Mindfulness-Based Stress Reduction Health Insurance Coverage: If, How, and When? An Integrated Knowledge Translation (iKT) Delphi Key Informant Analysis.

Objectives: Hundreds of trials have evaluated Mindfulness-Based Stress Reduction (MBSR), but in the United States, it is generally not covered by health insurance. Consequently, the aims were to identify the following: (1) key questions to make decisions about if, how, and when MBSR should be covered by health insurance; (2a) barriers and (2b) facilitators to understand and resolve for MBSR to be covered by health insurance; and (3) highest priority evidence needed to inform health insurance coverage decisions. Methods: Key informants (n = 26) included health insurers, healthcare administrators, policymakers, clinicians, MBSR instructors, and MBSR students. An initial pool of items related to the study aims was generated through qualitative interviews. Through the Delphi process, participants rated, discussed, and re-rated each item's relevance. Items were required to reach a consensus of ≥ 80% agreement to be retained for final inclusion. Results: Of the original 149 items, 42 (28.2%) met the ≥ 80% agreement criterion and were retained for final inclusion. The most highly rated items informing whether MBSR should be covered by health insurance included research demonstrating that MBSR works and that it is not harmful. The most highly rated barriers to coverage were that MBSR is not a medical treatment and patient barriers to attendance. Highly rated facilitators included the potential of MBSR to address common mental health and psychosomatic problems. Finally, understanding what conditions are effectively treated with MBSR and the impact of MBSR on stress were rated as the highest priority evidence needed to inform health insurance coverage decisions. Conclusions: Findings highlight priorities for future research and policy efforts to advance health insurance coverage of MBSR in the United States. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-024-02366-x.

The education of experience: Mixed methods evidence demonstrates the benefit of multiparity.

PROBLEM: Existing quantitative data is conflicting concerning whether multiparous birthing parents (individuals with an older child(ren)) experience an easier postpartum transition compared to primiparous birthing parents (first time parents). AIM: This convergent mixed methods study leverages the depth of qualitative inquiry to seek a clearer understanding of the way in which acquired parenting experience contributes to observed quantitative differences in outcomes between parity groups. This work can serve as a first step in planning for supportive interventions that effectively address the postpartum needs of both parity groups. METHODS: Thirty birthing parents (43.3% multiparous; 46.7% racial minorities) completed measures of postpartum functioning, perceived stress, anxiety symptoms, and depression symptoms as well as an interview inquiring about factors impacting postpartum functioning. Scores on postpartum functioning and emotional wellbeing were compared between parity groups, and these findings were merged with the qualitative data on firsthand parenting experience to clarify how acquired experience impacts functioning and emotional wellbeing during the postpartum transition. FINDINGS: Primiparous parents reported significantly: worse postpartum functioning, higher perceived stress, higher levels of depression symptoms, and higher levels of anxiety symptoms. Participants' qualitative report of how acquired parenting experience impacts wellbeing suggests that experience grants parents skills, knowledge, and the opportunity to disconfirm maladaptive cognitions about parenting which allows for increased comfort and confidence in the parental role. CONCLUSIONS: The practical and psychological resources gained from acquiring parenting experience during one's first postpartum period appear to be brought forward into subsequent pregnancies and protect against threats to functioning and emotional wellbeing.

Locked in and left out: the "prison penalty" for implementation of evidence-based interventions.

BACKGROUND: While the broader medical community grapples with the widely accepted notion that it takes an average of 17 years for research evidence to be incorporated into clinical practice, the implementation of evidence-based interventions in carceral settings (i.e., jails and prisons) faces longer delays, exacerbating health disparities. MAIN BODY: The "prison implementation penalty" describes the significant delay in and limited adoption of evidence-based healthcare practices in carceral settings. We explore the complex challenges of implementing evidence-based interventions in jails and prisons, environments where healthcare often plays a secondary role under security and discipline. We use specific frameworks to highlight the unique barriers within these settings and propose potential implementation strategies. These challenges have broad implications for health equity due to the disproportionate impact on the marginalized groups affected by mass incarceration. Implementation science has potential to mitigate these disparities. CONCLUSION: Bridging the gap between healthcare evidence and practice in carceral settings offers a public health opportunity. Implementation science offers a unique role in improving healthcare standards and reducing health inequities in this environment.

