Personalized mood prediction from patterns of behavior collected with smartphones.

Over the last ten years, there has been considerable progress in using digital behavioral phenotypes, captured passively and continuously from smartphones and wearable devices, to infer depressive mood. However, most digital phenotype studies suffer from poor replicability, often fail to detect clinically relevant events, and use measures of depression that are not validated or suitable for collecting large and longitudinal data. Here, we report high-quality longitudinal validated assessments of depressive mood from computerized adaptive testing paired with continuous digital assessments of behavior from smartphone sensors for up to 40 weeks on 183 individuals experiencing mild to severe symptoms of depression. We apply a combination of cubic spline interpolation and idiographic models to generate individualized predictions of future mood from the digital behavioral phenotypes, achieving high prediction accuracy of depression severity up to three weeks in advance (R2 ≥ 80%) and a 65.7% reduction in the prediction error over a baseline model which predicts future mood based on past depression severity alone. Finally, our study verified the feasibility of obtaining high-quality longitudinal assessments of mood from a clinical population and predicting symptom severity weeks in advance using passively collected digital behavioral data. Our results indicate the possibility of expanding the repertoire of patient-specific behavioral measures to enable future psychiatric research.

A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial.

BACKGROUND: The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely. OBJECTIVE: This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students. METHODS: US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness. RESULTS: Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated. CONCLUSIONS: STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.

Enhancing Racial/Ethnic Equity in College Student Mental Health Through Innovative Screening and Treatment.

Although college campuses are diversifying rapidly, students of color remain an underserved and understudied group. Online screening and subsequent allocation to treatment represents a pathway to enhancing equity in college student mental health. The purpose of the current study was to evaluate racial/ethnic differences in mental health problems and treatment enrollment within the context of a largescale screening and treatment research initiative on a diverse college campus. The sample was comprised of n = 2090 college students who completed an online mental health screening survey and were offered either free online or face-to-face treatment based on symptom severity as a part of a research study. A series of ordinal, binomial and multinomial logistic regression models were specified to examine racial/ethnic differences in mental health problems, prior treatment receipt, and enrollment in online and face-to-face treatment through the campus-wide research initiative. Racial/ethnic differences in depression, anxiety and suicidality endorsed in the screening survey were identified. Students of color were less likely to have received prior mental health treatment compared to non-Hispanic white students, but were equally likely to enroll in and initiate online and face-to-face treatment offered through the current research initiative. Rates of enrollment in online therapy were comparable to prior studies. Online screening and treatment may be an effective avenue to reaching underserved students of color with mental health needs on college campuses. Digital mental health tools hold significant promise for bridging gaps in care, but efforts to improve uptake and engagement are needed.

Pretreatment social network characteristics relate to increased risk of dropout and unfavorable outcomes among women in a residential treatment setting for substance use.

Increased retention in residential treatment for substance use disorder (SUD) has been associated with more favorable clinical outcomes for residents. Yet SUD treatment dropout remains high. It is essential to uncover factors contributing to these high rates. Little is known about whether features of an individual's social network prior to treatment entry are related to number of days in treatment or to clinical status at treatment termination. To examine these relationships, we analyzed data from 241 women (58.5% Hispanic) entering an SUD residential treatment facility, who agreed to participate in a parent randomized control trial. We assessed characteristics of these women's social networks prior to treatment entry at baseline. We extracted clinician-determined progress at treatment termination and days in treatment two months after treatment entry from clinical records. Data-driven analyses using purposeful selection of predictors showed that the overall size of the social network was associated with increased likelihood of being classified as having achieved good clinical progress in treatment at termination and that number of drug users in the pretreatment social network was related to staying fewer days in treatment. Contrary to our hypothesis, we found no significant associations between other pretreatment social support network characteristics (i.e., social support) and treatment retention or clinical discharge status. Future research should examine how features of social networks change through treatment and how these changes relate to treatment outcomes.

Acting with awareness and distress tolerance relate to PTSD symptoms among women with substance use disorder.

OBJECTIVES: Women with a history of trauma exposure and substance use disorder (SUD) are more likely to report co-occurring post-traumatic stress disorder (PTSD) symptoms than the general population. However, cognitive factors such as increased distress tolerance and mindfulness disposition might be especially protective against PTSD symptoms for women with SUD. METHODS: We examined the associations of distress tolerance and mindfulness disposition as potential resilience factors to PTSD symptoms in a sample of women receiving residential treatment for SUD (N = 237, M AGE = 32.34, 56.96% Hispanic). PTSD symptoms were divided into the clusters of Reexperiencing, Avoidance, Dysphoria and Arousal. RESULTS: Regression models revealed that distress tolerance and the mindfulness facet of acting with awareness are negatively and incrementally associated with total, dysphoria and arousal PTSD symptom severity, while non-reactivity has a significant negative relationship with avoidance PTSD symptoms. Only distress tolerance emerged to be negatively related to PTSD reexperiencing symptom severity. CONCLUSIONS: Our findings show that the ability to tolerate distress, as well as specific mindfulness skills, might protect against specific severe PTSD symptoms among women with SUD. Future research should examine whether targeting both of these facets is necessary for achieving favorable clinical outcomes on PTSD in this population.

