Effectiveness of Psychological and/or Educational Interventions in the Prevention of Anxiety: A Systematic Review, Meta-analysis, and Meta-regression

Efficacy of an Internet- and Mobile-Based Intervention for Subclinical Anxiety and Depression (ICare Prevent) with Two Guidance Formats: Results from a Three-Armed Randomized Controlled Trial

INTRODUCTION

Limited research exists on intervention efficacy for comorbid subclinical anxiety and depressive disorders, despite their common co-occurrence. Internet- and mobile-based interventions (IMIs) are promising to reach individuals facing subclinical symptoms.

OBJECTIVE

This study aimed to evaluate the efficacy of a transdiagnostic and self-tailored IMI in reducing subclinical anxiety and depressive symptom severity with either individualized (IG-IMI) or automated (AG-IMI) guidance compared to a waitlist control group with care-as-usual access (WLC).

METHODS

Participants included 566 adults with subclinical anxiety (GAD-7 ≥ 5) and/or depressive (CES-D ≥16) symptoms, who did not meet criteria for a full-syndrome depressive or anxiety disorder. In a three-arm randomized clinical trial, participants were randomized to a cognitive behavioral 7-session IMI plus booster session with IG-IMI (n = 186) or AG-IMI (n = 189) or WLC (n = 191). Primary outcomes included observer-rated anxiety (HAM-A) and depressive (QIDS) symptom severity 8 weeks after randomization assessed by blinded raters via telephone. Follow-up outcomes at 6 and 12 months are reported.

RESULTS

Symptom severity was significantly lower with small to medium effects in IG-IMI (anxiety: d = 0.45, depression: d = 0.43) and AG-IMI (anxiety: d = 0.31, depression: d = 0.32) compared to WLC. No significant differences emerged between guidance formats in primary outcomes. There was a significant effect in HAM-A after 6 months favoring AG-IMI. On average, participants completed 85.38% of IG-IMI and 77.38% of AG-IMI.

CONCLUSIONS

A transdiagnostic, self-tailored IMI can reduce subclinical anxiety and depressive symptom severity, but 12-month long-term effects were absent. Automated guidance holds promise for enhancing the scalability of IMIs in broad prevention initiatives.

Effectiveness of multiple health behavior change interventions in reducing symptoms of anxiety in the adult population: A systematic review and meta-analysis of randomized controlled trials

There is limited evidence regarding the effectiveness of preventive interventions for anxiety disorders. We aim to test the effectiveness of multiple health behavior change (MHBC) interventions in the reduction of symptoms of anxiety in the adult population. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted by searching the most relevant databases and registry platforms in the area. Reference lists of included articles and relevant systematic reviews and meta-analyses of MHBC interventions that examined anxiety or depression as outcomes were also manually searched. To identify RCTs that evaluated preventive interventions, we excluded studies in which the target population included only patients meeting the diagnostic criteria for anxiety disorders. To pool results, the standardized mean difference (SMD) was calculated using the random effects model. Sensitivity, subgroup and meta-regression analyses were performed. Forty-six RCTs were included in the qualitative synthesis, and 34 RCTs were included in the meta-analysis. Thirty RCTs were focused on promoting healthy diet and physical activity, whereas the other 16 studies also focused on smoking cessation. The pooled SMD was small (-0.183; 95% CI -0.276 to -0.091) but significant (p < 0.001). The effect became non-significant when only studies with a low risk of bias were included. There was substantial and significant heterogeneity between the studies. There is currently insufficient evidence regarding the effectiveness of MHBC interventions to reduce symptoms of anxiety in the adult population.

Generalized anxiety and mild anxiety symptoms in U.S. military veterans: Prevalence, characteristics, and functioning

Generalized anxiety disorder (GAD) is a mental disorder characterized by excessive anxiety and worries that impair daily functioning. While prior work has documented the prevalence and correlates of GAD and subthreshold GAD (SGAD) in clinical samples, contemporary data on the epidemiology of anxiety symptoms are lacking, particularly in higher-risk populations such as military veterans. To address this gap, we analyzed data from a large, nationally representative sample of U.S. veterans to examine the: prevalence of probable GAD and mild anxiety symptoms measured using a brief screener; sociodemographic and military characteristics associated with anxiety symptoms; and psychiatric and functional correlates of anxiety symptoms. Results revealed that a total of 7.9% (95% confidence interval [CI] = 6.7-9.3%) and 22.1% (95%CI = 20.5-23.9%) of veterans screened positive for probable GAD and mild anxiety symptoms, respectively. Relative to veterans without anxiety symptoms, those with probable GAD and mild anxiety symptoms were younger, more likely to be female and racial/ethnic minorities, and more likely to have served 2+ deployments. Further, a "dose-response" association was observed between anxiety symptom severity and clinical correlates, with robust associations observed between probable GAD and poorer mental health, suicidal thoughts and behaviors, and functional impairment. Mild anxiety symptoms showed intermediate magnitude associations with these outcomes. Results of this study suggest that 3-of-10 U.S. veterans report anxiety symptoms. While the use of a brief screener to assess mild anxiety symptoms and probable GAD is limited, findings underscore the importance of a dimensional approach to assessing anxiety symptoms and associated clinical and functional characteristics in veterans.

Health-Economic Evaluation of Psychological Interventions for Anxiety Prevention: A Systematic Review

OBJECTIVE

Although evidence supports the effectiveness of psychological interventions for prevention of anxiety, little is known about their cost-effectiveness. The aim of this study was to conduct a systematic review of health-economic evaluations of psychological interventions for anxiety prevention.

METHODS

PubMed, PsycInfo, Web of Science, Embase, Cochrane Central Register of Controlled Trials, EconLit, National Health Service (NHS) Economic Evaluations Database, NHS Health Technology Assessment, and OpenGrey databases were searched electronically on December 23, 2022. Included studies focused on economic evaluations based on randomized controlled trials of psychological interventions to prevent anxiety. Study data were extracted, and the quality of the selected studies was assessed by using the Consensus on Health Economic Criteria and the Cochrane risk-of-bias tool.

RESULTS

All included studies (N=5) had economic evaluations that were considered to be of good quality. In two studies, the interventions showed favorable cost-effectiveness compared with usual care groups. In one study, the intervention was not cost-effective. Findings from another study cast doubt on the cost-effectiveness of the intervention, and the cost-effectiveness of the intervention in the remaining study could not be established.

CONCLUSIONS

Although the findings suggest some preliminary evidence of cost-effectiveness of psychological interventions for preventing anxiety, they were limited by the small number of included studies. Additional research on the cost-effectiveness of psychological interventions for anxiety in different countries and populations is required.

Effectiveness of a universal personalized intervention for the prevention of anxiety disorders: Protocol of a randomized controlled trial (the prevANS project)

Background

To date, all preventive anxiety disorders interventions are one-fit-all and none of them are based on individual level and risk profile. The aim of this project is to design, develop and evaluate an online personalized intervention based on a risk algorithm for the universal prevention of anxiety disorders in the general population.

Methods

A randomized controlled trial (RCT) with two parallel arms (prevANS vs usual care) and 1-year follow-up including 2000 participants without anxiety disorders from Spain and Portugal will be conducted.The prevANS intervention will be self-guided and can be implemented from the prevANS web or from the participants' Smartphone (through an App). The prevANS intervention will have different intensities depending on the risk level of the population, evaluated from the risk algorithm for anxiety: predictA. Both low and moderate-high risk participants will receive information on their level and profile (risk factors) of anxiety disorders, will have access to stress management tools and psychoeducational information periodically. In addition, participants with a moderate-high risk of anxiety disorders will also have access to cognitive-behavioral training (problem-solving, decision-making, communication skills, and working with thoughts). The control group will not receive any intervention, but they will fill out the same questionnaires as the intervention group.Assessments will be completed at baseline, 6 and 12-month follow-up. The primary outcome is the cumulative incidence of anxiety disorders. Secondary outcomes include depressive and anxiety symptoms, risk probability of anxiety disorders (predictA algorithm) and depression (predictD algorithm), improvement in physical and mental quality of life, and acceptability and satisfaction with the intervention. In addition, cost-effectiveness and cost-utility analyses will also be carried out from two perspectives, societal and health system, and analyses of mediators and moderators will also be performed.

Discussion

To the best of our knowledge, prevANS study will be the first to evaluate the effectiveness and cost-effectiveness of a personalized online intervention based on a risk predictive algorithm for the universal prevention of anxiety disorders.

Trial registration

ClinicalTrials.gov: NCT05682365.

