A Qualitative Investigation of Barriers to Seeking Treatment for Suicidal Thoughts and Behaviors Among Army Soldiers with a Deployment History.

This study aimed to identify barriers to treatment seeking and service utilization among previously deployed Army soldiers who recently experienced a suicidal crisis. Confidential interviews were conducted on a psychiatric inpatient unit with 12 Army soldiers with a deployment history following a suicidal crisis. Qualitative analysis focused on statements coded as "barriers to seeking help" and "explicit recommendations." Suicidal Army soldiers with a deployment history experienced different barriers to seeking help, including stigma and logistical challenges (e.g., long wait times for appointments). Negative and positive perceptions of support were reported for various resources - for example, family, crisis hotlines, chaplains, and command. Suicidal Army soldiers, interviewed in this study, experienced a number of challenges and frustrations associated with various helping resources. This study highlights the need for greater attention toward understanding these challenges and subsequently addressing them through appropriate resource allocation and additional training for those working directly with Army soldiers at risk for suicide.

Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD.

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems.

OBJECTIVE: Use of expert-led workshops plus consultation has been established as an effective strategy for training community mental health (CMH) clinicians in evidence-based practices (EBPs). Because of high rates of staff turnover, this strategy inadequately addresses the need to maintain capacity to deliver EBPs. This study examined knowledge, competency, and retention outcomes of a two-phase model developed to build capacity for an EBP in CMH programs. METHODS: In the first phase, an initial training cohort in each CMH program participated in in-person workshops followed by expert-led consultation (in-person, expert-led [IPEL] phase) (N=214 clinicians). After this cohort completed training, new staff members participated in Web-based training (in place of in-person workshops), followed by peer-led consultation with the initial cohort (Web-based, trained-peer [WBTP] phase) (N=148). Tests of noninferiority assessed whether WBTP was not inferior to IPEL at increasing clinician cognitive-behavioral therapy (CBT) competency, as measured by the Cognitive Therapy Rating Scale. RESULTS: WBTP was not inferior to IPEL at developing clinician competency. Hierarchical linear models showed no significant differences in CBT knowledge acquisition between the two phases. Survival analyses indicated that WBTP trainees were less likely than IPEL trainees to complete training. In terms of time required from experts, WBTP required 8% of the resources of IPEL. CONCLUSIONS: After an initial investment to build in-house CBT expertise, CMH programs were able to use a WBTP model to broaden their own capacity for high-fidelity CBT. IPEL followed by WBTP offers an effective alternative to build EBP capacity in CMH programs, rather than reliance on external experts.

Implementation of transdiagnostic cognitive therapy in community behavioral health: The Beck Community Initiative.

OBJECTIVE: Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. METHOD: Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. RESULTS: Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). CONCLUSIONS: Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

A Mixed Methods Approach to Identify Cognitive Warning Signs for Suicide Attempts.

This study used a mixed methods approach to examine pathways to suicidal behavior by identifying cognitive warning signs that occurred within 1 day of a suicide attempt. Transcripts of cognitive therapy sessions from 35 patients who attempted suicide were analyzed using a modified grounded theory approach. Cognitive themes emerging from these transcripts included: state hopelessness, focus on escape, suicide as a solution, fixation on suicide, and aloneness. Differences in demographic and baseline diagnostic and symptom data were explored in relation to each cognitive theme. We propose a potential conceptual model of cognitive warning signs for suicide attempts that requires further testing.

What changes in cognitive therapy for depression? An examination of cognitive therapy skills and maladaptive beliefs.

This study examined effortful cognitive skills and underlying maladaptive beliefs among patients treated with cognitive therapy (CT) for depression. Depressed patients (n=44) completed cognitive measures before and after 16 weeks of CT. Measures included an assessment of CT skills (Ways of Responding Scale; WOR), an implicit test of maladaptive beliefs (Implicit Association Test; IAT), and a self-report questionnaire of maladaptive beliefs (Dysfunctional Attitude Scale; DAS). A matched sample of never-depressed participants (n=44) also completed study measures. Prior to treatment, depressed patients endorsed significantly more undesirable cognitions on the WOR, IAT, and DAS compared with never-depressed participants. Patients displayed improvement on the WOR and DAS over the course of treatment, but showed no change on the IAT. Additionally, improvements on the WOR and DAS were each related to greater reductions in depressive symptoms. Results suggest that the degree of symptom reduction among patients participating in CT is related to changes in patients' acquisition of coping skills requiring deliberate efforts and reflective thought, but not related to reduced endorsement of implicitly assessed maladaptive beliefs.

