Alishia D. Williams

CBT for depression: a pilot RCT comparing mobile phone vs. computer

BackgroundThis paper reports the results of a pilot randomized controlled trial comparing the delivery modality (mobile phone/tablet or fixed computer) of a cognitive behavioural therapy intervention for the treatment of depression. The aim was to establish whether a previously validated computerized program (The Sadness Program) remained efficacious when delivered via a mobile application.Method35 participants were recruited with Major Depression (80% female) and randomly allocated to access the program using a mobile app (on either a mobile phone or iPad) or a computer. Participants completed 6 lessons, weekly homework assignments, and received weekly email contact from a clinical psychologist or psychiatrist until completion of lesson 2. After lesson 2 email contact was only provided in response to participant request, or in response to a deterioration in psychological distress scores. The primary outcome measure was the Patient Health Questionnaire 9 (PHQ-9). Of the 35 participants recruited, 68.6% completed 6 lessons and 65.7% completed the 3-months follow up. Attrition was handled using mixed-model repeated-measures ANOVA.ResultsBoth the Mobile and Computer Groups were associated with statistically significantly benefits in the PHQ-9 at post-test. At 3 months follow up, the reduction seen for both groups remained significant.ConclusionsThese results provide evidence to indicate that delivering a CBT program using a mobile application, can result in clinically significant improvements in outcomes for patients with depression.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN 12611001257954

Categorization and cognitive deficits in compulsive hoarding.

According to the cognitive-behavioural model of compulsive hoarding, information-processing deficits in the areas of attention, memory, decision-making, and categorization contribute to hoarding behaviour. The purpose of the current study was to examine whether individuals with compulsive hoarding exhibited impairment on executive functioning and categorization tasks. Three groups of participants were recruited (N = 60): individuals with compulsive hoarding syndrome, individuals with an Axis I mood or anxiety disorder, and non-clinical control participants. All participants completed self-report measures of cognitive difficulties, neuropsychological tests of executive functioning and decision-making, and four categorization tasks. Results suggested that hoarding participants reported more cognitive failures and more problems with attention and decision-making than non-clinical control participants. In addition, hoarding participants performed worse than both control groups on the Stockings of Cambridge (SOC), a neuropsychological test of planning ability, and were slower and more anxious during a categorization task. These findings suggest that specific deficits in executive functioning may be associated with the difficulties hoarding patients have organizing their possessions.

Combining imagination and reason in the treatment of depression: a randomized controlled trial of internet-based cognitive-bias modification and internet-CBT for depression.

Objective: Computerized cognitive-bias modification (CBM) protocols are rapidly evolving in experimental medicine yet might best be combined with Internet-based cognitive behavioral therapy (iCBT). No research to date has evaluated the combined approach in depression. The current randomized controlled trial aimed to evaluate both the independent effects of a CBM protocol targeting imagery and interpretation bias (CBM-I) and the combined effects of CBM-I followed by iCBT. Method: Patients diagnosed with a major depressive episode were randomized to an 11-week intervention (1 week/CBM-I + 10 weeks/iCBT; n = 38) that was delivered via the Internet with no face-to-face patient contact or to a wait-list control (WLC; n = 31). Results: Intent-to-treat marginal models using restricted maximum likelihood estimation demonstrated significant reductions in primary measures of depressive symptoms and distress corresponding to medium-large effect sizes (Cohen’s d = 0.62–2.40) following CBM-I and the combined (CBM-I + iCBT) intervention. Analyses demonstrated that the change in interpretation bias at least partially mediated the reduction in depression symptoms following CBM-I. Treatment superiority over the WLC was also evident on all outcome measures at both time points (Hedges gs = .59–.98). Significant reductions were also observed following the combined intervention on secondary measures associated with depression: disability, anxiety, and repetitive negative thinking (Cohen’s d = 1.51–2.23). Twenty-seven percent of patients evidenced clinically significant change following CBM-I, and this proportion increased to 65% following the combined intervention. Conclusions: The current study provides encouraging results of the integration of Internet-based technologies into an efficacious and acceptable form of treatment delivery.

The effectiveness of Internet cognitive behavioural therapy (iCBT) for depression in primary care: a quality assurance study.

