Efficacy of an Unguided, Digital Single-Session Intervention for Internalizing Symptoms in Web-Based Workers: Randomized Controlled Trial.

BACKGROUND: The Common Elements Toolbox (COMET) is an unguided digital single-session intervention (SSI) based on principles of cognitive behavioral therapy and positive psychology. Although unguided digital SSIs have shown promise in the treatment of youth psychopathology, the data are more mixed regarding their efficacy in adults. OBJECTIVE: This study aimed to investigate the efficacy of COMET-SSI versus a waiting list control in depression and other transdiagnostic mental health outcomes for Prolific participants with a history of psychopathology. METHODS: We conducted an investigator-blinded, preregistered randomized controlled trial comparing COMET-SSI (n=409) with an 8-week waiting list control (n=419). Participants were recruited from the web-based workspace Prolific and assessed for depression, anxiety, work and social functioning, psychological well-being, and emotion regulation at baseline and at 2, 4, and 8 weeks after the intervention. The main outcomes were short-term (2 weeks) and long-term (8 weeks) changes in depression and anxiety. The secondary outcomes were the 8-week changes in work and social functioning, well-being, and emotion regulation. Analyses were conducted according to the intent-to-treat principle with imputation, without imputation, and using a per-protocol sample. In addition, we conducted sensitivity analyses to identify inattentive responders. RESULTS: The sample comprised 61.9% (513/828) of women, with a mean age of 35.75 (SD 11.93) years. Most participants (732/828, 88.3%) met the criteria for screening for depression or anxiety using at least one validated screening scale. A review of the text data suggested that adherence to the COMET-SSI was near perfect, there were very few inattentive respondents, and satisfaction with the intervention was high. However, despite being powered to detect small effects, there were negligible differences between the conditions in the various outcomes at the various time points, even when focusing on subsets of individuals with more severe symptoms. CONCLUSIONS: Our results do not support the use of the COMET-SSI in adult Prolific participants. Future work should explore alternate ways of intervening with paid web-based participants, including matching individuals to SSIs they may be most responsive to. TRIAL REGISTRATION: ClinicalTrials.gov NCT05379881, https://clinicaltrials.gov/ct2/show/NCT05379881.

Taking a Magnifying Glass to Measurement-Based Care Consultation Sessions: with What Issues Do Mental Health Clinicians Struggle?

PURPOSE: Ongoing consultation following initial training is one of the most commonly deployed implementation strategies to facilitate uptake of evidence-based practices, such as measurement-based care (MBC). Group consultation provides an interactive experience with an expert and colleagues to get feedback on actual issues faced, yet there is little research that unpacks the questions raised in consultation and what types of issues are important to address. METHODS: The current study characterized the questions and concerns raised by community mental health clinicians (N = 38 across six clinics) during group consultation sessions completed as part of an MBC implementation trial. We conducted a qualitative content analysis of consultation forms completed by clinicians before each MBC consultation session. RESULTS: Clinicians sought MBC consultation for clients across a range of ages and levels of depression severity. Qualitative results revealed five main questions and concerns in consultation sessions: (1) how to administer the PHQ-9, (2) how to review PHQ-9 scores, (3) how to respond to PHQ-9 score, (4) the types of clients for whom MBC would be appropriate, and (5) how MBC could impact a clinician's usual care. CONCLUSION: Findings highlight the need for ongoing consultation and limitations of workshop training alone. Practical recommendations for addressing the common questions and concerns identified are presented to support MBC use.

Posttraumatic stress symptom severity is associated with impaired processing of emotional faces in a large international sample.

