A trans-diagnostic review of anxiety disorder comorbidity and the impact of multiple exclusion criteria on studying clinical outcomes in anxiety disorders

Aligning categories of mental health conditions with intervention types in high-performance sports: A narrative cornerstone review and classification framework

Epidemiological studies suggest that psychiatric disorders are as prevalent amongst high-performance athletes as in general populations, challenging the myth of invulnerability. Despite efforts of sport organisations to highlight the significance of athletes' mental health, it is still many times tough to combine the sport performance ethos with a discourse on mental health. This narrative cornerstone review examines challenges related to definitions and classifications of athlete mental health in high-performance sports and how these influence assessments and the implementation of interventions. We discuss challenges with concept creep and psychiatrisation and outline their consequences for sport healthcare professionals. Based on this, we present a framework that aligns different categories of athlete mental health conditions (from the reduction of wellbeing to psychiatric disorders) with intervention types (from the provision of supporting environments to pharmacotherapy). We conclude that researchers and sport practitioners need to carefully consider conceptual creep and the risk of pathologising normal and healthy, albeit emotionally aversive, reactions to athlete lifeworld events when assessing athlete mental health. A clear separation of terminology denoting the athlete's resources to handle the lifeworld (including salutogenic factors) and terms describing psychiatric conditions and their management is necessary to avoid misguidance in intervention planning.

EEG Microstates in Mood and Anxiety Disorders: A Meta-analysis

To reduce the psycho-social burden increasing attention has focused on brain abnormalities in the most prevalent and highly co-occurring neuropsychiatric disorders, such as mood and anxiety. However, high inter-study variability in these patients results in inconsistent and contradictory alterations in the fast temporal dynamics of large-scale networks as measured by EEG microstates. Thus, in this meta-analysis, we aim to investigate the consistency of these changes to better understand possible common neuro-dynamical mechanisms of these disorders.In the systematic search, twelve studies investigating EEG microstate changes in participants with mood and anxiety disorders and individuals with subclinical depression were included in this meta-analysis, adding up to 787 participants.The results suggest that EEG microstates consistently discriminate mood and anxiety impairments from the general population in patients and subclinical states. Specifically, we found a small significant effect size for B microstates in patients compared to healthy controls, with larger effect sizes for increased B presence in unmedicated patients with comorbidity. In a subgroup meta-analysis of ten mood disorder studies, microstate D showed a significant effect size for decreased presence. When investigating only the two anxiety disorder studies, we found a significantly small effect size for the increased microstate A and a medium effect size for decreased microstate E (one study). However, more studies are needed to elucidate whether these findings are diagnostic-specific markers.Results are discussed in relation to the functional meaning of microstates and possible contribution to an explanatory mechanism of overlapping symptomatology of mood and anxiety disorders.

Transdiagnostic Mood, Anxiety and Trauma Symptom Factors in Alcohol Use Disorder: Neural Correlates Across Three Brain Networks

BACKGROUND

Alcohol use disorder (AUD) is associated with high rates of trauma, mood, and anxiety disorders. Individual symptoms highly overlap across diagnoses, highlighting the need for a transdiagnostic approach. Further, there is limited research on how transdiagnostic psychopathology impacts the neural correlates of AUD. Thus, we aimed to identify symptom factors spanning diagnoses and how they relate to the neurocircuitry of addiction.

METHODS

Eighty-six Veterans with AUD completed self-report measures and reward, incentive salience and cognitive control fMRI tasks. Factor analysis was performed on self-reported trauma, depression, anxiety, and stress symptoms to obtain transdiagnostic symptom compositions. Neural correlates with a-priori-defined regions of interest in the three networks were assessed. Independent samples t-tests compared the same nodes by DSM-5 diagnosis.

RESULTS

Four symptom factors were identified: trauma distress, negative affect, hyperarousal, and somatic anxiety. Trauma distress score was associated with increased cognitive control activity regions during response inhibition (dACC). Negative affect related to lower activation in reward regions (R.Caudate) but higher activation in cognitive control regions during response inhibition (L.dlPFC). Hyperarousal related to lower reward activity during monetary reward anticipation (L.Caudate, R.Caudate) Somatic anxiety was not significantly associated with brain activation. No difference in neural activity was found by PTSD, MDD or GAD diagnosis CONCLUSION: These preliminary, hypothesis-generating findings offer transdiagnostic symptom factors that are differentially associated with neural function and could guide us towards a brain-based classification of psychiatric dysfunction in AUD. Results warrant further investigation of transdiagnostic approaches to symptoms in addiction.

Venciendo la Depresión: A Pilot Study of Telehealth-Delivered Behavioral Activation for Depressed Spanish-Speaking Latinxs

Latinxs are substantially impacted by depression. The research literature has documented barriers (e.g., stigma, limited English proficiency, and lack of transportation) contributing to the underutilization of behavioral health services among Spanish-speaking Latinxs (SSLs). Telehealth can be broadly defined as the provision of healthcare information and services through the use of telecommunications technology. Behavioral Activation (BA) has well established empirical support for reducing symptoms of depression among ethnic minority groups. The unprecedent challenges associated with accessing in-person behavioral health services during the COVID-19 pandemic have underscored the need to examine alternate methods for treatment delivery. Thus, the proposed study aimed to conduct a feasibility study to determine the viability of telehealth-delivered BA for SSLs. Twenty-five SSL participants met eligibility criteria and were enrolled in the intervention and 17 participants completed treatment. The majority of participants experienced significant improvements in depressive symptoms and positive affect. These treatment gains were sustained at one-month follow-up. The present study offers promising preliminary data to support the acceptability and feasibility of telehealth-delivered BA, with the potential to lessen barriers to care by offering readily accessible behavioral health services for depressed individuals in underserved communities.

Cost-Effectiveness of Group Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders in Primary Care Settings: Economic Evaluation From the Healthcare System Perspective Over a 1-Year Time Horizon

AIM

To assess the incremental cost-effectiveness ratio (ICER) of group transdiagnostic cognitive-behavioural therapy (tCBT) added to treatment as usual (TAU) for anxiety disorders compared to TAU only from the healthcare system perspective over a 1-year time horizon.

METHODS

Data from a pragmatic multisite randomized controlled trial where adults (18-65 years) with an anxiety disorder were randomized to tCBT + TAU (n = 117) or TAU (n = 114). Group tCBT is a 12-week (2h weekly sessions) community-based intervention. Health service utilization and related costs were captured from medico-administrative data and included those for the intervention, ambulatory visits, hospitalizations and medications. Effectiveness was based on quality-adjusted life years (QALYs). The study included measures at baseline, 4, 8, and 12 months. Intention-to-treat and complete case analyses were carried out. Missing data were imputed using multiple imputation analyses. Seemingly unrelated regression analyses were used to assess the effect of the intervention on total costs and QALYs while also adjusting for baseline confounders. The probability of cost-effectiveness of the intervention was assessed according to different willingness-to-pay (WTP) thresholds using the net benefit regression method.

RESULTS

The ICER of tCBT + TAU as compared to TAU in the intention-to-treat analysis was $6,581/QALY. Complete case analyses showed a similar ICER of $6,642/QALY. The probability at a WTP threshold of $20,000 and $40,000 that tCBT + TAU as compared to TAU is cost-effective is 93.0% and 99.9%.

CONCLUSION

tCBT added to TAU appears to be cost-effective from the healthcare system perspective for treating adult patients with anxiety disorders. Larger trials including young and older adults as well as a range of anxiety disorders are needed to further investigate the cost-effectiveness of tCBT in different patient populations.

Which symptom to address in psychological treatment for cancer survivors when fear of cancer recurrence, depressive symptoms, and cancer-related fatigue co-occur? Exploring the level of agreement between three systematic approaches to select the focus of treatment

PURPOSE

To investigate the extent to which three systematic approaches for prioritizing symptoms lead to similar treatment advices in cancer survivors with co-occurring fear of cancer recurrence, depressive symptoms, and/or cancer-related fatigue.

METHODS

Psychological treatment advices were was based on three approaches: patient preference, symptom severity, and temporal precedence of symptoms based on ecological momentary assessments. The level of agreement was calculated according to the Kappa statistic.

