A component analysis of cognitive-behavioral treatment for depression

Improving outcomes for care partners of persons with traumatic brain injury: Protocol for a randomized control trial of a just-in-time-adaptive self-management intervention

Informal family care partners of persons with traumatic brain injury (TBI) often experience intense stress resulting from their caregiver role. As such, there is a need for low burden, and easy to engage in interventions to improve health-related quality of life (HRQOL) for these care partners. This study is designed to evaluate the effectiveness of a personalized just-in-time adaptive intervention (JITAI) aimed at improving the HRQOL of care partners. Participants are randomized either to a control group, where they wear the Fitbit® and provide daily reports of HRQOL over a six-month (180 day) period (without the personalized feedback), or the JITAI group, where they wear the Fitbit®, provide daily reports of HRQOL and receive personalized self-management pushes for 6 months. 240 participants will be enrolled (n = 120 control group; n = 120 JITAI group). Outcomes are collected at baseline, 1-, 2-, 3-, 4-, 5- & 6-months, as well as 3- and 6-months post intervention. We hypothesize that the care partners who receive the intervention (JITAI group) will show improvements in caregiver strain (primary outcome) and mental health (depression and anxiety) after the 6-month (180 day) home monitoring period. Participant recruitment for this study started in November 2020. Data collection efforts should be completed by spring 2025; results are expected by winter 2025. At the conclusion of this randomized control trial, we will be able to identify care partners at greatest risk for negative physical and mental health outcomes, and will have demonstrated the efficacy of this JITAI intervention to improve HRQOL for these care partners. Trial registration: ClinicalTrial.gov NCT04570930; https://clinicaltrials.gov/ct2/show/NCT04570930.

Behavioral Psychedelics: Integrating Mind and Behavior to Improve Health and Resilience

One of the most recent and potentially promising advancements in the health sciences has involved the attempted use of psychedelics for treating mental and behavioral health problems, such as anxiety, depression, posttraumatic stress disorder, and addiction. Despite surging scientific and public interest in this work, however, we presently have no standard of care or consensus regarding how best to combine psychotherapy and psychedelics or to assess effectiveness. We discuss these timely issues here through the lens of behavioral psychedelics, which we define as the study of psychedelics to foster intentional changes in habits and behaviors to improve health and resilience. Psychedelics may have the potential to reduce chronic disease risk caused by mental and behavioral rigidity. To fully realize this potential, though, we believe the field must establish best practices and guidelines that include how to induce lasting changes in behavior.

A Narrative Review of Empirical Literature of Behavioral Activation Treatment for Depression

Grounded in the profound tradition of behaviorism theory and research, behavioral activation (BA) has become a standalone psychotherapy for depression. It is simple, straightforward, and easy to comprehend, with comparable efficacy to traditional CBT, and has developed into an evidence-based guided self-help intervention. The main work in the theoretical models and treatment manuals, as well as empirical evidence of the effectiveness of BA for (comorbid) depression in primary and medical care setting are introduced. With the rise of the third wave of CBT, therapeutic components across diagnoses will be incorporated into BA (e.g., mindfulness). Extensive studies are required to examine the neurobiological reward mechanism of BA for depression, and to explore the feasibility and necessity of e-mental health BA application into the public healthcare system in China.

An App-Based Just-in-Time Adaptive Self-management Intervention for Care Partners (CareQOL): Protocol for a Pilot Trial

Background

Care partners (ie, informal family caregivers) of individuals with health problems face considerable physical and emotional stress, often with a substantial negative impact on the health-related quality of life (HRQOL) of both care partners and care recipients. Given that these individuals are often overwhelmed by their caregiving responsibilities, low-burden self-management interventions are needed to support care partners to ensure better patient outcomes.

Objective

The primary objective of this study is to describe an intensive data collection protocol that involves the delivery of a personalized just-in-time adaptive intervention that incorporates passive mobile sensor data feedback (sleep and activity data from a Fitbit [Fitbit LLC]) and real time self-reporting of HRQOL via a study-specific app called CareQOL (University of Michigan) to provide personalized feedback via app alerts.

Methods

Participants from 3 diverse care partner groups will be enrolled (care partners of persons with spinal cord injury, care partners of persons with Huntington disease, and care partners of persons with hematopoietic cell transplantation). Participants will be randomized to either a control group, where they will wear the Fitbit and provide daily reports of HRQOL over a 3-month (ie, 90 days) period (without personalized feedback), or the just-in-time adaptive intervention group, where they will wear the Fitbit, provide daily reports of HRQOL, and receive personalized push notifications for 3 months. At the end of the study, participants will complete a feasibility and acceptability questionnaire, and metrics regarding adherence and attrition will be calculated.

Results

This trial opened for recruitment in November 2020. Data collection was completed in June 2021, and the primary results are expected to be published in 2022.

Conclusions

This trial will determine the feasibility and acceptability of an intensive app-based intervention in 3 distinct care partner groups: care partners for persons with a chronic condition that was caused by a traumatic event (ie, spinal cord injury); care partners for persons with a progressive, fatal neurodegenerative disease (ie, Huntington disease); and care partners for persons with episodic cancer conditions that require intense, prolonged inpatient and outpatient treatment (persons with hematopoietic cell transplantation).

Trial Registration

ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591

International Registered Report Identifier (IRRID)

DERR1-10.2196/32842

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.

The contributions of focused attention and open monitoring in mindfulness-based cognitive therapy for affective disturbances: A 3-armed randomized dismantling trial

Objective

Mindfulness-based cognitive therapy (MBCT) includes a combination of focused attention (FA) and open monitoring (OM) meditation practices. The aim of this study was to assess both short- and long-term between- and within-group differences in affective disturbance among FA, OM and their combination (MBCT) in the context of a randomized controlled trial.

Method

One hundred and four participants with mild to severe depression and anxiety were randomized into one of three 8-week interventions: MBCT (n = 32), FA (n = 36) and OM (n = 36). Outcome measures included the Inventory of Depressive Symptomatology (IDS), and the Depression Anxiety Stress Scales (DASS). Mixed effects regression models were used to assess differential treatment effects during treatment, post-treatment (8 weeks) and long-term (20 weeks). The Reliable Change Index (RCI) was used to translate statistical findings into clinically meaningful improvements or deteriorations.

Results

All treatments demonstrated medium to large improvements (ds = 0.42–1.65) for almost all outcomes. While all treatments were largely comparable in their effects at post-treatment (week 8), the treatments showed meaningful differences in rapidity of response and pattern of deteriorations. FA showed the fastest rate of improvement and the fewest deteriorations on stress, anxiety and depression during treatment, but a loss of treatment-related gains and lasting deteriorations in depression at week 20. OM showed the slowest rate of improvement and lost treatment-related gains for anxiety, resulting in higher anxiety in OM at week 20 than MBCT (d = 0.40) and FA (d = 0.36), though these differences did not reach statistical significance after correcting for multiple comparisons (p’s = .06). MBCT and OM showed deteriorations in stress, anxiety and depression at multiple timepoints during treatment, with lasting deteriorations in stress and depression. MBCT showed the most favorable pattern for long-term treatment of depression.

Conclusions

FA, OM and MBCT show different patterns of response for different dimensions of affective disturbance.

Trial registration

This trial is registered at (v NCT01831362); www.clinicaltrials.gov.

Long-Term Effects of a Cognitive Behavioral Conference Call Intervention on Depression in Non-Professional Caregivers

Recent evidence supports the efficacy of conference call cognitive-behavioral interventions in preventing depression in caregivers at post-intervention, but we do not know whether the results are sustained long term. The main objective of this study was to evaluate the long-term efficacy of a cognitive-behavioral intervention administered by telephone conference call in preventing depression in caregivers with elevated depressive symptoms, comparing all components of the intervention versus only the behavioral ones. A randomized controlled trial was conducted using a dismantling strategy. At total of 219 caregivers were randomly assigned to a cognitive-behavioral conference call intervention (CBCC; n = 69), a behavioral-activation conference call intervention (BACC; n = 70), or a usual care control group (CG, n = 80). Information was collected on depressive symptoms and depression at pre-intervention and at 1, 3, 6, 12, and 36 months post-intervention. At 36 months, there was a reduction in depressive symptoms (p < 0.001) and a lower incidence of major depressive episodes in both the CBCC and BACC groups compared to CG (8.7%, 8.6%, and 33.7%, respectively). The results show that a conference call intervention was effective in the long term to prevent depression in caregivers and that the behavioral-activation component was comparable to the complete cognitive-behavioral protocol.