What Do We Know About Depression Among Youth and How Can We Make Progress Toward Improved Understanding and Reducing Distress? A New Hope

This paper summarizes many findings about depression among children and adolescents. Depression is prevalent, highly distressing, and exerts considerable burden worldwide. Rates surge from childhood through young adulthood and have increased over the last decade. Many risk factors have been identified, and evidence-based interventions exist targeting mostly individual-level changes via psychological or pharmacological means. At the same time, the field appears stuck and has not achieved considerable progress in advancing scientific understanding of depression's features or delivering interventions to meet the challenge of youth depression's high and growing prevalence. This paper adopts several positions to address these challenges and move the field forward. First, we emphasize reinvigoration of construct validation approaches that may better characterize youth depression's phenomenological features and inform more valid and reliable assessments that can enhance scientific understanding and improve interventions for youth depression. To this end, history and philosophical principles affecting depression's conceptualization and measurement are considered. Second, we suggest expanding the range and targets of treatments and prevention efforts beyond current practice guidelines for evidence-based interventions. This broader suite of interventions includes structural- and system-level change focused at community and societal levels (e.g., evidence-based economic anti-poverty interventions) and personalized interventions with sufficient evidence base. We propose that by focusing on the FORCE (Fundamentals, Openness, Relationships, Constructs, Evidence), youth depression research can provide new hope.

Transdiagnostic risk of mental disorders in offspring of affected parents: a meta-analysis of family high-risk and registry studies

The offspring of parents with mental disorders are at increased risk for developing mental disorders themselves. The risk to offspring may extend transdiagnostically to disorders other than those present in the parents. The literature on this topic is vast but mixed. To inform targeted prevention and genetic counseling, we performed a comprehensive, PRISMA 2020-compliant meta-analysis. We systematically searched the literature published up to September 2022 to retrieve original family high-risk and registry studies reporting on the risk of mental disorders in offspring of parents with any type of mental disorder. We performed random-effects meta-analyses of the relative risk (risk ratio, RR) and absolute risk (lifetime, up to the age at assessment) of mental disorders, defined according to the ICD or DSM. Cumulative incidence by offspring age was determined using meta-analytic Kaplan-Meier curves. We measured heterogeneity with the I2 statistic, and risk of bias with the Quality In Prognosis Studies (QUIPS) tool. Sensitivity analyses addressed the impact of study design (family high-risk vs. registry) and specific vs. transdiagnostic risks. Transdiagnosticity was appraised with the TRANSD criteria. We identified 211 independent studies that reported data on 3,172,115 offspring of parents with psychotic, bipolar, depressive, disruptive, attention-deficit/hyperactivity, anxiety, substance use, eating, obsessive-compulsive, and borderline personality disorders, and 20,428,575 control offspring. The RR and lifetime risk of developing any mental disorder were 3.0 and 55% in offspring of parents with anxiety disorders; 2.6 and 17% in offspring of those with psychosis; 2.1 and 55% in offspring of those with bipolar disorder; 1.9 and 51% in offspring of those with depressive disorders; and 1.5 and 38% in offspring of those with substance use disorders. The offspring's RR and lifetime risk of developing the same mental disorder diagnosed in their parent were 8.4 and 32% for attention-deficit/hyperactivity disorder; 5.8 and 8% for psychosis; 5.1 and 5% for bipolar disorder; 2.8 and 9% for substance use disorders; 2.3 and 14% for depressive disorders; 2.3 and 1% for eating disorders; and 2.2 and 31% for anxiety disorders. There were 37 significant transdiagnostic associations between parental mental disorders and the RR of developing a different mental disorder in the offspring. In offspring of parents with psychosis, bipolar and depressive disorder, the risk of the same disorder onset emerged at 16, 5 and 6 years, and cumulated to 3%, 19% and 24% by age 18; and to 8%, 36% and 46% by age 28. Heterogeneity ranged from 0 to 0.98, and 96% of studies were at high risk of bias. Sensitivity analyses restricted to prospective family high-risk studies confirmed the pattern of findings with similar RR, but with greater absolute risks compared to analyses of all study types. This study demonstrates at a global, meta-analytic level that offspring of affected parents have strongly elevated RR and lifetime risk of developing any mental disorder as well as the same mental disorder diagnosed in the parent. The transdiagnostic risks suggest that offspring of parents with a range of mental disorders should be considered as candidates for targeted primary prevention.

Towards a youth mental health paradigm: a perspective and roadmap

Most mental disorders have a typical onset between 12 and 25 years of age, highlighting the importance of this period for the pathogenesis, diagnosis, and treatment of mental ill-health. This perspective addresses interactions between risk and protective factors and brain development as key pillars accounting for the emergence of psychopathology in youth. Moreover, we propose that novel approaches towards early diagnosis and interventions are required that reflect the evolution of emerging psychopathology, the importance of novel service models, and knowledge exchange between science and practitioners. Taken together, we propose a transformative early intervention paradigm for research and clinical care that could significantly enhance mental health in young people and initiate a shift towards the prevention of severe mental disorders.

Effectiveness of Internet-based cognitive behavioural therapy for employees with depression: a systematic review and meta-analysis

Objectives. The effectiveness of Internet interventions for employees with depressive disorder remains controversial. We summarized all available evidence exploring the role of Internet interventions in reducing employees' depressive symptoms. Methods. This study was a comprehensive systematic review and meta-analysis that included acceptability and preliminary feasibility studies. We excluded programme descriptions, discussion articles and study protocols. We followed the PRISMA guidelines and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Library and Web of Science from database inception to May 2021 for articles published in English. We extracted data concerning demographics, intervention format, including Internet interventions, control group conditions and outcome measures. We used a random-effects model and calculated Hedges' g values for the scores of employees receiving Internet interventions versus control conditions. This systematic review is registered as INPLASY202160082. Results. Data from 19 studies were included. These 19 studies included 5898 participants (2813 participants received Internet interventions, 3085 participants were in control groups). Conclusions. The findings suggest that Internet interventions can be effective in improving depression in employees. However, more randomized controlled trials are needed to provide better evidence regarding Internet interventions for employees with depression, and robust studies are needed to observe the effectiveness of Internet interventions.

Association of Childhood Externalizing, Internalizing, and Comorbid Symptoms With Long-term Economic and Social Outcomes

IMPORTANCE

Little is known about the long-term economic and social outcomes for children with longitudinally assessed comorbid externalizing and internalizing symptoms, especially compared with children with externalizing symptoms or internalizing symptoms only.

OBJECTIVE

To examine the association between childhood trajectories of externalizing, internalizing, and comorbid symptoms and long-term economic and social outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A 32-year prospective cohort study linked with administrative data was conducted in school-aged participants aged 6 to 12 years in the Québec Longitudinal Study of Kindergarten Children (N = 3017) followed up from 1985 to 2017. Data analysis was conducted between August 1, 2021, and March 31, 2022.

EXPOSURES

Teacher-rated behavioral symptoms were used to categorize children from age 6 to 12 years into developmental profiles using group-based trajectory modeling.

MAIN OUTCOMES AND MEASURES

Multivariable regression models were used to test the association between childhood symptom profile group and adult employment earnings, welfare receipt, intimate partnership status, and having children living in the household. Participant sex, IQ, and socioeconomic background were adjusted for.

RESULTS

Of 3017 participants in this sample, 1594 (52.8%) were male and 1423 (47.2%) were female. Per confidentiality rules established by Statistics Canada, income variables were rounded to base 100 and count variables were rounded to base 10; the mean (SD) age was 37 (0.29) years at follow-up. Four symptom profiles were identified: no/low (n = 1369 [45.4%]), high externalizing (882 [29.2%]), high internalizing (354 [11.7%]), and comorbid (412 [13.7%]) symptoms. Compared with the no/low symptom profile, participants in the high externalizing-only profile earned $5904 (95% CI, -$7988 to -$3821) less per year and had 2.0 (95% CI, 1.58-2.53) times higher incidence of welfare receipt, while participants in the high internalizing group earned $8473 (95% CI, -$11 228 to -$5717) less per year, had a 2.07 (95% CI, 1.51-2.83) higher incidence of welfare receipt, and had a lower incidence of intimate partnership (incident rate ratio [IRR], 0.89; 95% CI, 0.80-0.99). Participants in the comorbid profile fared especially poorly: they earned $15 031 (95% CI, -$18 030 to -$12 031) less per year, had a 3.79 (95% CI, 2.75-5.23) times higher incidence of annual welfare receipt, and were less likely to have an intimate partner (IRR, 0.71; 95% CI, 0.63-0.79) and children living in the household (IRR, 0.86; 95% CI, 0.80-0.92). Estimated lost earnings over a 40-year working career were $140 515 for the high externalizing, $201 657 for the high internalizing, and $357 737 for the comorbid profiles.

CONCLUSIONS AND RELEVANCE

In this cohort study, children exhibiting sustained childhood high externalizing, high internalizing, or comorbid symptoms were at increased risk of poor economic and social outcomes into middle age. These findings suggest that children exhibiting comorbid problems were especially vulnerable and that early detection and support are indicated.

Challenges in Recruiting University Students for Web-Based Indicated Prevention of Depression and Anxiety: Results From a Randomized Controlled Trial (ICare Prevent)

BACKGROUND

Depression and anxiety are common mental health conditions in college and university student populations. Offering transdiagnostic, web-based prevention programs such as ICare Prevent to those with subclinical complaints has the potential to reduce some barriers to receiving help (eg, availability of services, privacy considerations, and students' desire for autonomy). However, uptake of these interventions is often low, and accounts of recruitment challenges are needed to complement available effectiveness research in student populations.

