Development and experiences of an internet-based acceptance and commitment training (I-ACT) intervention in ice hockey players: a qualitative feasibility study

Internet-based psychological interventions have increased the accessibility of evidence-based treatments in clinical psychology but are still an unexplored delivery format in sport psychology research. This study describes the development and evaluates the experiences of an internet-based acceptance and commitment therapy/training (I-ACT) intervention in ice hockey players focusing on performance enhancement and a sustainable sport participation. I-ACT consisted of seven weekly modules and the feasibility of the intervention was investigated using a qualitative research design. Four national level ice hockey players took part of I-ACT and were interviewed about their experiences using a semi-structured protocol. Interview transcripts were analyzed using qualitative content analysis. Findings suggest that the content of I-ACT was comprehensible, relevant, and that it was possible to put the psychological skills into practice. I-ACT was described as helpful to the ice hockey players either in their sport performance or in their life outside of sport. The internet-format was generally perceived as positive, flexible, and a feasible option for delivering psychological interventions in an elite sport context. Some concerns were raised regarding the timing of the intervention at the end of the season, and some players also wished for more time to complete I-ACT. It was also expressed that some of the exercises could have been better adapted for goaltenders. Further trials are needed to evaluate the effects of I-ACT on performance and mental health outcomes in various sport populations using robust quantitative research methodology. Internet-based psychological interventions are a potential future opportunity to make evidence-based practices more accessible for athletes.

Trajectories of mental health outcomes following COVID-19 infection: a prospective longitudinal study

BACKGROUND

The COVID-19 pandemic has triggered a global mental health crisis. Yet, we know little about the lasting effects of COVID-19 infection on mental health. This prospective longitudinal study aimed to investigate the trajectories of mental health changes in individuals infected with COVID-19 and to identify potential predictors that may influence these changes.

METHODS

A web-survey that targeted individuals that had been infected with COVID-19 was used at three time-points: T0 (baseline), T1 (six months), and T2 (twelve months). The survey included demographics, questions related to COVID-19 status, previous psychiatric diagnosis, post-COVID impairments, fatigue, and standardized measures of depression, anxiety, insomnia. Linear mixed models were used to examine changes in depression, anxiety, and insomnia over time and identify factors that impacted trajectories of mental health outcomes.

RESULTS

A total of 236 individuals completed assessments and was included in the longitudinal sample. The participants' age ranged between 19 and 81 years old (M = 48.71, SD = 10.74). The results revealed notable changes in mental health outcomes over time. The trajectory of depression showed significant improvement over time while the trends in anxiety and insomnia did not exhibit significant changes over time. Younger participants and individuals who experienced severe COVID-19 infection in the acute phase were identified as high-risk groups with worst mental ill-health. The main predictors of the changes in the mental health outcomes were fatigue and post-COVID impairments.

CONCLUSIONS

The findings of our study suggest that mental health outcomes following COVID-19 infection exhibit a dynamic pattern over time. The study provides valuable insights into the mental health trajectory following COVID-19 infection, emphasizing the need for ongoing assessment, support, and interventions tailored to the evolving mental health needs of this population.

Effects of Psychological Interventions to Enhance Athletic Performance: A Systematic Review and Meta-Analysis

BACKGROUND

Psychological interventions are commonly applied in sports to help athletes enhance their performance, but the effect psychological interventions have on actual performance is unclear despite decades of research.

OBJECTIVE

We conducted a systematic review with meta-analyses to investigate the effects of a wide range of psychological interventions on performance in competitive athletes.

METHODS

A study protocol was preregistered in PROSPERO, and a literary search was performed in the MEDLINE, PsycINFO, Web of Science, and SPORTDiscus databases. Psychological intervention studies were eligible by using a group design and a quantitative performance outcome with athletes competing at a regional or university level or higher. Included studies were assessed regarding intervention characteristics, research methodology, and risk of bias. A multi-level meta-analysis framework with cluster robust variance estimation was used to quantitatively synthesize the results.

RESULTS

A total of 111 studies met the inclusion criteria, and 25 of these studies (37 effects) could be synthesized into five meta-analyses in which there were similarities in the type of psychological intervention, comparator, and experimental design. Meta-analyses I (multimodal psychological skills training vs control), II (mindfulness- and acceptance-based approaches vs control), and III (imagery vs control) consisted of parallel-group studies, and random-effects models were used to calculate the standardized mean difference. Meta-analyses IV (attentional focus strategies, external vs internal) and V (regulatory focus performance instructions, prevention vs promotion) consisted of counterbalanced crossover design studies, and random-effects models were used to calculate the standardized mean change using change score standardization. Significant results were found in three of the meta-analyses (I, II, and III). Psychological skills training (g = 0.83, 95% confidence interval 0.21-1.45), mindfulness- and acceptance-based approaches (g = 0.67, 95% confidence interval 0.01-1.32), and imagery (g = 0.75, 95% confidence interval 0.14-1.36) outperformed controls with moderate effects. However, when non-randomized trials and subjective performance outcomes were removed in sensitivity analyses, the overall estimates of the effect size were no longer significant in any of the syntheses.

CONCLUSIONS

The significant moderate effects for psychological skills training, mindfulness- and acceptance-based approaches, and imagery are not stable, and further trials with robust research methodology, such as randomized controlled trials, are requested for all types of psychological interventions aiming to enhance performance in athletes. Moreover, improved reporting standards and the provision of datasets in open science repositories are important to consider in future trials in sport psychology.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42017056677.

Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial with long-term follow-up

Body dysmorphic disorder (BDD) is a prevalent and impairing psychiatric condition that typically debuts in adolescence and is associated with risky behaviours. The disorder can be effectively treated with cognitive behaviour therapy (CBT). However, CBT for BDD is seldom available primarily due to a shortage of trained therapists. Internet-delivered CBT (ICBT) can be a way to increase treatment availability. The aim of this feasibility trial was to evaluate the feasibility, safety, and preliminary efficacy of a CBT protocol for adolescents with BDD, adapted to be delivered over the Internet with minimal therapist support. A total of 20 participants (12-17-year-olds) meeting criteria for BDD were recruited nationally to a specialist outpatient clinic in Stockholm, Sweden. One participant withdrew consent and their data could not be analysed. Nineteen participants were offered 12 modules of therapist-guided ICBT for BDD and were followed up to 12 months post-treatment. Preliminary efficacy was measured at the a priori primary endpoint (3-month follow-up) and at the 12-month follow-up with the clinician-rated Yale-Brown Obsessive Compulsive Scale Modified for BDD for Adolescents. The treatment was rated as both credible and satisfactory and was associated with a large and statistically significant reduction in BDD symptom severity (d = 2.94). The proportion of participants classified as responders at the primary endpoint was 73.7%, and the proportion of full or partial remitters was 63.2%. The average therapist support time was 8 min per participant per week. Treatment gains continued to accrue up to the 12-month follow-up. Two participants attempted suicide and another two reported non-suicidal self-injuries during the study period. ICBT with minimal therapist support is a feasible, potentially efficacious, and durable treatment for adolescents with BDD. Risky behaviours typical of this patient group should be carefully monitored during treatment.