Behavioural activation therapy for depression in adults with non-communicable diseases

BACKGROUND

Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults.

OBJECTIVES

To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs. To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs.

SEARCH METHODS

We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches.

SELECTION CRITERIA

We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

We included two studies, contributing data from 181 participants to the analyses. Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy. Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias. Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence). There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD -1.15, 95% CI -2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI -0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI -6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD -1.70, 95% CI -4.50 to 1.10; low-certainty evidence). Neither study reported data on adverse effects.

AUTHORS' CONCLUSIONS

Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.

Effectiveness of behavioral activation for depression treatment in medical students: Study protocol for a quasi-experimental design

INTRODUCTION

Depression is a frequent mood disorder among medical students that can lead to multiple negative consequences at individual and social level (such as academic achievement and interpersonal conflicts) as well as patient care performance. Therefore, the need of depression decreasing treatments in medical students is important. This study is designed to evaluate the effectiveness of the Behavioral Activation Treatment for Depression in a sample of Mexican medical students.

METHODS

This study will be performed under a quasi-experimental design to verify the effectiveness of the Behavioral Activation Treatment for Depression to reduce depressive symptoms in medical students from two public universities in northwestern Mexico. The participants will be assessed with the Center for Epidemiologic Studies Depression Scale, the Depression Anxiety Stress Scales, the Pittsburgh Sleep Quality Index, and the Plutchik Suicide Risk Scale. In addition to the psychometric assessment, there will be an electroencephalogram evaluation using the EMOTIV (v 1.1) device.

RESULTS

A pre-post intervention of 10 Behavioral Activation Treatment for Depression sessions will be implemented. The results of the effectiveness of the Behavioral Activation Treatment for Depression will be analyzed in five measures at pre-post intervention and two follow-ups of 3 and 6 months.

CONCLUSIONS

This study looks for evidence regarding the efficacy and feasibility of the Behavioral Activation Treatment for Depression in a sample of medical students from two public universities in Mexico with high levels of depression along with stress and anxiety.

Behavioural activation therapy for depression in adults

BACKGROUND

Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy.

OBJECTIVES

To examine the effects of behavioural activation compared with other psychological therapies for depression in adults. To examine the effects of behavioural activation compared with medication for depression in adults. To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults.

SEARCH METHODS

We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs. We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment. We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies. There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy. Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants). Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text.

AUTHORS' CONCLUSIONS

This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence. We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence. No data were available about the efficacy of behaioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies. The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.

Feasibility of behavioral activation group therapy in reducing depressive symptoms and improving quality of life in patients with depression: the BRAVE pilot trial

BACKGROUND

Depression impacts the lives of millions of people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has the potential for improving depressive symptoms in patients with depression. Studies evaluating the effectiveness of BA specifically in the context of group therapy programs in a hospital setting for patients with depression are limited. In this study, we report findings from a pilot trial evaluating group BA for major depressive disorder.

OBJECTIVE

The objectives of this pilot trial are to assess the potential of a full trial of BA group therapy in a large-scale tertiary care setting and to provide preliminary information about possible results regarding mood symptoms and quality of life in adults with depression.

METHODS

Using a parallel single-cohort pragmatic pilot randomized controlled trial design, we evaluated the potential of conducting a large trial of BA effectiveness among adults with depression. Participants were randomized to the intervention (BA in addition to usual care) or control (support group in addition to usual care) groups and were assessed weekly for 18 consecutive weeks. Participants randomized to intervention underwent 28 2-h group BA therapy visits administered by trained therapists and completed assessments to examine treatment outcomes. Feasibility was measured in terms of enrollment rates (min. 20%), completion rates of study (min. 80%), and completion rates of weekly measurement scales (min. 80%). The reporting of this pilot trial is in accordance with the CONSORT extension for randomized pilot and feasibility trials.

RESULTS

We randomized 20 individuals of mean age of 48.8 years (standard deviation = 9.7) with a DSM-5 diagnosis of major depressive disorder to intervention (n = 10) or control (n = 10) groups. Based on our feasibility criteria, our recruitment rate was excellent (20/27; 74%), study completion was found to be a moderate (80% of the total participants in both arms completed the study; BA = 100%, control = 60%), and completeness of measurements on a weekly basis was adequate overall (82%; BA = 86%, control = 79%).

CONCLUSIONS

The study has demonstrated the potential feasibility to perform a larger scale trial upon modifications to the control group to avoid the low rate of study completion (60%) in this group.

TRIAL REGISTRATION

ClinicalTrials NCT02045771, Registered January 22, 2014.

Analysis of the Components of a Cognitive-Behavioral Intervention for the prevention of Depression Administered via Conference Call to Nonprofessional Caregivers: A Randomized Controlled Trial

Effective and accessible interventions for indicated prevention of depression are necessary and lacking, especially for informal caregivers. Although telephone-based interventions could increase the accessibility for caregivers, randomized controlled trials are scarce, with no examination of prevention to date. Moreover, the efficacy of specific therapeutic components in preventive cognitive-behavioral programs is unknown. The main objective of this study was to evaluate the efficacy of a telephone-administered psychological preventive intervention in informal caregivers with high depressive symptoms. A total of 219 caregivers were randomized to a cognitive-behavioral conference call intervention (CBCC, n = 69), a behavioral-activation conference call intervention (BACC, n = 70), or a usual care control group (CG, n = 80). Both interventions consisted of five 90-minute group sessions. At the post-intervention, incidence of depression was lower in CBCC and BACC compared to CG (1.5% and 1.4% vs. 8.8%). Relative risk was 0.17 for the CBCC and 0.16 for the BACC, and the number-needed-to-treat was 14 in both groups. Depressive symptoms were significantly lower in BACC and BACC groups compared to CG (d = 1.16 and 1.29), with no significant differences between CBCC and BACC groups. The conference call intervention was effective in preventing depression and the behavioral-activation component (BACC) was comparable to the CBCC intervention.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD).

METHODS

The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project.

DISCUSSION

Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries.

TRIAL REGISTRATION

The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Addressing heterogeneity (and homogeneity) in treatment mechanisms in depression and the potential to develop diagnostic and predictive biomarkers

It has been 10 years since machine learning was first applied to neuroimaging data in psychiatric disorders to identify diagnostic and prognostic markers at the level of the individual. Proof of concept findings in major depression have since been extended in international samples and are beginning to include hundreds of samples from multisite data. Neuroimaging provides the unique capability to detect an acute depressive state in major depression, while we would not expect perfect classification with current diagnostic criteria which are based solely on clinical features. We review developments and the potential impact of heterogeneity, as well as homogeneity, on classification for diagnosis and prediction of clinical outcome. It is likely that there are distinct biotypes which comprise the disorder and which predict clinical outcome. Neuroimaging-based biotypes could aid in identifying the illness in individuals who are unable to recognise their illness and perhaps to identify the treatment resistant form early in the course of the illness. We propose that heterogeneous symptom profiles can arise from a limited number of neural biotypes and that apparently heterogeneous clinical outcomes include a common baseline predictor and common mechanism of treatment. Baseline predictors of clinical outcome reflect factors which indicate the general likelihood of response as well as those which are selective for a particular form of treatment. Irrespective of the mechanism, the capacity for response will moderate the outcome, which includes inherent models of interpersonal relationships that could be associated with genetic risk load and represented by patterns of functional and structural neural correlates as a predictive biomarker. We propose that methods which directly address heterogeneity are essential and that a synergistic combination could bring together data-driven inductive and symptom-based deductive approaches. Through this iterative process, major depression can develop from being syndrome characterized by a collection of symptoms to a disease with an identifiable pathophysiology.

