Cognitive behavioral therapy for depressive disorders: Outcomes from a multi-state, multi-site primary care practice.

BACKGROUND: Individuals with depressive disorders often present to and seek treatment in primary care. Integrated behavioral health services within this setting can improve access to evidence-based cognitive behavioral therapy (CBT). However, limited information exists on the effectiveness of CBT for depression in primary care. METHODS: Of the 1,302 participants with a primary depressive disorder referred by their primary care provider, 435 endorsed moderate to severe depression at baseline and engaged in at least one CBT session. A psychotherapy tracking database was used to collect relevant data, which included demographics, clinical characteristics, treatment outcomes, and CBT intervention use. RESULTS: Participants with moderate to severe depression who participated in CBT reported a significant decrease in depression and anxiety symptoms at the end of treatment (p ≤ .001, d = 0.52-0.78). Rates of reliable change, response, and remission and types of CBT interventions used differed between major and persistent depressive disorders. LIMITATIONS: Multiple limitations must be noted, which are related to the naturalistic study design, inclusion and exclusion criteria, sample operationalization, symptomatic measurement, time-limited and focused assessment, data collection strategies, and psychological services. Together, these temper the conclusions that can be drawn. CONCLUSION: Significant reductions in depression and anxiety symptoms were reported by participants with depressive disorders who engaged in short-term CBT within primary care. This study indicates that CBT can be implemented within primary care and suggests that primary care patients with depression can benefit from integrated psychological services, supporting population-based models of care.

Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State, Multi-Site Primary Care Practice.

BACKGROUND: Anxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care. METHODS: Participants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database. RESULTS: Among participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p< .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations. DISCUSSION: Short-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.

Age-related delay in reduced accessibility of refreshed items.

Previously, we demonstrated that in young adults, briefly thinking of (i.e., refreshing) a just-seen word impairs immediate (100-ms delay) perceptual processing of the word, relative to words seen but not refreshed. We suggested that such reflective-induced inhibition biases attention toward new information. Here, we investigated whether reduced accessibility of refreshed targets dissipates with a longer delay and whether older adults would show a smaller and/or delayed effect compared with young adults. Young adult and older adult participants saw 2 words, followed by a cue to refresh one of these words. After either a 100-ms or 500-ms delay, participants read a word that was the refreshed word (refreshed probe), the nonrefreshed word (nonrefreshed probe), or a new word (novel probe). Young adults were slower to read refreshed probes than nonrefreshed probes at the 100-ms, but not the 500-ms, delay. Conversely, older adults were slower to read refreshed probes than nonrefreshed probes at the 500-ms, but not the 100-ms, delay. The delayed slowing of responses to refreshed probes was primarily observed in older-old adults (75+ years). A delay in suppressing the target of refreshing may disrupt the fluidity with which attention can be shifted to a new target. Importantly, a long-term memory benefit of refreshing was observed for both ages and delays. These results suggest that a full characterization of age-related memory deficits should consider the time course of effects and how specific component cognitive processes affect both working and long-term memory. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effects of face attractiveness on face memory depend on both age of perceiver and age of face.

Face attractiveness can influence memory for previously seen faces. This effect has been shown to differ for young and older perceivers. Two parallel studies examined the moderation of both the age of the face and the age of the perceiver on the relationship between facial attractiveness and face memory. Study 1 comprised 29 young and 31 older participants; Study 2 comprised 25 young and 24 older participants. In both studies, participants completed an incidental face encoding and a surprise old/new recognition test with young and older faces that varied in face attractiveness. Face attractiveness affected memory for young but not older faces. In addition, young but not older perceivers showed a linear effect of facial attractiveness on memory for young faces, while both young and older perceivers showed a quadratic effect on memory for young faces. These findings extend previous work by demonstrating that the effect of facial attractiveness on face memory is a function of both the age of the perceiver and the age of the face. Factors that could account for such moderations of face and perceiver age on the associations between face attractiveness and face memory are discussed (e.g. age differences in social goals and face similarity/distinctiveness).

Merely presenting one's own name along with target items is insufficient to produce a memory advantage for the items: A critical role of relational processing.

