Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial.

BACKGROUND: Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative. OBJECTIVE: This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program's impact on secondary psychosocial outcomes and explore potential change mechanisms. METHODS: Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences. RESULTS: Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=-0.68, 95% CI -1.00 to -0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size. CONCLUSIONS: Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches. TRIAL REGISTRATION: ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/44210.

Patients with depression symptoms are more likely to experience improvements of internet-based cognitive behavioral therapy: a secondary analysis of effect modifiers in patients with non-cardiac chest pain in a randomized controlled trial.

BACKGROUND: Non-cardiac chest pain is common and associated with increased anxiety and reduced health-related quality of life. Randomized controlled trials on psychological interventions for patients with non-cardiac chest pain have reported mixed results. Patients with non-cardiac chest pain are a heterogeneous group. Identifying sub-groups that could potentially benefit more (or less) from an intervention would be valuable knowledge. We have conducted a randomized controlled trial where internet-based cognitive behavioural therapy (iCBT) had effect on reducing cardiac anxiety and increasing health-related quality of life at 12-month follow-up. The aim of the present study was to explore potential effect modifiers of iCBT in patients with non-cardiac chest pain on cardiac anxiety and/or health related quality of life at 12-month follow-up. METHODS: We analysed data from our randomized, controlled trial where 161 patients with non-cardiac chest pain were included and randomized to either iCBT or a treatment as usual (control). Cardiac anxiety measured by the Cardiac Anxiety Questionnaire and health-related quality of life measured by the EuroQol Visual Analog Scale at 12 month follow-up were the primary outcomes. Four potential baseline characteristics where identified as potential effect modifiers by a theory-based approach: (1) depression measured by the Patient Health Questionnaire; (2) anxiety measured by the Body Sensations Questionnaire; (3) prior healthcare contacts measured by a self-developed question; and (4) chest pain frequency measured by a self-developed question. Each potential effect modifier was analysed in a linear regression model where cardiac anxiety and EQ-VAS scores at 12-month follow-up, separately, were used as dependent variables. The potential differential treatment effect for each effect modifier was assessed by the interaction term: effect modifier x treatment group. RESULTS: Depression symptoms at baseline predicted a differential treatment effect at 12-month follow-up on health-related quality of life in favor of the iCBT group (regression coefficient of the interaction term: -1.85 (CI -3.28 to -0.41), p = 0.01), but not on cardiac anxiety at 12-month follow-up. Fear of bodily symptoms, chest pain frequency and prior health care contacts at baseline did not predict a treatment effect on either health-related quality of life or cardiac anxiety. CONCLUSIONS: Depression symptoms at baseline predicted a positive treatment effect of iCBT on health-related quality of life in patients suffering from non-cardiac chest pain. This indicates that it is important to identify patients with non-cardiac chest pain and co-occurring depression symptoms given that they are particularly likely to benefit from iCBT. TRIAL REGISTRATION: ClinicalTrials.gov NCT03096925 .

Perceived interpersonal competence as a predictor of clinical outcomes in a randomized controlled trial for social anxiety and employment.

This study explored relationships among perceived interpersonal competence and demographic and work history variables in a randomized control trial for social anxiety disorder (SAD) that compared work-related group cognitive behavioral therapy plus vocational services (WCBT+VSAU) to vocational services only (VSAU-alone). Intervention effects of perceived interpersonal competence on treatment outcomes over 12 weeks were also examined. Data from 250 job seekers with SAD (59.2% Female; 40.8% Black/African American; 82.4% Non-Hispanic/non-Latino/a) were analyzed. We predicted negative relationships between perceived interpersonal competence and symptoms/impairment and that individuals with lower perceived interpersonal competence would benefit more quickly in WCBT+VSAU relative to VSAU-alone. Results indicated that perceived interpersonal competence did not vary by gender, race, ethnicity, homeless status, or employment history. There were no intervention effects of perceived interpersonal competence regarding social anxiety or overall functional impairment, but results supported negative relationships between perceived interpersonal competence and lower social anxiety and overall functional impairment in both conditions. Separately, perceived interpersonal competence moderated effects in the depression model such that there were faster declines in depression at lower perceived interpersonal competence levels in WCBT+VSAU, but not in VSAU-alone. Results indicate the value of attending to perceived interpersonal competence in interventions, which may result in mood benefits.

