Predictors of adherence to a publicly available self-guided digital mental health intervention.

Low adherence to self-guided digital mental health interventions (DMHIs) have raised concerns about their real-world effectiveness. Naturalistic data from self-guided DMHIs are often not available, hindering our ability to assess adherence among real-world users. This study aimed to analyze 3 years of user data from the public launch of an empirically supported 12-session self-guided DMHI, to assess overall program adherence rates and explore predictors of adherence. Data from 984 registered users were analyzed. Results showed that only 14.8% of users completed all 12 modules and 68.6% completed less than half of the modules. Users who were younger, had milder depression, had never seen a mental health provider, and who rejected signing-up for weekly program emails completed significantly more modules. Results add to concerns about the generalizability of controlled research on DMHIs due to lower adherence outside of research trials. This study highlights the potential of user data in identifying key factors that may be related to adherence. By examining adherence patterns among different sub-sets of users, we can pinpoint and focus on individuals who may adhere and benefit more from self-guided programs. Findings could also have implications for guiding intervention personalization for individuals who struggle to complete DMHIs.

Updated grading system for systemic allergic reactions: Joint Statement of the World Allergy Organization Anaphylaxis Committee and Allergen Immunotherapy Committee.

There is a lack of consensus over the description and severity assignment of allergic adverse reactions to immunotherapy, although there seems to be a consensus at least in terms of using the World Allergy Organization (WAO) grading systems to describe local adverse events for Sublingual Immunotherapy (SLIT) and Systemic Allergic Reactions (SARs) to Subcutaneous Immunotherapy (SCIT) amongst the major national/regional allergy societies. In this manuscript, we propose a modification of the previous WAO Grading system for SARs, which aligns with the newly-proposed Consortium for Food Allergy Research (CoFAR) Grading Scale for Systemic Allergic Reactions in Food Allergy (version 3.0). We hope this can facilitate a unified grading system appropriate to SARs due to allergen immunotherapy, independent of allergen and route of administration, and across clinical and research practice.

Reach, adoption, and maintenance of online acceptance and commitment therapy at a university: An implementation case study.

College students are undergoing a mental health crisis and existing clinical resources at universities may be inadequate to meet their needs. One solution to this problem could be the use of self-guided, online programs for mental health that can be easily distributed to students. A persistent issue, however, is the transition from program development to implementation of a self-guided program at campus-wide scale. We describe, in a self-narrative format, the steps taken to translate an online program we developed based in acceptance and commitment therapy, called Acceptance and Commitment Therapy Guide, from a research context to a campus-wide service at our university. We also present demographic, previous treatment, and referral data of over 1,500 student sign-ups to describe the reach of our program, how it was adopted into existing university services and systems, and how we maintained the program long term. Findings from these implementation efforts are discussed in the context of suggestions for using self-guided programs for students to fill gaps in mental health service provision in university settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Adding online storytelling-based acceptance and commitment therapy to antidepressant treatment for primary care patients: a randomized clinical trial.

Depression is most often treated in primary care, where the prevailing treatment is antidepressant medication. Primary care patients with depression are less likely to be exposed to psychosocial interventions, despite evidence suggesting many of these treatments are effective. An example is acceptance and commitment therapy (ACT), a behavioral treatment for depression with a growing evidence base. A self-guided ACT intervention with a peer narrative (i.e. storytelling) format was developed with the intention of creating a treatment option for primary care patients that was more accessible than traditional psychotherapy. Titled LifeStories, the online program features videos of real individuals sharing coping skills for depression based on lived experiences and key ACT principles. A total of 93 primary care patients taking antidepressants were randomized to either continued antidepressant treatment alone or antidepressant treatment plus LifeStories for 4 weeks. There were no differences over time on depression severity and psychological inflexibility. However, LifeStories led to greater improvements in quality of life and increased patients' interest in additional treatment compared to antidepressant medication alone.Clinical trial pre-registration: ClinicalTrials.gov (NCT04757961).

Gastrointestinal-isolated Distress is Common in Alpha-gal Allergic Patients on Mammalian Meat Challenge.

