Cultural Responsivity in Technology-Enabled Services: Integrating Culture Into Technology and Service Components.

Technology-enabled services (TESs) are clinical interventions that combine technological and human components to provide health services. TESs for mental health are efficacious in the treatment of anxiety and depression and are currently being offered as frontline treatments around the world. It is hoped that these interventions will be able to reach diverse populations across a range of identities and ultimately decrease disparities in mental health treatment. However, this hope is largely unrealized. TESs include both technology and human service components, and we argue that cultural responsivity must be considered in each of these components to help address existing treatment disparities. To date, there is limited guidance on how to consider cultural responsivity within these interventions, including specific targets for the development, tailoring, or design of the technologies and services within TESs. In response, we propose a framework that provides specific recommendations for targets based on existing models, both at the technological component level (informed by the Behavioral Intervention Technology Model) and the human support level (informed by the Efficiency Model of Support). We hope that integrating culturally responsive considerations into these existing models will facilitate increased attention to cultural responsivity within TESs to ensure they are ethical and responsive for everyone.

Effectiveness of the internet-based Unified Protocol transdiagnostic intervention for the treatment of depression, anxiety and related disorders in a primary care setting: a randomized controlled trial.

BACKGROUND: Research has shown that internet-based cognitive behavioural therapy (iCBT) can be a very promising solution to increase access to and the dissemination of evidence-based treatments to all of the population in need. However, iCBT is still underutilized in clinical contexts, such as primary care. In order to achieve the effective implementation of these protocols, more studies in ecological settings are needed. The Unified Protocol (UP) is a transdiagnostic CBT protocol for the treatment of emotional disorders, which includes depression, anxiety and related disorders, that has shown its efficacy across different contexts and populations. An internet-based UP (iUP) programme has recently been developed as an emerging internet-based treatment for emotional disorders. However, the internet-delivered version of the UP (iUP) has not yet been examined empirically. The current project seeks to analyse the effectiveness of the iUP as a treatment for depression, anxiety and related emotional disorders in a primary care public health setting. METHODS: The current study will employ a parallel-group, randomized controlled trial design. Participants will be randomly assigned to (a) the internet-based Unified Protocol (iUP), or (b) enhanced waiting list control (eWLC). Randomization will follow a 2:1 allocation ratio, with sample size calculations suggesting a required sample of 120 (iUP=80; eWLC=40). The Mini-International Neuropsychiatric Interview (M.I.N.I.) will be used for assessing potential participants. The Overall Anxiety Severity and Impairment Scale (OASIS) and the Overall Depression Severity and Impairment Scale (ODSIS) as well as other standardized questionnaires will be used for assessments at baseline, 4 weeks, 8 weeks and 12 weeks from baseline and for the iUP condition during the follow-up. DISCUSSION: Combining the advantages of a transdiagnostic treatment with an online delivery format may have the potential to significantly lower the burden of emotional disorders in public health primary care setting. Anxiety and depression, often comorbid, are the most prevalent psychological disorders in primary care. Because the iUP allows for the treatment of different disorders and comorbidity, this treatment could represent an adequate choice for patients that demand mental health care in a primary care setting. TRIAL REGISTRATION: ISRCTN18056450 https://doi.org/10.1186/ISRCTN18056450 .

The Impact of COVID-19 Related Social Distancing on Mental Health Outcomes: A Transdiagnostic Account.

The COVID-19 pandemic, and the social distancing practices that followed, have been associated with increased prevalence of emotional disorders. However, not all individuals affected by COVID-19-related social distancing experienced elevations in emotional disorder symptoms. Understanding this phenomenon is of crucial public health significance given the burden of emotional disorders on individuals and systems. In this narrative review, we consider the differential impact of COVID-19-related social distancing on mental health outcomes from a transdiagnostic perspective. We argue that individuals high in negative affect and aversive reactivity to emotion, that is, neuroticism, and who respond to such emotional experiences with emotion-motivated avoidant coping, are most likely to experience emotional disorders in the context of COVID-19 social distancing. We acknowledge the pro-social and adaptive function of some types of avoidance during the pandemic, which may have initially buffered against negative mental health outcomes. Implications of this conceptualization for treatment of emotional disorders in the present sociocultural context are discussed.

The role of experiential avoidance in the relation between racial discrimination and negative mental health outcomes.

Objective Racial discrimination has been shown to be associated with negative mental health outcomes among people of color (POC), and students of color (SOC) specifically. The current study examines experiential avoidance (EA) as a potential moderator in the relation between discrimination and mental health outcomes. Sample: Two-hundred students of color at a large, public university in Northeastern United States. Methods: We evaluated the associations between racial discrimination frequency and stress appraisal (GEDS and GEDS-A), EA (AAQ), and the Depression, Anxiety, and Stress Scales (DASS). Results: Discrimination frequency and appraised stress were associated with each DASS subscale. EA moderated the relation between GEDS and depression, and between GEDS-A and the stress subscale. Conclusions: Discrimination frequency and appraised stress were positively associated with DASS subscales, and at low EA scores, frequency and appraised stress of discrimination were no longer associated with depressive or stress symptoms, respectively.

