Transdiagnostic Processes Linking Posttraumatic Stress Disorder Symptoms to Alcohol Use Severity.

Objective: The high comorbidity between posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is well-established and complex. However, there is a need to explore transdiagnostic constructs that may underlie this association to better understand what accounts for this comorbidity and to inform treatment development. Method: Thus, the present study utilized a large, cross-sectional dataset (N = 513; Mage = 38.25 years, SD = 10.07; 49.9% female), based on national recruitment, to (1) examine whether the associations between PTSD symptom severity (PCL-5) and alcohol use severity (AUDIT) were statistically mediated by (a) anxiety sensitivity (SSASI); and (b) difficulties with emotion regulation (DERS-16); and (2) examine whether coping motives for drinking moderate this indirect effect. Sex assigned at birth was included as a covariate. Results: When examining the hypothesized mediators (SSASI and DERS-16) in separate models, there was a statistically significant indirect effect of PCL-5 on AUDIT through both SSASI and DERS. However, when both SSASI and DERS were entered into a model simultaneously, only SSASI served as a statistically significant mediator. Coping motives for drinking did not moderate the observed indirect effect. Conclusions: The current findings highlight anxiety sensitivity and emotion regulation as transdiagnostic processes that may explain, at least partially, the relationship between PTSD symptom severity and alcohol use; however, stronger evidence was evident for anxiety sensitivity. These findings may help inform the development of refined, streamlined interventions for PTSD and alcohol use that directly target these processes.

Evaluating training needs in clinical psychology doctoral programs.

OBJECTIVE: Advances in clinical psychology must be accompanied by advances in training. This study assessed training content, quality, and needs during clinical psychology doctoral programs among current or past doctoral students. METHODS: Current or past clinical psychology doctoral students (N = 343) completed an anonymous survey assessing training experiences and needs. A descriptive-focused exploratory factor analysis (EFA) also examined whether common subgroups of academic interests emerged. RESULTS: Most participants reported that they sought training beyond required coursework, primarily in clinical training, cultural competency, and professional development, and reported having taken one or more unhelpful course, including discipline-specific knowledge requirements. Descriptive results from the EFA demonstrated common training areas of interest: diversity topics, biological sciences, clinical practice, and research methods. DISCUSSION: This study demonstrates that trainees and early career psychologists are aware of their nuanced and in some cases, unmet training needs. CONCLUSION: This work foregrounds the need to adapt extant training opportunities to support the next generation of clinical psychologists.

Motivations for Prescription Drug Misuse Related to Mental Health Problems in Adults.

BACKGROUND: Prescription drug misuse (PDM) is a significant public health problem associated with mental health symptoms. OBJECTIVES: This project investigates the connections between PDM motivations and mental health to inform intervention efforts. METHODS: Using nationally representative adult data from the 2016-2018 National Survey on Drug Use and Health (N = 128,205; 53% female) this project investigated which motivations for misuse are related to past-year mental health problems including any mental illness, serious mental illness, major depressive episode, and suicidal thoughts. Complex samples logistic regression models of the main motivation of PDM for each mental health problem were conducted separately for each prescription drug class (i.e., opioids, tranquilizers, sedatives, and stimulants) while controlling for demographic characteristics. RESULTS: Adults that reported PDM were more likely than those with no PDM to endorse past year mental health problems. Compared to those that reported PDM of other medications, those misusing prescription opioids and tranquilizers to help with emotions and misusing sedatives to "relax or relieve tension" were more likely to have all categories of mental health problems. Those that misused prescription stimulants to "help study" had lower odds of all mental health problems. CONCLUSIONS: While there were differences based on prescription drug class, a range of motivations increased adults' likelihood to have mental health problems and common themes were found across drug classes. While causality is still undetermined, prevention and intervention efforts that are multifaceted and individualized, while broadly providing adults with other ways to cope with negative emotions are likely to help reduce PDM.

The Prevalence of Intimate Partner Violence and Association With Depression in University Students: Results of a Cross-Sectional Study.

