Addressing Antivaccine Sentiment on Public Social Media Forums Through Web-Based Conversations Based on Motivational Interviewing Techniques: Observational Study.

BACKGROUND: Health misinformation shared on social media can have negative health consequences; yet, there is a dearth of field research testing interventions to address health misinformation in real time, digitally, and in situ on social media. OBJECTIVE: We describe a field study of a pilot program of "infodemiologists" trained with evidence-informed intervention techniques heavily influenced by principles of motivational interviewing. Here we provide a detailed description of the nature of infodemiologists' interventions on posts sharing misinformation about COVID-19 vaccines, present an initial evaluation framework for such field research, and use available engagement metrics to quantify the impact of these in-group messengers on the web-based threads on which they are intervening. METHODS: We monitored Facebook (Meta Platforms, Inc) profiles of news organizations marketing to 3 geographic regions (Newark, New Jersey; Chicago, Illinois; and central Texas). Between December 2020 and April 2021, infodemiologists intervened in 145 Facebook news posts that generated comments containing either false or misleading information about vaccines or overt antivaccine sentiment. Engagement (emojis plus replies) data were collected on Facebook news posts, the initial comment containing misinformation (level 1 comment), and the infodemiologist's reply (level 2 reply comment). A comparison-group evaluation design was used, with numbers of replies, emoji reactions, and engagements for level 1 comments compared with the median metrics of matched comments using the Wilcoxon signed rank test. Level 2 reply comments (intervention) were also benchmarked against the corresponding metric of matched reply comments (control) using the Wilcoxon signed rank test (paired at the level 1 comment level). Infodemiologists' level 2 reply comments (intervention) and matched reply comments (control) were further compared using 3 Poisson regression models. RESULTS: In total, 145 interventions were conducted on 132 Facebook news posts. The level 1 comments received a median of 3 replies, 3 reactions, and 7 engagements. The matched comments received a median of 1.5 (median of IQRs 3.75) engagements. Infodemiologists made 322 level 2 reply comments, precipitating 189 emoji reactions and a median of 0.5 (median of IQRs IQR 0) engagements. The matched reply comments received a median of 1 (median of IQRs 2.5) engagement. Compared to matched comments, level 1 comments received more replies, emoji reactions, and engagements. Compared to matched reply comments, level 2 reply comments received fewer and narrower ranges of replies, reactions, and engagements, except for the median comparison for replies. CONCLUSIONS: Overall, empathy-first communication strategies based on motivational interviewing garnered less engagement relative to matched controls. One possible explanation is that our interventions quieted contentious, misinformation-laden threads about vaccines on social media. This work reinforces research on accuracy nudges and cyberbullying interventions that also reduce engagement. More research leveraging field studies of real-time interventions is needed, yet data transparency by technology platforms will be essential to facilitate such experiments.

'They've all endorsed it but I'm just not there:' a qualitative exploration of COVID-19 vaccine hesitancy reported by Black and Latinx individuals.

OBJECTIVE: We sought to examine reasons for vaccine hesitancy among online communities of US-based Black and Latinx communities to understand the role of historical racism, present-day structural racism, medical mistrust and individual concerns about vaccine safety and efficacy. DESIGN: A qualitative study using narrative and interpretive phenomenological analysis of online bulletin board focus groups. SETTING: Bulletin boards with a focus-group-like setting in an online, private, chat-room-like environment. PARTICIPANTS: Self-described vaccine hesitant participants from US-based Black (30) and Latinx (30) communities designed to reflect various axes of diversity within these respective communities in the US context. RESULTS: Bulletin board discussions covered a range of topics related to COVID-19 vaccination. COVID-19 vaccine hesitant participants expressed fears about vaccine safety and doubts about vaccine efficacy. Elements of structural racism were cited in both groups as affecting populations but not playing a role in individual vaccine decisions. Historical racism was infrequently cited as a reason for vaccine hesitancy. Individualised fears and doubts about COVID-19 (short-term and long-term) safety and efficacy dominated these bulletin board discussions. Community benefits of vaccination were not commonly raised among participants. CONCLUSIONS: While this suggests that addressing individually focused fear and doubts are central to overcoming COVID-19 vaccine hesitancy in Black and Latinx groups, addressing the effects of present-day structural racism through a focus on community protection may also be important.

Correlates of Mpox Vaccination among Sexual Minority Men in the United States: Sexual Behavior, Substance Use, and Main Partner Relationships.