Exploring Mediators of a Guided Web-Based Self-Help Intervention for People With HIV and Depressive Symptoms: Randomized Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is frequently used to treat depressive symptoms in people living with HIV. We developed an internet-based cognitive behavioral intervention for people with HIV and depressive symptoms, which was based on an effective self-help booklet. The Web-based intervention was previously found to be effective.

OBJECTIVE

The objective of this study was to investigate potential mediators of the Web-based intervention.

METHODS

This study was part of a randomized controlled trial, in which the intervention was compared with an attention-only waiting list control condition. Participants were 188 (97 in intervention group and 91 in control group) people with HIV and mild to moderate depressive symptoms recruited in HIV treatment centers in the Netherlands. A total of 22 participants (22/188, 11.7%) in the study were female and 166 (166/188, 88.3%) were male. The average age of the participants was 46.30 years (SD 10.63). The intervention comprised Web-based self-help CBT for 8 weeks, 1 to 2 hours a week, including minimal telephone support from a coach. The participants received Web-based questionnaires at pretest, 3 times during the intervention/or waiting period, and post intervention. The outcome was depressive symptoms. Factors tested as potential mediators were changes in behavioral activation, relaxation, the cognitive coping strategies catastrophizing and positive refocusing, goal re-engagement, and coping self-efficacy.

RESULTS

Using multilevel structural equation modeling, changes in behavioral activation (P=.006) and goal re-engagement (P=.009) were found to be significant mediators of the intervention effect. The mediation effect seemed to occur between weeks 3 and 5 for behavioral activation and weeks 1 and 3 for goal re-engagement. Using (bivariate) autoregressive latent trajectory analysis, we found a return effect (from the dependent variable to the mediator) for goal re-engagement but not for behavioral activation, which suggested that the mediation effect of changes in behavioral activation was stronger than that in goal re-engagement.

CONCLUSIONS

The results suggest that changes in behavioral activation and goal re-engagement may mediate the effect of the Web-based intervention for people with HIV and depressive symptoms. The results may lead to possible mechanisms of change of the intervention and improvement of therapy outcomes.

TRIAL REGISTRATION

Netherlands Trial Register NTR5407; https://www.trialregister.nl/trial/5298.

Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression

This study evaluated the putative mediating mechanisms of an Internet-facilitated cognitive-behavioral therapy (CBT) intervention for depression tailored to economically disadvantaged mothers of preschool-age children. The CBT mediators were tested across two previously published randomized controlled trials which included the same measures of behavioral activation, negative thinking, and savoring of positive events. Trial 1 included 70 mothers with elevated depressive symptoms who were randomized to either the eight-session, Internet-facilitated intervention (Mom-Net) or to treatment as usual. Trial 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition. Simple mediation models tested each putative mediator independently followed by tests of multiple mediation that simultaneously included all three mediators in the model to assess the salient contributions of each mediator. The pattern of results for the mediating effects were systematically replicated across the two trials and suggest that behavioral activation and negative thinking are salient mediators of the Mom-Net intervention; significant mediating effects for savoring were obtained only in the simple mediation models and were not obtained in the multiple mediation models.

Estimating outcome probabilities from early symptom changes in cognitive therapy for recurrent depression

OBJECTIVE

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) producing benefits comparable to pharmacotherapy, but not all patients respond or remit. The purpose of the current analyses was to estimate CT patients' probability of nonresponse and remission from symptom improvement early in treatment.

METHOD

Data from 2 clinical trials of acute-phase CT for recurrent depression were pooled for analysis (N = 679). Adult outpatients received 16- or 20-session CT protocols. Symptoms were measured repeatedly with the clinician-report Hamilton Rating Scale for Depression (HRSD) and Inventory of Depressive Symptomatology-Self-Report (IDS-SR). Outcomes at exit from CT were nonresponse (<50% reduction in HRSD scores) and remission (no MDD and HRSD score ≤6).

RESULTS

The nonresponse rate was 45.7%, and the remission rate was 33.4%. In logistic regression models, improvements on the HRSD or IDS-SR from intake to CT Sessions 3, 5, 7, 9, or 11 significantly predicted both outcomes, with prediction gaining in accuracy in later sessions. Clinician and self-report assessments yielded similar results. Prediction of outcomes replicated across data sets. Patients with no symptom improvement by CT Session 9 (Week 5) had ≤10% probability of remission and >75% probability of nonresponse.

CONCLUSIONS

Outcomes of CT for depression are predictable from early symptom changes. Clinicians may find nonresponse and remission probability estimates useful in the informed consent process and in choosing whether to continue, augment, or switch treatments for CT patients with recurrent MDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

[Cognitive therapy of depressive rumination]

Modern approaches to the therapy of depressive ruminations are reviewed. Depressive ruminations are thought to underlie and maintain depression. The authors describe different forms of ruminations and present the analysis of depressive ruminations and the role of childhood experience in their development as well as cognitive-behavioral techniques used for their correction.

Innovation in Psychotherapy, Challenges, and Opportunities: An Opinion Paper

Psychotherapy as a field tends toward conservativism, and the rate of innovation and development of new evidence-based effective treatments has been slow. The paper explores important barriers to innovation like the dodo bird verdict and the habit of starting the development of therapeutic methods from techniques. The paper looks at the opportunities for translating basic science in psychology into psychotherapeutic techniques. Metacognitive therapy stands out from other psychotherapies by its development from basic science. The paper describes the development of the techniques detached mindfulness and attention training, how they were derived from basic science and tested for their suitability in the therapy of patients with anxiety disorders. By this process, metacognitive therapy may be an important model for the innovation process in psychotherapy.

Mental Illness, Not Obesity Status, is Associated with Food Insecurity Among the Elderly in the Health and Retirement Study

OBJECTIVES

Food insecurity, limited or uncertain access to adequate nutrition, is an increasingly recognized determinant of health outcomes and is often associated with having obesity. It is unclear, however, if this association persists in elderly populations.

METHODS

We conducted a cross-sectional study of 2868 participants' aged 65+ years from the Health and Retirement Study. Multivariate logistic regression was used to assess associations between food insecurity and body mass index, demographic characteristics, psychiatric history, and medical history.

RESULTS

Participants with overweight/obesity had a higher prevalence of food insecurity than leaner counterparts, however, weight status was not a significant predictor of food insecurity after multivariate adjustment. Instead, mental illness, current smoking status, and non-White race were all independently associated with food insecurity.

DISCUSSION

Beyond financial status, health care providers are encouraged to use these characteristics to identify elderly patients that may be at risk of food insecurity.

Psychological therapies for anxiety and depression in children and adolescents with long-term physical conditions

BACKGROUND

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide. These individuals are at greater risk of developing psychological problems, particularly anxiety and depression, sometimes directly related to their illness or medical care (e.g. health-related anxiety). There is limited evidence regarding the effectiveness of psychological therapies for treating anxiety and depression in this population. Therapies designed for children and adolescents without medical issues may or may not be appropriate for use with those who have long-term physical conditions.

OBJECTIVES

This review was undertaken to assess the effectiveness and acceptability of psychological therapies in comparison with controls (treatment-as-usual, waiting list, attention placebo, psychological placebo, or non-psychological treatment) for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 27 September 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). In addition we searched the Web of Science (Core Collection) (12 October 2018) and conducted a cited reference search for reports of all included trials. We handsearched relevant conference proceedings, reference lists of included articles, and grey literature.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for treating anxiety or depression in children with long-term physical conditions were included.

DATA COLLECTION AND ANALYSIS

Abstracts and complete articles were independently reviewed by two authors. Discrepancies were addressed by a third author. Odds ratio (OR) was used for comparing dichotomous data and standardised mean differences (SMD) for comparing continuous data. Meta-analysis was undertaken when treatments, participants, and the underlying clinical question were similar. Otherwise, narrative analysis of data was undertaken.

