Feasibility and preliminary efficacy of a theory-informed resistance exercise training single-arm intervention for major depression.

Many adults with major depressive disorder (MDD) do not receive effective treatment. The potential benefits of resistance exercise training (RET) are understudied and may be mechanistically related to cerebral blood flow changes. PURPOSE: To assess feasibility, acceptability, and preliminary efficacy of a 16-week, theory-informed RET trial for the treatment of MDD and explore changes in cerebral blood flow. METHODS: Ten adults with DSM-5-diagnosed MDD were enrolled in a single-arm, 16-week, twice-weekly, whole-body RET intervention, consistent with US and WHO Physical Activity resistance exercise guidelines. To build intrinsic motivation and develop exercise-preparatory habits, motivators and commitment were discussed weekly. Screening, enrollment, and intervention attendance and compliance rates documented feasibility. At baseline and weeks 8, 16, and 26, current MDD diagnosis, clinician-rated, and self-reported symptom severity were evaluated along with cerebral blood flow which was assessed as middle cerebral artery (MCA) mean blood velocity, conductance, and pulsatility. RESULTS: Nine participants completed the intervention. Strong feasibility and acceptability (98 % adherence, 93 % compliance, and 90 % retention) were found. MDD remission was reached by 8/9 participants at week 16 and persisted through week 26. There were large decreases in clinician-rated and self-reported symptoms at each assessment (Hedges' g = 0.84-2.13). There were small-to-moderate increases in MCA velocity (g = 0.32-0.57) and conductance (g = 0.20-0.76) across time, with minimal changes in pulsatility (all g < 0.21). CONCLUSIONS: Preliminary results suggest RET for MDD treatment is feasible and plausibly efficacious, finding large antidepressant effects. A sufficiently powered randomized controlled trial to assess RET's efficacy for treating MDD via potential cerebrovascular mechanisms is warranted.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness.

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Predicting implicit and explicit exercise identity from descriptive social norms regarding exercise.

OBJECTIVES: Exercise identity may promote exercise maintenance. However, less is known about factors that affect exercise identity. Whether descriptive social norms are potential intervention targets for identity development was evaluated. DESIGN: A cross-sectional design using data from the Attitudes, Identities, and Individual Differences (AIID) study was employed - with additional cases collected to increase sample size and power - to evaluate whether descriptive social norms regarding exercise are related to implicit and explicit exercise identities. MAIN OUTCOME MEASURES: Participants completed measures of proximal and distal descriptive social norms regarding exercise, explicit and implicit exercise identity, physical activity behavior, and demographics. Multiple regression was used to assess whether social norms regarding exercise predict exercise identities. RESULTS: Only proximal descriptive social norms were significantly associated with explicit exercise identity, whereas neither proximal nor distal descriptive social norms were associated with implicit exercise identity. The slopes for explicit and implicit identity differed when predicted by distal (but not proximal) descriptive social norms. CONCLUSIONS: Proximal descriptive social norms may be associated with explicit exercise identity and may be a worthy intervention targeting alongside identity to influence change in exercise behavior. More research is needed to further understand these relationships.

Evaluating Objective Metrics of habit strength for taking medications.

Habit strength for taking medication is associated with medication adherence. However, habit strength is typically measured via self-reports, which have limitations. Objective sensors may provide advantages to self-reports. To evaluate whether habit-strength metrics derived from objective sensor data (MEMS® Caps; AARDEX Group) are associated with self-reported habit strength and adherence (objective and self-reported) and whether objective and self-reported habit strength are independently associated with adherence. Patients (N = 79) on oral medications for type 2 diabetes completed self-reports of habit strength and medication adherence and used MEMS® Caps to take their prescribed medication for one month. MEMS® Caps data were used to create five objective metrics of habit strength (e.g., individual-level variance in pill timing) and quantify medication adherence (% days correct dosing). Consistency in behavior from week to week (versus across each day) had the greatest association with self-reported habit strength (r(78) = 0.29, p = 0.01), self-reported adherence (r(78) = 0.32, p = 0.005), and objective adherence (r(78) = 0.61, p < 0.001). Objective and self-reported habit strength were independently associated with adherence. Weekly pill-timing consistency may be more useful than daily pill-timing consistency for predicting adherence and understanding patients' medication-taking habits. Self-reports and objective metrics of habit strength may be measuring different constructs, warranting further research.