Trauma exposure and posttraumatic stress symptoms (PTSS) are associated with biases in emotional face processing. Existing research has utilized a variety of methodological techniques to demonstrate hyperreactivity to threatening cues in posttraumatic stress disorder (PTSD; i.e., fearful faces), but studies to date have shown conflicting findings, including both increased and decreased time fixating on fearful faces. Moreover, the impact of PTSS severity on emotional face processing in the general population is unknown, as the generalizability of prior work is limited. The current study aimed to examine the associations between PTSS and sensitivity to detecting differences in fearful, angry, and happy faces in a large international sample. Participants were 1,182 visitors (Mage = 31.13 years, SD = 13.57, range: 18-85 years) to TestMyBrain.org who completed three emotion sensitivity tasks and the PTSD Checklist for DSM-5. The results indicated that higher PTSS scores were associated with poorer performance in detecting happiness, fear, and anger, ps < .001, with the largest effect for fear, f 2 = .06, controlling for age and gender. Participants who experienced more recent and more direct trauma exposure displayed higher levels of PTSS, with a small but significant effect whereby more direct trauma exposure was associated with higher (i.e., better) scores for anger and fear, f2 s = .02. Women showed heightened sensitivity to detecting fear compared to men, d = 0.17. The present findings underscore the value of citizen science initiatives that allow researchers to obtain clinical data from diverse samples with a high degree of PTSS variability.

The Road to Cognitive Skill Acquisition: Psychometric Evaluation of the Competencies of Cognitive Therapy Scale.

OBJECTIVE: Cognitive therapy (CT) skills are an index of treatment progress. They predict changes in patients' acute depressive symptoms and symptom relapses. However, the psychometric properties of the various measures of CT skills are poorly understood. This study aimed to investigate the factor structure of the Competencies of Cognitive Therapy Scale-Self Report (CCTS-SR) and assess its concurrent validity. METHODS: The psychometric properties of the CCTS-SR were explored by using data from a panel of online respondents (N=410). The fit of a one-factor solution was explored by using a confirmatory factor analysis. Exploratory bifactor analyses (EBFA) were then conducted to determine other possible factor structures. RESULTS: The one-factor solution did not fit the data well. Results of the EBFA suggested that the factor structure of the CCTS-SR may be characterized by a single underlying dimension capturing the general use of CT skills as well as by more specific factors the authors labeled "behavioral activation" and "CT comprehension." The variance captured by the factor initially labeled as CT comprehension was correlated with measures of depression and emotional dysregulation, suggesting that these items do not capture CT comprehension and should be removed from the scale. CONCLUSIONS: The CCTS-SR seems to be characterized by more than a single factor, and items that seemingly compose CT comprehension (i.e., items 13 and 14) may need to be removed. Although the CCTS-SR may be a valid index of therapy progress, more attention needs to be paid to its psychometric properties.

Data-driven personalized medicine approaches to cognitive-behavioral therapy allocation in a large sample: A reanalysis of the ENRICHED study.

BACKGROUND: Although effective treatments for common mental health problems are available, individual responses to treatments are difficult to predict. Treatment efficacy could be optimized by targeting interventions using individual predictions of treatment outcomes. The aim of this study was to develop a prediction algorithm using data from one of the largest randomized controlled trials on psychological interventions for common mental health problems. METHODS: This is a secondary analysis of the Enhancing Recovery in Coronary Heart Disease study investigating the effectiveness of cognitive behavioral therapy (CBT) and care as usual (CAU) for depression and low perceived social support following acute myocardial infarction. 2481 participants were randomly assigned to CBT and CAU. Baseline social-demographics, depression characteristics, comorbid symptoms, and stress and adversity measures were used to build an algorithm predicting post-treatment depression severity using elastic net regularization. Performance and generalizability of this algorithm were determined in a hold-out sample (n = 1203). RESULTS: Treatment matching based on predictions in the hold-out sample resulted in inconsistent and small effects (d = 0.15), that were more pronounced for individuals matched to CBT (d = 0.22). We identified a small subgroup of individuals for which CBT did not appear more efficacious than CAU. LIMITATIONS: Limitations are a poorly defined CAU condition, a low-severity sample, specific exclusion criteria and unavailability of certain baseline variables. CONCLUSIONS: Small matching effects are likely a realistic representation of the performance and generalizability of multivariable prediction algorithms based on clinical measures. Results indicate that future work and new approaches are needed.

