Maternal depression, parental attributions, and adolescent psychopathology: An evaluation using observational and video-mediated recall methods.

Parenting styles associated with maternal depression are a risk factor for adolescent psychopathology, and maternal attributional styles may be a key mechanism in this relationship. Mother-adolescent dyads (N = 180; 96 male; ages 10-15) completed in-person interactions and then the mothers participated in a video-mediated recall procedure to assess maternal attributions. Maternal depression was associated with negative attributions. Negative attributions were associated with low parental acceptance, aggressive parenting, and low positive parenting. Positive maternal attributions were associated with less aggressive parenting, and more positive parenting during one interaction task. Adolescent externalizing behaviors were associated with negative attributions. Future research should evaluate whether maternal attributions mediate the association between maternal depression and both parenting behaviors and adolescent mental health.

Sometimes It's Good to be Short: The Serotonin Transporter Gene, Positive Parenting, and Adolescent Depression.

In threatening environments, the short (S) allele of 5-HTTLPR is proposed to augment risk for depression. However, it is unknown whether 5-HTTLPR variation increases risk for depression in environments of deprivation, lacking positive or nurturant features. Two independent longitudinal studies (n = 681 and 176, respectively) examined whether 5-HTTLPR moderated associations between low levels of positive parenting at 11-13 years and subsequent depression at 17-19 years. In both studies only LL homozygous adolescents were at greater risk for depression with decreasing levels of positive parenting. Thus, while the S allele has previously been identified as a susceptible genotype, these findings suggest that the L allele may also confer sensitivity to depression in the face of specific environmental challenges.

Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression.

This study evaluated the putative mediating mechanisms of an Internet-facilitated cognitive-behavioral therapy (CBT) intervention for depression tailored to economically disadvantaged mothers of preschool-age children. The CBT mediators were tested across two previously published randomized controlled trials which included the same measures of behavioral activation, negative thinking, and savoring of positive events. Trial 1 included 70 mothers with elevated depressive symptoms who were randomized to either the eight-session, Internet-facilitated intervention (Mom-Net) or to treatment as usual. Trial 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition. Simple mediation models tested each putative mediator independently followed by tests of multiple mediation that simultaneously included all three mediators in the model to assess the salient contributions of each mediator. The pattern of results for the mediating effects were systematically replicated across the two trials and suggest that behavioral activation and negative thinking are salient mediators of the Mom-Net intervention; significant mediating effects for savoring were obtained only in the simple mediation models and were not obtained in the multiple mediation models.

Affective family interactions and their associations with adolescent depression: A dynamic network approach.

The prevalence of depression rises steeply during adolescence. Family processes have been identified as one of the important factors that contribute to affect (dys)regulation during adolescence. In this study, we explored the affect expressed by mothers, fathers, and adolescents during a problem-solving interaction and investigated whether the patterns of the affective interactions differed between families with depressed adolescents and families with nondepressed adolescents. A network approach was used to depict the frequencies of different affects, concurrent expressions of affect, and the temporal sequencing of affective behaviors among family members. The findings show that families of depressed adolescents express more anger than families of nondepressed adolescents during the interaction. These expressions of anger co-occur and interact across time more often in families with a depressed adolescent than in other families, creating a more self-sustaining network of angry negative affect in depressed families. Moreover, parents' angry and adolescents' dysphoric affect follow each other more often in depressed families. Taken together, these patterns reveal a particular family dynamic that may contribute to vulnerability to, or maintenance of, adolescent depressive disorders. Our findings underline the importance of studying affective family interactions to understand adolescent depression.

Parental autonomy granting and child perceived control: effects on the everyday emotional experience of anxious youth.