Developing and testing a produce prescription implementation blueprint to improve food security in a clinical setting: a pilot study protocol.

BACKGROUND: Food insecurity is common in the United States, especially in Rhode Island, where it affects up to 33% of residents. Food insecurity is associated with adverse health outcomes and disproportionally affects people from minoritized backgrounds. Produce prescription programs, in which healthcare providers write "prescriptions" for free or reduced cost vegetables, have been used to address food insecurity and diet-related chronic disease. Although there is growing evidence for the effectiveness of produce prescription programs in improving food security and diet quality, there have been few efforts to use implementation science methods to improve the adoption of these programs. METHODS: This two-phase pilot study will examine determinants and preliminary implementation and effectiveness outcomes for an existing produce prescription program. The existing program is funded by an Accountable Care Organization in Rhode Island and delivered in primary care practices. For the first phase, we conducted a formative evaluation, guided by the Consolidated Framework for Implementation Research 2.0, to assess barriers, facilitators, and existing implementation strategies for the produce prescription program. Responses from the formative evaluation were analyzed using a rapid qualitative analytic approach to yield a summary of existing barriers and facilitators. In the second phase, we presented our formative evaluation findings to a community advisory board consisting of primary care staff, Accountable Care Organization staff, and staff who source and deliver the vegetables. The community advisory board used this information to identify and refine a set of implementation strategies to support the adoption of the program via an implementation blueprint. Guided by the implementation blueprint, we will conduct a single-arm pilot study to assess implementation antecedents (i.e., feasibility, acceptability, appropriateness, implementation climate, implementation readiness), implementation outcomes (i.e., adoption), and preliminary program effectiveness (i.e., food and nutrition security). The first phase is complete, and the second phase is ongoing. DISCUSSION: This study will advance the existing literature on produce prescription programs by formally assessing implementation determinants and developing a tailored set of implementation strategies to address identified barriers. Results from this study will inform a future fully powered hybrid type 3 study that will use the tailored implementation strategies and assess implementation and effectiveness outcomes for a produce prescription program. TRIAL REGISTRATION: Clinical trials: NCT05941403 , Registered June 9, 2023.

Private Practice, Private Insurance, and Private Pay Mental Health Services: An Understudied Area in Implementation Science.

The private practice setting is understudied. Private practice includes settings in which mental health providers are unaffiliated with healthcare and hospital systems. Private practices may accept insurance (private and sometimes public) or no insurance (private pay). Increasing attention to this setting is critical to facilitating equitable access to mental health services, especially given enduring mental health workforce shortages and service waitlists. Further, there have been recent federal government calls to increase mental health and physical healthcare parity and to reduce out-of-pocket patient costs. Implementation science theories, models, frameworks, and methods can help illuminate determinants of private practice service availability and quality (e.g., evidence-based intervention delivery with fidelity), guide evaluation of implementation outcomes such as cost and acceptability of interventions to patients, and identify strategies to mitigate barriers to high-quality, affordable private practice services. This article suggests research questions to begin filling the private practice research gap using an implementation determinants framework - the Consolidated Framework for Implementation Research (CFIR) 2.0. Research questions are proposed across CFIR domains: outer context (e.g., policies impacting whether private practices accept insurance); individuals involved (e.g., provider professional experiences; direct-to-consumer marketing impacts on evidence-based intervention demand); innovation characteristics (e.g., appropriateness for private practice); inner context (e.g., organizational characteristics); and implementation processes (e.g., innovation sustainability). The illustrative research questions aim to begin a conversation amongst researchers and funders. Bringing an implementation science lens to the private practice context has the potential to improve the quality and affordability of mental health care for many.

Assessment of implementation methods in sepsis: study protocol for a cluster-randomized hybrid type 2 trial.