Validation of the Occupational Depression Inventory in Sweden

BACKGROUND

The Occupational Depression Inventory (ODI) was recently devised to assess depressive symptoms that individuals specifically attribute to their work. One purpose of the ODI is to overcome limitations in current assessments of job-related distress. This study aimed to validate the Swedish version of the ODI.

METHODS

The study involved 365 individuals employed in Sweden. In addition to the ODI, the study included the Satisfaction with Life Scale, the Effort-Reward Imbalance Questionnaire, the Demand-Control-Support Questionnaire, the GAD-2, and the PHQ-9. We inquired into the factorial validity, dimensionality, scalability, test-score reliability, criterion validity, convergent validity, discriminant validity, and measurement invariance of the ODI.

RESULTS

Exploratory structural equation modeling bifactor analysis indicated that the ODI's Swedish version meets the requirements for essential unidimensionality (e.g., explained common variance = 0.872). Measurement invariance held across sexes, age groups, and occupational categories. The instrument exhibited strong scalability (e.g., H = 0.662). The observed total scores thus accurately ranked respondents on the latent continuum underlying the scale. The ODI's total-score reliability was high (e.g., McDonald's ω = 0.929). Speaking to the instrument's criterion validity, we found occupational depression to correlate, in the expected direction, with various work (e.g., job support) and nonwork (e.g., general anxiety) variables. Occupational depression showed large correlations with effort-reward imbalance (r = 0.613) and demand-control imbalance (r = 0.566) at work. Multiple regression analyses supported these associations further. As expected, we observed both a degree of convergent validity and a degree of discriminant validity when examining the ODI against the PHQ-9, an attribution-free measure of depression.

DISCUSSION

This study indicates that the ODI performs well within the Swedish context, consistent with the findings obtained in other linguistic and geographic contexts. The ODI promises to help researchers, practitioners, and public health decision-makers address job-related distress more effectively.

Introducing Braining-physical exercise as adjunctive therapy in psychiatric care: a retrospective cohort study of a new method

BACKGROUND

Patients with severe mental disorders suffer from higher rates of poor somatic health and have shorter life expectancy than the average population. Physical activity can treat and prevent several diseases, e.g. cardiovascular and metabolic disorders as well as psychiatric symptoms. It is therefore of utmost importance to develop effective methods to integrate physical activity into psychiatric care. To meet this need, the physical activity intervention Braining was developed. This study aims to describe Braining, to assess the number of patients reached during the first years of pilot testing, to analyze clinical data in the group of patients participating in Braining 2017-2020 and to assess the intervention.

METHODS

In this descriptive retrospective study we analyzed data from all patients participating in Braining training sessions ≥ 3 times (n = 239), the Braining Participants. Regular patients at the clinic served as a comparison. Furthermore, medical records were studied for a smaller cohort (n = 51), the Braining Pilot Cohort. Data was analyzed using Chi-square and Fisher's tests.

RESULTS

During the introduction period of Braining, 580 patients attended an information meeting about Braining, or at least one training session. 239 patients participated in ≥ 3 training sessions, considered to be participants of Braining. These Braining Participants (n = 239), ages 19 to 82, males 23.4%, attended between 3 and 308 training sessions (median 9). The main diagnoses were affective and anxiety disorders. Number of diagnoses ranged from 0 to 10 (median = 2). For the subsample, the Braining Pilot Cohort (n = 51), participants attended between 3 and 208 training sessions (median = 20). Twelve percent were working full-time, and symptom severity of depression and general anxiety was moderate. Two thirds had ≥ 3 different classes of medication. Regarding metabolic morbidity, 28 had been diagnosed with hypertension, though blood lipids, blood glucose as well as blood pressure were within the normal range. Thirty-seven percent were prescribed Physical Activity on Prescription during 2017-2020. One severe adverse event was reported.

CONCLUSIONS

The Braining intervention reached all age-groups and patients with a wide and representative diagnostic panorama, suggesting that Braining could be a promising and safe method for implementing physical activity in a psychiatric patient population.

Corrigendum: Acceptance and commitment therapy preceded by attention bias modification on residual symptoms in depression: a 12-month follow-up

[This corrects the article DOI: 10.3389/fpsyg.2019.01995.].

Intolerance-of-uncertainty therapy versus metacognitive therapy for generalized anxiety disorder in primary health care: A randomized controlled pilot trial

OBJECTIVE

This randomized controlled pilot study investigated the feasibility of a future full-scale RCT to compare the effects of intolerance-of-uncertainty therapy (IUT) and metacognitive therapy (MCT) in primary health care patients with generalized anxiety disorder (GAD). Preliminary treatment effects were also evaluated.

MATERIALS AND METHODS

64 patients with GAD at a large primary health care center in Stockholm, Sweden, were randomized to IUT or MCT. Feasibility outcomes included participant recruitment and retention, willingness to receive psychological treatment, and therapists' competence in and adherence to treatment protocols. Self-reported scales were used to assess treatment outcomes, including worry, depression, functional impairment, and quality of life.

RESULTS

Recruitment was satisfactory, and dropout was low. On a scale from 0 to 6, participants were satisfied with participating in the study (M = 5.17, SD = 1.09). Following brief training, therapists' competence was rated as moderate, and adherence was rated as weak to moderate. From pre- to post-treatment, reductions on the primary treatment outcome measure of worry were of a large effect size and statistically significant in both the IUT and MCT conditions (Cohen's d for IUT = -2.69, 95% confidence interval [-3.63, -1.76] and d for MCT = -3.78 [-4.68, -2.90]). The between-group effect size from pre- to post-treatment was large and statistically significant (d = -2.03 [-3.31, -0.75]), in favor of the MCT condition.

CONCLUSION

It is feasible to carry out a full-scale RCT to compare the effects of IUT to MCT for patients with GAD in primary health care. Both protocols seem effective, and MCT seems superior to IUT, but a full-scale RCT is needed to confirm these conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov (no. NCT03621371).

Impairments following COVID-19 infection: manifestations and investigations of related factors

The COVID-19 pandemic had a major global impact on the health and wellbeing for many individuals. Even though the infection rates have gone down due to the availability of vaccines, the consequences of the disease are still present due to persistent symptoms among individuals. The aim of the current study was to map long-term impairments in individuals infected with COVID-19 by applying the framework of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) and also investigate the factors related to the context of an individual's life influencing the impairments. A web-survey that targeted individuals that had been infected with COVID-19 was used. The survey included a range of measures covering contextual factors and factors related to body functions and structures and post-COVID impairments. A total of 501 individuals were included in the study (with a mean age of 47.6 years). 96% of the respondents reported at least one moderate-to-severe impairment due to COVID-19 infection and the most frequent one was fatigue. In that, 79.6% and 86.9% of the study sample reported moderate-to-severe brain fatigue and tiredness or lack of energy, respectively. Severity of COVID-19 infection appeared as the strongest risk factor for post-COVID impairments. Based on the results, interventions can be tailored to help individuals with post-COVID-19 condition. This could be one way lessening the effect of COVID-19 on health care and society as a whole.

Factors influencing kidney transplantation rates: a study from the ERA Registry

BACKGROUND

Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade.

METHODS

KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010.

RESULTS

Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system.

CONCLUSIONS

In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.

