The effect of age on emotion processing in individuals with mood disorders and in healthy individuals.

Introduction: Emotion processing is an essential part of interpersonal relationships and social interactions. Changes in emotion processing have been found in both mood disorders and in aging, however, the interaction between such factors has yet to be examined in detail. This is of interest due to the contrary nature of the changes observed in existing research - a negativity bias in mood disorders versus a positivity effect with aging. It is also unclear how changes in non-emotional cognitive function with aging and in mood disorders, interact with these biases. Methods and results: In individuals with mood disorders and in healthy control participants, we examined emotional processing and its relationship to age in detail. Data sets from two studies examining facial expression recognition were pooled. In one study, 98 currently depressed individuals (either unipolar or bipolar) were compared with 61 healthy control participants, and in the other, 100 people with bipolar disorder (in various mood states) were tested on the same facial expression recognition task. Repeated measures analysis of variance was used to examine the effects of age and mood disorder diagnosis alongside interactions between individual emotion, age, and mood disorder diagnosis. A positivity effect was associated with increasing age which was evident irrespective of the presence of mood disorder or current mood episode. Discussion: Results suggest a positivity effect occurring at a relatively early age but with no evidence of a bias toward negative emotions in mood disorder or specifically, in depressed episodes. The positivity effect in emotional processing in aging appears to occur even within people with mood disorders. Further research is needed to understand how this fits with negative biases seen in previous studies in mood disorders.

Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating.

OBJECTIVE: This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy. METHOD: Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores. RESULTS: Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores. CONCLUSION: Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Establishing and sustaining high-quality services for people with young onset dementia: the perspective of senior service providers and commissioners.

OBJECTIVES: We aimed to understand the facilitators to developing and sustaining high-quality services for people with young onset dementia (YOD) and their families/supporters. DESIGN: This qualitative study used semi-structured interviews with commissioners and service managers, analyzed using inductive thematic analysis. SETTING: A purposive sample of providers was selected from diverse areas and contrasting YOD services. PARTICIPANTS: Eighteen senior staff from YOD services and two dementia service commissioners took part. MEASUREMENTS: For commissioners, key interview topics were experiences of commissioning YOD services, perceived facilitators or barriers, and how future guidance should be structured for ease of use. For service providers, key topics explored experiences of delivering YOD services; what was achievable or challenging; how the service was funded; how it linked with broader provision for YOD in the area; and how guidance should be structured. RESULTS: Recorded interviews lasted 30-40 minutes. Seven key facilitators to the development and sustaining of YOD services were identified: having knowledgeable, committed local champions; involvement of people living with YOD and family supporters; initial delivery within existing resources; partnership working within and between sectors; having a reflective, supportive organizational culture; gathering evidence of impact; and having wider support and guidance. CONCLUSIONS: Improvements in provision for those with YOD and their families need to be built on understanding of service-level and interpersonal influences as well as on understanding of YOD itself. Our findings highlight a set of facilitators which need to be in place to establish and sustain high-quality YOD services that fit the local context.

A Tale of Childhood Loss, Conditional Acceptance and a Fear of Abandonment: A Qualitative Study Taking a Narrative Approach to Eating Disorders.

Eating disorders (EDs) are serious mental health illnesses, yet there is a need to better understand the illness experience to improve treatment outcomes. Qualitative research, and narrative approaches in particular, can elicit life stories that allow for the whole illness journey to be explored. This study aimed to explore the experiences of women with a history of an ED, identifying the life events they perceived were relevant to the onset of their ED through to recovery. Interviews were conducted with 18 women with lived experience of an ED. Through structural narrative analysis, an overarching storyline of childhood loss contributing to a belief of conditional acceptance, fear of abandonment and struggle to seek emotional support due to the fear of being a burden was identified. Negative experiences with the health sector were common. These findings have implications for the way medical professionals respond to help seeking and deliver treatment.

Beliefs About Traumatic Memories, Thought Control Strategies, and the Impact on PTSD Symptoms After a Natural Disaster.

ABSTRACT: This study aimed to investigate the relationships among self-reported meta-memory beliefs, thought control strategies ( i.e. , distraction, reappraisal, worry, social control, and punishment), and posttraumatic stress disorder (PTSD) symptomology, among a sample of earthquake survivors ( N = 412). Correlational analysis and structural equation modeling were used on the responses and showed that stronger positive and negative meta-memory beliefs, and greater worry and punishment, were associated with greater PTSD symptom severity. The results also indicated that meta-memory beliefs had a prominent indirect influence toward PTSD symptomology via their effects toward thought control strategies. Follow-up analysis of variance indicated that those with a history of mental health difficulties reported higher levels of PTSD symptom severity, were more likely to score in the range of clinically relevant PTSD, and had a stronger tendency to negatively appraise unwanted thinking styles. The results of this research provide overall support for the validity of the metacognitive model for PTSD.