Assessing Patients' Cognitive Therapy Skills: Initial Evaluation of the Competencies of Cognitive Therapy Scale.

In Cognitive Therapy (CT), therapists work to help patients develop skills to cope with negative affect. Most current methods of assessing patients' skills are cumbersome and impractical for clinical use. To address this issue, we developed and conducted an initial psychometric evaluation of self and therapist reported versions of a new measure of CT skills: the Competencies of Cognitive Therapy Scale (CCTS). We evaluated the CCTS at intake and post-treatment in a sample of 67 patients participating in CT. The CCTS correlated with a preexisting measure of CT skills (the Ways of Responding Questionnaire) and was also related to concurrent depressive symptoms. Across CT, self-reported improvements in CT competencies were associated with greater changes in depressive symptoms. These findings offer initial evidence for the validity of the CCTS. We discuss the CCTS in comparison with other measures of CT skills and suggest future research directions.

Cognitive Therapy Skills Predict Cognitive Reactivity to Sad Mood Following Cognitive Therapy for Depression.

Both patients' competence in the coping skills taught in Cognitive Therapy (CT) and patients' endorsement of dysfunctional cognitions following a sad mood induction (i.e., their cognitive reactivity) have been found to predict risk of relapse following a successful course of CT for depression. We examined the relationship between these constructs, specifically whether CT skills would be related to less cognitive reactivity following a mood induction among patients who responded to a course of CT. In a sample of 28 depressed patients, post-treatment CT skills were significantly related to less cognitive reactivity in response to a sad mood induction procedure (ß = -.29). This relation was not accounted for by individual differences in mood reactivity. We discuss these findings as a key step in developing a more complete understanding of the role of CT coping skills and cognitive reactivity as markers of patients' vulnerability to relapse.

Quality of coping skills predicts depressive symptom reactivity over repeated stressors.

OBJECTIVE: The purpose of this study was to examine the quality of coping skills as a predictor of change in depressive symptoms surrounding a series of naturally occurring stressors. METHOD: A total of 213 undergraduate students completed study measures surrounding 3 stressors (involving 6 assessments per participant). Primary analyses focused on occasions of disappointing exam performance. RESULTS: Consistent with expectations, coping skill quality was predictive of more adaptive responses (i.e., less depressive symptom reactivity), with this relation being particularly strong among participants with high initial levels of depressive symptoms and on occasions when participants had a marked worsening of mood. The quality of skills used in coping with specific stressors continued to predict depressive symptom reactivity after controlling for a one-time measure of coping skill quality. CONCLUSIONS: Our results support the importance of both stressor-specific coping skill quality and consideration of key contextual factors in understanding depressive symptom reactivity surrounding stressors.

Cognitive biases in three prediction tasks: a test of the cognitive model of depression.

Cognitive therapy for depression is based on an assumption that depressed individuals have inaccurate, negative biases. Whether this assumption is accurate remains unresolved. Thus, this study sought to examine the relationship between depressive symptoms and bias in three sets of predictions (i.e., predictions of future life events, how one would be rated by a significant other, and performance on a vocabulary test). Following study announcements made to a subset of people pre-screened for depressive symptoms, 85 participants with widely varying depressive symptoms (17 of whom met diagnostic criteria for depression) made predictions on three judgment tasks and the outcomes for these tasks were assessed. Optimistic/pessimistic biases were related to depressive symptoms for each of the three tasks. Participants with high levels of depressive symptoms and depressed participants exhibited substantial pessimistic bias. Those high in depressive symptoms exhibited significant pessimistic bias on all three tasks. Participants meeting diagnostic criteria for depression exhibited pessimistic bias on two of three tasks. There was no evidence that depressive symptoms were associated with greater accuracy in judgments. Results are largely consistent with cognitive models of depression which postulate that depression is associated with pessimistic biases.

A developmental examination of amygdala response to facial expressions.

Several lines of evidence implicate the amygdala in face-emotion processing, particularly for fearful facial expressions. Related findings suggest that face-emotion processing engages the amygdala within an interconnected circuitry that can be studied using a functional-connectivity approach. Past work also underscores important functional changes in the amygdala during development. Taken together, prior research on amygdala function and development reveals a need for more work examining developmental changes in the amygdala's response to fearful faces and in amygdala functional connectivity during face processing. The present study used event-related functional magnetic resonance imaging to compare 31 adolescents (9-17 years old) and 30 adults (21-40 years old) on activation to fearful faces in the amygdala and other regions implicated in face processing. Moreover, these data were used to compare patterns of amygdala functional connectivity in adolescents and adults. During passive viewing, adolescents demonstrated greater amygdala and fusiform activation to fearful faces than did adults. Functional connectivity analysis revealed stronger connectivity between the amygdala and the hippocampus in adults than in adolescents. Within each group, variability in age did not correlate with amygdala response, and sex-related developmental differences in amygdala response were not found. Eye movement data collected outside of the magnetic resonance imaging scanner using the same task suggested that developmental differences in amygdala activation were not attributable to differences in eye-gaze patterns. Amygdala hyperactivation in response to fearful faces may explain increased vulnerability to affective disorders in adolescence; stronger amygdala-hippocampus connectivity in adults than adolescents may reflect maturation in learning or habituation to facial expressions.