OBJECTIVE

The aims of this study were to describe recruitment challenges together with effective recruitment strategies for ICare Prevent and provide basic information on the intervention's effectiveness.

METHODS

A 3-arm randomized controlled trial was conducted in a student sample with subclinical symptoms of depression and anxiety on the effectiveness of an individually guided (human support and feedback on exercises provided after each session, tailored to each participant) and automatically guided (computer-generated messages provided after each session, geared toward motivation) version of ICare Prevent, a web-based intervention with transdiagnostic components for the indicated prevention of depression and anxiety. The intervention was compared with care as usual. Descriptive statistics were used to outline recruitment challenges and effective web-based and offline strategies as well as students' use of the intervention. A basic analysis of intervention effects was conducted using a Bayesian linear mixed model, with Bayes factors reported as the effect size.

RESULTS

Direct recruitment through students' email addresses via the central student administration was the most effective strategy. Data from 35 participants were analyzed (individually guided: n=14, 40%; automatically guided: n=8, 23%; care as usual: n=13, 37%). Use of the intervention was low, with an average of 3 out of 7 sessions (SD 2.9) completed. The analyses did not suggest any intervention effects other than anecdotal evidence (all Bayes factors₁₀≤2.7).

CONCLUSIONS

This report adds to the existing literature on recruitment challenges specific to the student population. Testing the feasibility of recruitment measures and the greater involvement of the target population in their design, as well as shifting from direct to indirect prevention, can potentially help future studies in the field. In addition, this report demonstrates an alternative basic analytical strategy for underpowered randomized controlled trials.

TRIAL REGISTRATION

International Clinical Trials Registry Platform NTR6562; https://tinyurl.com/4rbexzrk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-018-2477-y.

Youth voices and experiences regarding a school-based cognitive behavioral therapy skills intervention: lessons for future engagement and adaptation

Background

The Cognitive Behavioral Therapy Skills Intervention (or CBTSI) aims to build mental health literacy and knowledge, allowing youth to build resilience and improve mental health broadly. In Ontario, Canada, youth voice is scant and European studies have largely reported on youth factors supporting stigma reduction, help-seeking intentions and overall satisfaction with a given intervention. Process evaluations and implementation that underpin what youth require to embrace mental health literacy interventions, particularly those that embed key learning principles in the everyday curriculum, have not been broached. The goal of this study is to understand both barriers and facilitators to engagement with the CBTSI (an intervention novel in itself because of the combined mental health plus cognitive behavior therapy (CBT) skills principles embedded in literacy) and the resources and structures that students report requiring, to fully engage with such an intervention.

Methods

Student focus groups were conducted utilizing qualitative interviews that were analyzed thematically. Analysis was informed using principles of pragmatism and analyzed inductively using thematic analysis (Braun and Clarke, Qual Res Psychol 3:77–101, 2006), first looking at the whole and then coding for themes, within an interpretivist framework. Youth were in middle school (grade 7 and 8) in Toronto, Canada who had received the CBTSI. Face to face interview guides with iterative questioning were conducted in February of 2020, and these interviews were audio-recorded and professionally transcribed. Teachers randomly chose a subset of youth whose parents consented to the research to ensure ethno-racial similarity to classroom demographics.

Results

There were eight groups with sixty students who participated. Students were 12 to 14 years of age. Major themes were identified: maximizing the opportunities for involvement and self-determination created an atmosphere where confidence and self-compassion could flourish, signalling to the students that they understood and were able to deploy the strategies they were taught; students expressed that the intervention needs to be adapted to enhance personal dignity, respecting both individual wishes and goals in light of the variability in student reported mental health. A model explains the structures and adaptations required to maximize learning based on youth feedback.

Interpretation

Mental health literacy incorporating CBT is a promising population-based health promotion intervention. Future adaptations and implementation decisions regarding the CBTSI need to address the wishes and experiences of these youth. Youth voice in this study explored factors that prevent and promote the uptake of the key lessons within the context of existing variability in student mental health that is often found within the context of a regular classroom. The results should be used to adapt the CBTSI as it is disseminated more broadly.

Physical activity and mental health in children and adolescents with intellectual disabilities: a meta-analysis using the RE-AIM framework

BACKGROUND

Children and adolescents with intellectual disabilities (IDs) tend to have lower levels of physical activity and poorer mental health than their typically developing peers. Studies on the effects of physical activity on the mental health of children with IDs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework are scarce.

METHODS

A systematic literature review using six databases (CINAHL, Eric, PsycINFO, PubMed, SPORTDiscus, and Web of Science) was conducted from January 2000 to September 2021. Studies reporting at least one physical activity intervention and mental health outcome in children and adolescents with IDs aged between 5 and 17 years were included in the meta-analysis. Preferred Reporting Items for Systematic Review and Meta-Analysis guideline, Comprehensive Meta-Analysis, and the RE-AIM framework were utilized.

RESULTS

A total of 15 studies that met the inclusion criteria were included in the meta-analysis. The effects of physical activity on mental health in children and adolescents with IDs were significant and large (Hedges' g = 0.897, p < 0.01), with medium effects on psychological health (Hedges' g = 0.542, p < 0.01) and large effects on cognitive function (Hedges' g = 1.236, p < 0.01). Randomized controlled trial (RCT) design and intervention components (> 120 minutes per week, therapeutic, and aerobic exercise) demonstrated the strongest effects. Moreover, study background (publication year, study location, and sample size), participant characteristics (age and sex), and Maintenance (RE-AIM framework) moderated the effects of physical activity on mental health. Based on the RE-AIM framework, there were higher proportions in the dimensions of Reach and Effectiveness than Adoption, Implementation, and Maintenance.

CONCLUSIONS

Physical activity appears to have positive effects on mental health, including psychological health and cognitive function, in children and adolescents with IDs. Physical activity interventions using the RE-AIM framework are recommended to assess short- and long-term impacts and translate scientific evidence into practice.

TRIAL REGISTRATION

The protocol for this meta-analysis was registered with PROSPERO ( CRD42021256543 ).

Improving Well-Being in Young Adults: A Social Marketing Proof-of-Concept

Approximately 1 in 5 Australians experience a mental disorder every year, costing the Australian economy $56.7 billion per year; therefore, prevention and early intervention are urgently needed. This study reports the evaluation results of a social marketing pilot program that aimed to improve the well-being of young adults. The Elevate Self Growth program aimed to help participants perform various well-being behaviors, including screen time reduction, quality leisure activities, physical activity, physical relaxation, meditation and improved sleep habits. A multi-method evaluation was undertaken to assess Elevate Self Growth for the 19 program participants who paid to participate in the proof-of-concept program. Social Cognitive Theory was used in the program design and guided the evaluation. A descriptive assessment was performed to examine the proof-of-concept program. Considerations were given to participants’ levels of program progress, performance of well-being behaviors, improvements in well-being, and program user experience. Participants who had made progress in the proof-of-concept program indicated improved knowledge, skills, environmental support and well-being in line with intended program outcomes. Program participants recommended improvements to achieve additional progress in the program, which is strongly correlated with outcome changes observed. These improvements are recommended for the proof-of-concept well-being program prior to moving to a full randomized control trial. This paper presents the initial data arising from the first market offerings of a theoretically mapped proof-of-concept and reports insights that suggest promise for approaches that apply Social Cognitive Theory in well-being program design and implementation.

Effectiveness of Physical Activity in Primary Prevention of Anxiety: Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of this study was to evaluate the effectiveness of physical activity in the primary prevention of anxiety. A systematic review of randomized controlled trials (RCTs) was performed. RCTs were searched in seven electronic databases. We included RCTs that assessed either the incidence of anxiety or the reduction of anxiety symptoms which excluded participants with baseline anxiety. Measurements were required to have been made using validated instruments. Objective or subjective (with validated questionnaires) verification of the performance of physical activity was required. Three reviewers carried out the search, selection, data extraction, and risk assessment of Cochrane Collaboration’s tool simultaneously and independently, reaching an agreement in their discrepancies by consensus. In addition, a meta-analysis of fixed-effects model was carried out. Three RCTs met inclusion criteria, comprising 350 patients from 3 different countries. A meta-analysis was performed using five comparisons extracted from the selected studies, and the pooled standardized mean difference (SMD) was −0.18 (95% CI: −0.44; 0.07), p = 0.158. The heterogeneity was irrelevant, I² = 17.7% (p = 0.30). There is no evidence that anxiety can be prevented through physical activity, although the quality of evidence was very low.

