Establishing how psychological therapies work: the importance of mediation analysis

One-year follow-up of the effectiveness and mediators of cognitive behavioural therapy among adults with attention-deficit/hyperactivity disorder: secondary outcomes of a randomised controlled trial

BACKGROUND

The long-term effectiveness of cognitive behavioural therapy (CBT) in medicated attention-deficit/hyperactivity disorder (ADHD) adults with residual symptoms needs to be verified across multiple dimensions, especially with respect to maladaptive cognitions and psychological quality of life (QoL). An exploration of the mechanisms underlying the additive benefits of CBT on QoL in clinical samples may be helpful for a better understanding of the CBT conceptual model and how CBT works in medicated ADHD.

METHODS

We conducted a secondary analysis of a randomised controlled trial including 98 medicated ADHD adults with residual symptoms who were randomly allocated to the CBT combined with medication (CBT + M) group or the medication (M)-only group. Outcomes included ADHD-core symptoms (ADHD Rating Scale), depression symptoms (Self-rating Depression Scale), maladaptive cognitions (Automatic Thoughts Questionnaire and Dysfunctional Attitude Scale), and psychological QoL (World Health Organization Quality of Life-Brief Version-psychological domain). Mixed linear models (MLMs) were used to analyse the long-term effectiveness at one-year follow-up, and structural equation modeling (SEM) was performed to explore the potential mechanisms of CBT on psychological QoL.

RESULTS

ADHD patients in the CBT + M group outperformed the M-only group in reduction of ADHD core symptoms (d = 0.491), depression symptoms (d = 0.570), a trend of reduction of maladaptive cognitions (d = 0.387 and 0.395, respectively), and improvement of psychological QoL (d = - 0.433). The changes in above dimensions correlated with each other (r = 0.201 ~ 0.636). The influence of CBT on QoL was mediated through the following four pathways: 1) changes in ADHD core symptoms; 2) changes in depressive symptoms; 3) changes in depressive symptoms and then maladaptive cognitions; and 4) changes firstly in depressive symptoms, maladaptive cognitions, and then ADHD core symptoms.

CONCLUSIONS

The long-term effectiveness of CBT in medicated ADHD adults with residual symptoms was further confirmed. The CBT conceptual model was verified in clinical samples, which would be helpful for a deeper understanding of how CBT works for a better psychological QoL outcome.

TRIAL REGISTRATION

ChiCTR1900021705 (2019-03-05).

Acceptance and Fear-Avoidance Mediate Outcomes of Interdisciplinary Pain Rehabilitation Programs at 12-Month Follow-Up: A Clinical Registry-Based Longitudinal Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Background

Factors that influence outcomes of interdisciplinary pain rehabilitation programs (IPRP) are poorly known. It is unclear how outcomes are influenced by pain intensity, psychological distress, and coping strategies.

Aim

This clinical registry-based longitudinal cohort study has three aims: 1) to determine the relative importance of pain intensity, psychological distress, acceptance, and fear-avoidance for changes in three outcomes of IPRP at 12-month follow-up; 2) to investigate whether the effects of pain intensity and psychological distress on the three outcomes are mediated via acceptance and fear-avoidance; and 3) to determine whether sex is a moderator.

Methods

This study uses Patient-Reported Outcome Measures (PROMs) from specialist units reporting data (2008-2016) to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Adult chronic pain patients (N = 1991) answered the PROMs (background, pain, psychological distress, coping, participation, and health-related quality of life (HRQoL)). Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to explore the aims.

Results

Changes in acceptance (β:0.424-0.553; all P<0.001) were the strongest predictor of the three outcomes (changes in life control, interference, and HRQoL) at 12-month follow-up. The next strongest predictor was baseline acceptance (β: 0.177-0.233; all P<0.001) and changes in fear-avoidance (β: -0.152- -0.186; all P<0.001). Baseline pain intensity and psychological distress showed weak positive associations. Their effects on the three outcomes were mediated via acceptance aspects. Sex was not a moderator.