BACKGROUND: Childhood anxiety is associated with low levels of parental autonomy granting and child perceived control, elevated child emotional reactivity and deficits in child emotion regulation. In early childhood, low levels of parental autonomy granting are thought to decrease child perceived control, which in turn leads to increases in child negative emotion. Later in development, perceived control may become a more stable, trait-like characteristic that amplifies the relationship between parental autonomy granting and child negative emotion. The purpose of this study was to test mediation and moderation models linking parental autonomy granting and child perceived control with child emotional reactivity and emotion regulation in anxious youth. METHODS: Clinically anxious youth (N = 106) and their primary caregivers were assessed prior to beginning treatment. Children were administered a structured diagnostic interview and participated in a parent-child interaction task that was behaviorally coded for parental autonomy granting. Children completed an ecological momentary assessment protocol during which they reported on perceived control, emotional reactivity (anxiety and physiological arousal) and emotion regulation strategy use in response to daily negative life events. RESULTS: The relationship between parental autonomy granting and both child emotional reactivity and emotion regulation strategy use was moderated by child perceived control: the highest levels of self-reported physiological responding and the lowest levels of acceptance in response to negative events occurred in children low in perceived control with parents high in autonomy granting. Evidence for a mediational model was not found. In addition, child perceived control over negative life events was related to less anxious reactivity and greater use of both problem solving and cognitive restructuring as emotion regulation strategies. CONCLUSION: Both parental autonomy granting and child perceived control play important roles in the everyday emotional experience of clinically anxious children.

Language use in depressed and non-depressed mothers and their adolescent offspring.

BACKGROUND: Approximately 10% of mothers experience depression each year, which increases risk for depression in offspring. Currently no research has analysed the linguistic features of depressed mothers and their adolescent offspring during dyadic interactions. We examined the extent to which linguistic features of mothers' and adolescents' speech during dyadic interactional tasks could discriminate depressed from non-depressed mothers. METHODS: Computer-assisted linguistic analysis (Linguistic Inquiry and Word Count; LIWC) was applied to transcripts of low-income mother-adolescent dyads (N = 151) performing a lab-based problem-solving interaction task. One-way multivariate analyses were conducted to determine linguistic features hypothesized to be related to maternal depressive status that significantly differed in frequency between depressed and non-depressed mothers and higher and lower risk offspring. Logistic regression analyses were performed to classify between dyads belonging to the two groups. RESULTS: The results showed that linguistic features in mothers' and their adolescent offsprings' speech during problem-solving interactions discriminated between maternal depression status. Many, but not all effects, were consistent with those identified in previous research using primarily written text, highlighting the validity and reliability of language behaviour associated with depressive symptomatology across lab-based and natural environmental contexts. LIMITATIONS: Our analyses do not enable to ascertain how mothers' language behaviour may have influenced their offspring's communication patterns. We also cannot say how or whether these findings generalize to other contexts or populations. CONCLUSION: The findings extend the existing literature on linguistic features of depression by indicating that mothers' depression is associated with linguistic behaviour during mother-adolescent interaction.

Engagement, Acceptability, and Effectiveness of the Self-Care and Coach-Supported Versions of the Vira Digital Behavior Change Platform Among Young Adults at Risk for Depression and Obesity: Pilot Randomized Controlled Trial.

BACKGROUND: Adolescence and early adulthood are pivotal stages for the onset of mental health disorders and the development of health behaviors. Digital behavioral activation interventions, with or without coaching support, hold promise for addressing risk factors for both mental and physical health problems by offering scalable approaches to expand access to evidence-based mental health support. OBJECTIVE: This 2-arm pilot randomized controlled trial evaluated 2 versions of a digital behavioral health product, Vira (Ksana Health Inc), for their feasibility, acceptability, and preliminary effectiveness in improving mental health in young adults with depressive symptoms and obesity risk factors. METHODS: A total of 73 participants recruited throughout the United States were randomly assigned to use Vira either as a self-guided product (Vira Self-Care) or with support from a health coach (Vira+Coaching) for 12 weeks. The Vira smartphone app used passive sensing of behavioral data related to mental health and obesity risk factors (ie, activity, sleep, mobility, and language patterns) and offered users personalized insights into patterns of behavior associated with their daily mood. Participants completed self-reported outcome measures at baseline and follow-up (12 weeks). All study procedures were completed via digital communications. RESULTS: Both versions of Vira showed strong user engagement, acceptability, and evidence of effectiveness in improving mental health and stress. However, users receiving coaching exhibited more sustained engagement with the platform and reported greater reductions in depression (Cohen d=0.45, 95% CI 0.10-0.82) and anxiety (Cohen d=0.50, 95% CI 0.13-0.86) compared to self-care users. Both interventions also resulted in reduced stress (Vira+Coaching: Cohen d=-1.05, 95% CI -1.57 to --0.50; Vira Self-Care: Cohen d=-0.78, 95% CI -1.33 to -0.23) and were perceived as useful and easy to use. Coached users also reported reductions in sleep-related impairment (Cohen d=-0.51, 95% CI -1.00 to -0.01). Moreover, participants increased their motivation for and confidence in making behavioral changes, with greater improvements in confidence among coached users. CONCLUSIONS: An app-based intervention using passive mobile sensing to track behavior and deliver personalized insights into behavior-mood associations demonstrated feasibility, acceptability, and preliminary effectiveness for reducing depressive symptoms and other mental health problems in young adults. Future directions include (1) optimizing the interventions, (2) conducting a fully powered trial that includes an active control condition, and (3) testing mediators and moderators of outcome effects. TRIAL REGISTRATION: ClinicalTrials.gov NCT05638516; https://clinicaltrials.gov/study/NCT05638516.