BACKGROUND AND AIMS: Alpha-gal allergy causes a delayed reaction to mammalian meats and has been reported worldwide. Patients with the allergy may present with isolated gastrointestinal (GI) symptoms, but this phenotype is poorly understood. METHODS: We pooled and analyzed symptoms and demographics of patients from two prospective cohorts of patients with a diagnosis of alpha-gal allergy who reacted after eating mammalian meat under observation. We compared the characteristics of patients who demonstrated GI-isolated symptoms on a challenge with those who exhibited symptoms outside the GI tract (skin, respiratory, and circulatory). RESULTS: Among the 91 children and adult alpha-gal allergic patients who exhibited symptoms after oral challenge with mammalian meat, 72.5% experienced GI distress with one or more GI symptoms, which was the most frequent class of symptoms, compared with skin changes in 57.1% and respiratory distress in 5.5%. The most common GI symptoms were abdominal pain (71%) and vomiting (22.0%). GI-isolated symptoms occurred in 37 patients (40.7%) who reacted, and those patients reacted more quickly than patients who exhibited systemic symptoms (median onset of symptoms in GI-isolated group 90 min vs 120 min) and were more likely to be children than adults (relative risk=1.94, 95% CI: 1.04-3.63). CONCLUSIONS: Isolated-GI distress occurred in 4 in every 10 alpha-gal allergic individuals who developed symptoms on oral food challenge with mammalian meat. Alpha-gal allergic patients, particularly children, may exhibit GI distress alone, and adult and pediatric gastroenterologists should be aware of the diagnosis and management of the allergy.

Efficacy and acceptability of mobile application-delivered acceptance and commitment therapy for posttraumatic stress disorder in China: A randomized controlled trial.

Due to the COVID-19 pandemic and its extensive effects, the incidence of posttraumatic stress disorder (PTSD) symptoms is rapidly increasing in China. This research aimed to assess the efficacy and acceptability of a mobile application delivering Acceptance and Commitment Therapy (ACT) in reducing PTSD symptoms. 221 Chinese individuals with elevated PTSD symptoms were randomly assigned to app-delivered ACT (ACT condition), app-delivered mindfulness (MI condition), or a waitlist (WL condition). Assessments were performed pre- and post-intervention. The results showed that participants in both the ACT and MI groups had significantly greater improvements across mental health outcomes compared to the WL group. No significant differences were observed between the ACT and MI groups except for psychological flexibility, which improved more in ACT than MI (d = -0.37). Compared to WL, the ACT group showed a greater improvement in PTSD symptoms (d = -0.79), anxiety (d = -0.62), depression (d = -0.51), posttraumatic growth (d = 0.46), and psychological flexibility (d = 0.76). The drop-out rates in the ACT and MI were 25.76% and 39.71%, respectively. Participants in the ACT condition reported medium program satisfaction. The study suggests app-delivered ACT is efficacious in reducing PTSD symptoms and improving overall mental health among Chinese adults.

The use of Acceptance and Commitment Therapy (ACT) in informal caregivers of people with dementia and other long-term or chronic conditions: A systematic review and conceptual integration.

Informal caregivers are the primary source of support for adults with chronic conditions and disabilities. Empirical research highlights chronic stress and other risks of adverse outcomes of caregiving. Acceptance and Commitment Therapy (ACT) is an emerging evidenced-based practice that shows promise in improving an array of outcomes, theoretically by increasing psychological flexibility as the primary process of change. Research has begun to evaluate ACT among informal caregivers of adult populations, and a systematic review is now needed to summarise this evidence base. Electronic searches from five databases, including PubMed, PsycInfo, Embase, CINAHL, and Cochrane Library, yielded an initial 7896 hits, which after screening for inclusion criteria, resulted in 21 clinical trials. Studies were coded to synthesise the feasibility, effectiveness, and quality of evidence. Findings show that ACT was reported to be largely feasible and acceptable. However, the efficacy of ACT was mixed, with a more consistent pattern for informal caregivers of people with dementia. Several methodological quality issues limited the findings. However, theoretical synthesis and preliminary evidence support the promising effect of ACT in subgroups of informal caregivers. Research on the process of change, as well as larger-scale, methodologically rigorous trials, are needed to consolidate these findings.

Health and nutrition claims for infant formula: international cross sectional survey.