Entertain Me Well: An Entertaining, Tailorable, Online Platform Delivering CBT for Depression.

Depression prevalence is high, impacting approximately 20% of Americans during their lifetime, and on the rise due to stress and loss associated with the COVID-19 pandemic. Despite the high prevalence of depression, unacceptable treatment access disparities persist. When depression goes untreated, it leads to substantial negative impacts in multiple life domains. Cognitive behavioral therapy (CBT), the gold-standard psychosocial treatment for depression, remains largely unavailable to individuals living with depression, particularly individuals who are members of underrepresented groups in our society. Digital mental health interventions (DMHI) have led to important advances in extending the reach of CBT for depression; however, they are underutilized and treatment engagement remains low. We sought to address some of the current gaps in DMHI by developing an online platform for delivering CBT for depression that is entertaining, simple and straightforward, and tailorable. First, this article introduces our online platform, Entertain Me Well (EMW) and its key innovations, including the use of an engaging, character-driven storyline presented as "episodes" within each session, as well as customizable content that allows for tailoring of text, images, and examples to create content most relevant to the target client population, context, or setting. Next, we describe two EMW depression treatment programs that have been tailored: one for delivery in the rural church setting, called Raising Our Spirits Together, and one tailored for delivery in dialysis centers, called Doing Better on Dialysis. Finally, we discuss future directions for the EMW platform, including the ability to create programs for other common mental health and health conditions, the development of additional character-driven storylines with greater treatment personalization, translation of content in multiple languages, and the use of additional technological innovation, such as artificial intelligence like natural language processing, to enhance platform interactivity.

Mental health provider perspectives of the COVID-19 pandemic impact on service delivery: a focus on challenges in remote engagement, suicide risk assessment, and treatment of psychosis.

BACKGROUND: The COVID-19 pandemic has been impacting the need, utilization, and delivery of mental health services with greater challenges being faced by clients and providers. With many clients facing reduced access to services and social isolation, a focus on suicide risk assessment and prevention is critical. Concern is particularly increased for clients with schizophrenia spectrum disorders given data show suicide rates are disproportionately high for those with psychosis in comparison to the general population. Provider perspectives of challenges in service delivery are needed to inform efforts to improve access, feasibility, and quality of mental health care throughout the evolving pandemic. This study explored mental health provider perspectives of client challenges in service utilization and provider challenges in service delivery, including remote engagement, suicide risk assessment, and treatment of psychosis. METHODS: Data were collected from social work mental health providers (n = 12) in United States community mental health setting. Providers consented to participate and responded to questions about service delivery experiences in late 2020 and in relation to COVID-19. Demographic and practice-related provider data were explored descriptively using SPSS and qualitative data using open coding and grounded theory methods in Dedoose. RESULTS: Among the 9 providers who engaged in remote service delivery, 7 (77.8%) experienced challenges in remote engagement with clients and 8 (88.9%) experienced challenges in treatment of psychosis. Among the 7 providers who engaged in remote suicide assessment, 4(57%) experienced challenges. Qualitative themes emerged including logistic (e.g., technology access and use), engagement (e.g., virtual rapport-building and limited remote services), and clinical (e.g., difficulty assessing suicide risk, internal stimuli, abnormal involuntary movement, and affect) challenges in service delivery. CONCLUSIONS: Provider perspectives are essential to inform efforts to build resources and problem-solve challenges and barriers that both providers and clients face throughout various shifts in mental health service delivery. Findings emphasize the need to troubleshoot client access to technology, bolster support for providers to prevent burnout, and greater provider training to improve skills in remote engagement, assessment, and treatment, particularly in relation to psychosis and suicide prevention. Study implications are not only critical for the evolving COVID-19 pandemic, but also in preparation for ongoing shifts in service delivery as technology evolves.

Effectiveness of Internet-Based Cognitive Behavioral Therapy With Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial.

BACKGROUND: Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. OBJECTIVE: In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. METHODS: We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. RESULTS: In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (-3.4 points, 95% CI -5.7 to -1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (-2.7 points, 95% CI -5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. CONCLUSIONS: This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925.