Sexual trauma history is associated with reduced orbitofrontal network strength in substance-dependent women.

AIM: Substance use disorders (SUDs) are highly comorbid with post-traumatic stress disorder (PTSD). PTSD-SUD comorbidity is associated with greater functional impairments and relapse risk. Women with SUDs experience markedly higher rates of trauma and PTSD compared to men with SUDs, particularly due to sexual and domestic abuse. Despite the strong association between trauma exposure and SUDs, the neurobiological correlates are understudied, particularly among females with SUDs. However, there is indication of abnormal somatic and interoceptive processing in women with PTSD. The present study examines interoception-linked differences in intrinsic brain networks in a group of women with SUDs and varying histories of trauma exposure, some of whom have a current PTSD diagnosis. METHODS: Pre-intervention data were analyzed from a subset (N = 43) of women in SUD residential treatment recruited for a mindfulness-based intervention efficacy clinical trial. Participants diagnosed with PTSD (n = 14) or not (n = 29) performed a task which involved attending to the somatic and visceral sensations of the breathing cycle (interoception) while undergoing a functional MRI (fMRI) scan. FMRI analysis employed independent components analysis and dual regression. First, we assessed differences in functional connectivity of interoception-modulated functional networks among those with and without PTSD. Second, we tested associations between network strength and lifetime sexual violence exposure across all participants on networks that showed significant group differences. RESULTS: PTSD diagnosis was associated with reduced functional connectivity of an orbitofrontal network with the precuneus, mid-posterior insula, lateral prefrontal cortex and angular gyrus. OFC network strength was inversely associated with sexual violence exposure over-and-above the contribution of PTSD status alone. CONCLUSIONS: Our findings provide a novel network-level account of brain activity associated with PTSD among women with SUDs, which may inform treatment response in this subpopulation.

Manipulating affective state influences conditioned appetitive responses.

Affective states influence how individuals process information and behave. Some theories predict emotional congruency effects (e.g. preferential processing of negative information in negative affective states). Emotional congruency should theoretically obstruct the learning of reward associations (appetitive learning) and their ability to guide behaviour under negative mood. Two studies tested the effects of the induction of a negative affective state on appetitive Pavlovian learning, in which neutral stimuli were associated with chocolate (Experiment 1) or alcohol (Experiment 2) rewards. In both experiments, participants showed enhanced approach tendencies towards predictors of reward after a negative relative to a positive performance feedback manipulation. This increase was related to a reduction in positive affect in Experiment 1 only. No effects of the manipulation on conditioned reward expectancies, craving, or consumption were observed. Overall, our findings support the idea of counter-regulation, rather than emotional congruency effects. Negative affective states might therefore serve as a vulnerability factor for addiction, through increasing conditioned approach tendencies.

A Primer on Bayesian Analysis for Experimental Psychopathologists.

The principal goals of experimental psychopathology (EPP) research are to offer insights into the pathogenic mechanisms of mental disorders and to provide a stable ground for the development of clinical interventions. The main message of the present article is that those goals are better served by the adoption of Bayesian statistics than by the continued use of null-hypothesis significance testing (NHST). In the first part of the article we list the main disadvantages of NHST and explain why those disadvantages limit the conclusions that can be drawn from EPP research. Next, we highlight the advantages of Bayesian statistics. To illustrate, we then pit NHST and Bayesian analysis against each other using an experimental data set from our lab. Finally, we discuss some challenges when adopting Bayesian statistics. We hope that the present article will encourage experimental psychopathologists to embrace Bayesian statistics, which could strengthen the conclusions drawn from EPP research.

Pathways towards the proliferation of avoidance in anxiety and implications for treatment.

Avoidance is a key symptom of anxiety disorders. Maladaptive avoidance impairs general functioning acutely and maintains chronic anxiety. A better understanding of the mechanisms that elicit and maintain excessive avoidance might provide opportunities to improve treatment. Here, we discuss pathways through which avoidance might get amplified in the context of anxiety disorders: 1) increased threat appraisal; 2) enhanced threat avoidance tendencies; 3) impaired regulation of avoidance; 4) habitual avoidance; and 5) attempts at increasing psychological distance. Novel strategies for reducing avoidance are considered. These include memory reconsolidation interference, retraining of avoidance tendencies, mindfulness training and habit disruption approaches. Throughout the paper, we highlight a number of suggestions for future research on avoidance and how to achieve lasting behavior change.

Lights action: Comparison of trauma films for use in the trauma film paradigm.

Affective films are often used in emotion research and negative films are frequently used as an analogue for trauma (trauma film paradigm). However, different films are used with possibly distinct consequences. We aimed to investigate specific effects of four negative films covering distinct themes (physical, sexual, traffic and food), and tested neutral and positive films with matching content. Self-reported emotional responses and heart rate during the films were examined (immediate responses) as well as intrusions of the films in the subsequent week (delayed responses). Within each theme, negative films were rated as more unpleasant than the positive and neutral counterparts. They also evoked more negative emotions and more intrusive memories. Across themes, the four negative films did not differ in terms of valence and arousal, but clearly differed on immediate (e.g., disgust, embarrassment, heart rate) and delayed (intrusions) effects. Thus, we urge researchers to carefully select negative films for their studies, as different films seem to evoke distinct emotional responses. In addition, using positive films within the same themes is recommended in order to control for effects of arousal. In general, the specific film material should be considered when comparing effects across studies.