OBJECTIVES: To review available health and nutrition claims for infant formula products in multiple countries and to evaluate the validity of the evidence used for substantiation of claims. DESIGN: International cross sectional survey. SETTING: Public facing and healthcare professional facing company owned or company managed formula industry websites providing information about products marketed for healthy infants delivered at full term in 15 countries: Australia, Canada, Germany, India, Italy, Japan, Nigeria, Norway, Pakistan, Russia, Saudi Arabia, South Africa, Spain, the United Kingdom, and the United States in 2020-22. MAIN OUTCOME MEASURES: Number and type of claims made for each product and ingredient. References cited were reviewed and risk of bias was assessed for registered clinical trials using the Cochrane risk of bias tool, and for systematic reviews using the Risk Of Bias in Systematic reviews tool. RESULTS: 757 infant formula products were identified, each with a median of two claims (range from 1 (Australia) to 4 (US)), and 31 types of claims across all products. Of 608 products with ≥1 claims, the most common claim types were "helps/supports development of brain and/or eyes and/or nervous system" (323 (53%) products, 13 ingredients), "strengthens/supports a healthy immune system" (239 (39%) products, 12 ingredients), and "helps/supports growth and development" (224 (37%) products, 20 ingredients). 41 groups of ingredients were associated with ≥1claims, but many claims were made without reference to a specific ingredient (307 (50%) products). The most common groups of ingredients cited in claims were long chain polyunsaturated fatty acids (278 (46%) products, 9 different claims); prebiotics, probiotics, or synbiotics (225 (37%) products, 19 claims); and hydrolysed protein (120 (20%) products, 9 claims). 161/608 (26%) products with ≥1 claims provided a scientific reference to support the claim-266 unique references were cited for 24 different claim types for 161 products. The reference types most frequently cited were clinical trials (50%, 134/266) and reviews (20%, 52/266). 28% (38/134) of referenced clinical trials were registered, 14% (19/134) prospectively. 58 claims referred to 32 registered clinical trials, of which 51 claims (27 trials) related to a randomised comparison. 46 of 51 claims (90%) referenced registered clinical trial outcomes at high risk of bias, and all cited systematic reviews and pooled analyses, carried a high risk of bias. CONCLUSIONS: Most infant formula products had at least one health and nutrition claim. Multiple ingredients were claimed to achieve similar health or nutrition effects, multiple claims were made for the same ingredient type, most products did not provide scientific references to support claims, and referenced claims were not supported by robust clinical trial evidence.

A systematic review and meta-analysis of self-guided online acceptance and commitment therapy as a transdiagnostic self-help intervention.

Online Acceptance and Commitment Therapy (ACT) interventions use websites and smartphone apps to deliver ACT exercises and skills. The present meta-analysis provides a comprehensive review of online ACT self-help interventions, characterizing the programs that have been studied (e.g. platform, length, content) and analyzing their efficacy. A transdiagnostic approach was taken, including studies that addressed a range of targeted problems and populations. Multi-level meta-analyses were used to nest multiple measures of a single construct within their respective studies. A total of 53 randomized controlled trials were included (n = 10,730). Online ACT produced significantly greater outcomes than waitlist controls at post-treatment for anxiety, depression, quality of life, psychological flexibility, and all assessed outcomes (i.e. omnibus effect), which were generally maintained at follow-up. However, only psychological flexibility and all assessed outcomes at post-treatment were found to be significantly greater for online ACT when compared to active controls, with no significant follow-up effects. Overall, these results further clarify that ACT can be effectively delivered in an online format to target a wide range of mental health concerns, although it is less clear if and when online ACT is more efficacious than other online interventions.

Choosing ACT or CBT: A preliminary test of incorporating client preferences for depression treatment with college students.

BACKGROUND: Depression is a significant concern among college students, who suffer at higher rates and with greater severity than the general population. Online self-help could reduce the burden currently placed on college counseling centers, and programs based in cognitive behavioral therapies (CBTs) have a strong evidence base. However, online CBTs for depression often suffer from low adherence rates. An understudied method for improving adherence in this population is offering students a choice between various CBTs. METHODS: We conducted a randomized trial with 142 students with high levels of depression, with a subset of participants randomly receiving either traditional cognitive behavioral therapy (tCBT) or acceptance and commitment therapy (ACT) and an additional arm who could choose between the two. RESULTS: Both treatments effectively reduced depression over 10 weeks, with ACT showing a slight advantage over tCBT. Surprisingly, students who were randomized to their treatment saw greater reductions in anxiety, and higher adherence to the program, than those who chose between the two. LIMITATIONS: Our study suffered from a notable amount of dropout and our results should be considered preliminary. Our sample size was relatively small at posttreatment, limiting our ability to make strong conclusions about group differences. Additionally, further steps could have been taken to minimize the risk of bias when presenting treatment options to the choice group. CONCLUSIONS: Our preliminary results suggest that simply providing students with an evidence-based resource may be more important than providing options and raise additional questions about the function of client preference in self-help dissemination.

Examining the feasibility and effectiveness of online acceptance and commitment therapy self-help in a quasi-stepped care model: A pilot study.

