Experiential Avoidance in Primary Care Providers: Psychometric Properties of the Brazilian "Acceptance and Action Questionnaire" (AAQ-II) and Its Criterion Validity on Mood Disorder-Related Psychological Distress.

BACKGROUND: A sizeable proportion of Brazilian Primary Care (PC) providers suffer from common mental disorders, such as anxiety and depression. In an effort to cope with job-related distress, PC workers are likely to implement maladaptive strategies such as experiential avoidance (EA). The Acceptance and Action Questionnaire (AAQ-II) is a widely used instrument that evaluates EA but has shown questionable internal consistency in specific populations. This study assesses the psychometric properties of the AAQ-II among Brazilian PC providers, evaluates its convergence and divergence with self-criticism and mindfulness skills, and explores its criterion validity on anxiety and depressive symptoms. METHODS: A cross-sectional design was conducted in Brazilian PC services, and the sample included 407 PC workers. The measures evaluated EA, self-criticism, mindfulness, depression, and anxiety. RESULTS: The one-factor model of the AAQ-II replicated the original version structure. The AAQ-II presented good internal consistency among Brazilian PC providers. A multiple regression model demonstrated higher relationships with self-criticism than mindfulness skills. The criterion validity of the AAQ-II on anxiety and depression was stronger in the context of more severe symptoms. CONCLUSIONS: The AAQ-II is an appropriate questionnaire to measure the lack of psychological flexibility among Brazilian PC workers in the sense of EA.

Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Adults with Prolonged Grief Disorder (PGD): A Study Protocol for a Randomized Feasibility Trial.

INTRODUCTION: Grief is an emotional reaction to the loss of a loved one with a natural recovery. Approximately 10% of people who lose a loved one develop prolonged grief disorder (PGD). Internet-based and computer-based interventions (ie, internet-delivered cognitive-behavioural therapy, iCBT) are a cost-effective alternative that makes it possible to reach more people with PGD. The main aim of this study is to assess the feasibility of a new iCBT-called GROw-for PGD. As a secondary objective, the potential effectiveness of GROw will be explored. METHODS AND ANALYSIS: This study is a two-arm feasibility randomised trial. A total of 48 adults with PGD who meet the eligibility criteria will be randomised to the experimental group (iCBT: GROw) or the active control group (face-to-face CBT treatment). The treatment is organised sequentially in eight modules in the iCBT format and 8-10 sessions in the face-to-face format, and both formats have the same therapeutic components. There will be five assessment points with qualitative and quantitative evaluations: screening, baseline, after the intervention, 3-month follow-up and 12-month follow-up. Consistent with the objectives, the measures are related to the feasibility outcomes for the main aim of the study (participant adherence, expectations and satisfaction with the treatment, preferences, alliance and utility) and psychological and mental health outcomes for secondary analyses (symptoms of grief, symptoms of depression, symptoms of anxiety, affectivity, quality of life, work and social adaptation, post-traumatic growth, purpose in life, mindfulness and compassion). ETHICS AND DISSEMINATION: The Ethics Committee of the Universitat Jaume I (Castellón, Spain) granted approval for the study (CD/002/2019). Dissemination will include publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04462146.

Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders.

Adjustment disorder (AjD) is one of the most common disorders in clinical practice, and its symptoms are severe enough to cause great distress and functional impairment. The AjD CBT protocol specifically developed for this disorder has shown positive results when delivered face to face and through virtual reality. Despite existing evidence supporting the benefits of therapeutic homework as part of a psychological intervention, little is known about how to increase homework engagement in psychotherapy. This study examines the feasibility (doability, initial efficacy and acceptability) of a digital support system to deliver homework via the Internet in the treatment of AjD. Participants were randomly assigned to a traditional homework condition or a digital support system condition. Both interventions resulted in statistically significant improvements, with large effect sizes, in all the outcome measures at post-treatment, with no significant differences between groups. At 12-month follow-up, these therapeutic gains were maintained, and an improvement was even observed in both conditions, with no significant differences between groups. Additionally, treatment satisfaction predicted efficacy in both groups separately and when the whole group was considered. This is the first study to explore the feasibility an initial efficacy of delivering a therapeutic homework component for AjD through the Internet.

Effectiveness of a brief psychological mindfulness-based intervention for the treatment of depression in primary care: study protocol for a randomized controlled clinical trial.

