Journal of Consulting and Clinical Psychology

Linardon, Jake; Fuller-Tyszkiewicz, Matthew

doi: 10.1037/ccp0000459pmid: 31697093

Objectives: Although the efficacy of smartphone-delivered interventions for mental health problems is emerging, randomized controlled trials (RCTs) of smartphone interventions are characterized by high rates of attrition and low adherence. High attrition and low adherence may threaten the validity of RCT findings, so a better understanding of these phenomena is needed. We examined attrition and adherence in 70 RCTs of smartphone interventions. Method: Four online databases were searched for RCTs of mental health interventions delivered via smartphones. Results: The mean meta-analytic study attrition rate was 24.1% (95% CI [19.3, 29.6]) at short-term follow up and 35.5% (95% CI [26.7, 45.3]) at longer-term follow up. These rates varied according to target mental health condition. Attrition rates were significantly lower in trials that delivered an acceptance-based intervention, offered participants monetary compensation, and reminded participants to engage in the intervention, and were significantly higher in trials that used an online enrollment method (relative to telephone or in-person enrollment). No participant-level baseline characteristic reliably predicted attrition. Evidence of attrition bias came from many RCTs not conducting intention-to-treat analyses. However, the mean difference in the between-groups effect size on primary outcomes in trials that reported both per protocol an intention-to-treat analyses was only Δd = 0.18. Adherence rates were also suboptimal based on our qualitative synthesis; several participants failed to download the intervention, and intervention usage consistently declined over the course of the trial. Conclusion: Study attrition and low adherence are common, problematic, and may undermine the validity of findings in RCTs of smartphone-delivered interventions for mental health problems.

Delgadillo, Jaime; Gonzalez Salas Duhne, Paulina

doi: 10.1037/ccp0000476pmid: 31841021

Objective: Depression is a highly common mental disorder and a major cause of disability worldwide. Several psychological interventions are available, but there is a lack of evidence to decide which treatment works best for whom. This study aimed to identify subgroups of patients who respond differentially to cognitive–behavioral therapy (CBT) or person-centered counseling for depression (CfD). Method: This was a retrospective analysis of archival routine practice data for 1,435 patients who received either CBT (N = 1,104) or CfD (N = 331) in primary care. The main outcome was posttreatment reliable and clinically significant improvement (RCSI) in the PHQ-9 depression measure. A targeted prescription algorithm was developed in a training sample (N = 1,085) using a supervised machine learning approach (elastic net with optimal scaling). The clinical utility of the algorithm was examined in a statistically independent test sample (N = 350) using chi-square analysis and odds ratios. Results: Cases in the test sample that received their model-indicated “optimal” treatment had a significantly higher RCSI rate (62.5%) compared to those who received the “suboptimal” treatment (41.7%); χ2(df = 1) = 4.79, p = .03, OR = 2.33 (95% CI [1.09, 5.02]). Conclusion: Targeted prescription has the potential to make best use of currently available evidence-based treatments, improving outcomes for patients at no additional cost to psychological services.

Webb, Christian A.; Cohen, Zachary D.; Beard, Courtney; Forgeard, Marie; Peckham, Andrew D.; Björgvinsson, Thröstur

doi: 10.1037/ccp0000451pmid: 31841022

Objective: Research on predictors of treatment outcome in depression has largely derived from randomized clinical trials involving strict standardization of treatments, stringent patient exclusion criteria, and careful selection and supervision of study clinicians. The extent to which findings from such studies generalize to naturalistic psychiatric settings is unclear. This study sought to predict depression outcomes for patients seeking treatment within an intensive psychiatric hospital setting and while comparing the performance of a range of machine learning approaches. Method: Depressed patients (N = 484; ages 18–72; 89% White) receiving treatment within a psychiatric partial hospital program delivering pharmacotherapy and cognitive behavioral therapy were split into a training sample and holdout sample. First, within the training sample, 51 pretreatment variables were submitted to 13 machine learning algorithms to predict, via cross-validation, posttreatment Patient Health Questionnaire–9 depression scores. Second, the best performing modeling approach (lowest mean squared error; MSE) from the training sample was selected to predict outcome in the holdout sample. Results: The best performing model in the training sample was elastic net regularization (ENR; MSE = 20.49, R2 = .28), which had comparable performance in the holdout sample (MSE = 11.26; R2 = .38). There were 14 pretreatment variables that predicted outcome. To demonstrate the translation of an ENR model to personalized prediction of treatment outcome, a patient-specific prognosis calculator is presented. Conclusions: Informed by pretreatment patient characteristics, such predictive models could be used to communicate prognosis to clinicians and to guide treatment planning. Identified predictors of poor prognosis may suggest important targets for intervention.