Is a Criterion A trauma necessary to elicit posttraumatic stress symptoms?

OBJECTIVE: The posttraumatic stress disorder (PTSD) diagnosis has undergone substantial revision since its first appearance in the DSM-III. Much of the controversy surrounds the definition of trauma, or Criterion A. Our study sought to evaluate the DSM-5-TR's Criterion A and severity of PTSD symptoms in college students. METHOD: Participants were 1500 college students who completed an online questionnaire about mental health symptoms. Responses to the Criterion A assessment were double coded by researchers to determine if the DSM-5-TR's Criterion A was met. Interpersonal agreement between raters was high (kappa = .81). Participants were compared across groups based on their PTSD Criterion A status: (1) DSM-Congruent, (2) DSM-Incongruent, (3) DSM-Ambiguous, and (4) Denied Trauma, using analysis of variance and multiple regression. RESULTS: Participants who reported a trauma that was coded as Criterion A by researchers had the highest levels of PTSD symptoms, even after controlling for perceived stress, depression, anxiety, and gender (p < .001). Comparing across groups, the DSM-Congruent Criterion A group had significantly higher overall PTSS than those in the DSM-Incongruent Criterion A group and also significantly higher hyperarousal symptoms. However, the DSM-Congruent Criterion A group did not differ from the DSM-Ambiguous trauma group on any PTSD symptom cluster. CONCLUSIONS: The lack of significant differences in scores between individuals with DSM- Congruent, DSM-Incongruent, and DSM-Ambiguous traumas provides evidence about the subjective nature of trauma and how college-age individuals interpret their symptoms of PTSD. Clinical implications are discussed.

"I Haven't Been Diagnosed, but I Should Be"-Insight Into Self-diagnoses of Common Mental Health Disorders: Cross-sectional Study.

BACKGROUND: In recent years, social media has become a rich source of mental health data. However, there is a lack of web-based research on the accuracy and validity of self-reported diagnostic information available on the web. OBJECTIVE: An analysis of the degree of correspondence between self-reported diagnoses and clinical indicators will afford researchers and clinicians higher levels of trust in social media analyses. We hypothesized that self-reported diagnoses would correspond to validated disorder-specific severity questionnaires across 2 large web-based samples. METHODS: The participants of study 1 were 1123 adults from a national Qualtrics panel (mean age 34.65, SD 12.56 years; n=635, 56.65% female participants,). The participants of study 2 were 2237 college students from a large university in the Midwest (mean age 19.08, SD 2.75 years; n=1761, 75.35% female participants). All participants completed a web-based survey on their mental health, social media use, and demographic information. Additionally, the participants reported whether they had ever been diagnosed with a series of disorders, with the option of selecting "Yes"; "No, but I should be"; "I don't know"; or "No" for each condition. We conducted a series of ANOVA tests to determine whether there were differences among the 4 diagnostic groups and used post hoc Tukey tests to examine the nature of the differences. RESULTS: In study 1, for self-reported mania (F3,1097=2.75; P=.04), somatic symptom disorder (F3,1060=26.75; P<.001), and alcohol use disorder (F3,1097=77.73; P<.001), the pattern of mean differences did not suggest that the individuals were accurate in their self-diagnoses. In study 2, for all disorders but bipolar disorder (F3,659=1.43; P=.23), ANOVA results were consistent with our expectations. Across both studies and for most conditions assessed, the individuals who said that they had been diagnosed with a disorder had the highest severity scores on self-report questionnaires, but this was closely followed by individuals who had not been diagnosed but believed that they should be diagnosed. This was especially true for depression, generalized anxiety, and insomnia. For mania and bipolar disorder, the questionnaire scores did not differentiate individuals who had been diagnosed from those who had not. CONCLUSIONS: In general, if an individual believes that they should be diagnosed with an internalizing disorder, they are experiencing a degree of psychopathology similar to those who have already been diagnosed. Self-reported diagnoses correspond well with symptom severity on a continuum and can be trusted as clinical indicators, especially in common internalizing disorders such as depression and generalized anxiety disorder. Researchers can put more faith into patient self-reports, including those in web-based experiments such as social media posts, when individuals report diagnoses of depression and anxiety disorders. However, replication and further study are recommended.

