Treatment Response Following Adaptive PASAT Training for Depression Vulnerability: a Systematic Review and Meta-Analysis.

In recent years, cognitive control training (CCT) has gained momentum as an intervention to remediate cognitive impairments and decrease depressive symptoms. One promising operationalization to train cognitive control is the adaptive Paced Auditory Serial Addition Task (aPASAT). In this systematic review and meta-analysis of aPASAT training, the efficacy of the intervention and potential moderators were examined. The PsycINFO, MEDLINE, Embase, Web of Science and Cochrane Library electronic databases were searched for studies examining aPASAT training for depressive symptomatology or rumination. Nineteen studies (n = 1255) were included, comprising of depressed patients, remitted depressed patients, at-risk, and healthy participants. We found small significant effects directly after training for both depressive symptomatology and rumination, with similar effect sizes at follow-up. Subgroup analyses suggest a significantly higher mean effect of aPASAT training in non-healthy populations for rumination immediately following training, but not for depressive symptomatology. The amount of training sessions did not moderate effects of CCT. aPASAT has a small but significant effect on depressive symptoms, with direct effects immediately after training, as well as sustained long-term effects. It is currently unclear how many sessions are required for sustained effects due to heterogeneity in training dosage and absence of sufficient trials. Our results suggest that aPASAT training may be most effective for at-risk, remitted- and clinically depressed populations. The effect sizes resulting from this meta-analysis could be used to adequately power future research, which could investigate a dose-response relationship and examine potential treatment gains when combining CCT with other antidepressant interventions.

Dynamic Interplay between Reward and Voluntary Attention Determines Stimulus Processing in Visual Cortex.

Reward enhances stimulus processing in the visual cortex, but the mechanisms through which this effect occurs remain unclear. Reward prospect can both increase the deployment of voluntary attention and increase the salience of previously neutral stimuli. In this study, we orthogonally manipulated reward and voluntary attention while human participants performed a global motion detection task. We recorded steady-state visual evoked potentials to simultaneously measure the processing of attended and unattended stimuli linked to different reward probabilities, as they compete for attentional resources. The processing of the high rewarded feature was enhanced independently of voluntary attention, but this gain diminished once rewards were no longer available. Neither the voluntary attention nor the salience account alone can fully explain these results. Instead, we propose how these two accounts can be integrated to allow for the flexible balance between reward-driven increase in salience and voluntary attention.

A randomized controlled trial of cognitive control training (CCT) as an add-on treatment for late-life depression: a study protocol.

BACKGROUND: Already a major health concern, late-life depression (LLD) is expected to form an increasing problem in the aging population. Moreover, despite current treatments, LLD is associated with a poor long-term prognosis and high rate of chronicity. Treatment provision and treatment accordingly warrant improvement, where add-on treatments might contribute to the efficacy of conventional therapies. Although it is known that impaired cognitive control contributes to LDD, it is not targeted sufficiently by current interventions. Research on cognitive control training (CCT) shows promising results on depressive symptoms, cognitive performance, and overall functioning. However, further research is needed to determine the long-term effects of CCT on LLD, its cost-effectiveness, and mechanisms of change. METHODS: In the current multicenter randomized controlled trial (RCT) with a between-subjects design participants aged 60 years and over with a current LLD receiving treatment as usual (TAU) are randomized to add-on CCT or placebo training. Randomization is stratified by depression severity. Participants will receive eight online CCT or placebo sessions spread across four consecutive weeks. They will complete a post-training assessment after 1 month and three follow-up assessments scheduled three, six and 12 months after completing the training. We expect CCT and TAU to be more (cost-)effective in reducing depressive symptoms than placebo training and TAU. Additionally, we will be looking at secondary clinical, cognitive and global functioning outcomes and likely mechanisms of change (e.g., improved cognitive functioning, reduced rumination, and improved inhibition of negative stimuli). DISCUSSION: The proposed RCT aims to contribute to the clinical and scientific knowledge on the long-term effects of CCT as an add-on treatment for LLD. Cost-effectiveness is particularly relevant considering the expected volume of the target demographic. The study will be a pragmatic trial with few inclusion restrictions, providing information on feasibility of web-based trainings in clinical settings. The outcomes are potentially generalizable to guidelines for treatment of LLD. TRIAL REGISTRATION: This trial is registered in the Netherlands Trial Register (code: NL7639 ). Registered 3 april 2019.