Pahl, Kerstin; Williams, Sharifa Z.; Lee, Jung Yeon; Joseph, Adriana; Blau, Chloe

doi: 10.1037/ccp0000449pmid: 31647275

Objective: To examine the effect of long-term violent victimization from late adolescence to the mid-30s on posttraumatic stress disorder (PTSD) and comorbid psychiatric disorders in adulthood among urban African Americans and Puerto Ricans. Method: Data were collected from a large urban community sample (N = 674) at 4 time points associated with mean ages of 19, 24, 29, and 36 years. Trajectories of violent victimization were extracted using growth mixture modeling and used to predict psychiatric disorders and comorbidities in adulthood. Results: The sample was 52.8% African American and 47.2% Puerto Rican, with 60% females. Three trajectory groups of violent victimization were identified: high, intermediate, and low. Over half of the sample reported relatively high- and intermediate-level violent victimization experiences from adolescence to adulthood. Group comparisons showed that participants belonging to the relatively high-victimization group had greater odds of having PTSD, major depressive episode (MDE), and substance use disorder (SUD) separately, as well as comorbid PTSD–SUD and PTSD–MDE, compared with those classified as having relatively low levels of victimization. Having intermediate-level victimization experiences, compared with low-level victimization experiences, over time was associated with higher odds of PTSD and MDE separately and comorbid PTSD–MDE. Conclusions: Long-term exposure to relatively high levels of violent victimization during emerging and young adulthood is associated with PTSD and comorbid psychiatric disorders in the 30s. Social, structural, and interpersonal factors underlying the differential patterns of violent victimization in urban African American and LatinX youth need to be identified to adequately inform prevention efforts.

Brotto, Lori A.; Bergeron, Sophie; Zdaniuk, Bozena; Basson, Rosemary

doi: 10.1037/ccp0000473pmid: 31841023

Objective: Provoked vestibulodynia (PVD) is a chronic vulvo-vaginal pain condition affecting 8% of premenopausal women. Cognitive–behavioral therapy (CBT) is effective in managing pain and associated sexual and psychological symptoms, and a recent study found group mindfulness-based cognitive therapy (MBCT) to be equivalent. Our goal was to examine the long-term outcomes of these treatments and to explore mediators of change. Method: Participants were 130 women diagnosed with PVD who had participated in a clinical trial comparing 8 weeks of group CBT to 8 weeks of group MBCT. Data were collected at pretreatment, posttreatment, and at 6- and 12-month follow-up periods. Outcomes focused on (a) pain with vaginal penetration, (b) pain elicited with a vulvalgesiometer, and (c) sex-related distress. Mediators of interest included pain acceptance (both pain willingness and activities engagement), self-compassion, self-criticism, mindfulness, decentering, and pain catastrophizing. Results: All improvements in the 3 outcomes were retained at 12-month follow-up, with no group differences. Pain catastrophizing, decentering, and chronic pain acceptance (both scales) were mediators of improvement common to both MBCT and CBT. Changes in mindfulness, self-criticism, and self-compassion mediated improvements only in the MBCT group. Conclusions: Both MBCT and CBT are effective for improving symptoms in women with PVD when assessed 12 months later. The findings have implications for understanding common and potentially distinct pathways by which CBT and MBCT improve pain and sex-related distress in women with PVD.