Validation of the Longitudinal Interval Follow-Up Evaluation for the Long-Term Measurement of Mood Symptoms in Bipolar Disorder.

The long-term burden of symptoms is an important outcome in bipolar disorder (BD). A method which has minimal burden of assessment uses a retrospective interview, the Longitudinal Interval Follow-up Examination (LIFE), although this may be subject to problems with recall. This study examines the relationship between the retrospective LIFE scale and concurrently-rated mood rating scales in two clinical trials of 18 months of psychotherapy for patients with BD. The Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) were administered every eight to nine weeks and the LIFE was carried out every 6 months. Correlations between scores on mood rating scales and at equivalent times on the LIFE were examined, as well as of potential clinical moderators. There were significant correlations between LIFE depression ratings and concurrent MADRS score (r = 0.57) and between LIFE mania ratings and YMRS score (r = 0.40). In determining "mild depression" on the MADRS, a receiver operating characteristics (ROC) analysis showed an AUC of 0.78 for LIFE scores. Correlations, particularly for depression scores, were high even when the LIFE rating was several months before the interview, suggesting that the LIFE has validity in examining the burden of mood symptoms over time, with relatively little burden of assessment. Future research should examine the relationship between symptom burden and quality of life measured in this way.

Relationship between baseline cognition and 18-month treatment response in bipolar disorder.

BACKGROUND: To date, few studies have examined baseline cognitive function as a predictor of clinical outcome following treatment in bipolar disorder (BD). The aim of this analysis was therefore to examine the relationship between baseline cognitive function and treatment outcome in a sample of young adults with BD receiving Interpersonal Social Rhythm Therapy (IPSRT) or Specialist Supportive Care (SSC) with adjunctive pharmacotherapy. METHODS: Eighty-six BD patients underwent baseline cognitive testing and completed 18 months of IPSRT or SCC. Univariate analyses examined the relationship between baseline cognitive function (global and individual cognitive domains) and change in mood symptom burden, and psychosocial functioning, from baseline to treatment-end. RESULTS: Baseline global cognition was not predictive of change in mood symptom burden over 18 months of treatment. However, poorer baseline psychomotor speed performance was associated with less improvement in mood symptom burden at treatment-end. Neither baseline global cognition nor individual cognitive domain scores were associated with change in psychosocial functioning. LIMITATIONS: Due to the exploratory nature of the study, correction was not made for multiple comparisons. Data was obtained from a relatively small sample and has been the subject of prior analysis, thereby increasing the likelihood of chance findings. CONCLUSION: Although global cognition was not associated with outcome, when examining individual domains, poorer baseline psychomotor speed predicted less change in mood symptom burden following 18-months of psychotherapy and pharmacotherapy. This suggests that pre-treatment measures of psychomotor speed may help to identify those who require additional, and more targeted, intervention. Further large-scale research is required.

Nutrition interventions for youth with dyslipidemia: a National Lipid Association clinical perspective.

A heart-healthy lifestyle, beginning at an early age and sustained throughout life, may reduce risk for cardiovascular disease in youth. Among youth with moderate to severe dyslipidemia and/or those with familial hypercholesterolemia, lipid-lowering medications are often needed for primary prevention of cardiovascular disease. However, lifestyle interventions are a foundation for youth with dyslipidemia, as well as those without dyslipidemia. There are limited data supporting the use of dietary supplements in youth with dyslipidemia at this time. A family-centered approach and the support of a multi-disciplinary healthcare team, which includes a registered dietitian nutritionist to provide nutrition counseling, provides the best opportunity for primary prevention and improved outcomes. While there are numerous guidelines that address the general nutritional needs of youth, few address the unique needs of those with dyslipidemia. The goal of this National Lipid Association Clinical Perspective is to provide guidance for healthcare professionals caring for youth with disorders of lipid and lipoprotein metabolism, including nutritional guidance that complements the use of lipid lowering medications.

Lessons learnt from delivering the public and patient involvement forums within a younger onset dementia project.

