Elizabeth M. Goetter

mHealth: A Mechanism to Deliver More Accessible, More Effective Mental Health Care

UNLABELLED The increased popularity and functionality of mobile devices has a number of implications for the delivery of mental health services. Effective use of mobile applications has the potential to (a) increase access to evidence-based care; (b) better inform consumers of care and more actively engage them in treatment; (c) increase the use of evidence-based practices; and (d) enhance care after formal treatment has concluded. The current paper presents an overview of the many potential uses of mobile applications as a means to facilitate ongoing care at various stages of treatment. Examples of current mobile applications in behavioural treatment and research are described, and the implications of such uses are discussed. Finally, we provide recommendations for methods to include mobile applications into current treatment and outline future directions for evaluation. KEY PRACTITIONER MESSAGE Mobile devices are becoming increasingly common among the adult population and have tremendous potential to advance clinical care. Mobile applications have the potential to enhance clinical care at stages of treatment-from engaging patients in clinical care to facilitating adherence to practices and in maintaining treatment gains. Research is needed to validate the efficacy and effectiveness of mobile applications in clinical practice. Research on such devices must incorporate assessments of usability and adherence in addition to their incremental benefit to treatment.

A Randomized Controlled Trial of Acceptance-Based Behavior Therapy and Cognitive Therapy for Test Anxiety: A Pilot Study.

Many university students suffer from test anxiety that is severe enough to impair performance. Given mixed efficacy results of previous cognitive-behavior therapy (CBT) trials and a theoretically driven rationale, an acceptance-based behavior therapy (ABBT) approach was compared to traditional CBT (i.e., Beckian cognitive therapy; CT) for the treatment of test anxiety. In this pilot study, 16 university students with test anxiety were randomly assigned to receive either a CT or ABBT 2-hr group workshop. The two treatments produced markedly different effects on test performance (measured by exam scores), with those receiving ABBT experiencing improvements in performance, whereas those receiving CT exhibited reduced performance. In addition, there was a suggestion that ABBT might have been more effective at reducing subjectively experienced test anxiety (i.e., a nonsignificant but medium-sized group by time interaction effect). Implications of these results for the treatment of test anxiety and for theoretical notions related to cognitive change strategies are discussed.

Acceptance based behavior therapy for social anxiety disorder through videoconferencing

Most individuals with social anxiety disorder (SAD) do not receive any type of treatment. Reasons include logistical barriers (e.g., geographic location, travel time), fear of stigmatization, and fear of the social interactions associated with seeking treatment. Videoconferencing technology holds great promise in the widespread delivery of evidence-based treatments to those who would otherwise not receive treatment. This pilot study assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavioral intervention using Skype videoconferencing to treat adults with generalized SAD. Twenty-four participants received 12 sessions of weekly therapy and were assessed at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up. Participants and therapists rated the intervention as acceptable and feasible. Analyses revealed significant pre-treatment to follow-up improvements in social anxiety, depression, disability, quality of life, and experiential avoidance, with effect sizes comparable to or larger than previously published results of studies delivering in-person CBT for SAD. Implications and future directions are discussed.

A meta-analysis of cognitive functioning in older adults with PTSD.

A meta-analysis was conducted to summarize and integrate the literature on the cognitive functioning of older adults with posttraumatic stress disorder (PTSD). We hypothesized that those with PTSD would exhibit worse performance in each of the cognitive domains studied when compared to older adults without PTSD. Major databases were queried and eleven articles met criteria for review. As predicted, there was evidence of worse performance across cognitive measures in older adult samples with PTSD relative to older samples without PTSD. The strongest effect across samples was found for lower test scores in the broad domain of memory among older adults with PTSD, and there was evidence that trauma exposure is uniquely associated with worse performance on tests specific to learning. We outline factors thought to contribute to the interactions among PTSD, cognitive deficits, and the aging process. These findings highlight the need for thorough evaluation of cognitive functioning in older adults with PTSD, particularly in the areas of processing speed, learning, memory, and executive functioning.

Treatment of Social Anxiety Disorder Using Online Virtual Environments in Second Life

Over 80% of people with social anxiety disorder (SAD) do not receive any type of treatment, despite the existence of effective evidence-based treatments. Barriers to treatment include lack of trained therapists (particularly in nonmetropolitan areas), logistical difficulties (e.g., cost, time, transportation), concerns regarding social stigma, and fear of negative evaluation from health care providers. Interventions conducted through electronic communication media, such as the Internet, have the potential to reach individuals who otherwise would not have access to evidence-based treatments. Second Life is an online virtual world that holds great promise in the widespread delivery of evidence-based treatments. We assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavior therapy in Second Life to treat adults with generalized SAD. Participants (n=14) received 12 sessions of weekly therapy and were assessed at pretreatment, midtreatment, posttreatment, and follow-up. Participants and therapists rated the treatment program as acceptable and feasible, despite frequently encountered technical difficulties. Analyses showed significant pretreatment to follow-up improvements in social anxiety symptoms, depression, disability, and quality of life, with effect sizes comparable to previously published results of studies delivering in-person cognitive behavior therapy for SAD. Implications and future directions are discussed.