Maternal parenting behaviors and adolescent depression: the mediating role of rumination.

Substantial evidence suggests that rumination is an important vulnerability factor for adolescent depression. Despite this, few studies have examined environmental risk factors that might lead to rumination and, subsequently, depression in adolescence. This study examined the hypothesis that an adverse family environment is a risk factor for rumination, such that the tendency to ruminate mediates the longitudinal association between a negative family environment and adolescent depressive symptoms. It also investigated adolescent gender as a moderator of the relationship between family environment and adolescent rumination. Participants were 163 mother-adolescent dyads. Adolescents provided self-reports of depressive symptoms and rumination across three waves of data collection (approximately at ages 12, 15, and 17 years). Family environment was measured via observational assessment of the frequency of positive and aggressive parenting behaviors during laboratory-based interactions completed by mother-adolescent dyads, collected during the first wave. A bootstrap analysis revealed a significant indirect effect of low levels of positive maternal behavior on adolescent depressive symptoms via adolescent rumination, suggesting that rumination might mediate the relationship between low levels of positive maternal behavior and depressive symptoms for girls. This study highlights the importance of positive parenting behaviors as a possible protective factor against the development of adolescent rumination and, subsequently, depressive symptoms. One effective preventive approach to improving adolescent mental health may be providing parents with psychoeducation concerning the importance of pleasant and affirming interactions with their children.

Multimodal Feature Selection for Detecting Mothers' Depression in Dyadic Interactions with their Adolescent Offspring.

Depression is the most common psychological disorder, a leading cause of disability world-wide, and a major contributor to inter-generational transmission of psychopathology within families. To contribute to our understanding of depression within families and to inform modality selection and feature reduction, it is critical to identify interpretable features in developmentally appropriate contexts. Mothers with and without depression were studied. Depression was defined as history of treatment for depression and elevations in current or recent symptoms. We explored two multimodal feature selection strategies in dyadic interaction tasks of mothers with their adolescent children for depression detection. Modalities included face and head dynamics, facial action units, speech-related behavior, and verbal features. The initial feature space was vast and inter-correlated (collinear). To reduce dimensionality and gain insight into the relative contribution of each modality and feature, we explored feature selection strategies using Variance Inflation Factor (VIF) and Shapley values. On an average collinearity correction through VIF resulted in about 4 times feature reduction across unimodal and multimodal features. Collinearity correction was also found to be an optimal intermediate step prior to Shapley analysis. Shapley feature selection following VIF yielded best performance. The top 15 features obtained through Shapley achieved 78% accuracy. The most informative features came from all four modalities sampled, which supports the importance of multimodal feature selection.

Language Use in Mother-Adolescent Dyadic Interaction: Preliminary Results.

This preliminary study applied a computer-assisted quantitative linguistic analysis to examine the effectiveness of language-based classification models to discriminate between mothers (n = 140) with and without history of treatment for depression (51% and 49%, respectively). Mothers were recorded during a problem-solving interaction with their adolescent child. Transcripts were manually annotated and analyzed using a dictionary-based, natural-language program approach (Linguistic Inquiry and Word Count). To assess the importance of linguistic features to correctly classify history of depression, we used Support Vector Machines (SVM) with interpretable features. Using linguistic features identified in the empirical literature, an initial SVM achieved nearly 63% accuracy. A second SVM using only the top 5 highest ranked SHAP features improved accuracy to 67.15%. The findings extend the existing literature base on understanding language behavior of depressed mood states, with a focus on the linguistic style of mothers with and without a history of treatment for depression and its potential impact on child development and trans-generational transmission of depression.

Maternal and adolescent temperament as predictors of maternal affective behavior during mother-adolescent interactions.