Discussion and Conclusion

Acceptance aspects (baseline and changes) were important predictors of IPRP outcomes. Changes in fear-avoidance were also important although to a lesser degree. Some of the effects of pain intensity and psychological distress on outcomes were mediated via acceptance at baseline. Future PLS-SEM analysis of real-world IPRP should include more potential mediators (eg, catastrophizing and more facets of psychological flexibility and fear-avoidance) and the components of IPRP.

A rule-based theoretical account of social stories to address the double empathy problem

Social Stories™ (SS) is one of the most popular and researched interventions for autistic children. To date, research that focuses on outcomes has been prioritized over the investigation of the psychological mechanisms that inform the intervention. In this article we consider theoretical accounts proposed thus far which could underpin SS. We argue that mechanisms that are based on social deficit theories lack validity, and propose a rule-based theoretical account to inform a strengths-based approach toward conceptualizing the mechanisms that underpin SS. We apply this account to the 'double-empathy problem' to propose that SS can be adapted to involve all parties in the development and delivery of SS support by adopting a rule-based perspective. We use the example of systemizing (the drive to analyze and explore systems in terms of 'if-and-then' rules), which is proposed to be a relative autistic strength, as a form of rule-based thinking that can provide a theoretical account of SS and a framework to address the double-empathy problem.

Does cognitive improvement translate into functional changes? Exploring the transfer mechanisms of cognitive remediation therapy for euthymic people with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with cognitive and functional difficulties, persistent beyond mood episodes. Cognitive remediation (CR) is a psychological therapy targeting cognitive and functioning difficulties. Recent evidence suggests that CR may enhance long-term functioning but transfer mechanisms on functional outcomes have not been explored. We aim to investigate whether and how cognitive gains after CR transfer to functional improvement.

METHODS

We considered data from a randomized controlled trial comparing CR (n = 40) to treatment-as-usual (TAU; n = 40) in euthymic people with BD. Treatment outcomes included individual cognitive domains and global cognition, psychosocial functioning, and goal attainment. Regression-based mediation and moderation modelling were used to assess whether and how post-treatment cognitive changes translate into functional improvement at follow-up, three months after treatment end.

RESULTS

Cognitive gains after CR transferred to functional changes three months later: improvement in post-treatment global cognition partially mediated the effect of CR on psychosocial functioning (standardized indirect effect: -0.23, 95% CI -0.51 to -0.04). Goal attainment was not significantly mediated by changes in cognition, but post-treatment cognitive performance moderated the effect of CR on the GAS at follow-up (interaction effect: 0.78, 95% CI 0.08-1.55).

CONCLUSIONS

Our findings suggest that cognitive improvements contribute to functional improvement but transfer mechanisms differ between psychosocial functioning and idiosyncratic recovery goals. Cognition accounted for only a proportion of the total CR effect on functional outcomes. Future studies should consider other variables, such as metacognition, that may drive the transfer of CR effects to functional outcomes.

Understanding the Mental Health Impacts of the COVID-19 Pandemic on Railway Workers: Risks and Protective Factors

OBJECTIVE

Railway workers have provided an essential service throughout the COVID-19 pandemic. This study explored the effects of COVID-19 on the mental well-being of railway workers (N = 906) in the United Kingdom during the third lockdown period.

METHOD

The online survey included measures of COVID-19-related risk factors (perceived risk, stress, burnout, trauma) and protective factors (resilience coping, team resilience, general help seeking) associated with mental well-being. Responses were analyzed using multiple regression and content analysis.

RESULTS

COVID-19-related risk factors negatively predicted well-being. Higher scores on adaptive resilience, intentions to seek help, and team resilience significantly predicted higher mental well-being scores. Mental health decline throughout the COVID-19 pandemic and concerns for the future were reported.

CONCLUSIONS

Building a resilient railway workforce requires attention to staff mental well-being and to ensuring that support systems are robust and accessible.