Acceptability and Outcomes of Transdiagnostic Guided Self-help Bibliotherapy for Internalizing Disorder Symptoms in Adults: A Fully Remote Nationwide Open Trial.

Introduction: Doing What Matters in Times of Stress (DWM) is a five-module transdiagnostic guided self-help (GSH) intervention developed by the World Health Organization, originally in a group-based format. In a sample of individuals recruited from across the United States, we conducted an open trial to study the feasibility and acceptability of an adaptation of DWM in which guidance was provided individually and remotely via phone and videoconferencing. Methods: We assessed internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation over the course of 6 weeks. Results: A total of 263 individuals completed our screening. Of those, 75.29% (n = 198) qualified for the intervention. We reached most participants who qualified (71.21%, n = 141) via phone to schedule a GSH session. Most of those scheduled attended a study session (84.4%, n = 119), and most of those who attended a session completed more than half the treatment (84.03%, n = 100). Retention rates were comparable to meta-analytic estimates of dropout rates in GSH. Participants showed improvement on internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation. Conclusion: DWM is a freely available, seemingly efficacious transdiagnostic intervention for internalizing disorder symptoms. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-022-10338-5.

Sociodemographics and Transdiagnostic Mental Health Symptoms in SOCIAL (Studies of Online Cohorts for Internalizing Symptoms and Language) I and II: Cross-sectional Survey and Botometer Analysis.

BACKGROUND: Internalizing, externalizing, and somatoform disorders are the most common and disabling forms of psychopathology. Our understanding of these clinical problems is limited by a reliance on self-report along with research using small samples. Social media has emerged as an exciting channel for collecting a large sample of longitudinal data from individuals to study psychopathology. OBJECTIVE: This study reported the results of 2 large ongoing studies in which we collected data from Twitter and self-reported clinical screening scales, the Studies of Online Cohorts for Internalizing Symptoms and Language (SOCIAL) I and II. METHODS: The participants were a sample of Twitter-using adults (SOCIAL I: N=1123) targeted to be nationally representative in terms of age, sex assigned at birth, race, and ethnicity, as well as a sample of college students in the Midwest (SOCIAL II: N=1988), of which 61.78% (1228/1988) were Twitter users. For all participants who were Twitter users, we asked for access to their Twitter handle, which we analyzed using Botometer, which rates the likelihood of an account belonging to a bot. We divided participants into 4 groups: Twitter users who did not give us their handle or gave us invalid handles (invalid), those who denied being Twitter users (no Twitter, only available for SOCIAL II), Twitter users who gave their handles but whose accounts had high bot scores (bot-like), and Twitter users who provided their handles and had low bot scores (valid). We explored whether there were significant differences among these groups in terms of their sociodemographic features, clinical symptoms, and aspects of social media use (ie, platforms used and time). RESULTS: In SOCIAL I, most individuals were classified as valid (580/1123, 51.65%), and a few were deemed bot-like (190/1123, 16.91%). A total of 31.43% (353/1123) gave no handle or gave an invalid handle (eg, entered "N/A"). In SOCIAL II, many individuals were not Twitter users (760/1988, 38.23%). Of the Twitter users in SOCIAL II (1228/1988, 61.78%), most were classified as either invalid (515/1228, 41.94%) or valid (484/1228, 39.41%), with a smaller fraction deemed bot-like (229/1228, 18.65%). Participants reported high rates of mental health diagnoses as well as high levels of symptoms, especially in SOCIAL II. In general, the differences between individuals who provided or did not provide their social media handles were small and not statistically significant. CONCLUSIONS: Triangulating passively acquired social media data and self-reported questionnaires offers new possibilities for large-scale assessment and evaluation of vulnerability to mental disorders. The propensity of participants to share social media handles is likely not a source of sample bias in subsequent social media analytics.