Using the self as a reference point at encoding produces a memory advantage over other types of encoding activities. Even simply co-presenting a target item with self-relevant versus other-relevant information can produce an "incidental" self-memory advantage in the absence of any explicit task demand to evaluate the item's self-relevancy. In the present study, we asked whether an incidental self-memory advantage results from (a) the mere co-presentation of a target item with self-relevant information at encoding or (b) relational processing between a target item and self-relevant information at encoding. During incidental encoding, words were presented in two different colors either above or below a name (the participant's own or another person's). Participants judged either the location of each word in relation to the name ("Is the word above or below the name?") or the color of each word to which the name had no relevance ("Is the word in red or green?"). In a subsequent memory test, we found a self-memory advantage for both items and their associated source features in the location judgment task but not in the color judgment task. Our findings show that a memory advantage for a target item presented with self-relevant versus other-relevant information is more likely when a task agenda places, via relational processing demands, the self-relevant/other-relevant information in the focus of attention along with the target item. Potential processes that mediate this attention-dependent effect are discussed.

Children's Initial Responses and Beyond: Effects of Niceness and Similarity on Preference, Giving, and Memory.

This study assessed children's preference, giving, and memory to investigate the impact of social information over time. We compared 5- and 6-year-olds' (N = 144) immediate or delayed responses to an individual who does or does not share their toy preference (similar vs. dissimilar) or an individual who treats others kindly or poorly (nice vs. mean). Immediately, children all preferred the similar or nice characters but gave more stickers to the similar character. This strong initial effect of similarity was not evident after 1 week; children's preference, giving, and memory reflected a greater long-term impact of niceness than similarity. These findings highlight the importance of using multiple features and measures to elucidate children's evolving views about others.

Initial outcomes of a real-world multi-site primary care psychotherapy program.

OBJECTIVE: Although anxiety, mood, and adjustment disorders are commonly treated in primary care, little evidence exists regarding psychotherapy outcomes within this setting. The primary objective of this study was to describe outcomes of a large-scale primary care psychotherapy program. METHODS: Patients (N = 2772) participated in cognitive behavioral therapy (CBT) as part of a multi-site primary care program. A tracking system was utilized to collect data on demographics, diagnoses, course of care, anxiety and depressive symptoms, and frequencies of psychotherapy principles used over the course of primary care CBT. RESULTS: Anxiety disorders were most frequent, often comorbid with depression. Over two-thirds of the sample participated in at least one CBT session. Case formulation, cognitive interventions, exposure, and behavioral activation were frequently utilized approaches. Significant improvements on the GAD-7 and PHQ-9 occurred for all groups, yielding medium effect sizes (d = 0.50-0.68). Rates of reliable change (48-80%), response (35-53%), and remission (21-36%) were noted for those scoring in the moderate range of severity. CONCLUSION: Patients suffering from anxiety, depression, and adjustment disorders can be effectively treated in primary care with CBT. Future efforts are needed to match patient characteristics with the types and timing of therapy interventions to improve clinical and functional outcomes.

Children's decision making: When self-interest and moral considerations conflict.

When children's self-interests are at odds with their moral considerations, what do they do? In the current study of 5- and 6-year-olds (N=160), we asked (a) whether children would select the offering of a do-gooder over a neutral individual at a personal cost, (b) whether they would reject the offering of a wrongdoer over a neutral individual at a personal cost, and (c) whether these two types of decisions involve comparable levels of conflict. In the absence of material considerations, children preferred a nice character to a neutral one, but this preference was easily overcome for material gain; children accepted a larger offering from a neutral source over a smaller offering from a nice source. In contrast, children's aversion to negative characters was largely unaffected by the same material consideration; they rejected a larger offering from a mean source in favor of a smaller offering from a neutral source. In addition, children's response times indicated that deciding whether or not to "sell out" to a wrongdoer for personal gain engenders conflict but that deciding whether to take a lesser gain from a do-gooder does not. These findings indicate that children weigh both their own material interests and others' social behaviors when selecting social partners and, importantly, that an aversion to wrongdoers is a more powerful influence on these choices than an attraction to do-gooders.

Brain Mechanisms of Reality Monitoring.

Reality monitoring processes are necessary for discriminating between internally generated information and information that originated in the outside world. They help us to identify our thoughts, feelings, and imaginations, and to distinguish them from events we may have experienced or have been told about by someone else. Reality monitoring errors range from confusions between real and imagined experiences, that are byproducts of normal cognition, to symptoms of mental illness such as hallucinations. Recent advances support an emerging neurocognitive characterization of reality monitoring that provides insights into its underlying operating principles and neural mechanisms, the differing ways in which impairment may occur in health and disease, and the potential for rehabilitation strategies to be devised that might help those who experience clinically significant reality monitoring disruption.

Source memory that encoding was self-referential: the influence of stimulus characteristics.

