Anna McKinnon

Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood

A broad array of transdiagnostic psychological treatments for depressive and anxiety disorders have been evaluated, but existing reviews of this literature are restricted to face-to-face cognitive behavioural therapy (CBT) protocols. The current meta-analysis focused on studies evaluating clinician-guided internet/computerised or face-to-face manualised transdiagnostic treatments, to examine their effects on anxiety, depression and quality of life (QOL). Results from 50 studies showed that transdiagnostic treatments are efficacious, with large overall mean uncontrolled effects (pre- to post-treatment) for anxiety and depression (gs=.85 and .91 respectively), and medium for QOL (g=.69). Uncontrolled effect sizes were stable at follow-up. Results from 24 RCTs that met inclusion criteria showed that transdiagnostic treatments outperformed control conditions on all outcome measures (controlled ESs: gs=.65, .80, and .46 for anxiety, depression and QOL respectively), with the smallest differences found compared to treatment-as-usual (TAU) control conditions. RCT quality was generally poor, and heterogeneity was high. Examination of the high heterogeneity revealed that CBT protocols were more effective than mindfulness/acceptance protocols for anxiety (uncontrolled ESs: gs=.88 and .61 respectively), but not depression. Treatment delivery format influenced outcomes for anxiety (uncontrolled ESs: group: g=.70, individual: g=.97, computer/internet: g=.96) and depression (uncontrolled ESs: group: g=.89, individual: g=.86, computer/internet: g=.96). Preliminary evidence from 4 comparisons with disorder-specific treatments suggests that transdiagnostic treatments are as effective for reducing anxiety, and may be superior for reducing depression. These findings show that transdiagnostic psychological treatments are efficacious, but higher quality research studies are needed to explore the sources of heterogeneity amongst treatment effects.

Clinical Predictors of Response to Cognitive-Behavioral Therapy in Pediatric Anxiety Disorders: The Genes for Treatment (GxT) Study

Objective The Genes for Treatment study is an international, multisite collaboration exploring the role of genetic, demographic, and clinical predictors in response to cognitive-behavioral therapy (CBT) in pediatric anxiety disorders. The current article, the first from the study, examined demographic and clinical predictors of response to CBT. We hypothesized that the child’s gender, type of anxiety disorder, initial severity and comorbidity, and parents’ psychopathology would significantly predict outcome. Method A sample of 1,519 children 5 to 18 years of age with a primary anxiety diagnosis received CBT across 11 sites. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each time point (posttreatment, 3-, 6-, and/or 12-month follow-up) and analyzed using linear and logistic mixed models. Separate analyses were conducted using data from posttreatment and follow-up assessments to explore the relative importance of predictors at these time points. Results Individuals with social anxiety disorder (SoAD) had significantly poorer outcomes (poorer response and lower rates of remission) than those with generalized anxiety disorder (GAD). Although individuals with specific phobia (SP) also had poorer outcomes than those with GAD at posttreatment, these differences were not maintained at follow-up. Both comorbid mood and externalizing disorders significantly predicted poorer outcomes at posttreatment and follow-up, whereas self-reported parental psychopathology had little effect on posttreatment outcomes but significantly predicted response (although not remission) at follow-up. Conclusion SoAD, nonanxiety comorbidity, and parental psychopathology were associated with poorer outcomes after CBT. The results highlight the need for enhanced treatments for children at risk for poorer outcomes.

Predictors of posttraumatic stress in children following injury: The influence of appraisals, heart rate, and morphine use.

Prospective studies of posttraumatic stress disorder (PTSD) in children that investigate simultaneously both cognitive and biological or psychophysiological predictors are rare. The present research reports on the impact of cognitive factors (trauma-related appraisals) and biological indicators (heart rate, morphine use) in predicting PTSD and depression symptoms following single-incident trauma. Children and adolescents (N=48) were assessed within 4 weeks of an injury that led to hospital treatment and followed up 6-months later. While morphine did not predict initial PTSD severity, it was associated with lower levels of PTSD at follow-up. Reductions in PTSD symptoms (change scores) between assessments were similarly associated with morphine dosage. Trauma-related appraisals also contributed to PTSD and depression symptom severity. While slightly different patterns of results were obtained depending on whether static or change scores were examined, as a whole the study adds to a growing literature that morphine has the potential to reduce PTSD symptoms severity. Likewise the relationship between unhelpful trauma appraisals and posttrauma psychopathology was replicated.