The significance of anxiety symptoms in predicting psychosocial functioning across borderline personality traits.

Emotion regulation is a central task of daily life. Difficulty regulating emotions is a core feature of borderline personality disorder (BPD), one of the most common and impairing personality disorder diagnoses. While anger and symptoms of depression are instantiated in the criteria for BPD, anxiety is not, despite being among the most common psychiatric symptoms. In a sample of online respondents (N = 471), we explored the interactions between anxiety symptoms and BPD traits in predicting well-being (WHO-5) as well as poorer work and social adjustment (WSAS), while controlling for anger and depression. We hypothesized that anxiety would lead to more impairment (i.e., lower well-being and poorer work and more difficulties with work and social adjustment) as BPD traits increased. BPD traits and symptoms of anxiety both contributed to overall lower levels well-being and higher levels of psychosocial dysfunction. However, contrary to our expectations, at higher (vs. lower) levels of BPD traits, symptoms of anxiety were less conducive to lower well-being on the WHO-5. For the WSAS, there was no consistent evidence for an interaction between BPD traits and anxiety in predicting functioning. By and large, our results do not support the idea that anxiety contributes to more impairment at higher levels of BPD traits.

Social Media Use, Physical Activity, and Internalizing Symptoms in Adolescence: Cross-sectional Analysis.

BACKGROUND: Most American adolescents have access to smartphones, and recent estimates suggest that they spend considerable time on social media compared with other physical and leisure activities. A large body of literature has established that social media use is related to poor mental health, but the complicated relationship between social media and symptoms of depression and anxiety in adolescents is yet to be fully understood. OBJECTIVE: We aim to investigate the relationship between social media use and depression and anxiety symptoms in adolescents by exploring physical activity as a mediator. METHODS: A Qualtrics survey manager recruited adult panel participants between February and March 2019, who indicated that they had adolescent children who spoke English. A total of 4592 adolescent-parent dyads completed the survey that took approximately 39 minutes. The survey entailed completing web-based questionnaires assessing various aspects of social media use, psychological symptoms, and psychosocial factors. The average age of the adolescent participants was 14.62 (SD 1.68; range 12-17) years, and the majority of the adolescent sample was male (2392/4592, 52.09%). RESULTS: Total social media use was associated with more depressive symptoms (multiple R2=0.12; F3,4480=207.1; P<.001), anxiety (multiple R2=0.09; F3,4477=145.6; P<.001), and loneliness (multiple R2=0.06; F3,4512=98.06; P<.001), controlling for age and gender. Physical activity was associated with decreased depression and anxiety symptoms after controlling for other extracurricular activities and social media use (multiple R2=0.24; F5,4290=266.0; P<.001). There were significant differences in symptoms based on gender: female adolescents reported higher rates of social media use and males reported higher rates of depression. Nonbinary and transgender adolescents had higher rates of depression, anxiety, and loneliness than the female and male adolescents in the sample. CONCLUSIONS: In a nationally representative sample of adolescents, more social media use was associated with more severe symptoms of depression, anxiety, and loneliness. Increased physical activity was associated with decreased depression and anxiety symptoms. Physical activity partially mediated the relationship between social media use and depression and anxiety. As this was a cross-sectional study, we cannot conclude that social media use causes internalizing symptoms or that physical activity leads to decreased internalizing symptoms-there may be additional confounding variables producing the relationships we observed. Physical activity may protect against the potentially harmful effect of social media on some adolescents. The effect sizes were small to medium, and the results should be interpreted with caution. Other limitations of this study include our reliance on self-reporting. Future work should examine social media use beyond how much time adolescents spend using social media and instead focus on the nature of social media activity.