Technology-Assisted, Group-Based CBT for Rural Adults' Depression: Open Pilot Trial Results.

Purpose: This pilot study assesses the association of Raising Our Spirits Together (ROST), a technology-assisted, group-based cognitive behavioral therapy for depression, with rural adults' depressive symptoms and anxiety. Method: Nine adults from rural Michigan participated in an open pilot of ROST. Clergy facilitated pilot groups. The pilot began in February 2020 in-person. Due to COVID-19, the pilot was completed virtually. Results: Mean depressive symptom scores, based on the PHQ-9, significantly decreased from pre-treatment (M = 14.4) to post-treatment (M = 6.33; t (8) = 6.79; P < .001). Symptom reduction was maintained at 3-month follow-up (M = 8.00), with a significant pattern of difference in depressive symptoms over time (F(2) = 17.7; P < .001; eta-squared = .689). Similar patterns occurred for anxiety based on the GAD-7. Participants attended an average of 7.33 of 8 sessions. Fidelity ratings were excellent. Discussion: ROST is a potentially feasible intervention for rural adults' depressive symptoms. ROST offers a promising model for increasing treatment access and building capacity in rural areas.

Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: a systematic review and meta-analysis.

Background: This study aimed to review and synthesize evidence related to the effectiveness of internet-based cognitive behavioral therapy (iCBT) for reducing depressive symptoms in older adults.Method: The authors conducted a systematic review of intervention studies testing iCBT for symptoms of depression in older adults. An initial search of PubMed, PsychINFO, and Web of Science was undertaken, followed by a manual search of reference lists of the relevant articles. The Cochrane Risk of Bias Tool was used to appraise study quality. The mean effect size for included studies was estimated in a random effects model. Meta-regression was used to examine potential moderators of effect sizes.Results: Nine studies met the inclusion criteria, including 1272 participants averaging 66 years of age. The study design included randomized controlled trials (k = 3), controlled trials without randomization (k = 2), uncontrolled trials (k = 2), and naturalistic evaluation (k = 2). Seven studies tested iCBT with some level of therapist involvement and 2 examined self-guided iCBT. Six studies tested interventions specifically adapted for older adults. The mean within-group effect size was 1.27 (95% CI = 1.09, 1.45) and the mean between-group effect size was 1.18 (95% CI = 0.63, 1.73). Participants' age was negatively associated with within-group effect sizes (b = -0.06, p = .016).Conclusions: iCBT is a promising approach for reducing depressive symptoms among older adults with mild to moderate depressive symptoms. However, studies involving older adults in iCBT trials were limited, had considerable heterogeneity, and were of low quality, calling for more studies with rigorous designs to produce a best-practice guideline.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States.

BACKGROUND: Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers. OBJECTIVES: We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications. METHODS: We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability. RESULTS: Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints. CONCLUSIONS: Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Early maladaptive schemas impact on long-term outcome in patients treated with group behavioral therapy for obsessive-compulsive disorder.

BACKGROUND: Some studies have previously found that certain elevated early maladaptive schemas (EMSs) are negative predictors for outcome for patients with obsessive-compulsive disorder (OCD) treated with Cognitive-Behavioral Therapy (CBT) or Exposure and Response Prevention (ERP). The current study explores whether EMS were related to reductions in OCD symptom severity at long-term follow-up (Mean = 8 years) after group ERP for patients with OCD. The central hypothesis was that patients with no response to treatment or patients who relapsed during the follow-up period were more likely to have elevated pre-treatment EMSs compared to those who responded to initial treatment and maintained gains over time. We also investigated whether there were any differences in change over time of overall EMS between patients who were recovered versus patients who were not recovered at extended follow-up. METHODS: Young Schema Questionnaire -Short Form (YSQ-SF), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) were measured in 40 OCD patients in a general outpatient clinic before and after group ERP, after 12-months and at extended follow-up. To analyze the predictors, a multiple regression analyses was conducted. Changes in overall EMS was analyzed by mixed models procedures. RESULTS: The major finding is that patients with high pre-treatment YSQ-SF total scores were less likely to respond to initial treatment or were more likely to relapse between post-treatment and the extended follow-up. The YSQ-SF total score at pre-treatment explained 10.5% of the variance of extended long-term follow-up outcome. The entire sample experienced a significant reduction in overall EMS over time with largest reduction from pre- to post-test. There were no statistically significant differences in total EMS change trajectories between the patients who were recovered at the extended follow-up compared to those who were not. CONCLUSION: The results from the present study suggest that patients with higher pre-treatment EMSs score are less likely to recover in the long-term after receiving group ERP for OCD. A combined treatment that also targets early maladaptive schemas may be a more effective approach for OCD patients with elevated EMS who don't respond to standard ERP.

