Alexis E. Whitton

Reward processing dysfunction in major depression, bipolar disorder and schizophrenia.

Purpose of review This article reviews the recent literature on reward processing dysfunction in major depression (MDD), bipolar disorder and schizophrenia, with a focus on approach motivation, reward learning and reward-based decision-making. Recent findings Emerging evidence indicates the presence of reward processing abnormalities across all three disorders, supporting a transdiagnostic approach. In particular, findings are consistent with a role of abnormal phasic striatal dopamine signaling, which is critical for reinforcement learning, efficient mobilization of effort to obtain reward and allocation of attention to reward-predictive cues. Specifically, reward-related striatal signaling appears blunted in MDD and the negative symptoms of schizophrenia, elevated in bipolar (hypo)mania, and contextually misallocated in the positive symptoms of psychosis. However, whether shared or distinct pathophysiological mechanisms contribute to abnormal striatal signaling across the three disorders remains unknown. Summary New evidence of reward processing abnormalities in MDD, bipolar disorder and schizophrenia has led to a greater understanding of the neural processes associated with symptomatology common across these conditions (e.g., anhedonia). Dissecting various subcomponents of reward processing that map onto partially different neurobiological pathways and investigating their dysregulation in different psychiatric disorders holds promise for developing more targeted, and hopefully efficacious treatment and intervention strategies.

Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial.

BackgroundMobile phone-based psychological interventions enable real time self-monitoring and self-management, and large-scale dissemination. However, few studies have focussed on mild-to-moderate symptoms where public health need is greatest, and none have targeted work and social functioning. This study reports outcomes of a CONSORT-compliant randomised controlled trial (RCT) to evaluate the efficacy of myCompass, a self-guided psychological treatment delivered via mobile phone and computer, designed to reduce mild-to-moderate depression, anxiety and stress, and improve work and social functioning.MethodCommunity-based volunteers with mild-to-moderate depression, anxiety and/or stress (N = 720) were randomly assigned to the myCompass program, an attention control intervention, or to a waitlist condition for seven weeks. The interventions were fully automated, without any human input or guidance. Participants’ symptoms and functioning were assessed at baseline, post-intervention and 3-month follow-up, using the Depression, Anxiety and Stress Scale and the Work and Social Adjustment Scale.ResultsRetention rates at post-intervention and follow-up for the study sample were 72.1% (n = 449) and 48.6% (n = 350) respectively. The myCompass group showed significantly greater improvement in symptoms of depression, anxiety and stress and in work and social functioning relative to both control conditions at the end of the 7-week intervention phase (between-group effect sizes ranged from d = .22 to d = .55 based on the observed means). Symptom scores remained at near normal levels at 3-month follow-up. Participants in the attention control condition showed gradual symptom improvement during the post-intervention phase and their scores did not differ from the myCompass group at 3-month follow-up.ConclusionsThe myCompass program is an effective public health program, facilitating rapid improvements in symptoms and in work and social functioning for individuals with mild-to-moderate mental health problems.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN 12610000625077

Effects of adjunctive peer support on perceptions of illness control and understanding in an online psychoeducation program for bipolar disorder: A randomised controlled trial

OBJECTIVES To examine the comparative effectiveness of an online psychoeducation program for people diagnosed with bipolar disorder within the previous 12 months, completed alone or with adjunctive peer support, on symptoms and perceived control over the illness. METHOD Participants were randomly allocated to an eight-week online psychoeducation program (n=139), a psychoeducation program plus online peer support (n=134) or an attentional control condition (n=134). RESULTS Increased perceptions of control, decreased perceptions of stigmatisation and significant improvements in levels of anxiety and depression, from pre- to post-intervention were found across all groups. There were no significant differences between groups on outcome measures, although a small clinical difference was found between the supported and unsupported conditions in depression symptoms and in functional impairment at the six-month follow-up. Adherence to the treatment program was significantly higher in the supported intervention than in the unsupported program. Gender and age were also significant predictors of adherence, with females and those over the age of 30 showing greater adherence. LIMITATIONS Mood state at study entry was measured by self-report rather than by clinical interview. CONCLUSIONS The pattern of outcomes suggests a primary influence of non-specific or common therapeutic factors across all three intervention groups. A personally tailored intervention may be more suitable for individuals recently diagnosed with bipolar disorder, and longer term coaching may increase program adherence and long-term improvement in symptoms and functioning.