RESULTS

Overall, we found limited agreement between the three approaches. Pairwise comparison showed moderate agreement between patient preference and symptom severity. Most patients preferred treatment for fatigue. Treatment for fear of cancer recurrence was mostly indicated when based on symptom severity. Agreement between temporal precedence and the other approaches was slight. A clear treatment advice based on temporal precedence was possible in 57% of cases. In cases where it was possible, all symptoms were about equally likely to be indicated.

CONCLUSIONS

The three approaches lead to different treatment advices. Future research should determine how the approaches are related to treatment outcome. We propose to discuss the results of each approach in a shared decision-making process to make a well-informed and personalized decision with regard to which symptom to target in psychological treatment.

IMPLICATIONS FOR CANCER SURVIVORS

This study contributes to the development of systematic approaches for selecting the focus of psychological treatment in cancer survivors with co-occurring symptoms by providing and comparing three different systematic approaches for prioritizing symptoms.

The Feasibility and Efficacy of a Group-Based, Brief Transdiagnostic Cognitive-Behavioral Treatment for Adolescents with Internalizing Problems

The present study aimed to assess the efficacy of a group-based, brief transdiagnostic cognitive-behavioral therapy (CBT) program for adolescents with internalizing problems, such as anxiety and depressive disorders, seeking help in a primary health care clinic in Iceland. The group-based CBT program consisted of eight weekly 110-min sessions covering psychoeducation, cognitive restructuring, behavioral activation, exposure, problem-solving, social skills, and mindfulness. The study recruited 53 participants, who were randomly assigned to either receive the group treatment or be placed on a wait-list for monitoring purposes. Measures were taken at baseline, during treatment (week 4), at posttreatment (week 8), and at 2-, 4-month, and 1-year follow-ups. The primary outcome measures were the self-reported total scores of total anxiety and depression using the Revised Children's Anxiety and Depression Scale (RCADS). The study found a significant effect of time and time * treatment interaction on the depression and anxiety total scores. The secondary outcome measures, RCADS parent-rated depression and anxiety total scores, did not show significant effects of time * treatment interaction. However, during naturalistic follow-up, a significant reduction in parent-reported depression and anxiety total scores was observed. The study also observed good treatment adherence, as well as high satisfaction among parents and youth. The results suggest that this group-based, brief transdiagnostic CBT group treatment is feasible and effective in reducing depressive and anxiety symptoms in adolescents with internalizing problems and highlights the importance of addressing comorbidity in treatment.

A model for irritable bowel syndrome and anxiety comorbidities in relation to alcohol use disorders

About 95% of human body serotonin synthesis occurs in the gastrointestinal tract (GI). Lack of sufficient serotonin levels is thought to play a key role in mood disorders, including anxiety disorders. In this study, we looked at a disorder affecting the GI tract, irritable bowel syndrome (IBS), and aimed to determine whether IBS is differentially associated with anxiety disorders in 252 chronic pain patients in the presence of a history of alcohol use disorders (AUD) given that alcohol is an extremely aggressive substance for the GI mucosa. We found that while the prevalence of IBS was not affected by the presence of AUD in chronic pain patients, IBS had significantly higher comorbidity with anxiety disorders in chronic pain patients with comorbid alcohol use disorders. We argue that these findings highlight mechanistic differences in the comorbidity of anxiety disorders with chronic pain and AUD, implicating a central role for GI problems stemming from chronic alcohol use. The findings may have important implications for the treatment of IBS patients with AUD who commonly present with anxiety disorders which could motivate the continuation of problematic drinking and impede recovery success. We propose that addressing GI problems in patients with AUD may help manage AUD and recovery more effectively.

The current state-of-the-art in pharmacotherapy for pediatric generalized anxiety disorder

INTRODUCTION

Anxiety disorders are the most prevalent psychiatric disorders among youth. Among the various anxiety disorders, generalized anxiety disorder is particularly prevalent. Youth with GAD appear at elevated risk of developing other anxiety disorders, mood disorder, and substance use disorders. Functional outcomes of youth with GAD can be improved through early recognition and treatment, thus promoting better longer-term outcomes.

AREAS COVERED

The current article summarizes evidence-based state-of-the-art pharmacotherapy for pediatric GAD based on open-label, randomized, and controlled trials. Two electronic databases (PubMed and Scopus) were systematically searched in April 2022 for relevant publications.

EXPERT OPINION

The literature supports a combination of psychotherapy and pharmacotherapy as being associated with better outcomes when compared to mono-therapies. While longer-term follow-ups are limited, one such study does challenge this notion. Both selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) have been found across studies to have moderate effect sizes in the treatment of pediatric anxiety disorders. SSRIs continue to be a first-line intervention, whereas SNRIs may be considered a second-line treatment. While more evidence is needed, there are emerging data indicating that SSRIs are associated with a more rapid and greater reduction in anxiety symptoms when compared to SNRIs.

Child and Adolescent Anxiety and Depression Prior to and During the COVID-19 Pandemic in the United States

Childhood anxiety and depression have been increasing for years, and evidence suggests the COVID-19 pandemic has exacerbated this trend. However, research has examined anxiety and depression primarily as exclusive conditions, overlooking comorbidity. This study examined relationships between the COVID-19 pandemic and anxiety and depression to clarify risk factors for singular and comorbid anxiety and depression in children. Using 2018-2019 and 2020-2021 samples from the National Survey of Children's Health, a nationally representative survey of children aged 0-17 in the United States, associations between the COVID-19 pandemic and child anxiety and depression were examined via survey-weights' adjusted bivariate and multiple regression analyses, controlling for demographic characteristics. The COVID-19 pandemic was associated with higher odds of having comorbid anxiety and depression but not singular anxiety or depression. Female sex, older age, having special healthcare needs, more frequent inability to cover basic needs on family income, and poorer caregiver mental health were associated with having been diagnosed with singular and comorbid anxiety and depression. Children that witnessed or were victims of violence in the neighborhood were also more likely to have comorbid anxiety and depression. Implications for prevention, intervention, and policy are discussed.

An examination of sudden gain prevalence across cognitive-behavioural therapy for anxiety and depressive disorders: A quantitative analysis and meta-analytic review

Sudden gains, incidences of unexpectedly large and stable session to session symptom reductions during psychotherapy, have been shown in samples of individuals receiving treatment for both anxiety and depressive disorders, although seemingly more frequently in sample receiving treatment for depressive disorders. This may suggest that sudden gains are a function of depression, but the high comorbidity between anxiety and depressive disorders makes this difficult to assess. Study One utilised a sample of 117 adults undergoing CBT for a principal anxiety disorder to explore the effect of comorbid depression on sudden gain prevalence. Results indicated that sudden gains were not more prevalent in the comorbid depression group; however, the frequency of sudden gains was significantly related to comorbid depressive disorder severity. Study Two involved a meta-analysis of 48 studies to compare sudden gain prevalence between trials of CBT for depressive disorders versus anxiety-related disorders. The results of the meta-analysis indicated significantly higher rates of sudden gains in samples with a principal depressive disorder diagnosis, compared to a principal anxiety disorder diagnosis. Sudden gains may therefore be driven by depression, but only at the more severe level.

Anxiety sensitivity as a predictor, and non-specific therapeutic factors as predictors and mediators of CBT outcome for obsessive-compulsive disorder in a naturalistic mental health setting

OBJECTIVE

We examined the unique predictive strength of anxiety sensitivity (AS) and the role of expectancy, credibility, and therapeutic alliance (TA) as predictors and mediators of cognitive-behavioral treatment (CBT) outcomes in obsessive-compulsive disorder (OCD).

METHOD

The current study is a prospective cohort study. Participants (N = 116) were treatment-seeking individuals with a primary diagnosis of OCD. Independent raters assessed patients on Yale-Brown Obsessive-Compulsive Scale (YBOCS) and Anxiety Sensitivity Index-3 at baseline, post-intervention, and three-month follow-up. Participants responded to the Credibility and Expectancy questionnaire and Working Alliance Inventory-Short revised at baseline, first-session, and mid-session.