Cognitive remediation following electroconvulsive therapy in patients with treatment resistant depression: randomized controlled trail of an intervention for relapse prevention - study protocol.

BACKGROUND: Major depressive episode (MDE) is worldwide one of the most prevalent and disabling mental health conditions. In cases of persistent non-response to treatment, electroconvulsive therapy (ECT) is a safe and effective treatment strategy with high response rates. Unfortunately, longitudinal data show low sustained response rates with 6-month relapse rates as high as 50% using existing relapse prevention strategies. Cognitive side effects of ECT, even though transient, might trigger mechanisms that increase relapse in patients who initially responded to ECT. Among these side effects, reduced cognitive control is an important neurobiological driven vulnerability factor for depression. As such, cognitive control training (CCT) holds promise as a non-pharmacological strategy to improve long-term effects of ECT (i.e., increase remission, and reduce depression relapse). METHOD/DESIGN: Eighty-eight patients aged between 18 and 70 years with MDE who start CCT will be included in this randomized controlled trial (RCT). Following (partial) response to ECT treatment (at least a 25% reduction of clinical symptoms), patients will be randomly assigned to a computer based CCT or active placebo control. A first aim of this RCT is to assess the effects of CCT compared to an active placebo condition on depression symptomatology, cognitive complaints, and quality of life. Secondly, we will monitor patients every 2 weeks for a period of 6 months following CCT/active placebo, allowing the detection of potential relapse of depression. Thirdly, we will assess patient evaluation of the addition of cognitive remediation to ECT using qualitative interview methods (satisfaction, acceptability and appropriateness). Finally, in order to further advance our understanding of the mechanisms underlying effects of CCT, exploratory analyses will be conducted using video footage collected during the CCT/active control phase of the study. DISCUSSION: Cognitive remediation will be performed following response to ECT, and an extensive follow-up period will be employed. Positive findings would not only benefit patients by decreasing relapse, but also by increasing acceptability of ECT, reducing the burden of cognitive side-effects. TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov . Study ID: NCT04383509 Trial registration date: 12.05.2020.

Early maladaptive schemas and borderline personality disorder features in a nonclinical sample: A network analysis.

Borderline personality disorder (BPD) is a challenging problem. Early maladaptive schemas (EMSs) are considered as important vulnerability factors for the development and maintenance of BPD. Literature suggests a complex relationship between BPD and EMSs. The current study employed network analysis to model the complex associations between central BPD features (i.e., affective instability, identity problems, negative relations, and self-harm) and EMSs in 706 undergraduate students. The severity of BPD symptoms was assessed using the Personality Assessment Inventory-Borderline subscale; the Young Schema Questionnaire-Short Form was used to assess EMSs. Results suggest that specific EMSs show unique associations with different BPD features. Interestingly, affective instability showed no unique associations with EMSs. Identity problems were uniquely associated with abandonment, insufficient self-control, dependence/incompetence, and vulnerability to harm/illness schemas. Negative relations in BPD showed unique connections with mistrust/abuse and abandonment. Finally, BPD self-harm was connected to emotional deprivation and failure. These findings indicate potential pathways between EMSs and specific BPD features that could improve our understanding of BPD theoretically and clinically.

Can training change attentional breadth? Failure to find transfer effects.

Recently, there is increasing interest in the causal relationship between attentional breadth and emotion regulation. To test this causal relationship, attentional breadth needs to be manipulated stringently. The aim of the current research was to establish whether visual attentional breadth could be manipulated through experimental training procedures. We conducted two single-session training experiments and one multiple-session training experiment, all of which contained pre- and post-training assessments to test the direct transfer effects of training on attentional breadth construed in different measures. For the first single-session training (Experiment 1), no training effects were found to transfer to the subsequent attentional breadth measures in terms of global-local processing preference. For the second single-session training (Experiment 2) and the 5-day training (Experiment 3) which combined both trainings from Experiment 1 and 2, there were some indications that attentional breadth can be decreased, but there was no evidence that it could be increased neither in terms of global-local processing preference nor in terms of scope of visual perception. Bayesian analysis confirmed the null hypothesis of no increase in attentional breadth through delivery of these training procedures. Therefore, our findings do not support the hypothesis that training variants of the Global-Local attentional breadth task or of the visuospatial attentional breadth task can stably alter attentional breadth in healthy students. Possible explanations and implications are discussed.