BACKGROUND: Depressive symptoms are quite prevalent in Primary Care (PC) settings. The treatment as usual (TAU) in PC is pharmacotherapy, despite the high relapse rates it produces. Many patients would prefer psychotherapy, but specialized services are overloaded. Studies that apply Mindfulness-Based Interventions (MBIs) for the treatment of depression have obtained significant improvements. Brief low-intensity approaches delivered from PC could be a promising approach. This study aims to compare a low-intensity mindfulness intervention for the treatment of depression in PC using different intervention formats - a face-to-face MBI delivered in a group and the same MBI individually applied on the Internet - to a control group that will receive PC medical treatment as usual. METHODS: A randomized controlled clinical trial will be conducted in PC, with about 120 depressed patients allocated (1:1:1) to three groups: "face-to-face MBI + TAU", "Internet-delivered MBI + TAU", and "TAU alone". The MBI programs will be composed of four modules. The primary outcome will be depressive symptoms, measured through the Beck Depression Inventory, assessed at pre- and post-treatment and 6- and 12-month follow-ups. Other outcomes will be mindfulness, happiness, affectivity, quality of life, and the use of healthcare services. Intention-to-treat analysis using linear mixed models adjusted for baseline scores and routine sociodemographic analysis that could show baseline differences will be conducted. Per-protocol secondary outcome analyses will also be performed. DISCUSSION: This is the first Spanish RCT to apply a low-intensity face-to-face MBI (plus TAU) to treat depression in PC settings compared to TAU (alone). Moreover, this study will also make it possible to evaluate the same MBI program (plus TAU), but Internet-delivered, considering their cost-effectiveness. Positive results from this RCT might have an important impact on mental health settings, helping to decrease the overload of the system and offering treatment alternatives beyond antidepressant medication through high-quality, flexible PC interventions. TRIAL REGISTRATION: Clinical Trials.gov NCT03034343 . Trial Registration date 24 January 2017, retrospectively registered.

Attachment-based compassion therapy and adapted mindfulness-based stress reduction for the treatment of depressive, anxious and adjustment disorders in mental health settings: a randomised controlled clinical trial protocol.

INTRODUCTION: Depressive, anxiety and adjustment disorders are highly prevalent among mental health outpatients. The lack of funding for mental health problems produces inefficient results and a high burden of disease. New cost-effective group interventions aimed at treating these symptoms might be an appropriate solution to reduce the healthcare burden in mental health units. Mindfulness-based interventions (MBIs) have shown significant reductions in anxious, depressive and adjustment symptomatology. Recent research highlights the influence of compassion as a key mechanism of change. However, MBIs only address compassion implicitly, whereas compassion-based protocols consider it a core aspect of psychotherapy. In this randomised controlled trial, we hypothesise that the provision of attachment-based compassion therapy (ABCT), which is a compassion-based protocol, will be more effective than mindfulness-based stress reduction (MBSR), which is a conventional MBI programme, for the treatment of depressive, anxious and adaptive symptoms in patients in mental health settings. METHODS AND ANALYSIS: Approximately 90 patients suffering from depressive, anxious or adjustment disorders recruited from Spanish mental health settings will be randomised to receive 8 weekly 2 hours group sessions of ABCT, 8 weekly 2.5 hours group sessions of adapted MBSR (with no full-day silent retreat) or treatment as usual (TAU), with a 1:1:1 allocation rate. Patients in the ABCT and adapted MBSR groups will also receive TAU. The main outcome will be general affective distress measured by means of the 'Depression Anxiety Stress Scales-21' at post-test as primary endpoint. Other outcomes will be quality of life, mindfulness, self-compassion and the use of healthcare services. There will be a 6-month follow-up assessment. Intention-to-treat analysis will be conducted using linear mixed models. Per-protocol and secondary outcome analyses will be performed. A data monitoring committee comprising the trial manager, the ABCT and MBSR teachers and an independent clinical psychologist will monitor for possible negative side effects. ETHICS AND DISSEMINATION: Approval was obtained from the Ethics Committee of the General University Hospital of Castellón, Spain. The results will be submitted to peer-reviewed specialised journals, and brief reports will be sent to participants on request. TRIAL REGISTRATION NUMBER: NCT03425487.

Evaluation of a Mindfulness-Based Intervention With and Without Virtual Reality Dialectical Behavior Therapy® Mindfulness Skills Training for the Treatment of Generalized Anxiety Disorder in Primary Care: A Pilot Study.