Sexual minority men (SMM) have accounted for the majority of infections during the 2022 outbreak of the orthopox virus known as mpox (previously "monkeypox") in the US. This study examined correlates of mpox vaccination. Between July 28 and September 22, 2022, adult cisgender SMM (n = 2,620) not previously diagnosed with mpox responded to recruitment advertisements on social networking applications and completed an online survey. Of these, 730 (27.9%) received at least one vaccine dose. Logistic regression indicated sex with a casual partner was positively associated with vaccination. Stimulant drug use was negatively associated with vaccination; meanwhile, the use of ecstasy, ketamine, gamma-hydroxybutyrate (GHB) or psychedelics was positively associated with vaccination. Among partnered SMM, non-monogamous sexual agreements, relationship length of ≥2 years, and relationship functioning were positively associated with vaccination. Even at low levels of relationship functioning, SMM in non-monogamous relationships of ≥2 years were more likely to be vaccinated than single SMM. At very high levels of relationship functioning, partnered SMM were more likely to be vaccinated than single SMM regardless of sexual agreement or relationship length. Findings are discussed in relation to prior research on HIV, other STI prevention, and theories of dyadic functioning and health in this population.

Community-oriented Motivational Interviewing (MI): A novel framework extending MI to address COVID-19 vaccine misinformation in online social media platforms.

Researchers have linked circulating misinformation in online platforms to low COVID-19 vaccine uptake. Two disparate literatures provide relevant initial guidance to address the problem. Motivational Interviewing (MI) effectively reduces vaccine hesitancy in clinical environments; meanwhile, social scientists note inoculation, rebuttal, and appeals to accuracy are persuasive in digital contexts. A tension is inherent in these approaches. MI in digital forums may induce an 'illusory truth effect,' wherein falsehoods appear more accurate through repetition. Yet, rebutting misinformation directly may elicit backfire or reactance effects, motivating some to amplify their presentation of misinformation. Building on Identity Process Theory, we propose a theoretical framework for conducting MI-based infodemiology interventions among digital communities that conceptualizes the community in toto (rather than one specific person) as the unit of focus. Case examples from interventions on public Facebook posts illustrate three processes unique to such interventions: 1) Navigating tension between addressing commenters and "bystanders"; 2) Activating pro-vaccine bystanders; and 3) Reframing uncertainty or information individuals might find concerning or threatening according to implied collective values. This paper suggests community-oriented MI can maximize persuasive effects on bystanders while minimizing potential reactance from those with committed beliefs, thereby guiding community-oriented public health messaging interventions enacted in digital environments.

Improving maternal mental health: assessing the extent of screening and training about peripartum depression.

OBJECTIVE: Peripartum depression (PPD) is a common mental health complication of pregnancy and increases risk for maternal mortality and poorer outcomes for children. Despite its importance, screening rates vary across organizations and care team members. The goal of the current study was to explore the perspectives from care team members in both behavioral health and acute care settings about how they screen and refer pregnant and post pregnant women for PPD, what training around PPD is currently offered by their organization, and if they could benefit from additional PPD training. METHODS: Data were collected from an online self-report survey of care team members from behavioral health and acute care settings in the US. Questions focused on (1) when/if the care teams had a screening protocol for PPD, (2) beliefs about the efficacy of their organization's PPD screening, identification, and referral process, and (3) if their organization currently offered or needed training around the topic of PPD. RESULTS: A total of 794 care team members in behavioral health and acute care responded to the survey between December 2021 and May 2022. Nearly, all (96.7%) reported having a specific protocol for screening for PPD when they know a patient is pregnant; however, only 69.6% of respondents routinely screen regardless of symptoms being reported by the patient. While 93.3% of the sample believed their organization does a good job screening for and identifying PPD, gaps in the referral processes were described, especially in acute settings. 95.3% of the sample reported their organization currently gives training in screening, identifying, or treating PPD or in the process for establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients; however, 96.5% also reported their organization would benefit from additional training in one or more of these areas. CONCLUSION: High rates of self-reported PPD screening and training indicate that care team members in both behavioral health and acute care are aware of the importance of maternal mental health issues. However, other research indicates that high rates of screening may not lead to improved outcomes, and there are still high rates of maternal suicide and suicidal ideation in the US. It is possible that high self-reported screening rates may indicate a false sense of security such that care team members feel the issue is addressed while problems remain. Alternatively, many respondents felt their organizations would benefit from further training, perhaps indicating an awareness of this gap. Care team members in behavioral health and acute care settings should increase collaboration to ensure high rates of screening lead to improved maternal mental health care.