A structural equation model in adults with type 1 and 2 diabetes: exploring the interplay of psychological states and diabetes outcomes, and the mediating effect of resilience

AIMS

Type 1 and 2 diabetes mellitus (T1DM and T2DM) can lead to emotional distress and cognitive impairments, often caused by psychological factors such as low mood or anxiety; yet, few studies have explored the theoretical mechanisms underlying these relationships and within one study. This study explored the relationships between psychological states (anxiety/worry, fatigue) and diabetes outcomes (diabetes distress, cognitive dysfunction), and whether resilience mediated the association between these in T1DM and T2DM.

METHODS

A sample of 307 UK adults with a clinical diagnosis of diabetes (T1DM = 129; T2DM = 178) completed a cross-sectional online survey, composed of six questionnaires. Associations between variables were investigated using Pearson's correlations and Structural Equation Modelling (SEM).

RESULTS

Psychological states were significantly correlated with diabetes outcomes, and resilience was significantly related to both psychological states and diabetes outcomes. The SEM model achieved an acceptable model fit with a significant mediating effect of resilience between psychological states (anxiety/worry, fatigue) and diabetes outcomes (diabetes distress, cognitive dysfunction), with no significant differences between diabetes type.

CONCLUSIONS

We propose a new theoretical model of T1DM and T2DM that could be used to provide guidance for those designing interventions. These findings help to understand the complex nature of diabetes management, suggesting resilience could be a key factor in managing psychological states and diabetes outcomes.

Transdiagnostic therapy for persistent physical symptoms: A mediation analysis of the PRINCE secondary trial

The PRINCE secondary trial did not find any evidence that transdiagnostic cognitive behavioural therapy (TDT-CBT) plus standard medical care (SMC) was more efficacious than SMC for patients with Persistent Physical Symptoms (PPS) for the primary outcome Work and Social Adjustment Scale (WSAS) at final follow-up (52 weeks). There was a significant treatment effect for TDT-CBT plus CBT compared with SMC for two secondary outcomes: WSAS at the end of active treatment (20 weeks) and symptom severity (Patient Health Questionnaire, PHQ-15) at 52 weeks. To understand mechanisms that lead to effects of TDT-CBT plus SMC versus SMC we performed a planned secondary mediation analysis. We investigated whether TDT-CBT treatment effects on these two secondary outcomes at the end of the treatment could be explained by effects on variables that were targeted by TDT-CBT during the initial phase of treatment. We pre-specified mediator variables measured at mid-treatment (9 weeks). Reductions in catastrophising and symptom focusing were the strongest mediators of TDT-CBT treatment effects on WSAS at the end of treatment. Improvements in symptom focusing also mediated the effect of TDT-CBT on PHQ-15. Future developments of the TDT-CBT intervention could benefit from targeting these mediators.

Assessing an Internet-Delivered, Emotion-Focused Intervention Compared With a Healthy Lifestyle Active Control Intervention in Improving Mental Health in Cancer Survivors: Protocol for a Randomized Controlled Trial

BACKGROUND

Cancer survivors are vulnerable to experiencing symptoms of anxiety and depression and may benefit from accessible interventions focused on improving emotion regulation. CanCope Mind (CM) was developed as an internet-delivered intervention adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders to improve emotion regulation and support the mental health of cancer survivors.

OBJECTIVE

This protocol aims to provide an outline of the CanCope Study, a trial comparing the efficacy of a Unified Protocol-adapted internet-delivered intervention (CM) designed for cancer survivors compared with an active control condition-an internet-delivered healthy lifestyle intervention, CanCope Lifestyle (CL). The primary aim is to assess and compare the efficacy of both interventions in improving emotion regulation, anxiety and depressive symptoms, and quality of life. The secondary aims involve assessing the mechanisms of the CM intervention.

METHODS

This trial is a 2-arm randomized controlled trial that allocates cancer survivors to either CM or CL. Both interventions comprise 4 web-based modules and are expected to take participants at least 8 weeks to complete. Participants' mental and physical health will be assessed via self-reported surveys at baseline (T0), between each module (T1, T2, and T3), immediately after the intervention (T4), and at 3-month follow-up (T5). The study aims to recruit 110 participants who have completed T4.