Individual differences in cognitive control over emotional material modulate cognitive biases linked to depressive symptoms.

Deficient cognitive control over emotional material and cognitive biases are important mechanisms underlying depression, but the interplay between these emotionally distorted cognitive processes in relation to depressive symptoms is not well understood. This study investigated the relations among deficient cognitive control of emotional information (i.e. inhibition, shifting, and updating difficulties), cognitive biases (i.e. negative attention and interpretation biases), and depressive symptoms. Theory-driven indirect effect models were constructed, hypothesising that deficient cognitive control over emotional material predicts depressive symptoms through negative attention and interpretation biases. Bootstrapping analyses demonstrated that deficient inhibitory control over negative material was related to negative attention bias which in turn predicted a congruent bias in interpretation and subsequently depressive symptoms. Both shifting and updating impairments in response to negative material had an indirect effect on depression severity through negative interpretation bias. No evidence was found for direct effects of deficient cognitive control over emotional material on depressive symptoms. These findings may help to formulate an integrated understanding of the cognitive foundations of depressive symptoms.

The effects of active worrying on working memory capacity.

According to the attentional control theory, worry, a crucial component of anxiety, impairs task performance through its direct effect on working memory capacity (WMC) by using up the limited resources available for performance thus reducing attentional control. We tested this hypothesis in the current study by examining the causal influence of active worrying on WMC in a sample of undergraduate university students (n = 64) assigned either to a worry condition or to a non-worry control condition. Participants performed a change detection task before and after the worry/control manipulation. Mediation analyses showed that the level of self-reported worry mediated the effects of condition on change in WMC as demonstrated by the significant indirect effect of worry and the resulting non-significant direct effect of condition on change in WMC. Similar results were obtained when using state anxiety measures as mediating factors. Results of the current study are amongst the first to demonstrate that worry impairs WMC and as such have important implications for understanding the impact of worry.

Mapping the interplay among cognitive biases, emotion regulation, and depressive symptoms.

Cognitive biases and emotion regulation (ER) difficulties have been instrumental in understanding hallmark features of depression. However, little is known about the interplay among these important risk factors to depression. This cross-sectional study investigated how multiple cognitive biases modulate the habitual use of ER processes and how ER habits subsequently regulate depressive symptoms. All participants first executed a computerised version of the scrambled sentences test (interpretation bias measure) while their eye movements were registered (attention bias measure) and then completed questionnaires assessing positive reappraisal, brooding, and depressive symptoms. Path and bootstrapping analyses supported both direct effects of cognitive biases on depressive symptoms and indirect effects via the use of brooding and via the use of reappraisal that was in turn related to the use of brooding. These findings help to formulate a better understanding of how cognitive biases and ER habits interact to maintain depressive symptoms.

Internet-delivered cognitive control training as a preventive intervention for remitted depressed patients: Protocol for a randomized controlled trial.

BACKGROUND: Preventing recurrence of depression forms an important challenge for current treatments. Cognitive control impairments often remain present during remission of depression, putting remitted depressed patients at heightened risk for new depressive episodes by disrupting emotion regulation processes. Importantly, research indicates that cognitive control training targeting working memory functioning shows potential in reducing maladaptive emotion regulation and depressive symptomatology in clinically depressed patients and at-risk student samples. The current study aims to test the effectiveness of cognitive control training as a preventive intervention in a remitted depressed sample, exploring effects of cognitive control training on rumination and depressive symptomatology, along with indicators of adaptive emotion regulation and functioning. METHODS/DESIGN: We present a double blind randomized controlled design. Remitted depressed adults will complete 10 online sessions of a cognitive control training targeting working memory functioning or a low cognitive load training (active control condition) over a period of 14 days. Effects of training on primary outcome measures of rumination and depressive symptomatology will be assessed pre-post training and at three months follow-up, along with secondary outcome measure adaptive emotion regulation. Long-term effects of cognitive control training on broader indicators of functioning will be assessed at three months follow-up (secondary outcome measures). DISCUSSION: This study will provide information about the effectiveness of cognitive control training for remitted depressed adults in reducing vulnerability for depression. Furthermore, this study will address key questions concerning the mechanisms underlying the effects of cognitive control training, will take into account the subjective experience of the patients (including a self-report measure for cognitive functioning), and explore whether these effects extend to broad measures of functioning such as Quality of Life and disability. TRIAL REGISTRATION: This study is registered with ClinicalTrials.Gov, number NCT02407652 .

