Interpretation training to target repetitive negative thinking in generalized anxiety disorder and depression

An intervention study on college students' employment anxiety based on interpretation bias modification: A randomized controlled experiment

External environmental factors and internal cognitive bias affect college students' anxiety while job hunting. The current study is an intervention study on alleviating employment anxiety among college students through an Interpretation Bias Modification (IBM) computer-based intervention. A total of 79 valid participants were recruited. The Interpretation Bias Modification (IBM) group participants were required to complete employment-related IBM Internet training twice a week for three weeks. The placebo control group participants were required to complete neutral Internet training at the same frequency. The waiting list control group did not undergo any training. The groups were tested at three time points: prior to the intervention (pre-test), immediately after (post-test), and one month after the intervention (one-month follow-up). The IBM intervention group [F(2, 72) = 31.68, p < 0.001] showed greater significance in reducing employment anxiety than participants in the placebo control group [F(2, 72) = 9.83, p < 0.001] from the pre-test to one-month follow-up. There was no significant difference in employment anxiety among the waiting-list control group over time. The IBM intervention for college students can effectively decrease employment anxiety and reduce interpretation bias, which can be maintained at the one-month follow-up.

Induced worry increases risk aversion in patients with generalized anxiety

Generalized anxiety disorder is characterized by disruptions in decision-making, including an enhanced aversion to uncertain outcomes (i.e., risk aversion), which is not specific to negative outcomes (i.e., no loss aversion). It is unknown if this uncertainty bias is a trait-like causal factor contributing to anxiety symptoms, or a state-like feature triggered by anxiety symptoms such as worry chains. Here, in-patients with Major Depression Disorder (MDD), with (N = 16) or without (N = 24) Generalized anxiety (GA) symptoms, and healthy controls (N = 23), completed an economic decision-making task before and after worry induction. They were asked to choose between a certain monetary payoff, and an uncertain gamble, allowing for estimation of risk and loss aversion through a computational prospect-theoretic model. There were no significant differences in risk and loss aversion between any of the three groups at baseline. After worry induction, patients with GA symptoms, compared to those without, showed increased risk aversion. This increase was modulated by the severity of anxiety symptoms. These findings suggest that decision-making disruptions in anxiety disorder may be driven by anxiety symptoms such as worry, rather than causing them. This could shape etiological models, motivate standardization of emotional state in research on decision-making in anxiety disorders, support treatment strategies primarily aimed at worry management, and could guide novel interventions focusing on uncertainty exposure across aversive and appetitive domains.

Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward

Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.

The effect of training to target cognitive biases towards social rejection in eating disorders

OBJECTIVE

This study examined the effect of cognitive bias modification for interpretation (CBM-I) training in Korean women with eating disorders (EDs).

METHOD

Sixty-three women with EDs participated in the study. Participants were randomly assigned to the intervention group where they received six sessions of CBM-I training (n = 31) in addition to treatment-as-usual or were put on a waiting list (n = 32). Participants' interpretation and attention biases, emotion regulation, affect, and ED psychopathology were assessed at baseline, end-of-intervention (4 weeks), and follow-up (8 weeks).

RESULTS

Participants who completed the CBM-I training displayed greater reductions in negative interpretation bias (Δη2 = 0.107) and emotion dysregulation (Δη2 = 0.085) with medium to large effect sizes compared to the control group, which were maintained from baseline to follow-up. Disengagement from negative faces and a focus on positive faces was found in the intervention group with a moderate effect size at the end-of-intervention (Δη2 = 0.090). Both intervention and control groups showed improvements in ED psychopathology. Baseline neuroticism was positively correlated with CBM-I effect.

DISCUSSION

The results suggest that modifying interpretation bias towards ambiguous social stimuli might be an effective adjuvant treatment to reduce negative expectations of social situations and improve emotion regulation in women with bulimia nervosa and anorexia nervosa.

Basic processes and clinical applications of mental imagery in worry: A systematic review

BACKGROUND

In this systematic review, we aimed to synthesise existing research on the phenomenology of mental imagery among high worriers compared to healthy individuals, and to characterise the nature and effectiveness of existing imagery-related interventions in treatment of worry.

METHODS

PsycInfo, CENTRAL, EMBASE, Medline, Medline Epub, and PubMed were searched for studies examining the relationship between worry/GAD and mental imagery, or interventions using imagery in treatment of worry/GAD. We assessed study quality and used qualitative narrative synthesis to comprehensively map study results.

RESULTS

The search yielded 2589 abstracts that were assessed for eligibility independently by two authors. From this, 183 full texts were screened and 50 qualitatively synthesised. Twenty-seven reported an association between worry/GAD and an aspect of mental imagery. Here, overactive negative and worry imagery, and diminished positive future imagining, were associated with worry/GAD. Twenty-three studies reported an intervention. This literature suggested mixed findings regarding efficacy, including for imaginal exposure as an independent technique for GAD.

CONCLUSIONS

Findings support dysfunctional negative imagining and diminished positive prospective imagery in GAD. General imagining abilities remain intact, which is promising for efforts to utilise imagery in treatment. Further research is warranted to develop innovative clinical applications of imagery in treatment of GAD.

Treatment condition as a moderator and change in trait mindfulness as a mediator of a brief mindfulness ecological momentary intervention for generalized anxiety disorder

BACKGROUND

Theories propose that judgment of and reactivity to inner experiences are mediators of the effect of mindfulness-based interventions on generalized anxiety disorder (GAD). However, no study has tested such theories using brief, mindfulness ecological momentary intervention (MEMI). We thus tested these theories using a 14-day MEMI versus self-monitoring app (SM) control for GAD.

METHODS

Participants (N = 110) completed self-reports of trait mindfulness (Five Facet Mindfulness Questionnaire), GAD severity (GAD-Questionnaire-IV), and trait perseverative cognitions (Perseverative Cognitions Questionnaire) at prerandomization, posttreatment, and 1-month follow-up (1MFU). Counterfactual mediation analyses with temporal precedence were conducted.