MAIN RESULTS

Twenty-eight RCTs and one cross-over trial with 1349 participants were included in the review. Most participants were recruited from community settings and hospital clinics in high-income countries. For the primary outcome of treatment efficacy, short-term depression (versus any control), there was low-quality evidence from 16 trials involving 1121 participants suggesting that psychological therapies may be more effective than control therapies (SMD -0.31, 95% CI -0.59 to -0.03; I² = 79%). For the primary outcome of treatment efficacy, short-term anxiety (versus any control), there was inadequate evidence of moderate-quality from 13 studies involving 578 participants to determine whether psychological therapies were more effective than control conditions (SMD -0.26, CI -0.59 to 0.07, I² = 72%). Planned sensitivity analyses could not be undertaken for risk of bias due to the small number of trials that rated high for each domain. Additional sensitivity analysis demonstrated that psychological interventions specifically designed to reduce anxiety or depression were more effective than psychological therapies designed to improve other symptoms or general coping. There was some suggestion from subgroup analyses that they type of intervention (Chi² = 14.75, df = 5 (P = 0.01), I² = 66.1%), the severity of depression (Chi² = 23.29, df = 4 (P = 0.0001), I² = 82.8%) and the type of long-term physical condition (Chi² = 10.55, df = 4 (P = 0.03), I² = 62.1%) may have an impact on the overall treatment effect.There was qualitative (reported), but not quantitative evidence confirming the acceptability of selected psychological therapies for anxiety and depression. There was low-quality evidence that psychological therapies were more effective than control conditions in improving quality of life (SMD 1.13, CI 0.44 to 1.82, I² = 89%) and symptoms of long-term physical conditions (SMD -0.34, CI -0.6 to -0.06, I² = 70%), but only in the short term. There was inadequate low-quality evidence to determine whether psychological therapies were more effective than control conditions at improving functioning in either the short term or long term. No trials of therapies for addressing health-related anxiety were identified and only two trials reported adverse effects; these were unrelated to psychological therapies. Overall, the evidence was of low to moderate quality, results were heterogeneous, and only one trial had an available protocol.

AUTHORS' CONCLUSIONS

A limited number of trials of variable quality have been undertaken to assess whether psychological therapies are effective for treating anxiety and depression in children and adolescents with long-term physical conditions. According to the available evidence, therapies specifically designed to treat anxiety or depression (especially those based on principles of cognitive behaviour therapy (CBT)) may be more likely to work in children and adolescents who have mild to moderate levels of symptoms of these disorders, at least in the short term. There is a dearth of therapies specifically designed to treat health-related anxiety in this age group.

E-Health interventions for anxiety and depression in children and adolescents with long-term physical conditions

BACKGROUND

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide; these individuals are at greater risk of developing psychological problems, particularly anxiety and depression. Access to face-to-face treatment for such problems is often limited, and available interventions usually have not been tested with this population. As technology improves, e-health interventions (delivered via digital means, such as computers and smart phones and ranging from simple text-based programmes through to multimedia and interactive programmes, serious games, virtual reality and biofeedback programmes) offer a potential solution to address the psychological needs of this group of young people.

OBJECTIVES

To assess the effectiveness of e-health interventions in comparison with attention placebos, psychological placebos, treatment as usual, waiting-list controls, or non-psychological treatments for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Controlled Trials Register (CCMDTR to May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 8, 2017), Web of Science (1900 - 18 August 2016, updated 31 August 2017) and Ovid MEDLINE, Embase, PsycINFO (cross-search 2016 to 18 Aug 2017). We hand-searched relevant conference proceedings, reference lists of included articles, and the grey literature to May 2016. We also searched international trial registries to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and cross-over trials of e-health interventions for treating any type of long-term physical condition in children and adolescents (aged 0 to 18 years), and that measured changes in symptoms or diagnoses of anxiety, depression, or subthreshold depression. We defined long-term physical conditions as those that were more than three-months' duration. We assessed symptoms of anxiety and depression using patient- or clinician-administered validated rating scales based on DSM III, IV or 5 (American Psychological Association 2013), or ICD 9 or 10 criteria (World Health Organization 1992). Formal depressive and anxiety disorders were diagnosed using structured clinical interviews. Attention placebo, treatment as usual, waiting list, psychological placebo, and other non-psychological therapies were eligible comparators.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles, abstracts, and full-text articles; discrepancies were resolved through discussion or addressed by a third author. When available, we used odds ratio (OR) to compare dichotomous data and standardised mean differences (SMD) to analyse continuous data, both with 95% confidence intervals (CI). We undertook meta-analysis when treatments, participants, and the underlying clinical question were adequately similar. Otherwise, we undertook a narrative analysis.

MAIN RESULTS

We included five trials of three interventions (Breathe Easier Online, Web-MAP, and multimodal cognitive behavioural therapy (CBT)), which included 463 participants aged 10 to 18 years. Each trial contributed to at least one meta-analysis. Trials involved children and adolescents with long-term physical conditions, such as chronic headache (migraine, tension headache, and others), chronic pain conditions (abdominal, musculoskeletal, and others), chronic respiratory illness (asthma, cystic fibrosis, and others), and symptoms of anxiety or depression. Participants were recruited from community settings and hospital clinics in high income countries.For the primary outcome of change in depression symptoms versus any control, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.06, 95% CI -0.35 to 0.23; five RCTs, 441 participants). For the primary outcome of change in anxiety symptoms versus any comparator, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.07, 95% CI -0.29 to 0.14; two RCTs, 324 participants). For the primary outcome of treatment acceptability, there was very low-quality evidence that e-health interventions were less acceptable than any comparator (SMD 0.46, 95% CI 0.23 to 0.69; two RCTs, 304 participants).For the secondary outcome of quality of life, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.83, 95% CI -1.53 to -0.12; one RCT, 34 participants). For the secondary outcome of functioning, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.08, 95% CI -0.33 to 0.18; three RCTs, 368 participants). For the secondary outcome of status of long-term physical condition, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD 0.06, 95% CI -0.12 to 0.24; five RCTs, 463 participants).The risk of selection bias was considered low in most trials. However, the risk of bias due to inadequate blinding of participants or outcome assessors was considered unclear or high in all trials. Only one study had a published protocol; two trials had incomplete outcome data. All trials were conducted by the intervention developers, introducing another possible bias. No adverse effects were reported by any authors.

AUTHORS' CONCLUSIONS

At present, the field of e-health interventions for the treatment of anxiety or depression in children and adolescents with long-term physical conditions is limited to five low quality trials. The very low-quality of the evidence means the effects of e-health interventions are uncertain at this time, especially in children aged under 10 years.Although it is too early to recommend e-health interventions for this clinical population, given their growing number, and the global improvement in access to technology, there appears to be room for the development and evaluation of acceptable and effective technologically-based treatments to suit children and adolescents with long-term physical conditions.

The Relations of Cognitive, Behavioral, and Physical Activity Variables to Depression Severity in Traumatic Brain Injury: Reanalysis of Data From a Randomized Controlled Trial

OBJECTIVE

To explore the relations of cognitive, behavioral, and physical activity variables to depression severity among people with traumatic brain injury (TBI) undergoing a depression treatment trial.

SETTING

Community.

PARTICIPANTS

Adults (N = 88) who sustained complicated mild to severe TBI within the past 10 years, met criteria for major depressive disorder, and completed study measures.

DESIGN

Randomized controlled trial.

METHODS

Participants were randomized to cognitive-behavioral therapy (n = 58) or usual care (n = 42). Outcomes were measured at baseline and 16 weeks. We combined the groups and used regressions to explore the relations among theoretical variables and depression outcomes.

MAIN MEASURES

Depression severity was measured with the Hamilton Depression Rating Scale and Symptom Checklist-20. Theory-based measures were the Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ), Environmental Rewards Observation Scale (EROS), and the International Physical Activity Questionnaire (IPAQ).