BACKGROUND: Sepsis is the leading cause of intensive care unit (ICU) admission and ICU death. In recognition of the burden of sepsis, the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement developed sepsis "bundles" (goals to accomplish over a specific time period) to facilitate SSC guideline implementation in clinical practice. Using the SSC 3-h bundle as a base, the Centers for Medicare and Medicaid Services developed a 3-h sepsis bundle that has become the national standard for early management of sepsis. Emerging observational data, from an analysis conducted for the AIMS grant application, suggest there may be additional mortality benefit from even earlier implementation of the 3-h bundle, i.e., the 1-h bundle. METHOD: The primary aims of this randomized controlled trial are to: (1) examine the effect on clinical outcomes of Emergency Department initiation of the elements of the 3-h bundle within the traditional 3 h versus initiating within 1 h of sepsis recognition and (2) examine the extent to which a rigorous implementation strategy will improve implementation and compliance with both the 1-h bundle and the 3-h bundle. This study will be entirely conducted in the Emergency Department at 18 sites. A secondary aim is to identify clinical sepsis phenotypes and their impact on treatment outcomes. DISCUSSION: This cluster-randomized trial, employing implementation science methodology, is timely and important to the field. The hybrid effectiveness-implementation design is likely to have an impact on clinical practice in sepsis management by providing a rigorous evaluation of the 1- and 3-h bundles. FUNDING: NHLBI R01HL162954. TRIAL REGISTRATION: ClinicalTrials.gov NCT05491941. Registered on August 8, 2022.

What caregivers like the most (and least) about cognitive behavioral therapy for youth anxiety: A mixed methods approach.

Cognitive behavioral therapy (CBT) is an efficacious therapy for youth anxiety disorders. Caregivers are key stakeholders in youth therapy, and their feedback on treatment can help to inform intervention personalization. This mixed-methods study applied a systematic inductive thematic analysis to identify themes among most- and least-liked CBT features reported by caregivers using open-ended responses on the Client Satisfaction Questionnaire (CSQ-8). The sample included 139 caregivers of youth ages 7-17 (M = 12.21, SD = 3.05; 59% female; 79.1% Caucasian, 5.8% Black, 2.9% Asian, 2.2% Hispanic, 7.9% Multiracial, 2.2% Other) with principal anxiety diagnoses who completed 16-sessions of CBT. CSQ-8 quantitative satisfaction scores (M = 29.18, SD = 3.30; range: 16-32) and survey-based treatment response rates (responders n = 93, 67%) were high. Most-liked treatment features included: coping skills (i.e., exposure, understanding/identifying anxiety, rewards, homework), therapist factors (interpersonal style/skill, relationship, accessibility), caregiver involvement, one-on-one time with a therapist, structure, consistency, and personally tailored treatment. Least-liked treatment features included: questionnaires, logistical barriers, telehealth, need for more sessions, non-anxiety concerns not addressed, insufficient caregiver involvement, and aspects of exposure tasks. Proportional frequencies of most- and least-liked themes differed by treatment responder status (e.g., responders cited exposure and homework as most-liked more frequently).

From court to the community: improving access to evidence-based treatment for underserved youth involved in the juvenile legal system at-risk for suicide.

