very-high from 13.2 to 14.8%. In women aged 55-64, very-high distress rose significantly and substantially from 3.5 to 7.2% and high/very-high distress from 12.4 to 18.7%. In men aged 25-34, very-high distress increased from 2.1 to 4.0% and high/very-high from 10.6 to 11.5%. Income was strongly and inversely associated with distress (lowest vs. highest quintile adjusted OR 11.4). An apparent association of increased distress with regional location disappeared with adjustment for income.

CONCLUSION

Australia's population level of psychological distress increased significantly from 2001-2017/18, with levels highest in women and with rates inversely associated with income. This is likely to be indicative of increased community rates of mental disorders. Given that this has occurred whilst mental healthcare expenditure has increased, there is an urgent need to reconsider how best to respond to mental illness, including targeting the most vulnerable based on social determinants such as age, gender, and lower incomes.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Using implementation intentions to prevent relapse after remission from psychological treatment for depression: The SMArT intervention

OBJECTIVE

To provide evidence of the effectiveness of a brief relapse prevention intervention using implementation intentions (Self-Management after Therapy, SMArT), following remission from depression and to identify effective relapse prevention strategies.

METHOD

The SMArT intervention was provided to 107 patients who were recovered after psychological therapy for depression. Relapse events were calculated as reliable and clinically significant increases in PHQ-scores. Sixteen patients receiving the intervention and eight practitioners providing it were interviewed. Framework Analysis identified seven themes which highlighted effective relapse prevention strategies and effective implementation of the SMArT intervention.

RESULTS

Relapse rates at the final SMArT session (four months after the end of acute stage therapy) were 11%. Seven themes were identified that supported effective self-management: (1) Relationship with the practitioner-feeling supported; (2) Support networks; (3) Setting goals, implementing plans and routine; (4) Changing views of recovery; (5) The SMArT sessions-mode, content, timing, duration; (6) Suitability for the person; and (7) Suitability for the service.

CONCLUSION

The study provides some support for the effectiveness of the SMArT intervention, although a randomized controlled trial is required; and identifies important relapse prevention strategies.