Implementing Measurement-Based Care in Behavioral Health: A Review.

Importance: Measurement-based care (MBC) is the systematic evaluation of patient symptoms before or during an encounter to inform behavioral health treatment. Despite MBC's demonstrated ability to enhance usual care by expediting improvements and rapidly detecting patients whose health would otherwise deteriorate, it is underused, with typically less than 20% of behavioral health practitioners integrating it into their practice. This narrative review addresses definitional issues, offers a concrete and evaluable operationalization of MBC fidelity, and summarizes the evidence base and utility of MBC. It also synthesizes the extant literature's characterization of barriers to and strategies for supporting MBC implementation, sustainment, and scale-up. Observations: Barriers to implementing MBC occur at multiple levels: patient (eg, concerns about confidentiality breach), practitioner (eg, beliefs that measures are no better than clinical judgment), organization (eg, no resources for training), and system (eg, competing requirements). Implementation science-the study of methods to integrate evidence-based practices such as MBC into routine care-offers strategies to address barriers. These strategies include using measurement feedback systems, leveraging local champions, forming learning collaboratives, training leadership, improving expert consultation with clinical staff, and generating incentives. Conclusions and Relevance: This narrative review, informed by implementation science, offers a 10-point research agenda to improve the integration of MBC into clinical practice: (1) harmonize terminology and specify MBC's core components; (2) develop criterion standard methods for monitoring fidelity and reporting quality of implementation; (3) develop algorithms for MBC to guide psychotherapy; (4) test putative mechanisms of change, particularly for psychotherapy; (5) develop brief and psychometrically strong measures for use in combination; (6) assess the critical timing of administration needed to optimize patient outcomes; (7) streamline measurement feedback systems to include only key ingredients and enhance electronic health record interoperability; (8) identify discrete strategies to support implementation; (9) make evidence-based policy decisions; and (10) align reimbursement structures.

Assessing homeland chemical hazards outside the military gates: industrial hazard threat assessments for department of defense installations.

As part of comprehensive joint medical surveillance measures outlined by the Department of Defense, the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) is beginning to assess environmental health threats to continental US military installations. A common theme in comprehensive joint medical surveillance, in support of Force Health Protection, is the identification and assessment of potential environmental health hazards, and the evaluation and documentation of actual exposures in both a continental US and outside a continental US setting. For the continental US assessments, the USACHPPM has utilized the US Environmental Protection Agency (EPA) database for risk management plans in accordance with Public Law 106-40, and the toxic release inventory database, in a state-of the art geographic information systems based program, termed the Consequence Assessment and Management Tool Set, or CATS, for assessing homeland industrial chemical hazards outside the military gates. As an example, the US EPA toxic release inventory and risk management plans databases are queried to determine the types and locations of industries surrounding a continental US military installation. Contaminants of concern are then ranked with respect to known toxicological and physical hazards, where they are then subject to applicable downwind hazard simulations using applicable meteorological and climatological data sets. The composite downwind hazard areas are mapped in relation to emergency response planning guidelines (ERPG), which were developed by the American Industrial Hygiene Association to assist emergency response personnel planning for catastrophic chemical releases. In addition, other geographic referenced data such as transportation routes, satellite imagery and population data are included in the operational, equipment, and morale risk assessment and management process. These techniques have been developed to assist military medical planners and operations personnel in determining the industrial hazards, vulnerability assessments and health risk assessments to continental United States military installations. These techniques and procedures support the Department of Defense Force Protection measures, which provides awareness of a terrorism threat, appropriate measures to prevent terrorist attacks and mitigate terrorism's effects in the event that preventive measures are ineffective.