The purpose of this cross-sectional study was to determine the prevalence of intimate partner violence (IPV) among university students, investigate the potential predictors of IPV in this population, and study the link between IPV and depression. The survey included sociodemographic, relationship quality, and depression-related questions. From 498 respondents, the prevalence of IPV was 4.8%, depression was 30.9%, and suicidal ideation was 20.3%. After adjusting for covariates and confounders, relationship satisfaction (odds ratio [OR], 0.201; 95% confidence interval [CI], 0.101-0.401; p < 0.001) and jealousy (OR, 0.270; 95% CI, 0.094-0.776; p = 0.015) were significant predictors of IPV. Relationship satisfaction predicted depressive disorders (OR, 0.504; 95% CI, 0.365-0.698; p < 0.001). IPV trended toward predicting the presence of a depressive disorder (OR, 0.436; 95% CI, 0.170-1.113; p = 0.083). Relationship satisfaction and jealousy predicted IPV. Although IPV did not predict depression, poor relationship satisfaction increased the odds of depression, implicating the influence of relationship satisfaction on both IPV and depression.

Depression Severity and Depression Stigma Among Students: A Survey of Universities in Five Countries.

In the university setting, mental disorders have come under greater scrutiny and more attention has been given toward addressing the social stigmas associated with mental illness in an effort to promote mental well-being and improve mental health care delivery on-campus. Depression has been previously linked to a reduction in quality of life, suicidal ideation, and poor academic performance. However, few studies have directly compared the burden of depression or stigmatized views between multiple universities. As a result, this cross-sectional study of university students from five countries was performed to determine the burden of depressive disorders, the stigmatizations of beliefs related to depression, and international variation. A questionnaire consisting of a sociodemographic survey, Patient Health Questionnaire-9 (PHQ-9), and Depression Stigma Scale (DSS) was distributed via multiple routes to undergraduate and graduate students at institutions in the United States, Taiwan, United Arab Emirates, Egypt, and Czech Republic. The point prevalence of depression was determined by using the algorithm scoring method of the PHQ-9. Depression severity was determined according to the summed-item scoring method of the PHQ-9. The degree of stigmatization of beliefs was determined by continuous scores on the DSS subscales for personal and perceived stigma. Differences in depression severity, personal stigma, and perceived stigma were determined according to analysis of variance and further studied using post hoc Tukey's tests. Responses were collected from students in the United States (n = 593), United Arab Emirates (n = 134), Taiwan (n = 217), Egypt (n = 105), and Czech Republic (n = 238). Of 1287 responses, 30.7% (n = 396) screened positive for a depressive disorder: 18.0% (n = 232) for major depressive disorder and 12.7% (n = 164) for another depressive disorder. Depression severity differed internationally (p < 0.001). Emirati students significantly exhibited most depression followed by Czech, American, and Taiwanese students (all ps < 0.001). There was also a difference between students of different countries in terms of personal stigma (p < 0.001), with Emirati students holding more stigmatized personal views than Czech, American, Egyptian, and Taiwanese students (all ps < 0.001). Students similarly demonstrated differences in terms of personal stigma (p < 0.001). Egyptian students exhibited the most perceived stigma followed by Emirati, Taiwanese, American, and Czech students (all ps < 0.001). These findings suggest a high point prevalence of depression among university students and differences in the severity of depression, which has implications for the delivery of mental health care in this population. There were significant differences in terms of personal and perceived stigma between university students, indicating resource allocation for university-based campaigns to reduce depression stigma may need to be tailored to the population. After implementation of stigma reduction programs, future follow-up surveys can be done to compare degrees of stigma before and after the intervention.

The effects of safety behavior availability versus utilization on inhibitory learning during exposure.

