Implementing a complex mental health intervention in occupational settings: process evaluation of the MENTUPP pilot study.

BACKGROUND: According to the Medical Research Council (MRC) framework, the theorisation of how multilevel, multicomponent interventions work and the understanding of their interaction with their implementation context are necessary to be able to evaluate them beyond their complexity. More research is needed to provide good examples following this approach in order to produce evidence-based information on implementation practices. OBJECTIVES: This article reports on the results of the process evaluation of a complex mental health intervention in small and medium enterprises (SMEs) tested through a pilot study. The overarching aim is to contribute to the evidence base related to the recruitment, engagement and implementation strategies of applied mental health interventions in the workplace. METHOD: The Mental Health Promotion and Intervention in Occupational Settings (MENTUPP) intervention was pilot tested in 25 SMEs in three work sectors and nine countries. The evaluation strategy of the pilot test relied on a mixed-methods approach combining qualitative and quantitative research methods. The process evaluation was inspired by the RE-AIM framework and the taxonomy of implementation outcomes suggested by Proctor and colleagues and focused on seven dimensions: reach, adoption, implementation, acceptability, appropriateness, feasibility and maintenance. RESULTS: Factors facilitating implementation included the variety of the provided materials, the support provided by the research officers (ROs) and the existence of a structured plan for implementation, among others. Main barriers to implementation were the difficulty of talking about mental health, familiarisation with technology, difficulty in fitting the intervention into the daily routine and restrictions caused by COVID-19. CONCLUSIONS: The results will be used to optimise the MENTUPP intervention and the theoretical framework that we developed to evaluate the causal mechanisms underlying MENTUPP. Conducting this systematic and comprehensive process evaluation contributes to the enhancement of the evidence base related to mental health interventions in the workplace and it can be used as a guide to overcome their contextual complexity. TRIAL REGISTRATION NUMBER: ISRCTN14582090.

Implementation and evaluation of a multi-level mental health promotion intervention for the workplace (MENTUPP): study protocol for a cluster randomised controlled trial.

BACKGROUND: Well-organised and managed workplaces can be a source of wellbeing. The construction, healthcare and information and communication technology sectors are characterised by work-related stressors (e.g. high workloads, tight deadlines) which are associated with poorer mental health and wellbeing. The MENTUPP intervention is a flexibly delivered, multi-level approach to supporting small- and medium-sized enterprises (SMEs) in creating mentally healthy workplaces. The online intervention is tailored to each sector and designed to support employees and leaders dealing with mental health difficulties (e.g. stress), clinical level anxiety and depression, and combatting mental health-related stigma. This paper presents the protocol for the cluster randomised controlled trial (cRCT) of the MENTUPP intervention in eight European countries and Australia. METHODS: Each intervention country will aim to recruit at least two SMEs in each of the three sectors. The design of the cRCT is based on the experiences of a pilot study and guided by a Theory of Change process that describes how the intervention is assumed to work. SMEs will be randomly assigned to the intervention or control conditions. The aim of the cRCT is to assess whether the MENTUPP intervention is effective in improving mental health and wellbeing (primary outcome) and reducing stigma, depression and suicidal behaviour (secondary outcome) in employees. The study will also involve a process and economic evaluation. CONCLUSIONS: At present, there is no known multi-level, tailored, flexible and accessible workplace-based intervention for the prevention of non-clinical and clinical symptoms of depression, anxiety and burnout, and the promotion of mental wellbeing. The results of this study will provide a comprehensive overview of the implementation and effectiveness of such an intervention in a variety of contexts, languages and cultures leading to the overall goal of delivering an evidence-based intervention for mental health in the workplace. TRIAL REGISTRATION: Please refer to Item 2a and registration ISRCTN14104664. Registered on 12th July 2022.

Promoting employee wellbeing and preventing non-clinical mental health problems in the workplace: a preparatory consultation survey.