RESULTS

Improvement in pre-post mindfulness domains (acceptance of emotions, describing feelings accurately, acting with awareness, judgment of inner experience, and reactivity to inner experience) predicted pre-1MFU reduction in GAD severity and pre-1MFU reduction in trait perseverative cognitions from MEMI but not SM. MEMI reduced pre-post reactivity to inner experiences (but not other mindfulness domains) significantly more than SM. Only reduced pre-post reactivity significantly mediated stronger efficacy of MEMI over SM on pre-1MFU reductions in GAD severity (indirect effect: β = -2.970 [-5.034, -0.904], p = .008; b path: β = -3.313 [-6.350, -0.276], p = .033; percentage mediated: 30.5%) and trait perseverative cognitions (indirect effect: β = -0.153 [-0.254, -0.044], p = .008; b path: β = -0.145 [-0.260, -0.030], p = .014; percentage mediated: 42.7%). Other trait mindfulness domains were non-significant mediators.

CONCLUSIONS

Reactivity to inner experience might be a mindfulness-based intervention change mechanism and should be targeted to optimize brief MEMIs for GAD.

Rumination as a Transdiagnostic Phenomenon in the 21st Century: The Flow Model of Rumination

Rumination and its related mental phenomena share associated impairments in cognition, such as executive functions and attentional processes across different clinical conditions (e.g., in psychotic disorders). In recent decades, however, the notion of rumination has been increasingly narrowed to the "self-focused" type in depressive disorders. A closer review of the literature shows that rumination may be construed as a broader process characterized by repetitive thoughts about certain mental contents that interfere with one's daily activities, not only limited to those related to "self". A further examination of the construct of rumination beyond the narrowly focused depressive rumination would help expand intervention opportunities for mental disorders in today's context. We first review the development of the clinical construct of rumination with regard to its historical roots and its roles in psychopathology. This builds the foundation for the introduction of the "Flow Model of Rumination (FMR)", which conceptualizes rumination as a disruption of a smooth flow of mental contents in conscious experience that depends on the coordinated interactions between intention, memory, affect, and external events. The conceptual review concludes with a discussion of the impact of rapid technological advances (such as smartphones) on rumination. Particularly in contemporary societies today, a broader consideration of rumination not only from a cognition viewpoint, but also incorporating a human-device interaction perspective, is necessitated. The implications of the FMR in contemporary mental health practice are discussed.

Study protocol for a randomized controlled trial investigating the effect of online interpretation bias intervention on stress reactivity in the children of parents with depression: the CoCo study

BACKGROUND

Current preventive interventions for the children of parents with depression demonstrate modest effects on depression incidence. This may be because existing interventions tend to comprise general psychotherapeutic tools, rather than targeting the specific mechanisms underlying familial transmission. Improved theoretical models of familial transmission could enhance the development of targeted interventions. Although existing models assume that cognitive and biological vulnerability factors influence one another, the precise mechanisms are unknown. This project is the first to experimentally test whether negative interpretation bias has an impact on cortisol response in children of parents with depression. This study protocol reports a randomised controlled trial of an interpretation bias intervention which aims to shift participants' interpretation bias in a more positive direction and thereby alter their stress response.

METHODS

Children aged 10-14 years who have i) one parent with a current or previous depression diagnosis, with at least one episode occurring during the child's lifetime and ii) do not have a current or previous psychiatric diagnosis themselves, will be assigned to one of two conditions: an interpretation bias intervention (n = 50) or a structurally similar placebo intervention (n = 50). The interpretation bias intervention consists of a short lab-based cognitive reappraisal of interpretations training, a four-week app-based Cognitive Bias Modification of Interpretations intervention and interpretation bias specific if-then plans. Interpretation bias will be assessed before and after the intervention using the Scrambled Sentences Task. The effect of the intervention on participants' stress response will be assessed by salivary cortisol collected at five different time points: from immediately before until 45 min after administering the Trier Social Stressor Test for Children. Stress reactivity will be measured via baseline to peak cortisol and stress recovery will be measured via the 45 min cortisol marker. We hypothesise that children who participate in the interpretation bias intervention will display a positive shift in interpretation bias and this, in turn, will alter their stress response. Children who receive the placebo intervention are expected to show a smaller positive shift in interpretation bias and stress reactivity.

DISCUSSION

The findings of the present study will contribute to models of familial depression transmission as well as informing preventive interventions. If training a more positive interpretation bias subsequently alters participants' stress response, then incorporating such tools may increase the efficacy of existing preventive interventions.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien DRKS00028842. Registered August 19, 2022.

Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study

BACKGROUND

Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring.

OBJECTIVE

In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm.

METHODS

We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged.

RESULTS

We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users.

CONCLUSIONS

These games may help improve the effectiveness and engagement levels of computerized interventions for depression.

Mediators of outcome in adolescent psychotherapy and their implications for theories and mechanisms of change: a systematic review

Psychotherapeutic treatment of adolescents requires age-specific approaches and thus plausibly also involves different change mechanisms than adult psychotherapy. To guide further research and improve therapeutic outcomes for adolescents, we reviewed all RCTs investigating mechanisms of change in the psychological treatment of adolescents to identify the most promising age-, disorder- or treatment-specific mediators. Following the preferred reporting items for systematic reviews (PRISMA), 106 studies were included that reported 252 statistical mediation tests assessed with 181 different measures. Most often studied and significant mediators were cognitive, followed by family-related, and behavioral variables. Several mediators were identified to be promising for future investigations: changes in negative thoughts, dysfunctional beliefs and metacognitive skills; family functioning and parenting skills; as well as successful engagement in therapy activities and increased impulse control. Symptom change during therapy was least often a mediator for other therapeutic changes. Relational and emotional mediators were largely understudied, whereas peer-influence appeared a promising mediator for intervention outcomes. Adolescence-specific mediators were most commonly investigated. Majority of studied mediators were not disorder-specific. There was a tendency to mainly test change mechanisms of specific theoretical models without considering other possible change theories. Further, virtually no studies fulfilled all criteria for rigorously investigating mediation and only nine were classified with an overall good study quality. While bearing in mind the current limitations in study designs, methodological rigor and reporting, there appears to be substantial evidence for transdiagnostic age-specific change models in the psychological treatment of adolescents. For future research, need for consensus on a core set of transdiagnostic and transtheoretical mediators and measures is highlighted. These should address likely core mechanisms of change, as well as take into account age-relevant developmental challenges and biological markers.

Cognitive mechanisms and resilience in UK-based general practitioners: cross-sectional findings

BACKGROUND

Being a general practitioner (GP) is a stressful occupation, and the strain GPs are under can have negative effects on their psychological well-being, as well as on the patients' experience of healthcare. Resilience can help buffer against this and is a dynamic process by which one can cope with adversity and stress.

AIMS

This study aimed to identify modifiable cognitive mechanisms related to resilience in GPs, specifically interpretation bias and cognitive reappraisal.