This study re-analyzes data from Sy and colleagues (2011; Behaviour Research and Therapy, 49, 305-314) comparing safety behavior availability (SBA) to safety behavior utilization (SBU) during exposure therapy for claustrophobic concerns. The present investigation assessed differential rates of inhibitory learning (i.e. change in danger expectancy and coping self-efficacy) between SBA and SBU before, during, and after a single-session treatment. Thirty-nine participants with marked claustrophobic fear completed six consecutive 5-minute exposure trials in a claustrophobia chamber. Participants in the SBA condition exhibited more interference with inhibitory learning relative to the SBU condition. Danger expectancy was significantly higher in the SBA group and decreased at a markedly slower rate across exposure trials relative to SBU. Coping self-efficacy was also significantly lower among participants in the SBA condition, although groups demonstrated similar rates of change across trials. Limitations, clinical implications, and future directions are discussed.

Predictive Associations Among the Repeated Measurements of Anxiety, Depression, and Craving in a Dual Diagnosis Program.

Objective: Anxiety and depression commonly co-occur with substance use disorders. Conceptual models would presume that changes in anxiety and depression should lead to changes in drug and alcohol craving during treatment for co-occurring disorders, but no longitudinal investigation has explored this assumption. This study examined the associations among craving, anxiety, and depression in a dual diagnosis program. Methods: In all, 93 adult patients at a community-based dual diagnosis program for substance use disorders and comorbid anxiety and mood disorders provided daily ratings of anxiety and depression. We examined whether these ratings predicted changes in craving and vice versa. Results: Using hierarchical linear modeling to examine day-to-day change over time, we observed that anxiety and depression ratings uniquely and independently predicted subsequent craving ratings, and craving ratings also predicted subsequent anxiety and depression ratings. Conclusions: These preliminary findings support mutual maintenance models of substance use and psychiatric comorbidity, thus providing preliminary support for integrated programs that simultaneously address both problems. Implications and future directions are discussed.

Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure); however, delivery of CBT for anxiety disorders in real-world community clinics is lacking. This study utilized surveys we developed with key stakeholder feedback (patient, provider, and administrator) to assess patient and provider/administrator perceptions of the barriers to delivering (or receiving) CBT for anxiety disorders. Providers/administrators from two counties in California (N = 106) indicated lack of training/competency as primary barriers. Patients in one large county (N = 42) reported their own symptoms most often impacted treatment receipt. Both groups endorsed acceptability of exposure but indicated that its use in treatment provided/received had been limited. Implications and recommendations are discussed.

Do emotion regulation, attentional control, and attachment style predict response to cognitive behavioral therapy for anxiety disorders? - an investigation in clinical settings.

Objective: Approximately, 50% of all individuals with anxiety disorders do not benefit from the "gold standard" treatment, namely cognitive behavioral therapy (CBT). Reliable predictors of treatment effect are lacking. The primary aim of this study was to investigate the predictive value of emotion regulation, attentional control, and attachment style for group-based CBT outcomes in routine clinical settings. Method: A total of 76 patients with anxiety disorders received manual-based group CBT at psychiatric outpatient clinics. Emotion regulation, attachment style, and attentional control were assessed with self-report measures and with an experimental computer-based attentional control task at baseline. The severity of anxiety was assessed at intake, post-treatment, and at a 6-month follow-up. Results: Attentional control, emotion regulation, and attachment avoidance did not predict treatment outcomes. Higher attachment anxiety at baseline was significantly related to poorer outcome. Conclusion: In routine clinical settings, high attachment anxiety may predict poorer outcomes for group-based CBT.

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.

The Effects of Childhood and Adolescent Adversity on Substance Use Disorders and Poor Health in Early Adulthood.

Childhood and adolescent adversity have been shown to predict later mental and physical health outcomes. Understanding which aspects and developmental timings of adversity are important, and the mechanisms by which they have their impact may help guide intervention approaches. A large subset of adolescents (N = 457; Female 68.9 %) from the 10-year longitudinal Youth Emotion Project was examined to better understand the associations among childhood/adolescent adversity, substance use disorder, and later health quality. Adolescent (but not childhood) adversities were associated with poorer health in late adolescence/early adulthood, adolescent adversities were associated with subsequent onset of substance use disorder, and adolescent adversities continued to be associated with poorer health in late adolescence/early adulthood after accounting for the variance explained by substance use disorder onset. These associations were observed after statistically accounting for emotional disorders and socioeconomic status. Specific domains of adversity uniquely predicted substance use disorder and poorer health outcomes. In contrast with current recent research, our findings suggest the association between childhood/adolescent adversity and poorer health outcomes in late adolescence and emerging adulthood are not entirely accounted for by substance use disorder, suggesting efforts to curtail family-based adolescent adversity may have downstream health benefits.