Major Depression and Subthreshold Depression among Older Adults Receiving Home Care.

OBJECTIVE: This study aims to estimate the prevalence and correlates of major and subthreshold depression and the extent of treatment utilization in older adults receiving home care. METHODS: The study sample included 811 community-dwelling adults aged 60 and over who received paid home care during the 2008-2014 waves of the Health and Retirement Study. Depression was assessed using short forms of the Composite International Diagnostic Interview and the Center for Epidemiologic Studies Depression Scale. Logistic regression was used to examine correlates of depression type and treatment utilization. RESULTS: One in two older home care recipients suffered from probable depression; 13.4% of the sample suffered from major depression and an additional 38.7% met study criteria for subthreshold depression. The majority (72.7%) of participants with major depression and almost half (44.5%) of participants with subthreshold depression reported taking medication for anxiety or depression. One-third (33.2%) of older home care recipients with major depression and 14.2% of those with subthreshold depression reported receiving formal psychiatric or psychological treatment. Males as compared with females and persons with pain problems as compared with no pain complaints had a higher risk of subthreshold and major depression. The receipt of medication or psychiatric treatment declined with age. African Americans were less likely to receive medication for anxiety or depression compared with non-Hispanic whites. CONCLUSION: Depression affects a substantial proportion of older adults receiving home care and may be inappropriately treated. Future research is needed to develop optimal strategies for integrating depression assessment and treatment into home care.

Differences in Mental Health Service Use Among Unemployed Veterans of Different Eras.

Mental disorders have been linked to unemployment among veterans. Improving mental health conditions, such as depression, can improve veteran employment outcomes. This study compared mental health treatment among unemployed Operation Enduring Freedom (OEF; in Afghanistan) and Operation Iraqi Freedom (OIF; in Iraq) veterans and veterans from other service eras. The study included 3165 unemployed veterans from six Veterans Affairs medical centers with a positive screen that indicates a possible mental disorder. Chi-squared tests and logistic regression analyses assessed whether veteran era was associated with mental health treatment. Unemployed OEF/OIF veterans were less likely to receive psychotropic medication and four or more psychotherapy sessions compared to veterans from other eras. Multivariable analyses controlling for age found associations based on younger age rather than era. Younger unemployed veterans received fewer mental health services, which is concerning because reducing mental health symptoms may increase employment and employment may reduce symptoms, which are key factors in reintegration into civilian life.

Family, friends, and 12-month PTSD among African Americans.

PURPOSE: Despite a growing literature on the influence of social support on mental health, little is known about the relationship between social support and specific psychiatric disorders for African Americans, such as PTSD. This study investigated the relationship between social support, negative interaction with family and 12-month PTSD among African Americans. METHODS: Analyses were based on a nationally representative sample of African Americans from the National Survey of American Life (n = 3315). Social support variables included emotional support from family, frequency of contact with family and friends, subjective closeness with family and friends, and negative interactions with family. RESULTS: Results indicated that emotional support from family is negatively associated with 12-month PTSD while negative interaction with family is predictive of 12-month PTSD. Additionally, a significant interaction indicated that high levels of subjective closeness to friends could offset the impact of negative family interactions on 12-month PTSD. CONCLUSIONS: Overall, study results converged with previously established findings indicating that emotional support from family is associated with 12-month PTSD, while, negative interaction with family is associated with increased risk of 12-month PTSD. The findings are discussed in relation to prior research on the unique association between social support and mental health among African Americans.

Are women's parenting-specific beliefs associated with depressive symptoms in the perinatal period? Development of the rigidity of maternal beliefs scale.