METHODS

One hundred and fourteen GPs completed an online cross-sectional correlational study. This comprised questionnaires assessing resilience, emotional distress, work environment and cognitive mechanisms (emotion regulation), as well as a task assessing interpretation bias.

RESULTS

Resilience of GPs was negatively correlated with measures of emotional distress. Furthermore, resilience was positively correlated with positive interpretation bias (r = 0.60, ρ = 0.60, P < 0.01) and cognitive reappraisal (r = 0.39, ρ = 0.40, P < 0.01). In a hierarchical regression, positive interpretation bias (B = 0.25, SE B = 0.06, β = 0.39, P < 0.01) was a significant independent predictor of resilience when controlling for depression, anxiety and stress.

CONCLUSIONS

This is the first study to establish an association between resilience and positive interpretation bias and cognitive reappraisal in GPs. Future research should use longitudinal designs to determine if they have a causal role in promoting resilience, and importantly whether interventions focusing on these processes may foster resilience in less resilient GPs.

Effects of Training Body-Related Interpretations on Panic-Related Cognitions and Symptoms

Background

Interpretation biases (IBs) are central in panic disorder, and there is rich evidence showing that these are correlated with and predictive of panic-relevant symptomatology. However, experimental studies are needed to examine the potential causal effects of IBs, as predicted by cognitive models.

Methods

Panic-related IBs were manipulated via a sentence-completion Cognitive Bias Modification-Interpretation (CBM-I) training. The sample included N = 112 healthy participants reporting moderate levels of fear of bodily sensations. Participants were randomly allocated to a positive, negative, or control CBM-I condition. To test the trainings' effect on panic-relevant cognitive processing, IBs were assessed via proximal and distal measures. Symptom provocation tasks were applied to test transfer to panic-relevant symptomatology.

Results

Results on the proximal measure showed that positive CBM-I led to more positive IBs compared to negative, and control training. Further, positive CBM-I led to more positive IBs on the distal measure as compared to negative CBM-I. However, there were no differential training effects on panic-related symptomatology triggered via the provocation tasks.

Conclusion

The findings indicate a limited generalization of the effects of CBM-I on IBs and panic-related symptoms. Potential means to improve generalization, such as applying more nuanced measures and combining CBM-I with psychoeducation are discussed.

Support from friends moderates the relationship between repetitive negative thinking and postnatal wellbeing during COVID-19

BACKGROUND

Increasing evidence has linked repetitive negative thinking (RNT) to postnatal depression and anxiety, yet the factors moderating this relationship have been minimally investigated. During the COVID-19 pandemic of 2020, social restrictions imposed to reduce viral transmission limited access to social support, which is critical to postnatal psychological wellbeing - potentially intensifying RNT.

OBJECTIVE

We examined whether perceived social support (from friends, family, and a significant other) played a moderating role in the relationship between RNT and maternal postnatal anxiety and depressive symptoms.

METHODS

A sample of women (N = 251) who had given birth in the preceding 12 months completed an online battery of standardised measures during the COVID-19 'lockdown' of May 2020.

RESULTS

As predicted, social support moderated the relationship between RNT and depression such that the association between RNT and depression was stronger for women who reported lower levels of social support. Interestingly, this finding emerged for social support from friends only; for support from family and significant other, social support did not play a moderating role. Further, and unexpectedly, overall social support did not moderate the relationship between RNT and postnatal anxiety, however, social support from friends was a significant moderator.

CONCLUSIONS

High levels of perceived social support from friends (but not family or significant others) buffered the effects of RNT on depression and anxiety during the postpartum period. Strategies to bolster peer social support may be a valuable inclusion in interventions to prevent and treat postnatal depression and anxiety.

Development and psychometric evaluation of a scrambled sentences test specifically for worry in individuals with generalised anxiety disorder

The tendency to draw negative conclusions from ambiguous information (interpretation bias) is prevalent across emotional disorders and plays a key role in the development and maintenance of pathological worry and anxious mood. Assessing interpretation bias using valid and reliable measures is central to empirical research. A commonly used measure of interpretation bias is the scrambled sentences test (SST), originally relating to depression. Given the association between interpretation bias and worry, we aimed to develop and psychometrically evaluate a new version of the SST with items pertaining to common worry domains for use in worry and anxiety research. In Studies 1-3 (analogue samples, combined N = 288), the new worry SST showed excellent construct validity (moderate-to-strong associations with worry and anxiety-related measures), and reliability (split-half and test-retest reliability). We confirmed construct validity in Study 4 (N = 215 individuals with generalised anxiety disorder). Furthermore, we demonstrated version specificity in analogue and clinical samples: the worry SST was associated with trait worry but not trait rumination, while the original depression SST largely showed the opposite pattern. Overall, the new worry SST is a psychometrically robust measure that may be especially useful for research into cognitive processes underpinning worry and anxiety.

A Single-Session Online Cognitive Bias Modification of Interpretations Modified for Adults With Anxiety and Depressive Symptoms

Anxiety and depression are common, co-occurring, and costly mental health disorders. Cognitive bias modification aims to modify biases to reduce associated symptoms. Few studies have targeted multiple biases associated with both anxiety and depression, and those that have lacked a control condition. This study piloted a single-session online cognitive bias modification (known as CBM-IA) designed to target two biases associated with anxiety and depression-interpretation bias and attribution style-in adults with varying levels of anxiety and depressive symptoms. Participants (18-26 years) with at least mild levels of anxiety/stress and depressive symptoms on the DASS-21 were randomly allocated to an intervention (n = 23) or a control (n = 22) condition. The training consisted of a single-session online CBM-IA to encourage positive interpretations and a positive attribution style. Interpretation bias, attribution style, anxious and depressive mood states, and anxiety, stress and depressive symptoms improved at posttraining and at follow-up, irrespective of condition. Changes in interpretation bias from pre- to posttraining were significantly associated with changes in anxious mood state. CBM-IA, as implemented in this single-session pilot study, did not significantly reduce targeted biases and symptoms compared to a control condition. This adds to the mixed evidence on the efficacy of single-session CBM-I for altering biases and symptoms.

Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms

This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I² = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I² = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.

Operationalizing Engagement With an Interpretation Bias Smartphone App Intervention: Case Series

BACKGROUND

Engagement with mental health smartphone apps is an understudied but critical construct to understand in the pursuit of improved efficacy.