Triggers of mania and depression in young adults with bipolar disorder

BACKGROUND Early intervention significantly decreases the impact of bipolar disorder. However, there is little research investigating triggers that may be unique precipitants of manic/hypomanic episodes, and how these may differ from triggers specific to bipolar depression, in young adults with the disorder. METHODS Individuals aged 18 to 30 years who had been diagnosed with bipolar disorder (n=198) completed an online survey to identify triggers unique to mania/hypomania and depression, as well as triggers which were common to both. Respondents rated how frequently a series of situations and behaviours had precipitated either a manic/hypomanic episode or a depressive episode in the past. Survey data was supplemented by in-depth face-to-face interviews (n=11). RESULTS Triggers specifically associated with the onset of manic/hypomanic episodes included falling in love, recreational stimulant use, starting a creative project, late night partying, going on vacation and listening to loud music. Triggers associated with depressive episodes included stressful life events, general stress, fatigue, sleep deprivation, physical injury or illness, menstruation and decreases in physical exercise. A further set of triggers were identified as being common to both manic/hypomanic and depressive episodes. Consistent themes arose from the analysis of face-to-face interviews, which extended and illuminated the findings of the survey data. CONCLUSIONS Identification of a unique set of triggers for mania/hypomania and a unique set for depression in young adults with bipolar disorder may allow for earlier identification of episodes, thus increasing opportunities for early intervention.

Effects of mental health self-efficacy on outcomes of a mobile phone and web intervention for mild-to-moderate depression, anxiety and stress: secondary analysis of a randomised controlled trial

BackgroundOnline psychotherapy is clinically effective yet why, how, and for whom the effects are greatest remain largely unknown. In the present study, we examined whether mental health self-efficacy (MHSE), a construct derived from Bandura’s Social Learning Theory (SLT), influenced symptom and functional outcomes of a new mobile phone and web-based psychotherapy intervention for people with mild-to-moderate depression, anxiety and stress.MethodsSTUDY I: Data from 49 people with symptoms of depression, anxiety and/or stress in the mild-to-moderate range were used to examine the reliability and construct validity of a new measure of MHSE, the Mental Health Self-efficacy Scale (MHSES). STUDY II: We conducted a secondary analysis of data from a recently completed randomised controlled trial (N = 720) to evaluate whether MHSE effected post-intervention outcomes, as measured by the Depression, Anxiety and Stress Scales (DASS) and Work and Social Adjustment Scale (WSAS), for people with symptoms in the mild-to-moderate range.ResultsSTUDY I: The data established that the MHSES comprised a unitary factor, with acceptable internal reliability (Cronbach’s alpha = .89) and construct validity. STUDY II: The intervention group showed significantly greater improvement in MHSE at post-intervention relative to the control conditions (p’s < = .000). MHSE mediated the effects of the intervention on anxiety and stress symptoms. Furthermore, people with low pre-treatment MHSE reported the greatest post-intervention gains in depression, anxiety and overall distress. No effects were found for MHSE on work and social functioning.ConclusionMental health self-efficacy influences symptom outcomes of a self-guided mobile phone and web-based psychotherapeutic intervention and may itself be a worthwhile target to increase the effectiveness and efficiency of online treatment programs.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12610000625077.