RESULTS

The CanCope study began recruitment in September 2020. A total of 224 participants have been randomized to the CM (n=110, 49.1%) and CL (n=114, 50.9%) groups.

CONCLUSIONS

This is one of the first trials to develop and investigate the efficacy of a web-based intervention for cancer survivors that specifically targets emotion regulation.

TRIAL REGISTRATION

Australian Clinical Trials ACTRN12620000943943; https://tinyurl.com/b3z9cjsp.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36658.

The role of self-efficacy and self-esteem in mediating positive associations between functional social support and psychological wellbeing in people with a mental health diagnosis

BACKGROUND

Previous research has observed positive associations between perceived quality of social support and mental well-being. Having access to functional social support that provides sources of care, compassion and helpful information have shown to be beneficial for mental health. However, there is a need to identify the psychological processes through which functional social support can elicit therapeutic outcomes on mental well-being.

AIMS

The present cross-sectional study aimed to examine the extent to which self-efficacy and self-esteem mediated the association between functional social support and mental well-being.

METHOD

Seventy-three people with a mental health diagnosis, who attended group-based activities as facilitated by a third sector community mental health organisation, took part in the present study. Participants were required to complete measures that assessed perceived quality of functional social support, self-efficacy, self-esteem, and subjective mental well-being.

RESULTS

A multiple mediation analysis revealed that self-efficacy and self-esteem fully mediated the positive association between perceived functional social support and mental well-being.

CONCLUSIONS

The implications of these results are that social interventions, which aim to facilitate the delivery of functional social support, could enhance mental well-being via their positive effects on self-efficacy and self-esteem.

Determining the potential link of self-compassion with eating pathology and body image among women: a longitudinal mediational study

PURPOSE

This longitudinal study aims to determine what factors mediate the previously established link between self-compassion and eating pathology/body image concerns, over a 6-month period.

METHODS

A community sample of 274 adult women (M = 29.50 years) completed standardised validated measures of self-compassion (Self-Compassion Scale), rumination (Ruminative Thought Style Questionnaire), shame (Other as Shamer Scale), perfectionism (Short Form of the Revised Almost Perfect Scale), self-criticism (Levels of Self-Criticism Scale), eating pathology (Eating Disorder Examination Questionnaire) and body image (Body Shape Questionnaire). They reported levels of: self-compassion at Time 1, potential mediators (rumination, shame, self-criticism, perfectionism) at 3 months; and eating pathology and body dissatisfaction a further 3 months later. Missing data were handled using multiple imputation. Stepwise multiple regression showed that shame was the most consistent mediator.

RESULTS

Shame acted as a full mediator of the self-compassion-eating/body image relationship {respectively, [B = .04, SE = .01, t(268) = 3.93, p < .001], [B = .33, SE = .15, t(268) = 2.25, p < .05]}. Discrepancy perfectionism also played a mediating role in the link between self-compassion and body image dissatisfaction [B = .59, SE = .28, t(268) = 2.10, p < .05].

CONCLUSION

These results support the hypothesis that self-compassion is relevant to eating pathology and body image disturbance, and demonstrate that shame is an important mechanism in that relationship. This pattern suggests that interventions that reduce shame should be considered when addressing issues relating to self-compassion and its links to eating disorders.

LEVEL OF EVIDENCE

Level IV, multiple time series without intervention.

Resilience and Mental Health in the Polish Population during the COVID-19 Lockdown: A Mediation Analysis

The aim of this paper was to assess the state of resilience and well-being in the Polish population during the COVID-19 pandemic. We also assessed the relationship between resilience and mental health. Finally, we tested the mediating role of COVID-19 anxiety, persistent thinking, and the stress burden in the relationship between mental health and resilience. This research perspective can provide important insights into how individuals can become mentally stronger during the COVID-19 pandemic.