The cognitive anxiety sensitivity treatment (CAST) in anxiety prevention - Focus on separation anxiety and interoception

Given the high prevalence and considerable clinical and societal burden of anxiety disorders, preventive measures are urgently warranted to reduce their incidence and overall healthcare impact. Anxiety sensitivity (AS) - a key element in learning theories of anxiety disorders in the context of interoceptive conditioning - constitutes a malleable risk factor of particularly panic disorder and separation anxiety, which share developmental, nosological, epidemiological and pathomechanistic characteristics. The computer-assisted 'Cognitive Anxiety Sensitivity Treatment' (CAST) targeting interoceptive anxiety symptoms (cf. Schmidt et al., 2014) was translated, intensified and culturally adapted to German and evaluated in a sample of 105 healthy adult volunteers with elevated AS (mean ASI-3: 29.5) applying a randomized design. Success of the intervention was measured as a function of AS and separation anxiety (ASA-27) ∼6 weeks (T1) and ∼6 months (T2) after the intervention. As compared to waitlist, CAST resulted in a significant reduction of AS at both T1 and T2. Separation anxiety was not directly reduced by the intervention, but decreased mediated by a decline in AS. A composite interoceptive score capturing changes in sensitivity to respiratory symptoms during the baseline therapist-accompanied CAST session was shown to be predictive of overall response at T1. In sum, CAST-German Version was successfully established as an effective intervention reducing AS, while at the same time indirectly decreasing separation anxiety. A composite interoceptive score predicting treatment response might aid in further delineating risk markers informing targeted preventive interventions for anxiety disorders.

Effectiveness of caregiver non-pharmacological interventions for behavioural and psychological symptoms of dementia: An updated meta-analysis

BACKGROUND

The behavioural and psychological symptoms of dementia (BPSD) have significant negative effects on the health of both patients with dementia and their caregivers. However, the reported effectiveness of non-pharmacological interventions targeting caregivers of patients with dementia for BPSD is inconsistent.

METHODS

We systematically searched the databases PubMed, PsycINFO, CINAHL, Embase, Cochrane Library and four Chinese databases from 2010 through April 2021. The Standardised mean difference (SMD) was calculated using random-effects models. Risk of bias in individual studies was assessed using Cochrane Collaboration's tool, and the certainty of evidence was assessed using the five GRADE criteria.

RESULTS

Thirty-one randomised controlled trials (RCTs) involving 3501 dyads were included. The meta-analysis indicated that non-pharmacological interventions showed small but significant effects on both BPSD in patients with dementia (SMD = -0.14; 95% CI, -0.22 to -0.06; P = 0.001) and caregiver reactions to BPSD (SMD = -0.16; 95% CI, -0.25 to -0.07; P = 0.001). The effect sizes of BPSD in patients at follow-up (SMD = -0.24; 95% CI, -0.38 to -0.09; P = 0.002) were larger than those at post-test. Tailored interventions were associated with more substantial reductions in BPSD in patients (SMD = -0.24; 95% CI, -0.37 to -0.11; P < 0.001) than standardised interventions (SMD = -0.07; 95% CI, -0.18 to 0.04; P = 0.218).

CONCLUSIONS

Non-pharmacological interventions targeting caregivers have the potential to reduce BPSD in patients with dementia and improve caregiver negative reactions to BPSD. Moreover, tailored interventions seemed to be more effective in reducing BPSD, and more significant improvements in BPSD may be observed in long-term follow-up.

Effectiveness of exercise-based interventions in reducing depressive symptoms in people without clinical depression: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

In most trials and systematic reviews that evaluate exercise-based interventions in reducing depressive symptoms, it is difficult to separate treatment from prevention.

AIMS

To evaluate the effectiveness of exercise-based interventions in reducing depressive symptoms in people without clinical depression.

METHOD

We searched PubMed, PsycINFO, Embase, WOS, SPORTDiscus, CENTRAL, OpenGrey and other sources up to 25 May 2020. We selected randomised controlled trials (RCTs) that compared exclusively exercise-based interventions with control groups, enrolling participants without clinical depression, as measured using validated instruments, and whose outcome was reduction of depressive symptoms and/or incidence of new cases of people with depression. Pooled standardised mean differences (SMDs) were calculated using random-effect models (registration at PROSPERO: CRD42017055726).

RESULTS

A total of 14 RCTs (18 comparisons) evaluated 1737 adults without clinical depression from eight countries and four continents. The pooled SMD was -0.34 (95% CI -0.51 to -0.17; P < 0.001) and sensitivity analyses confirmed the robustness of this result. We found no statistical evidence of publication bias and heterogeneity was moderate (I2 = 54%; 95% CI 22-73%). Only two RCTs had an overall low risk of bias and three had long-term follow-up. Multivariate meta-regression found that a larger sample size, country (Asia) and selective prevention (i.e. people exposed to risk factors for depression) were associated with lower effectiveness, although only sample size remained significant when adjustment for multiple tests was considered. According to the Grading of Recommendations Assessment, Development and Evaluation tool, the quality of evidence was low.

CONCLUSIONS

Exercise-based interventions have a small effect on the reduction of depressive symptoms in people without clinical depression. It could be an alternative to or complement psychological programmes, although further higher-quality trials with larger samples and long-term follow-up are needed.

Cost-benefit Analysis of the Coping and Promoting Strength Program

This study sought to estimate the net benefits and return on investment (ROI, %) of the Coping and Promoting Strength (CAPS) program to families and insurers, respectively, using data from a multi-year follow up of 136 US families who had participated in a randomized efficacy trial of CAPS. CAPS is a brief parent-focused psychosocial intervention that was compared to information monitoring in the trial. Of the 136 original participants, 113 (83%) completed follow-up interviews 7.1 years, on average, after the CAPS study baseline (mean follow-up age: 15.8 years; range: 13.1 to 20.8 years). Parent-reported willingness-to-pay values and estimates of behavioral healthcare cost savings from delayed onset of anxiety were used to simulate the average net benefits of CAPS to families and insurance plans, respectively, assuming patients pay 20% coinsurance. Psychologists in private offices were expected to charge an average of approximately $195 per CAPS session or $1417 in total in 2020 dollars. The estimated family share of the total CAPS session cost was $283 per youth, while the insurer share was $1134 per youth. Given these costs, the CAPS intervention was estimated to result in average overall net benefits of $1033 per youth (95% CI: -$546 to $2611). Families gained $344 (95% CI: $232 to $455 per family) for an ROI of 121%. Insurance plans on average gained a net savings of $689 per youth (95% CI: -$778 to $2156 per youth) for an average ROI of 61%. In this multiyear follow-up of offspring of anxious parents, exposure to the CAPS pediatric anxiety prevention program was found to be more economically efficient than was waiting for an anxiety disorder to be diagnosed. ClinicalTrials.gov Identifier: NCT00847561.

Climate Change and Children’s Mental Health: A Developmental Perspective

Climate change is a major global public-health challenge that will have wide-ranging impacts on human psychological health and well-being. Children and adolescents are at particular risk because of their rapidly developing brain, vulnerability to disease, and limited capacity to avoid or adapt to threats and impacts. They are also more likely to worry about climate change than any other age group. Drawing on a developmental life-course perspective, we show that climate-change-related threats can additively, interactively, and cumulatively increase psychopathology risk from conception onward; that these effects are already occurring; and that they constitute an important threat to healthy human development worldwide. We then argue that monitoring, measuring, and mitigating these risks is a matter of social justice and a crucial long-term investment in developmental and mental health sciences. We conclude with a discussion of conceptual and measurement challenges and outline research priorities going forward.

Association of Different Forms of Child Maltreatment With Peer Victimization in Mexican Children and Adolescents

Objective: To examine the relationship between exposure to multiple forms of child abuse and neglect within the family context and peer victimization at school, accounting for the moderator effect of sex and educational level.

Methods: Two thousand four hundred fifteen children and adolescents, aged 9 to 15 years, attending public schools in Mexico completed the Childhood Trauma Questionnaire-Short Form and a modified version of the Olweus' Bully/Victim Questionnaire. We used linear regression models to assess the association of five different forms of child abuse (emotional, physical, and sexual abuse, and emotional and physical negligence) with three forms of peer victimization (direct, indirect, and cyberbullying).

Results: Direct forms of child abuse within the family (i.e., emotional, physical, and sexual abuse), but not neglect, were significantly and positively associated with a risk for peer victimization. In the fully adjusted models, emotional abuse was significantly associated with the three types of peer victimization: [indirect b = 0.48, t = 6.75, p < 0.001, direct (b = 0.47, t = 4.89, p < 0.001), and cyberbullying (b = 0.85, t = 5.45, p < 0. 001)]; while physical abuse was positive and significantly associated with direct victimization (b = 0.29, t = 3.28, p < 0.001). Boys suffering from sexual abuse within the family context showed higher levels of all subtypes of peer victimization. Students attending secondary school who suffered from sexual abuse showed higher levels of indirect victimization than did students attending primary schools.