The global burden of mental illness and limited resources make increasing the efficiency of available mental healthcare resources especially crucial. One way this can be done is a stepped care approach to treatment. To test the viability of using internet-based self-help in a stepped care model, we examined the feasibility, acceptability, and effectiveness of an online self-help acceptance and commitment (ACT) program prior to starting in-person therapy at a university community clinic (N = 51). Online program acceptability was at least moderate. There was clinically significant change in 75.9%-79.3% and reliable change in 31.0%-100% of our sample on three of four outcomes of interest (e.g., symptom impairment) after the online program. In addition, 60%-100% reliably improved from the online program as well as from subsequent treatment on three of four outcomes, indicating that most of our sample progressed through the steps of care effectively and benefited from the quasi-stepped care approach. Scores also indicated positive overall effects of the online program and in-person therapy. Our findings tentatively support the use of low-intensity resources like online self-help programs to reduce therapist burden in outpatient clinics by initiating client progress before intake. Limitation to this approach and the study are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using peer-support coaching to improve adherence to online ACT self-help for college mental health: A randomized controlled trial.

Online self-help programs such as the Acceptance and Commitment Therapy (ACT) Guide address significant barriers to receiving therapy but suffer from low adherence rates. Peer-delivered coaching, using undergraduate students as coaches, is an innovative alternative to traditional coaching methods which may improve adherence in a more scalable format. To test the efficacy of peer-support coaching for college students using ACT Guide in a naturalistic setting, we conducted a pragmatic randomized controlled trial with three conditions (phone coaching, text message coaching, and a no support control group; N = 230). Participants were block randomized, and program adherence (i.e., number of modules completed) was the primary outcome. Participants completed significantly more ACT Guide modules in phone (M = 7.1, SD = 4.9) and text (M = 5.7, SD = 5) coaching than the no support control condition (M = 1.6, SD = 3.3, p < .001). Participants who received phone coaching experienced significant improvements across almost all measured outcomes as compared to the control group, while participants who received text coaching improved only on some outcomes compared to control (ps < .05). These results support peer-support coaching, particularly when delivered through phone calls, as an efficacious method for improving adherence to and outcomes from online self-help programs.

Examining the role of experiential avoidance and valued action in the negative effects of weight self-stigma.

Harmful effects of weight self-stigma on quality of life and health behaviors have been well-established. However, the processes that lead to these negative outcomes are less understood. Psychological inflexibility is defined as a pattern of rigid psychological reactions dominating over values and meaningful actions. A lack in valued action is characterized by the absence of activities that are connected to what is personally meaningful. In this secondary analysis, we aim to extend research by examining two subprocesses of psychological inflexibility, experiential avoidance and lack of valued action, as statistical mediators of the relations between weight self-stigma and quality of life/health behavior outcomes. Baseline data from a clinical trial comparing weight loss maintenance interventions in a sample of 194 adults living with overweight or obesity and seeking treatment is analyzed. Results show that greater experiential avoidance and lower valued action were significantly related to lower quality of life and satisfaction with social roles, as well as greater depression, anxiety, and binge eating. Further, results from a parallel mediation analysis indicated that weight self-stigma is indirectly related to anxiety, disinhibited eating, and hunger through the relationship with experiential avoidance and lack of valued action.

A randomized controlled trial of a multi-modal palliative care intervention to promote advance care planning and psychological well-being among adults with advanced cancer: study protocol.

BACKGROUND: Up to half of adults with advanced cancer report anxiety or depression symptoms, which can cause avoidance of future planning. We present a study protocol for an innovative, remotely-delivered, acceptance-based, multi-modal palliative care intervention that addresses advance care planning (ACP) and unmet psychological needs commonly experienced by adults with metastatic cancer. METHODS: A two-armed, prospective randomized controlled trial (RCT) randomizes 240 adults with Stage IV (and select Stage III) solid tumor cancer who report moderate to high anxiety or depression symptoms to either the multi-modal intervention or usual care. The intervention comprises five weekly two-hour group sessions (plus a booster session one month later) delivered via video conferencing, with online self-paced modules and check-ins completed between the group sessions. Intervention content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based model. Participants are recruited from a network of community cancer care clinics, with group sessions led by the network's oncology clinical social workers. Participants are assessed at baseline, mid-intervention, post-intervention, and 2-month follow-up. The primary outcome is ACP completion; secondary outcomes include anxiety and depression symptoms, fear of dying, and sense of life meaning. Relationships between anxiety/depression symptoms and ACP will be evaluated cross-sectionally and longitudinally and theory-based putative mediators will be examined. DISCUSSION: Among adults with advanced cancer in community oncology settings, this RCT will provide evidence regarding the efficacy of the group ACT intervention on ACP and psychosocial outcomes as well as examine the relationship between ACP and anxiety/ depression symptoms. This trial aims to advance palliative care science and inform clinical practice. TRIAL REGISTRATION: Clinicaltrials.gov NCT04773639 on February 26, 2021.

Online process-based training for perfectionism: A randomized trial.