Training on the DSM-5 Cultural Formulation Interview Improves Cultural Competence in General Psychiatry Residents: A Multi-site Study.

OBJECTIVE: The authors assessed whether a 1-h didactic session on the DSM-5 Cultural Formulation Interview (CFI) improves cultural competence of general psychiatry residents. METHODS: Psychiatry residents at six residency programs completed demographics and pre-intervention questionnaires, were exposed to a 1-h session on the CFI, and completed a post-intervention questionnaire. Repeated measures ANCOVA compared pre- to post-intervention change. Linear regression assessed whether previous cultural experience predicted post-intervention scores. RESULTS: Mean scores on the questionnaire significantly changed from pre- to post-intervention (p < 0.001). Previous cultural experience did not predict post-intervention scores. CONCLUSIONS: Psychiatry residents' cultural competence scores improved with a 1-h session on the CFI but with notable limitations.

Examination of anxiety sensitivity and distress tolerance as transdiagnostic mechanisms linking multiple anxiety pathologies to alcohol use problems in adolescents.

BACKGROUND: Multiple forms of anxiety psychopathology are associated with alcohol use problems in adolescents. Yet, the mechanisms underlying this association are unclear. Anxiety sensitivity (AS) and distress tolerance (DT) represent 2 distinct, conceptually relevant transdiagnostic constructs implicated in multiple manifestations of anxiety that may also underlie alcohol use problems and thereby explain why people with anxiety are more likely to have alcohol problems. METHODS: The current cross-sectional study examined whether AS and DT accounted for (i.e., statistically mediated) the relationship between manifest indicators of the 3 common anxiety phenotypes (generalized anxiety, social anxiety, and panic disorders) and alcohol problems in a sample of 534 high school students (14 to 15 years old). RESULTS: Multiple manifestations of anxiety were associated with greater alcohol use problems. AS statistically mediated multiple anxiety-alcohol associations, but DT did not. CONCLUSIONS: These findings provide preliminary evidence suggesting AS may be an important transdiagnostic target for alcohol prevention programs for those in early adolescence that experience elevated anxiety symptoms.

Family Accommodation Scale for Obsessive-Compulsive Disorder-Interviewer-Rated (FAS-IR), Brazilian Portuguese version: internal consistency, reliability, and exploratory factor analysis.

OBJECTIVE: To examine the psychometric properties of the Brazilian Portuguese version of the Family Accommodation Scale for Obsessive-Compulsive Disorder-Interviewer-Rated (FAS-IR). METHOD: A total of 114 family members of patients with obsessive-compulsive disorder (OCD) were assessed. The following analyses of the FAS-IR were carried out: internal consistency, inter-rater and test-retest reliability, and exploratory factor analysis. RESULTS: The Brazilian Portuguese version of the FAS-IR showed excellent inter-rater reliability (intraclass correlation coefficient [ICC]=0.94) and acceptable test-retest reliability (ICC=0.77), with no significant differences in FAS-IR scores. Factor analysis produced three factors for the scale. However, factor loadings were not well defined within each factor, and the factors did not have distinct constructs. Thus, a global analysis approach was chosen, revealing good internal consistency of the scale as a whole (Cronbach's α=0.805). CONCLUSIONS: The Brazilian Portuguese FAS-IR showed sound psychometric properties for the evaluation of family accommodation, and is, therefore, a reliable instrument for use in research and clinical practice.

Experiencing core symptoms of anxiety and unipolar mood disorders in late adolescence predicts disorder onset in early adulthood.