Including the 'voices' of people living with dementia in a meaningful way is pivotal in shaping local, national and international health and social dementia care research. The Alzheimer's Society (United Kingdom) funded Angela Project (2016-19) was aimed at improving the diagnosis and post-diagnostic support for younger people living with dementia. From the outset, the Project Team ensured that the knowledge and expertise of people living with a younger onset dementia was integral to all decisions taken in respect to overall project design, implementation, and dissemination processes. This was achieved by establishing two project public and patient involvement (PPI) forums; a London PPI Forum and a Bradford-based local PPI Hub. This paper describes how the two groups were formed; the format of the meetings; and the key points learnt by the Project Team from involving people with dementia in all aspects of developing and delivering the Angela Project. Ultimately, the aim is to demonstrate to other researchers in the dementia field how the perspectives of those with a diagnosis can be included in research studies in an active and meaningful way.

Modified metacognitive therapy for anorexia nervosa: An open trial in an outpatient setting.

OBJECTIVE: Current evidence indicates treatment for adults with anorexia nervosa (AN) requires improvement given recovery rates are low to moderate, and relapse rates are high. Metacognitive therapy (MCT) is an effective treatment for anxiety and depressive disorders. This study evaluates if MCT can be successfully modified to treat AN in a naturalistic clinical setting. METHOD: Twenty-four patients with AN participated in an open trial of modified metacognitive therapy (MCT-AN). Twelve of the 24 patients (50%) completed treatment. MCT was modified to include components specific to eating disorders. The MCT-AN was delivered by clinical psychologists who had undertaken training in MCT in a specialist outpatient service. Group and single participant data analyses were undertaken on those who completed treatment. RESULTS: As well as statistically significant differences from pre- to posttreatment in the group data there were also clinically significant improvements at the individual patient level for eating disorder and depressive symptoms, as well as weight. The mean number of therapy sessions was 18. DISCUSSION: These findings indicate that MCT-AN may be a promising intervention in the treatment of AN, warranting further investigation. PUBLIC SIGNIFICANCE: Treatment for anorexia nervosa in adults requires improvement. Research indicates that Metacognitive therapy (MCT) is an effective treatment for anxiety and depression and may be applicable to the eating disorders. This small open trial suggests that MCT can be modified successfully to treat patients with anorexia nervosa (AN). The results are preliminary and require further research to provide more evidence on the effectiveness of this treatment for AN.

The effect of temperament and character on body dissatisfaction in women with bulimia nervosa: The role of low self-esteem and depression.

OBJECTIVE: Although personality traits have been found to be associated with body dissatisfaction for women in the general population, little research has explored these associations for people with eating disorders. Furthermore, it is unknown whether these associations are direct or are mediated by other factors. In this cross-sectional study, secondary analyses of data from two clinical trials were conducted to determine which personality dimensions contributed to body dissatisfaction in women with bulimia nervosa, and whether low self-esteem and depression mediate these associations independently or in serial. METHOD: Participants were 193 women with bulimia nervosa. Participants completed self-report measures of temperament and character, body dissatisfaction, low self-esteem, and depression before receiving treatment for their eating disorder. RESULTS: The temperament dimension, harm avoidance, contributed significantly to body dissatisfaction. Serial mediation analyses showed this association was fully mediated, revealing two significant indirect effects. The first was through low self-esteem and the second through depression and low self-esteem in serial. CONCLUSIONS: Findings suggest body dissatisfaction in women with bulimia nervosa may be indirectly targeted through addressing harm avoidance, depression and low self-esteem.

Perceptions of Divine Forgiveness, Religious Comfort, and Depression in Psychiatric Inpatients: A Mixed Methods Study.

Understanding how forgiveness relates to mental health outcomes may improve clinical care. This study assessed 248 adult psychiatric inpatients, testing associations of forgiveness, religious comfort (RC), religious strain (RS), and changes in depressive symptomatology from admission to discharge. Experiencing divine forgiveness and self-forgiveness was both directly associated with RC and inversely associated with RS. Using structural equation modeling, the path from divine forgiveness to depression through RC was significant, ß = - .106, SE = .046, z = - 2.290, p = .022, bootstrapped 95% CI = - .196 to - .015. Qualitative findings illustrated patients' changed perspectives on divine forgiveness during hospitalization.

Specialist supportive clinical management for anorexia nervosa: Analysis of therapy content and relation to outcome.