Background Depression is a common, recurrent, and debilitating problem and Internet delivered cognitive behaviour therapy (iCBT) could offer one solution. There are at least 25 controlled trials that demonstrate the efficacy of iCBT. The aim of the current paper was to evaluate the effectiveness of an iCBT Program in primary care that had been demonstrated to be efficacious in two randomized controlled trials (RCTs). Method Quality assurance data from 359 patients prescribed the Sadness Program in Australia from October 2010 to November 2011 were included. Results Intent-to-treat marginal model analyses demonstrated significant reductions in depressive symptoms (PHQ9), distress (K10), and impairment (WHODAS-II) with medium-large effect sizes (Cohens d = .51–1.13.), even in severe and/or suicidal patients (Cohens d = .50–1.49.) Secondary analyses on patients who completed all 6 lessons showed levels of clinically significant change as indexed by established criteria for remission, recovery, and reliable change. Conclusions The Sadness Program is effective when prescribed by primary care practitioners and is consistent with a cost-effective stepped-care framework.

Deficits in emotion regulation associated with pathological gambling

OBJECTIVES The concept of emotion regulation features in many models of psychopathology and it has been proposed that individuals with poorly regulated emotions often engage in maladaptive behaviours to escape from or down-regulate their emotions, creating risk for a range of disorders. One such disorder may be pathological gambling. To our knowledge, no study had assessed the use of emotion-regulation strategies in this population. The goal of the present study was therefore to examine emotion-regulation difficulties among a sample of pathological gamblers (n= 56), a mixed clinical comparison group (n= 50), and a sample of healthy community controls (n= 49). DESIGN Multivariate analysis of variance controlling for age. METHODS Participants were recruited from the community and a gambling treatment unit in Australia and completed clinical diagnostic interviews (ADIS-IV; SCIP), self-report measures of psychopathology (DASS-21), substance use (AUDIT), and emotion-regulation difficulties (DERS; ERQ). RESULTS Pathological gamblers and the clinical comparison group reported significantly less use of reappraisal as an adaptive emotion-regulation strategy, and reported a greater lack of emotional clarity and more impulsivity than individuals in the healthy community comparison group. Pathological gamblers reported a greater lack of emotional awareness compared to the healthy control group and reported differences in access to effective emotion-regulation strategies compared to both comparison groups. CONCLUSIONS The results support specific deficits of emotion regulation in pathological gamblers and emphasize the need to address these underlying vulnerabilities in addition to directly targeting gambling behaviours in therapy.

An investigation of the cognitive and experiential features of intrusive memories in depression

Intrusive autobiographical memories of negative past events are a clinical feature common to post-traumatic stress disorder (PTSD) and depression. Recent investigations provide increasing evidence that shared cognitive processes are linked to the maintenance of intrusive memories in both conditions. Still absent from the existing literature, however, is a systematic examination of the basic content and defining characteristics of intrusive memories in depression. This study sought to: (i) outline the content and features of intrusive memories in depression, and (ii) investigate whether intrusion characteristics linked to the persistence of intrusive memories in PTSD are also characteristic of intrusive memories in depression. A sample of undergraduate students (n=250) were interviewed and assessed for the presence of an intrusive memory in the past week, and completed a battery of measures that indexed cognitive and affective responses to the memory. Consistent with prediction, intrusive memories contained high levels of sensory experience and were marked by a sense of “nowness”. In accord with studies with PTSD samples, sensory features accounted for unique variance in the prediction of depression severity, over and above that accounted for by intrusion frequency. This pattern of findings was replicated in a dysphoric (BDI-II≥12) sub-sample of participants. Our results underscore the value of drawing on theoretical conceptualisations and empirical findings from the post-traumatic stress literature to extend our understanding of intrusive memories in depression.

An Investigation of the Relationship Between Cognitive Reactivity and Rumination

Teasdales (Teasdale, J.D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2, 247-274) differential activation hypothesis refers to the ease with which maladaptive cognitive processes are triggered by mild dysphoria as cognitive reactivity. Supporting this model is evidence of a differential association between sad mood and dysfunctional cognitions in formerly depressed and never-depressed individuals and the finding that cognitive reactivity predicts depression recurrence in remitted depressives. The Leiden Index of Depression Sensitivity-Revised (LEIDS-R; Van der Does, A.J.W., Williams, J.M.G. (2003). Leiden Index of Depression Sensitivity-Revised (LEIDS-R). Retrieved September 4, 2007, from http://www.dousa.nl/publications_depression.htm#LEIDS) is a recently developed self-report measure that provides clinicians and researchers with a time-efficient means by which to assess cognitive reactivity. This study investigated the relationship between cognitive reactivity (indexed by the LEIDS-R) and depressive rumination in a nonclinical sample (N=324). As predicted, partial correlations between the LEIDS-R (subscale and Total scores) and the Ruminative Response Scale (RRS; Nolen-Hoeksema, S., and Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115-121) were significant after controlling for current depressive symptoms. A subsample of participants (n=130) was administered a structured interview to determine current and past depression diagnostic status. Recovered depressed individuals scored more highly on the LEIDS-R Total and LEIDS-R Rumination subscale; however, the groups did not differ on the remaining subscales. Regression analyses indicated that (across all participants) LEIDS-R Total made a unique contribution to the prediction of depression over and above trait level of depressive rumination. Overall, the LEIDS-R is a time-efficient self-report index of cognitive reactivity that demonstrates promise in distinguishing recovered and never-depressed individuals.