OBJECTIVE

This study aimed to examine engagement as a multidimensional construct for a novel app called HabitWorks. HabitWorks delivers a personalized interpretation bias intervention and includes various strategies to enhance engagement such as human support, personalization, and self-monitoring.

METHODS

We examined app use in a pilot study (n=31) and identified 5 patterns of behavioral engagement: consistently low, drop-off, adherent, high diary, and superuser.

RESULTS

We present a series of cases (5/31, 16%) from this trial to illustrate the patterns of behavioral engagement and cognitive and affective engagement for each case. With rich participant-level data, we emphasize the diverse engagement patterns and the necessity of studying engagement as a heterogeneous and multifaceted construct.

CONCLUSIONS

Our thorough idiographic exploration of engagement with HabitWorks provides an example of how to operationalize engagement for other mental health apps.

A systematic review of the literature on interpretation bias and its physiological correlates

An important, yet under-explored area of interpretation bias research concerns the examination of potential physiological correlates and sequalae of this bias. Developing a better understanding of the physiological processes that underpin interpretation biases will extend current theoretical frameworks underlying interpretation bias, as well as optimising the efficacy of cognitive bias modification for interpretation (CBM-I) interventions aimed at improving symptoms of emotional disorders. To this end, systematic searches were conducted across the Web of Science, PsycInfo and Pubmed databases to identify physiological markers of interpretation bias. In addition, grey literature database searches were conducted to compliment peer-reviewed research and to counter publication bias. From a combined initial total of 898 records, 15 studies were included in qualitative synthesis (1 of which obtained from the grey literature). Eligible studies were assessed using a quality assessment tool adapted from the Quality Checklist for Healthcare Intervention Studies. The searches revealed seven psychophysiological markers of interpretation bias, namely event-related potentials, heart rate and heart rate variability, respiratory sinus arrythmia, skin conductance response, pupillometry, and electromyography. The respective theoretical and practical implications of the research are discussed, followed by recommendations for future research.

Hierarchical Structure of Depression Knowledge Network and Co-word Analysis of Focus Areas

Contemporarily, depression has become a common psychiatric disorder that influences people's life quality and mental state. This study presents a systematic review analysis of depression based on a hierarchical structure approach. This research provides a rich theoretical foundation for understanding the hot spots, evolutionary trends, and future related research directions and offers further guidance for practice. This investigation contributes to knowledge by combining robust methodological software for analysis, including Citespace, Ucinet, and Pajek. This paper employed the bibliometric methodology to analyze 5,000 research articles concerning depression. This current research also employed the BibExcel software to bibliometrically measure the keywords of the selected articles and further conducted a co-word matrix analysis. Additionally, Pajek software was used to conduct a co-word network analysis to obtain a co-word network diagram of depression. Further, Ucinet software was utilized to calculate K-core values, degree centrality, and mediated centrality to better present the research hotspots, sort out the current status and reveal the research characteristics in the field of depression with valuable information and support for subsequent research. This research indicates that major depressive disorder, anxiety, and mental health had a high occurrence among adolescents and the aged. This present study provides policy recommendations for the government, non-governmental organizations and other philanthropic agencies to help furnish resources for treating and controlling depression orders.

Scrambled but valid? The scrambled sentences task as a measure of interpretation biases in psychopathology: A systematic review and meta-analysis

The Scrambled Sentences Task (SST) is frequently used to assess interpretation biases (IBs). However, neither the range of its applications nor the quality of the empirical evidence it provides has been systematically examined. This systematic review investigates the types of samples and disorders in which the SST has been applied and evaluates its psychometric properties via a meta-analysis. The databases PubMed and EBSCOhost (including PsycINFO, PsycARTICLES, PSYNDEX, MEDLINE) were examined (last search: September 2021) and 93 studies from 91 manuscripts were included. Results showed that the SST has been applied predominantly in unselected samples or those with elevated levels of subsyndromal symptoms, with about a third of the studies employing the SST in a clinical population. While the SST was initially developed to assess depression-related IBs, it has now been extended to other disorders, in particular anxiety disorders. Results of the meta-analyses indicated good convergent validity and reliability across disorders, albeit in the context of substantial heterogeneity. Findings concerning divergent validity were mixed with high correlations across disorders between the SST and trait anxiety in particular, questioning its specificity. Future research should consider developing standardized SST versions and investigating its relationships with other measures of IB.

Development of a cognitive bias modification intervention for anxiety disorders in primary care

OBJECTIVES

There is a great need for low-intensity, scalable treatments in primary care, where most anxious patients first present for treatment. We describe Stage IA treatment development and a Stage IB feasibility trial of cognitive bias modification (CBM) for transdiagnostic anxiety in primary care.

METHODS

The online intervention, Mental Habits, comprised eight sessions of a personalized CBM targeting attention and interpretation biases. Coaches assisted patients in using the website, monitored progress via a dashboard, and shared information with primary care providers. We evaluated Mental Habits in an open trial (N = 14) and a randomized controlled trial (RCT) (N = 40) in primary care patients with anxiety disorders.

RESULTS

We compared results to a priori benchmarks of clinically meaningful outcomes. In the open trial, Mental Habits met feasibility, acceptability, and efficacy benchmarks. In the pilot RCT, there was greater dropout at one study site which ultimately closed. In the intent-to-treat analyses, Mental Habits met the benchmark for self-report, but not the interview measure of anxiety. Symptom Tracking did not meet the benchmark for self-report or interview measures of anxiety. In per-protocol analyses, Mental Habits exceeded the benchmark for both self-report and interview measures, whereas Symptom Tracking met the benchmark for self-report. Interpretation bias improved in the Mental Habits group, but not in Symptom Tracking. No effects were observed for attention bias.

CONCLUSION

The online CBM intervention demonstrated good acceptability and, when delivered at a stable primary care clinic, preliminary effectiveness in primary care. A larger RCT is warranted to test effectiveness.

PRACTITIONER POINTS

A personalized, transdiagnostic Cognitive Bias Modification (CBM) intervention for anxiety in primary care is acceptable to primary care patients with social anxiety disorder, generalized anxiety disorder, and/or panic disorder /agoraphobia. With training and supervision from licensed mental health clinicians, bachelor's-level coaches can assist primary care patients to self-administer CBM. Offering a low-intensity, self-directed anxiety intervention in primary care can greatly expand the reach of anxiety treatment, with minimal need for additional resources. Interpretation bias may be an important clinical target for primary care patients with anxiety.