Efficacy of the Unified Protocol for the treatment of comorbid alcohol use and anxiety disorders: Study protocol and methods.

Alcohol Use Disorder (AUD) and anxiety disorders (ANX) are each highly prevalent and frequently co-occur, resulting in a complex clinical presentation. The existing literature to date has not yet identified how to best treat comorbid AUD/ANX, partially due to limitations in understanding what factors and mechanisms are implicated in their co-occurrence. This manuscript describes the rationale and methods for an ongoing randomized-controlled trial designed to evaluate the efficacy of a cognitive behavioral intervention, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), compared to Take Control (TC), a psychosocial and motivational treatment serving as a control condition in this study, for comorbid AUD/ANX. Sixty individuals with comorbid AUD/ANX will be randomized to UP or TC, and complete assessments at pre- and post-treatment, as well as one- and six-month follow-up points. We hypothesize that the UP, compared to TC, will result in significantly greater reductions in drinking-related outcomes, as well as anxiety and depressive-related outcomes. Additionally, the current study is designed to evaluate exploratory aims to contribute to our theoretical understanding of why AUD and ANX frequently co-occur. Specifically, we will examine the relationship between changes in AUD and ANX symptoms in relation to changes in emotional disorder mechanisms, such as emotion regulation. Because the UP is a transdiagnostic treatment that specifically targets underlying components of emotional disorders generally, it may be well suited to effectively target comorbid AUD/ANX.

Unified Protocol for the Transdiagnostic Prevention of Emotional Disorders: Evaluation of a Brief, Online Course for College Freshmen.

The transition to college represents a period of increased risk for developing a range of mental health conditions, highlighting the need for effective preventive interventions delivered in this setting. The purpose of the present study was to explore the feasibility, acceptability, and efficacy of a preventive version of the unified protocol for college students; this intervention, called emotions 101 was provided in a very brief, online course format. Unselected students (N = 243) were randomized to either the course (n = 120) or wait-list (n = 123) condition, and all participants were asked to complete self-report measures of stress, negative affectivity, and quality of life at baseline, 1-month, 6-month, and 8-month follow-up time points. Despite recruitment challenges, once participants enrolled in the course, they were likely to complete it and provide favorable satisfaction ratings and qualitative feedback. With regard to efficacy, there were no significant differences on our primary (emotional) outcomes (i.e., stress, negative affectivity, quality of life) as a function of condition, though individuals randomized to receive the course demonstrated significantly higher grade point averages at the end of their first college semester than those in the wait-list condition. Taken together, the findings from the present study suggest that a very brief, online prevention program for emotional disorders administered in a healthy sample does not significantly impact mental health variables.

The Unified Protocol compared with diagnosis-specific protocols for anxiety disorders: 12-month follow-up from a randomized clinical trial.

OBJECTIVE: To examine whether the Unified Protocol (UP) remains equivalent to single-disorder protocols (SDPs) in the treatment of anxiety disorders at 12-month follow-up. METHOD: We report results from the 12-month follow-up of a recent randomized equivalence trial [1]. Data are from 179 participants (55.31% female sex, 83.24% White, average age 30.66) who met criteria for a principal anxiety disorder and were randomized to either the UP or SDP conditions. Consistent with the parent trial, the primary outcome was principal diagnosis clinician severity rating (CSR) from the Anxiety Disorder Interview Schedule (ADIS). Secondary outcomes included anxiety, depression, and impairment. Missing data were accommodated using multiple imputation (10,000 imputed data sets) under a missing at random assumption. Equivalence between the UP and SDPs was tested using slope difference scores from latent growth models and 95% confidence interval of between-condition effect sizes. RESULTS: The results indicated that the UP and SDP conditions remained equivalent with regard to principal diagnosis clinician severity rating at 12-month follow-up. In addition, there were no significant differences between conditions on secondary outcomes at 12-month follow-up. CONCLUSIONS: The UP continues to yield outcomes comparable to SDPs at 12-month follow-up, and therefore provides a single intervention that can be used to treat the most commonly occurring psychiatric disorders with durable effects.

Innovations in the Treatment of Perinatal Depression: the Role of Yoga and Physical Activity Interventions During Pregnancy and Postpartum.