Ramifications of behavioural complexity for habit conceptualisation, promotion, and measurement.

Behavioural theories, predictions, and interventions should be relevant to complex, real-world health behaviours and conditions. Habit theory and habit formation interventions show promise for predicting and promoting, respectively, longer-term behaviour change and maintenance than has been attained with theories and interventions focused only on deliberative behavioural factors. However, the concept of habit has largely been treated as uniform across different types of behaviours. In this conceptual review, we contend that the definitional aspects of habit differ at a conceptual level for simple versus more complex behaviours, with ramifications for prediction, promotion, and measurement of habits. Specifically, habits are defined as direct context-response associations learned through repeatedly rewarded responding - but what is meant by 'response' and 'reward' depends upon the complexity of the behaviour. We review literature that suggests (1) responses in complex habits have separable and substitutable components (vs a single and static, unitary component) and (2) rewards for complex habits are necessarily continued and intrinsic (vs temporary and extrinsic, respectively). We discuss some empirical and theoretical questions raised by these issues around behavioural complexity and habit. Lastly, we outline the ramifications of these issues for habit measurement (habit strength and habit formation) via self-report and objective measures.

Corrigendum: Evaluating behavior change factors over time for a simple vs. complex health behavior.

[This corrects the article DOI: 10.3389/fpsyg.2022.962150.].

The utility of the integrated behavior change model as an extension of the theory of planned behavior.

Introduction: There are several widely used theories of health behavior change, which mostly utilize the social cognitive approach. These theories tend to posit that intention is a direct predictor of behavior, do not include automatic influences on behavior, and propose a one-size-fits-all theory for both initiators and maintainers. However, the intention-behavior gap is a well-observed phenomenon, researchers have highlighted that both automatic and reflective factors promote behavioral engagement, and predictors of behavior have been shown to differ between initiators and maintainers-three issues that necessitate theory advancement. To that end, the present research compares the utility of the Integrated Behavior Change Model (IBCM) - a social cognitive model that includes automatic factors involved in behavioral engagement and a moderator of the intention-behavior gap - to its theoretical predecessor, the Theory of Planned Behavior (TPB). Further, the relevance of the IBCM factors for predicting exercise behavior is compared in initiators versus maintainers. Method: Participants were 494 US undergraduates. Participants reported on variables from the IBCM (and TPB) at baseline and reported on their exercise behavior in two surveys at seven- and 14-days post-baseline. Results: Findings supported the first hypothesis that the IBCM would be more relevant for initiators in comparison with maintainers, using structural equation modeling. Specifically, only the paths between intrinsic motivation and affective attitude, affective attitude and intention, and intention and behavior were reliably found for maintainers. For initiators, the aforementioned paths were also reliably supported and the additional following paths were also supported: intrinsic motivation and perceived behavioral control, perceived behavioral control and intention, and intention and action planning. However, results did not support the second hypothesis that the IBCM would predict significantly more variance in behavior than its theoretical predecessor, the TPB. Specifically, the addition of action planning, implicit attitude, implicit motivation, and the interaction between intention and action planning only predicted an additional 0.3% (p < 0:05) of the variance in exercise behavior above and beyond intention. Conclusion: Results highlight the continued need for theoretical refinement in terms of delineating mechanisms of initiation and maintenance and the need for further development in terms of improving upon current predictions of behavior engagement and change.

Evaluating behavior change factors over time for a simple vs. complex health behavior.

Background: Researchers are working to identify dynamic factors involved in the shift from behavioral initiation to maintenance-factors which may depend on behavioral complexity. We test hypotheses regarding changes in factors involved in behavioral initiation and maintenance and their relationships to behavioral frequency over time, for a simple (taking a supplement) vs. complex (exercise) behavior. Methods: Data are secondary analyses from a larger RCT, in which young adult women, new to both behaviors, were randomly assigned to take daily calcium (N = 161) or to go for a daily, brisk walk (N = 171), for 4-weeks. Factors (intentions, self-efficacy, intrinsic motivation, self-identity, habit strength) were measured weekly. Multi-level modeling evaluated their change over time. Bivariate correlations and multiple regression determined the relationships between factors and the subsequent-week behavioral frequency (self-report and objective). Finding: Results were partly in-line with expectations, in that individuals' intentions and self-efficacy predicted initial behavioral engagement for both behaviors, and habit strength increased for both behaviors, becoming a significant predictor of behavioral frequency in later weeks of the study in some analyses. However, results depended on whether the outcome was self-reported or objectively measured and whether analyses were bivariate or multivariate (regression). Discussion: The factors theorized to play a role in behavioral maintenance (intrinsic motivation, self-identity, and habit strength) started to develop, but only habit strength predicted behavioral frequency by study-end, for both behaviors. Differences in initiation and maintenance between behaviors of differing complexity may not be as stark as theorized, but longer follow-up times are required to evaluate maintenance factors.