Effects of positive mood on attention broadening for self-related information.

Studies on cognitive effects of positive emotions have associated positive emotions to broadened attention. Given the widely investigated relationship between self-focused attention and mood, it is important to investigate the effect of positive mood on visuospatial attention for self-related information. We used a performance-based measure to assess fluctuations in attentional broadening from self-related contrasted to not-self-related information. In Experiment 1, we checked that the self-related versus not-self-related stimuli did not evoke differential attention effects in general. In Experiment 2, we manipulated mood and found that an increase in positive mood was associated with a relative broadening of attention for self-related information. These results suggest that the meaning of the target of attention provides an interesting dimension for further investigation into the relation between positive emotions and attentional broadening.

Worrying and rumination are both associated with reduced cognitive control.

Persistent negative thought is a hallmark feature of both major depressive disorder and generalized anxiety disorder. Despite its clinical significance, little is known about the underlying mechanisms of persistent negative thought. Recent studies suggest that reduced cognitive control might be an explanatory factor. We investigated the association between persistent negative thought and switching between internal representations in working memory, using the internal shift task (IST). The IST was administered to a group of undergraduates, classified as high-ruminators versus low-ruminators, or high-worriers versus low-worriers. Results showed that high-ruminators and high-worriers have more difficulties to switch between internal representations in working memory as opposed to low-ruminators and low-worriers. Importantly, results were only significant when the negative stimuli used in the IST reflected personally relevant worry themes for the participants. The results of this study indicate that rumination and worrying are both associated with reduced cognitive control for verbal information that is personally relevant.

The influence of working memory on the anger superiority effect.

The anger superiority effect shows that an angry face is detected more efficiently than a happy face. However, it is still controversial whether attentional allocation to angry faces is a bottom-up process or not. We investigated whether the anger superiority effect is influenced by top-down control, especially working memory (WM). Participants remembered a colour and then searched for differently coloured facial expressions. Just holding the colour information in WM did not modulate the anger superiority effect. However, when increasing the probabilities of trials in which the colour of a target face matched the colour held in WM, participants were inclined to direct attention to the target face regardless of the facial expression. Moreover, the knowledge of high probability of valid trials eliminated the anger superiority effect. These results suggest that the anger superiority effect is modulated by top-down effects of WM, the probability of events and expectancy about these probabilities.

Clinical efficacy of attentional bias modification procedures: an updated meta-analysis.

CONTEXT: Attentional bias modification (ABM) treatment is a promising intervention tool for a variety of clinical conditions. OBJECTIVES: This study provides an updated review of the clinical effect of ABM by employing standard meta-analytic procedures to (a) estimate the average effect size of ABM in reducing both attention bias (AB) and symptoms, (b) estimate the average effect size for different conditions (e.g., anxiety, depression, and substance abuse), (c) test possible variables that may moderate the effect sizes, and (d) investigate the relationship between preexistent AB and the reduction in AB and symptoms. METHOD: We included 43 controlled trials with a total of 2,268 participants providing 47 group comparisons (i.e., training vs. control condition). Inclusion criteria were as follows: AB was specifically targeted to reduce symptomatology and emotional vulnerability; participants were randomized to the experimental conditions; a control condition (defined as sham training) existed; symptoms were assessed at least postintervention; sufficient data were provided to allow effect size estimation. RESULTS: We obtained a small overall effect size on symptoms postintervention, g = 0.160, 95% confidence interval (CI) = [0.055, 0.265], driven by anxiety studies, g = 0.260, 95% CI = [0.132, 0.388], and studies conducted in healthy participants, g = 0.211, 95% CI = [0.046, 0.375]; no significant effect sizes were found postintervention for other symptom categories. CONCLUSION: The therapeutic benefit of ABM is rather small for anxiety, while the amount of data for other symptom categories is limited. We argue that more efficient, psychometrically sound procedures are needed for assessing and modifying AB.