Mechanisms underpinning effective peer support: a qualitative analysis of interactions between expert peers and patients newly-diagnosed with bipolar disorder

BackgroundThe increasing burden on mental health services has led to the growing use of peer support in psychological interventions. Four theoretical mechanisms have been proposed to underpin effective peer support: advice grounded in experiential knowledge, social support, social comparison and the helper therapy principle. However, there has been a lack of studies examining whether these mechanisms are also evident in clinical populations in which interpersonal dysfunction is common, such as bipolar disorder.MethodThis qualitative study, conducted alongside a randomized controlled trial, examined whether the four mechanisms proposed to underpin effective peer support were expressed in the email exchange between 44 individuals newly-diagnosed with bipolar disorder and their Informed Supporters (n = 4), over the course of a supported online psychoeducation program for bipolar disorder. A total of 104 text segments were extracted and coded. The data were complemented by face-to-face interviews with three of the four Informed Supporters who participated in the study.ResultsQualitative analyses of the email interchange and interview transcripts revealed rich examples of all four mechanisms. The data illustrated how the involvement of Informed Supporters resulted in numerous benefits for the newly-diagnosed individuals, including the provision of practical strategies for illness management as well as emotional support throughout the intervention. The Informed Supporters encouraged the development of positive relationships with mental health services, and acted as role models for treatment adherence. The Informed Supporters themselves reported gaining a number of benefits from helping, including a greater sense of connectedness with the mental health system, as well as a broader knowledge of illness management strategies.ConclusionsExamples of the mechanisms underpinning effective peer support were found in the sample of emails from individuals with newly-diagnosed bipolar disorder and their Informed Supporters. Experiential knowledge, social support, social comparison and helper therapy were apparent, even within a clinical population for whom relationship difficulties are common. Trial registration number ACTRN12608000411347.

Breaking Open the Black Box: Isolating the Most Potent Features of a Web and Mobile Phone-Based Intervention for Depression, Anxiety, and Stress.

Background Internet-delivered mental health (eMental Health) interventions produce treatment effects similar to those observed in face-to-face treatment. However, there is a large degree of variation in treatment effects observed from program to program, and eMental Health interventions remain somewhat of a black box in terms of the mechanisms by which they exert their therapeutic benefit. Trials of eMental Health interventions typically use large sample sizes and therefore provide an ideal context within which to systematically investigate the therapeutic benefit of specific program features. Furthermore, the growth and impact of mobile phone technology within eMental Health interventions provides an opportunity to examine associations between symptom improvement and the use of program features delivered across computer and mobile phone platforms. Objective The objective of this study was to identify the patterns of program usage associated with treatment outcome in a randomized controlled trial (RCT) of a fully automated, mobile phone- and Web-based self-help program, “myCompass”, for individuals with mild-to-moderate symptoms of depression, anxiety, and/or stress. The core features of the program include interactive psychotherapy modules, a symptom tracking feature, short motivational messages, symptom tracking reminders, and a diary, with many of these features accessible via both computer and mobile phone. Methods Patterns of program usage were recorded for 231 participants with mild-to-moderate depression, anxiety, and/or stress, and who were randomly allocated to receive access to myCompass for seven weeks during the RCT. Depression, anxiety, stress, and functional impairment were examined at baseline and at eight weeks. Results Log data indicated that the most commonly used components were the short motivational messages (used by 68.4%, 158/231 of participants) and the symptom tracking feature (used by 61.5%, 142/231 of participants). Further, after controlling for baseline symptom severity, increased use of these alert features was associated with significant improvements in anxiety and functional impairment. Associations between use of symptom tracking reminders and improved treatment outcome remained significant after controlling for frequency of symptom tracking. Although correlations were not statistically significant, reminders received via SMS (ie, text message) were more strongly associated with symptom reduction than were reminders received via email. Conclusions These findings indicate that alerts may be an especially potent component of eMental Health interventions, both via their association with enhanced program usage, as well as independently. Although there was evidence of a stronger association between symptom improvement and use of alerts via the mobile phone platform, the degree of overlap between use of email and SMS alerts may have precluded identification of alert delivery modalities that were most strongly associated with symptom reduction. Future research using random assignment to computer and mobile delivery is needed to fully determine the most ideal platform for delivery of this and other features of online interventions. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN): 12610000625077; http://www.anzctr.org.au/TrialSearch.aspx? (Archived by WebCite http://www.webcitation.org/6WPqHK0mQ).