Effectiveness of transdiagnostic internet cognitive behavioural treatment for mixed anxiety and depression in primary care

BACKGROUND Internet-delivered cognitive behavioural treatment (iCBT) has been shown to be effective for the combined treatment of depression and anxiety in randomised controlled trials. The degree to which these findings generalise to patients in primary care awaits further investigation. METHODS Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson therapist-assisted iCBT program for mixed anxiety and depression for patients (n = 707) who completed the program under the supervision of primary care clinicians (general practitioners, psychologists and other allied health professionals). Primary outcome measures were the PHQ-9 (depression), GAD-7 (generalised anxiety), K-10 (distress), WHODAS-II (disability), mini-SPIN (social anxiety) and panic disorder severity scale self-report version (PDSS). RESULTS Adherence to the iCBT program was modest (47.3%), but within-subjects effect sizes ranged from medium (0.51 for PDSS) to large (1.20 for PHQ-9). LIMITATIONS The lack of control group, limited post-treatment data due to drop-out, and short follow-up period. CONCLUSIONS iCBT is an effective treatment for mixed depression and anxiety when delivered in primary care settings. Methods to increase adherence are needed to optimise the benefits to patients.

Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): A randomized controlled trial

Background Accruing evidence suggests that positive imagery-based cognitive bias modification (CBM) could have potential as a standalone targeted intervention for depressive symptoms or as an adjunct to existing treatments. We sought to establish the benefit of this form of CBM when delivered prior to Internet cognitive behavioral therapy (iCBT) for depression Methods A randomized controlled trial (RCT) of a 1-week Internet-delivered positive CBM vs. an active control condition for participants (N=75, 69% female, mean age=42) meeting diagnostic criteria for major depression; followed by a 10-week iCBT program for both groups. Results Modified intent-to-treat marginal and mixed effect models demonstrated no significant difference between conditions following the CBM intervention or the iCBT program. In both conditions there were significant reductions (Cohen׳s d .57–1.58, 95% CI=.12–2.07) in primary measures of depression and interpretation bias (PHQ9, BDI-II, AST-D). Large effect size reductions (Cohen׳s d .81–1.32, 95% CI=.31–1.79) were observed for secondary measures of distress, disability, anxiety and repetitive negative thinking (K10, WHODAS, STAI, RTQ). Per protocol analyses conducted in the sample of participants who completed all seven sessions of CBM indicated between-group superiority of the positive over control group on depression symptoms (PHQ9, BDI-II) and psychological distress (K10) following CBM (Hedges g .55–.88, 95% CI=−.03–1.46) and following iCBT (PHQ9, K10). The majority (>70%) no longer met diagnostic criteria for depression at 3-month follow-up. Limitations The control condition contained many active components and therefore may have represented a smaller ‘dose’ of the positive condition. Conclusions Results provide preliminary support for the successful integration of imagery-based CBM into an existing Internet-based treatment for depression.

Manipulating recall vantage perspective of intrusive memories in dysphoria

The current study attempted to experimentally manipulate mode of recall (field, observer perspective) in a sample of mildly dysphoric participants (N=134) who reported a distressing intrusive memory of negative autobiographical event. Specifically, the current study sought to ascertain whether shifting participants into a converse perspective would have differential effects on the reported experience of their memory. Results indicated that shifting participants from a field to an observer perspective resulted in decreased experiential ratings: specifically, reduced distress and vividness. Also, as anticipated, the converse shift in perspective (from observer to field) did not lead to a corresponding increase in experiential ratings, but did result in reduced ratings of observation and a trend was observed for decreased levels of detachment. The findings support the notion that recall perspective has a functional role in the regulation of intrusion-related distress and represents a cognitive avoidance mechanism.