Multiple paths to rumination within a network analytical framework.

Theories of rumination have proposed different psychological factors to place one at risk for repetitive negative thinking. A comprehensive empirical test that captures the most relevant contributors to rumination is lacking. Building on influential self-regulatory and metacognitive frameworks, we modeled how key constructs in this context relate to ruminative thinking. 498 participants completed online questionnaires including indicators of rumination, metacognition, promotion goal orientation, effortful control, and depression. We estimated regularized partial correlation networks to investigate unique associations between the different constructs and followed these analyses up with directed acyclic graphs to identify potential pathways towards rumination. Results demonstrated that: (1) both self-regulatory and metacognitive factors were directly linked to rumination, amongst these were (2) positive beliefs, negative beliefs about uncontrollability and harm, cognitive self-consciousness, depression, effortful control, perfectionism, and (lack of) cognitive confidence, and (3) we identified multiple directed pathways, suggesting three direct contributors to rumination while controlling for the influence of all other variables: diminished effortful control, positive beliefs, and cognitive self-consciousness. This study is the first to comprehensively assess metacognitive and self-regulatory frameworks of rumination in a data-driven manner. Our findings suggest that there are multiple pathways towards rumination, which should be incorporated in clinical case conceptualization of rumination and related disorders.

Computerized cognitive control training to reduce rumination in major depression: A randomized controlled trial.

OBJECTIVE: Rumination is a major risk factor for the onset and recurrence of depressive episodes and has been associated with deficits in updating working memory content. This randomized controlled trial examines whether training updating-specific cognitive control processes reduces daily ruminative thoughts in clinically depressed individuals. METHODS: Sixty-five individuals with a current major depressive episode were randomized to 10 sessions of either cognitive control training (N = 31) or placebo training (N = 34). The frequency and negativity of individuals' daily ruminative thoughts were assessed for seven days before training, after training, and at a 3-month follow-up using experience sampling methodology. Secondary outcomes were depressive symptoms, depressed mood, and level of disability. RESULTS: Cognitive control training led to stronger improvements in the trained task than placebo training. However, cognitive control training did not lead to greater reductions in the frequency or negativity of daily ruminative thoughts than placebo training. There were no training-specific effects on participants' depressive symptoms or level of disability. CONCLUSIONS: The robustness of the present null-findings, combined with the methodological strengths of the study, suggest that training currently depressed individuals to update emotional content in working memory does not affect the frequency or negativity of their daily ruminative thoughts.

Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward.

Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives.

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Happy but still focused: failures to find evidence for a mood-induced widening of visual attention.

In models of affect and cognition, it is held that positive affect broadens the scope of attention. Consistent with this claim, previous research has indeed suggested that positive affect is associated with impaired selective attention as evidenced by increased interference of spatially distant distractors. However, several recent findings cast doubt on the reliability of this observation. In the present study, we examined whether selective attention in a visual flanker task is influenced by positive mood induction. Across three experiments, positive affect consistently failed to exert any impact on selective attention. The implications of this null-finding for theoretical models of affect and cognition are discussed.

The indirect effect of attention bias on memory via interpretation bias: evidence for the combined cognitive bias hypothesis in subclinical depression.

Little research has investigated functional relations among attention, interpretation, and memory biases in depressed samples. The present study tested the indirect effect of attention bias on memory through interpretation bias as an intervening variable in a mixed sample of non-depressed and subclinically depressed individuals. Subclinically depressed and non-depressed individuals completed a spatial cueing task (to measure attention bias), followed by a scrambled sentences test (to measure interpretation bias), and an incidental free recall task (to measure memory bias). Bias-corrected bootstrapping yielded evidence for the hypothesised indirect effect model, in that an emotional bias in attention is related to a congruent bias in interpretative choices which are in turn reflected in memory. These findings extend previous research and provide further support for the combined cognitive bias hypothesis in depression. Theoretical and clinical implications of our findings are discussed.