Decades of research suggest that encoding information with respect to the self improves memory (self-reference effect, SRE) for items (item SRE). The current study focused on how processing information in reference to the self affects source memory for whether an item was self-referentially processed (a source SRE). Participants self-referentially or non-self-referentially encoded words (Experiment 1) or pictures (Experiment 2) that varied in valence (positive, negative, neutral). Relative to non-self-referential processing, self-referential processing enhanced item recognition for all stimulus types (an item SRE), but it only enhanced source memory for positive words (a source SRE). In fact, source memory for negative and neutral pictures was worse for items processed self-referentially than non-self-referentially. Together, the results suggest that item SRE and source SRE (e.g., remembering an item was encoded self-referentially) are not necessarily the same across stimulus types (e.g., words, pictures; positive, negative). While an item SRE may depend on the overall likelihood the item generates any association, the enhancing effects of self-referential processing on source memory for self-referential encoding may depend on how embedded a stimulus becomes in one's self-schema, and that depends, in part, on the stimulus' valence and format. Self-relevance ratings during encoding provide converging evidence for this interpretation.

Holistic versus feature-based binding in the medial temporal lobe.

A central question for cognitive neuroscience is how feature-combinations that give rise to episodic/source memories are encoded in the brain. Although there is much evidence that the hippocampus (HIP) is involved in feature binding, and some evidence that other brain regions are as well, there is relatively little evidence about the nature of the resulting representations in different brain regions. We used multivoxel pattern analysis (MVPA) to investigate how feature combinations might be represented, contrasting two possibilities, feature-based versus holistic. Participants viewed stimuli that were composed of three source features - a person (face or body), a scene (indoor or outdoor), and an object (bike or luggage) - which were combined to make eight unique stimulus identities. We reasoned that regions that can classify the eight identities (a multiclass classification) but not the individual features (a binary classification) likely have a holistic representation of each identity. In contrast, regions that can classify the eight identities and can classify each feature are likely to contain feature-based representations of these identities. To further probe the extent of feature-based or holistic classification in each region, we developed and validated a novel approach that directly compares binary and multiclass classification. We found clear evidence for holistic representation in the parahippocampal cortex (PHC), consistent with theories that posit that pattern-separation-like binding mechanisms are not unique to the HIP. Further clarifying the mechanisms of feature binding should benefit from systematic comparisons of multi-feature representations and whether they vary with task, type of stimulus, and/or experience.

Monitoring what is real: The effects of modality and action on accuracy and type of reality monitoring error.

Reality monitoring refers to processes involved in distinguishing internally generated information from information presented in the external world, an activity thought to be based, in part, on assessment of activated features such as the amount and type of cognitive operations and perceptual content. Impairment in reality monitoring has been implicated in symptoms of mental illness and associated more widely with the occurrence of anomalous perceptions as well as false memories and beliefs. In the present experiment, the cognitive mechanisms of reality monitoring were probed in healthy individuals using a task that investigated the effects of stimulus modality (auditory vs visual) and the type of action undertaken during encoding (thought vs speech) on subsequent source memory. There was reduced source accuracy for auditory stimuli compared with visual, and when encoding was accompanied by thought as opposed to speech, and a greater rate of externalization than internalization errors that was stable across factors. Interpreted within the source monitoring framework (Johnson, Hashtroudi, & Lindsay, 1993), the results are consistent with the greater prevalence of clinically observed auditory than visual reality discrimination failures. The significance of these findings is discussed in light of theories of hallucinations, delusions and confabulation.

Evaluation of the use of oseltamivir prophylaxis in the control of influenza outbreaks in long-term care facilities in Alberta, Canada: a retrospective provincial database analysis.

OBJECTIVES: To evaluate the impact of oseltamivir prophylaxis in the management and control of influenza outbreaks in long-term care facilities in Alberta, Canada. SETTING AND PARTICIPANTS: Long-term care facilities where 127 influenza outbreaks were reported to public health authorities in Alberta, Canada, during two influenza seasons from 2013 to 2015. DESIGN AND OUTCOME MEASURES: Using routinely collected surveillance and administrative data, we examined the association between decision-making time for oseltamivir recommendation as prophylaxis strategy for influenza outbreaks in long-term care facilities (explanatory variable) and the duration of an influenza outbreak, the postprophylaxis risk of influenza-like illness and hospitalisation among residents of long-term care facilities in Alberta (outcome variables) using multivariable linear and Poisson regression models. RESULTS: Oseltamivir prophylaxis decision-making time was positively associated with the postintervention duration of an outbreak, with a 1-day delay in making decision on oseltamivir prophylaxis associated with 2.22 (95% CI 1.37 to 3.06) more days of the duration of an outbreak after controlling for potential confounding effect of the number of residents at risk at intervention, outbreak progression time, prevalence of influenza-like illness during outbreak progression, facility location, presence of mixed strain and based on optimal timing of oseltamivir prophylaxis. Although not statistically significant, a 1-day delay in making decision on oseltamivir prophylaxis was associated with a 5% (95% CI -1% to 11%) increase in the postintervention risk of influenza-like illness, and a 6% (95% CI -8% to 22%) increase in the postintervention risk of hospitalisation after controlling for the same potential confounders. CONCLUSIONS: Our study demonstrated benefits of using oseltamivir prophylaxis to shorten the duration of influenza outbreaks; however, there were no significant differences in the influenza-like illness and hospitalisation risk occurring after the intervention. Surveillance data may offer means of rapid evaluation of oseltamivir prophylaxis in long-term care facilities as a public health measure.