Use of Predictive Analytics to Identify Unhealthy Opioid Use and Guide Intervention.

OBJECTIVE: The authors aimed to use the newly developed Opioid Risk Stratification Tool to identify individuals who may be at risk for unhealthy opioid use and to examine the impact of applying a mailing and engagement intervention to this population and their prescribers, with the goal of reducing high-risk prescribing behaviors, opioid medication use, and mortality rates. METHODS: A nonrandomized controlled study was conducted with members from two Medicaid managed care organizations. In both the intervention (N=131) and control (N=187) groups, an algorithm identified members at moderate to high risk for hazardous opioid use. Members at increased risk in the intervention group and their prescribers received a letter from the managed care organization, and members still at risk 3 months after the mailing were contacted by a care coordinator. Individuals in the control group were not contacted. Medicaid claims data were used to compare opioid use and prescribing practices between groups before and after the intervention. RESULTS: Individuals in the intervention group were less likely to have any opioid prescription postintervention compared with those in the control group (OR=0.55, p<0.001), and the intervention group had a greater reduction in the number of individuals with concurrent opioid and benzodiazepine prescriptions (OR=0.49, p=0.042). Practices such as multiple opioid prescriptions and multiple prescribers of opioids were not affected by the intervention. CONCLUSIONS: An intervention targeting individuals at risk for hazardous opioid use was associated with a reduction in some high-risk prescribing practices. Future research should determine the ideal mix of interventions to reduce as many risk factors as possible.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder.

Objective The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Corrigendum: Implications of COVID-19 Vaccine Hesitancy: Results of Online Bulletin Board Interviews.

[This corrects the article DOI: 10.3389/fpubh.2021.757283.].

Screening for Information Environments: A Role for Health Systems to Address the Misinformation Crisis.

Misinformation about health topics is a public health issue. We are bombarded with information from many sources, across many digital means of communication, affecting the ways in which we are born, grow, work, live, and age. This makes information environments a social determinant of health (SDoH), but one not currently adequately addressed by clinical or public health practitioners. Since health systems are already screening for social determinants of health, existing mechanisms can additionally screen for unhealthy information environments. Then, for those patients who screen positive, we can apply best practices learned from initiatives addressing vaccine hesitancy: providing a non-judgmental environment in which to discuss health beliefs, using motivational interviewing techniques to gage patient perspectives and readiness for change, and taking a harm-reduction approach in recognizing that behavior change evolves over time. Displacing misinformation is a process, not an event. As such, we need to address the underlying psychological and sociological reasons that people maintain unscientific beliefs as we would hope to do with any other SDoH. Furthermore, as information environments are the product of both individual choices and structural factors, clinicians should approach patients immersed in unhealthy information environments without blame or ostracism, much as we would approach any patient adversely impacted by social determinants of health.

Behavioral Health Diagnoses and Health Care Use Before and During the COVID-19 Pandemic.

OBJECTIVE: Emerging evidence has suggested a population-wide worsening of psychiatric symptoms during the COVID-19 pandemic, particularly among individuals with preexisting mental health conditions. The authors investigated whether reported behavioral health problems are being identified and treated. METHODS: This observational cohort study retrospectively compared Medicaid data of patients from the first year of the pandemic (2020) in the United States (N=1,589,111 patients) with the corresponding data from the year before (2019; N=1,715,872 patients). Outcome measures included several behavioral health diagnoses and health care utilization. RESULTS: During the pandemic period examined, the numbers of patients served, adults receiving a new diagnosis of anxiety, and children receiving a new diagnosis of depression all increased. Across all age groups, nonbehavioral health emergency department visits significantly decreased. CONCLUSIONS: These findings support reports of increases in psychiatric morbidity but do not provide evidence for increased demand for health care services.

Implications of COVID-19 Vaccine Hesitancy: Results of Online Bulletin Board Interviews.

Reluctance to accept vaccination against COVID-19 poses a significant public health risk and is known to be a multi-determined phenomenon. We conducted online focus groups, or "bulletin boards," in order to probe the nature of COVID-19 vaccine hesitancy and its implications. Participants were 94 individuals from three distinct U.S. geographical areas and represented a range of demographic and socioeconomic characteristics. Six themes emerged from the 3 day-long bulletin boards: the most trusted source of health information sought is the personal physician; information about health is nevertheless obtained from a wide variety of sources; stories about adverse side effects are especially "sticky"; government health institutions like CDC and FDA are not trusted; most respondents engaged in individualistic reasoning; and there is a wide spectrum of attitudes toward vaccination.