RESULTS

The individual addition of AS, end-of-first-session credibility and expectancy, mid-session credibility and expectancy, and therapeutic alliance predicted significant CBT outcomes. There was a moderate positive correlation between baseline OCD severity and the global score of AS, but a weak one with AS dimensions. Both expectancy and credibility significantly improved from baseline to end-of-first-session treatment. End-of-first and third-session outcome expectancies, not credibility, have significant, indirect effects on OCD CBT outcomes.

CONCLUSIONS

AS, within-session credibility and expectancies and TA independently predict CBT outcomes. Within-sessions outcome expectancies mediate CBT outcomes in OCD, not credibility. Expectancy and credibility both include state-like elements that can be influenced to enhance the outcomes of CBT. Proposals for reducing treatment barriers in CBT for OCD are offered.

A transdiagnostic network for psychiatric illness derived from atrophy and lesions

Psychiatric disorders share neurobiology and frequently co-occur. This neurobiological and clinical overlap highlights opportunities for transdiagnostic treatments. In this study, we used coordinate and lesion network mapping to test for a shared brain network across psychiatric disorders. In our meta-analysis of 193 studies, atrophy coordinates across six psychiatric disorders mapped to a common brain network defined by positive connectivity to anterior cingulate and insula, and by negative connectivity to posterior parietal and lateral occipital cortex. This network was robust to leave-one-diagnosis-out cross-validation and specific to atrophy coordinates from psychiatric versus neurodegenerative disorders (72 studies). In 194 patients with penetrating head trauma, lesion damage to this network correlated with the number of post-lesion psychiatric diagnoses. Neurosurgical ablation targets for psychiatric illness (four targets) also aligned with the network. This convergent brain network for psychiatric illness may partially explain high rates of psychiatric comorbidity and could highlight neuromodulation targets for patients with more than one psychiatric disorder.

Remote cognitive behavioral therapy for older adults with anxiety symptoms: A systematic review and meta-analysis

INTRODUCTION

In-person cognitive behavioral therapy (CBT) can reduce self-reported anxiety in older adults. However, studies are limited for remote CBT. We assessed the effectiveness of remote CBT in mitigating self-reported anxiety in older adults.

METHODS

We conducted a systematic review and meta-analysis based on a literature search of PubMed, Embase, PsycInfo, and Cochrane databases up to March 31, 2021, for randomized controlled clinical trials comparing the effectiveness of remote CBT versus non-CBT controls on mitigating self-reported anxiety in older adults. We calculated within-group pre-to-post-treatment standardized mean difference using Cohen's d, obtained the difference between a remote CBT group and a non-CBT control group as our effect size for cross-study comparison, and conducted a random-effects meta-analysis. Changes in scores on self-reported anxiety symptoms (Generalized Anxiety Disorder-7 item Scale, Penn State Worry Questionnaire, or Penn State Worry Questionnaire - Abbreviated), and self-reported depressive symptoms (Patient Health Questionnaire-9 item Scale or Beck Depression Inventory) were primary and secondary outcomes, respectively.

RESULTS

Six eligible studies, containing 633 participants with a pooled mean age of 66.6 years, were included in the systematic review and meta-analysis. There was a significant mitigating effect of intervention on self-reported anxiety, favoring remote CBT over non-CBT controls (between-group effect size: -0.63; 95% CI: -0.99 to -0.28). We also found a significant mitigating effect of intervention on self-reported depressive symptoms (between-group effect size: -0.74; 95% CI: -1.24 to -0.25).

DISCUSSION

Remote CBT is more effective in reducing self-reported anxiety and depressive symptoms than non-CBT control in older adults.

Gender Impacts the Relationship between Mood Disorder Symptoms and Effortful Avoidance Performance

We must often decide how much effort to exert or withhold to avoid undesirable outcomes or obtain rewards. In depression and anxiety, levels of avoidance can be excessive and reward-seeking may be reduced. Yet outstanding questions remain about the links between motivated action/inhibition and anxiety and depression levels, and whether they differ between men and women. Here, we examined the relationship between anxiety and depression scores, and performance on effortful active and inhibitory avoidance (Study 1) and reward seeking (Study 2) in humans. Undergraduates and paid online workers ([Formula: see text] = 545, [Formula: see text] = 310; [Formula: see text] = 368, [Formula: see text] = 450, [Formula: see text] = 22.58, [Formula: see text] = 17-62) were assessed on the Beck Depression Inventory II (BDI) and the Beck Anxiety Inventory (BAI) and performed an instructed online avoidance or reward-seeking task. Participants had to make multiple presses on active trials and withhold presses on inhibitory trials to avoid an unpleasant sound (Study 1) or obtain points toward a monetary reward (Study 2). Overall, men deployed more effort than women in both avoidance and reward-seeking, and anxiety scores were negatively associated with active reward-seeking performance based on sensitivity scores. Gender interacted with anxiety scores and inhibitory avoidance performance, such that women with higher anxiety showed worse avoidance performance. Our results illuminate effects of gender in the relationship between anxiety and depression levels and the motivation to actively and effortfully respond to obtain positive and avoid negative outcomes.

A meta-analytic review of randomized clinical trials of online treatments for anxiety: Inclusion/exclusion criteria, uptake, adherence, dropout, and clinical outcomes

Over the last decade there has been rapid growth in the number of clinical trials examining internet-delivered interventions for anxiety. While there have been numerous analyses of treatment efficacy, few studies have examined treatment engagement. The current meta-analysis examined participant eligibility, uptake, adherence, and drop-out in clinical trials of internet-delivered treatments for anxiety. This meta-analysis used random effects models to obtain estimates of participant inclusion, uptake, adherence, drop-out, and within-group treatment effect size. Moderator analyses examined the effects of anxiety disorder type, treatment type, and level of clinician guidance. After screening, 140 trials with 199 treatment arms (N = 11,021) were included. An average of 46% (95% CI 42, 50) of interested people were included in the clinical trials. In the active treatment arms, 98% (95% CI 97, 99) of participants began treatment, 81% (95% CI 78, 85) of the assigned treatments were completed, 21% (95% CI 18, 23) of individuals dropped out at post-treatment based on questionnaire non-completion, and an overall within-group effect size of g = 1.03 (95% CI 0.94, 1.13) was obtained. Several moderators of interest were significant (e.g., clinical guidance, anxiety disorder type), and there was substantial heterogeneity in estimates. In conclusion, a large number of inclusion and exclusion criteria have been used in trials of internet-delivered treatments for anxiety. Once recruited into a trial, however, most people appear to begin, adhere, and complete internet-delivered treatment for anxiety. Further research exploring various eligibility criteria and their impact on engagement and efficacy is warranted.

Infraslow closed-loop brain training for anxiety and depression (ISAD): a protocol for a randomized, double-blind, sham-controlled pilot trial in adult females with internalizing disorders

Background

The core intrinsic connectivity networks (core-ICNs), encompassing the default-mode network (DMN), salience network (SN) and central executive network (CEN), have been shown to be dysfunctional in individuals with internalizing disorders (IDs, e.g. major depressive disorder, MDD; generalized anxiety disorder, GAD; social anxiety disorder, SOC). As such, source-localized, closed-loop brain training of electrophysiological signals, also known as standardized low-resolution electromagnetic tomography (sLORETA) neurofeedback (NFB), targeting key cortical nodes within these networks has the potential to reduce symptoms associated with IDs and restore normal core ICN function. We intend to conduct a randomized, double-blind (participant and assessor), sham-controlled, parallel-group (3-arm) trial of sLORETA infraslow (<0.1 Hz) fluctuation neurofeedback (sLORETA ISF-NFB) 3 times per week over 4 weeks in participants (n=60) with IDs. Our primary objectives will be to examine patient-reported outcomes (PROs) and neurophysiological measures to (1) compare the potential effects of sham ISF-NFB to either genuine 1-region ISF-NFB or genuine 2-region ISF-NFB, and (2) assess for potential associations between changes in PRO scores and modifications of electroencephalographic (EEG) activity/connectivity within/between the trained regions of interest (ROIs). As part of an exploratory analysis, we will investigate the effects of additional training sessions and the potential for the potentiation of the effects over time.