Psychometric evaluation of the Swedish Multidimensional Psychological Flexibility Inventory (MPFI)

Psychiatric disorders are common, and reliable measures are crucial for research and clinical practice. A cross-diagnostic construct that can be used to index treatment outcomes as well as prevalence of psychological ill health is psychological flexibility. The aim of this study was to validate a Swedish version of the Multidimensional Psychological Flexibility Inventory (MPFI). The MPFI has 12 subscales, six of which measure flexibility, and six that measure inflexibility. Using confirmatory factor analysis in a community sample of 670 participants, we found that a model with two higher order factors had satisfactory fit (CFI = .933) and a 12-factor model had the best fit to the data (CFI = .955). All 12 subscales showed adequate reliability (CRs = .803-.933) and the factor structure was similar across age groups and gender. Findings suggest that the Swedish version of the MPFI is a reliable instrument that can be used to index psychological flexibility. Potential areas for improvement of the instrument are discussed.

Isolation and worry in relation to gambling and onset of gambling among psychiatry patients during the COVID-19 pandemic: A mediation study

When the COVID-19 pandemic started spreading globally, there was a fear that addictive behaviors would increase due to changes in everyday life caused by restrictions due to COVID-19. Studies were carried out to explore if this was true for gambling, typically revealing no overall increase in gambling behavior, although individuals who had previous experience with gambling problems were more likely to increase gambling during the pandemic. However, these studies only included individuals with previous gambling problems. It remains unknown whether other vulnerable groups, such as individuals with common mental disorders increased their gambling. This study aimed to explore the level of gambling problems among individuals with a history of mental disorders, namely, (i) pre-pandemic gamblers and (ii) pandemic-onset gamblers. Furthermore, we explored if worry and isolation mediate gambling and problem gambling. The data were analyzed using descriptive statistics and a structural equation model to investigate mediation. The results showed a high prevalence of at-risk and problem gambling in both groups. The pre-pandemic gamblers had a high level of at-risk and problem gambling. Furthermore, the individuals that started to gamble during the pandemic had an even higher degree of at-risk and problem gambling. The mediation showed that the onset of gambling was linked with the worry of COVID-infection and that worry predicted the level of gambling problems. This study highlights that vulnerability factors, isolation, and worry can be triggers for individuals with common mental disorders to engage in gambling as well as the importance of screening this population for gambling problems.

Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting

LAY ABSTRACT

Autistic adults are often stressed and feel depressed or anxious. However, mental health programs that are suited for autistic adults are few. Acceptance and commitment therapy is a psychotherapy method that seems to help people feel better, although not thoroughly evaluated in autistic individuals. In this study, 20 autistic adults had 14 weeks of acceptance and commitment therapy group treatment suited for autism (NeuroACT), while 19 autistic adults had ordinary care. The acceptance and commitment therapy group treatment program seemed logical and reasonable to the participants. Also, when comparing the participants in the NeuroACT group with those in the ordinary care group, the NeuroACT participants reported less stress and higher quality of life. Compared to the ordinary care group, they could also manage distressing thoughts better, perceived themselves as more flexible, and did not avoid stressful situations as much as before. However, there was no significant difference between the groups in depression, anxiety, sleep problems, social aspects of autism, everyday functioning, or executive challenges. Slightly more NeuroACT participants did not finish the treatment than ordinary care participants. In conclusion, the NeuroACT program may be a treatment for autistic adults who feel stressed and have reduced quality of life. More studies are needed to see how helpful the NeuroACT program is for autistic adults.

Mental health outcomes following COVID-19 infection: impacts of post-COVID impairments and fatigue on depression, anxiety, and insomnia - a web survey in Sweden

BACKGROUND

The negative impact of the COVID-19 pandemic on the mental health is now clearly established. However, information on the levels of mental ill health of people infected with COVID-19 and potential correlates of poor mental health is still limited. Therefore, the current study aimed to study indicative of potential mental health problems in individuals with a history of probable or confirmed SARS CoV-2 infection/infections and address the impacts of post-COVID impairments and fatigue following COVID-19 infection/infections on depression, anxiety, and insomnia.

METHODS

A web-survey including demographics, questions related to COVID-19 status and post-COVID impairments, and standardized measures of depression, anxiety, insomnia, and fatigue was completed by 507 individuals with a history of probable or confirmed SARS CoV-2 infection/infections.

RESULTS

We found significant rates of significant depression, anxiety, and insomnia in our sample, with more than 70% experiencing levels above the clinical cut offs for at least one psychological health problems. Higher levels of depression, anxiety, and insomnia were associated with the severity of COVID-19 infection in the acute phase, hospitalization because of COVID-19, and higher levels of post-COVID impairments and fatigue. Reduced motivation emerged as the strongest predictor for mental ill health.

CONCLUSIONS

These findings highlight that individuals infected with COVID-19, especially those who still have experienced post-COVID impairments, are more likely to suffer from mental ill-health and may be more vulnerable for poor mental health outcomes. Therefore, more effective actions are needed to take in order to promote and protect mental health of individuals with a history of COVID-19 infection.

Acceptance and Compassion-Based Therapy Targeting Shame in Body Dysmorphic Disorder: A Multiple Baseline Study

Shame is considered central in body dysmorphic disorder (BDD) and empirical accounts highlight the link between shame and BDD symptoms as well as common negative psychosocial effects of the disorder, yet there is a lack of interventions addressing shame in this context. In the past decade, Acceptance and commitment therapy (ACT) and interventions that foster self-compassion have shown promise for reducing the negative effects of shame in a range of clinical problems. The aim of the present study was to develop and evaluate an acceptance and compassion-based treatment specifically targeting shame in BDD. Using a randomized nonconcurrent multiple baseline design, the 12-session intervention, ACT with Compassion (ACTwC), was examined in a psychiatric outpatient sample of five adults diagnosed with BDD. The daily ratings showed marked reductions in BDD-behaviors and self-criticism at posttreatment for four of five participants, while three participants demonstrated decreases in body shame compared to baseline. Improvements were maintained at 6-months follow-up. The intervention also led to reliable long-term improvements in general shame, overall BDD-symptoms, depressive symptoms, and quality of life for four of five participants. All treatment responders showed significant gains in psychological flexibility and self-compassion. Participants reported high credibility and satisfaction with the treatment. These preliminary results suggest that ACTwC may be a promising approach to treating shame in BDD, worthy of further investigation.

The Persian version of the psychological flexibility in sport scale: a psychometric study

Background

There is a growing body of research suggesting that psychological flexibility (PF) is an important psychological construct related to psychological health and human performance. The Psychological Flexibility in Sport Scale (PFSS) is the first general scale to assess sport-related PF. So far, the PFSS has not yet been validated in other contexts than Sweden. Therefore, the current study sought to investigate a Persian version of the PFSS (P-PFSS) and extend the investigation of the psychometric properties of the PFSS in Iranian athletes.

Methods

A total of 302 athletes from both team and individual sports (average age of 20.7 years, SD ± 7.5, 62.3% were female) were involved in the current study. Statistical analysis was performed on the data to test validity and reliability. The validity of the P-PFSS was tested through face and content validity, construct validity, criterion validity, and known-groups validity. The reliability of P-PFSS was verified through internal consistency and temporal stability of the scale.