Fearing shades of grey: individual differences in fear responding towards generalisation stimuli.

Individual differences in fear generalisation have been proposed to play a role in the aetiology and/or maintenance of anxiety disorders, but few data are available to directly support that claim. The research that is available has focused mostly on generalisation of peripheral and central physiological fear responses. Far less is known about the generalisation of avoidance, the behavioural component of fear. In two experiments, we evaluated how neuroticism, a known vulnerability factor for anxiety, modulates an array of fear responses, including avoidance tendencies, towards generalisation stimuli (GS). Participants underwent differential fear conditioning, in which one conditioned stimulus (CS+) was repeatedly paired with an aversive outcome (shock; unconditioned stimulus, US), whereas another was not (CS-). Fear generalisation was observed across measures in Experiment 1 (US expectancy and evaluative ratings) and Experiment 2 (US expectancy, evaluative ratings, skin conductance, startle responses, safety behaviours), with overall highest responding to the CS+, lowest to the CS- and intermediate responding to the GSs. Neuroticism had very little impact on fear generalisation (but did affect GS recognition rates in Experiment 1), in line with the idea that fear generalisation is largely an adaptive process.

Moving threat: Attention and distance change interact in threat responding.

Defensive reactions need to be quick and appropriate to ensure survival. Thus, it is crucial that threats trigger immediate action upon detection, even in the absence of awareness. In addition, the form of such action should be appropriate to the imminence of the threat. Thus, attention should be guided by signals of increasing threat imminence. We examined whether subliminally presented threat stimuli provoke automatic avoidance tendencies, and whether threat cues' distance change and threat potential determine attention allocation. Following fear conditioning, participants performed an approach-avoidance task with subliminally presented conditioned threat and safety stimuli, and an attentional bias task with approaching versus distancing signals of threat and safety. Preattentive processing of threat cues resulted in approach rather than avoidance tendencies; attention was captured preferentially by signals of increasing threat imminence. The results support the importance of threat imminence and extend findings of previous research on preattentive influences on defensive responding. (PsycINFO Database Record

Effects of Approach-Avoidance Training on the Extinction and Return of Fear Responses.

BACKGROUND AND OBJECTIVES: Exposure therapy for anxiety involves confronting a patient with fear-evoking stimuli, a procedure based partially on Pavlovian extinction. Exposure and other extinction-based therapies usually lead to (partial) reduction of fear symptoms, but a substantial number of patients experience a return of fear after treatment. Here we tested whether the combination of fear extinction with modification of approach-avoidance tendencies using an Approach-Avoidance Task (AAT) would result in the further reduction of conditioned fear and/or help prevent return of fear after extinction. METHODS: Two groups of participants underwent a fear acquisition procedure during which pictures of one neutral object were sometimes paired with shock (CS+), whereas pictures of another neutral object were not (CS-). The next day, in a fear extinction procedure, both objects were presented without shock. During the subsequent joystick AAT, one group primarily pulled CS+ pictures towards themselves and pushed CS- pictures away from themselves; reversed contingencies applied for the other group. RESULTS: Approach training was effective in modifying conditioned action tendencies, with some evidence for transfer to a different approach/avoidance task. No group differences in subjective fear or physiological arousal were found during subsequent post- training and return-of-fear testing. LIMITATIONS: No reliable return-of-fear was observed in either group for either subjective or physiological fear measures. CONCLUSIONS: Our results suggest that approach training may be of limited value for enhancing the short- and long-term effects of extinction-based interventions.

Individual Differences in Discriminatory Fear Learning under Conditions of Ambiguity: A Vulnerability Factor for Anxiety Disorders?

Complex fear learning procedures might be better suited than the common differential fear-conditioning paradigm for detecting individual differences related to vulnerability for anxiety disorders. Two such procedures are the blocking procedure and the protection-from-overshadowing procedure. Their comparison allows for the examination of discriminatory fear learning under conditions of ambiguity. The present study examined the role of individual differences in such discriminatory fear learning. We hypothesized that heightened trait anxiety would be related to a deficit in discriminatory fear learning. Participants gave US-expectancy ratings as an index for the threat value of individual CSs following blocking and protection-from-overshadowing training. The difference in threat value at test between the protected-from-overshadowing conditioned stimulus (CS) and the blocked CS was negatively correlated with scores on a self-report tension-stress scale that approximates facets of generalized anxiety disorder (GAD), the Depression Anxiety Stress Scale-Stress (DASS-S), but not with other individual difference variables. In addition, a behavioral test showed that only participants scoring high on the DASS-S avoided the protected-from-overshadowing CS. This observed deficit in discriminatory fear learning for participants with high levels of tension-stress might be an underlying mechanism for fear overgeneralization in diffuse anxiety disorders such as GAD.