Contrasting constructs or continuum? Examining the dimensionality of body appreciation and body dissatisfaction.

Individuals experiencing body dissatisfaction have poorer health outcomes in part due to engaging in less physical activity. Body appreciation is protective of health behaviors and proposed to be conceptually different from body dissatisfaction. Two studies evaluated whether body appreciation and dissatisfaction represented two distinct dimensions, and whether body appreciation and dissatisfaction would interact in their effect on activity-related motivation and behavior. Study 1 (n = 313) was prospective and utilized a self-report measure of physical activity whereas Study 2 (n = 123) was prospective and used an objective measure. All hypotheses and analyses were pre-registered. A multiverse approach was taken to demonstrate the robustness of results. In exploratory factor analyses, body appreciation and dissatisfaction did not represent two distinct dimensions of body image as both loaded onto the same factor. This result was largely supported by latent profile analyses, which revealed that participants scored high, moderate, or low on both body satisfaction and appreciation. Additionally, body appreciation did not buffer the negative impact of body dissatisfaction on activity-related motivation and behavior. This study provides the first statistical evaluation of the theoretical proposition that body appreciation and dissatisfaction may be distinct constructs with distinct relationships to outcomes.

Source-Orientation and Avoidance/Approach-Orientation are Important Components of Introjected Regulation for Leisure-Time Physical Activity.

Introjected regulation has been inconsistently linked to physical activity, which may be due to it being an umbrella construct for different types of introjected regulation that have the potential to be differentially related to behavior. We evaluated (1) whether self-oriented approach, self-oriented avoidance, other-oriented approach, and other-oriented avoidance were distinct constructs from one another and from identified regulation, and (2) whether the following were related to physical activity engagement from strongest to weakest: self-oriented approach, self-oriented avoidance, other-oriented approach, and other-oriented avoidance. Behavioral regulations were measured at baseline, physical activity was measured via self-report at baseline and follow-up, and using daily diaries (N = 336). A factor analysis revealed a four-factor solution: general approach, self-oriented avoidance, other-oriented avoidance, and identified regulation. Self-oriented avoidance was the strongest predictor of physical activity, followed by general approach, and other-oriented avoidance. Including measures that capture these subdimensions of introjected regulation in future research has the potential to clarify inconsistent relationships in the literature.

Time-of-Day Differences in Treatment-Related Habit Strength and Adherence.

BACKGROUND: Many of our daily behaviors are habitual, occurring automatically in response to learned contextual cues, and with minimal need for cognitive and self-regulatory resources. Behavioral habit strength predicts adherence to actions, including to medications. The time of day (morning vs. evening) may influence adherence and habit strength to the degree that stability of contexts/routines varies throughout the day. PURPOSE: The current study evaluates whether patients are more adherent to morning versus evening doses of medication and if morning doses show evidence of greater habit strength than evening doses. METHODS: Objective adherence data (exact timing of pill dosing) were collected in an observational study by electronic monitoring pill bottles in a sample of patients on twice-daily pills for Type 2 diabetes (N = 51) over the course of 1 month. RESULTS: Data supported the hypothesis that patients would miss fewer morning than evening pills. However, counter to the hypothesis, variability in dose timing (an indicator of habit strength) was not significantly different for morning versus evening pills. CONCLUSIONS: Findings suggest that medication adherence may be greater in the morning than in the evening. However, more research is needed to evaluate the role of habitual action in this greater adherence. Furthermore, future research should evaluate the validity of behavioral timing consistency as an indicator of habit strength.

Accelerating Our Science: Finding Innovative Solutions to Tomorrow's Health Challenges.

This introduction to the special issue outlines key ways that behavioral medicine researchers can accelerate their science. The authors highlight the 2020 Society of Behavioral Medicine's annual meeting plenary sessions, that fit this theme.

Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors.