Methods

We will randomly assign participants who meet the criteria for MDD, GAD, and/or SOC per the MINI (Mini International Neuropsychiatric Interview for DSM-5) to one of three groups: (1) 12 sessions of posterior cingulate cortex (PCC) ISF-NFB up-training (n=15), (2) 12 sessions of concurrent PCC ISF up-training and dorsal anterior cingulate cortex (dACC) ISF-NFB down-training (n=15), or (3) 6 sessions of yoked-sham training followed by 6 sessions genuine ISF-NFB (n=30). Transdiagnostic PROs (Hospital Anxiety and Depression Scale, HADS; Inventory of Depression and Anxiety Symptoms – Second Version, IDAS-II; Multidimensional Emotional Disorder Inventory, MEDI; Intolerance of Uncertainty Scale – Short Form, IUS-12; Repetitive Thinking Questionnaire, RTQ-10) as well as resting-state neurophysiological measures (full-band EEG and ECG) will be collected from all subjects during two baseline sessions (approximately 1 week apart) then at post 6 sessions, post 12 sessions, and follow-up (1 month later). We will employ Bayesian methods in R and advanced source-localisation software (i.e. exact low-resolution brain electromagnetic tomography; eLORETA) in our analysis.

Discussion

This protocol will outline the rationale and research methodology for a clinical pilot trial of sLORETA ISF-NFB targeting key nodes within the core-ICNs in a female ID population with the primary aims being to assess its potential efficacy via transdiagnostic PROs and relevant neurophysiological measures.

Trial registration

Our study was prospectively registered with the Australia New Zealand Clinical Trials Registry (ANZCTR; Trial ID: ACTRN12619001428156). Registered on October 15, 2019.

A literature review of the impact of exclusion criteria on generalizability of clinical trial findings to patients with chronic pain

The ability of clinical trials to inform the care of chronic pain may be limited if only an unrepresentative subset of patients are allowed to enroll. We summarize and report new insights on published studies that report on how trial exclusions affect the generalizability of their results. We conducted a PubMed search on the following terms: (("eligibility criteria" AND generalizability) OR ("exclusion criteria" AND generalizability) OR "exclusion criteria"[ti] OR "eligibility criteria"[ti]) AND pain. We only considered studies relevant if they analyzed data on (1) the prevalence and nature of exclusion criteria or (2) the impact of exclusion criteria on sample representativeness or study results. The 4 articles that were identified reported differences in patients who were included and excluded in different clinical trials: excluded patients were older, less likely to have a paid job, had more functional limitations at baseline, and used strong opioids more often. The clinical significance of these differences remains unclear. The pain medicine literature has very few published studies on the prevalence and impact of exclusion criteria, and the outcomes of excluded patients are rarely tracked. The frequent use of psychosocial exclusions is especially compromising to generalizability because chronic pain commonly co-occurs with psychiatric comorbidities. Inclusion of more representative patients in research samples can reduce recruitment barriers and broaden the generalizability of findings in patients with chronic pain. We also call for more studies that examine the use of exclusion criteria in chronic pain trials to better understand their implications.

Amygdala-pons connectivity is hyperactive and associated with symptom severity in depression

Knowledge of the neural underpinnings of processing sad information and how it differs in people with depression could elucidate the neural mechanisms perpetuating sad mood in depression. Here, we conduct a 7 T fMRI study to delineate the neural correlates involved only in processing sad information, including pons, amygdala, and corticolimbic regions. We then conduct a 3 T fMRI study to examine the resting-state connectivity in another sample of people with and without depression. Only clinically depressed people demonstrate hyperactive amygdala–pons connectivity. Furthermore, this connectivity is related to depression symptom severity and is a significant indicator of depression. We speculate that visual sad information reinforces depressed mood and stimulates the pons, strengthening the amygdala–pons connectivity. The relationship between this connectivity and depressive symptom severity suggests that guiding one’s visual attention and processing of sad information may benefit mood regulation.

A study on patients with major depressive disorder (MDD) suggests that a specific sadness-processing connection between the amygdala and pons appears to be dysfunctional among people with MDD and associated with severity of depression.

Subthreshold lifetime depression and anxiety are associated with increased lifetime suicide attempts: A Korean nationwide study

BACKGROUND

Subthreshold depression and anxiety are highly prevalent and known to be associated with functional limitations and future onset of major depression or anxiety disorders. However, studies regarding suicidality at subthreshold levels of depression and anxiety are limited.

METHODS

A total of 17,639 Koreans aged from 18 to 64 responded to the Korean version of the WHO-composite international diagnostic interview (K-CIDI) version 2.1 between 2006 and 2016. Prevalence of subthreshold depression and anxiety, and information on lifetime suicide attempt (SA) were assessed. Multivariable logistic regression was performed to calculate the risk of SA by the level of depression or anxiety.

RESULTS

The risk of lifetime SA increased incrementally according to the level of depression and anxiety. In the subthreshold depression group, individuals with subthreshold anxiety increased the odds about threefold (OR = 3.15, 95% CI 3.12-3.18) and the threshold anxiety disorder group increased the odds about fivefold (OR = 5.33, 95% CI 5.27-5.38) for SA, compared to the group without any level of anxiety. In threshold depressive disorder, the subthreshold anxiety group showed about 1.8-fold higher odds (OR = 1.76, 95% CI 1.75-1.77) and the threshold anxiety disorder group showed threefold higher odds (OR = 2.93, 95% CI 2.92-2.95) for SA compared to the group without any level of anxiety.

CONCLUSIONS

Subthreshold levels of depression and anxiety were prevalent among Koreans and were associated with an increased prevalence of lifetime SA. A detailed assessment of depression and anxiety symptoms according to their level should be performed on a diagnostic continuum to prevent suicide.

Personality traits associate with behavioral problems in pet dogs

Personality traits, especially neuroticism, strongly predict psychopathology. The domestic dog (Canis lupus familiaris Linnaeus, 1758) is used as a natural model for psychiatric disorders, but the similarity between dog and human personality and the association between dog personality and unwanted behavioral traits, such as fearfulness, aggressiveness, and impulsivity/inattention, remain unknown. This study utilized structural equation modeling (SEM) with survey data of 11,360 dogs to examine the associations and correlations between seven personality and ten unwanted behavioral traits. Personality traits included insecurity, energy, training focus, aggressiveness/dominance, human sociability, dog sociability, and perseverance. Unwanted behavioral traits included fearfulness, noise sensitivity, fear of surfaces/heights, separation anxiety, barking, stranger-directed aggression, owner-directed aggression, dog-directed aggression, hyperactivity/impulsivity, and inattention. We first fitted confirmatory factor models for the unwanted behavioral traits and the best model grouped unwanted behaviors into four latent traits: fear-related behavior, fear-aggression, aggression, and impulsivity/inattention and used this structure in the subsequent SEM model. Especially, insecurity, which resembles the human neuroticism trait, was strongly associated with unwanted behavior, paralleling the association between neuroticism and psychopathology. Similarly, training focus, resembling conscientiousness, was negatively related to impulsivity/inattention, and aggressiveness/dominance was associated with aggressive behaviors, resembling associations of conscientiousness and agreeableness with attention deficit hyperactivity disorder and aggression-related psychopathology, respectively. These results indicate that dog personality traits resemble human personality traits, suggesting that their neurological and genetic basis may also be similar and making the dog a suitable animal model for human behavior and psychiatric disorders.

Event-related potentials to acoustic startle probes during unpredictable threat are associated with individual differences in intolerance of uncertainty

Individual differences in sensitivity to unpredictable threat may be a critical mechanism for internalizing psychopathology phenotypes. The present study examined whether the startle probe-elicited N100 and P300 during unpredictable threat - two event-related potentials indexing early and elaborative attentional processing of unpredictable threat - may be endophenotypes for internalizing psychopathology, including fear and distress/misery disorders and intolerance of uncertainty (IU), a clinical trait that is transdiagnostically associated with internalizing disorders. A large sample of adult siblings (N = 375) completed the no, predictable, and unpredictable threat task, during which the N100 and P300 were recorded. Relative to the no threat condition, N100 was more strongly enhanced in anticipation of unpredictable than predictable threat while P300 was suppressed to both predictable and unpredictable threat. While neither N100 enhancement nor P300 suppression to unpredictable threat was associated with fear or distress/misery disorders, they were negatively linked to inhibitory IU (a facet of IU). Thus, individuals high in inhibitory IU showed reduced attentional engagement with the threatening context when it was unpredictable. Further, N100 enhancement and, to a lesser degree, P300 suppression to unpredictable threat showed familial aggregation - a key criterion for determining whether a biomarker is an endophenotype. In sum, N100 enhancement and P300 suppression to unpredictable threat may be endophenotypes for dimensional measures of internalizing psychopathology.