PURPOSE OF REVIEW: We review evidence for physical activity and yoga as interventions for depressed pregnant and postpartum women. RECENT FINDINGS: Results from existing trials have generally indicated that physical activity and yoga interventions are acceptable to women during the perinatal period, and that these interventions can be effective in reducing depression. However, some studies have not found significant differences between intervention and control conditions. In addition, symptom improvements were not always maintained. The available research on physical activity and yoga as interventions for perinatal depression is encouraging with regard to feasibility, acceptability, patient safety, and preliminary efficacy. These interventions have the ability to reach a large number of women who may not engage in traditional treatment. Additional high quality, rigorous, randomized controlled trials are needed. Future research is also needed to examine the optimal dose of these interventions and how to best increase sustained engagement.

Surviving and Thriving During Stress: A Randomized Clinical Trial Comparing a Brief Web-Based Therapist-Assisted Acceptance-Based Behavioral Intervention Versus Waitlist Control for College Students.

The high rates of anxiety in college students and the many barriers to accessing evidence-based care in communities and on campuses indicate a clear need to explore ways to increase access to evidence-based treatments. Web-based interventions and preventions are one way to bridge this gap; they hold the potential to decrease mental health disparities and enhance student functioning. The current RCT examined the acceptability and efficacy of a 3-session web-based therapist-assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress) for college students versus a waitlist (WL) control condition, in a sample of racially and ethnically diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-effects regression models (MRMs) were run in SPSS to examine the effects of time, condition, and Condition × Time on outcomes and hypothesized mechanisms. Significant Condition × Time interactions for general anxiety, depression, and quality of life (QOL) emerged, suggesting that SATDS participants reported significantly greater changes on these outcomes from pre- to posttreatment versus WL. However, interaction effects were nonsignificant for anxious arousal and social anxiety. MRMs examining hypothesized mechanisms revealed significant Condition × Time interactions for experiential avoidance, decentering, and values-based living. However, interaction effects were nonsignificant for mindfulness. All significant gains were maintained at 1-month follow-up, with the exception of QOL. Results contribute to the growing literature on the acceptability and efficacy of web-based approaches, and suggest these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care.

Complementary Health Practices for Treating Perinatal Depression.

This article provides a focused review of the evidence for several complementary health approaches (ie, omega-3 fatty acids, folate, vitamin D, selenium, zinc, magnesium, B vitamins, physical activity, yoga) in the treatment of perinatal depression. There is evidence that some of these treatments may be reasonable to consider in women during pregnancy or the postpartum period. However, there are little data on the comparative safety and efficacy of these relative to traditional treatments (eg, psychotherapy, pharmacotherapy). Adequately powered high-quality studies are necessary to determine the role of complementary health practices for treating perinatal depression.

Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder.

As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007). Identifying these mechanisms would help streamline evidence-based approaches, increase treatment response rates, and aid in the dissemination and implementation of evidence-based approaches in diverse contexts. The current study examined reductions in experiential avoidance (EA; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, as a potential mechanism of change in participants with a principal diagnosis of generalized anxiety disorder (GAD) receiving either acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Participants' EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions. Greater change in EA across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches.

Delivering cognitive processing therapy in a community health setting: The influence of Latino culture and community violence on posttraumatic cognitions.

Despite the applicability of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) to addressing sequelae of a range of traumatic events, few studies have evaluated whether the treatment itself is applicable across diverse populations. The present study examined differences and similarities among non-Latino, Latino Spanish-speaking, and Latino English-speaking clients in rigid beliefs-or "stuck points"-associated with PTSD symptoms in a sample of community mental health clients. We utilized the procedures of content analysis to analyze stuck point logs and impact statements of 29 participants enrolled in a larger implementation trial for CPT. Findings indicated that the content of stuck points was similar across Latino and non-Latino clients, although fewer total stuck points were identified for Latino clients compared to non-Latino clients. Given that identification of stuck points is central to implementing CPT, difficulty identifying stuck points could pose significant challenges for implementing CPT among Latino clients and warrants further examination. Thematic analysis of impact statements revealed the importance of family, religion, and the urban context (e.g., poverty, violence exposure) in understanding how clients organize beliefs and emotions associated with trauma. Clinical recommendations for implementing CPT in community settings and the identification of stuck points are provided.

Mindfulness and acceptance-based behavioral therapies for anxiety disorders.

This article presents a brief conceptual overview of acceptance-based behavioral therapies (ABBTs) for anxiety disorders, followed by a review and summary of the recent efficacy studies of ABBTs for anxiety and comorbid disorders. We discuss clinical implications, including the importance of targeting reactivity and experiential avoidance in interventions for anxiety disorders through the use of mindfulness and other acceptance-based strategies, as well the encouragement of engagement in meaningful activities or valued action. We also address future directions for research, such as expanding research to include more randomized control trials comparing ABBTs for specific anxiety disorders to other active treatments, examining mechanisms of change, exploring adaptations in different care-delivery contexts, as well as determining the applicability of these approaches to clients from marginalized or non-dominant statuses.