Results

Results revealed that validity of the P-PFSS was satisfactory. The instrument was determined to have strong face and content validity. With modifications, the confirmatory factor analysis confirmed the scale’s unidimensionality. The convergent validity of the P-PFSS was found to be acceptable (average variance extracted = 0.66) and satisfactory results were also found in the correlation matrix for the assessment of construct validity. The P-PFSS showed good criterion validity related to generic psychological flexibility and athletic-related variables. Also, the P-PFSS was able to differentiate PF between known groups. The P-PFSS was found to be reliable, with good internal consistency (Cronbach’s alpha = 0.92; composite reliability = 0.92) and temporal stability on retest (intraclass correlation coefficient = 0.95).

Conclusions

Overall, the Persian version of the PFSS showed good psychometric qualities in Iranian athletes. The current study provides additional support for the PFSS and extends the context-specific utility for practitioners and researchers in assessing sport-related PF.

Facial affect recognition in first-episode psychosis is impaired but not associated with psychotic symptoms

Introduction

Aims

Method

Results

Discussion

•

Impaired affect recognition (FAR) present already in first episode psychosis (FEP).

•

Preserved FAR of happiness found in individuals with FEP.

•

Individuals with FEP mainly have impaired FAR of negative affects.

•

Both FEP and controls mainly mistook negative affects for other negative affects.

•

Psychotic symptoms are not associated with FAR in individuals with FEP.

Effectiveness of Multimodal Treatment for Young People With Body Dysmorphic Disorder in Two Specialist Clinics

Body dysmorphic disorder (BDD) typically originates in adolescence and is associated with considerable adversity. Evidence-based treatments exist but research on clinical outcomes in naturalistic settings is extremely scarce. We evaluated the short- and long-term outcomes of a large cohort of adolescents with BDD receiving specialist multimodal treatment and examined predictors of symptom improvement. We followed 140 young people (age range 10-18) with a diagnosis of BDD treated at two national and specialist outpatient clinics in Stockholm, Sweden (n = 96) and London, England (n = 44), between January 2015 and April 2021. Participants received multimodal treatment consisting of cognitive behavior therapy and, in 72% of cases, medication (primarily selective serotonin reuptake inhibitors). Data were collected at baseline, posttreatment, and 3, 6, and 12 months after treatment.The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent version (BDD-YBOCS-A). Secondary outcomes included self-reported measures of BDD symptoms, depressive symptoms, and global functioning. Mixed-effects regression models showed that BDD-YBOCS-A scores decreased significantly from baseline to posttreatment (coefficient [95% confidence interval] = -16.33 [-17.90 to -14.76], p<0.001; within-group effect size (Cohen's d) = 2.08 (95% confidence interval, 1.81 to 2.35). At the end of the treatment, 79% of the participants were classified as responders and 59% as full or partial remitters. BDD symptoms continued to improve throughout the follow-up. Improvement was also seen on all secondary outcome measures. Linear regression models identified baseline BDD symptom severity as a predictor of treatment outcome at posttreatment, but no consistent predictors were found at the 12-month follow-up. To conclude, multimodal treatment for adolescent BDD is effective in both the short- and long-term when provided flexibly within a specialist setting. Considering the high personal and societal costs of BDD, specialist care should be made more widely available.

What are the effects of implementing patient-controlled admissions in inpatient care? A study protocol of a large-scale implementation and naturalistic evaluation for adult and adolescent patients with severe psychiatric conditions throughout Region Stockholm

INTRODUCTION

Patient-controlled admissions (PCAs) represent a change in psychiatric inpatient care where patients are allowed to decide for themselves when hospitalisation might be required. Prior research has demonstrated that PCA increase the number of admissions, but decrease days in inpatient care, while both the admissions to and days in involuntary care decrease. However, investigations have been restricted to specific patient groups and have not examined other possible benefits, such as effects on symptoms, quality of life and autonomy.

METHODS AND ANALYSIS

This study explores the implementation process and effects of PCA in Region Stockholm, who is currently introducing PCA for all patients with severe psychiatric conditions and extensive healthcare utilisation. In total, the study comprises approximately 45 inpatient wards, including child and adolescent psychiatry. In a naturalistic evaluation, patients assigned PCA will be followed up to 36 months, both with regard to hospitalisation rates and self-reported outcomes. In addition, qualitative studies will explore the experiences of patients, caregivers of adolescents and healthcare providers.

ETHICS AND DISSEMINATION

Approval has been granted by the Swedish Ethical Review Authority (Dnr: 2020-06498). The findings from this study will be disseminated via publications in international peer-reviewed journals, at scientific conferences, as part of two doctoral theses, and through the Swedish Partnership for Mental Health.

TRIAL REGISTRATION NUMBER

NCT04862897.

Correspondence between practitioners’ self-assessment and independent motivational interviewing treatment integrity ratings

As evaluation of practitioners’ competence is largely based on self-report, accuracy in practitioners’ self-assessment is essential for ensuring high quality treatment-delivery. The aim of this study was to assess the relationship between independent observers’ ratings and practitioners’ self-reported treatment integrity ratings of Motivational interviewing (MI). Practitioners (N = 134) were randomized to two types of supervision [i.e., regular institutional group supervision, or individual telephone supervision based on the MI Treatment Integrity (MITI) code]. The mean age was 43.2 years (SD = 10.2), and 62.7 percent were females. All sessions were recorded and evaluated with the MITI, and the MI skills were self-assessed with a questionnaire over a period of 12 months. The associations between self-reported and objectively assessed MI skills were overall weak, but increased slightly from baseline to the 12-months assessment. However, the self-ratings from the group that received monthly objective feedback were not more accurate than those participating in regular group supervision. These results expand findings from previous studies and have important implications for assessment of practitioners’ treatment fidelity: Practitioners may learn to improve the accuracy of self-assessment of competence, but to ensure that patients receive intended care, adherence and competence should be assessed objectively.

The Psychological Flexibility in Epilepsy Questionnaire (PFEQ): Psychometric properties of the Persian version

The present study aimed to evaluate the psychometric properties of a Persian version of the Psychological Flexibility Epilepsy Questionnaire (P-PFEQ). Transcultural adaptation and validation of the Persian version of the PFEQ were performed using translation and back-translation with pilot testing (on 17 patients) and expert evaluation. Participants in the current study involved 100 patients with an EEG-verified epilepsy diagnosis and an average age of 30.96 years (SD ± 6.46) (63% were female). Data collection included a sociodemographic questionnaire, epilepsy-specific questionnaire, the Depression-Anxiety-stress scale (DASS-21), the Insomnia Severity Index (ISI), the 31-item Quality-of-Life questionnaire in Epilepsy (QOLIE-31), the Acceptance and Action Questionnaire (AAQ), the Committed Action Questionnaire (CAQ), and the short form of the Freiburg Mindfulness Inventory (FMI). Descriptive and inferential analyses were conducted by SPSS software V.26. The P-PFEQ demonstrated semantic, conceptual, and content validity in equivalence with the Swedish version. Based on Exploratory Factor Analysis (EFA), five items were eliminated and unidimensional scale of PFEQ with 12 items, explaining 50.38% of the total variance, was accepted. The scale showed good reliability through internal consistency (Cronbach's α of 0.9) and temporal stability on retest (n = 85, Intraclass correlation = 0.92). Convergent and divergent validity findings were acceptable for the P-PFEQ. The findings show that the P-PFEQ is a reliable and valid scale for assessing psychological flexibility in the Iranian patients with epilepsy. Also, it can be confidently recommended as a useful instrument in clinical practice.