Executive Functioning Constructs in Anxiety, Obsessive-Compulsive, Post-Traumatic Stress, and Related Disorders

PURPOSE OF REVIEW

We synthesize theories proposing complex relations between cognitive functioning and anxiety-related concepts. We evaluate vulnerability theories suggesting that deficits in various cognitive functioning domains predict future anxiety-associated concepts. We examine scar theories asserting the opposite direction of effects (i.e., anxiety predicting cognitive dysfunction). Furthermore, we examine more novel frameworks on this topic.

RECENT FINDINGS

Reliable evidence exists for the scar and vulnerability theories. This includes mounting data on diverse anxiety symptoms predicting cognitive dysfunction (and conversely) unfolding at between- and within-person levels (dynamic mutualism theory). It also includes data on the stronger effects or central influence of anxiety (versus non-anxiety) symptoms on executive functioning (EF; i.e., higher-order cognitive control governing myriad thinking and action repertoires) versus non-EF domains and vice versa (network theory). In addition, it reviews emerging evidence that enhanced cognitive control can correlate with higher anxiety among children (overgeneralized control theory). The generally inverse relations between anxiety symptoms and cognitive dysfunction are bidirectional and complex within and between persons. Plausible mediators and moderators merit more attention, including immune, metabolism, and neural markers and the social determinants of health.

The effects of a high eicosapentaenoic acid multinutrient supplement on measures of stress, anxiety and depression in young adults: Study protocol for NutriMOOD, a randomised double-blind placebo-controlled trial

Anxiety disorders affect nearly 20% of young adults aged 18-29 years. First-line treatment for anxiety disorders comprises pharmacotherapy and Cognitive Behavioural Therapy, options often criticised for their low efficacy and safety. In contrast, fish-oil-based supplements comprising omega-3 polyunsaturated fatty acids and supporting nutrients are gaining recognition as safe and effective alternatives. Here we present the protocol for a randomised, double-blind, placebo-controlled trial investigating the effects of a high eicosapentaenoic acid multinutrient supplement on validated measures of anxiety and depression in healthy university students experiencing non-clinical levels of anxiety and depression. The primary outcome is improvement in anxiety compared to the placebo group assessed via the Generalised Anxiety Disorder Assessment-7 scale. The participants will be randomised to active treatment comprising a daily dose of 1125 mg eicosapentaenoic acid, 441 mg docosahexaenoic acid, 330 mg magnesium and 7.5 mg vitamin E, or placebo, for 24 weeks, and will complete validated questionnaires and tablet-based tasks sensitive to mood at baseline and end of intervention. Circulating fatty acids and key biomarkers will also be assessed. The students will be genotyped for polymorphisms thought to influence the relationship between long-chain omega-3 polyunsaturated fatty acids and affect. Trial registration; ClinicalTrials.gov, NCT04844034.

Multiple Comorbidity Profile of Psychiatric Disorders in Epilepsy

The co-occurrence of psychiatric disorders in people with epilepsy (PWE) is not well documented or studied. Anxiety and depressive disorders are the most frequent comorbid disorders in PWE. In this paper, we characterized the rates of multiple psychiatric disorder comorbidity by reanalyzing data from a study sample of PWE. A total of 96 outpatient PWE completed the self-report symptom scale, and were diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) Axis I disorders (SCID-I). For analyses, patients were assigned to a comprehensive diagnostic group of anxiety and depressive disorders. In order to determine comorbidity across psychiatric diagnoses for the DSM-IV categories, Pearson's chi-squared test (χ²) was used. In the study sample, eight patients (8.3% of the study sample, n = 96) had comorbid major depressive disorder and anxiety disorder. When looking at comorbidity of each diagnosis separately, it was determined that 50% of individuals with an anxiety disorder had comorbid Major Depressive Disorder (MDD) and 38% patients with MDD had comorbid anxiety disorder. This finding encourages a more systematic reporting of psychiatric prevalence data in epilepsy, especially taking into account the high ratio of multiple comorbid anxiety and depressive disorders in PWE.

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

Merging Our Understanding of Anxiety and Exposure: Using Inhibitory Learning to Target Anxiety Sensitivity in Exposure Therapy

Exposure-based therapies are the gold standard treatment for anxiety disorders, and recent advancements in basic and clinical research point to the need to update the implementation of exposure. Recent research has highlighted the importance of transdiagnostic factors such as anxiety sensitivity (AS), or fear of anxiety-related sensations. Elevated AS is common among all anxiety disorders and contains three dimensions, or expectancies, that can be used to guide treatment. Recently, treatments directly targeting AS have shown potential in reducing symptoms of anxiety. In addition, inhibitory learning theory (ILT) provides an alternative explanation of exposure processes based on basic learning research. ILT extends the current framework by accounting for renewal of fear, which is important given the substantial number of individuals who experience a return of symptoms following treatment. The current paper will provide an overview of ILT and discuss several ILT techniques that can be used to target AS. These two converging bodies of research hold strong potential for optimizing treatment for anxiety.

Acceptance and commitment-based therapy for patients with psychiatric and physical health conditions in routine general hospital care - Development, implementation and outcomes

OBJECTIVE

Transdiagnostic approaches are needed to effectively treat patients with a broad range of diagnoses and comorbidities in routine general hospital care. Yet the evidence for the effectiveness of treatments beyond Cognitive Behavioral Therapy (CBT) is largely lacking. We describe the process of implementing an interdisciplinary multi-professional Acceptance and Commitment Therapy (ACT)-based treatment for patients with psychiatric and physical health conditions and present outcomes before and after implementation.

METHOD

The present investigation was a naturalistic comparative study comparing ACT-based (n = 126) vs. CBT-based (n = 127) treatments in a psychiatric day hospital in Berlin, Germany. Within- and between-group changes (pre- to post-treatment) in everyday functioning and health-related quality of life (primary outcomes; assessed by the Short Form 36 (SF-36)), as well as anxiety and depressive symptoms (secondary outcomes; assessed by the Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory-II (BDI-II)), were analyzed with Generalized Linear Models, and Wilcoxon signed-rank tests and effect size r.

RESULTS

Data analysis showed statistically significant improvements from pre- to post-treatment (r ranging from 0.27 to 0.61, p < 0.001) for most SF-36 scales as well as for all HADS and BDI-II scores (r ranging from 0.38 to 0.60, p < 0.001) for both the ACT and CBT groups. ACT and CBT showed comparable effects in relation to clinical outcomes.

CONCLUSION

An interdisciplinary multi-professional ACT-based group treatment is a valuable approach for patients with psychiatric and physical health conditions in real-life hospital settings, with effects equivalent to CBT interventions.

Computer-delivered personalized feedback intervention for hazardous drinkers with elevated anxiety sensitivity: A pilot randomized controlled trial

Hazardous drinkers with emotional vulnerabilities (e.g., elevated anxiety sensitivity) remain an underserved group. This study aimed to evaluate the feasibility, acceptability, and initial efficacy of a single session remotely-delivered personalized feedback intervention (PFI) targeting alcohol (mis)use and anxiety sensitivity among college students. Hazardous drinkers with elevated anxiety sensitivity (N = 125; 76.8% female; M_age = 22.14; 66.4% racial/ethnic minorities) were randomized to receive the integrated PFI (n = 63) or attention control (n = 62). Follow-up assessments were conducted one-week, one-month and three-months post-intervention. Latent growth curve modeling was used to test pilot outcomes. It was feasible to recruit and retain hazardous drinking students with elevated anxiety sensitivity through follow-up with no group differences in retention. The integrated PFI was rated as more acceptable than the control with medium/large differences (p's < 0.004; d's = 0.54-0.80). The integrated PFI group had statistically significantly greater change in primary outcomes: motivation, hazardous alcohol use, and anxiety sensitivity (p's < 0.05; d's = 0.08-0.37) with larger within-group effect sizes (d's = 0.48-0.61) than in control (d's = 0.26-0.54). Despite a small sample size, this one-session intervention offers promise among a high-risk group of drinkers with emotional vulnerabilities. The computer-based format may allow for mass distribution of a low-cost intervention in the future; however, follow-up testing in larger samples is needed.

Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State, Multi-Site Primary Care Practice

BACKGROUND

Anxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care.

METHODS

Participants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database.

RESULTS

Among participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p< .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations.

DISCUSSION

Short-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.

Chronic traumatic encephalopathy-a blueprint for the bridge between neurological and psychiatric disorders

Chronic traumatic encephalopathy (CTE) is a perplexing condition characterized by a broad and diverse range of neuropathology and psychopathology. While there are no agreed upon or validated clinical criteria for CTE, case series of CTE have described a wide range of neuropsychiatric symptoms that have been attributed to repetitive traumatic brain injuries (rTBI). However, the direct links between the psychopathology of psychiatric and neurological conditions from rTBI to CTE remains poorly understood. Prior studies suggest that repetitive cerebral injuries are associated with damage to neural circuitry involved in emotional and memory processes, but these studies do not offer longitudinal assessments that prove causation. More recent studies on novel targets, such as transmission of misfolded proteins, as well as newly advanced non-invasive imaging techniques may offer more direct evidence of the pathogenesis of CTE by tracing the progression of pathology and display of related behavioral impairments. Understanding this interface in the context of rTBI can play an important role in future approaches to the definition, assessment, prevention, and treatment of CTE and mental illnesses.

Comorbidity Patterns of Older Lung Cancer Patients in Northeast China: An Association Rules Analysis Based on Electronic Medical Records

Purposes: This study aims to identify the comorbidity patterns of older men with lung cancer in China. Methods: We analyzed the electronic medical records (EMRs) of lung cancer patients over age 65 in the Jilin Province of China. The data studied were obtained from 20 hospitals of Jilin Province in 2018. In total, 1510 patients were identified. We conducted a rank–frequency analysis and social network analysis to identify the predominant comorbidities and comorbidity networks. We applied the association rules to mine the comorbidity combination with the values of confidence and lift. A heatmap was utilized to visualize the rules. Results: Our analyses discovered that (1) there were 31 additional medical conditions in older patients with lung cancer. The most frequent comorbidities were pneumonia, cerebral infarction, and hypertension. (2) The network-based analysis revealed seven subnetworks. (3) The association rules analysis provided 41 interesting rules. The results revealed that hypertension, ischemic cardiomyopathy, and pneumonia are the most frequent comorbid combinations. Heart failure may not have a strong implicating role in these comorbidity patterns. Cerebral infarction was rarely combined with other diseases. In addition, glycoprotein metabolism disorder comorbid with hyponatremia or hypokalemia increased the risk of anemia by more than eight times in older lung cancer patients. Conclusions: This study provides evidence on the comorbidity patterns of older men with lung cancer in China. Understanding the comorbidity patterns of older patients with lung cancer can assist clinicians in their diagnoses and contribute to developing healthcare policies, as well as allocating resources.

Beyond the Lab: Empirically Supported Treatments in the Real World

Laboratory studies of empirically supported treatments (ESTs) for mental health problems achieve much higher rates of clinical improvement than has been observed following treatment in the community. This discrepancy is likely to due to limited reliance on ESTs by therapists outside of academia. Concerns about the generalizability of ESTs to patients in the community, who may have comorbid problems, likely limit rates of adoption. The present study examined the impact of ESTs delivered in the real-world for 1,256 adults who received services through an employee assistance program specializing in the delivery of ESTs. Rates of anxiety and depression decreased significantly, following treatment with an EST, and 898 (71.5%) patients demonstrated reliable improvement. Even among patients comorbid for depression and anxiety at baseline, over half reported reliable improvement in both disorders. Findings suggest ESTs can be effectively delivered outside of academic RCTs. However, additional research is needed to understand and overcome barriers to disseminating ESTs to the broader community.

The human connectome project for disordered emotional states: Protocol and rationale for a research domain criteria study of brain connectivity in young adult anxiety and depression

Through the Human Connectome Project (HCP) our understanding of the functional connectome of the healthy brain has been dramatically accelerated. Given the pressing public health need, we must increase our understanding of how connectome dysfunctions give rise to disordered mental states. Mental disorders arising from high levels of negative emotion or from the loss of positive emotional experience affect over 400 million people globally. Such states of disordered emotion cut across multiple diagnostic categories of mood and anxiety disorders and are compounded by accompanying disruptions in cognitive function. Not surprisingly, these forms of psychopathology are the leading cause of disability worldwide. The Research Domain Criteria (RDoC) initiative spearheaded by NIMH offers a framework for characterizing the relations among connectome dysfunctions, anchored in neural circuits and phenotypic profiles of behavior and self-reported symptoms. Here, we report on our Connectomes Related to Human Disease protocol for integrating an RDoC framework with HCP protocols to characterize connectome dysfunctions in disordered emotional states, and present quality control data from a representative sample of participants. We focus on three RDoC domains and constructs most relevant to depression and anxiety: 1) loss and acute threat within the Negative Valence System (NVS) domain; 2) reward valuation and responsiveness within the Positive Valence System (PVS) domain; and 3) working memory and cognitive control within the Cognitive System (CS) domain. For 29 healthy controls, we present preliminary imaging data: functional magnetic resonance imaging collected in the resting state and in tasks matching our constructs of interest ("Emotion", "Gambling" and "Continuous Performance" tasks), as well as diffusion-weighted imaging. All functional scans demonstrated good signal-to-noise ratio. Established neural networks were robustly identified in the resting state condition by independent component analysis. Processing of negative emotional faces significantly activated the bilateral dorsolateral prefrontal and occipital cortices, fusiform gyrus and amygdalae. Reward elicited a response in the bilateral dorsolateral prefrontal, parietal and occipital cortices, and in the striatum. Working memory was associated with activation in the dorsolateral prefrontal, parietal, motor, temporal and insular cortices, in the striatum and cerebellum. Diffusion tractography showed consistent profiles of fractional anisotropy along known white matter tracts. We also show that results are comparable to those in a matched sample from the HCP Healthy Young Adult data release. These preliminary data provide the foundation for acquisition of 250 subjects who are experiencing disordered emotional states. When complete, these data will be used to develop a neurobiological model that maps connectome dysfunctions to specific behaviors and symptoms.

Inclusion of Cannabis Users in Alcohol Research Samples: Screening In, Screening Out, and Implications

BACKGROUND

Alcohol and cannabis are frequently co-used, as 20-50% of those who drink alcohol report co-using cannabis. This study is based on the argument that alcohol researchers should enroll cannabis users in human laboratory studies of alcohol use disorder (AUD) to strengthen generalizability. This study examines how heavy drinking cannabis users differ from non-cannabis using heavy drinkers.

METHODS

In a community sample of non-treatment-seeking heavy drinkers (n = 551, 35% female), cannabis users were identified through: (a) self-reported cannabis use in the past 6 months and (b) positive urine toxicology test for tetrahydrocannabinol (THC). Cannabis users, identified as described previously, were compared with non-cannabis users on demographic and clinical characteristics.

RESULTS

Those who endorsed cannabis use in the past 6 months reported more binge drinking days. Participants who tested positive for THC had higher Alcohol Use Disorder Identification Test scores and more binge drinking days. Younger age and being a tobacco smoker were associated with an increased likelihood of cannabis use in the past 6 months, whereas male gender and being a tobacco use were associated with a greater likelihood of testing positive for THC. Individuals with cannabis use disorder (CUD) endorsed more depression and anxiety and had higher AUD symptom counts than cannabis users without CUD.

CONCLUSIONS

The inclusion of cannabis users in AUD samples allows for increased clinical severity. Excluding cannabis users from AUD studies may limit representativeness and expend unnecessary study resources. Lastly, tobacco use may explain a large portion of the effects of cannabis use on sample characteristics.