Editorial: Exemplifying a Cognitive Science-Driven Approach to Intervention Innovation: Targeting Face Emotion Labeling to Reduce Anger-Proneness in Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a condition in which children or adolescents experience chronically irritable or angry mood. These feelings typically manifest through frequent and intense temper outbursts that can be verbal (eg, yelling) or physical (eg, hitting). These symptoms carry a personal cost, affecting family life, peer relationships, and school functioning. Yet, evidence-based treatment options can be difficult to access. A recent therapeutic solution-Cognitive Bias Modification (CBM)-lies in targeting neurocognitive mechanisms known to maintain and contribute to irritability. In this issue, Haller and colleagues use a fast-fail approach (based on a pre-registered study protocol) to evaluate the potential of a new CBM intervention for young people with DMDD. Here, we discuss what work is needed before the potential of this intervention can be translated for clinical use..

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.

Digital Interventions for Generalized Anxiety Disorder (GAD): Systematic Review and Network Meta-Analysis

Background: Generalized anxiety disorder is the most common mental health condition based on weekly prevalence. Digital interventions have been used as alternatives or as supplements to conventional therapies to improve access, patient choice, and clinical outcomes. Little is known about their comparative effectiveness for generalized anxiety disorder. Methods: We conducted a systematic review and network meta-analysis of randomized controlled trials comparing digital interventions with medication, non-digital interventions, non-therapeutic controls, and no intervention. Results: We included 21 randomized controlled trials with a total of 2,350 participants from generalized anxiety disorder populations. Pooled outcomes using analysis of Covariance and rankograms based on the surface under the cumulative ranking curves indicated that antidepressant medication and group therapy had a higher probability than digital interventions of being the "best" intervention. Supported digital interventions were not necessarily "better" than unsupported (pure self-help) ones. Conclusions: Due to very wide confidence intervals, network meta-analysis results were inconclusive as to whether digital interventions are better than no intervention and non-therapeutic active controls, or whether they confer an additional benefit to standard therapy. Future research needs to compare digital interventions with one-to-one therapy and with manualized non-digital self-help and to include antidepressant medication as a treatment comparator and effect modifier.

Modifying insecure attachment style with cognitive bias modification

BACKGROUND AND OBJECTIVES

Attachment theory suggests that internal working models developed from early experiences with attachment figures biases cognitive appraisals a person makes of themselves and others. The current paper investigates whether attachment-related interpretative biases can be altered using Cognitive Bias Modification (CBM-I).

METHODS

Eighty anxiously attached participants were randomly assigned to receive either secure or insecure CBM-I training. To measure training effects on attachment-related interpretation bias, participants read scenarios involving attachment figures whereby the availability of the attachment figure was undetermined, followed by test sentences that assigned an attachment-secure or -insecure interpretation to the situations. Participants rated the similarity of these sentences to the previously read ambiguous situations.

RESULTS

Participants who received secure CBM-I training ascribed higher similarity ratings to secure sentence interpretations of ambiguous scenarios compared to insecure sentence interpretations. Attachment anxiety increased after CBM-I training for those who received insecure training, but did not differ for those who received secure training.

LIMITATIONS

This study was limited to healthy participants and did not include clinical participants. These findings need to be replicated by assessing the effects of CBM-I over an extended period.

CONCLUSIONS

CBM-I training may provide a viable means of modulating attachment anxiety. If validated with more potent strategies for secure attachment training, this approach could have significant implications for the treatment of affective disorders characterized by insecure attachments.

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

An experimental study to identify key psychological mechanisms that promote and predict resilience in the aftermath of treatment for breast cancer

OBJECTIVE

Women living with and beyond breast cancer (BC) frequently encounter cancer-related information in day-to-day life. The extent they are emotionally resilient to this information differs between women. Identifying key modifiable psychological mechanisms predicting resilience in these women could highlight targets for interventions to improve resilience in others. This study investigates resilience over time in women living beyond BC and how this relates to individual differences in the way the brain processes information.

METHODS

Seventy women within a year of finishing first-line treatment for BC (clinical and community recruitment) completed computerised tasks to assess the tendency to attend to cancer information (dot-probe task), the tendency to draw negative cancer-related interpretations from ambiguous information (ambiguous scenarios task) and extent of executive functioning (attentional network task). Questionnaires were completed assessing resilience, and other clinically relevant psychological variables (fear of cancer recurrence, distress, quality of life, and worry) at the time of the laboratory tasks (T1) and again 6 months later (T2).

RESULTS

The only cognitive process associated with self-reported resilience was interpretation bias. Generating more negative cancer-related interpretations of ambiguous information at T1 significantly predicted resilience at T2, whilst controlling for T1 resilience and other clinically relevant variables. Furthermore, resilience scores were relatively stable over time and moderately correlated with other clinically relevant variables.

CONCLUSIONS

This study is the first to identify a key cognitive mechanism that predicts resilience in women living beyond BC. This finding suggests interventions to reduce cancer-related interpretations of ambiguous information could promote resilience in women living beyond BC.

Attentional Processing and Interpretative Bias in Functional Neurological Disorder

OBJECTIVE

Altered attentional processing (automatically attending to negative or illness-relevant information) and interpretative biases (interpreting ambiguous information as negative or illness relevant) may be mechanistically involved in functional neurological disorder (FND). Common mechanisms between FND and chronic fatigue syndrome (CFS) have been proposed but not compared experimentally.

METHODS

We compared the cognitive task performance of FND, CFS, and healthy control (HC) groups. The tasks assessed attentional bias toward illness-relevant stimuli (visual probe task), attentional control (attention network task), and somatic interpretations (interpretative bias task), alongside self-reported depression, anxiety, fatigue, and general health.

RESULTS

Thirty-seven participants diagnosed with FND, 52 participants diagnosed with CFS, and 51 HC participants were included. Although participants with CFS showed attentional bias for illness-relevant stimuli relative to HC (t = -3.13, p = .002, d = 0.624), individuals with FND did not (t = -1.59, p = .118, d = 0.379). Both the FND (t = 3.08, p = .003, d = 0.759) and CFS (t = 2.74, p = .007, d = 0.548) groups displayed worse attentional control than did the HC group. Similarly, the FND (t = 3.63, p < .001, d = 0.801) and CFS groups (t = 4.58, p < .001, d = 0.909) showed more somatic interpretative bias than did the HC group.