Technology-delivered cognitive-behavioral therapy for pediatric anxiety disorders: a meta-analysis of remission, posttreatment anxiety, and functioning

BACKGROUND

The efficacy of technology-delivered cognitive-behavioral therapy (tCBT) for pediatric anxiety disorders (ADs) is uncertain as no meta-analysis has examined outcomes in trials that used structured diagnostic assessments at pre- and posttreatment.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) of tCBT for pediatric ADs that included participants <18 years of age with a confirmed primary AD according to a structured diagnostic interview. Nine studies with 711 participants were included.

RESULTS

tCBT outperformed control conditions for remission for primary AD (37.9% vs. 10.2%; k = 9; OR = 4.73; p < .0001; I²  = 0%; moderate certainty), remission for all ADs (19.5% vs. 5.3%; k = 8; OR = 3.32; p < .0001; I²  = 0%; moderate certainty), clinician-rated functioning (k = 7; MD = -4.38; p < .001; I²  = 56.9%; low certainty), and caregiver-reported anxiety (k = 7; SMD = 0.27; p = .02; I²  = 41.4%; low certainty), but not for youth-reported anxiety (k = 9; SMD = 0.13; p = .12; I²  = 0%; low certainty). More severe pretreatment anxiety, a lower proportion of completed sessions, no face-to-face sessions, media recruitment, and a larger proportion of females were associated with lower remission rates for primary AD.

CONCLUSIONS

tCBT has a moderate effect on remission for pediatric ADs and clinician-rated functioning, a small effect on caregiver-reported anxiety, and no statistically significant effect on youth-reported anxiety. The certainty of these estimates is low to moderate. Remission rates vary substantially across trials and several factors that may influence remission were identified. Future research should examine for whom tCBT is most appropriate and what care to offer the large proportion that does not remit. Future RCTs should consider contrasting tCBT with partial tCBT (e.g., including therapist-led exposure) and/or face-to-face CBT.

Mental health in individuals with self-reported psychiatric symptoms during the COVID-19 pandemic: Baseline data from a swedish longitudinal cohort study

OBJECTIVE

Individuals with psychiatric disorders may be both vulnerable and sensitive to rapid societal changes that have occurred during the COVID-19 pandemic. To fully understand these impacts, repeated measurements of these individuals are warranted. The current longitudinal study set out to perform monthly assessment of individuals with common psychiatric disorders using established questionnaires with a possibility for them to self- rate their symptoms, over time.

METHODS

Recruitment of individuals who identified themselves as struggling with mental health problems, living in Sweden between July 2020 and June 2021 using an online survey. The individuals answered questions on demographics, psychiatric history, current psychiatric symptoms (e.g., Patient Health Questionnaire, PHQ-9; General Anxiety Disorder, GAD-7), somatic health, health-care contacts and any changes therein during the pandemic. Monthly, longitudinal assessments are still ongoing (consenting participants provide data for 1 year), and here we present descriptive statistics from the baseline measurement. All measurements from baseline (>400 items), and follow-ups are presented in detail.

RESULTS

A total of 6.095 participants (average age 35 years) submitted complete baseline data. Marital status (43% single) and number of years of education (48% highest degree being high school) were evenly distributed in this population. The most common lifetime psychiatric disorder in the sample was depressive disorder (80.5%) and generalized anxiety disorder (45.9%), with a substantial proportion having severe symptoms of depression. (30.5%) and anxiety (37.1%). Lifetime suicidal ideation (75.0%) and non-suicidal self-harm (57.7%) were prevalent in the group and 14.5% reported drug use during the pandemic. Allergies (36.8%) were the most common somatic condition, followed by irritable bowel syndrome (18.7%). For those having experienced a traumatic event, 39% showed symptoms during the pandemic indicating PTSD. Regarding contact with mental health services during the pandemic, 22% had established a new contact, and 20% reported to have increased their psychiatric medication compared to before the pandemic.

CONCLUSION

Baseline data collected during the pandemic from individuals in Sweden with pre-existing psychiatric disorders demonstrate that this sample represents a population suitable for an investigation on the long-term impact of the pandemic, as intended by the longitudinal investigation that is ongoing. Follow-up questionnaires over a 12-month period are being collected and will indicate how the health and well-being of this population was impacted during the changes and uncertainties that have been characteristic of the past 2 years.

Clinical characteristics of 172 children and adolescents with body dysmorphic disorder

Body dysmorphic disorder (BDD) often starts in childhood, with most cases developing symptoms before age 18. Yet, BDD research has primarily focused on adults. We report the clinical characteristics of the world's largest cohort of carefully diagnosed youths with BDD and focus on previously unexplored sex and age differences. We systematically collected clinical data from 172 young people with BDD consecutively referred to 2 specialist pediatric obsessive-compulsive and related disorders outpatient clinics in Stockholm, Sweden and in London, England. A series of clinician-, self-, and parent-reported measures were administered. The cohort consisted of 136 girls, 32 boys, and 4 transgender individuals (age range 10-19 years). The mean severity of BDD symptoms was in the moderate to severe range, with more than one third presenting with severe symptoms and more than half showing poor or absent insight/delusional beliefs. We observed high rates of current psychiatric comorbidity (71.5%), past or current self-harm (52.1%), suicide attempts (11.0%), current desire for cosmetic procedures (53.7%), and complete school dropout (32.4%). Compared to boys, girls had significantly more severe self-reported BDD symptoms, depression, suicidal thoughts, and self-harm. Compared to the younger participants (14 or younger), older participants had significantly more severe compulsions and were more likely to report a desire for conducting cosmetic procedures. Adolescent BDD can be a severe and disabling disorder associated with significant risks and substantial functional impairment. The clinical presentation of the disorder is largely similar across sexes and age groups, indicating the importance of early detection and treatment. More research is needed specifically focusing on boys and pre-pubertal individuals with BDD.

Ongoing supervision as a method to implement Motivational interviewing: Results of a randomized controlled trial

OBJECTIVE

To assess skills in Motivational interviewing (MI) at the Swedish National Board of Institutional Care (SiS), and to evaluate different ways to provide MI supervision.

METHODS

SiS practitioners (n = 134) were randomized to regular group supervision, or individual telephone supervision based on only the behavioral component of a feedback protocol, or the full protocol. Participant's mean age was 43.2 (SD =10.2), and the majority (62.7%) were females.

RESULTS

Many participants showed beginning proficiency already at baseline, indicating a successful implementation. Still, results varied widely. The regular supervision and the supervision based on objective feedback were equally effective, and the group receiving feedback based on fewer variables of the protocol performed better on only one of the seven skill measures. The objective feedback did not provoke supervisee discomfort/distress, or negatively affect the supervisory relationship.

CONCLUSIONS

Extensive MI implementation can increase practitioners' skills in MI, but the question of the best mode of ongoing supervision needs further attention.

PRACTICE IMPLICATIONS

Objective feedback does not seem to negatively affect the supervisee's skill acquisition or the supervisor-supervisee working alliance, but the question of how to most efficiently provide feedback from multifaceted feedback tools remains unanswered.