METHODS

This study included 1758 people (73% women) aged 18-80 years. The procedure consisted of completing a questionnaire measuring well-being, COVID-19 anxiety, obsession with COVID-19, stress over COVID-19, and resilience.

RESULTS

Bootstrap sampling analysis showed significant partial mediators for the relationship between resilience and well-being. Important mediators were coronavirus anxiety, persistent thinking, and perceived stress.

CONCLUSIONS

The results of the present study clearly indicate that resilience as a protective factor is associated with reduced anxiety about COVID-19, perceived stress burden, obsessive thoughts about the pandemic, and increased well-being of individuals. Resilience plays an important role in minimizing negative and enhancing positive health indicators in the face of challenging life events.

Determining the potential links of self-compassion with eating pathology and body image among women and men: A cross-sectional mediational study

This study examined whether rumination, shame, self-criticism, and perfectionism mediate the previously established link between self-compassion and both eating and body image concerns. A cross-sectional online survey was completed by a community sample of non-clinical adult women (n = 369) and men (n = 201). Participants completed standardised measures of self-compassion (predictor), rumination, external shame, perfectionism and self-criticism (mediating variables), and eating pathology and body image (criterion variables). Path analyses confirmed that higher self-compassion was serially linked to lower eating pathology and body dissatisfaction through comparative self-criticism and external shame. Compared with women, the association between higher self-compassion and lower body dissatisfaction was weaker in men. However, there were no mediating effects of rumination, perfectionism, or internalized self-criticism. Overall results indicate notable similarities between women and men, and emphasise the potential value of targeting external shame during eating disorder prevention and treatment. Longitudinal study of these constructs is warranted in future research.

Power and Sample Size Determination for Multilevel Mediation in Three-Level Cluster-Randomized Trials

Mediation analyses supply a principal lens to probe the pathways through which a treatment acts upon an outcome because they can dismantle and test the core components of treatments and test how these components function as a coordinated system or theory of action. Experimental evaluation of mediation effects in addition to total effects has become increasingly common but literature has developed only limited guidance on how to plan mediation studies with multi-tiered hierarchical or clustered structures. In this study, we provide methods for computing the power to detect mediation effects in three-level cluster-randomized designs that examine individual- (level one), intermediate- (level two) or cluster-level (level three) mediators. We assess the methods using a simulation and provide examples of a three-level clinic-randomized study (individuals nested within therapists nested within clinics) probing an individual-, intermediate- or cluster-level mediator using the R package PowerUpR and its Shiny application.

Attachment-related dimensions in the epigenetic era: A systematic review of the human research

In recent years, an increasing number of studies documented potential links between parental care and epigenetic mechanisms. The present systematic review focuses on the potential association and interrelationship between attachment-related dimensions and DNA methylation in human studies. We performed a literature review using electronic databases such as PubMed, Scopus, Web of Science, and EBSCOhost. Thirteen papers were included in the review. Findings support significant associations between attachment-related dimensions and epigenetic status in studies which considered different populations, age ranges, attachment measures and peripheral tissues. Although research in this area is still under investigation, available results suggest that DNA methylation associated with attachment-related dimensions might affect the development of stress regulation system and social-emotional capacities, thus contributing to the emerging phenotypic outcomes. However, identifying mediator and moderator effects in the interrelationship between these parameters was problematic owing to heterogeneous methodologies. Finally, we discuss clinical implications, unanswered questions, and future directions for human development in epigenetics research.

Brief mindfulness-based training and mindfulness trait attenuate psychological stress in university students: a randomized controlled trial

BACKGROUND

Psychological distress in University settings has grown and became a public health concern. In this context, contemplative practices such as mindfulness have been proposed as a strategy to help students on stress management.