Specificity of facial expression labeling deficits in childhood psychopathology.

BACKGROUND: We examined whether face-emotion labeling deficits are illness-specific or an epiphenomenon of generalized impairment in pediatric psychiatric disorders involving mood and behavioral dysregulation. METHOD: Two hundred fifty-two youths (7-18 years old) completed child and adult facial expression recognition subtests from the Diagnostic Analysis of Nonverbal Accuracy (DANVA) instrument. Forty-two participants had bipolar disorder (BD), 39 had severe mood dysregulation (SMD; i.e., chronic irritability, hyperarousal without manic episodes), 44 had anxiety and/or major depressive disorders (ANX/MDD), 35 had attention-deficit/hyperactivity and/or conduct disorder (ADHD/CD), and 92 were controls. Dependent measures were number of errors labeling happy, angry, sad, or fearful emotions. RESULTS: BD and SMD patients made more errors than ANX/MDD, ADHD/CD, or controls when labeling adult or child emotional expressions. BD and SMD patients did not differ in their emotion-labeling deficits. CONCLUSIONS: Face-emotion labeling deficits differentiate BD and SMD patients from patients with ANX/MDD or ADHD/CD and controls. The extent to which such deficits cause vs. result from emotional dysregulation requires further study.

Abnormal attention modulation of fear circuit function in pediatric generalized anxiety disorder.

CONTEXT: Considerable work implicates abnormal neural activation and disrupted attention to facial-threat cues in adult anxiety disorders. However, in pediatric anxiety, no research has examined attention modulation of neural response to threat cues. OBJECTIVE: To determine whether attention modulates amygdala and cortical responses to facial-threat cues differentially in adolescents with generalized anxiety disorder and in healthy adolescents. DESIGN: Case-control study. SETTING: Government clinical research institute. PARTICIPANTS: Fifteen adolescents with generalized anxiety disorder and 20 controls. MAIN OUTCOME MEASURES: Blood oxygenation level-dependent signal as measured via functional magnetic resonance imaging. During imaging, participants completed a face-emotion rating task that systematically manipulated attention. RESULTS: While attending to their own subjective fear, patients, but not controls, showed greater activation to fearful faces than to happy faces in a distributed network including the amygdala, ventral prefrontal cortex, and anterior cingulate cortex (P<.05, small-volume corrected, for all). Right amygdala findings appeared particularly strong. Functional connectivity analyses demonstrated positive correlations among the amygdala, ventral prefrontal cortex, and anterior cingulate cortex. CONCLUSIONS: This is the first evidence in juveniles that generalized anxiety disorder-associated patterns of pathologic fear circuit activation are particularly evident during certain attention states. Specifically, fear circuit hyperactivation occurred in an attention state involving focus on subjectively experienced fear. These findings underscore the importance of attention and its interaction with emotion in shaping the function of the adolescent human fear circuit.

fMRI predictors of treatment outcome in pediatric anxiety disorders.

INTRODUCTION: A growing number of studies have found evidence that anxiety and depressive disorders are associated with atypical amygdala hyperactivation, which decreases with effective treatment. Interest has emerged in this phenomenon as a possible biological marker for individuals who are likely to benefit from tailored treatment approaches. OBJECTIVE: The present study was designed to examine relationships between pretreatment amygdala activity and treatment response in a sample of anxious children and adolescents. MATERIALS AND METHODS: Participants, who were diagnosed predominantly with generalized anxiety disorder (GAD), underwent functional magnetic resonance imaging (fMRI) scanning before treatment with fluoxetine or cognitive behavioral therapy (CBT). RESULTS: Results indicated significant negative associations between degree of left amygdala activation and measures of posttreatment symptom improvement in the group, as a whole. DISCUSSION: Taken together with research on associations between adult amygdala activation and treatment response, these findings suggest that patients whose pretreatment amygdala activity is the strongest may be particularly likely to respond well to such widely used treatments as selective serotonin reuptake inhibitor (SSRI) medications and CBT.