BACKGROUND: Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship. METHODS: The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis. RESULTS: Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior. CONCLUSIONS: These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Cultural incongruity predicts adjustment to college for student veterans.

Little is known about what predicts student service members' and veterans' (SSM/V) adjustment to college. In qualitative research, SSM/V report feeling they do not belong and are misunderstood by college communities, a phenomenon that counseling psychologists call cultural incongruity. The goal of the current study was to quantitatively examine the relationship between cultural incongruity and adjustment to college. We surveyed 814 SSM/V about their adjustment to college using the Student Adaptation to College Questionnaire. Cultural incongruity was operationalized in two ways: feelings of not belonging were measured via direct report and the association with adjustment to college assessed with regression. Feelings of being misunderstood about academic barriers were assessed by comparing SSM/V's perceptions of academic barriers and SSM/V's perceptions of how others view the SSM/V's academic barriers and the association with adjustment was assessed using polynomial regression and response surface analysis. Cultural incongruity predicted adjustment to college. After controlling for other known predictors, feelings of not belonging accounted for 18% of the variance in adjustment to college. Polynomial regression showed that feeling understood about academic barriers protected against the negative impact of the barrier on adjustment to college. Cultural incongruity predicts adjustment to college for SSM/V. Helping SSM/V feel their unique barriers to college adjustment are understood may blunt the impact of these barriers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mutual maintenance of PTSD and physical symptoms for Veterans returning from deployment.

Background: The mutual maintenance model proposes that post-traumatic stress disorder (PTSD) symptoms and chronic physical symptoms have a bi-directional temporal relationship. Despite widespread support for this model, there are relatively few empirical tests of the model and these have primarily examined patients with a traumatic physical injury. Objective: To extend the assessment of this model, we examined the temporal relationship between PTSD and physical symptoms for military personnel deployed to combat (i.e., facing the risk of death) who were not evacuated for traumatic injury. Methods: The current study used a prospective, longitudinal design to understand the cross-lagged relationships between PTSD and physical symptoms before, immediately after, 3 months after, and 1 year after combat deployment. Results: The cross-lagged results showed physical symptoms at every time point were consistently related to greater PTSD symptoms at the subsequent time point. PTSD symptoms were related to subsequent physical symptoms, but only at one time-point with immediate post-deployment PTSD symptoms related to physical symptoms at three months after deployment. Conclusion: The findings extend prior work by providing evidence that PTSD and physical symptoms may be mutually maintaining even when there is not a severe traumatic physical injury.

Antecedentes: El modelo de mantención mutua propone que los síntomas de TEPT y los síntomas físicos crónicos tienen una relación temporal bidireccional. A pesar del apoyo ampliamente difundido para este modelo, existen relativamente pocas pruebas empíricas del modelo y éstas sólo estudian a pacientes hospitalizados por una lesión traumática.Objetivo: Para extender el estudio de este modelo, estudiamos la relación temporal entre síntomas de TEPT y síntomas físicos en personal militar desplegado en combate (por ej., enfrentando riesgo de muerte), quienes no fueron evacuados por lesión traumática.Métodos: El presente estudio utilizó un diseño prospectivo de correlaciones cruzadas para comprender las relaciones entre síntomas de TEPT y síntomas físicos antes, inmediatamente después, 3 meses después, y 1 año después tras el despliegue de combate.Resultados: Los resultados de correlación cruzada mostraron que los síntomas físicos en cada punto temporal estuvieron consistentemente relacionados con mayores síntomas de TEPT al siguiente punto temporal (λ1=.15, λ2=.16 and λ3 =.27). Los síntomas de TEPT se relacionaron con síntomas físicos posteriores, pero sólo en un punto temporal; los síntomas de TEPT inmediatamente tras despliegue se relacionaron con síntomas físicos a los 3 meses tras despliegue (=.28).Conclusión: Los resultados extienden los trabajos previos al proveer evidencia de que síntomas de TEPT y síntomas físicos se mantienen mutuamente incluso cuando no existe una lesión física traumática severa.

The influence of body dissatisfaction on cardiovascular and strength-based physical activity by gender: a self-determination theory approach.