RESULTS

Compared with non-TBI norms, baseline DAS and ATQ scores were high and EROS and IPAQ scores were low. All outcomes improved from baseline to 16 weeks except the DAS. The ATQ was an independent predictor of baseline depression. An increase in EROS scores was correlated with decreased depression.

CONCLUSIONS

Increasing participation in meaningful roles and pleasant activities may be a promising approach to treating depression after TBI.

Acceptance, Psychiatric Symptoms, and Migraine Disability: An Observational Study in a Headache Center

OBJECTIVE

To evaluate relationships between psychiatric symptoms, acceptance, and migraine-related disability in a sample of people with migraine presenting at a tertiary care headache center.

BACKGROUND

Migraine is a chronic disease that can be severely disabling. Despite a strong theoretical basis and evidence in other pain conditions, little is known about relationships between acceptance, psychiatric symptoms, and migraine-related disability.

METHODS

Ninety patients with physician-diagnosed migraine completed surveys assessing demographics, headache symptoms, severe migraine-related disability (Migraine Disability Assessment Scale total score dichotomized at ≥ 21), depression (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder-7), and acceptance (Chronic Pain Acceptance Questionnaire; subscales: Pain Willingness and Activity Engagement).

RESULTS

Participants (77.8% white, non-Hispanic; 85.6% women; and 50.0% with a graduate level education) reported an average headache pain intensity of 6.7/10 (SD = 2.0). One-third (36.0%) reported chronic migraine, and half (51.5%) reported severe migraine-related disability. Lower acceptance was associated with severe migraine-related disability, t(54) = 4.13, P < .001. Higher activity engagement was associated with lower average headache pain intensity (r = -.30, P = .011). Higher acceptance was associated with lower levels of depression (r = -.48, P < .001) and anxiety symptoms (r = -.37, P = .003). Pain willingness and activity engagement serially mediated relationships between depression symptoms and severe migraine-related disability (indirect effect = 0.05, 95% CI = 0.01, 0.15), and between anxiety symptoms and severe migraine-related disability (indirect effect = 0.12, 95% CI = 0.02, 0.31).

CONCLUSION

Results provided preliminary support for a theoretical pathway by which psychiatric symptoms may influence migraine-related disability, in part, through their relationships with pain willingness and activity engagement.

Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study

BACKGROUND

Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions.

METHODS

To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity.

DISCUSSION

Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

A Historical and Theoretical Review of Cognitive Behavioral Therapies: From Structural Self-Knowledge to Functional Processes

This paper critically examines the historical conceptualization of cognitive behavioral psychotherapy approaches (CBT) as a direct clinical counterpart of the cognitive revolution. The main "second wave" cognitive psychotherapies, either standard cognitive therapy (CT) or constructivist, in spite of their differences, share a common conceptualization of psychopathological factors as superordinate structural cognitive content belonging to the self: self-beliefs, self-schemata, personality organizations and so on. On the other hand, rational emotive behavior therapy (REBT) is an exception given that in REBT self-knowledge is not the core psychopathological tenet, being rather a derivate mechanism. Moreover, in non clinical cognitive science cognition is conceived as a regulatory function that operates retroactively and not in a hierarchically super- ordered fashion centered on the self. A historical review suggests that in both CT and constructivist model the structuralistic model of self-centered cognition may have emerged for both cultural and scientific reasons: self-centered cognitive models may be more readily understandable to clinicians as they allow for a straightforward identification of operationalizable self-beliefs. The emergence of new "third wave" process-centered CBT approaches may represent a comeback to functionalism, where cognition is considered again a regulatory function and not a structure. In addition, REBT's interest in dysfunctional evaluations not focused on the self presaged this clinical and scientific turning point toward functionalism.

Dismantling Mindfulness-Based Cognitive Therapy: Creation and validation of 8-week focused attention and open monitoring interventions within a 3-armed randomized controlled trial

BACKGROUND

While mindfulness-based interventions (MBIs) employ two distinct practices, focused attention (FA) and open monitoring (OM), the integrated delivery of these practices in MBIs precludes understanding of their practice-specific effects or mechanisms of action. The purpose of this study is to isolate hypothesized active ingredients and practice-specific mechanistic target engagement by creating structurally equivalent interventions that differ only by the active ingredient (meditation practice) offered and to test whether the hypothesized components differentially engage the mechanistic targets that they are purported to engage.

METHODS

Participants were intended to be representative of American meditators and had mild to severe affective disturbances. Measures of structural equivalence included participant-level (sample characteristics), treatment-level (program structure and duration, program materials, class size, attendance, homework compliance, etc.), and instructor-level variables (training, ratings and adherence/fidelity). Measures of differential validity included analysis of program materials and verification of differential mechanistic target engagement (cognitive and affective skills and beliefs about meditation acquired by participants after the 8-week training).

RESULTS

The results indicate successful creation of structurally equivalent FA and OM programs that were matched on participant-level, treatment-level, and instructor-level variables. The interventions also differed as expected with respect to program materials as well as mechanistic targets engaged (skills and beliefs acquired).

CONCLUSIONS

These validated 8-week FA and OM training programs can be applied in future research to assess practice-specific effects of meditation.

Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood.

OBJECTIVE

The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program.

METHODS

This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity.

RESULTS

A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as "test-drive a new car," "go to a coffee shop after lunch," or "call up an old friend" were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with "What would be your advice to a friend who has a similar problem?" found more helpful than some other strategies.

CONCLUSIONS

The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general.

TRIAL REGISTRATION

Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik).

Implications of a Culturally Evolved Self for Notions of Free Will

Most schools in psychology have emphasized individual choice despite evidence of genetic and cultural determinism. It is suggested in this paper that the rejection of classical behaviorism by psychology and other humanities flowed from deeply held cultural assumptions about volition and free will. While compatibilists have suggested that notions of free will and determinism are not mutually exclusive, the psychological mechanisms by which such an accommodation could be explained have been inadequately explored. Drawing on research into classical cultures, this paper builds an argument that the notion of free will was adaptive flowing from culturally evolved changes to the self, and that this “evolved self,” containing assumptions of personal volition, continuity, and reason, became benchmarks of what it means to be human. The paper proposes a model of a culturally evolved self that is compatible with understandings of free will and determinism. Implications for therapeutic practice and future research are discussed.

The neural correlates of the metacognitive function of other perspective: a multiple regression analysis study

Perspective taking is defined as the social cognitive function of imagining the world or imagining oneself from another’s viewpoint. Previously, we reported that behavioral activation increased the dorsal medial prefrontal cortex (dmPFC) activation during other perspective self-referential processing for positive words in subthreshold depression, but did not report whether metacognitive function was related to the dmPFC activation. Therefore, we sought to test the relationship between the dmPFC activation during other perspective self-referential processing for positive words and an individual’s metacognitive evaluation of other perspective. Thirty-four healthy individuals underwent functional MRI scans during a referential task with two viewpoints (self/other) and two emotional valences (positive/negative). Neural activation during other perspective self-referential processing for positive words was correlated with the metacognitive function of participants measured by the Interpersonal Reactivity Index (IRI). We found a positive correlation between the score in perspective taking of the IRI and activation in the dmPFC during other perspective self-referential processing for positive words. The present findings showed that self-report questionnaires assessing participants’ metacognitive evaluation of other perspective were correlated with dmPFC activation during positive metacognition of other perspective task. However, we did not conduct a behavioral activation intervention in the present study. The present students were healthy. The IRI is a subjective measure of multidimensional trait empathy. It is necessary to develop an objective measurement for the metacognitive function of other perspective in the near future.

Developing and Testing an Intervention to Reduce Distress in Mothers of Adolescents with Type 1 Diabetes

Objectives

To develop and pilot test a program to meet the needs of mothers of adolescents with type 1 diabetes (T1D) and improve outcomes in adolescents with type 1 diabetes.