CONCLUSIONS

Similar attentional control deficits and somatic interpretative bias in individuals with FND and CFS support potential shared mechanisms underlying symptoms. Interpretative bias toward somatic and illness-relevant stimuli in functional disorders may prove a therapeutic target.

Looking on the Bright Side Reduces Worry in Pregnancy: Training Interpretations in Pregnant Women

Background

Recent evidence suggests that anxiety is more common than depression in the perinatal period, however there are few interventions available to treat perinatal anxiety. Targeting specific processes that maintain anxiety, such as worry, may be one potentially promising way to reduce anxiety in this period. Given evidence that negative interpretation bias maintains worry, we tested whether interpretation bias could be modified, and whether this in turn would lead to less negative thought (i.e., worry) intrusions, in pregnant women with high levels of worry.

Method

Participants (N = 49, at least 16 weeks gestation) were randomly assigned to either an interpretation modification condition (CBM-I) which involved training in accessing positive meanings of emotionally ambiguous scenarios, or an active control condition in which the scenarios remained ambiguous and unresolved.

Results

Relative to the control condition, participants in the CBM-I condition generated significantly more positive interpretations and experienced significantly less negative thought intrusions.

Conclusions

Our findings indicate that worry is a modifiable risk factor during pregnancy, and that it is possible to induce a positive interpretation bias in pregnant women experiencing high levels of worry. Although preliminary, our findings speak to exciting clinical possibilities for the treatment of worry and the prevention of perinatal anxiety.

Multi-session online interpretation bias training for anxiety in a community sample

The present study assessed target engagement, preliminary efficacy, and feasibility as primary outcomes of a free multi-session online cognitive bias modification of interpretation (CBM-I) intervention for anxiety in a large community sample. High trait anxious participants (N = 807) were randomly assigned to a CBM-I condition: 1) Positive training (90% positive-10% negative); 2) 50% positive-50% negative training; or 3) no-training control. Further, half of each CBM-I condition was randomized to either an anxious imagery prime or a neutral imagery prime. Due to attrition, results from six out of eight sessions were analyzed using structural equation modeling of latent growth curves. Results for the intent-to-treat sample indicate that for target engagement, consistent with predictions, decreases in negative interpretations over time were significantly greater among those receiving positive CBM-I training compared to no-training or 50-50 training, and vice-versa for increases in positive interpretations. For intervention efficacy, the decrease in anxiety symptoms over time was significantly greater among those receiving positive CBM-I training compared to no-training. Interaction effects with imagery prime were more variable with a general pattern of stronger results for those completing the anxious imagery prime. Findings indicate that online CBM-I positive training is feasible and shows some promising results, although attrition rates were very high for later training sessions.

More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research

While the evidence on the effectiveness of different psychotherapies is often strong, it is not settled whereby and how these therapies work. Knowledge on the causal factors and change mechanisms is of high clinical and public relevance, as it contributes to the empirically informed advancement of psychotherapeutic interventions. Here, digitalized research approaches might possess the potential to generate new insights into human behavior change, contributing to augmented interventions and mental healthcare practices with better treatment outcomes. In this perspective article, we describe recent findings of research into change mechanisms that were only feasible with digital tools and outline important future directions for this rather novel branch of research. Furthermore, we indicate several challenges and pitfalls that are to be solved, in order to advance digitalized psychotherapy process research, both methodologically and technologically.

Evidence on Technology-Based Psychological Interventions in Diagnosed Depression: Systematic Review

BACKGROUND

Evidence on technology-based psychological interventions (TBIs) for the treatment of depression is rapidly growing and covers a broad scope of research. Despite extensive research in this field, guideline recommendations are still limited to the general effectiveness of TBIs.

OBJECTIVE

This study aims to structure evidence on TBIs by considering different application areas (eg, TBIs for acute treatment and their implementation in health care, such as stand-alone interventions) and treatment characteristics (eg, therapeutic rationale of TBIs) to provide a comprehensive evidence base and to identify research gaps in TBIs for diagnosed depression. Moreover, the reporting of negative events in the included studies is investigated in this review to enable subsequent safety assessment of the TBIs.

METHODS

Randomized controlled trials on adults diagnosed with unipolar depression receiving any kind of psychotherapeutic treatment, which was at least partly delivered by a technical medium, were eligible for inclusion in our preregistered systematic review. We searched for trials in CENTRAL (Cochrane Central Register of Controlled Trials; until August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL; until the end of January 2018), clinical trial registers, and sources of gray literature (until the end of January 2019). Study selection and data extraction were conducted by 2 review authors independently.

RESULTS

Database searches resulted in 15,546 records, of which 241 publications were included, representing 83 completed studies and 60 studies awaiting classification (ie, preregistered studies, study protocols). Almost all completed studies (78/83, 94%) addressed the acute treatment phase, being largely either implemented as stand-alone interventions (66/83, 80%) or blended treatment approaches (12/83, 14%). Studies on TBIs for aftercare (4/83, 5%) and for bridging waiting periods (1/83, 1%) were scarce. Most TBI study arms (n=107) were guided (59/107, 55.1%), delivered via the internet (80/107, 74.8%), and based on cognitive behavioral treatment approaches (88/107, 79.4%). Almost all studies (77/83, 93%) reported information on negative events, considering dropouts from treatment as a negative event. However, reports on negative events were heterogeneous and largely unsystematic.

CONCLUSIONS

Research has given little attention to studies evaluating TBIs for aftercare and for bridging waiting periods in people with depression, even though TBIs are seen as highly promising in these application areas; thus, high quality studies are urgently needed. In addition, the variety of therapeutic rationales on TBIs has barely been represented by identified studies hindering the consideration of patient preferences when planning treatment. Finally, future studies should use specific guidelines to systematically assess and report negative events.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-028042.

From cognitive targets to symptom reduction: overview of attention and interpretation bias modification research

Cognitive bias modification (CBM) is a class of mechanised psychological interventions designed to target specific aberrant cognitive processes considered key in the aetiology and/or maintenance of specific psychiatric disorders. In this review, we outline a multistage translational process that allows tracking progress in CBM research. This process involves four steps: (1) the identification of reliable cognitive targets and establishing their association with specific disorders; (2) clinical translations designed to rectify the identified cognitive targets; (3) verification of effective target engagement and (4) testing of clinical utility in randomised controlled trials. Through the prism of this multistage process, we review progress in clinical CBM research in two cognitive domains: attention and interpretation; in six psychiatric conditions: anxiety disorders, major depressive disorder, post-traumatic stress disorder, addictive disorders, eating disorders and obsessive-compulsive disorder. The review highlights achievement as well as shortcomings of the CBM approach en route to becoming a recognised evidence-supported therapy for these disorders.