BACKGROUND: Perinatal depression negatively impacts women, parenting, and children's development. However, not much is known about maternal specific beliefs that may be associated with perinatal depression. We created a new measure that examined the rigidity of perinatal women's beliefs in three major domains suggested to be closely related to mood and behavior: anticipated maternal self-efficacy, perceptions of child vulnerability, and perceptions of societal expectations of mothers (PSEM). METHODS: A 26-item measure (the Rigidity of Maternal Beliefs Scale, RMBS) was developed and completed by women at two time points, pregnancy (n = 134) and postpartum (n = 113), along with the Edinburgh Postnatal Depression Scale. Exploratory factor analysis (EFA) examined the factor structure of the RMBS and validity and reliability were also tested. RESULTS: The EFA suggested that a four-factor solution was most interpretable, with few items cross-loading, and there were common themes that unified the items in each factor, resulting in a 24-item final measure. Cronbach's alpha confirmed the internal consistency, whereas bivariate correlations revealed the measure had good test-retest reliability, discriminant validity, and convergent validity. Regression analyses established predictive validity of the RMBS for postpartum depressive symptoms. CONCLUSIONS: The RMBS may be useful with clinical populations to identify maladaptive or rigid thoughts that could be a focus of intervention. This tool may also be used to guide conversation about motherhood expectations within any context where pregnant women present (e.g., prenatal care, social services), as well as potentially identifying women who are at risk for postpartum depression in clinical contexts.

Psychotic and schizotypal symptoms in non-psychotic patients with obsessive-compulsive disorder.

BACKGROUND: Research is scarce with regard to the role of psychotic and schizotypal symptoms in treatment of obsessive-compulsive disorder (OCD). The aim of the current study was to investigate the occurrence and specificity of psychotic and schizotypal symptoms among non-psychotic OCD patients, and to examine whether such symptoms was associated with response to exposure and response prevention (ERP), and whether ERP for OCD had an impact on psychotic and schizotypal symptoms. METHODS: Non-psychotic OCD patients (n = 133) and a general non-psychotic psychiatric outpatient sample (n = 110) were assessed using self-report inventories before and after psychological treatment. RESULTS: Non-psychotic OCD patients did not report greater degree of psychotic or schizotypal symptoms than the control group. Psychotic and schizotypal symptoms were not associated with OCD symptoms before or after ERP. Psychotic and schizotypal symptom were significantly reduced following ERP. CONCLUSIONS: Psychotic and schizotypal symptoms seem to be equally prevalent among non-psychotic OCD patients and non-psychotic psychiatric controls. These symptoms were more linked to depressive symptoms than OCD symptoms. In non-psychotic OCD patients, ERP seems sufficient in reducing OCD symptoms despite the presence of psychotic- and schizotypal symptoms, and reductions in psychotic- and schizotypal symptoms were observed following ERP.

Family and friendship informal support networks and social anxiety disorder among African Americans and Black Caribbeans.

BACKGROUND: This study explores relationships between Social Anxiety Disorder (SAD) and quality and frequency of involvement with family and friends. METHODS: Data are from a nationally representative sample of African American and Black Caribbean adults (n = 5191), the National Survey of American Life. SAD was assessed using the DSM-IV World Mental Health Composite International Diagnostic Interview. RESULTS: Findings indicated that among both populations, close supportive ties with family members and friends are protective against meeting criteria for SAD. Negative interactions with family (e.g., conflicts), however, are a risk factor for SAD among both African Americans and Black Caribbeans. For African Americans, an interaction indicates that the relationship between negative interaction and social anxiety is much stronger among African Americans who are not emotionally close to their families. For Caribbean Blacks, an interaction suggests that the odds of meeting criteria for SAD were higher among Black Caribbeans who had high negative interaction with family as well as low levels of friendship closeness. LIMITATIONS: The cross-sectional nature of the study does not allow for causal attributions for findings. CONCLUSIONS: This study demonstrates that SAD may impact black ethnic subgroups differently, which has important implications for understanding the nature, etiology, and treatment of this disorder.

Discrimination and social anxiety disorder among African-Americans, Caribbean blacks, and non-Hispanic whites.