Physical activity-or lack thereof-is one behaviour that may help explain why individuals who are dissatisfied with their bodies experience poor health outcomes. OBJECTIVE: The purpose of the present study was to examine the mediating role of behavioural regulations (i.e., autonomous and controlled) in the relation between body dissatisfaction and physical activity and to determine whether this mediated relationship was moderated by gender. Additionally, this relation was examined for both cardiovascular and strength-based physical activity. DESIGN: A two-week daily-diary study was conducted. MEASURES: The Body Shape Satisfaction Questionnaire, the Behavioural Regulation in Exercise Questionnaire - 3, and the International Physical Activity Questionnaire were used to test the main hypotheses. RESULTS: For men and women, body dissatisfaction was related to less frequent cardiovascular and strength-based activity due to lower levels of intrinsic regulation. In women, the relation between body dissatisfaction and activity (cardiovascular and strength-based) was partially mediated by controlled regulations (i.e., external and introjected). That is, women who were dissatisfied exercised more because they were more likely to feel that they had to appease others or themselves. CONCLUSION: The present study provides direction for targeting physical activity behaviours in college students who are dissatisfied with their bodies.

Experimental test of a planning intervention for forming a 'higher order' health-habit.

Objective: Habit-formation interventions may help individuals initiate and maintain behaviour change. This paper proposes and empirically tests the idea that it is possible for individuals to form 'higher-order habits', or behaviours that can be executed in more than one way, and still be habitual. Design: Participants (N = 82) were healthy adults randomly assigned to an action-and-coping-planning intervention for forming a 'higher-order habit' of filling half of their dinner plates with fruits and vegetables or a control condition. Key measures were collected at baseline and 1, 2 and 3 weeks post-baseline. Participants submitted 3 pictures per week of their dinner plates via snapchat/email. Main Outcome Measures: Intrinsic motivation, habit strength and behavioural frequency for filling half their dinner plates with fruits and vegetables. Results: Intervention participants reported significantly greater habit strength at each follow-up time point. Controls did show some degree of habit formation, despite not fully forming a habit. Behavioural automaticity increased despite consuming a variety of fruits/vegetables; results did not depend on participants' intrinsic motivation to consume fruits/vegetables. Conclusion: It may be possible for individuals to form 'higher-order' habits, which may be particularly important in health contexts, in which many target behaviours are complex and can be seen as higher-order.

Evaluating Motivational Interviewing and Habit Formation to Enhance the Effect of Activity Trackers on Healthy Adults' Activity Levels: Randomized Intervention.

BACKGROUND: While widely used and endorsed, there is limited evidence supporting the benefits of activity trackers for increasing physical activity; these devices may be more effective when combined with additional strategies that promote sustained behavior change like motivational interviewing (MI) and habit development. OBJECTIVE: This study aims to determine the utility of wearable activity trackers alone or in combination with these behavior change strategies for promoting improvements in active and sedentary behaviors. METHODS: A sample of 91 adults (48/91 female, 53%) was randomized to receive a Fitbit Charge alone or in combination with MI and habit education for 12 weeks. Active and sedentary behaviors were assessed pre and post using research-grade activity monitors (ActiGraph and activPAL), and the development of habits surrounding the use of the trackers was assessed postintervention with the Self-Reported Habit Index. During the intervention, Fitbit wear time and activity levels were monitored with the activity trackers. Linear regression analyses were used to determine the influence of the trial on outcomes of physical activity and sedentary time. The influence of habits was examined using correlation coefficients relating habits of tracker use (wearing the tracker and checking data on the tracker and associated app) to Fitbit wear time and activity levels during the intervention and at follow-up. RESULTS: Regression analyses revealed no significant differences by group in any of the primary outcomes (all P>.05). However, personal characteristics, including lower baseline activity levels (beta=-.49, P=.01) and lack of previous experience with pedometers (beta=-.23, P=.03) were predictive of greater improvements in moderate and vigorous physical activity. Furthermore, for individuals with higher activity levels at the baseline, MI and habit education were more effective for maintaining these activity levels when compared with receiving a Fitbit alone (eg, small increase of ~48 steps/day, d=0.01, vs large decrease of ~1830 steps/day, d=0.95). Finally, habit development was significantly related to steps/day during (r=.30, P=.004) and following the intervention (r=.27, P=.03). CONCLUSIONS: This study suggests that activity trackers may have beneficial effects on physical activity in healthy adults, but benefits vary based on individual factors. Furthermore, this study highlights the importance of habit development surrounding the wear and use of activity trackers and the associated software to promote increases in physical activity. TRIAL REGISTRATION: ClinicalTrials.gov NCT03837366; https://clinicaltrials.gov/ct2/show/NCT03837366.