Reward Responsiveness Varies by Smoking Status in Women with a History of Major Depressive Disorder

Major depressive disorder (MDD) and nicotine dependence are highly comorbid, with studies showing that ~50% of individuals with MDD smoke. The link between these disorders persists even after the clinical symptoms of depression subside, as indicated by high levels of nicotine dependence among individuals with remitted depression (rMDD). Recent evidence indicates that individuals with rMDD show blunted responses to reward as measured by a probabilistic reward task (PRT), which assesses the ability to modify behavior as a function of reward history. Given nicotine’s ability to enhance reward responsiveness, individuals with rMDD might smoke to address this persistent reward deficit. However, it is unclear whether smokers with rMDD show enhanced reward responsiveness relative to rMDD individuals who do not smoke. To test this hypothesis, we evaluated reward responsiveness on the PRT in four groups (N=198): individuals with and without rMDD who were or were not nicotine dependent. As hypothesized, rMDD nonsmokers had lower reward responsiveness relative to both control nonsmokers and rMDD smokers; conversely, smokers with rMDD showed behavioral patterns comparable to those without a history of depression. Given nicotine’s ability to enhance reward sensitivity, it is possible that nicotine normalizes the otherwise blunted reward responsiveness in individuals with rMDD. Therapies aimed at enhancing this reward-based deficit may be beneficial in the treatment of both nicotine dependence and MDD.

Disgust, but not anger provocation, enhances levator labii superioris activity during exposure to moral transgressions

Physical disgust is elicited by, and amplifies responses to, moral transgressions, suggesting that moral disgust may be a biologically expanded form of physical disgust. However, there is limited research comparing the effects of physical disgust to that of other emotions like anger, making it difficult to determine if the link between disgust and morality is unique. The current research evaluated the specificity of the relationship between disgust and morality by comparing links with anger, using state, physiological and trait measures of emotionality. Participants (N=90) were randomly allocated to have disgust, anger or no emotion induced. Responses to images depicting moral, negative non-moral, and neutral themes were then recorded using facial electromyography. Inducing disgust, but not anger, increased psychophysiological responses to moral themes. Trait disgust, but not trait anger, correlated with levator labii responses to moral themes. These findings provide strong evidence of a unique link between physical disgust and morality.

The relationship between sub-clinical obsessive-compulsive symptoms and social cognition in chronic schizophrenia

OBJECTIVES Comorbid obsessive-compulsive (OC) symptoms in individuals with a primary diagnosis of schizophrenia are related to poorer cognitive performance and functional outcomes, but no study to date has assessed whether this comorbidity might also have implications for social cognition. The aim of the present study was to provide the first test of this possibility. DESIGN AND METHODS Individuals with schizophrenia (n = 34) and demographically matched non-clinical controls (n = 44) were assessed on two of the most important aspects of social cognitive function (1) facial affect recognition and (2) theory of mind, alongside more standard measures of cognitive function. RESULTS The presence of OC symptoms was related to poorer performance on some of the cognitive measures, as well as one of the social cognitive measures (facial affect recognition). However, these relationships disappeared after controlling for scores on more general indices of schizophrenia psychopathology. CONCLUSIONS The presence of OC symptoms in schizophrenia is not only associated with increased cognitive impairment but also increased difficulties with at least some aspects of social cognitive function. However, these relationships appear to reflect the elevated levels of psychopathology seen in this cohort more generally, rather than being uniquely attributable to OC symptomatology.