Reactivation during encoding supports the later discrimination of similar episodic memories.

Episodic memory is characterized by remembering events as unique combinations of features. Even when some features of events overlap, we are later often able to discriminate among them. Here we ask whether hippocampally mediated reactivation of an earlier event when a similar one occurs supports subsequent memory that two similar but not identical events occurred (mnemonic discrimination). In two experiments, participants viewed objects (Experiment 1) or scenes (Experiment 2) during functional MRI (fMRI). After scanning, participants had to remember whether repeated items had been identical or similar. In Experiment 2, representational similarity between the 1st and 2nd presentation predicted participants' ability to remember that the presentations were different, suggesting that the first item was reactivated while viewing the second. A similar but weaker result was found in Experiment 1 that did not survive correction for multiple comparisons. Furthermore, both experiments yielded evidence that the hippocampus was involved in reactivation; hippocampal pattern similarity (and, in Experiment 2, hippocampal activity during the 2nd presentation) correlated with pattern similarity in several regions of visual cortex. These results provide the first fMRI evidence that hippocampally mediated reactivation contributes to the later memory that two similar, but different events occurred. © 2016 Wiley Periodicals, Inc.

Cross-trial prediction of treatment outcome in depression: a machine learning approach.

BACKGROUND: Antidepressant treatment efficacy is low, but might be improved by matching patients to interventions. At present, clinicians have no empirically validated mechanisms to assess whether a patient with depression will respond to a specific antidepressant. We aimed to develop an algorithm to assess whether patients will achieve symptomatic remission from a 12-week course of citalopram. METHODS: We used patient-reported data from patients with depression (n=4041, with 1949 completers) from level 1 of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D; ClinicalTrials.gov, number NCT00021528) to identify variables that were most predictive of treatment outcome, and used these variables to train a machine-learning model to predict clinical remission. We externally validated the model in the escitalopram treatment group (n=151) of an independent clinical trial (Combining Medications to Enhance Depression Outcomes [COMED]; ClinicalTrials.gov, number NCT00590863). FINDINGS: We identified 25 variables that were most predictive of treatment outcome from 164 patient-reportable variables, and used these to train the model. The model was internally cross-validated, and predicted outcomes in the STAR*D cohort with accuracy significantly above chance (64·6% [SD 3·2]; p<0·0001). The model was externally validated in the escitalopram treatment group (N=151) of COMED (accuracy 59·6%, p=0.043). The model also performed significantly above chance in a combined escitalopram-buproprion treatment group in COMED (n=134; accuracy 59·7%, p=0·023), but not in a combined venlafaxine-mirtazapine group (n=140; accuracy 51·4%, p=0·53), suggesting specificity of the model to underlying mechanisms. INTERPRETATION: Building statistical models by mining existing clinical trial data can enable prospective identification of patients who are likely to respond to a specific antidepressant. FUNDING: Yale University.

A self-serving bias in children's memories?

Although children's initial perceptions and judgments about sociomoral situations are being actively explored, little is known about what children remember about them. In four experiments testing over 400 children, we investigated children's memories for small acts of giving and taking. When asked to recall their own giving and taking, children were relatively accurate following a number of delays. In contrast, when asked to recall a child's giving or taking, children exaggerated the child's taking after a 1-day or 1-week delay. Notably, this pattern of misremembering occurred only when children recalled the actions of a child but not an adult. We consider the idea that children spontaneously engage in social comparison, which colors their memories of the social world.

Electrophysiological Correlates of Refreshing: Event-related Potentials Associated with Directing Reflective Attention to Face, Scene, or Word Representations.