BACKGROUND: Identification of youth at risk for anxiety and unipolar mood disorders (UMDs) can improve public health by targeting those who may warrant early or preventive intervention. This study examined whether endorsing core features of anxiety and UMDs predicted onset of later anxiety and UMDs across the next 7-9 years, and whether having subthreshold or subclinical manifestations of these disorders similarly predicted onset. METHODS: Data from this study come from the Youth Emotion Project (YEP), a two-site investigation of common and specific risk factors for emotional disorders. Endorsement of core features of a disorder and subclinical or subthreshold anxiety and UMD diagnoses were determined using data from the Structured Clinical Interview for DSM-IV (SCID) at the baseline assessment. Participants completed annual SCIDs over the course of the next 7-9 years (depending on cohort). RESULTS: Endorsement of panic attacks, obsessions and/or compulsions, and depression and/or anhedonia predicted onset of panic disorder, obsessive compulsive disorder, and major depressive disorder, respectively. When including all anxiety disorders in a model, only the presence of panic attacks uniquely predicted anxiety disorder onset. The presence of subclinical or subthreshold panic disorder, obsessive compulsive disorder, and social phobia at baseline predicted the full onset of these disorders over the follow-up period. CONCLUSIONS: Experiencing some symptoms of anxiety and UMDs in the absence of meeting diagnostic criteria is indicative of risk for later onsets of clinically significant DSM manifestations of these disorders. These individuals should be identified and targeted for prevention programs.

Changes in self-efficacy and outcome expectancy as predictors of anxiety outcomes from the CALM study.

BACKGROUND: Although self-efficacy (SE) and outcome expectancy (OE) have been well researched as predictors of outcome, few studies have investigated changes in these variables across treatments. We evaluated changes in OE and SE throughout treatment as predictors of outcomes in a large sample with panic disorder, generalized anxiety disorder, social anxiety disorder, or posttraumatic stress disorder. We hypothesized that increases in SE and OE would predict reductions in anxiety and depression as well as improvement in functioning. METHODS: Participants (mean age = 43.3 years, SD = 13.2, 71.1% female, 55.5% white) were recruited from primary care centers throughout the United States and were randomized to receive either Coordinated Anxiety Learning and Management (CALM) treatment - composed of cognitive behavioral therapy, psychotropic medication, or both - or usual care. SE and OE ratings were collected at each session for participants in the CALM treatment (n = 482) and were entered into a structural equation model as predictors of changes in Brief Symptom Inventory, Anxiety Sensitivity Index, Patient Health Questionnaire (PHQ), and Sheehan Disability Scale outcomes at 6, 12, and 18 months after baseline. RESULTS: The best-fitting models predict symptom levels from OE and SE and not vice versa. The slopes and intercept of OE significantly predicted change in each outcome variable except PHQ-8. The slope and intercept of SE significantly predicted change in each outcome variable. CONCLUSION: Over and above absolute level, increases in SE and OE were significant predictors of decreases in symptoms and increases in functioning. Implications for treatment are discussed, as well as future directions of research.

Effects of the serotonin transporter polymorphism and history of major depression on overgeneral autobiographical memory.

Overgeneral autobiographical memory (OGM) is a key memory deficit in major depressive disorder (MDD). Much research has examined cognitive mechanisms underlying OGM, but little work has investigated potential neurobiological influences. There is preliminary evidence that a genetic serotonergic vulnerability coupled with depressive symptoms may be associated with other memory impairments, and experimental research suggests a role for serotonin in OGM. We investigated whether a polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was associated with OGM in interaction with a lifetime history of MDD in 370 young adults in a longitudinal study of risk for emotional disorders. There was a significant interaction between 5-HTTLPR genotype and lifetime history of MDD in predicting OGM. Among S allele homozygotes, MDD history was associated with greater OGM, whereas no significant relationship between MDD history and OGM emerged among L carriers. Furthermore, there was evidence that a greater number of S alleles were associated with greater memory specificity in individuals without a history of MDD. Implications for understanding cognitive and biological risk for depression are discussed.

Integrated behavioral treatments for comorbid anxiety and substance use disorders: A model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy.