The effectiveness of Internet-delivered treatment for generalized anxiety disorder: An updated systematic review and meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a highly prevalent, chronic disorder associated with impaired quality of life, societal burden, and poor treatment rates. Internet-delivered interventions may improve the accessibility of treatments and are increasingly being used. This study aimed to update a previous meta-analysis to determine the effectiveness of available Internet-delivered interventions in treating symptoms of GAD.

METHOD

Systematic literature searches were conducted (through April 2020) using Embase, PubMed, PsychINFO, and Cochrane to find randomized controlled trials of Internet-delivered interventions for GAD. Risk of bias was evaluated, and Hedge's g was calculated at posttreatment and follow-up.

RESULTS

Twenty studies met eligibility criteria and were included in the meta-analysis. Random-effect models detected large effect sizes for primary outcomes of anxiety (g = 0.79) and worry (g = 0.75), favoring treatment. Effect sizes for depression, functional impairment, and quality of life were moderate to large. Maintenance of effects at follow-up seems likely.

CONCLUSIONS

Results support the effectiveness of Internet-delivered treatments for GAD. Considerable heterogeneity between studies appeared moderated by variability in the interventions themselves, highlighting the importance of further investigation into the characteristics that may optimize treatment outcomes. Overall, Internet-delivery appears to be a viable mode of treatment for GAD with potential to relieve existing gaps in the provision of treatment.

Perceived social support and prenatal wellbeing; The mediating effects of loneliness and repetitive negative thinking on anxiety and depression during the COVID-19 pandemic

Problem

Prenatal depression and anxiety are linked to poor maternal and infant outcomes. We need to understand predictors of poor mental health to identify at-risk women, and targets for support.

Background

Previous research has demonstrated a relationship between low levels of perceived social support, and depression and anxiety in pregnant women. However, there is a lack of research into the factors that may mediate this relationship.

Aim

As social distancing measures (e.g., lockdown) are likely to negatively affect women’s perceived support in the prenatal period, we investigated the relationship between perceived social support and both anxiety and depression in UK-based pregnant women during the COVID-19 pandemic. Further, we examined two potential mediators that may contribute to psychological symptoms: repetitive negative thinking and loneliness.

Methods

We administered a battery of online measures to a sample of pregnant women (N = 205) between May-June 2020, during the first peak of the pandemic in the UK, when perceived social support was likely to be low.

Results

Consistent with predictions, perceived social support was significantly negatively related to depression, anxiety, loneliness and repetitive negative thinking. Furthermore, repetitive negative thinking and loneliness mediated the relationship between perceived social support and both depression and anxiety. Moreover, perceived social support and loneliness were associated with specific types of online behaviours.

Conclusions

Taken together, the findings shed light on the processes through which social support may exert its effects on depression and anxiety and highlight potential therapeutic targets for interventions which aim to prevent and treat mood disorders in perinatal cohorts.

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Repetitive Negative Thinking and Interpretation Bias in Pregnancy

Background

Repetitive negative thinking (RNT; e.g., worry about the future, rumination about the past) and the tendency to interpret ambiguous information in negative ways (interpretation bias) are cognitive processes that play a maintaining role in anxiety and depression, and recent evidence has demonstrated that interpretation bias maintains RNT. In the context of perinatal mental health, RNT has received minimal research attention (despite the fact that it predicts later anxiety and depression), and interpretation bias remains unstudied (despite evidence that it maintains depression and anxiety which are common in this period).

Method

We investigated the relationship between RNT, interpretation bias and psychopathology (depression, anxiety) in a pregnant sample (n = 133). We also recruited an age-matched sample of non-pregnant women (n = 104), to examine whether interpretation bias associated with RNT emerges for ambiguous stimuli regardless of its current personal relevance (i.e., pregnancy or non-pregnancy-related).

Results

As predicted, for pregnant women, negative interpretation bias, RNT, depression and anxiety were all positively associated. Interpretation bias was evident to the same degree for material that was salient (pregnancy-related) and non-salient (general), and pregnant and non-pregnant women did not differ. RNT was associated with interpretation bias for all stimuli and across the full sample.

Conclusion

Our findings highlight the need to further investigate the impact of interpretation bias in pregnant women, and test the effectiveness of interventions which promote positive interpretations in reducing RNT in the perinatal period.

Catastrophising and repetitive negative thinking tendencies in patients with psychogenic non-epileptic seizures or epilepsy

PURPOSE

Previous research suggests that catastrophisation and perseverative, or repetitive negative thinking (RNT) could play an important role in the aetiology of Psychogenic Nonepileptic Seizures (PNES). This study was designed to explore whether these cognitive tendencies are more prevalent in patients with PNES than those with epilepsy and to examine the relationship between these cognitions, depression, anxiety, seizure frequency and diagnosis.

METHODS

26 patients with PNES (PWPNES) and 29 with epilepsy (PWE) self-reported RNT (Perseverative Thinking Questionnaire), catastrophisation tendencies (modified Safety Behaviors and Catastrophizing Scale), symptoms of anxiety (Generalised Anxiety Disorder Assessment 7) and depression (Primary Health Questionnaire 9) as well as seizure frequency.

RESULTS

RNT and catastrophic thinking were highly correlated with each other and more prevalent in PWPNES than PWE. Positive correlations were also found between all other self-report measures and seizure frequency. The PNES diagnosis predicted RNT (perseverative thinking) independently of catastrophic thinking, anxiety, depression and seizure frequency.

CONCLUSION

PWPNES exhibit greater negative perseverative and catastrophising cognitive tendencies than PWE. PNES as a diagnosis independently predicted RNT. Hence, RNT and catastrophisation should be considered as possible specific targets for psychological interventions in patients with PNES.

Effectiveness and acceptance of technology-based psychological interventions for the acute treatment of unipolar depression: a systematic review and meta-analysis (Preprint)

Background

Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder.

Objective

The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions).

Methods

Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data.