BACKGROUND: Small and medium-sized enterprises (SMEs) face major financial losses due to mental health issues affecting employees at all levels but seldom apply programs to promote wellbeing and prevent mental health issues among employees. To support the development of a multi-country workplace-based mental health intervention for SMEs (MENTUPP), a multinational consultation study was conducted. The study aimed to examine the experiences and needs of SMEs concerning the promotion of employee wellbeing, and the prevention and management of non-clinical mental health problems in workplaces. METHODS: A survey consisting of open and closed questions was designed to assess key informants' opinion about the acceptability, the use, and the implementation of interventions to promote wellbeing and prevent mental health issues in the workplace. Academic experts and representatives of SME organisations, specific sector organisations, labour or advocacy groups, and occupational health organisations across the nine MENTUPP intervention countries (eight European countries and Australia) were invited to complete the survey. Data were collected via the online platform Qualtrics. Sixty-five of 146 informants responded, representing a 44.5% response rate. Descriptive statistics were used to analyse the quantitative data and qualitative data were analysed through thematic analysis. RESULTS: Measures to create mentally healthy workplaces were most used in SMEs, while more specific mental health interventions, such as training staff on how to promote wellbeing, were hardly used. Managers lack resources to implement mental health interventions and are concerned about employees spending too much time on these interventions during working hours. Receiving information about the economic benefits of mental health interventions and hearing successful testimonials from other SMEs can persuade managers otherwise. Employees have concerns about confidentiality, discrimination and stigma, and career opportunities when using such interventions. CONCLUSIONS: The study identifies a variety of challenges, needs and possibilities related to implementing mental health interventions in SMEs. Employers need to be convinced that investing in mental health in the workplace is worth their time and money. This requires more studies on the (cost-)effectiveness of mental health interventions. Once employers are engaged, their knowledge and competencies about how to implement such interventions should be increased and privacy concerns of employees to participate in them should be addressed.

Outcome assessment of a complex mental health intervention in the workplace. Results from the MENTUPP pilot study.

OBJECTIVE: Multicomponent interventions are recommendable to achieve the greatest mental health benefits, but are difficult to evaluate due to their complexity. Defining long-term outcomes, arising from a Theory of Change (ToC) and testing them in a pilot phase, is a useful approach to plan a comprehensive and meaningful evaluation later on. This article reports on the pilot results of an outcome evaluation of a complex mental health intervention and examines whether appropriate evaluation measures and indicators have been selected ahead of a clustered randomised control trial (cRCT). METHODS: The MENTUPP pilot is an evidence-based intervention for Small and Medium Enterprises (SMEs) active in three work sectors and nine countries. Based on our ToC, we selected the MENTUPP long-term outcomes, which are reported in this article, are measured with seven validated scales assessing mental wellbeing, burnout, depression, anxiety, stigma towards depression and anxiety, absenteeism and presenteeism. The pilot MENTUPP intervention assessment took place at baseline and at 6 months follow-up. RESULTS: In total, 25 SMEs were recruited in the MENTUPP pilot and 346 participants completed the validated scales at baseline and 96 at follow-up. Three long-term outcomes significantly improved at follow-up (p < 0.05): mental wellbeing, symptoms of anxiety, and personal stigmatising attitudes towards depression and anxiety. CONCLUSIONS: The results of this outcome evaluation suggest that MENTUPP has the potential to strengthen employees' wellbeing and decrease anxiety symptoms and stigmatising attitudes. Additionally, this study demonstrates the utility of conducting pilot workplace interventions to assess whether appropriate measures and indicators have been selected. Based on the results, the intervention and the evaluation strategy have been optimised.

Developing a framework for evaluation: a Theory of Change for complex workplace mental health interventions.

BACKGROUND: There is a gap between the necessity of effective mental health interventions in the workplace and the availability of evidence-based information on how to evaluate them. The available evidence outlines that mental health interventions should follow integrated approaches combining multiple components related to different levels of change. However, there is a lack of robust studies on how to evaluate multicomponent workplace interventions which target a variety of outcomes at different levels taking into account the influence of different implementation contexts. METHOD: We use the MENTUPP project as a research context to develop a theory-driven approach to facilitate the evaluation of complex mental health interventions in occupational settings and to provide a comprehensive rationale of how these types of interventions are expected to achieve change. We used a participatory approach to develop a ToC involving a large number of the project team representing multiple academic backgrounds exploiting in tandem the knowledge from six systematic reviews and results from a survey among practitioners and academic experts in the field of mental health in SMEs. RESULTS: The ToC revealed four long-term outcomes that we assume MENTUPP can achieve in the workplace: 1) improved mental wellbeing and reduced burnout, 2) reduced mental illness, 3) reduced mental illness-related stigma, and 4) reduced productivity losses. They are assumed to be reached through six proximate and four intermediate outcomes according to a specific chronological order. The intervention consists of 23 components that were chosen based on specific rationales to achieve change on four levels (employee, team, leader, and organization). CONCLUSIONS: The ToC map provides a theory of how MENTUPP is expected to achieve its anticipated long-term outcomes through intermediate and proximate outcomes assessing alongside contextual factors which will facilitate the testing of hypotheses. Moreover, it allows for a structured approach to informing the future selection of outcomes and related evaluation measures in either subsequent iterations of complex interventions or other similarly structured programs. Hence, the resulting ToC can be employed by future research as an example for the development of a theoretical framework to evaluate complex mental health interventions in the workplace.