Health professionals’ attitudes towards AOD-related work: Moving the traditional focus from education and training to organizational culture

Aim: This article presents a critical review of research on health professionals’ attitudes towards alcohol and other drug (AOD)-related work relevant to both researchers and practitioners. It moves beyond education and training programs to examine the relevance of organizational culture in influencing attitudes. Method: A review of research conducted on health professionals’ attitudes towards AOD-related work, and strategies to develop positive attitudes was undertaken. Findings: 12 evidence-based tenets were identified in regard to attitudes towards AOD-related work. Key findings include the importance of professional attitudes related to confidence and perceived legitimacy of responding, and personal attitudes related to social justice concerns. Education/training and role support were identified as important evidence-based strategies to develop and support positive attitudes. Conclusion: To foster development of positive attitudes and effective responses in regard to AOD-related work a focus that extends beyond the individual worker is required. Education and training are a necessary, but not sufficient, condition to ensure health professionals’ capacity and willingness to respond to AOD issues. Research on organizational culture provides valuable insight into the types of organizational and systems factors likely to influence AOD-related attitudes and work practice. Key strategies to develop an organizational culture supportive of AOD-related work and future research areas are highlighted.

Phenomenological reports diagnose accuracy of eyewitness identification decisions

This study investigated whether measuring the phenomenology of eyewitness identification decisions aids evaluation of their accuracy. Witnesses (N=502) viewed a simulated crime and attempted to identify two targets from lineups. A divided attention manipulation during encoding reduced the rate of remember (R) correct identifications, but not the rates of R foil identifications or know (K) judgments in the absence of recollection (i.e., K/[1-R]). Both RK judgments and recollection ratings (a novel measure of graded recollection) distinguished correct from incorrect positive identifications. However, only recollection ratings improved accuracy evaluation after identification confidence was taken into account. These results provide evidence that RK judgments for identification decisions function in a similar way as for recognition decisions; are consistent with the notion of graded recollection; and indicate that measures of phenomenology can enhance the evaluation of identification accuracy.

The influence of data-driven processing on perceptions of memory quality and intrusive symptoms in children following traumatic events.

Ehlers and Clark [(2000). A cognitive model of post-traumatic stress disorder. Behaviour Research and Therapy, 38, 319-345] cognitive model of post-traumatic stress disorder (PTSD) has been relatively untested with children. Seventy-five children (7-16 years) were interviewed within 4 weeks of an injury that led to hospital treatment to examine whether peri-traumatic processing strategies (data-driven processing and fear) were associated with perceptions of memory quality and intrusive memories. Perceptions of memory quality mediated the relationship between data-driven processing and intrusive reactions but not avoidance, arousal or depressive reactions. Finally, the relationship between peri-event fear and intrusion reactions was mediated by perceptions of memory quality even after data-driven processing was controlled. The implications of these findings are discussed in the context of a cognitive developmental model of PTSD in children.

Non-replication of the association between 5HTTLPR and response to psychological therapy for child anxiety disorders

Background We previously reported an association between 5HTTLPR genotype and outcome following cognitive–behavioural therapy (CBT) in child anxiety (Cohort 1). Children homozygous for the low-expression short-allele showed more positive outcomes. Other similar studies have produced mixed results, with most reporting no association between genotype and CBT outcome. Aims To replicate the association between 5HTTLPR and CBT outcome in child anxiety from the Genes for Treatment study (GxT Cohort 2, n = 829). Method Logistic and linear mixed effects models were used to examine the relationship between 5HTTLPR and CBT outcomes. Mega-analyses using both cohorts were performed. Results There was no significant effect of 5HTTLPR on CBT outcomes in Cohort 2. Mega-analyses identified a significant association between 5HTTLPR and remission from all anxiety disorders at follow-up (odds ratio 0.45, P = 0.014), but not primary anxiety disorder outcomes. Conclusions The association between 5HTTLPR genotype and CBT outcome did not replicate. Short-allele homozygotes showed more positive treatment outcomes, but with small, non-significant effects. Future studies would benefit from utilising whole genome approaches and large, homogenous samples.

Cognitive therapy as an early treatment for post-traumatic stress disorder in children and adolescents: a randomized controlled trial addressing preliminary efficacy and mechanisms of action