Methods

We conducted focus groups with mothers of adolescents to identify needs and develop a cognitive behavioral intervention aimed at reducing maternal distress, improving parenting practices, and reducing family conflict. This intervention was pilot tested in a randomized trial; mothers were randomized to either the Coping & Communication (N=15) intervention or Usual Care (N=15). Mothers and adolescents completed questionnaires measuring distress, parenting, and family conflict pre- and post-intervention, and HbA1c values were obtained from adolescents' medical records pre- and post-intervention.

Results

Intervention materials (Communication & Coping) received high scores on health literacy and engagement. There was a significant Time × Group interaction for maternal diabetes distress, family conflict (as reported by both mothers and adolescents) and adolescent quality of life. Mothers and adolescents randomized to the intervention group reported significant improvements on these factors as compared to those randomized to usual care.

Conclusions

The Communication & Coping program was developed by adapting existing interventions proven to reduce depressive symptoms and improve parenting practices to address the specific needs of mothers of adolescents with T1D. The program shows promise for not only reducing distress in mothers, but also for improving adolescent outcomes, possibly through reductions in family conflict.

Clinical Depression and Punishment Sensitivity on the BART

Depression is associated with altered sensitivity to reward and punishment, which can influence complex decision-making. We examined punishment sensitivity in the performance of participants with major depressive disorder (MDD) with that of a comparison group on the automatic Balloon Analogue Risk Task (BART), which is a direct measure of risk taking. The present study examined the BART performance of 30 individuals with MDD and 30 matched comparison individuals. The comparison group (M = 63.25) entered a significantly (p < 0.001; d = 1.1) higher number of pumps on the BART than the MDD group (M = 50.83). Higher levels of depression symptoms were significantly correlated (r = -0.40, p < 0.05) with entering a lower number of pumps in the MDD group. MDD patients showed an increased sensitivity to punishment on the BART: after a loss, the MDD group decreased (M = 13.7) the number of subsequent pumps they entered by a significantly (p < 0.001, d = 0.81) greater amount than the comparison group (M = 4.35). This difference applied to losses only: no difference was found between the groups regarding the magnitude of change in pumps selected after a win. Findings suggest the presence of elevated punishment sensitivity among individuals with MDD, which may contribute to the maintenance of depressive symptoms.

Perceived social support moderates the relationship between activities of daily living and depression after lower limb loss

OBJECTIVE

This study examined the moderating influence of perceived social support on the prospective relationship between baseline levels of activities of daily living (ADL) and depressive symptoms during the 1st year following amputation.

METHOD

Participants included 73 veterans with new/first unilateral lower extremity amputation due to vascular disease or diabetes. Baseline levels of perceived social support, ADL function, and mobility were assessed by retrospective recall 6 weeks after amputation. Depressive symptoms were measured at 6 weeks and 12 months following surgery.

RESULTS

Perceived social support moderated the relationship between baseline ADL functioning and depressive symptoms at 12 months (β = -0.27, p < .001) after controlling for 6-week depressive symptoms and sociodemographic and physical/functional variables. Lower levels of baseline ADL function were associated with depressive symptoms at 12 months among those who reported lower levels of perceived social support.

CONCLUSION

These data allowed us to identify those participants with both low ADL function at baseline and low social support as being at higher risk for depression symptoms postamputation. The findings support the stress buffering hypothesis and suggest that perceived social support may be an important modifiable target of intervention among individuals with lower levels of functioning. (PsycINFO Database Record

The Techniques for Overcoming Depression Questionnaire: Mokken Scale Analysis, Reliability, and Concurrent Validity in Depressed Cardiac Patients

OBJECTIVES

The Techniques for Overcoming Depression (TOD) questionnaire assesses the frequency with which patients being treated for depression use cognitive-behavioral techniques in daily life. This study examined its latent structure, reliability and concurrent validity in depressed cardiac patients.

METHOD

The TOD was administered at the initial and final treatment sessions in three trials of cognitive behavior therapy (CBT) (n = 260) for depression in cardiac patients. Mokken scaling was used to determine its dimensionality.

RESULTS

The TOD is unidimensional in depressed cardiac patients, both at the initial evaluation (H = .46) and the end of treatment (H = .47). It is sensitive to change and the total score correlates with therapist ratings of the patient's socialization to CBT (r=.40, p<.05), homework adherence (r=0.36, p<0.05), and use of cognitive-behavioral techniques (r=.51, p<.01). TOD scores were associated with post-treatment depression scores in two of the trials (p<.01 in both analyses).

CONCLUSIONS

The TOD is a unidimensional, reliable, valid, and clinically informative measure of self-reported use of cognitive-behavioral techniques for overcoming depression in cardiac patients. Studies of the TOD in other depressed patient populations are needed.

Behavioral activation group therapy for reducing depressive symptoms and improving quality of life: a feasibility study

BACKGROUND

Depression is associated with a loss of productivity and noticeable personal, social, and economic decline; it affects more than 350 million people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has drawn increasingly more interest as a means of treatment for major depressive disorder due to its relative cost-effectiveness and efficacy. In this study, we disseminate findings from a feasibility study evaluating barriers to implementing a group BA program for major depressive disorder. The purpose of this feasibility study is to assess both patient and clinician perceptions on components of a group-based behavioral activation (BA) program. In particular, this feasibility study provides in-depth evaluation of the acceptability of BA prior to the design and implementation of a randomized trial to investigate BA effectiveness. Findings from this study directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study.

METHODS

This qualitative study was completed through the Mood Disorders Program at St. Joseph's Healthcare Hamilton. The authors of this study used data from two focus group sessions, one consisting of an interdisciplinary group of clinicians working in the Mood Disorders Program, and the other of registered outpatients of the Mood Disorders Program with a confirmed clinical diagnosis of depression. The benefits of offering this program in a group format, mainly social skill development opportunities and the use of technology such as activity tracking device, smart phones, and tablets during the therapy sessions, are a major focus of both the clinician and patient groups. Both groups emphasized the importance of offering sustainable activation.

RESULTS

Differences in opinions existed between staff and patient groups regarding the use of technology in the program, though ultimately it was agreed upon that technology could be useful as a therapeutic aid. All participants agreed that behavioral activation was essential to the development of positive habits and routines necessary for recovery from depression. Patients agreed the program looked sustainable and stressed the potential benefit for improving depressive symptoms.

CONCLUSIONS

Discussions from clinician and patient-centered focus groups directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study. These findings provide insight for clinicians providing behavioral activation programming, and will serve as a framework for the development of the Out of the Blues program, a group-based BA program to be piloted in the Mood Disorders Program at St. Joseph's Healthcare Hamilton.

TRIAL REGISTRATION

Clinical Trials registration number NCT02045771.

A pragmatic pilot randomized trial to investigate the effectiveness of behavioural activation group therapy in reducing depressive symptoms and improving quality of life in patients with depression: the BRAVE pilot trial protocol

BACKGROUND

Depression is a common disorder with a lifetime prevalence of 16 %. Despite the availability of several treatment options for depression, many patients do not respond to treatment and develop chronic illness associated with several secondary comorbidities. Behavioural activation (BA) is a simple therapy that has the potential for improving symptoms of depression and quality of life in patients with depression. The effectiveness of BA has not, however, been tested in a group format for patients with moderate to severe depression attending a specialized mood disorders tertiary care setting. Group format has the advantage of treating more patients at the same time especially in resource-limited settings. The primary objective of this pilot study is to test the feasibility of a main trial by assessing the recruitment and retention rates, average group size, completion of data and resources needed and receive the participants' feedback on the intervention. The secondary objective is to explore the change in mood and quality of life measures in adults with depression receiving BA.

METHODS/DESIGN

Using a pragmatic pilot randomized controlled trial design, we will test the feasibility of a large trial to assess the effectiveness of BA added to usual care compared to a depression support group with usual care. Participants will be randomized after obtaining informed written consent to one of two study arms. Face-to-face group therapy will be provided in a hospital setting by trained therapists. Intervention and control groups will be seen twice weekly for 10 weeks and then once weekly for further 8 weeks. Participants will be completing mood symptom scales, quality of life questionnaires and anthropometric measures and provide blood samples for future analysis of biomarkers of response to treatment. During the pilot study we will also solicit participants' feedback and experience regarding the number, frequency and contents of the sessions as well as to explore participant perceptions of barriers or benefits associated with the BA program.