Wilver, Natalie L.; Summers, Berta J.; Cougle, Jesse R.

doi: 10.1037/ccp0000453pmid: 31670542

Objective: Appearance-related safety behaviors (SBs; e.g., mirror checking, grooming) have been implicated in body dysmorphic disorder (BDD), eating disorders, and social anxiety disorder. The proposed project aimed to extend previous research efforts by exploring the experimental effects of reducing engagement in appearance-related SBs on appearance concerns and related symptoms. Method: Eighty-four undergraduate female participants with elevated appearance concerns were randomly assigned to a SB fading group or a no instructions control group. For 2 weeks, participants in the SB fading condition were sent daily reminders via text message to decrease their engagement in appearance-related SBs, whereas participants in the control group completed assessments only. Self-report assessments of study variables of interest were administered at baseline, midmanipulation, postmanipulation, and 2-week follow-up. Participants also completed an appearance-related in vivo stressor task at post, during which participants rated their reactivity to having their photographs taken from various angles. Results: Compared to the control group, the SB fading group exhibited significantly lower social anxiety, BDD symptoms, body dissatisfaction, and maladaptive cognitions at the postmanipulation and follow-up assessments. SB fading had stronger effects on BDD symptoms at postmanipulation among those high versus those low in baseline BDD symptoms. The SB fading group also showed less reactivity to some aspects of the in vivo appearance-related stressor task. Conclusions: This study provides strong evidence for the importance of appearance-related SBs in the maintenance of BDD and other disorders characterized by body image disturbances. Findings point to the potential utility of decreasing appearance-related SBs as a transdiagnostic treatment strategy.

Frost, David M.

doi: 10.1037/ccp0000458pmid: 31647276

Objective: The extent to which the outcome of the European Union referendum (“Brexit”) has affected the mental health of migrants living in the United Kingdom has been the subject of much speculation. However, no empirical attempts to examine the mental health impact of the Brexit vote have been made. Through the combination of structural stigma and minority stress theories, this study examined the extent to which the outcome of the Brexit referendum was associated with the mental health of migrants in the United Kingdom as a result of increased discrimination. Method: Adult migrants living in the United Kingdom (N = 311) participated in a longitudinal survey containing measures of discrimination and symptoms of generalized anxiety disorder (GAD) at baseline and at 1-month and 6-month follow-ups. Participant data were matched to official voting records at the electorate level. Results: The percentage of “leave” voters where participants lived was associated with increased discrimination, which was in turn associated with increased GAD symptoms, including the likelihood of experiencing clinically significant GAD symptoms over the course of the study (OR = 3.01, 95% confidence interval [CI: 1.25, 7.33]). The percentage of leave voters where participants lived was associated with increased GAD symptoms indirectly via increased discrimination (standardized indirect effect = .12; 95% bias-corrected CI [.07, .19]). Conclusions: This study demonstrates that voter referenda can have a detrimental impact on migrants’ mental health. Findings illustrate how aspects of structural stigma can produce experiences of minority stress, which can lead to negative mental health outcomes for members of marginalized populations.

Probst, Thomas; Berger, Thomas; Meyer, Björn; Späth, Christina; Schröder, Johanna; Hohagen, Fritz; Moritz, Steffen; Klein, Jan Philipp

doi: 10.1037/ccp0000441pmid: 31682137

Objective: Data from the EVIDENT trial were reanalyzed to examine whether specific anxiety-related comorbidities moderate the effect of an Internet intervention on depression outcome. Method: The EVIDENT study is a randomized controlled trial that included N = 1,013 participants with mild to moderate depressive symptoms (i.e., scores between 5 and 14 on the Patient Health Questionnaire−9 [PHQ-9]) who were randomized to a control group with access to care-as-usual (n = 504) or to an intervention group, which accessed the Internet intervention Deprexis adjunctively to care-as-usual (n = 509). Anxiety-related comorbidities (generalized anxiety disorder, social phobia, panic disorder, agoraphobia, panic disorder with agoraphobia, specific phobia, posttraumatic stress disorder, obsessive–compulsive disorder) were assessed with the Web Screening Questionnaire at baseline. Multilevel models were performed. Results: Twelve potential moderators (8 specific anxiety-related comorbidities, depression severity, and 3 previously identified moderators in the EVIDENT trial) were examined within 1 multilevel model, and only social phobia moderated the intervention effect on depression outcome (in favor of Deprexis). This moderating effect of social phobia did not depend on the other moderators’ being included in the model. These results emerged for continuous PHQ-9 scores as well as for clinically important PHQ-9 changes as outcome (p < .05). However, moderating effects did not reach small effect sizes, accounted for less than 1% of the variance in change in depressive symptoms, and showed limited reproducibility in randomly selected split halves. Conclusions: Deprexis appears to be most effective for participants with mild to moderate depressive symptoms and comorbid social phobia, but further replications of this finding are necessary.