BACKGROUND: Juvenile legal involved youth (JLIY) experience disproportionately high rates of suicidal and self-injurious thoughts and behaviors (SSITB). Many JLIY lack access to evidence-based treatment specifically designed to treat SSITB, thereby increasing the overall risk of suicide. The overwhelming majority of JLIY are not placed in secure facilities and almost all incarcerated youth are eventually released to the community. Consequently, SSITB are a major concern of JLIY residing in the community and it is critical that this population has access to evidence-based treatment for SSITB. Unfortunately, most community mental health providers who treat JLIY have not been trained in evidence-based interventions that are specifically designed to SSITB, which often leads to youth experiencing prolonged periods of SSITB. Training community mental health providers who serve JLIY in the detection and treatment of SSITB shows promise for decreasing the overall suicide risk for JLIY. METHODS: The current proposal aims to reduce SSITB among JLIY, and thus reduce mental health disparities in this vulnerable and underserved youth population, by increasing access to evidence-based treatment strategies specifically designed to treat SSITB behaviors. We will implement an agency-wide training among at least 9 distinct community mental health agencies that serve JLIY referred to treatment by a statewide court system in the Northeast. Agencies will be trained in an adapted version of the COping, Problem Solving, Enhancing life, Safety, and Parenting (COPES+) intervention. Training will be implemented via a cluster-randomized stepped wedge trial that proceeds through multiple phases. DISCUSSION: This research engages multiple systems (i.e., juvenile legal and mental health systems) serving JLIY and has the potential to directly inform treatment practices in juvenile legal and mental health systems. The current protocol has significant public health implications as the primary goals are to reduce SSITB among adolescents involved in the juvenile legal system. By implementing a training protocol with community-based providers to help them learn an evidence-based intervention, this proposal aims to reduce mental health disparities in a marginalized and underserved population. TRIAL REGISTRATION: osf.io/sq9zt.

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping.

Background: Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved. Methods: Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes. Results: Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms. Conclusion: A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation.

Background: Exposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs. Methods: The study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training. Anticipated results: It is hypothesized that the E2E training condition will produce greater reductions in therapists' negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients. Conclusion: Implementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.

Development of split-root assays for loblolly pine (Pinus taeda L.) seedlings to study ectomycorrhizal symbioses.

Split-root techniques are valuable to investigate systemic vs. local plant responses to biotic and abiotic environmental factors, including interactions with soil microbes. Loblolly pine (Pinus taeda L.) is an economically important tree species that associates with many ectomycorrhizal fungi. However, a protocol for the establishment of split-roots experiments with loblolly pine has not been described so far. This method successfully establishes a split-root system in eight weeks following germination of loblolly pine seedlings. Rapid lateral root elongation is promoted by cutting the primary root tip and growing the seedlings in a hydroponic medium. Lateral roots can then be divided into two separated compartments and inoculated with ectomycorrhizal fungi. The method was validated by growth of split roots with or without inoculation. Root dry biomass was not significantly different between separated non-inoculated roots. Ectomycorrhizal colonization was not detected on the non-inoculated side of roots that were inoculated only on one side, demonstrating the success of the technique as a valuable method for split-root experiments in P. taeda. In addition to ectomycorrhizal fungi, researchers can use this method with loblolly pine to study systemic and local responses to a variety of other biotic or abiotic factors in the root environment.•We describe a protocol to produce split-roots in loblolly pine (Pinus taeda L.) in eight weeks.•This protocol uses hydroponics to promote the elongation of loblolly pine roots.•We validated this protocol by determining split-root biomass and inoculating the seedlings with the ectomycorrhizal fungi Paxillus ammoniavirescens or Hebeloma cylindrosporum.

Therapist perceptions of experiential training for exposure therapy.

BACKGROUND: Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS: This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD: Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS: Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION: Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

Preliminary Implementation Outcomes of a Free Online Toolkit to Support Exposure Therapy Implementation for Youth.

Background: Exposure therapy ("exposure") for youth anxiety is highly underutilized in clinical practice. Asynchronous, online implementation strategies such as online toolkits hold promise as pragmatic approaches for extending the sustainability of evidence-based interventions, but their long-term usage, perceived utility, and impact are rarely studied. Objective: This study presents three-year preliminary implementation outcomes for a free, online toolkit to support exposure therapy use with youth: the Resource for Exposure for Anxiety Disordered Youth (READY; www.bravepracticeforkids.com). Implementation outcomes of interest included READY usage statistics, adoption, perceived utility, and clinician exposure use. Methods: Web analytics characterized usage patterns. A survey of READY users (N = 49; M age = 34.2, 82.9% female, 71% White) assessed adoption, perceived utility, clinician exposure use, and persistent barriers to exposure use. Results: In its first three years, READY had 13,543 page views across 1,731 unique users; 442 (25.6%) registered as a site user to access specialized content. Survey data suggested variability in usage and perceived utility across toolkit components. Qualitative analyses highlighted persistent exposure barriers that pointed to potential READY refinements. Conculsions: Overall, READY has been accessed by hundreds of clinicians, but its impact was limited by low return to the site. This study highlights strengths and limitations of standalone online implementation supports and identifies additional steps needed to optimally support clinicians to deliver exposure to youth in need.

Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary.

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

The Pediatric Accommodation Scale: Psychometric Evaluation of a Therapist-Report Format.

Anxiety disorders are the most common mental health problem in youth, and accommodation is prevalent among youth with anxiety disorders. The Pediatric Accommodation Scale (PAS) is an interview administered by trained evaluators and a parent-report form (PAS-PR) to assess accommodation and its impact. Both have strong psychometric properties including internal consistency, inter-rater reliability, and data supporting construct validity. The present study evaluates the Pediatric Accommodation Scale - Therapist Report (PAS-TR), a therapist-reported version of the PAS-PR. Participants were 90 youth enrolled in cognitive behavioral therapy for anxiety. Therapists completed the PAS-TR over 16 therapy sessions. Internal consistency at baseline, convergent validity, divergent validity, and parent-therapist agreement were evaluated. Results suggest that the PAS-TR has mixed psychometric qualities suggesting that while not strong prior to the initiation of treatment, the PAS-TR may be a useful measure for therapists to rate accommodation as treatment progresses. Implications for assessment, treatment, and research are discussed.

Precision Implementation: An Approach to Mechanism Testing in Implementation Research.

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.

Bringing Evidence-Based Interventions into the Schools: An Examination of Organizational Factors and Implementation Outcomes.

Although schools are one of the largest providers of behavioral health services for youth, many barriers exist to the implementation of evidence-based interventions in schools. This study used the Stages of Implementation Completion (SIC) to examine school-based implementation outcomes for a computer-assisted cognitive behavioral therapy intervention for anxious youth. Organizational factors and predictors of program startup also were examined. Results indicated that the SIC detected implementation variability in schools and suggested that spending more time completing pre-implementation activities may better prepare schools for active implementation of program delivery. Furthermore, proficiency emerged as a potentially important organizational factor to examine in future school-based implementation research.

It's all in the name: why exposure therapy could benefit from a new one.

Exposure therapy for anxiety and related disorders is the psychological intervention with the strongest support for its efficacy and effectiveness to date. Yet, it is the least used evidence-based intervention in routine clinical practice, with a long-acknowledged public relations problem. Despite a wealth of research aimed at improving uptake of exposure, exposure's marketing and branding remains an untapped target. We first introduce principles from the marketing literature to propose that the field take steps toward a rebranding and repackaging of exposure therapy to support efforts to implement it widely. Second, we present preliminary data on clinician preferences for the use of alternative terminology developed to be more palatable and marketable - "Supported Approach of Feared Experiences - Cognitive Behavioral Therapy (SAFE-CBT)" - compared to traditional terminology. This initial survey indicated that most clinicians preferred use of the SAFE-CBT term when talking to patients, whereas only a minority preferred it for use among training clinicians. We conclude by discussing implications of these results for future efforts to implement exposure therapy more widely and set an agenda for future research in this space.

The evolution of sour taste.

The evolutionary history of sour taste has been little studied. Through a combination of literature review and trait mapping on the vertebrate phylogenetic tree, we consider the origin of sour taste, potential cases of the loss of sour taste, and those factors that might have favoured changes in the valence of sour taste-from aversive to appealing. We reconstruct sour taste as having evolved in ancient fish. By contrast to other tastes, sour taste does not appear to have been lost in any major vertebrate taxa. For most species, sour taste is aversive. Animals, including humans, that enjoy the sour taste triggered by acidic foods are exceptional. We conclude by considering why sour taste evolved, why it might have persisted as vertebrates made the transition to land and what factors might have favoured the preference for sour-tasting, acidic foods, particularly in hominins, such as humans.