DISCUSSION

The pilot study will help to inform a larger trial and assist in modifying the intervention based on patients' feedback.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT02045771. Hamilton Integrated Research Ethics Board (HiREB) number: 14-042.

Baseline Depressive Symptoms, Completion of Study Assessments, and Behavior Change in a Long-Term Dietary Intervention Among Breast Cancer Survivors

Background

Depressive symptoms can lower adherence and change in dietary studies. Behavioral activation may reduce these effects.

Purpose

This study aims to assess relationships among depressive symptoms on adherence and dietary change in the Women’s Healthy Eating and Living (WHEL) Study

Methods

Secondary analyses from the WHEL Study, which achieved major dietary change in breast cancer survivors (N = 2817), were conducted. Logistic regressions were undertaken of baseline depressive symptoms (six-item Center for Epidemiologic Studies Depression Scale (CES-D)) with (1) completion of 1- and 4-year study assessments and (2) validated change in dietary behavior in the intervention group.

Results

In the comparison group (vs. intervention), depressive symptoms lowered completion of dietary recalls and clinic visits [4 years: odds ratio (OR) = 2.0; 95 % confidence interval (CI) = 1.4–3.0]. The behaviorally oriented intervention achieved major change in those furthest from study targets, although changes were lower in those with depressive symptoms: fruit/vegetable (+37.2 %), fiber (+49.0 %), and fat (−22.4 %).

Conclusions

Behavioral activation in dietary change interventions can overcome the impact of depressive symptoms.

Behavioural Activation Therapy for Depression after Stroke (BEADS): a study protocol for a feasibility randomised controlled pilot trial of a psychological intervention for post-stroke depression

BACKGROUND

There is currently insufficient evidence for the clinical and cost-effectiveness of psychological therapies for treating post-stroke depression.

METHODS/DESIGN

BEADS is a parallel group feasibility multicentre randomised controlled trial with nested qualitative research and economic evaluation. The aim is to evaluate the feasibility of undertaking a full trial comparing behavioural activation (BA) to usual stroke care for 4 months for patients with post-stroke depression. We aim to recruit 72 patients with post-stroke depression over 12 months at three centres, with patients identified from the National Health Service (NHS) community and acute services and from the voluntary sector. They will be randomly allocated to receive behavioural activation in addition to usual care or usual care alone. Outcomes will be measured at 6 months after randomisation for both participants and their carers, to determine their effectiveness. The primary clinical outcome measure for the full trial will be the Patient Health Questionnaire-9 (PHQ-9). Rates of consent, recruitment and follow-up by centre and randomised group will be reported. The acceptability of the intervention to patients, their carers and therapists will also be assessed using qualitative interviews. The economic evaluation will be undertaken from the National Health Service and personal social service perspective, with a supplementary analysis from the societal perspective. A value of information analysis will be completed to identify the areas in which future research will be most valuable.

DISCUSSION

The feasibility outcomes from this trial will provide the data needed to inform the design of a definitive multicentre randomised controlled trial evaluating the clinical and cost-effectiveness of behavioural activation for treating post-stroke depression.

TRIAL REGISTRATION

Current controlled trials ISRCTN12715175.

Integrating Motivational Interviewing and Brief Behavioral Activation Therapy: Theoretical and Practical Considerations

Behavioral Activation and specifically the Brief Behavioral Activation Therapy for Depression (BATD) has a strong record of empirical support but its focus on practical out of session activation-based assignments can lead to poor levels of adherence if efforts to enhance motivation are not prioritized. Towards this end, this manuscript describes the assimilative integration of Motivational Interviewing (MI) and BATD to improve clinical outcomes by integrating MI's focus on building and maintaining motivation to change into BATD. The manuscript provides an overview of MI and BATD, theoretical issue raised in integrating the two approaches, and examples of how this integration results in a nondirective and motivation-focused approach to conducting BATD.

Effects of Affective and Anxiety Disorders on Outcome in Problem Gamblers Attending Routine Cognitive-Behavioural Treatment in South Australia

This study evaluated the influence of 12-month affective and anxiety disorders on treatment outcomes for adult problem gamblers in routine cognitive-behavioural therapy. A cohort study at a state-wide gambling therapy service in South Australia. Primary outcome measure was rated by participants using victorian gambling screen (VGS) 'harm to self' sub-scale with validated cut score 21+ (score range 0-60) indicative of problem gambling behaviour. Secondary outcome measure was Work and Social Adjustment Scale (WSAS). Independent variable was severity of affective and anxiety disorders based on Kessler 10 scale. We used propensity score adjusted random-effects models to estimate treatment outcomes for sub-populations of individuals from baseline to 12 month follow-up. Between July, 2010 and December, 2012, 380 participants were eligible for inclusion in the final analysis. Mean age was 44.1 (SD = 13.6) years and 211 (56%) were males. At baseline, 353 (92.9%) were diagnosed with a gambling disorder using VGS. For exposure, 175 (46%) had a very high probability of a 12-month affective or anxiety disorder, 103 (27%) in the high range and 102 (27%) in the low to moderate range. For the main analysis, individuals experienced similar clinically significant reductions (improvement) in gambling related outcomes across time (p < 0.001). Individuals with co-varying patterns of problem gambling and 12 month affective and anxiety disorders who present to a gambling help service for treatment in metropolitan South Australia gain similar significant reductions in gambling behaviours from routine cognitive-behavioural therapy in the mid-term.

Study protocol for a randomized controlled trial of telephone-delivered cognitive behavior therapy compared with befriending for treating depression and anxiety in older adults with COPD

BACKGROUND

COPD is an umbrella term to describe chronic lung diseases that cause limitations in lung airflow, including emphysema and chronic bronchitis. The prevalence of depression and anxiety in people with COPD is high, although these comorbidities are often undiagnosed, untreated, or undertreated. There is a need to identify efficacious treatments for depression and anxiety in people with COPD. Cognitive behavior therapy (CBT) for the treatment of anxiety and depression has a strong evidence base. There has been some success delivering this treatment over the telephone in limited studies. The aim of this study is to evaluate the efficacy of both telephone-administered CBT and befriending on outcomes for patients with diagnosed COPD who have at least mild levels of depression and/or anxiety.

METHODS

The protocol described in this paper is of a pragmatic randomized controlled trial comparing eight sessions of telephone CBT to an active social control, referred to as befriending. Primary outcome measures will include depression and anxiety symptoms, and secondary outcome measures will include quality of life, self-efficacy, and COPD symptom severity. Participants' satisfaction with the intervention and therapeutic alliance will also be assessed. Measures will be taken pre- and postdelivery of the intervention and again at 8 weeks following the intervention.

CONCLUSION

People with COPD often have limitations to their mobility because of their breathlessness. They are often already attending many medical appointments and could be reluctant to attend for face-to-face psychological treatment. The results of this study should identify the relative efficacy of CBT delivered over the telephone to this population, which, if successful, may be a cost-effective and more palatable alternative to face-to-face treatment of depression or anxiety for this population.

Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq

BACKGROUND

Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq.

METHODS

This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting.

RESULTS

Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT-ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility.

CONCLUSIONS

BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.

Delivery Characteristics, Acceptability, and Depression Outcomes of a Home-based Depression Intervention for Older African Americans: The Get Busy Get Better Program

PURPOSE OF THE STUDY

To facilitate replication, we examined delivery characteristics, acceptability, and depression outcomes of a home-based intervention, Get Busy Get Better, Helping Older Adults Beat the Blues (GBGB). GBGB, previously tested in a randomized trial, reduced depressive symptoms and enhanced quality of life in African Americans.