Acceptance and Commitment Training for Ice Hockey Players: A Randomized Controlled Trial

Recent systematic reviews on the topic of mindfulness- and acceptance-based approaches in sport psychology conclude that there is a need for further trials using a more robust research methodology with direct performance as outcome. Acceptance and Commitment Training (ACT) is a contextual behavioral change method that focuses on facilitating psychological processes such as values, committed action, acceptance and mindfulness. In the present study designed as a randomized controlled trial, 34 junior elite ice hockey players were allocated into either an ACT group intervention or a wait list control group. Results showed significant effects on both objective performance outcomes (goals, assists, and taken shots) and blinded coach ratings of players' performance, focus and commitment to their development in favor of the ACT group. Effects lasted at 3-month follow-up for the coach ratings, but not for the objective performance measures. All ACT trained players recommended ACT to other players and considered the training as important for their development as ice hockey players. The results add to the growing body of evidence on ACT interventions for athletes and its effect on performance. Future studies should investigate the maintenance of effects from the psychological training over time, using robust research methodology and investigate theoretical coherent potential mediating variables.

Patient-controlled admissions to inpatient care: A twelve-month naturalistic study of patients with schizophrenia spectrum diagnoses and the effects on admissions to and days in inpatient care

BACKGROUND

Patients with schizophrenia spectrum diagnoses have a poor prognostic outlook and rates of recovery. Inpatient care is common, but the decision to initiate such care is not solely up to the patient but also influenced by the healthcare providers. Recent ideas about shared decision-making however challenges this idea. Patient-Controlled Admissions (PCA) refers to a care model where a patient signs a contract that allows the decision for admission into inpatient care to be transferred onto the patient.

METHODS

In Region Stockholm's public healthcare PCA was introduced to patients with schizophrenia spectrum diagnoses deemed to have the greatest care needs. Outcomes of a 12-month naturalistic within-group follow-up was analyzed using Wilcoxon signed-rank test.

RESULTS

In total, 56 patients fulfilled the study's inclusion criteria, with between 20 to 42 patients having complete data and being able to analyze statistically, depending on the variable. Number of admissions, inpatient days, number of involuntary admissions, and involuntary admission days decreased, but only significantly so for inpatient days, p < .01 (a mean reduction of 11.5 days). Neither self-rated well-being, as assessed using the EQ5D-3L, or a clinician-administered rating of overall health status, the Clinical Global Impression Scale, demonstrated a significant change.

CONCLUSIONS

The use of PCA points towards a trend in decreased hospitalization for patients with schizophrenia spectrum diagnoses, although this needs to be explored further in larger samples and over a longer follow-up.

Patterns of Relational Framing in Executive Function: An Investigation of the Wisconsin Card Sorting Test

Executive function (EF) is a concept widely used to describe higher order cognitive functioning. However, the concept seems to lack a precise definition upon which even experts in the area can agree. Examples of existing definitions describe EF as capacities for independent self-serving behavior and aspects of working memory, planning and organizational skills. It has been argued that the definition of EF is too imprecise, in terms of informing effective interventions. To possibly understand the range of behaviors termed EF in a more workable way, we administered a well-known computerized test (the Wisconsin Card Sorting Test; WCST) of EF to a sample of normal functioning participants (n = 11). During administration, they were asked questions about their ways of thinking. Transcriptions of questions and answers were analyzed in search of common patterns, using a behavioral theory of language and cognition (relational frame theory; RFT). The analysis suggested that a specific relationship between deictic and temporal framing, on the one hand, and coordination and spatial framing, on the other, was in effect when participants performed well on the WCST. At critical time points during the test (i.e., when need for EF was arguably most acute), deictic and temporal framing dominated participants’ behavior, whereas coordination and spatial framing were used relatively less.

Development and preliminary evaluation of the psychometric properties of the psychological flexibility in epilepsy questionnaire (PFEQ)

The present study describes the development and preliminary psychometric evaluation of the Psychological Flexibility in Epilepsy Questionnaire (PFEQ), which was developed to measure the construct referred to as Psychological Flexibility (PF) in epilepsy. Results from 81 participants with epilepsy support a one-factor solution, consisting of 12 items, indicating a satisfactory structure and reliability with an alpha coefficient of 0.92. Criterion validity of the instrument was supported by moderate correlations with outcomes predicting quality of life, PF in the general population, depressive symptoms, and anxiety symptoms. Number of seizures in the past three and 12 months was positively correlated with scores on the PFEQ. These findings are consistent with the instrument's underlying theory. Further development and investigation of the PFEQ is recommended, as the preliminary results of the questionnaire suggest that the scale has the potential to be a valuable contribution to the future exploration of the role of PF in epilepsy.

Efficacy of an Internet-Based Community Reinforcement and Family Training Program to Increase Treatment Engagement for AUD and to Improve Psychiatric Health for CSOs: A Randomized Controlled Trial

Aims

Community Reinforcement Approach and Family Training (CRAFT) is a support program for concerned significant others (CSOs) to identified persons (IPs) with alcohol use disorders, with the purpose of engaging IPs to treatment and to improve CSO functioning. The purpose of the present study was to investigate the efficacy of an internet-based version of CRAFT (iCRAFT).

Methods

Randomized controlled trial comparing iCRAFT with a wait-list (WL) condition with a nation-wide uptake in Sweden. A total of 94 CSOs to a treatment refusing IP, who described the IP according to DSM-IV criteria for alcohol dependence or abuse, were included in the study. iCRAFT consisted of five weekly administered therapist-guided modules with the following content: (a) improve CSOs’ own mental health, (b) improve the CSOs skills in asking the IP to seek treatment, (c) positive communication skills training, (d) contingency management of IP drinking behavior. Main outcome measure was IPs initiative to seek treatment measured at 24 weeks. Secondary outcomes were IP’s daily alcohol consumption, CSOs mental health, quality of life and relational satisfaction.

Results

Of 94 participants, 15 CSOs reported IP treatment initiative during the study period. Of these, 10 belonged to the iCRAFT condition and five to the WL condition. The difference between conditions was nonsignificant, and the results were inconclusive. Participants in iCRAFT showed short-term improvements regarding depressive symptoms, quality of life and relational happiness.

Conclusion

This study was unable to demonstrate substantial changes in the iCRAFT program regarding IP treatment seeking or CSO mental health.

Psychological Flexibility Among Competitive Athletes: A Psychometric Investigation of a New Scale

There is increasing interest in applying acceptance and mindfulness interventions among athletes. However, there is a lack of sport-specific psychometrically evaluated scales to measure the impact of these interventions. The present study describes the development of a measure: the Psychological Flexibility in Sport Scale (PFSS). Its validity was tested in two studies. In the first study, with 152 elite athletes from various sports, explorative factor analysis was used to evaluate the scale's validity, and one factor emerged with seven items. Significant correlations between psychological flexibility, performance, and quality of life were found. Moreover, the PFSS was significantly negatively associated with age, number of years in sport, and number of years as an elite athlete. In the second study, the confirmatory factor analysis with a new population (252 athletes) supported the one-factor solution. Further, positive associations were found with anxiety (BAI) and depression (BDI-I), indicating construct validity. In conclusion, this study presents a scale for measuring psychological flexibility in a broad range of athletes, with satisfactory psychometric properties and the potential to be a useful instrument for both researchers and clinicians in the sport field.