Early Life Stress Associated With Increased Striatal N-Acetyl-Aspartate: Cerebrospinal Fluid Corticotropin-Releasing Factor Concentrations, Hippocampal Volume, Body Mass and Behavioral Correlates.

INTRODUCTION: Using proton magnetic resonance spectroscopy imaging (1H-MRSI), the effects of early life stress (ELS) on nonhuman primate striatal neuronal integrity were examined as reflected by N-acetyl aspartate (NAA) concentrations. NAA measures were interrogated through examining their relationship to previously documented ELS markers -- cerebrospinal fluid (CSF) corticotropin-releasing factor (CRF) concentrations, hippocampal volume, body mass and behavioral timidity. Rodent models of depression exhibit increases in neurotrophic effects in the nucleus accumbens (NAcc). We hypothesized that rearing under conditions of ELS [Variable Foraging Demand: (VFD)] would produce persistent elevations of NAA concentrations (in absolute or ratio form) in ventral striatum/caudate nucleus (VS/CN) with altered correlation to ELS markers. METHODS: Eleven bonnet macaque males reared under VFD conditions and seven age-matched control subjects underwent 1H-MRSI during young adulthood. Voxels were placed over ventral striatum/caudate nucleus (VS/CN) to capture NAcc. Cisternal CSF CRF concentrations, hippocampal volume, body mass and response to a human intruder had been previously determined. RESULTS: VFD-reared monkeys exhibited significantly increased NAA/Cr concentrations in right VS/CN in comparison to normally-reared controls, controlling for multiple comparisons. In comparison to controls, VFD CSF CRF concentrations were directly associated with right VS/CN absolute NAA. Left hippocampal volume was inversely associated with left VS/CN N-acetyl aspartate/creatine (NAA/Cr) in VFD-reared but not in controls. Disruption of a normative inverse correlation between left VS/CN NAA and body mass was noted in VFD. Only non-VFD subjects exhibited a direct relationship between timidity response to an intruder and right VS/CN NAA. CONCLUSION: ELS produced persistent increases in VS/CN NAA, which demonstrated specific patterns of association (or lack thereof) to ELS markers in comparison to non-VFD subjects. The data are broadly consistent with a stable nonhuman primate phenotype of anxiety and mood disorder vulnerability whereby in vivo indicators of neuronal integrity, although reduced in hippocampus, are increased in striatum. The findings may provide a catalyst for further studies in humans and other species regarding a reciprocal hippocampal/NAcc relationship in affective disorders.

Multimethod assessment of baseline depression and relationship to hepatitis C treatment discontinuation.

Objective The primary study objective is to determine which measures of depression are associated with early discontinuation of hepatitis C virus infection treatment and to determine which measure best characterizes the depression that develops during treatment. Methods Seventy-eight treatment-naïve subjects who initiated pegylated interferon/ribavirin treatment for hepatitis C virus infection were included. Baseline depression was assessed with the Structured Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the Hamilton Depression Rating Scale, and the Beck Depression Inventory-II. The latter two measures were repeated at treatment weeks 12 and 24. Results Depression scores, as measured by the three instruments, lacked adequate consistency. Baseline depression as measured by the Beck Depression Inventory-II, but not by the other scales, was associated with early treatment discontinuation at weeks 12 and 24. Changes in depression during treatment were restricted to somatic symptoms. Of those who completed treatment, those who were not depressed at baseline tended to demonstrate significant depression increases during treatment. Conclusion The Beck Depression Inventory-II is recommended to assess depression prior to hepatitis C virus infection treatment. Somatic symptoms of depression should be monitored during treatment. Baseline depression as measured by the Beck Depression Inventory-II was associated with early treatment discontinuation. The Beck Depression Inventory-II, Structured Interview for DSM-IV, and Hamilton Depression Rating Scale yielded results that were not consistent with each other in this sample. Future research should focus on standardizing depression assessment in medically ill populations to identify measures that predict treatment discontinuation.

Integrated Pharmacies at Community Mental Health Centers: Medication Adherence and Outcomes.