This study examined maternal and early adolescent temperament dimensions as predictors of maternal emotional behavior during mother-adolescent interactions. The sample comprised 151 early adolescents (aged 11-13) and their mothers (aged 29-57). Adolescent- and mother-reports of adolescent temperament and self-reports of maternal temperament were collected. Mother-adolescent dyads participated in event-planning and problem-solving interactions, which were coded for frequency of aggressive, dysphoric, and positive interpersonal maternal behavior. Analyses indicated that adolescents who are higher in temperamental Negative Affectivity and lower in Effortful Control are generally exposed to more frequent aggressive and less frequent positive interpersonal maternal behavior. Furthermore, mothers lower in Effortful Control engaged in more frequent dysphoric behavior toward their adolescent. Given the associations between parental emotional behavior and the development of adolescent emotion regulation, these findings suggest that temperamental dispositions, particularly of early adolescents, may influence their ongoing socialization of emotion regulation skills, and thus their emotional well being.

How do I feel about feelings? Emotion socialization in families of depressed and healthy adolescents.

Emotional and cognitive changes that occur during adolescence set the stage for the development of adaptive or maladaptive beliefs about emotions. Although research suggests that parents' behaviors and beliefs about emotions relate to children's emotional abilities, few studies have looked at parental socialization of children's emotions, particularly in families with depressed adolescents. The present study examined associations between parent and adolescent meta-emotion philosophies (MEP), defined as thoughts, reactions, and feelings about their own emotions. Additionally, adolescent depressive status was tested as a moderator of relationships between parents' and adolescents' MEP. One hundred and 52 adolescents, aged 14-18 (65.8% female), and their parents (148 mothers, 106 fathers) participated in a study on emotion socialization in families of depressed and healthy adolescents. Depressed adolescents (n = 75) and matched healthy adolescents (n = 77) were recruited based on research criteria for mental health status. The sample was largely Caucasian (82%) and of middle socioeconomic class status. Results indicated that mothers' and fathers' MEP about their children's emotions were associated with adolescents' MEP, although parents' MEP about their own emotions was unrelated to adolescents' MEP. Fathers' MEP about children's emotions made unique contributions to adolescents' MEP across both adolescent groups. Adolescents' depressive status moderated the relationship between mothers' and adolescents' MEP such that mothers' MEP was particularly relevant for depressed adolescents. The continued influence of parents in the emotional lives of adolescents is discussed as well as differences in emotion socialization in families with depressed and healthy adolescents.

Human-Guided Modality Informativeness for Affective States.

This paper studies the hypothesis that not all modalities are always needed to predict affective states. We explore this hypothesis in the context of recognizing three affective states that have shown a relation to a future onset of depression: positive, aggressive, and dysphoric. In particular, we investigate three important modalities for face-to-face conversations: vision, language, and acoustic modality. We first perform a human study to better understand which subset of modalities people find informative, when recognizing three affective states. As a second contribution, we explore how these human annotations can guide automatic affect recognition systems to be more interpretable while not degrading their predictive performance. Our studies show that humans can reliably annotate modality informativeness. Further, we observe that guided models significantly improve interpretability, i.e., they attend to modalities similarly to how humans rate the modality informativeness, while at the same time showing a slight increase in predictive performance.

Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis.

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures: Patient Health Questionnaire-9 (PHQ-9) scores. Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.

Emotional inertia and psychological maladjustment.

In this article, we examine the concept of emotional inertia as a fundamental property of the emotion dynamics that characterize psychological maladjustment. Emotional inertia refers to the degree to which emotional states are resistant to change. Because psychological maladjustment has been associated with both emotional underreactivity and ineffective emotion-regulation skills, we hypothesized that its overall emotion dynamics would be characterized by high levels of inertia. We provide evidence from two naturalistic studies that, using different methods, showed that the emotional fluctuations of individuals who exhibited low self-esteem (Study 1) and depression (Study 2) were characterized by higher levels of inertia in both positive and negative emotions than the emotional fluctuations of people who did not exhibit low self-esteem and depression. We also discuss the usefulness of the concept of emotional inertia as a hallmark of maladaptive emotion dynamics.

Positive affect between close friends: Brain-behavior associations during adolescence.