OBJECTIVE: Psychotherapy for anorexia nervosa (AN) is complex and multifaceted, with little known about likely effective components of treatments. The current study explored the spoken content of specialist supportive clinical management (SSCM) for AN, a treatment with evidence of effectiveness in several randomized clinical trials. METHOD: One hundred seventy-eight therapy sessions constituting all ten therapist-patient dyads of those who completed SSCM treatment in the original clinical trial of SSCM, were transcribed verbatim. Themes were developed and content analyzed using qualitative content analysis of complete therapy sessions by four analysts, with 10% of sessions cocoded for interrater agreement. RESULTS: Over three quarters of session content was within the clinical management theme, the largest subtheme relating to normalizing eating, followed by weight, mechanics of SSCM, and encouragement of self-care. Approximately 20% of total content was in the supportive psychotherapy theme, half about relationships. The relative proportion of clinical management content remained high, decreasing during the last five sessions. Those achieving good outcome did not have a lower ratio of clinical management to supportive psychotherapy content. DISCUSSION: The current study revealed strong clinical management focus on core symptoms of AN-normalization of eating and weight gain-throughout SSCM for AN. PUBLIC SIGNIFICANCE: Six clinical trials have found SSCM to be effective in treating AN. Content of SSCM sessions in the original trial was classified using qualitative content analysis. Study findings revealed strong clinical management focus on core AN symptoms-normalization of eating and weight gain-throughout SSCM, with the ratio of clinical management to supportive psychotherapy greater for those with a good outcome.

The metacognitive model of post-traumatic stress disorder and metacognitive therapy for post-traumatic stress disorder: A systematic review.

The metacognitive model of post-traumatic stress disorder (PTSD) implicates metacognitive beliefs, meta-memory beliefs and metacognitive control strategies in perpetuating and maintaining symptoms of PTSD. Despite this expanding area of research, the evidence for the metacognitive model of PTSD has not been reviewed. A systematic review according to the PRISMA statement was conducted. Searches across MEDLINE, PubMed and PsycNET, as well as reference lists of the included studies (2004 to March 2020), yielded 221 records. Two independent reviewers screened articles, which were included where the impact of the constructs of interest on PTSD symptoms was investigated within the framework of the metacognitive model for PTSD. Eighteen articles were included in the review. Eleven studies were determined to have good methodological robustness. Metacognitive therapy for PTSD demonstrated reductions in symptoms from pretreatment to post-treatment, which were maintained at follow-up. Predictors of greater PTSD symptom severity included metacognitive beliefs, meta-memory beliefs, and worry, punishment, thought suppression, experiential avoidance, and rumination. Overall, support was found for the validity of the metacognitive model of PTSD.

Helpful post-diagnostic services for young onset dementia: Findings and recommendations from the Angela project.

There is a significant lack of evidence regarding optimum models for service provision in young onset dementia (YOD). Our study aim was to gather detailed information about services experienced as helpful by those with YOD and family carers. The objective was to identify the core features of these services to inform service design, delivery and improvements. A qualitative approach based on appreciative inquiry was used, posing open-ended questions about services experienced as helpful, as part of a national UK survey of people with YOD and carers. We used inductive thematic analysis to analyse the free-text responses. The resulting template was used as a basis for analysis of in-depth follow-up interviews, conducted to acquire greater in-depth understanding. Two hundred and thirty-three survey respondents provided 856 examples of helpful support. Twenty-four follow-up interviews were conducted (two with dyads, so 26 participants in total: 8 with people with YOD, 14 with carers, 2 with dyads). Twelve themes capturing the features of helpful services were clustered into three super-ordinate themes. 'Person-centredness' reflects micro levels of person-professional interaction (positive attitude, flexibility, collaborative, user-friendly materials, and in-person). 'Functional consistency' captures the meso level, demonstrating that services were helpful when organised consistently with needs (age-appropriate, holistic, responsive, and accessible). 'Organisational coherence', at the macro level, emphasises the need for service integration, specialist services and service continuity. Key conclusions are that the needs for flexibility and a collaborative stance may be particularly important for those under 65 years with dementia, who have full lives and are used to being in control; to be age-appropriate, helpful services need to provide activities and opportunities suitable for active middle-aged people; and to be holistic, services need to provide for needs associated with rare dementias and be family-centred. Specialist services need to be commissioned and arrangements need to be stable over time to enable continuity.

Long-term efficacy of metacognitive therapy and cognitive behaviour therapy for depression.

OBJECTIVE: To examine the two-year outcomes for depression, anxiety, cognitive and global social functioning after cognitive behavioural therapy (CBT) and metacognitive therapy (MCT) for depression. METHOD: Participants were 31 adults with a diagnosis of major depressive disorder in a randomised pilot study comparing MCT and CBT. Therapy modality differences in change in depression and anxiety symptoms, dysfunctional attitudes, metacognitions, rumination, worry and global social functioning were examined at the two-year follow-up for those who completed therapy. RESULTS: Significant improvements, with large effect sizes, were evident for all outcome variables. There were no significant differences in outcome between CBT and MCT. The greatest change over time occurred for depression and anxiety. Large changes were evident for metacognitions, rumination, dysfunctional attitudes, worry and global social functioning. Sixty-seven percent had not experienced a major depression and had been well during all of the past year, prior to the follow-up assessment. CONCLUSION: The finding at end treatment, of no modality specific differences, was also evident at two-year follow-up. Although CBT and MCT targeted depression, improvements were much wider, and although CBT and MCT take different approaches, both therapies produced positive change over time across all cognitive variables. CBT and MCT provide treatment options, that not only improve the longer-term outcome of depression, but also result in improvements in anxiety, global social functioning and cognitive status.