Psychological Flexibility in Depression Relapse Prevention: Processes of Change and Positive Mental Health in Group-Based ACT for Residual Symptoms

Relapse rates following a depressive episode are high, with limited treatments available aimed at reducing such risk. Acceptance and commitment therapy (ACT) is a cognitive-behavioral approach that has gained increased empirical support in treatment of depression, and thus represents an alternative in relapse prevention. Psychological flexibility (PF) plays an important role in mental health according to the model on which ACT is based. This study aimed to investigate the role of PF and its subprocesses in reducing residual symptoms of depression and in improving positive mental health following an 8-week group-based ACT treatment. Adult participants (75.7% female) with a history of depression, but currently exhibiting residual symptoms (N = 106) completed measures before and after intervention, and at 6 and 12-month follow-up. A growth curve model showed that positive mental health increased over 12-months. Multilevel mediation modeling revealed that PF significantly mediated these changes as well as the reduction of depressive symptoms, and that processes of acceptance, cognitive defusion, values and committed action, in turn, mediated increased PF.

Acceptance and Commitment Therapy Preceded by Attention Bias Modification on Residual Symptoms in Depression: A 12-Month Follow-Up

Depression is a highly recurrent disorder with limited treatment alternatives for reducing risk of subsequent episodes. Acceptance and commitment therapy (ACT) and attention bias modification (ABM) separately have shown some promise in reducing depressive symptoms. This study investigates (a) if group-based ACT had a greater impact in reducing residual symptoms of depression over a 12-month follow-up than a control condition, and (b) if preceding ACT with ABM produced added benefits. This multisite study consisted of two phases. In phase 1, participants with a history of depression, currently in remission (N = 244), were randomized to either receive 14 days of ABM or a control condition. In phase 2, a quasi- experimental design was adopted, and only phase-1 participants from the Sørlandet site (N = 124) next received an 8-week group-based ACT intervention. Self-reported and clinician-rated depression symptoms were assessed at baseline, immediately after phase 1 and at 1, 2, 6, and 12 months after the conclusion of phase 1. At 12-month follow-up, participants who received ACT exhibited fewer self-reported and clinician-rated depressive symptoms. There were no significant differences between ACT groups preceded by ABM or a control condition. There were no significant differences between ACT groups preceded by ABM or a control condition. Group-based ACT successfully decreased residual symptoms in depression over 12 months, suggesting some promise in preventing relapse.

The Values, Acceptance, and Mindfulness Scale for Ice Hockey: A Psychometric Evaluation

There is an increased interest in mindfulness, acceptance, and values based skills training interventions in sports but there is a lack of psychometrically evaluated instruments to investigate the processes adapted to sport populations. This paper describes the development and investigation of an instrument that measure acceptance, mindfulness, and values for ice hockey players. Ice hockey players at elite and sub elite level (n = 94) in Sweden participated in the study. The results reveal that the values, acceptance, and mindfulness (VAMS) shows acceptable internal consistency (α = 0.76) and satisfactory validity. Furthermore, scores on the VAMS predicts ice hockey performance as measured by assists and team points. Future research is suggested to evaluate the sensitivity of the instrument for longitudinal research design studies. In conclusion, VAMS is a useful instrument for practitioners and researchers to increase the knowledge in how psychological processes such as acceptance, mindfulness, and values influence performance among ice hockey players.

Ex Vivo Generation of Donor Antigen-Specific Immunomodulatory Cells: A Comparison Study of Anti-CD80/86 mAbs and CTLA4-lg Costimulatory Blockade

Adoptive transfer of alloantigen-specific immunomodulatory cells generated ex vivo with anti-CD80/CD86 mAbs (2D10.4/IT2.2) holds promise for operational tolerance after transplantation. However, good manufacturing practice is required to allow widespread clinical application. Belatacept, a clinically approved cytotoxic T-lymphocyte antigen 4-immunoglobulin that also binds CD80/CD86, could be an alternative agent for 2D10.4/IT2.2. With the goal of generating an optimal cell treatment with clinically approved reagents, we evaluated the donor-specific immunomodulatory effects of belatacept- and 2D10.4/IT2.2-generated immunomodulatory cells. Immunomodulatory cells were generated by coculturing responder human peripheral blood mononuclear cells (PBMCs) (50 × 10⁶ cells) with irradiated donor PBMCs (20 × 10⁶ cells) from eight human leukocyte antigen-mismatched responder–donor pairs in the presence of either 2D10.4/IT2.2 (3 μg/10⁶ cells) or belatacept (40 μg/10⁶ cells). After 14 days of coculture, the frequencies of CD4⁺ T cells, CD8⁺ T cells, and natural killer cells as well as interferon gamma (IFN-γ) production in the 2D10.4/IT2.2- and belatacept-treated groups were lower than those in the control group. The percentage of CD19⁺ B cells was higher in the 2D10.4/IT2.2- and belatacept-treated groups than in the control group. The frequency of CD4⁺CD25⁺CD127^lowFOXP3⁺ T cells increased from 4.1±1.0% (preculture) to 7.1±2.6% and 7.3±2.6% (day 14) in the 2D10.4/IT2.2- and belatacept-treated groups, respectively (p<0.05). Concurrently, delta-2 FOXP3 mRNA expression increased significantly. Compared with cells derived from the no-antibody treated control group, cells generated from both the 2D10.4/IT2.2- and belatacept-treated groups produced lower IFN-γ and higher interleukin-10 levels in response to donor-antigens, as detected by enzyme-linked immunospot. Most importantly, 2D10.4/IT2.2- and belatacept-generated cells effectively impeded the proliferative responses of freshly isolated responder PBMCs against donor-antigens. Our results indicate that belatacept-generated donor-specific immunomodulatory cells possess comparable phenotypes and immunomodulatory efficacies to those generated with 2D10.4/IT2.2. We suggest that belatacept could be used for ex vivo generation of clinical grade alloantigen-specific immunomodulatory cells for tolerance induction after transplantation.

Psychological treatments for adults and children with epilepsy: Evidence-based recommendations by the International League Against Epilepsy Psychology Task Force

Given the significant impact that psychosocial factors and epilepsy treatments can have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness-based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.

Acceptance and Commitment Therapy preceded by an experimental Attention Bias Modification procedure in recurrent depression: study protocol for a randomized controlled trial

Background

This project studies the effect of group-based Acceptance and Commitment Therapy (ACT) following Attention Bias Modification (ABM) on residual symptoms in recurrent depression. ACT is a cognitive-behavioral intervention combining acceptance and mindfulness processes with commitment and behavior-change processes. ACT enjoys modest empirical support in treating depression and has also shown promising results in secondary prevention of depression. The experimental cognitive bias modification (ABM) procedure has been shown to reduce surrogate markers of depression vulnerability in patients in remission from depression. The aim of the current project is to investigate if the effect of group-based ACT on reducing residual depressive symptoms can be enhanced by preceding it with ABM. Also, assessment of the relationship between conceptually relevant therapeutic processes and outcome will be investigated.