METHODS

Forty university students (20 female), aged between 18 to 30 years (mean = 24.15; SD = 3.56), with no previous experience with meditation or yoga were recruited at the Federal University of Rio Grande do Norte and randomized to a mindfulness training (MT) or active control (AC) groups. We analyzed measures of anxiety, affect, stress, as well as state and trait mindfulness in order to evaluate the effects of trait mindfulness and a brief mindfulness intervention in forty healthy young students. Participants were classified as Low (n = 27, females = 13) or High (n = 13, females = 7) Trait Mindfulness by k-means clustering and compared between them using Wilcoxon sum rank test. Furthermore, the sample was randomly allocated to an AC (n = 20, females = 10) or a MT (n = 20, females = 10) group, and mixed analysis of variance was performed to analyze the effect of interventions. The mechanisms and role of trait mindfulness in the intervention was assessed by a moderated mediation analysis.

RESULTS

We found that High Trait individuals have lower anxiety trait, anxiety state and perceived stress levels. Only the MT group reduced their anxiety state and perceived stress after the intervention and increased their state mindfulness. Both groups reduced negative affect and cortisol, and no change was found in positive affect. Moderated mediation analysis showed that the training-induced change in state mindfulness mediated the increase in positive affect and the decrease in perceived stress and cortisol, regardless of trait mindfulness. For anxiety state the decrease only occurred in individuals with High Trait Mindfulness.

CONCLUSIONS

Together, these results suggest that higher trait mindfulness is associated with low levels of psychological distress and that a brief mindfulness-based intervention seems to be useful to reduce distress measures in university students.

TRIAL REGISTRATION

ReBEC, U1111-1194-8661. Registered 28 March 2017-Retrospectively registered, http://www.ensaiosclinicos.gov.br/rg/RBR-7b8yh8.

Perceived Risk and Mental Health Problems among Healthcare Professionals during COVID-19 Pandemic: Exploring the Mediating Effects of Resilience and Coronavirus Fear

During coronavirus (COVID-19) pandemic, healthcare professionals were particularly at high-risk of developing symptoms of mental health problems due to being on the frontline in the battle against COVID-19. This study examined the mediating roles of resilience and coronavirus fear in the relationship between perceived risk and mental health problems among healthcare professionals including doctors and nurses who were actively treating patients confirmed with COVID-19. We recruited 204 healthcare professionals (50% females) with a mean age of 32.92 years (SD = 7.01). Results showed that perceived risk and coronavirus fear positively predicted depression, anxiety, and stress while resilience negatively predicted those mental health problems. Coronavirus fear mediated the relationship between perceived risk and resilience, depression, anxiety, and stress. Additionally, resilience mitigated the effect of coronavirus fear on depression, anxiety, and stress. This study is among the first indicating the importance of resilience and fear as a critical mechanism that explains the relationship between perceived risk and mental health problems among health professionals directly caring for COVID-19 patients.

Statistical power in partially nested designs probing multilevel mediation

Objective: Analysis of the intermediate behaviors and mechanisms through which innovative therapies come to shape outcomes is a critical objective in many areas of psychotherapy research because it supports the iterative exploration, development and refinement of theories and therapies. Despite widespread interest in the intermediate behaviors and mechanisms that convey treatment effects, there is limited guidance on how to effectively and efficiently design studies to detect such mediated effects in the types of partially nested designs that commonly arise in psychotherapy research. In this study, we develop statistical power formulas to identify requisite sample sizes and guide the planning of studies probing mediation under two- and three-level partially nested designs. Method: We investigate multilevel mediation in partially nested structures and models for two- and three-level designs. Results: Well-powered studies probing mediation using partially nested designs will typically require moderate to large sample sizes or moderate to large effects. Discussion: We implement these formulas in the R package PowerUpR and a simple Shiny web application (https://poweruprshiny.shinyapps.io/PartiallyNestedMediationPower/) and demonstrate their use to plan studies using partially nested designs.

Spirituality and subjective well-being of Ghanaian parents of children with special needs: The mediating role of resilience

The study explored the mediating role of resilience in the relationship between spirituality and subjective well-being of 107 Ghanaian biological parents raising children with special needs. Results from mediational analyses revealed that spirituality indirectly influenced life satisfaction, positive affect and negative affect through resilience. Specifically, greater levels of spirituality predicted greater resilience, which successively led to greater life satisfaction, greater positive affect and reduced negative affect. These findings emphasize the necessity of targeting parents' well-being through resilience to help them deal with the burden of providing care for their children with special needs.

Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes

One way to improve treatment effects of chronic pain is to identify and improve control over mechanisms of therapeutic change. One treatment approach that includes a specific proposed mechanism is acceptance and commitment therapy (ACT) with its focus on increasing psychological flexibility (PF). The aim of the present study was to examine the role of PF as a mechanism of change in ACT. This is based on mediation analyses of data from a previously reported randomized controlled trial, evaluating the effectiveness of an ACT-based online intervention for chronic pain (ACTonPain). We performed secondary analyses on pretreatment, posttreatment, and follow-up data from 302 adults, receiving a guided (n = 100) or unguided (n = 101) version of ACTonPain, or allocated to the waitlist control group (n = 101). Structural equation modelling and a bias-corrected bootstrap approach were applied to examine the indirect effects of the treatment through pretreatment and posttreatment changes in the latent construct reflecting PF. The latent construct consisted of data from the Chronic Pain Acceptance Questionnaire and the Acceptance and Action Questionnaire. The outcomes were pretreatment to follow-up changes in pain interference, anxiety, depression, pain, and mental and physical health. Structural equation modelling analyses revealed that changes in PF significantly mediated pretreatment to follow-up changes in all outcomes in the intervention groups compared with waitlist (standardized estimates ranged from I0.16I to I0.69I). Global model fit yielded modest but acceptable results. Findings are consistent with the theoretical framework behind ACT and contribute to growing evidence, supporting a focus on PF to optimize treatment effects.

Coping Mechanisms for Psychosomatic Symptoms among Aging Roman Catholic German priests

To identify and investigate coping mechanisms and other factors which may impact upon the psychosomatic symptoms of aging German Roman Catholic priests. A cross-sectional study was conducted among 499 aging German Roman Catholic priests with standardized questionnaires: Brief Symptom Inventory, Coping Inventory Stressful Situations, and Religious Coping Scale. Task-Oriented Coping exhibited a significant difference between the two groups. Multiple regression analyses indicated that psychosomatic symptoms could be best predicted by means of Task-Oriented Coping mechanisms, identification with priesthood, and by a low Negative Religious Coping. The success of adaptive coping processes for older clergy may depend on how they employ strategies, strengthen their spiritual dimensions, and manage important psychosocial aspects of aging. In our sample, Depression and Somatization are explained best by Emotion-Oriented Coping. It is desirable for aging priests to be aware of protective factors like Role Identification, Task-Oriented Coping, and low Negative Religious Coping, which may be helpful in improving their psychological well-being.

Exploring psychological mechanisms of clinical response to an internet-delivered psychological pain management program

BACKGROUND

The evidence for Internet-delivered pain management programs for chronic pain is growing, but there is little empirical understanding of how they effect change. Understanding mechanisms of clinical response to these programs could inform their effective development and delivery.

METHODS

A large sample (n = 396) from a previous randomized controlled trial of a validated internet-delivered psychological pain management program, the Pain Course, was used to examine the influence of three potential psychological mechanisms (pain acceptance, pain self-efficacy, fear of movement/re-injury) on treatment-related change in disability, depression, anxiety and average pain. Analyses involved generalized estimating equation models for clinical outcomes that adjusted for co-occurring change in psychological variables. This was paired with cross-lagged analysis to assess for evidence of causality. Analyses involved two time points, pre-treatment and post-treatment.

RESULTS

Changes in pain-acceptance were strongly associated with changes in three (depression, anxiety and average pain) of the four clinical outcomes. Changes in self-efficacy were also strongly associated with two (anxiety and average pain) clinical outcomes. These findings suggest that participants were unlikely to improve in these clinical outcomes without also experiencing increases in their pain self-efficacy and pain acceptance. However, there was no clear evidence from cross-lagged analyses to currently support these psychological variables as direct mechanisms of clinical improvements. There was only statistical evidence to suggest higher levels of self-efficacy moderated improvements in depression.