Identifying the neural correlates of positive interactions between friendship dyads may provide insights into mechanisms associated with adolescent social development. Forty-eight 14- to 18-year-old typically developing adolescents were video-recorded discussing a shared positive event with a close friend and subsequently viewed clips during an fMRI scan of that friend during the interaction and of an unfamiliar peer in a similar interaction. Adolescents also reported on their positive affect in daily life while with friends using ecological momentary assessment. We used multivariate repeated measures models to evaluate how positive affect with friends in the laboratory and in daily life was associated with neural response to friend and stranger positive and neutral clips. Adolescents who exhibited more positive affect when with friends in the laboratory showed less dorsolateral prefrontal cortex to friend positive clips. More positive affect when with friends in daily life was associated with less bilateral anterior insula response to friend positive clips, but greater left anterior insula response to stranger positive clips. Findings provide information on the role of lateral prefrontal cortex and anterior insula in enjoyment of friendships during adolescence.

Minding the Gatekeepers: Referral and Recruitment of Postpartum Mothers with Depression into a Randomized Controlled Trial of a Mobile Internet Parenting Intervention to Improve Mood and Optimize Infant Social Communication Outcomes.

Mothers in the United States (U.S.) who are of non-dominant culture and socioeconomically disadvantaged experience depression during postpartum at a rate 3 to 4 times higher than mothers in the general population, but these mothers are least likely to receive services for improving mood. Little research has focused on recruiting these mothers into clinical intervention trials. The purpose of this article is to report on a study that provided a unique context within which to view the differential success of three referral approaches (i.e., community agency staff referral, research staff referral, and maternal self-referral). It also enabled a preliminary examination of whether the different strategies yielded samples that differed with regard to risk factors for adverse maternal and child outcomes. The examination took place within a clinical trial of a mobile intervention for improving maternal mood and increasing parent practices that promote infant social communication development. The sample was recruited within the urban core of a large southern city in the U.S. and was comprised primarily of mothers of non-dominant culture, who were experiencing severe socioeconomic disadvantage. Results showed that mothers self-referred at more than 3.5 times the rate that they were referred by either community agency staff or research staff. Moreover, compared to women referred by research staff, women who self-referred and those who were referred by community gatekeepers were as likely to eventually consent to study participation and initiate the intervention. Results are discussed with regard to implications for optimizing referral into clinical intervention trials.

Exploratory Factor Analysis of Observational Parent-Child Interaction Data.

The majority of studies using observational coding systems for family interaction data derive scales describing family members' behaviors based on rational/theoretical approaches. This study explored an empirical approach to identifying the component structure of parent-child observational data that incorporated the affective context of the interaction. Dyads of 155 typically developing 8-year-olds and their mothers completed questionnaires and two interaction tasks, one each designed to illicit positive and negative interactions. Behaviors were coded based on a modified version of the Family Interaction Macro-coding System. Multiple factor analysis identified four-component solutions for the maternal and child data. For both, two of the components included negative behaviors, one positive behavior, and one communicative behavior. Evidence for the validity of the maternal and child components was demonstrated by associations with child depression and anxiety symptoms and behavioral problems. Preliminary evidence supports an empirical approach to identify context-specific components in parent-child observational data.

Dynamics of affective experience and behavior in depressed adolescents.

BACKGROUND: Depression is often characterized as a disorder of affect regulation. However, research focused on delineating the key dimensions of affective experience (other than valence) that are abnormal in depressive disorder has been scarce, especially in child and adolescent samples. As definitions of affect regulation center around processes involved in initiating, maintaining, and modulating the occurrence, intensity, and duration of affective experiences, it is important to examine the extent to which affective experiences of depressed youth differ on these dimensions from those of healthy youth. METHODS: The affective behavior and experience of adolescents with major depressive disorder (MDD; n = 75) were compared to a demographically matched cohort of healthy adolescents (n = 77). Both samples were recruited from community high schools. A multi-source (parents and adolescent), multi-method (interviews, behavioral observations, questionnaires) assessment strategy was used to examine positive and negative affects. RESULTS: Depressed youth had significantly longer durations, higher frequency, and greater intensity when experiencing angry and dysphoric affects and shorter durations and less frequency of happy affect when compared to healthy youth. The most consistent, cross-method results were evident for duration of affect. CONCLUSIONS: Clinically depressed adolescents experienced disturbances in affective functioning that were evident in the occurrence, intensity, and duration of affect. Notably, the disturbances were apparent in both positive and negative affects.

Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis.

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.