SHORT SUMMARY

Alcohol and cannabis are frequently co-used substances. In a sample of non-treatment-seeking heavy drinkers (n = 551, 35% female), cannabis users reported higher alcohol use and higher likelihood of tobacco use than non-cannabis users. Including cannabis users in alcohol research studies will improve representativeness and likely increase clinical severity.

Prefrontal-amygdala connectivity in trait anxiety and generalized anxiety disorder: Testing the boundaries between healthy and pathological worries

BACKGROUND

Current brain-based theoretical models of generalized anxiety disorder (GAD) suggest a dysfunction of amygdala-ventromedial prefrontal cortex emotional regulatory mechanisms. These alterations might be reflected by an altered resting state functional connectivity between both areas and could extend to vulnerable non-clinical samples such as high worriers without a GAD diagnosis. However, there is a lack of information in this regard.

METHODS

We investigated differences in resting state functional connectivity between the basolateral amygdala and the ventromedial prefrontal cortex (amygdala-vmPFC) in 28 unmedicated participants with GAD, 28 high-worriers and 28 low-worriers. We additionally explored selected clinical variables as predictors of amygdala-vmPFC connectivity, including anxiety sensitivity.

RESULTS

GAD participants presented higher left amygdala-vmPFC connectivity compared to both groups of non-GAD participants, and there were no differences between the latter two groups. In our exploratory analyses, concerns about the cognitive consequences of anxiety (the cognitive dimension of anxiety sensitivity) were found to be a significant predictor of the left amygdala-vmPFC connectivity.

LIMITATIONS

The cross-sectional nature of our study preclude us from assessing if functional connectivity measures and anxiety sensitivity scores entail an increased risk of GAD.

CONCLUSIONS

These results suggest a neurobiological qualitative distinction at the level of the amygdala-vmPFC emotional-regulatory system in GAD compared to non-GAD participants, either high- or low-worriers. At this neural level, they question previous hypotheses of continuity between high worries and GAD development. Instead, other anxiety traits such as anxiety sensitivity might confer a greater proneness to the amygdala-vmPFC connectivity alterations observed in GAD.

Internet-based psychodynamic therapy vs cognitive behavioural therapy for social anxiety disorder: A preference study

OBJECTIVE

Both Internet-delivered cognitive behavioural therapy (ICBT) and Internet-delivered psychodynamic psychotherapy (IPDT) have shown promise in the treatment of social anxiety disorder (SAD). However, little is known about client preferences and what predicts treatment outcome. The objective of the present pilot study was to examine preference for ICBT versus IPDT in the treatment of SAD and whether participants' preference strength and therapeutic alliance predicted treatment response. Further, we also investigated the effect of the two treatments, including 6-months follow-up.

METHOD

Thirty-six participants were instructed to choose between either IPDT or ICBT based on a brief description. Both treatments were 10 weeks long. Liebowitz Social Anxiety Scale - Self Report was used as the primary outcome measure.

RESULTS

IPDT (N = 23; 63.9%) was preferred more often than ICBT (N = 13; 36.1%), but the difference did not reach statistical significance (p = .10). Preference strength did not predict the treatment effect but therapeutic alliance did. The observed within-group effects for the treatment period were d = 0.40 [-0.21, 0.99] for the IPDT group and d = 0.53 [-0.29, 1.31] for the ICBT group. An intention-to-treat (ITT) analysis revealed no significant difference between the two treatments on any outcome measure at either post-treatment or at six months follow-up.

CONCLUSION

The present pilot study did not find a difference in preference for IPDT or ICBT in the treatment of SAD and both treatments resulted in small to moderate improvements in symptoms of SAD. Preference strength might not predict treatment effect, but this needs to be tested in larger studies.

Prevalence, comorbidity, and breed differences in canine anxiety in 13,700 Finnish pet dogs

Behaviour problems and anxieties in dogs decrease their quality of life and may lead to relinquishment or euthanasia. Considering the large number of pet dogs and the commonness of these problematic behaviours, a better understanding of the epidemiology and related molecular and environmental factors is needed. We have here studied the prevalence, comorbidity, and breed specificity of seven canine anxiety-like traits: noise sensitivity, fearfulness, fear of surfaces and heights, inattention/impulsivity, compulsion, separation related behaviour and aggression with an online behaviour questionnaire answered by dog owners. Our results show that noise sensitivity is the most common anxiety-related trait with a prevalence of 32% in 13,700 Finnish pet dogs. Due to the high prevalence of noise sensitivity and fear, they were the most common comorbidities. However, when comparing the relative risk, the largest risk ratios were seen between hyperactivity/inattention, separation related behaviour and compulsion, and between fear and aggression. Furthermore, dog breeds showed large differences in prevalence of all anxiety-related traits, suggesting a strong genetic contribution. As a result, selective breeding focusing on behaviour may reduce the prevalence of canine anxieties. Anxious animals may suffer from chronic stress and thus, modified breeding policies could improve the welfare of our companion dogs.

Connecting During COVID-19: A Protocol of a Volunteer-Based Telehealth Program for Supporting Older Adults' Health

Introduction: Social-distancing due to COVID-19 has led to social isolation, stress, and mental health issues in older adults, while overwhelming healthcare systems worldwide. Telehealth involving phone calls by trained volunteers is understudied and may be a low-cost, scalable, and valuable preventive tool for mental health. In this context, from patient participatory volunteer initiatives, we have adapted and developed an innovative volunteer-based telehealth intervention program for older adults (TIP-OA). Methods and analysis: To evaluate TIP-OA, we are conducting a mixed-methods longitudinal observational study. Participants: TIP-OA clients are older adults (age ≥ 60) recruited in Montreal, Quebec. Intervention: TIP-OA volunteers make weekly friendly phone calls to seniors to check in, form connections, provide information about COVID-19, and connect clients to community resources as needed. Measurements: Perceived stress, fear surrounding COVID-19, depression, and anxiety will be assessed at baseline, and at 4- and 8-weeks. Semi-structured interviews and focus groups will be conducted to assess the experiences of clients, volunteers, and stakeholders. Results: As of October 15th, 2020, 150 volunteers have been trained to provide TIP-OA to 305 older clients. We will consecutively select 200 clients receiving TIP-OA for quantitative data collection, plus 16 volunteers and 8 clinicians for focus groups, and 15 volunteers, 10 stakeholders, and 25 clients for semi-structured interviews. Discussion: During COVID-19, healthcare professionals' decreased availability and increased needs related to geriatric mental health are expected. If successful and scalable, volunteer-based TIP-OA may help prevent and improve mental health concerns, improve community participation, and decrease healthcare utilization. Clinical Trial Registration: ClinicalTrials.gov NCT04523610; https://clinicaltrials.gov/ct2/show/NCT04523610?term=NCT04523610&draw=2&rank=1.

Biological and Clinical Markers to Differentiate the Type of Anxiety Disorders

The present chapter is an overview of possible biomarkers which distinguish anxiety disorders as classified by the DSM-5. Structural or activity changes in the brain regions; changes in N-acetylaspartate/creatine, dopamine, serotonin, and oxytocin; hearth rate variability; hypothalamic-pituitary-adrenal axis activity; error-related negativity; respiratory regulation; and genetic variants are proposed. However, their clinical utility is questionable due to low specificity and sensitivity: the majority does not distinguish subjects with different anxiety disorders, and they might be influenced by stress, comorbidity, physical activity, and psychotropic medications. In this framework, the staging model, a clinimetric tool which allows to define the degree of progression of a disease at a point in time and where the patient is located on the continuum of the course of the disease, is proposed since several DSM anxiety disorders take place at different stages of the same syndrome according to the staging model. Thus, a stage-specific biomarker model for anxiety disorders is hypothesized and illustrated.

The Üstikuddus sherbiti in the treatment of abnormal cold and dry-type depression patients with comorbid anxiety: A randomized and controlled clinical trial

Objective: To evaluate the clinical effect of Üstikuddus sherbiti (US), a traditional herbal prescription of Uyghur medicine, in the treatment of cold and dry-type major depression disorder (MDD) patients with comorbid anxiety.