Results

Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD –0.44, 95% CI –0.73 to –0.15, k=10; I²=86%), attention placebo (SMD –0.51, 95% CI –0.73 to –0.30; k=12; I²=66%), and waitlist controls (SMD –1.01, 95% CI –1.23 to –0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD –0.24, 95% CI –0.41 to –0.07; k=6; I²=48%) attention placebo (SMD –0.23, 95% CI –0.40 to –0.07; k=7; I²=21%) and waitlist controls (SMD –0.74, 95% CI –1.31 to –0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD –0.27, 95% CI –0.48 to –0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD –0.20, 95% CI –0.36 to –0.04; k=2; I²=0%) and long-term (SMD –0.23, 95% CI –0.39 to –0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09).

Conclusions

We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028042

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. We explore the psychological, social, and neuroscientific effects of COVID-19 and set out the immediate priorities and longer-term strategies for mental health science research. These priorities were informed by surveys of the public and an expert panel convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health, in the first weeks of the pandemic in the UK in March, 2020. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. The need to maintain high-quality research standards is imperative. International collaboration and a global perspective will be beneficial. An immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with COVID-19. There is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19. Discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. Rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK's world-leading infrastructure. This Position Paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries.

Impact of imagery-enhanced interpretation training on offline and online interpretations in worry

Worry and rumination are forms of repetitive negative thinking (RNT) that are maintained by negative interpretations and a predominance of abstract, verbal thinking. Hence, facilitating more positive interpretations and imagery-based thinking in combination may reduce RNT. Study 1 administered interpretation training with and without enhanced imagery, and an active control condition (designed not to change interpretations), in individuals with high levels of RNT (worry and/or rumination). Combining interpretation training with sustained imagery resulted in the highest levels of positive interpretation bias using an offline test of interpretation bias (when individuals have time to reflect). Study 2 investigated whether imagery-enhanced interpretation training influences online interpretations when ambiguous information is first encountered, indexed by reaction times and amplitude of the N400 event-related potential, as well as enhances offline positive interpretations in high worriers. It also examined whether imagery-enhanced interpretation training reduces negative thought intrusions associated with worry. Both online (reaction time) and offline interpretations were more positive following imagery-enhanced interpretation training, and negative thoughts were reduced, compared to the active control. However, no differences emerged on neurophysiological markers during the online task. Hence, brief interpretation training encompassing sustained imagery modifies online and offline interpretations, but further training may be required to impact upon neurophysiological measures.

Approaching Cognitive Behavior Therapy For Generalized Anxiety Disorder From A Cognitive Process Perspective

Generalized anxiety disorder (GAD), with uncontrollable worry at its core, is a common psychological disorder with considerable individual and societal costs. Cognitive behavior therapy (CBT) is recommended as the first-line treatment for GAD; however, further investigation into its effectiveness in routine clinical care is indicated and improvement is required in treatment outcomes for worry. Improvements to CBT need to be guided by experimental research that identifies key mechanisms maintaining core aspects of the disorder. This paper summarizes how theory-driven experimental research guided selection and refinements of CBT techniques originally developed by Borkovec and Costello, to target key cognitive processes that maintain worry in GAD. Hirsch and Mathews' model specifies three key research-supported processes that maintain uncontrollable worry in GAD: implicit cognitive biases such as negative interpretation bias and attention bias, generalized verbal thinking style, and impaired ability to re-direct attentional control away from worry. Specific CBT techniques outlined in this paper aim to target these key processes. Clinical data from clients treated using our refined CBT protocol for GAD in a routine clinical care service with a special interest in anxiety disorders were collected as part of service procedures. Large pre-to-posttreatment effect sizes were obtained for anxiety (GAD-7), depression (PHQ-9), and worry (PSWQ) (d=.90-2.54), and a moderate effect size was obtained for quality of life (WASA; d=.74). Recovery was indicated for 74% of cases for anxiety, 78% for depression, and 53% for worry. These findings exceeded most previous effectiveness studies in routine care and were in-line with GAD efficacy trials. This paper also outlines the application of specific clinical techniques selected, adapted or developed to target key cognitive mechanisms which maintain worry in GAD.

A Hot-Cold Cognitive Model of Depression: Integrating the Neuropsychological Approach Into the Cognitive Theory Framework

In the 50 years following Beck’s cognitive theory, empirical research has consistently supported the role of dysfunctional, ‘hot’ cognition in the onset and maintenance of major depressive disorder. Compromised ‘cold’ cognition in attention, memory, and executive control abilities, independent of the affective state, has attracted much clinical interest for its role throughout the course of illness and into remission. We propose integrating cold cognition into Beck’s cognitive theory framework to account for the complementary roles of both hot and cold cognition in depression onset and maintenance.

A critical review of cognitive research was conducted to inform an integrated hot-cold cognitive model of depression.

Cold cognitive deficits likely act as a gateway to facilitate the activation and expression of the hot cognitive biases through a weakened ability to attend, retrieve, and critically assess information. Cold deficits become exacerbated by the negative mood state, essentially ‘becoming hot’, lending to maladaptive emotion regulation through ruminative processes. Depleted cognitive resources contribute to the manifestation of further deficit in problem-solving ability in everyday life, which in itself, may act as a stressor for the onset of recurrent episodes, perpetuating the depressive cycle.

We discuss the interaction between hot and cold cognition within the cognitive theory framework and the potential of complementary hot-cold pathways to elucidate novel means of prevention and treatment for depression.

Dysfunction in hot (emotion-dependent) and cold (emotion-independent) cognition has been demonstrated in depression, but psychological treatment has largely focused on hot cognition only.

Hot and cold cognition are complementary processes throughout the activation and maintenance of depressive schemas and biases, necessitating the consideration of both hot and cold cognitive aspects to disrupt the depressive cycle.

The proposed hot-cold cognitive model shows promise to stimulate new research avenues for the prevention and treatment of depression.

Using event-related potential and behavioural evidence to understand interpretation bias in relation to worry

The tendency to interpret ambiguous information in a consistent (e.g., negative) manner (interpretation bias) may maintain worry. This study explored whether high and low worriers generate different interpretations and examined at which stages of information processing these interpretations can occur. Participants completed interpretation assessment tasks yielding behavioural and N400 event-related potential indices, which index whether a given interpretation was generated. High worriers lacked the benign interpretation bias found in low worriers. This was evident for early "online" interpretations (reflected in reaction times to relatedness judgments and lexical decisions, as well as at a neurophysiological level, N400, for lexical decisions only), to later "offline" interpretations (observed at a behavioural level on the scenario task and recognition task) when participants had time for reflection. Results suggest that a benign interpretation bias may be a protective factor for low worriers, and that these interpretations remain active across online and offline stages of processing.