INTRODUCTION: Substance use disorders (SUD) and anxiety disorders are highly comorbid, and this comorbidity is associated with poor clinical outcomes. Emerging research in the last decade has shifted from addressing these problems separately to the development and evaluation of behavioral treatments that integrate care for anxiety disorders (or elevated symptoms of anxiety) and SUD. METHODS: An extensive literature search revealed a sufficient number of studies (K=11) to conduct a meta-analysis comparing the efficacy of integrated SUD/anxiety disorder behavioral treatment to SUD treatment alone on substance use and anxiety symptom outcomes. Randomized clinical trials including those with SUD and either anxiety disorders or elevations in constructs implicated in the maintenance of anxiety disorder/SUD comorbidity were included. This study meta-analyzes the effects of these studies. RESULTS: Integrated treatments outperformed SUD treatments alone on both substance use and anxiety outcomes, with small to moderate effects favoring integrated treatments. There was no significant heterogeneity across studies in the primary analyses, such that moderator analyses to identify variables that yielded differential patterns of effect sizes were not conducted. DISCUSSION: Integrated treatments for SUD/anxiety disorders demonstrate an incremental but significant and clinically meaningful improvement over SUD treatment alone for SUD/anxiety disorder comorbidity. Implications for future research and clinical practice paradigm shifting are discussed.

Recent advances in the understanding and psychological treatment of social anxiety disorder.

Social anxiety disorder (SAD) is characterized by persistent anxiety or avoidance of social situations because of a fear of negative evaluation. Cognitive behavioral therapy (CBT) (typically with an exposure component) is a first-line treatment for social anxiety, but there remains room for improvement with regard to treatment efficacy. Therefore, the field continues to better understand the mechanisms underlying SAD and its common and complex comorbidities in order to develop targeted interventions to improve symptom outcomes. Additionally, efforts are under way to improve the efficacy and accessibility of CBT. This review outlines major advances in understanding and treating SAD in adults over the past roughly 3 years (2019 to early May 2022). Themes are identified and discussed, as are recommendations for future research.

A randomized controlled trial on using predictive algorithm to adapt level of psychological care for community college students: STAND triaging and adapting to level of care study protocol.

BACKGROUND: There is growing interest in using personalized mental health care to treat disorders like depression and anxiety to improve treatment engagement and efficacy. This randomized controlled trial will compare a traditional symptom severity decision-making algorithm to a novel multivariate decision-making algorithm for triage to and adaptation of mental health care. The stratified levels of care include a self-guided online wellness program, coach-guided online cognitive behavioral therapy, and clinician-delivered psychotherapy with or without pharmacotherapy. The novel multivariate algorithm will be comprised of baseline (for triage and adaptation) and time-varying variables (for adaptation) in four areas: social determinants of mental health, early adversity and life stressors, predisposing, enabling, and need influences on health service use, and comprehensive mental health status. The overarching goal is to evaluate whether the multivariate algorithm improves adherence to treatment, symptoms, and functioning above and beyond the symptom-based algorithm. METHODS/DESIGN: This trial will recruit a total of 1000 participants over the course of 5 years in the greater Los Angeles Metropolitan Area. Participants will be recruited from a highly diverse sample of community college students. For the symptom severity approach, initial triaging to level of care will be based on symptom severity, whereas for the multivariate approach, the triaging will be based on a comprehensive set of baseline measures. After the initial triaging, level of care will be adapted throughout the duration of the treatment, utilizing either symptom severity or multivariate statistical approaches. Participants will complete computerized assessments and self-report questionnaires at baseline and up to 40 weeks. The multivariate decision-making algorithm will be updated annually to improve predictive outcomes. DISCUSSION: Results will provide a comparison on the traditional symptom severity decision-making and the novel multivariate decision-making with respect to treatment adherence, symptom improvement, and functional recovery. Moreover, the developed multivariate decision-making algorithms may be used as a template in other community college settings. Ultimately, findings will inform the practice of level of care triage and adaptation in psychological treatments, as well as the use of personalized mental health care broadly. TRIAL REGISTRATION: ClinicalTrials.gov NCT05591937, submitted August 2022, published October 2022.