The effectiveness of organisational-level workplace mental health interventions on mental health and wellbeing in construction workers: A systematic review and recommended research agenda.

OBJECTIVES: This systematic review assesses the scientific evidence regarding the effectiveness of organisational-level workplace mental health interventions on stress, burnout, non-clinical depressive and anxiety symptoms, and wellbeing in construction workers. METHODS: Eligibility criteria were randomized controlled trials (RCTs), cluster randomized controlled trials (cRCTs), controlled or uncontrolled before- and after studies published in peer-reviewed journals between 2010 and May 2022 in five databases (Academic Search Complete, PsycInfo, PubMed, Scopus and Web of Science). Outcomes were stress, burnout and non-clinical depression and anxiety symptoms, and wellbeing (primary) and workplace changes and sickness absenteeism (secondary). Quality appraisal was conducted using the QATQS scale, a narrative synthesis was applied. The protocol was published in PROSPERO CRD42020183640 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020183640. MAIN RESULTS: We identified five articles (four studies) with a total sample size of 260, one cRCT, one controlled before- and after study, and two uncontrolled before- and after studies. The methodological quality of one study was rated as moderate, while for three studies it was weak. One study showed significant effects of a work redesign programme in short-term physiological stress parameters, one study showed a significant employee perceived improvement of information flow after supervisor training and one study showed a substantial non-significant decline in sick leave. There was no significant effect on general mental health (SF12) nor on emotional exhaustion. The focus of all studies was on physical health, while detailed mental health and wellbeing measures were not applied. MAIN CONCLUSIONS: The evidence for the effectiveness of organisational-level workplace mental health interventions in construction workers is limited with opportunities for methodological and conceptual improvement. Recommendations include the use of a wider range of mental health and wellbeing outcomes, interventions tailored to the specific workplace and culture in construction and the application of the principles of complex interventions in design and evaluation.

Mental Health Promotion and Intervention in Occupational Settings: Protocol for a Pilot Study of the MENTUPP Intervention.

Depression and anxiety are the most prevalent mental health difficulties in the EU, causing immense suffering and costing the global economy EUR 1 trillion each year in lost productivity. Employees in construction, health and information and communications technology have an elevated risk of mental health difficulties. Most mental health interventions for the workplace have been targeted at larger companies and small and medium-sized enterprises (SMEs) are often overlooked despite most people being employed in SMEs. The MENTUPP intervention aims to improve mental health and wellbeing and reduce depression, anxiety, and suicidal behaviour. The MENTUPP project involves the development, implementation, and evaluation of a multilevel intervention targeting both clinical and non-clinical mental health issues and combating the stigma of mental (ill-)health, with a specific focus on SMEs. The intervention is underpinned by a framework of how to create a mentally healthy workplace by employing an integrated approach and has been informed by several systematic reviews designed to understand organisational mental health interventions and a consultation survey with key experts in the area. The intervention is facilitated through the MENTUPP Hub, an online platform that presents interactive psychoeducational materials, toolkits, and links to additional resources in an accessible and user-friendly manner. This paper presents the pilot study protocol for delivering the MENTUPP intervention in eight European countries and Australia. Each intervention country will aim to recruit at least 23 participants in 1-3 SMEs in one of the three high-risk sectors. The central aim of the pilot study will be to examine the feasibility, acceptability, and uptake of the MENTUPP intervention across the target SMEs. The findings will contribute to devising the protocol for a cluster randomised controlled trial (cRCT) of the MENTUPP intervention. Findings from this study will also be used to inform the optimisation phase of the MENTUPP intervention which will aim to improve the materials and the implementation of the intervention as well as enhancing the evaluation strategy which will be employed for the cRCT.