Conclusion: Child abuse within the family context seems to be associated with the risk of peer victimization. Preventive strategies to address bullying and promote resilience should take family factors into account. Interventions for high-risk families might be useful to prevent child multi-victimization.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Preventive psychiatry: a blueprint for improving the mental health of young people

Preventive approaches have latterly gained traction for improving mental health in young people. In this paper, we first appraise the conceptual foundations of preventive psychiatry, encompassing the public health, Gordon's, US Institute of Medicine, World Health Organization, and good mental health frameworks, and neurodevelopmentally-sensitive clinical staging models. We then review the evidence supporting primary prevention of psychotic, bipolar and common mental disorders and promotion of good mental health as potential transformative strategies to reduce the incidence of these disorders in young people. Within indicated approaches, the clinical high-risk for psychosis paradigm has received the most empirical validation, while clinical high-risk states for bipolar and common mental disorders are increasingly becoming a focus of attention. Selective approaches have mostly targeted familial vulnerability and non-genetic risk exposures. Selective screening and psychological/psychoeducational interventions in vulnerable subgroups may improve anxiety/depressive symptoms, but their efficacy in reducing the incidence of psychotic/bipolar/common mental disorders is unproven. Selective physical exercise may reduce the incidence of anxiety disorders. Universal psychological/psychoeducational interventions may improve anxiety symptoms but not prevent depressive/anxiety disorders, while universal physical exercise may reduce the incidence of anxiety disorders. Universal public health approaches targeting school climate or social determinants (demographic, economic, neighbourhood, environmental, social/cultural) of mental disorders hold the greatest potential for reducing the risk profile of the population as a whole. The approach to promotion of good mental health is currently fragmented. We leverage the knowledge gained from the review to develop a blueprint for future research and practice of preventive psychiatry in young people: integrating universal and targeted frameworks; advancing multivariable, transdiagnostic, multi-endpoint epidemiological knowledge; synergically preventing common and infrequent mental disorders; preventing physical and mental health burden together; implementing stratified/personalized prognosis; establishing evidence-based preventive interventions; developing an ethical framework, improving prevention through education/training; consolidating the cost-effectiveness of preventive psychiatry; and decreasing inequalities. These goals can only be achieved through an urgent individual, societal, and global level response, which promotes a vigorous collaboration across scientific, health care, societal and governmental sectors for implementing preventive psychiatry, as much is at stake for young people with or at risk for emerging mental disorders.

Classroom-based cognitive behavioural therapy: a large-scale non-randomised controlled trial of the 'Journey of the Brave'

BACKGROUND

In Japan, 'Journey of the Brave', a cognitive behavioural therapy (CBT)-based anxiety preventive education programme, was previously developed and its effectiveness examined in two small-scale controlled trials. These studies had some limitations, including a small number of participants and not having regular classroom teachers as programme facilitators. Therefore, we conducted a large-scale controlled trial, with teachers as programme implementers.

METHODS

Twenty-seven elementary schools participated: 1622 and 1123 children were allocated to the intervention and control groups, respectively. The intervention group received a programme comprising ten 45-min sessions, while the control group underwent the regular school curriculum. Anxiety symptoms among participants were assessed using the Spence Children's Anxiety Scale (SCAS) at three stages (pre-intervention, post-intervention, and follow-up).

RESULTS

Following primary analysis, estimated mean changes in SCAS from baseline to follow-up were - 4.91 (95% CI - 5.91, - 3.90) in the intervention group and - 2.53 (95% CI - 3.52, - 1.54) in the control group; the group difference was 2.37 (95% CI 1.42, 3.33, p < 0.0001). Children in the intervention group showed significant reduction in their anxiety score versus children in the control group.

CONCLUSIONS

The results showed a statistically significant anxiety score reduction in the intervention group, thus verifying the programme's effectiveness. Trial registration The University Hospital Medical Information Network (UMIN): UMIN000032517. Registered 10 May 2018-Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000037083.

Anxiety disorders

Anxiety disorders form the most common group of mental disorders and generally start before or in early adulthood. Core features include excessive fear and anxiety or avoidance of perceived threats that are persistent and impairing. Anxiety disorders involve dysfunction in brain circuits that respond to danger. Risk for anxiety disorders is influenced by genetic factors, environmental factors, and their epigenetic relations. Anxiety disorders are often comorbid with one another and with other mental disorders, especially depression, as well as with somatic disorders. Such comorbidity generally signifies more severe symptoms, greater clinical burden, and greater treatment difficulty. Reducing the large burden of disease from anxiety disorders in individuals and worldwide can be best achieved by timely, accurate disease detection and adequate treatment administration, scaling up of treatments when needed. Evidence-based psychotherapy (particularly cognitive behavioural therapy) and psychoactive medications (particularly serotonergic compounds) are both effective, facilitating patients' choices in therapeutic decisions. Although promising, no enduring preventive measures are available, and, along with frequent therapy resistance, clinical needs remain unaddressed. Ongoing research efforts tackle these problems, and future efforts should seek individualised, more effective approaches for treatment with precision medicine.

Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19): protocol for an international prospective cohort study

BACKGROUND

Corona Virus Disease 19 (COVID-19) is a new pandemic, declared a public health emergency by the World Health Organization, which could have negative consequences for pregnant and postpartum women. The scarce evidence published to date suggests that perinatal mental health has deteriorated since the COVID-19 outbreak. However, the few studies published so far have some limitations, such as a cross-sectional design and the omission of important factors for the understanding of perinatal mental health, including governmental restriction measures and healthcare practices implemented at the maternity hospitals. Within the Riseup-PPD COST Action, a study is underway to assess the impact of COVID-19 in perinatal mental health. The primary objectives are to (1) evaluate changes in perinatal mental health outcomes; and (2) determine the risk and protective factors for perinatal mental health during the COVID-19 pandemic. Additionally, we will compare the results between the countries participating in the study.

METHODS

This is an international prospective cohort study, with a baseline and three follow-up assessments over a six-month period. It is being carried out in 11 European countries (Albania, Bulgaria, Cyprus, France, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom), Argentina, Brazil and Chile. The sample consists of adult pregnant and postpartum women (with infants up to 6 months of age). The assessment includes measures on COVID-19 epidemiology and public health measures (Oxford COVID-19 Government Response Tracker dataset), Coronavirus Perinatal Experiences (COPE questionnaires), psychological distress (BSI-18), depression (EPDS), anxiety (GAD-7) and post-traumatic stress symptoms (PTSD checklist for DSM-V).

DISCUSSION

This study will provide important information for understanding the impact of the COVID-19 pandemic on perinatal mental health and well-being, including the identification of potential risk and protective factors by implementing predictive models using machine learning techniques. The findings will help policymakers develop suitable guidelines and prevention strategies for perinatal mental health and contribute to designing tailored mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04595123 .

Use of a personalised depression intervention in primary care to prevent anxiety: a secondary study of a cluster randomised trial

Background

In the predictD-intervention, GPs used a personalised biopsychosocial programme to prevent depression. This reduced the incidence of major depression by 21.0%, although the results were not statistically significant.

Aim

To determine whether the predictD-intervention is effective at preventing anxiety in primary care patients without depression or anxiety.

Design and setting

Secondary study of a cluster randomised trial with practices randomly assigned to either the predictD-intervention or usual care. This study was conducted in seven Spanish cities from October 2010 to July 2012.

Method

In each city, 10 practices and two GPs per practice, as well as four to six patients every recruiting day, were randomly selected until there were 26–27 eligible patients for each GP. The endpoint was cumulative incidence of anxiety as measured by the PRIME-MD screening tool over 18 months.

Results

A total of 3326 patients without depression and 140 GPs from 70 practices consented and were eligible to participate; 328 of these patients were removed because they had an anxiety syndrome at baseline. Of the 2998 valid patients, 2597 (86.6%) were evaluated at the end of the study. At 18 months, 10.4% (95% CI = 8.7% to 12.1%) of the patients in the predictD-intervention group developed anxiety compared with 13.1% (95% CI = 11.4% to 14.8%) in the usual-care group (absolute difference = −2.7% [95% CI = −5.1% to −0.3%]; P = 0.029).

Conclusion

A personalised intervention delivered by GPs for the prevention of depression provided a modest but statistically significant reduction in the incidence of anxiety.

[Prevention of anxiety disorders]

Preventive interventions, such as universal and targeted, i.e. selective and indicated, interventions can effectively reduce the incidence of anxiety disorders and thus lower the high individual and socioeconomic burden of anxiety disorders. This review article provides an overview of internationally established prevention programs for children, adolescents and adults. The efficacy and cost effectiveness of preventive interventions are discussed. Due to the large target group, universally implemented strategies are costly and organizationally complex but can prevent a large number of manifest anxiety disorders or reduce the clinical expression, despite only small effect sizes. Selective preventive measures are aimed at persons with a high risk for anxiety disorders (e.g. with high anxiety sensitivity, behavioral inhibition, harm avoidance, family history of anxiety disorders). The indicated preventive interventions in high-risk individuals with first subclinical anxiety symptoms are successful in preventing the manifestation of anxiety disorders and constitute the most cost-effective type of preventive measures. Biological, i.e. genetic, imaging or neurophysiological markers, or their combination, are discussed as promising future targets for selective or indicated prevention of anxiety disorders.

Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: A systematic review and meta-analysis

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) outbreak has escalated the burden of psychological distress. We aimed to evaluate factors associated with psychological distress among the predominantly general population during the COVID-19 pandemic.

METHODS

We searched PubMed, EMBASE, Scopus, Cochrane Library, PsycINFO, and World Health Organization COVID-19 databases (Dec 2019-15 July 2020). We included cross-sectional studies that reported factors associated with psychological distress during the COVID-19 pandemic. Primary outcomes were self-reported symptoms of anxiety and depression. Random-effects models were used to pool odds ratios (OR) and 95% confidence intervals (CI). The protocol was registered in PROSPERO (#CRD42020186735).

FINDINGS

We included 68 studies comprising 288,830 participants from 19 countries. The prevalence of anxiety and depression was 33% (95% CI: 28%-39%) and 30% (26%-36%). Women versus men (OR: 1.48 [95% CI: 1.29-1.71; I2 = 90.8%]), younger versus older (< versus ≥35 years) adults (1.20 [1.13-1.26]; I2 = 91.7%), living in rural versus urban areas (1.13 [1.00-1.29]; I2 = 82.9%), lower versus higher socioeconomic status (e.g. lower versus higher income: 1.45 [1.24-1.69; I2 = 82.3%]) were associated with higher anxiety odds. These factors (except for residential area) were also associated with higher depression odds. Furthermore, higher COVID-19 infection risk (suspected/confirmed cases, living in hard-hit areas, having pre-existing physical or mental conditions) and longer media exposure were associated with higher odds of anxiety and depression.

INTERPRETATION

One in three adults in the predominantly general population have COVID-19 related psychological distress. Concerted efforts are urgently needed for interventions in high-risk populations to reduce urban-rural, socioeconomic and gender disparities in COVID-19 related psychological distress.

Moderators of psychological and psychoeducational interventions for the prevention of anxiety: A systematic review

The aim of this study was to assess the available evidence on potential moderators of psychological and psychoeducational interventions for the prevention of anxiety. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and CENTRAL was performed up to October 2019. Two independent researchers assessed the fulfillment of eligibility criteria, extracted the data and performed a quality assessment of the included studies. Outcomes were moderators of the reduction of anxious symptoms or the incidence of anxiety disorders. Fourteen studies reporting results on moderator analyses performed in 13 randomized controlled trials were included. Twenty-seven potential moderators were organized into six categories: sociodemographic, clinical characteristics, cognitive variables, life events, interpersonal functioning and intervention characteristics. The most frequently examined variables were gender, age and baseline anxiety. We found insufficient evidence for all moderator categories studied. In children and adolescents, we found some studies with significant results for the low family support variable and higher levels of anxiety symptoms at baseline, which were both associated with higher effectiveness. Limited conclusions can be drawn about for whom and under what conditions interventions work in the prevention of anxiety. A strong need to improve the methodological quality and the number of moderator studies was identified.

Anxiety disorders, climate change, and the challenges ahead: Introduction to the special issue

Climate change involves (1) increases in the prevalence of extreme weather events (e.g., wildfires, floods, hurricanes), (2) more gradual climatic changes (e.g., rising sea levels, desertification), and (3) increased risks of pandemics and other widespread disease outbreaks. Anxiety evoked by the threat of climate change can be either adaptive or maladaptive. Adaptive anxiety can motivate climate activism, such as efforts to reduce one's carbon footprint. Maladaptive anxiety can take the form of anxious passivity, where the person feels anxious but incapable of addressing the problem of climate change, and may take the form of an anxiety disorder triggered or exacerbated by climatic stressors. Such stressors may involve exposure to extreme weather events or may involve exposure to other stressors such as forced migration due to rising sea levels or desertification. Three types of interventions are needed to address the various types of climate-related anxiety: (1) programs that motivate people to overcome anxious passivity and thereby take action to mitigate the effects of climate change, (2) treatment programs that address anxiety associated with exposure to climatic stressors, and (3) programs that build resilience at an individual and community level, to help people better cope with the challenges ahead.

[Common mental disorders in primary care: diagnostic and therapeutic difficulties, and new challenges in prediction and prevention. SESPAS Report 2020]

In primary health care only chronic pain surpass depression and anxiety in loss of quality-adjusted life years. More than 70% of people suffering from common mental disorders consulted their GPs for this reason. However, 'the declining halves rule' is a reality: less than 50% of primary care attendees with common mental disorders were correctly diagnosed, of these less than 50% received adequate treatment (pharmacological or psychological) and of these less than 50% patients were adherent. Collaborative models of common mental disorders care in primary health care have demonstrated their effectiveness through clinical trials; however, its implementation in a more general and real context is difficult and its effectiveness remains unclear. Risk algorithms have been developed and validated in primary health care to predict the onset and prognosis of common mental disorders; which are useful for their treatment and prevention. There is evidence that psychological and psychoeducational interventions (and possibly those of physical exercise) are effective for the primary prevention of common mental disorders, even in primary health care; although their effects are small or moderate. These interventions have a high potential to be scalable in schools, workplace and primary health care; in addition, when they are administered through information and communication technologies (e.g. by App), in self-guided or minimally guided programs, they have demonstrated their effectiveness for the treatment and prevention of common mental disorders. They are also very accessible, have low cost and contribute to the massive implementation of these interventions in different settings.

Cognitive-behavioural interventions for prevention and treatment of anxiety in young children: A systematic review and meta-analysis

BACKGROUND

Anxiety disorders are common and impairing throughout the life course. Propensity to anxiety disorders manifests as distress and avoidance of novel stimuli (called behavioural inhibition) as early as in infancy. Already in preschool children, anxiety disorders impact emotional development and school readiness. Anxiety disorders and behavioural inhibition are prospectively associated with increased risk of mood disorders, substance use, and suicide. Therefore, early targeted prevention and treatment need to be considered. Cognitive-behavioural interventions are effective for anxiety in older age group but their efficacy for preschool children remains to be established.

METHODS

We searched PsycINFO, PubMed, and Embase until September 19th, 2019 using terms describing anxiety, behavioural inhibition, intervention, and young children. We included studies with young children participating in a cognitive-behavioural intervention for anxiety disorders, anxiety symptoms, or behavioural inhibition. We completed random-effects robust meta-analyses to (1) compare anxiety measures before and after intervention and to (2) compare intervention and control groups.

RESULTS

We identified 43 samples including 2656 participants with a mean age of 5.45 (SD = 1.00) years. Anxiety decreased after cognitive-behavioural intervention (standardized mean difference [SMD] = -1.34, 95%CI -1.59 to -1.09, p < 0.0001). Anxiety decreased more in children who received intervention than in children in control conditions (SMD = -0.81, 95%CI -1.00 to -0.63, p < 0.0001). The difference remained significant after correcting for potential publication bias and outliers (SMD = -0.89, 95% CI -1.13 to -0.66, p < 0.0001). The improvement was maintained over follow-up.

CONCLUSIONS

Cognitive-behavioural interventions are effective for prevention and treatment of anxiety in young children.

Risk and protective factors for anxiety and obsessive-compulsive disorders: an umbrella review of systematic reviews and meta-analyses

BACKGROUND

A multitude of risk/protective factors for anxiety and obsessive-compulsive disorders have been proposed. We conducted an umbrella review to summarize the evidence of the associations between risk/protective factors and each of the following disorders: specific phobia, social anxiety disorder, generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder, and to assess the strength of this evidence whilst controlling for several biases.

METHODS

Publication databases were searched for systematic reviews and meta-analyses examining associations between potential risk/protective factors and each of the disorders investigated. The evidence of the association between each factor and disorder was graded into convincing, highly suggestive, suggestive, weak, or non-significant according to a standardized classification based on: number of cases (>1000), random-effects p-values, 95% prediction intervals, confidence interval of the largest study, heterogeneity between studies, study effects, and excess of significance.

RESULTS

Nineteen systematic reviews and meta-analyses were included, corresponding to 216 individual studies covering 427 potential risk/protective factors. Only one factor association (early physical trauma as a risk factor for social anxiety disorder, OR 2.59, 95% CI 2.17-3.1) met all the criteria for convincing evidence. When excluding the requirement for more than 1000 cases, five factor associations met the other criteria for convincing evidence and 22 met the remaining criteria for highly suggestive evidence.

CONCLUSIONS

Although the amount and quality of the evidence for most risk/protective factors for anxiety and obsessive-compulsive disorders is limited, a number of factors significantly increase the risk for these disorders, may have potential prognostic ability and inform prevention.

Recognition of anxiety disorders in children: a cross-sectional vignette-based survey among general practitioners

OBJECTIVE

To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.

DESIGN AND SETTING

In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.

PARTICIPANTS

A sample of 229 GPs, resulting in a total of 1128 vignette evaluations.

MAIN OUTCOME MEASURE

GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).

RESULTS

Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.