Process-based therapy (PBT) is model of psychotherapy designed to improve people's ability to use a variety of skills from evidence-based treatments to match environmental needs and personal goals in the moment. This randomized trial tested the effect of an online self-help intervention modeled after PBT principles for participants with perfectionism (N = 77). The intervention comprised two four-session trainings teaching skills from different evidence-based treatments (e.g., cognitive-behavioral therapy, acceptance and commitment therapy) and targeting cognitive and motivational processes: (1) cognitive training and (2) motivational training respectively. Participants completed 17 assessments throughout the intervention and at 3- and 6-month follow-up. Results indicated that the full intervention led to improvement in perfectionism, self-compassion, psychological distress, and cognitive skills targeted by the cognitive intervention (e.g., cognitive defusion; absolute ßs = 0.02 to 0.66). In addition, the second four-session training (i.e., training after first four-session training) was associated with improvements in perfectionism, self-compassion, quality of life, and psychological distress (absolute ßs = 0.09 to 2.90), suggesting it had incremental benefit. Whereas the cognitive training appeared to specifically impact cognitive processes, the motivational training increased both cognitive and motivational processes. These findings provide initial support for the feasibility and efficacy of a process-based approach, because they show that participants can benefit from learning skills from different orientations and applying them with reference to their goals. However, specific aspects of the PBT model, including whether interventions can precisely improve targeted skills, still need to be empirically tested in larger and more diverse clinical samples.

Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors.

BACKGROUND: Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence. PURPOSE: To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence. METHODS: A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation. RESULTS: The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions. CONCLUSIONS: REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.

Skin and nasal colonization of coagulase-negative staphylococci are associated with atopic dermatitis among South African toddlers.

BACKGROUND: Skin colonization with coagulase-negative staphylococci (CoNS) is generally beneficial, but recent investigations suggest its association with flares and atopic dermatitis (AD) severity. However, this relationship remains unclear. OBJECTIVE: To assess patterns of staphylococcal colonization and biofilm formation in toddlers with and without AD from rural and urban South African settings. METHODS: We conducted a cross-sectional study of AD-affected and non-atopic AmaXhosa toddlers from rural Umtata and urban Cape Town, South Africa. CoNS isolates were recovered from lesional, nonlesional skin samples and the anterior nares of participants. Identification of the staphylococci was achieved by MALDI-TOF mass spectrometry. The microtiter plate assay assessed in-vitro biofilm formation. RESULTS: CoNS and S. aureus commonly co-colonized nonlesional skin among cases (urban: 24% vs. 3%, p = 0.037 and rural 21% vs. 6%, p<0.001), and anterior nares in urban cases (24% vs. 0%, p = 0.002) than the control group. S. capitis colonization on nonlesional skin and anterior nares was positively associated with more severe disease in rural (48.3±10.8 vs. 39.7±11.5, P = 0.045) and urban cases (74.9±10.3 vs. 38.4±13, P = 0.004), respectively. Biofilm formation was similar between cases and controls, independent of rural-urban living. CONCLUSION: CoNS colonization is associated with AD and disease severity and may be implicated in AD exacerbations. Studies are needed to understand their underlying pathological contribution in AD pathogenesis.

Tracking Valued and Avoidant Functions with Health Behaviors: A Randomized Controlled Trial of the Acceptance and Commitment Therapy Matrix Mobile App.

This randomized controlled trial evaluated the acceptability and additive effects of self-monitoring avoidant and valued functions of behavior, in the context of self-monitoring physical activity and dietary behavior in a mobile app. The self-monitoring approach was based on the Acceptance and Commitment Therapy (ACT) Matrix. A sample of 102 adults interested in improving their diet and physical activity were randomized to a Health Behavior Tracking app (HBT), HBT plus ACT matrix app (HBT+ACT), or waitlist condition. Online self-report assessments were completed at baseline, mid (2 weeks), and post-intervention (4 weeks). Participants reported high usability, but mixed satisfaction with both apps. About half of the prompted app check-ins were completed on average, with 14% never using the ACT app. Participants in the HBT+ACT app condition reported greater self-reported physical activity over time relative to HBT and waitlist, potentially due to protecting against a decrease over time in physical activity observed in the other two conditions. HBT and HBT+ACT conditions both improved self-reported sedentary behavior relative to waitlist. HBT+ACT improved cognitive restraint with eating more than HBT. Neither the HBT or HBT+ACT app improved other health behavior outcome measures or values processes relative to the waitlist. Overall, findings suggest some benefits of the ACT Matrix app for addressing physical activity by tracking valued/avoidant functions, but mixed findings on acceptability, outcomes, and processes of change suggests impact may be relatively limited.