Workplace interventions to reduce depression and anxiety in small and medium-sized enterprises: A systematic review.

BACKGROUND: Depression and anxiety are the most prevalent mental health difficulties in the workplace, costing the global economy $1 trillion each year. Evidence indicates that symptoms may be reduced by interventions in the workplace. This paper is the first to systematically review psychosocial interventions for depression, anxiety, and suicidal ideation and behaviours in small-to medium-size enterprises (SMEs). METHODS: A systematic search following PRISMA guidelines, registered in PROSPERO (CRD42020156275), was conducted for psychosocial interventions targeting depression, anxiety, and suicidal ideation/behaviour in SMEs. The PubMed, PsycINFO, Scopus, and two specific occupational health databases were searched, as well as four databases for grey literature, without time limit until 2nd December 2019. RESULTS: In total, 1283 records were identified, 70 were retained for full-text screening, and seven met the inclusion criteria: three randomised controlled trials (RCTs), three before and after designs and one non-randomised trial, comprising 5111 participants. Study quality was low to moderate according to the Quality Assessment Tool for Quantitative Studies. Five studies showed a reduction in depression and anxiety symptoms using techniques based on cognitive behavioural therapy (CBT), two reported no significant change. LIMITATIONS: Low number and high heterogeneity of interventions and outcomes, high attrition and lack of rigorous RCTs. CONCLUSIONS: Preliminary evidence indicates CBT-based interventions can be effective in targeting symptoms of depression and anxiety in SME employees. There may be unique challenges to implementing programmes in SMEs. Further research is needed in this important area.

Evidence for implementation of interventions to promote mental health in the workplace: a systematic scoping review protocol.

BACKGROUND: Mental health problems are common in the working population and represent a growing concern internationally, with potential impacts on workers, organisations, workplace health and compensation authorities, labour markets and social policies. Workplace interventions that create workplaces supportive of mental health, promote mental health awareness, destigmatise mental illness and support those with mental disorders are likely to improve health and economical outcomes for employees and organisations. Identifying factors associated with successful implementation of these interventions can improve intervention quality and evaluation, and facilitate the uptake and expansion. Therefore, we aim to review research reporting on the implementation of mental health promotion interventions delivered in workplace settings, in order to increase understanding of factors influencing successful delivery. METHODS AND ANALYSIS: A scoping review will be conducted incorporating a stepwise methodology to identify relevant literature reviews, primary research and grey literature. This review is registered with Research Registry (reviewregistry897). One reviewer will conduct the search to identify English language studies in the following electronic databases from 2008 through to July 1, 2020: Scopus, PROSPERO, Health Technology Assessments, PubMed, Campbell Collaboration, Joanna Briggs Library, PsycINFO, Web of Science Core Collection, CINAHL and Institute of Occupational Safety and Health (IOSH). Reference searching, Google Scholar, Grey Matters, IOSH and expert contacts will be used to identify grey literature. Two reviewers will screen title and abstracts, aiming for 95% agreement, and then independently screen full texts for inclusion. Two reviewers will assess methodological quality of included studies using the Mixed Methods Appraisal Tool and extract and synthesize data in line with the RE-AIM framework, Nielson and Randall's model of organisational-level interventions and Moore's sustainability criteria, if the data allows. We will recruit and consult with international experts in the field to ensure engagement, reach and relevance of the main findings. DISCUSSION: This will be the first systematic scoping review to identify and synthesise evidence of barriers and facilitators to implementing mental health promotion interventions in workplace settings. Our results will inform future evaluation studies and randomised controlled trials and highlight gaps in the evidence base. SYSTEMATIC REVIEW REGISTRATION: Research Registry ( reviewregistry897 ).

Effectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression.