Refreshing is the component cognitive process of directing reflective attention to one of several active mental representations. Previous studies using fMRI suggested that refresh tasks involve a component process of initiating refreshing as well as the top-down modulation of representational regions central to refreshing. However, those studies were limited by fMRI's low temporal resolution. In this study, we used EEG to examine the time course of refreshing on the scale of milliseconds rather than seconds. ERP analyses showed that a typical refresh task does have a distinct electrophysiological response as compared to a control condition and includes at least two main temporal components: an earlier (∼400 msec) positive peak reminiscent of a P3 response and a later (∼800-1400 msec) sustained positivity over several sites reminiscent of the late directing attention positivity. Overall, the evoked potentials for refreshing representations from three different visual categories (faces, scenes, words) were similar, but multivariate pattern analysis showed that some category information was nonetheless present in the EEG signal. When related to previous fMRI studies, these results are consistent with a two-phase model, with the first phase dominated by frontal control signals involved in initiating refreshing and the second by the top-down modulation of posterior perceptual cortical areas that constitutes refreshing a representation. This study also lays the foundation for future studies of the neural correlates of reflective attention at a finer temporal resolution than is possible using fMRI.

Age-related differences in the neural basis of the subjective vividness of memories: evidence from multivoxel pattern classification.

Although older adults often show reduced episodic memory accuracy, their ratings of the subjective vividness of their memories often equal or even exceed those of young adults. Such findings suggest that young and older adults may differentially access and/or weight different kinds of information in making vividness judgments. We examined this idea using multivoxel pattern classification of fMRI data to measure category representations while participants saw and remembered pictures of objects and scenes. Consistent with our hypothesis, there were age-related differences in how category representations related to the subjective sense of vividness. During remembering, older adults' vividness ratings were more related, relative to young adults', to category representations in prefrontal cortex. In contrast, young adults' vividness ratings were more related, relative to older adults, to category representations in parietal cortex. In addition, category representations were more correlated among posterior regions in young than in older adults, whereas correlations between PFC and posterior regions did not differ between the 2 groups. Together, these results are consistent with the idea that young and older adults differentially weight different types of information in assessing subjective vividness of their memories.

A ten-year follow-up of a study of memory for the attack of September 11, 2001: Flashbulb memories and memories for flashbulb events.

Within a week of the attack of September 11, 2001, a consortium of researchers from across the United States distributed a survey asking about the circumstances in which respondents learned of the attack (their flashbulb memories) and the facts about the attack itself (their event memories). Follow-up surveys were distributed 11, 25, and 119 months after the attack. The study, therefore, examines retention of flashbulb memories and event memories at a substantially longer retention interval than any previous study using a test-retest methodology, allowing for the study of such memories over the long term. There was rapid forgetting of both flashbulb and event memories within the first year, but the forgetting curves leveled off after that, not significantly changing even after a 10-year delay. Despite the initial rapid forgetting, confidence remained high throughout the 10-year period. Five putative factors affecting flashbulb memory consistency and event memory accuracy were examined: (a) attention to media, (b) the amount of discussion, (c) residency, (d) personal loss and/or inconvenience, and (e) emotional intensity. After 10 years, none of these factors predicted flashbulb memory consistency; media attention and ensuing conversation predicted event memory accuracy. Inconsistent flashbulb memories were more likely to be repeated rather than corrected over the 10-year period; inaccurate event memories, however, were more likely to be corrected. The findings suggest that even traumatic memories and those implicated in a community's collective identity may be inconsistent over time and these inconsistencies can persist without the corrective force of external influences.

Distinct neural networks support the mere ownership effect under different motivational contexts.

The "mere ownership effect" refers to individuals' tendency to evaluate objects they own more favorably than comparable objects they do not own. There are numerous behavioral demonstrations of the mere ownership effect, but the neural mechanisms underlying the expression of this self-positivity bias during the evaluation of self-associated objects have not been identified. The present study aimed to identify the neurobiological expression of the mere ownership effect and to assess the potential influence of motivational context. During fMRI scanning, participants made evaluations of objects after ownership had been assigned under the presence or absence of self-esteem threat. In the absence of threat, the mere ownership effect was associated with brain regions implicated in processing personal/affective significance and valence (ventromedial prefrontal cortex [vMPFC], ventral anterior cingulate cortex [vACC], and medial orbitofrontal cortex [mOFC]). In contrast, in the presence of threat, the mere ownership effect was associated with brain regions implicated in selective/inhibitory cognitive control processes (inferior frontal gyrus [IFG], middle frontal gyrus [MFG], and lateral orbitofrontal cortex [lOFC]). These findings indicate that depending on motivational context, different neural mechanisms (and thus likely different psychological processes) support the behavioral expression of self-positivity bias directed toward objects that are associated with the self.