Methods/design

An invitation to participate in this project was extended to 120 individuals within a larger sample who had just completed a separate randomized, multisite, clinical trial (referred to hereafter as Phase 1) in which they received either ABM (n = 60) or a control condition without bias modification (n = 60). This larger Phase-1 sample consisted of 220 persons with a history of at least two episodes of major depression who were currently in remission or not fulfilling the criteria of major depression. After its inclusion, Phase-1 participants from the Sørlandet site (n = 120) were also recruited for this study in which they received an 8-week group-based ACT intervention. Measures will be taken immediately after Phase 1, 1 month, 2 months, 6 months, and 1 year after the conclusion of Phase 1.

Discussion

This study sequentially combines acceptable, nondrug interventions from neuropsychology and cognitive-behavioral psychology in treating residual symptoms in depression. The results will provide information about the effectiveness of treatment and on mechanisms and processes of change that may be valuable in understanding and further developing ABM and ACT, combined and alone.

Trial registration

ClinicalTrials.gov, Identifier: NCT02648165. Registered on 6 January 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2515-9) contains supplementary material, which is available to authorized users.

Psychological treatments for people with epilepsy

BACKGROUND

Given the significant impact epilepsy can have on the health-related quality of life (HRQoL) of individuals with epilepsy and their families, there is great clinical interest in evidence-based psychological treatments, aimed at enhancing psychological well-being in people with epilepsy. A review of the current evidence was needed to assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes, in order to inform future therapeutic recommendations and research designs.

OBJECTIVES

To assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes.

SEARCH METHODS

We searched the following databases on 20 September 2016, without language restrictions: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE PsycINFO, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQoL was the main outcome measure. For the operational definition of 'psychological treatments', we included a broad range of treatments that used psychological or behavioral techniques designed to improve HRQoL, seizure frequency and severity, and psychiatric comorbidities for adults and children with epilepsy, compared to treatment as usual (TAU) or an active control group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

We included 24 completed RCTs, with a total of 2439 participants. Eleven studies investigated psychological interventions, such as cognitive, behavioral, and mindfulness-based interventions. The remaining studies were classified as educational interventions (N = 7), self-management interventions (N = 3), adherence interventions (N = 1), and mixed interventions (N = 2). Two studies investigated interventions for children and adolescents, and five studies investigated interventions for adolescents and adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from six adult studies, two studies on adolescents and adults, and one on adolescents and young adults (468 participants) for HRQoL, measured with the Quality of Life in Epilepsy-31 (QOLIE-31). We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes of the QOLIE-31 total score (mean improvement of 5.68 points (95% CI 3.11 to 8.24; P < 0.0001), and three subscales, emotional well-being (mean improvement of 7.03 points (95% CI 2.51 to 11.54; P = 0.002); energy and Fatigue (mean improvement of 6.90 points (95% CI 3.49 to 10.31; P < 0.0001); and overall QoL (mean improvement of 6.47 points (95% CI 2.68 to 10.25; P = 0.0008) exceeded the threshold of minimally important change (MIC), indicating a clinically meaningful post-intervention improvement of QoL. We downgraded the quality of the evidence provided by the meta-analysis because of serious risk of bias in some of the included studies. Consequentially, these results provided evidence of moderate quality that psychological treatments for adults with epilepsy may enhance overall QoL in people with epilepsy.

AUTHORS' CONCLUSIONS

Implications for practice: Psychological interventions and self-management interventions improved QoL, and emotional well-being, and reduced fatigue in adults and adolescents with epilepsy. Adjunctive use of psychological treatments for adults and adolescents with epilepsy may provide additional benefits to QoL in those who incorporate patient-centered management.

IMPLICATIONS FOR RESEARCH

Authors should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of the intervention protocol is necessary to ensure reproducibility.When researching psychological treatments for people with epilepsy, the use of Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. There is a critical gap in pediatric RCTs for psychological treatments, particularly those that use an epilepsy-specific measure of HRQoL.Finally, in order to increase the overall quality of study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued when conducting RCTs. As attrition is often high in research that requires active participant participation, an intention-to-treat analysis should be carried out.

The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review

Clinical supervision is a central part of psychotherapist training but the empirical support for specific supervision theories or features is unclear. The aims of this study were to systematically review the empirical research literature regarding the effects of clinical supervision on therapists' competences and clinical outcomes within Cognitive Behavior Therapy (CBT). A comprehensive database search resulted in 4103 identified publications. Of these, 133 were scrutinized and in the end 5 studies were included in the review for data synthesis. The five studies were heterogeneous in scope and quality and only one provided firm empirical support for the positive effects of clinical supervision on therapists' competence. The remaining four studies suffered from methodological weaknesses, but provided some preliminary support that clinical supervision may be beneficiary for novice therapists. No study could show benefits from supervision for patients. The research literature suggests that clinical supervision may have some potential effects on novice therapists' competence compared to no supervision but the effects on clinical outcomes are still unclear. While bug-in-the-eye live supervision may be more effective than standard delayed supervision, the effects of specific supervision models or features are also unclear. There is a continued need for high-quality empirical studies on the effects of clinical supervision in psychotherapy.

Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement

Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.

The effects of clinical supervision on supervisees and patients in cognitive-behavioral therapy: a study protocol for a systematic review

BACKGROUND

Clinical supervision by a senior therapist is a very common practice in psychotherapist training and psychiatric care settings. Though clinical supervision is advocated by most educational and governing institutions, the effects of clinical supervision on the supervisees' competence, e.g., attitudes, behaviors, and skills, as well as on treatment outcomes and other patient variables are debated and largely unknown. Evidence-based practice is advocated in clinical settings but has not yet been fully implemented in educational or clinical training settings. The aim of this systematic review is to synthesize and present the empirical literature regarding effects of clinical supervision in cognitive-behavioral therapy.

METHODS

This study will include a systematic review of the literature to identify studies that have empirically investigated the effects of supervision on supervised psychotherapists and/or the supervisees' patients. A comprehensive search strategy will be conducted to identify published controlled studies indexed in the MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases. Data on supervision outcomes in both psychotherapists and their patients will be extracted, synthesized, and reported. Risk of bias and quality of the included studies will be assessed systematically.

DISCUSSION

This systematic review will rigorously follow established guidelines for systematic reviews in order to summarize and present the evidence base for clinical supervision in cognitive-behavioral therapy and may aid further research and discussion in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016046834.

Impaired Cytotoxicity in Papillon-Lefèvre Syndrome

Papillon-Lefèvre syndrome (PLS), palmoplantar hyperkeratosis with periodontitis, has been genetically characterized. However, suspected associated immune dysfunctions remain elusive. The purpose of this study was to evaluate peripheral blood lymphocyte levels and natural killer (NK) cell cytotoxicity in PLS. Twenty patients and 20 healthy controls were examined. Peripheral blood lymphocytes were analyzed by flow cytometry for surface markers. NK cell cytotoxicity against K562 cells was determined by means of a 51Cr release assay. White blood cell differential and proportions of B-, T-, T-helper, T-suppressor, and NK cells revealed only sporadic borderline variations from control values. In contrast, NK cell cytotoxicity was consistently and severely depressed (32–53% of control values) in all patients. To the best of our knowledge, this newly described impairment of NK cell cytotoxic function is the first consistent immune dysfunction reported in PLS. This suggests that the impaired NK cell cytotoxicity might contribute to the pathogenesis of PLS-associated periodontitis.