Background Few efficacious early treatments for post‐traumatic stress disorder (PTSD) in children and adolescents exist. Previous trials have intervened within the first month post‐trauma and focused on secondary prevention of later post‐traumatic stress; however, considerable natural recovery may still occur up to 6‐months post‐trauma. No trials have addressed the early treatment of established PTSD (i.e. 2‐ to 6‐months post‐trauma). Methods Twenty‐nine youth (8–17 years) with PTSD (according to age‐appropriate DSM‐IV or ICD‐10 diagnostic criteria) after a single‐event trauma in the previous 2–6 months were randomly allocated to Cognitive Therapy for PTSD (CT‐PTSD; n = 14) or waiting list (WL; n = 15) for 10 weeks. Results Significantly more participants were free of PTSD after CT‐PTSD (71%) than WL (27%) at posttreatment (intent‐to‐treat, 95% CI for difference .04–.71). CT‐PTSD yielded greater improvement on child‐report questionnaire measures of PTSD, depression and anxiety; clinician‐rated functioning; and parent‐reported outcomes. Recovery after CT‐PTSD was maintained at 6‐ and 12‐month posttreatment. Beneficial effects of CT‐PTSD were mediated through changes in appraisals and safety‐seeking behaviours, as predicted by cognitive models of PTSD. CT‐PTSD was considered acceptable on the basis of low dropout and high treatment credibility and therapist alliance ratings. Conclusions This trial provides preliminary support for the efficacy and acceptability of CT‐PTSD as an early treatment for PTSD in youth. Moreover, the trial did not support the extension of ‘watchful waiting’ into the 2‐ to 6‐month post‐trauma window, as significant improvements in the WL arm (particularly in terms of functioning and depression) were not observed. Replication in larger samples is needed, but attention to recruitment issues will be required.

Research Review: Changes in the prevalence and symptom severity of child post-traumatic stress disorder in the year following trauma – a meta-analytic study

Background Understanding the natural course of child and adolescent posttraumatic stress disorder (PTSD) has significant implications for the identification of, and intervention for, at‐risk youth. We used a meta‐analytic approach to examine longitudinal changes in youth PTSD prevalence and symptoms over the first 12 months posttrauma. Methods We conducted a systematic review to identify longitudinal studies of PTSD in young people (5–18 years old), excluding treatment trials. The search yielded 27 peer‐reviewed studies and one unpublished dataset for analysis of pooled prevalence estimates, relative prevalence reduction and standardised mean symptom change. Key moderators were also explored, including age, proportion of boys in the sample, initial prevalence of PTSD and PTSD measurement type. Results Analyses demonstrated moderate declines in PTSD prevalence and symptom severity over the first 3–6 months posttrauma. From 1 to 6 months posttrauma, the prevalence of PTSD reduced by approximately 50%. Symptoms also showed moderate decline, particularly across the first 3 months posttrauma. There was little evidence of further change in prevalence or symptom severity after 6 months, suggesting that it is unlikely a child would lose a PTSD diagnosis without intervention beyond this point. Conclusions The current findings provide key information about the likelihood of posttrauma recovery in the absence of intervention and have important implications for our understanding of child and adolescent PTSD. Results are discussed with reference to the timing of PTSD screening and the potential role of early interventions. Findings particularly highlight the importance of future research to develop our understanding of what factors prevent the action of normal recovery from the ‘acute’ posttrauma period.

A comparison of MEmory Specificity Training (MEST) to education and support (ES) in the treatment of recurrent depression: study protocol for a cluster randomised controlled trial

BackgroundDepression is a debilitating mental health problem that tends to run a chronic, recurrent course. Even when effectively treated, relapse and recurrence rates remain high. Accordingly, interventions need to focus not only on symptom reduction, but also on reducing the risk of relapse by targeting depression-related disturbances that persist into remission. We are addressing this need by investigating the efficacy, acceptability and feasibility of a MEmory Specificity Training (MEST) programme, which directly targets an enduring cognitive marker of depression - reduced autobiographical memory specificity. Promising pilot data suggest that training memory specificity ameliorates this disturbance and reduces depressive symptoms. A larger, controlled trial is now needed to examine the efficacy of MEST. This trial compares MEST to an education and support (ES) group, with an embedded mechanism study.Methods/DesignIn a single blind, parallel cluster randomised controlled trial, 60 depressed individuals meeting diagnostic criteria for a current major depressive episode will be recruited from the community and clinical services. Using a block randomisation procedure, groups of 5 to 8 participants will receive five weekly sessions of MEST (n = 30) or education and support (n = 30). Participants will be assessed immediately post-treatment, and at 3- and 6-months post-treatment (MEST group only for 6-month follow-up). Depressive symptoms at 3-month follow-up will be the primary outcome. Secondary outcomes will be change in depressive status and memory specificity at post-treatment and 3-months. The 6-month follow-up of the MEST group will allow us to examine whether treatment gains are maintained. An explanatory question will examine variables mediating improvement in depression symptoms post-treatment and at 3-month follow-up.DiscussionThis trial will allow us to investigate the efficacy of MEST, whether treatment gains are maintained, and the mechanisms of change. Evidence will be gathered regarding whether this treatment is feasible and acceptable as a low-intensity intervention. If efficacy can be demonstrated, the results will support MEST as a treatment for depression and provide the foundation for a definitive trial.Trial registrationNCT01882452 (ClinicalTrials.gov), registered on 18 June 2013.