Methods: A total of 150 cold and dry-type depressive patients with comorbid anxiety were randomly divided into three groups of 50 patients; then they were, respectively, treated with US, modern medicine Fluoxetine, and the combination of Fluoxetine and US. The depression degrees of patients were evaluated zero and six weeks after the treatment based on the Hamilton Anxiety Scale (HAMA), in the clinical study. Analysis of variance (ANOVA) was used to detect significant differences at various time points or among the three groups. Statistical analysis was performed by SPSS version 21.0.

Results: The main results are as follows: After taking the medicine, the depressive condition of patients with comorbid anxiety in the three groups was getting better with the passage of time; particularly, the clinical efficacy of US combined with Fluoxetine was significantly improved, indicating that the effect of combined treatment is better than treatment with pure Fluoxetine or pure US treatment. Statistical difference exists between the end time point within groups, but not among the three groups. Moreover, in the detection process of the patient’s physical indicators, no obvious side effects were found. These results together suggested that US can strengthen the curative effect of modern medicine in the treatment of depression, which would lay a foundation for studying the molecular mechanism and potential target of US.

Conclusion: Fluoxetine and US combination therapy played a significant role in the treatment of depressive symptoms, suggesting that it can improve the curative effect of depression. The study provided a new way of thinking to clarify the US molecular mechanism for the treatment of depression and potential target.

The relationship between obsessive-compulsive disorder and anxiety disorders: A question of diagnostic boundaries or simply severity of symptoms?

BACKGROUND

A growing number of studies are questioning the validity of current DSM diagnoses, either as "discrete" or distinct mental disorders and/or as phenotypically homogeneous syndromes. In this study, we investigated how symptom domains in patients with a main diagnosis of obsessive-compulsive disorder (OCD), panic disorder (PD) and social anxiety disorder (SAD) coaggregate. We predicted that symptom domains would be unrelated to DSM diagnostic categories and less likely to cluster with each other as severity increases.

METHODS

One-hundred eight treatment seeking patients with a main diagnosis of OCD, SAD or PD were assessed with the Dimensional Obsessive-Compulsive Scale (DOCS), the Social Phobia Inventory (SPIN), the Panic and Agoraphobia Scale (PAS), the Anxiety Sensitivity Index-Revised (ASI-R), and the Beck Depression and Anxiety Inventories (BDI and BAI, respectively). Subscores generated by each scale (herein termed "symptom domains") were used to categorize individuals into mild, moderate and severe subgroups through K-means clusterization and subsequently analysed by means of multiple correspondence analysis.

RESULTS

Broadly, we observed that symptom domains of OCD, SAD or PD tend to cluster on the basis of their severities rather than their DSM diagnostic labels. In particular, symptom domains and disorders were grouped into (1) a single mild "neurotic" syndrome characterized by multiple, closely related and co-occurring mild symptom domains; (2) two moderate (complicated and uncomplicated) "neurotic" syndromes (the former associated with panic disorder); and (3) severe but dispersed "neurotic" symptom domains.

CONCLUSION

Our findings suggest that symptoms domains of treatment seeking patients with OCD and anxiety disorders tend to be better conceptualized in terms of severity rather than rigid diagnostic boundaries.

Multimodal canonical correlation reveals converging neural circuitry across trauma-related disorders of affect and cognition

Trauma-related disorders of affect and cognition (TRACs) are associated with a high degree of diagnostic comorbidity, which may suggest that these disorders share a set of underlying neural mechanisms. TRACs are characterized by aberrations in functional and structural circuits subserving verbal memory and affective anticipation. Yet, it remains unknown how the neural circuitry underlying these multiple mechanisms contribute to TRACs. Here, in a sample of 47 combat Veterans, we measured affective anticipation using functional magnetic resonance imaging (fMRI), verbal memory with fluorodeoxyglucose positron emission tomography (FDG-PET), and grey matter volume with structural magnetic resonance imaging (sMRI). Using a voxel-based multimodal canonical correlation analysis (mCCA), the set of neural measures were statistically integrated, or fused, with a set of TRAC symptom measures including mild traumatic brain injury (mTBI), posttraumatic stress, and depression severity. The first canonical correlation pair revealed neural convergence in clusters encompassing the middle frontal gyrus and supplemental motor area, regions implicated in top-down cognitive control and affect regulation. These results highlight the potential of leveraging multivariate neuroimaging analysis for linking neurobiological mechanisms associated with TRACs, paving the way for transdiagnostic biomarkers and targets for treatment.

Transdiagnostic Symptom Clusters and Associations With Brain, Behavior, and Daily Function in Mood, Anxiety, and Trauma Disorders

IMPORTANCE

The symptoms that define mood, anxiety, and trauma disorders are highly overlapping across disorders and heterogeneous within disorders. It is unknown whether coherent subtypes exist that span multiple diagnoses and are expressed functionally (in underlying cognition and brain function) and clinically (in daily function). The identification of cohesive subtypes would help disentangle the symptom overlap in our current diagnoses and serve as a tool for tailoring treatment choices.

OBJECTIVE

To propose and demonstrate 1 approach for identifying subtypes within a transdiagnostic sample.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from the Brain Research and Integrative Neuroscience Network Foundation Database that had been collected at the University of Sydney and University of Adelaide between 2006 and 2010 and replicated at Stanford University between 2013 and 2017. The study included 420 individuals with a primary diagnosis of major depressive disorder (n = 100), panic disorder (n = 53), posttraumatic stress disorder (n = 47), or no disorder (healthy control participants) (n = 220). Data were analyzed between October 2016 and October 2017.

MAIN OUTCOMES AND MEASURES

We followed a data-driven approach to achieve the primary study outcome of identifying transdiagnostic subtypes. First, machine learning with a hierarchical clustering algorithm was implemented to classify participants based on self-reported negative mood, anxiety, and stress symptoms. Second, the robustness and generalizability of the subtypes were tested in an independent sample. Third, we assessed whether symptom subtypes were expressed at behavioral and physiological levels of functioning. Fourth, we evaluated the clinically meaningful differences in functional capacity of the subtypes. Findings were interpreted relative to a complementary diagnostic frame of reference.

RESULTS

Four hundred twenty participants with a mean (SD) age of 39.8 (14.1) years were included in the final analysis; 256 (61.0%) were female. We identified 6 distinct subtypes characterized by tension (n=81; 19%), anxious arousal (n=55; 13%), general anxiety (n=38; 9%), anhedonia (n=29; 7%), melancholia (n=37; 9%), and normative mood (n=180; 43%), and these subtypes were replicated in an independent sample. Subtypes were expressed through differences in cognitive control (F5,383 = 5.13, P < .001, ηp2 = 0.063), working memory (F5,401 = 3.29, P = .006, ηp2 = 0.039), electroencephalography-recorded β power in a resting paradigm (F5,357 = 3.84, P = .002, ηp2 = 0.051), electroencephalography-recorded β power in an emotional paradigm (F5,365 = 3.56, P = .004, ηp2 = 0.047), social functional capacity (F5,414 = 21.33, P < .001, ηp2 = 0.205), and emotional resilience (F5,376 = 15.10, P < .001, ηp2 = 0.171).

CONCLUSIONS AND RELEVANCE

These findings offer a data-driven framework for identifying robust subtypes that signify specific, coherent, meaningful associations between symptoms, behavior, brain function, and observable real-world function, and that cut across DSM-IV-defined diagnoses of major depressive disorder, panic disorder, and posttraumatic stress disorder.

Exclusion criteria and generalizability in bipolar disorder treatment trials

Objective

The current paper reviews the English-language research on exclusion criteria in bipolar disorder treatment trials and discusses how study samples compare to the general bipolar patient population.

Methods

& Results: Across 8 identified studies of exclusion criteria and their impact, between 55% and 96% of people with bipolar disorder would be excluded from treatment research. The number of exclusion criteria varies across bipolar disorder treatment research, with one study estimate of a median of 7 criteria used across studies. The criteria that excluded the greatest number of potential participants were comorbid substance use disorder, suicidal risk, and comorbid medical conditions. Both studies that compared treatment responses among participants who met and did not meet exclusion criteria found no statistically significant differences.

Conclusions

Most potential participants are excluded from outcome research, which creates challenges for recruitment and limits generalizability of study findings. Common exclusionary practices lead to unrepresentative samples that limit generalizability and reduce the confidence of clinicians that findings can be translated to front-line practice with bipolar disorder patients.