Long-term follow-up of a randomized controlled trial comparing acceptance and commitment therapy and standard cognitive behavior therapy for anxiety and depression.

The present study represents one of the first comparisons of the long-term effectiveness of traditional cognitive behavior therapy (i.e., Beckian cognitive therapy; CT) and acceptance and commitment therapy (ACT). One hundred thirty-two anxious or depressed outpatients were randomly assigned to receive either CT or ACT, and were assessed at posttreatment (n=90) and at 1.5-year (n=91) follow-up. As previously reported, the two treatments were equivalently effective at posttreatment according to measures of depression, anxiety, overall (social/occupational/symptom-related) functioning, and quality of life. However, current results suggest that treatment gains were better maintained at follow-up in the CT condition. Clinical significance analyses revealed that, at follow-up, one-third more CT patients were in the clinically normative range in terms of depressive symptoms and more than twice as many CT patients were in the normative range in terms of functioning levels. The possible long-term advantage of CT relative to ACT in this population is discussed.

A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans.

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.

An open trial of videoconference-mediated exposure and ritual prevention for obsessive-compulsive disorder

The gold-standard treatment for OCD is exposure and ritual prevention (ERP), yet despite its well-established efficacy, only a small percentage of OCD patients have access to this treatment. Remote treatments (e.g., videoconferencing) are becoming increasingly popular avenues for treatment delivery and show promise in increasing patient access to evidence-based mental health care. The current pilot study utilized an open trial to examine the feasibility and preliminary efficacy of videoconference-mediated, twice weekly, ERP for adults (n=15) with OCD. Results revealed that ERP was associated with significant improvements in OCD symptoms and large within-group effect sizes. Among the 10 individuals who completed a 3-month follow-up assessment, 30% of participants no longer met DSM-IV-TR criteria for OCD and 80% of participants were rated as very much or much improved on the CGI. This study adds to the growing body of literature suggesting that videoconference-based interventions are viable alternatives to face-to-face treatment.

Heightened sensitivity to emotional expressions in generalised anxiety disorder, compared to social anxiety disorder, and controls.

ABSTRACT Few studies have examined potential differences between social anxiety disorder (SAD) and generalised anxiety disorder (GAD) in the sensitivity to detect emotional expressions. The present study aims to compare the detection of emotional expressions in SAD and GAD. Participants with a primary diagnosis of GAD (n = 46), SAD (n = 70), and controls (n = 118) completed a morph movies task. The task presented faces expressing increasing degrees of emotional intensity, slowly changing from a neutral to a full-intensity happy, sad, or angry expressions. Participants used a slide bar to view the movie frames from left to right, and to stop at the first frame where they perceived an emotion. The frame selected thus indicated the intensity of emotion required to identify the facial expression. Participants with GAD detected the onset of facial emotions at lower intensity of emotion than participants with SAD (p = 0.002) and controls (p = 0.039). In a multiple regression analysis controlling for age, race, and depressive symptom severity, lower frame at which the emotion was detected was independently associated and GAD diagnosis (B = –5.73, SE = 1.74, p < 0.01). Our findings suggest that individuals with GAD exhibit enhanced detection of facial emotions compared to those with SAD or controls.

Examining the Role of Anxiety Sensitivity in Sleep Dysfunction Across Anxiety Disorders

Anxiety Sensitivity (AS) has been associated with sleep difficulties in certain anxiety disorder populations, but no studies have examined cross-diagnostically the role of anxiety sensitivity in sleep dysfunction. Three hundred one participants with generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD) completed an ancillary questionnaire-based study. Linear regression was used to examine AS and sleep dysfunction, and mediation analyses were used to examine whether AS was a mediator of the effect of primary diagnosis on sleep. AS was associated with increased sleep dysfunction across anxiety disorders, and primary anxiety disorder diagnosis was significantly associated with sleep dysfunction. However, after controlling for AS, primary diagnosis was no longer significant. AS significantly mediated the effects of PD versus SAD and of PD versus GAD on sleep dysfunction, but did not significantly mediate the effect of GAD versus SAD on sleep dysfunction. Taken together, AS appears to be a more important predictor of sleep dysfunction overall, emphasizing the cross-diagnostic nature of AS and bolstering the RDoC initiative approach for treating psychological dysfunction.