CONCLUSION

A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition.

The association of physical activity and sleep duration with incident anxiety symptoms: A cohort study of 134,957 Korean adults

BACKGROUND

Maintaining adequate levels of sleep and physical activity (PA) as self-help for the prevention of new-onset anxiety symptoms is becoming more important.

METHODS

A cohort study was performed with 134,957 adults, free of anxiety symptoms at baseline who underwent at least two comprehensive health screening examinations between 2012 and 2017. At baseline, the amount of PA was measured using the International Physical Activity Questionnaire-Short Form and sleep duration per day was assessed using a self-report questionnaire. The study's end point was new-onset anxiety symptoms, defined as a Beck Anxiety Inventory score of ≥19.

RESULTS

During 361,969 person-years of follow-up, 5086 participants developed case-level anxiety. Compared with a reference (0-600 METs-min/wk), a U-shaped relationship was observed between PA and case-level anxiety. The most beneficial levels of PA for reducing incident anxiety symptoms were higher in men than women (men: 1800-3000 METs-min/wk HR, 0.88 [95% CI, 0.78-0.81], 3000-6000 METs-min/wk HR, 0.81 [95% CI, 0.70-0.93]; women: 600-1,200 METs-min/wk HR, 0.86 [95% CI, 0.76-0.98]). In comparison with a reference (<6 h), the relationship between sleep duration and case-level anxiety also had a U-shaped pattern. The optimal sleep duration for decreasing the onset of case-level anxiety was 7-8 h, regardless of sex (men: HR, 0.75 [95% CI, 0.63-0.90]; women; HR, 0.61 [95% CI, 0.54-0.70]).

LIMITATIONS

PA, sleep duration, and anxiety symptoms were measured using self-report questionnaires.

CONCLUSIONS

The results of this study revealed the appropriate levels of PA and total sleep time for reducing incident anxiety symptoms.

Risk Factors and Prevention Strategies for Anxiety Disorders in Childhood and Adolescence

Anxiety is prevalent in childhood and adolescence. Youth with maladaptive responses to common situations and stressors are at risk of having anxiety disorders. Persistent anxiety symptoms and anxiety disorders can be debilitating with long-term adverse outcomes in adulthood. Hence, decreasing the burden of anxiety disorders is an important public health priority. Development of anxiety disorders has a multifactorial etiology. There is a considerable complex interaction of genetics, temperament, parenting behavior, environmental triggers, and physiologic factors. Identification of these risk factors is key to early detection, prevention, and development of applicable management approaches. Despite several evidence-based treatments published, there are limited prevention strategies available. Effective implementation of prevention strategies is essential and can be achieved by either elimination or reduction of the negative risk factors or strengthening the protective factors on anxiety symptoms and anxiety disorders. This chapter reviews the common risk and protective factors and provides current literature on prevention strategies for pediatric and adolescent anxiety disorders.

What is good mental health? A scoping review

Promotion of good mental health in young people with and without mental disorders has received little empirical research attention and interventions for improving mental health in young people are not well established. This situation could be explained among other reasons due to the difficulties to define and operationalise what good mental health is. The current manuscript, produced by the European College of Neuropsychopharmacology Thematic Working Group on the Prevention of Mental Disorders and Mental Health Promotion (ECNP TWG PMD-MHP), presents a critical review of the available operationalizations for good mental health. A pragmatic conceptual operationalisation of good mental health is a much-needed step towards more standardised research in this field. Good mental health can be defined as a state of well-being that allows individuals to cope with the normal stresses of life and function productively. Universal and selective interventions are suitable to promote mental health. Core domains that define good mental health encompass: (i) mental health literacy, (ii) attitude towards mental disorders, (iii) self-perceptions and values, (iv) cognitive skills, (v) academic/ occupational performance, (vi) emotions, (vii) behaviours, (viii) self-management strategies, (ix) social skills, (x) family and significant relationships (xi) physical health, (xii) sexual health, (xiii) meaning of life, (xiv) and quality of life. These domains should be widely traceable in the literature and can be used to conduct further empirical research in the field of good mental health. Such data can lead to more robust evidence to identify and establish the pathways to follow in order to improve mental health.

Mediators in psychological and psychoeducational interventions for the prevention of depression and anxiety. A systematic review

Although efforts have been undertaken to determine how psychological interventions exert their effects, research on mediators and mechanisms of change remains limited, especially in the field of prevention. We aimed to assess available evidence on mediators of psychological and psychoeducational interventions for the prevention of depression and anxiety in varied populations. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and the Cochrane Central Register of Controlled Trials was performed. Two independent reviewers assessed the eligibility criteria of all articles, extracted data, determined the risk of bias in randomized controlled trials, and the requirements for mediators. The outcomes were mediators of the incidence of depression or anxiety and/or the reduction of symptoms of depression or anxiety. We identified 28 nested mediator studies within randomized controlled trials involving 7442 participants. Potential cognitive, behavioral, emotional and interpersonal mediators were evaluated in different psychological and psychoeducational interventions to prevent depression and anxiety. The effects were mediated mainly by cognitive variables, which were the most commonly assessed factors. For depression, the mediator with the strongest empirical support was negative thinking in adults. Cognitive change is an important mediator in preventive psychological and psychoeducational interventions for both anxiety and depression. REGISTRATION DETAILS: Registration number (PROSPERO): CRD42018092393.

Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online intervention

BACKGROUND

Substance use, depression, and anxiety in adolescence are major public health problems requiring new scalable prevention strategies. We aimed to assess the effectiveness of a combined online universal (ie, delivered to all pupils) school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

METHODS

We did a multicentre, cluster-randomised controlled trial in secondary schools in Australia, with pupils in year 8 or 9 (aged 13-14 years). Participating schools were randomly assigned (1:1:1:1) to one of four intervention conditions: (1) Climate Schools-Substance Use, focusing on substance use only; (2) Climate Schools-Mental Health, focusing on depression and anxiety only; (3) Climate Schools-Combined, focusing on the prevention of substance use, depression, and anxiety; or (4) active control. The interventions were delivered in school classrooms in an online delivery format and used a mixture of peer cartoon storyboards and classroom activities that were focused on alcohol, cannabis, anxiety, and depression. The interventions were delivered for 2 years and primary outcomes were knowledge related to alcohol, cannabis, and mental health; alcohol use, including heavy episodic drinking; and depression and anxiety symptoms at 12, 24, and 30 months after baseline. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000723785) and an extended follow-up is underway.

FINDINGS

Between Sept 1, 2013, and Feb 28, 2014, we recruited 88 schools (12 391 pupils), of whom 71 schools and 6386 (51·5%) pupils were analysed (17 schools dropped out and 1308 pupils declined to participate). We allocated 18 schools (1739 [27·25%] pupils; 1690 [97·2%] completed at least one follow-up) to the substance use condition, 18 schools (1594 [25·0%] pupils; 1560 [97·9%] completed at least one follow-up) to the mental health condition, 16 schools (1497 [23·4%] pupils; 1443 [96·4%] completed at least one follow-up) to the combined condition, and 19 schools (1556 [23·4%] pupils; 1513 [97·2%] completed at least one follow-up) to the control condition. Compared with controls, the combined intervention group had increased knowledge related to alcohol and cannabis at 12, 24, and 30 months (standardised mean difference [SMD] for alcohol 0·26 [95% CI 0·14 to 0·39] and for cannabis 0·17 [0·06 to 0·28] at 30 months), increased knowledge related to mental health at 24 months (0·17 [0·08 to 0·27]), reduced growth in their odds of drinking and heavy episodic drinking at 12, 24, and 30 months (odds ratio for drinking 0·25 [95% CI 0·12 to 0·51], and for heavy episodic drinking 0·15 [0·04 to 0·58] at 30 months), and reduced increases in anxiety symptoms at 12 and 30 months (SMD -0·12 [95% CI -0·22 to -0·01] at 30 months). We found no difference in symptoms or probable diagnosis of depression. The combined intervention group also showed improvement in alcohol use outcomes compared with the substance use and mental health interventions and improvements in anxiety outcomes when compared with the mental health intervention only.

INTERPRETATION

Combined online prevention of substance use, depression, and anxiety led to increased knowledge of alcohol, cannabis, and mental health, reduced increase in the odds of any drinking and heavy episodic drinking, and reduced symptoms of anxiety over a 30-month period. These findings provide the first evidence of the effectiveness of an online universal school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

FUNDING

Australian National Health and Medical Research Council.