CONCLUSIONS

The findings suggest that, while clinical improvements are closely associated with improvements in pain acceptance and self-efficacy, these psychological variables may not drive the treatment effects observed.

SIGNIFICANCE

This study employed robust statistical techniques to assess the psychological mechanisms of an established internet-delivered pain management program. While clinical improvements (e.g. depression, anxiety, pain) were closely associated with improvements in psychological variables (e.g. pain self-efficacy and pain acceptance), these variables do not appear to be treatment mechanisms.

Cognitive behavioural therapy for MS-related fatigue explained: A longitudinal mediation analysis

BACKGROUND

Cognitive behavioural therapy (CBT) effectively reduces fatigue directly following treatment in patients with Multiple Sclerosis (MS), but little is known about the process of change during and after CBT.

DESIGN

Additional analysis of a randomized clinical trial.

OBJECTIVE

To investigate which psychological factors mediate change in fatigue during and after CBT.

METHODS

TREFAMS-CBT studied the effectiveness of a 16-week CBT treatment for MS-related fatigue. Ninety-one patients were randomized (44 to CBT, 47 to the MS-nurse consultations). Mediation during CBT treatment was studied using assessments at baseline, 8 and 16weeks. Mediation of the change in fatigue from post-treatment to follow-up was studied separately using assessments at 16, 26 and 52weeks. Proposed mediators were: changes in illness cognitions, general self-efficacy, coping styles, daytime sleepiness, concentration and physical activity, fear of disease progression, fatigue perceptions, depression and physical functioning. Mediators were separately analysed according to the product-of-coefficients approach. Confidence intervals were calculated with a bootstrap procedure.

RESULTS

During treatment the decrease in fatigue brought on by CBT was mediated by improved fatigue perceptions, increased physical activity, less sleepiness, less helplessness, and improved physical functioning. Post-treatment increases in fatigue levels were mediated by reduced physical activity, reduced concentration, and increased sleepiness.

CONCLUSION

These results suggests that focusing on improving fatigue perceptions, perceived physical activity, daytime sleepiness, helplessness, and physical functioning may further improve the effectiveness of CBT for fatigue in patients with MS. Maintenance of treatment effects may be obtained by focusing on improving physical activity, concentration and sleepiness.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULT

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

CONCLUSIONS

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

Treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis: all roads lead to Rome

This review explores the current evidence on benefits and harms of therapeutic interventions in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and makes recommendations. CFS/ME is a complex, multi-system, chronic medical condition whose pathophysiology remains unknown. No established diagnostic tests exist nor are any FDA-approved drugs available for treatment. Because of the range of symptoms of CFS/ME, treatment approaches vary widely. Studies undertaken have heterogeneous designs and are limited by sample size, length of follow-up, applicability and methodological quality. The use of rintatolimod and rituximab as well as counselling, behavioural and rehabilitation therapy programs may be of benefit for CFS/ME, but the evidence of their effectiveness is still limited. Similarly, adaptive pacing appears to offer some benefits, but the results are debatable: so is the use of nutritional supplements, which may be of value to CFS/ME patients with biochemically proven deficiencies. To summarize, the recommended treatment strategies should include proper administration of nutritional supplements in CFS/ME patients with demonstrated deficiencies and personalized pacing programs to relieve symptoms and improve performance of daily activities, but a larger randomized controlled trial (RCT) evaluation is required to confirm these preliminary observations. At present, no firm conclusions can be drawn because the few RCTs undertaken to date have been small-scale, with a high risk of bias, and have used different case definitions. Further, RCTs are now urgently needed with rigorous experimental designs and appropriate data analysis, focusing particularly on the comparison of outcomes measures according to clinical presentation, patient characteristics, case criteria and degree of disability (i.e. severely ill ME cases or bedridden).