BACKGROUND: General Practitioners (GPs) are well placed as gatekeepers for managing depression and suicidal ideation but not always well prepared. Capacity building has therefore been recommended as a useful strategy for suicide prevention. This study aimed to examine whether GPs' knowledge and attitudes towards and confidence to deal with depression and suicide improve after following a training program. METHODS: As part of the OSPI-Europe multilevel intervention, a standardized training on depression and suicide was provided to 208 GPs in three European countries. Core outcomes were assessed using the Depression Attitude Questionnaire, the Attitude towards Suicide Prevention Scale, and the Morriss Confidence Scale. Data were collected before and after training, and at three to six months follow-up. RESULTS: At baseline, GPs demonstrated various stigmatizing attitudes towards depression and low optimism about the therapeutic treatment of depression. They showed moderately positive attitudes towards suicide prevention but felt little confident in dealing with depression and suicide in daily practice. The training resulted in improved knowledge, attitudes and confidence regarding depression and suicide and their prevention and treatment. At follow-up, only the increase in confidence to deal with depression and suicide was sustained. LIMITATIONS: The Depression Attitude Questionnaire has rather weak psychometric properties. Other external factors may have contributed to the observed training effects as the study included no control group. CONCLUSIONS: The OSPI-Europe training program was able to improve the GPs' attitudes towards suicide prevention, several attitudes towards depression and its treatment as well as the GPs' confidence to deal with depression and suicide in everyday practice. At follow, only the GPs' confidence to deal with depression and suicide was preserved.

Public attitudes toward depression and help-seeking: Impact of the OSPI-Europe depression awareness campaign in four European regions.

BACKGROUND: Public attitudes toward depression and help-seeking behaviour are important factors influencing depressed people to obtain professional help and adequate treatment. OSPI-Europe is a multi-level suicide prevention programme including a public awareness campaign. It was implemented in four regions of four European countries (Germany, Hungary, Ireland and Portugal). This paper reports the results of the evaluation of the campaign, including its visibility and effects of the campaign on stigma associated with depression and help-seeking behaviour. METHODS: A representative general population survey (N=4004) including measures on personal stigma, perceived stigma, openness to help, perceived value of help, and socio-demographic variables was conducted in the four intervention and four control regions in a cross-sectional pre-post design. RESULTS: The public awareness campaign was considerably more visible in Germany and Portugal compared to Ireland and Hungary. Visibility was further affected by age and years of schooling. Personal stigma, perceived stigma and openness toward professional help varied significantly across the four countries. Respondents in the intervention regions showed significantly less personal depression stigma than respondents in the control regions after the campaign. Respondents of the intervention region who were aware of the campaign reported more openness toward seeking professional help than respondents who were unaware of it. CONCLUSION: The OSPI-Europe awareness campaign was visible and produced some positive results. At the same time, it proved to be difficult to show strong, measurable and unambiguous effects, which is in line with previous studies. Public awareness campaigns as conducted within OSPI-Europe can contribute to improved attitudes and knowledge about depression in the general public and produce synergistic effects, in particular when the dissemination of awareness campaign materials is simultaneously reinforced by other intervention levels of a multi-level intervention programme. LIMITATIONS: The survey was cross-sectional and based on self-report, so no causal inferences could be drawn.

Study protocol for 'we DECide': implementation of advance care planning for nursing home residents with dementia.

AIM: To evaluate the effects of 'we DECide', an educational intervention for nursing home staff on shared decision-making in the context of advance care planning for residents with dementia. BACKGROUND: Advance care planning (preparing care choices for when persons no longer have decision-making capacity) is of utmost importance for nursing home residents with dementia, but is mostly not realized for this group. Advance care planning consists of discussing care choices and making decisions and corresponds to shared decision-making (the involvement of persons and their families in care and treatment decisions). DESIGN: This quasi-experimental pre-test-post-test study is conducted in 19 nursing homes (Belgium). Participants are nursing home staff. METHODS: 'We DECide' focuses on three crucial moments for discussing advance care planning: the time of admission, crisis situations and everyday conversations. The 'ACP-audit' assesses participants' views on the organization of advance care planning (organizational level), the 'OPTION scale' evaluates the degree of shared decision-making in individual conversations (clinical level) and the 'IFC-SDM Questionnaire' assesses participants' views on Importance, Frequency and Competence of realizing shared decision-making (clinical level). (Project funded: July 2010). DISCUSSION: The study hypothesis is that 'we DECide' results in a higher realization of shared decision-making in individual conversations on advance care planning. A better implementation of advance care planning will lead to a higher quality of end-of-life care and more person-centred care. We believe our study will be of interest to researchers and to professional nursing home caregivers and policy-makers.