Generalized Anxiety Disorder (GAD) is a very prevalent disorder in primary care (PC). Most patients with GAD never seek treatment, and those who do seek treatment often drop out before completing treatment. Although it is an understudied treatment, Mindfulness-Based Interventions (MBIs) indicate preliminary efficacy for the treatment of GAD symptoms, but many patients with GAD present other associated symptoms (e.g., attention deficits) that complicate the treatment. Virtual Reality DBT® Mindfulness Skills learning has recently been developed to make learning mindfulness easier for patients with emotion dysregulation who have trouble concentrating. Virtual Reality (VR) might serve as a visual guide for practicing mindfulness as it gives patients the illusion of "being there" in the 3D computer generated world. The main goal of this study was to evaluate the effect of two MBIs (a MBI in a group setting alone and the same MBI plus 10 min VR DBT® Mindfulness skills training) to reduce GAD symptoms. A secondary aim was to explore the effect in depression, emotion regulation, mindfulness, and interoceptive awareness. Other exploratory aims regarding the use of VR DBT® Mindfulness skills were also carried out. The sample was composed of 42 patients (roughly half in each group) with GAD attending PC visits. After treatment, both groups of patients showed significant improvements in General Anxiety Disorder measured by the GAD-7 using mixed regression models [MBI alone (B = -5.70; p < 0.001; d = -1.36), MBI+VR DBT® Mindfulness skills (B = -4.38; p < 0.001; d = -1.33)]. Both groups also showed significant improvements in anxiety, depression, difficulties of emotion regulation and several aspects of mindfulness and interoceptive awareness. Patients in the group that received additional 10 min VR DBT Mindfulness Skills training were significantly more adherent to the treatment than those receiving only standard MBI (100% completion rate in MBI + VR vs. 70% completion rate in MBI alone; Fisher = 0.020). Although randomized controlled studies with larger samples are needed, this pilot study shows preliminary effectiveness of MBI to treat GAD, and preliminary evidence that adjunctive VR DBT® Mindfulness Skills may reduce dropouts.

Economic Impact of Third-Wave Cognitive Behavioral Therapies: A Systematic Review and Quality Assessment of Economic Evaluations in Randomized Controlled Trials.

The term third-wave cognitive behavioral therapy (CBT) encompasses new forms of CBT that both extend and innovate within CBT. Most third-wave therapies have been subject to randomized controlled trials (RCTs) focused on clinical effectiveness; however, the number and quality of economic evaluations in these RCTs has been unknown and may be few. Evidence about efficiency of these therapies may help support decisions on efficient allocation of resources in health policies. The main aim of this study was to systematically review the economic impact of third-wave therapies in the treatment of patients with physical or mental conditions. We conducted a systematic literature search in PubMed, PsycINFO, EMBASE, and CINALH to identify economic evaluations of third-wave therapies. Quality and Risk of Bias (RoB) assessment of economic evaluations was also made using the Drummond 35-item checklist and the Cochrane Collaboration's tool for assessing risk of bias, respectively. Eleven RCTs were included in this systematic review. Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Stress Reduction (MBSR), Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and extended Behaviour Activation (eBA) showed acceptable cost-effectiveness and cost-utility ratios. No study employed a time horizon of more than 3 years. Quality and RoB assessments highlight some limitations that temper the findings. There is some evidence that MBCT, MBSR, ACT, DBT, and eBA are efficient from a societal or a third-party payer perspective. No economic analysis was found for many third-wave therapies. Therefore, more economic evaluations with high methodological quality are needed.

Is cognitive-behavioural therapy more effective than relaxation therapy in the treatment of anxiety disorders? A meta-analysis.

BACKGROUND: It is not clear whether relaxation therapies are more or less effective than cognitive and behavioural therapies in the treatment of anxiety. The aims of the present study were to examine the effects of relaxation techniques compared to cognitive and behavioural therapies in reducing anxiety symptoms, and whether they have comparable efficacy across disorders. METHOD: We conducted a meta-analysis of 50 studies (2801 patients) comparing relaxation training with cognitive and behavioural treatments of anxiety. RESULTS: The overall effect size (ES) across all anxiety outcomes, with only one combined ES in each study, was g = -0.27 [95% confidence interval (CI) = -0.41 to -0.13], favouring cognitive and behavioural therapies (number needed to treat = 6.61). However, no significant difference between relaxation and cognitive and behavioural therapies was found for generalized anxiety disorder, panic disorder, social anxiety disorder and specific phobias (considering social anxiety and specific phobias separately). Heterogeneity was moderate (I2 = 52; 95% CI = 33-65). The ES was significantly associated with age (p < 0.001), hours of cognitive and/or behavioural therapy (p = 0.015), quality of intervention (p = 0.007), relaxation treatment format (p < 0.001) and type of disorder (p = 0.008), explaining an 82% of variance. CONCLUSIONS: Relaxation seems to be less effective than cognitive and behavioural therapies in the treatment of post-traumatic stress disorder, and obsessive-compulsive disorder and it might also be less effective at 1-year follow-up for panic, but there is no evidence that it is less effective for other anxiety disorders.