European college of neuropsychopharmacology network on the prevention of mental disorders and mental health promotion (ECNP PMD-MHP)

Prevention is the most promising way to reduce the high personal, familial, societal, clinical and economic costs of mental disorders in Europe and worldwide. A complementary approach is to go beyond the prevention of mental ill health, to promote good mental health. This manuscript highlights the first European consortium fostering cutting-edge multidisciplinary research in these two areas. The ECNP-funded Network on the Prevention of Mental Disorders and Mental Health Promotion (ECNP PMD-MHP) brings together European sites of excellence with different expertise for translational research collaboration, including partnerships with the industry. The ECNP PMD-MHP Network adopts a transdiagnostic, lifespan, clinical staging model which cuts across different mental disorders and different methodologies. The main aims of the ECNP PMD-MHP Network are to facilitate multidisciplinary collaboration, enhance knowledge and data sharing, standardise core assessment and outcome measures, promote clinical research, apply for grant funding, and generate research reports. By supporting collaborative research, the ECNP PMD-MHP Network will be vital for fostering European psychiatry in the field of prevention of mental disorders and promotion of good mental health.

The Diagnosis and Treatment of Anxiety Disorders

BACKGROUND

Anxiety disorders are the most common type of mental illness in Europe, with a 12-month prevalence of 14% among persons aged 14 to 65. Their onset is usually in adolescence or early adulthood. The affected patients often develop further mental or somatic illnesses (sequential comorbidity).

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

The group of anxiety disorders includes generalized anxiety disorder (GAD), phobic disorders, panic disorders, and two disorders that are often restricted to childhood-separation anxiety and selective mutism. A comprehensive differential diag- nostic evaluation is essential, because anxiety can be a principal manifestation of other types of mental or somatic illness as well. Psychotherapy and treatment with psychoactive drugs are the therapeutic strategies of first choice. Of all types of psycho- therapy, cognitive behavioral therapy has the best documented efficacy. Modern antidepressants are the drugs of first choice for the treatment of panic disorders, agoraphobia, social phobia, and GAS; pregabalin is a further drug of first choice for GAS.

CONCLUSION

In general, anxiety disorders can now be effectively treated. Patients should be informed of the therapeutic options and should be involved in treatment planning. Current research efforts are centered on individualized and therefore, it is hoped, even more effective treatment approaches than are available at present.

Web-based CBT for the prevention of anxiety symptoms among medical and health science graduate students

Medical and health science graduate students report greater anxiety problems than the general population, but they are less likely to seek treatment due to cultural and logistical barriers. One preventative approach that overcomes these barriers is web-based cognitive behavioral therapy (webCBT). It is unknown whether webCBT is effective for preventing anxiety escalation within this population. A randomized controlled trial was conducted, comparing the effects of webCBT versus a control group (CG). Medical university students (n=594; Mage=27; 67% female; 80% Caucasian) completed online baseline measures and four assigned online activities. Measures were re-administered after approximately three months. There was a small interaction effect between time of assessment and treatment condition. Anxiety severity was lower in the webCBT (M[SD]=2.88[3.36]) versus CG condition (M[SD]=3.69 [3.35]) at follow-up. This effect was moderate for students with mild, versus minimal, anxiety at baseline. The proportion of students with possible anxiety disorder was lower in the webCBT (4.5%) versus CG (8.5%) condition, and the proportion of mildly anxious students with a clinically significant increase in symptoms was lower in the webCBT (10%) versus CG (20%) condition. WebCBT may aid in preventing anxiety escalation in this population, particularly for at-risk students who report mild anxiety symptoms.

Darwin's Other Dilemmas and the Theoretical Roots of Emotional Connection

Modern scientific theories of emotional behavior, almost without exception, trace their origin to Charles Darwin, and his publications On the Origin of Species (1859) and The Expression of the Emotions in Man and Animals (1872). The most famous dilemma Darwin acknowledged as a challenge to his theory of evolution through natural selection was the incomplete Sub-Cambrian fossil record. However, Darwin struggled with two other rarely referenced theoretical and scientific dilemmas that confounded his theories about emotional behavior. These included (1) the origin of social instincts (e.g., altruism, empathy, reciprocity and cooperation) and the reasons for their conservation in evolution and (2) the peripheral control of heart rate vis-à-vis emotional behavior outside of consciousness. Darwin acknowledged that social instincts are critical to the survival of some species, but had difficulty aligning them with his theory of natural selection in humans. Darwin eventually proposed that heart rate and emotions are controlled via one's intellect and cortical mechanisms, and that instinctive behavior is genetically programmed and inherited. Despite ongoing efforts, these two theoretical dilemmas are debated to this day. Simple testable hypotheses have yet to emerge for the biological mechanisms underlying instinctive behavior or the way heart rate is controlled in infants. In this paper, we review attempts to resolve these issues over the past 160 years. We posit that research and theories that supported Darwin's individualistic brain-centric and genetic model have become an "orthodox" Western view of emotional behavior, one that produced the prevailing behavioral construct of attachment as developed by John Bowlby. We trace research and theories that challenged this orthodoxy at various times, and show how these challenges were repeatedly overlooked, rejected, or misinterpreted. We review two new testable theories, emotional connection theory and calming cycle theory, which we argue resolve the two dilemmas We show emerging scientific evidence from physiology and a wide variety of other fields, as well from clinical trials among prematurely born infants, that supports the two theories. Clinical implications of the new theories and possible new ways to assess risk and intervene in emotional, behavioral and developmental disorders are discussed.

The Fountain of Health: effective health promotion knowledge transfer in individual primary care and group community-based formats

ABSTRACTBackground:The Fountain of Health (FoH) initiative is a knowledge transfer (KT) project on the science of brain health and resilience promotion, in alignment with positive psychiatry.

OBJECTIVES

Assess the effectiveness of FoH KT delivered in individual and group-based formats.

DESIGN

Pre- and post-intervention quality assurance survey of FoH KT.

SETTING

Interventions occurred in Nova Scotia, Canada.

PARTICIPANTS

Adults over age 50 years without pre-existing dementia were targeted. A total of 92 participants received FoH KT in individualized (n = 41) and group-based (n = 51) formats.

INTERVENTION

FoH KT (e.g. sharing evidence, lifestyle coaching, and goal setting) using a range of KT supports (e.g. FoH website, paper materials) was delivered to (1) individual patients by primary care clinicians and (2) community-based groups by lay leaders.

MEASUREMENTS

The main outcome measure was participant pre- and post-quality assurance self-reports.

RESULTS

Improvements were found in participant awareness of FoH, knowledge of evidence-based mental health promotion initiatives, and in application of this information in daily life in both individual and group-based settings. Improvements in participant knowledge about epigenetic factors that impact health and confidence with health behavior goal setting were reported in both contexts. Changes in self-perceptions of aging scores reached significance in the group intervention.

CONCLUSIONS

FoH KT produced short-term positive self-reported changes in participants in both individual and group formats. Larger control studies with long-term follow up are needed to better assess effects of both individual and group formats of FoH KT and longer term impacts on health behaviors and outcomes.

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

Preventive strategies for mental health

Available treatment methods have shown little effect on the burden associated with mental health disorders. We review promising universal, selective, and indicated preventive mental health strategies that might reduce the incidence of mental health disorders, or shift expected trajectories to less debilitating outcomes. Some of these interventions also seem to be cost-effective. In the transition to mental illness, the cumulative lifetime effect of multiple small effect size risk factors progressively increases vulnerability to mental health disorders. This process might inform different levels and stages of tailored interventions to lessen risk, or increase protective factors and resilience, especially during sensitive developmental periods. Gaps between knowledge, policy, and practice need to be bridged. Future steps should emphasise mental health promotion, and improvement of early detection and interventions in clinical settings, schools, and the community, with essential support from society and policy makers.

The effect of programmed exercise over anxiety symptoms in midlife and older women: a meta-analysis of randomized controlled trials

We aimed to perform a systematic review and meta-analysis in order to clarify the effect of programmed exercise over mild-to-moderate anxiety symptoms (ASs) in midlife and older women. A structured search of PubMed, Medline, Web of Science, Scopus, Embase, Cochrane Library, Scielo, and the US, UK and Australian Clinical Trials databases (from inception through July 27, 2017) was performed, with no language restriction using the following terms: 'anxiety', 'anxiety symptoms', 'exercise', 'physical activity', 'menopause', and 'randomized controlled trial' (RCTs) in mid-aged and older women. We assessed RCTs that compared the effect of exercise for at least 6 weeks versus no intervention over ASs as outcome (as defined by trial authors). Exercise was classified according to duration as 'mid-term exercise intervention' (MTEI; for 12 weeks to 4 months), and 'long-term exercise intervention' (LTEI; for 6-14 months). Mean ± standard deviations of changes for ASs, as assessed with different questionnaires, were extracted to calculate Hedges' g and then used as effect size for meta-analyses. Standardized mean differences (SMDs) of ASs after intervention were pooled using a random-effects model. Ten publications were included for analysis related to 1463 midlife and older women (minimum age 54.2 ± 3.5 and maximum age 77.6 ± 5.4 years). Eight MTEIs were associated with a significant reduction of ASs (SMD = -0.42; 95% CI -0.81 to -0.02) as compared to controls. There was no reduction of ASs in seven LTEIs (SMD = -0.03; 95% CI -0.18 to 0.13). It can be concluded that MTEIs of low-to-moderate intensity seem to improve mild-moderate ASs in midlife and older women.