Effectiveness of community facilitator training in improving knowledge, attitudes, and confidence in relation to depression and suicidal behavior: results of the OSPI-Europe intervention in four European countries.

BACKGROUND: Community facilitators (CFs), such as teachers, nurses and social workers, are well placed as gatekeepers for depression and suicidal behavior, but not properly prepared to provide preventive and supportive services. The current study aimed: (1) to improve CFs' attitudes toward depression, knowledge on suicide, and confidence to detect suicidal behavior in four European countries and (2) to identify specific training needs across regions and CF groups. METHODS: A standardized training program was provided to 1276 CFs in Germany, Hungary, Ireland, and Portugal. Attitudes toward depression, knowledge about suicide, and confidence in identifying suicidal persons were assessed before training, after training, and at three to six months follow-up. Additionally, several participants' characteristics were registered. RESULTS: At baseline, CFs showed relatively favorable attitudes toward depression, but limited knowledge on suicide, and little confidence to identify suicidal behavior. Basic skills strongly differed across CF groups and countries. For example, in Germany, carers for the elderly, nurses, teachers, and managers were most in need of training, while in Portugal pharmacists and the clergy appeared to be important target groups. Most importantly, the training program improved the competencies of CF groups across countries and these improvements were sustained after three to six months. CFs with low basic skills benefited most of the training. LIMITATIONS: The observed training effects could be influenced by other external factors as our results are based upon a pre-post comparison with no control group. CONCLUSIONS: Gatekeeper trainings in community settings are successful in improving knowledge, reshaping attitudes, and boosting the confidence of gatekeepers. The most effective strategy to achieve the preferred objectives is to target those CF groups that are most in need of training and to tailor the content of the training program to the individual needs of the target group.

Public attitudes toward depression and help-seeking in four European countries baseline survey prior to the OSPI-Europe intervention.

BACKGROUND: Stigmatizing attitudes toward depression and toward help-seeking are important barriers for people with mental health problems to obtain adequate professional help. This study aimed to examine: (1) population attitudes toward depression and toward seeking professional help in four European countries; (2) the relation between depression stigma and attitudes toward help-seeking; (3) the relation between both attitudes and socio-demographic characteristics; and (4) differences in attitudes across countries. METHODS: A representative general population survey (n=4011) was conducted in Germany, Hungary, Ireland, and Portugal, assessing attitudes toward depression and toward help-seeking, and a number of socio-demographic variables. RESULTS: Respondents showed a moderate degree of personal stigma toward depression and a strikingly higher degree of perceived stigma. Although a substantial majority showed openness to seek professional help, only half of the people perceived professional help as valuable. More negative attitudes were found in Hungary and were associated with male gender, older age, lower educational level and living alone. Also, personal stigma was related to less openness to and less perceived value of professional treatment. LIMITATIONS: The survey was cross-sectional, so no causal inferences could be drawn. CONCLUSIONS: Personal and perceived stigma toward depression deserves public health attention, since they impact upon the intention of people with depression to seek professional help. Public media campaigns should focus on the credibility of the mental health care sector, and target males, older people, and those with a lower educational level and living alone. The content of each campaign should be adapted to the cultural norms of the country for which it is intended.

Fear conditioning following a unilateral anterior temporal lobectomy: reduced autonomic responding and stimulus contingency knowledge.

Animal research demonstrated that during fear conditioning the amygdala plays a central role in forming an association between the conditioned stimulus (CS) and the unconditioned stimulus (US). Lesion studies conducted in patients who underwent a unilateral anterior temporal lobe resection, however; yielded contradictory findings. To date, it remains unclear whether amygdala damage only affects fear-conditioned startle responding or impairs both the latter and fear-conditioned skin conductance responding (SCR). Moreover inconsistency exists regarding the preservation of contingency knowledge in amygdala-damaged patients. In the current study, a differential fear conditioning task was presented to a unilaterally amygdala-damaged patient group and a healthy control group, recording fear-potentiated startle responses along with SCRs. Retrospectively, the valence of the CSs and contingency awareness was assessed. Unlike the control group, unilaterally amygdala-damaged patients showed neither in their SCRs nor in their valence ratings an effect of fear conditioning. The startle data, however, yielded in none of the two test groups fear-conditioned responding. Finally, considerably fewer patients (37.5%) than controls (95%) acquired correct memory of the presented contingency. Based on these findings we concluded that the fear conditioning impairment in amygdala-damaged patients was not restricted to SCRs, but also affected valence ratings and memory of the presented contingency. A broader theory of the amygdala as relevance detector is proposed in order to account for the diverse neurological findings obtained so far.