The present study investigated the relationship between discrimination and social anxiety disorder (SAD) in a sample of African-Americans, Caribbean blacks, and non-Hispanic whites using the National Survey of American Life, the most comprehensive study of psychopathology among American blacks to date (N = 6082). Previous work has highlighted a strong association between discrimination and mental health symptoms (Keith, Lincoln, Taylor, and Jackson [Sex Roles 62:48-59, ]; Kessler, Mickelson, and Williams [J Health Soc Behav 40:208-230, 1999]; Soto, Dawson-Andoh, and BeLue [J Anxiety Disord 25:258-265, ]). However, few studies have examined the effects of particular types of discrimination on specific anxiety disorders or among different black subgroups. In this study, logistic regression analyses indicated that everyday but not major experiences of discrimination are associated with SAD for African-Americans, Caribbean blacks, and non-Hispanic whites. This study adds to the extant literature by demonstrating that specific types of discrimination may be uniquely associated with SAD for different ethnic/racial groups.

Changes in Brain Network Connections After Exposure and Response Prevention Therapy for Obsessive-Compulsive Disorder in Adolescents and Adults.

BACKGROUND: Functional alterations of tripartite neural networks during cognitive control (i.e., frontoparietal network [FPN], cingulo-opercular network, and default mode network) occur in patients with obsessive-compulsive disorder (OCD) and may contribute to illness expression. However, the degree to which changes in these networks are elicited by gold standard treatment (e.g., exposure and response prevention [EX/RP]) remains unknown. Understanding how EX/RP modulates network connectivity in adolescent versus adult patients with OCD may aid the identification of developmentally sensitive treatment targets that enhance cognitive control. METHODS: Data from a total of 169 adolescents (13-17 years) and adults (25-40 years; 57% female) were analyzed, including healthy control participants (n = 58) and patients with OCD (n = 111) who were randomized to either EX/RP or an active control therapy (stress management training). Participants performed a flanker task during functional magnetic resonance imaging pre- and posttreatment. To retain sensitivity to individual differences in connectivity, group iterative multiple model estimation was used to assess functional connectivity (i.e., density) within and between brain networks. RESULTS: Significant increases in FPN density and decreases in FPN-default mode network density were observed from pre- to posttreatment in patients who received EX/RP. The opposite patterns of change occurred in patients who received stress management training. These treatment-related changes in network density did not differ across age group. CONCLUSIONS: Results suggest EX/RP-specific changes in task-based connectivity in patients with OCD. Given baseline differences between healthy control participants and patients by age group, these treatment-related changes may indicate restoration of healthy FPN and default mode network development across patients, providing targets for improving response to EX/RP.

Exposure and response prevention versus stress management training for adults and adolescents with obsessive compulsive disorder: A randomized clinical trial.

OBJECTIVE: Though exposure and response prevention (ERP) is a well-proven treatment for OCD across the lifespan, prior RCTs have not studied adolescent and adult patients with the same ERP protocol relative to an active comparator that controls for non-specific effects of treatment. This approach assesses differences in the effect of OCD-specific exposures in affected adolescents and adults and in response to ERP compared to a stress-management control therapy (SMT). METHODS: This assessor-blinded, parallel, 2-arm, randomized, ambulatory clinical superiority trial randomized adolescents (aged 12-18) and adults (24-46) with OCD (N = 126) to 12 weekly sessions of ERP or SMT. OCD severity was measured before, during and after treatment using the child or adult version of the Yale-Brown Obsessive Compulsive Scale (C/Y-BOCS), depending on participant age. We predicted that ERP would produce greater improvement in OCD symptoms than SMT and that there would be no significant post-treatment differences across age groups. RESULTS: ERP (n = 63) produced significantly greater improvements on C/Y-BOCS scores at post-treatment than SMT (n = 63) (Effect size = -0.72, CI = -0.52 to -0.91, p < .001). ERP also produced more treatment responders (ERP = 86%, SMT = 32%; χ2 = 46.37, p < .001) and remitters than SMT (ERP = 39%, SMT = 7%; χ2 = 16.14, p < .001). Finally, there were no statistically significant post-treatment differences in C/Y-BOCS scores between adolescents and adults assigned to ERP. CONCLUSION: A single ERP protocol is superior to SMT in treating both adolescents and adults with OCD. OCD-specific therapy is necessary across the lifespan for optimal outcomes in this highly disabling disorder, though non-specific treatments like SMT are still all-too-commonly provided.