Personality traits and night eating syndrome in women with bulimia nervosa and binge eating disorder.

PURPOSE: Previous research suggests that eating disorders may be associated with certain personality profiles; however, there is limited research investigating associations with night eating syndrome (NES). This research suggests harm avoidance personality trait is higher in NES individuals than in the general population, however, evidence of associations with other personality traits is inconsistent. To understand which personality traits are associated with NES symptoms, the current study aimed to improve understanding of the relationship between NES symptoms and a range of personality traits, addressing limitations in the earlier literature in this area by controlling for common confounders. METHODS: Baseline data were analysed from an outpatient psychotherapy trial for 111 women with bulimia nervosa or binge eating disorder. Pre-treatment measures of personality traits (measured with the Temperament and character inventory-revised) and NES symptoms (measured with the Night eating questionnaire) were used. Regression analyses tested associations between these variables, adjusting for potential confounders, including age and ethnicity. RESULTS: Low cooperativeness scores were associated with greater NES symptoms in the multivariable model (mean difference: - 0.10, 95% confidence intervals: - 0.20 to - 0.01, p = 0.033). There was weak evidence of associations between both high harm avoidance and low self-directedness personality traits and greater NES symptoms. CONCLUSIONS: This study adds to the limited research measuring associations between a range of personality traits and NES, addressing limitations of previous research. Weak evidence for an association between high harm avoidance and low self-directedness and increased NES symptoms was found. A novel association was found between low cooperativeness and greater NES symptoms. Further research is needed to validate its presence in those with and without comorbid eating disorders and to examine the relative change in NES, eating disorder symptoms and personality scores in treatments focusing on cooperativeness. LEVEL OF EVIDENCE: Level IV (cross-sectional data from a randomised controlled trial, CTB/04/08/139).

Current UK clinical practice in diagnosing dementia in younger adults: compliance with quality indicators in electronic health records from mental health trusts.

OBJECTIVES: To examine current UK practice in diagnosis of patients under 65 with young onset dementia, within 5 years of date of diagnosis, identified from electronic health records of 8 NHS mental health trusts. METHODS: Patients diagnosed with young onset dementia were assembled from the UK-Clinical Record Interactive System, (UK-CRIS) using diagnosis of dementia as the index date. A pre-designed proforma, derived by international Delphi consensus from experts in the field in previous work, was used to assess components of the diagnostic assessment in 402 electronic health records across 8 NHS sites. Information was extracted on key aspects of clinical and physical examination according to both a minimum and gold standard. RESULTS: Percentage compliance rates analysed by NHS site and statement, including compliance for site for minimum standard (11 statements), the additional 20 statements required for Gold standard, and the complete Gold standard set (31 statements) show that the additional 20 statements in the Gold standard had consistently higher compliance rates for every site compared to the minimum set. CONCLUSION: Findings confirmed variation in clinical practice and identified commonly missed items in examination and enquiry compared to expert consensus. This suggests that a template proforma, which contains the key indicators for comprehensive assessment of dementia in young adults according to a quality standard could help support clinicians to improve record keeping and reduce gaps in knowledge.

The five year outcome of major depression: Effects of baseline variables and type of treatment.

BACKGROUND: Depression is commonly a relapsing or chronic disorder. Long-term outcome is therefore important. We report on the outcome of major depression five years after receiving treatment with medication or psychotherapy. METHODS: 472 patients were treated in three consecutive randomised controlled trials in one clinical research centre. 298 were followed up at five years. Of these, 106 patients were treated with medications, while the remaining 192 were given psychotherapy. The a priori outcome measure was mood symptoms in the two years prior to the assessment. RESULTS: The majority (56%) of patients had no depressive symptoms in the prior two years. One third (32%) had fluctuating depression, while 12% were chronic depressed. Predictors of outcome were few; baseline severity, suicidality, personality pathology, and type of treatment. Those receiving medication did somewhat worse, even when adjusted for this group's higher depression severity, suicidality and personality pathology at baseline. CONCLUSIONS: Long-term depressive symptoms are common after evidence-based treatment, although over half the patients appear to recover. Psychotherapy may be superior to medication in reducing the level of symptoms in the longer term. Personality remains one of the few baseline predictors of long-term outcome.