Classically conditioned fear responses are preserved following unilateral temporal lobectomy in humans when concurrent US-expectancy ratings are used.

Previous lesion studies demonstrate that patients who underwent a unilateral temporal lobe resection show impaired skin conductance responding (SCR) to aversively conditioned stimuli. The aim of the current lesion study was to examine whether the amygdala is also critically involved in differential SCR during a more explicit form of fear learning. A simple discrimination task was presented to a unilaterally amygdala-damaged patient group and a control group, in which one neutral stimulus was always followed by an electric shock (CS+), whereas a second stimulus always appeared alone (CS-). To direct attention towards the stimulus contingencies, participants were asked to predict the occurrence of the shock continuously throughout the whole task. The results revealed that patients and controls rapidly acquired contingency knowledge as measured by the online US-expectancy ratings. Crucially, both test groups showed differential SCRs during CS+ and CS- trials. Thus, contrary to earlier findings, robust conditioned SCRs can be obtained in patients with unilateral temporal lobe resection as long as they are able to acquire explicit stimulus contingency knowledge. The two-level account of Ohman and Mineka [Ohman, A., & Mineka, S. (2001). Fears, phobias, and preparedness: Toward an evolved module of fear and fear learning. Psychological Review, 108, 483-522] is proposed in order to explain the diverse lesion data obtained so far.

Automatic affective stimulus processing is intact after unilateral resection of the anterior temporal lobe in humans.

Only hundreds of milliseconds after an incoming stimulus is perceived, we make an evaluation of whether it is good or bad. This evaluation seems to occur automatically and can significantly influence behavior. According to several functional imaging studies, the amygdala, which is localized in the temporal lobes of the brain, is an important structure for the automatic processing of affective stimuli. To investigate how critical a role the amygdala plays in this process, we had 20 participants with unilateral resection of the temporal lobe and 20 controls perform an affective priming task. Both controls and patients demonstrated shorter response latencies on trials where prime and target had the same valence than on trials where prime and target had the opposite valence. This finding is generally known as the affective priming effect and is considered to reflect automatic stimulus evaluation. More specifically, it is assumed that the valence of the prime stimulus is activated automatically and exerts an influence on the speed by which the target stimulus is evaluated. Given that the affective priming effect is equally large in both groups, our results suggest that the automatic processing of stimulus valence is intact in participants who sustained unilateral resection of the temporal lobe.

Evaluative conditioning is intact after unilateral resection of the anterior temporal lobe in humans.

Several lesion and functional imaging studies conducted in animals and humans suggest that structures within the amygdaloid nuclear complex (ANC) are important for the occurrence of fear conditioning. Whether this brain structure is also critical for evaluative conditioning, has been investigated less frequently. In the current experiment, a group of participants with unilateral resection of the anterior temporal lobe and a control group received a differential evaluative flavor-taste conditioning task. In the pre-acquisition phase, two fruit flavors (the conditioned stimuli (CSs)) were presented and participants were instructed to evaluate both. In the subsequent acquisition phase, one of these fruit flavors (CS+) was presented together with a bad tasting substance Tween20 (polysorbate 20, the US), while the other flavor (CS-) was never paired with Tween20. Finally, in the post-acquisition phase, the two flavors were presented again without Tween20 and participants were asked to evaluate both of them for a last time. The control group as well as the lesion group rated the CS+ in the post-acquisition phase less favorable than in the pre-acquisition phase, while the ratings of the CS- remained the same in both phases. We clearly demonstrated evaluative conditioning in both test groups. Because the lesion group had still one intact ANC it would be premature, however, to conclude that the ANC is not involved in evaluative conditioning. We conclude that despite evidence for impaired fear conditioning, unilateral damage to the ANC does not impair evaluative conditioning.