BACKGROUND: Patients receiving psychiatric services at community mental health centers (CMHCs) are often prescribed medication that is critical to the treatment of behavioral health conditions, including schizophrenia, bipolar disorder, anxiety, and depression. Previous studies have shown correlation between rates of medication adherence and risk of hospitalization, but potential differences in medication adherence and other outcomes for patients of CMHCs by pharmacy type have not been widely studied. OBJECTIVE: To determine potential benefits of placing a pharmacy within a mental health service delivery setting on both adherence to medication and health outcomes. METHODS: A retrospective cohort analysis of medication adherence rates, hospital and emergency department (ED) use, and related costs between patients of CMHCs was conducted using integrated pharmacies versus community pharmacies. Data were from Medicaid claims paid by Southwest Michigan Behavioral Health for all (behavioral and nonbehavioral) inpatient and outpatient services as well as pharmacy prescriptions filled from April 1, 2014, through April 30, 2015. The primary study analysis was composed of an adult dataset representing persons served from 1 of the 2 CMHCs who had filled at least 2 prescriptions for a specific medication from 1 of 2 Genoa pharmacies located in a CMHC during the study period. Each unique patient dataset in the treatment group was matched to a corresponding control patient dataset prescribed the same medication using a modified version of the Gale-Shapley algorithm. The primary analysis compared medication possession ratio, which is a measure of adherence that indicates gaps or oversupply in a patient's medication use history. Statistical tests were performed using the R statistical programming language and Microsoft Excel. RESULTS: Patients using pharmacies integrated within the CMHCs had higher medication adherence rates, lower rates of hospitalization, and lower ED use than those filling their prescriptions at community pharmacies. These results were associated with a cost savings of $58 per member per month (approximately $700,000 per 1,000 patients annually). CONCLUSIONS: Pharmacies integrated within CMHCs not only can improve medication adherence but also can reduce the need for other expensive health care services. DISCLOSURES: Southwest Michigan Behavioral Health sponsored this study, which was funded by Genoa, a QoL Healthcare Company. SWMBH is a client of Care Management Technologies and permitted the use of its data for this analysis. Wright and Clayton are employed by Care Management Technologies, which was contracted by Genoa to conduct this analysis. Gorman owns Franklin Behavioral Health Consultants and reports consulting fees from Care Management Technologies; Gorman also reports stock ownership in various pharmaceutical companies. Odorzynski and Peterson are employed by Genoa. Study concept and design were contributed by Clayton, Odorzynski, Peterson, and Gorman, with assistance from Wright. Wright took the lead in data collection, with assistance from Clayton and Odorzynski, and data interpretation was performed by Wright and Gorman, with assistance from Odorzynski, Clayton, and Peterson. The manuscript was written by Gorman, Wright, and Odorzynski, assisted by Clayton and Peterson, and revised by Clayton, Gorman, Odorzynski, and Peterson.

Combining Psychodynamic Psychotherapy and Pharmacotherapy.

Many patients with depression, anxiety disorders, and other psychiatric disorders are treated with combinations of psychodynamic psychotherapy and medication. Whether this is better than monotherapy is an empirical question that requires much more extensive research than is currently available. When medications were first introduced to treat psychiatric illnesses, some psychopharmacologists insisted that it heralded a new area of "biological psychiatry" that would ultimately render psychotherapy obsolete. Psychodynamic theorists and practitioners, on the other hand, argued that psychopharmacology offered only a superficial approach to treatment. Fortunately, these battles are now largely supplanted by the belief that whatever treatment offers the patient the best outcome should be employed, regardless of the therapist's theoretical outlook. This should motivate more extensive study of the value of combination treatment. So far, the few studies that have been done suggest that the combination of psychodynamic psychotherapy and medication may be superior for the treatment of mood and anxiety disorders, but most of these studies have small sample sizes and involve only short-term psychotherapy. An examination of the neuroscience of mood and anxiety disorders and of the mechanism of action of psychodynamic psychotherapy and of antidepressant medication suggests several routes by which the two treatment modalities could be synergistic: stimulation of hippocampal neurogenesis; epigenetic regulation of gene expression; dendritic remodeling; enhanced prefrontal cortical control of limbic system activity; and action at specific neurohormonal and neurotransmitter targets. The evidence for each of these mechanisms is reviewed with an eye toward potential experiments that might be relevant to them.

SECOND-STAGE TREATMENTS FOR RELATIVE NONRESPONDERS TO COGNITIVE BEHAVIORAL THERAPY (CBT) FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA-CONTINUED CBT VERSUS SSRI: A RANDOMIZED CONTROLLED TRIAL.

BACKGROUND: Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT. METHOD: The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively. RESULTS: Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms. CONCLUSIONS: These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368.

The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder.

BACKGROUND: Previous research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population. METHODS: The present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder. RESULTS: We found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity. CONCLUSION: These results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.