DESIGN AND METHODS

A total of 208 African Americans aged above 55 years with Patient Health Questionnaire (PHQ-9) scores ≥5 on two subsequent screenings were randomized to receive GBGB immediately or 4 months later. GBGB involves up to 10 home sessions consisting of care management, referral/linkage, depression education/symptom recognition, stress reduction, and behavioral activation. Interventionists recorded delivery characteristics (dose, intensity) and perceived acceptability of sessions. Baseline and post-tests were used to characterize participants and examine associations between dose/intensity and depression scores. Participant satisfaction and perceived benefits were examined at 8 months.

RESULTS

Of 208 participants, 181 (87%, mean age = 69.6) had treatment data. Of these, 165 (91.2%) had ≥3 treatment sessions (minimal dose). Participants had on average 8.1 sessions (SD = 2.6) for an average of 65.4min (SD = 18.3) each. Behavioral activation and care management were provided the most (average of six sessions for average duration = 17.9 and 22.2min per session respectively), although all participants received each treatment component. GBGB was perceived as highly acceptable and beneficial by interventionists and participants. More sessions and time in program were associated with greater symptom reduction.

IMPLICATIONS

GBGB treatment components were highly acceptable to participants. Future implementation and sustainability challenges include staffing, training requirements, reimbursement limitations, competing agency programmatic priorities, and generalizability to other groups.

Measuring Acceptance of Sleep Difficulties: The Development of the Sleep Problem Acceptance Questionnaire

STUDY OBJECTIVES

Acceptance may be an important therapeutic process in sleep medicine, but valid psychometric instruments measuring acceptance related to sleep difficulties are lacking. The purpose of this study was to develop a measure of acceptance in insomnia, and to examine its factor structure as well as construct validity.

DESIGN

In a cross-sectional design, a principal component analysis for item reduction was conducted on a first sample (A) and a confirmatory factor analysis on a second sample (B). Construct validity was tested on a combined sample (C).

SETTING

Questionnaire items were derived from a measure of acceptance in chronic pain, and data were gathered through screening or available from pretreatment assessments in four insomnia treatment trials, administered online, via bibliotherapy and in primary care.

PARTICIPANTS

Adults with insomnia: 372 in sample A and 215 in sample B. Sample C (n = 820) included sample A and B with another 233 participants added.

MEASURES

Construct validity was assessed through relations with established acceptance and sleep scales.

RESULTS

The principal component analysis presented a two-factor solution with eight items, explaining 65.9% of the total variance. The confirmatory factor analysis supported the solution. Acceptance of sleep problems was more closely related to subjective symptoms and consequences of insomnia than to diary description of sleep, or to acceptance of general private events.

CONCLUSIONS

The Sleep Problem Acceptance Questionnaire (SPAQ), containing the subscales "Activity Engagement" and "Willingness", is a valid tool to assess acceptance of insomnia.

Relationships among adaptive and maladaptive emotion regulation strategies and psychopathology during the treatment of comorbid anxiety and alcohol use disorders

Both maladaptive and adaptive emotion regulation strategies have been linked with psychopathology. However, previous studies have largely examined them separately, and little research has examined the interplay of these strategies cross-sectionally or longitudinally in patients undergoing psychological treatment. This study examined the use and interplay of adaptive and maladaptive emotion regulation strategies in 81 patients receiving cognitive-behavioral interventions for comorbid alcohol use and anxiety disorders. Patients completed measures of emotion regulation strategy use and symptoms of psychopathology pre- and post-treatment. Cross-sectionally, higher use of maladaptive strategies (e.g., denial) was significantly related to higher psychopathology pre- and post-treatment, whereas higher use of adaptive strategies (e.g., acceptance) only significantly related to lower psychopathology post-treatment. Prospectively, changes in maladaptive strategies, but not changes in adaptive strategies, were significantly associated with post-treatment psychopathology. However, for patients with higher pre-treatment maladaptive strategy use, gains in adaptive strategies were significantly associated with lower post-treatment psychopathology. These findings suggest that psychological treatments may maximize efficacy by considering patient skill use at treatment outset. By better understanding a patient's initial emotion regulation skills, clinicians may be better able to optimize treatment outcomes by emphasizing maladaptive strategy use reduction predominately, or in conjunction with increasing adaptive skill use.

Advantages and Challenges of A Village Doctor-Based Cognitive Behavioral Therapy for Late-Life Depression in Rural China: A Qualitative Study

Background

The delivery of mental health services in rural China has been notably limited due to lack of qualified mental health professionals among other impeding factors. A village doctor-based cognitive behavioral therapy intervention may be one way of improving accessibility. The purpose of this study was to explore the advantages and challenges of implementing this intervention, as delivered by trained village doctors, to treat late-life depression in rural China.

Methods

We conducted one focus group discussion with 10 village doctors, 10 individual interviews with each of the village doctors, and individual interviews with 19 older adults. The topic guides were advantages and challenges of the intervention program from the perspective of the village doctors and older adults. Interviews were audio-recorded, transcribed, coded using NVivo 8, and analyzed using thematic analysis.

Results

The village doctors stressed the importance of role-playing and using instructive manuals in the training. Proper supervision was also a key component of the program. The benefits received from the intervention for the village doctors and the elders were positive such that both the doctors and the older adults were willing to implement/receive this intervention. Cultural and political factors (renqing and perceived policy consideration) facilitated the elders’ access to mental health services. Challenges included a lack of real therapy (in contrast to role-playing) demonstrated in the training and lack of a step-by-step manual based on different types of problems encountered. Other impediments to the successful implementation of the intervention included the time constraints of village doctors and the presence of other people when conducting the intervention.

Conclusions

The present study has demonstrated that the intervention program is likely to be an acceptable geriatric depression intervention in rural China if several challenges are appropriately addressed.

Identifying Shared Latent Dimensions of Psychological Symptoms: Implications for the Psychological Correlates of Smoking

Shared latent dimensions may account for the co-occurrence of multiple forms of psychological dysfunction. However, this conceptualization has rarely been integrated into the smoking literature, despite high levels of psychological symptoms in smokers. In this study, we used confirmatory factor analysis to compare three models (1-factor, 2-factor [internalizing-externalizing], and 3-factor [low positive affect-negative affect-disinhibition]) of relations among nine measures of affective and behavioral symptoms implicated in smoking spanning depression, anxiety, happiness, anhedonia, ADHD, aggression, and alcohol use disorder symptoms. We then examined associations of scores from each of the manifest scales and the latent factors from the best-fitting model to several smoking characteristics (i.e., experimentation, lifetime established smoking [≥100 cigarettes lifetime], age of smoking onset, cigarettes/day, nicotine dependence, and past nicotine withdrawal). We used two samples: (1) College Students (N =288; mean age =20; 75 % female) and (2) Adult Daily Smokers (N=338; mean age=44; 32 % female). In both samples, the 3-factor model separating latent dimensions of deficient positive affect, negative affect, and disinhibition fit best. In the college students, the disinhibition factor and its respective indicators significantly associated with lifetime smoking. In the daily smokers, low positive and high negative affect factors and their respective indicators positively associated with cigarettes/day and nicotine withdrawal symptom severity. These findings suggest that shared features of psychological symptoms may be parsimonious explanations of how multiple manifestations of psychological dysfunction play a role in smoking. Implications for research and treatment of co-occurring psychological symptoms and smoking are discussed.

Development and preliminary testing of a web-based, self-help application for disaster-affected families

Technology-based self-help interventions have the potential to increase access to evidence-based mental healthcare, especially for families affected by natural disasters. However, development of these interventions is a complex process and poses unique challenges. Usability testing, which assesses the ability of individuals to use an application successfully, can have a significant impact on the quality of a self-help intervention. This article describes (a) the development of a novel web-based multi-module self-help intervention for disaster-affected adolescents and their parents and (b) a mixed-methods formal usability study to evaluate user response. A total of 24 adolescents were observed, videotaped, and interviewed as they used the depressed mood component of the self-help intervention. Quantitative results indicated an above-average user experience, and qualitative analysis identified 120 unique usability issues. We discuss the challenges of developing self-help applications, including design considerations and the value of usability testing in technology-based interventions, as well as our plan for widespread dissemination.