The effectiveness of unguided self-help psychological interventions for obsessive-compulsive disorder: A meta-analysis of randomized controlled trials.

BACKGROUND: Evidence-based psychological interventions exist for individuals with obsessive-compulsive disorder (OCD), but many individuals with OCD are unable to access them because of barriers, such as geographical isolation, treatment cost, and stigma etc. Unguided self-help psychological intervention has emerged as a potential solution to this problem. However, there is limited research on its overall effectiveness. This study aimed to address this gap. METHODS: Comprehensive searches from inception to 1st Jan 2023 were conducted in both international (PubMed, Embase, PsycINFO, International clinical trials registry platform of WHO) and Chinese (China National Knowledge Infrastructure, WeiPu, WanFang, Chinese Clinical Trial Registry) databases. The registered protocol is accessible at https://doi.org/10.17605/OSF.IO/FKB5W. We included randomized controlled trials (RCTs) comparing unguided self-help psychological interventions to control groups for individuals with OCD. The primary outcome was OCD symptom severity, with Hedges' g calculated post-intervention. Heterogeneity was deemed to be low, moderate, and high if the I2 value was quantified 25%, 50%, and 75% respectively. Relative Risks (RRs) was calculated for dropout rates post-intervention. Random-effects models were used for all analyses. RESULTS: 12 RCTs comparing unguided self-help psychological interventions to control groups were identified, with a total of 20 comparisons and 769 OCD patients. Overall, unguided self-help psychological interventions demonstrated a significant moderate effect on reducing OCD symptom severity (g = -0.42; 95% CI [-0.69; -0.14]) compared to control groups, with a moderate heterogeneity (I2 = 59%; 95% CI [22.73; 78.38]). This finding remained significant in sensitivity analyses for the self-rated Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; k = 7, g = -0.46; 95% CI [-0.71; -0.2]) and after removing an outlier (g = -0.37; 95% CI [-0.55; -0.19]), but not for the clinician-rated Y-BOCS (k = 4, g = -0.78; 95% CI [-2.75; 1.19]) and Obsessive Compulsive Inventory-Revised (k = 6, g = -0.26; 95% CI [-0.53; 0]). Subgroup analyses revealed a significant difference in effect size between studies conducting intention-to-treat and completers-only analyses (p = .01). The completers-only analyses demonstrated a moderate significant effect (g = -0.65; 95% CI [-1.08; -0.21]), whereas the effect of the intention-to-treat analyses was not significant (g = -0.18; 95% CI [-0.36; 0]). Participants in the unguided self-help groups exhibited a significantly higher dropout rate (RR = 2.08; 95% CI [1.53; 2.81]) compared to control groups. Furthermore, participants recruited from the community had a higher likelihood of dropping out compared to those recruited from clinical settings (p < .001). Additionally, participants who received cognitive-behavioural therapy intervention were more likely to drop out than those who received other types of intervention (p < .001). Most trials (92%) were rated at a high risk of bias. CONCLUSION: Unguided self-help psychological interventions demonstrate potential effectiveness in alleviating OCD symptom severity post-intervention. However, caution should be exercised when interpreting the results due to high risk of bias across trials and the relatively small sample size. And the considerable dropout rate might hinder treatment effects. Future studies with strict methodology should investigate the long-term effectiveness of unguided self-help psychological interventions for OCD, explore the reasons for high dropout rates, and improve intervention adherence.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students.

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study.

BACKGROUND: Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood. OBJECTIVE: This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress. METHODS: A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis. RESULTS: Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience. CONCLUSIONS: The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention. TRIAL REGISTRATION: Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1016/j.invent.2021.100369.

A Guided Web-Based Intervention Targeting Procrastination in College Students: Protocol for an Open Trial.

BACKGROUND: Academic procrastination is a widespread problem among college students. It is linked to poor academic performance and increased college dropout intentions, as well as several mental health problems such as depression, anxiety, and stress. Guided web-based interventions can help reduce procrastination. However, guidance by professional clinicians draws upon valuable and limited societal resources, and a more efficient, scalable form of guidance is needed. Guidance by trained clinical psychology students has not yet been examined. OBJECTIVE: The aim of this open trial is to examine the feasibility and acceptability of a web-based procrastination intervention for college students under the guidance of student digital coaches (e-coaches). METHODS: We developed a single-arm trial of a guided web-based intervention targeting procrastination for the Dutch student population. Guidance is delivered by trained clinical psychology students asynchronously in the form of textual feedback on intervention progress, with the aim of supporting and motivating the participant. Participants are recruited at 7 Dutch universities. Primary outcomes are intervention satisfaction, usability, and adherence, which are assessed by the Client Satisfaction Scale (CSQ-8), System Usability Scale (SUS-10), and number of completed modules, respectively. The primary outcomes will be examined by calculating descriptive statistics. Secondary outcomes are e-coach satisfaction and changes to procrastination, depression, stress, and quality of life from pre- to posttest and follow-up. RESULTS: The project was funded in 2019, and recruitment began in January 2021. As of May 2023, a total of 985 participants were enrolled, of which 372 had completed the posttest and 192 had completed the follow-up. The expected date of analysis and publication of the results is 2024. CONCLUSIONS: The results are expected to contribute to the body of literature regarding eHealth in 3 ways. First, we will examine whether students who procrastinate adhere to and are satisfied with an eHealth intervention targeting this problem. Second, we will explore whether an intervention targeting procrastination can also decrease depression and stress. Lastly, we will investigate whether trained psychology students can effectively guide their peers in web-based interventions. Given the shortage of licensed psychologists, exploring alternative sources of guidance is much needed in order to provide students with the mental health support they need. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44907.

User profile of an online cognitive behavioral therapy self-help platform in Turkey.

Online mental health self-help services are of societal importance and increasingly popular. Therefore, we have developed an online platform offering free self-help to the Turkish public with modules based on Cognitive Behavioral Therapy (CBT) targeting depression, anxiety, and stress respectively. The main purpose of this study is to describe the user profile of this platform. A pre-intervention self-report assessment including general demographic information and the Brief Symptom Inventory questionnaire during October 2020 until September 2022. 8331 participants completed the assessment and created an account out of the 11.228 users who registered during a two-year period, of which 8.331 (74%) completed the assessment and created an account. The majority of these users were female (76.17%), highly educated (82%), single (68%) and actively studying or working (84%). Slightly more than half (57%) of the platform user had not received psychological assistance before, while those who did receive previous assistance indicate to have benefitted from that (74%). The psychological symptoms of users are widely distributed, encompassing a broad range of user profiles. Approximately half of all users actively used the platform, while the other half did not complete any module. Among active users, the course "coping with depressive mood" was the most popular (41.45%), followed by "coping with anxiety" (37.25%) and "coping with stress" (21.30%). Offering a free online CBT self-help platform to the Turkish public seems feasible, with strong uptake among both man and woman struggling with a variety of psychological symptoms. Further research is needed to assess user satisfaction and change in symptoms over time during platform use by means of a feasibility trial.

Effectiveness of a guided internet-based intervention for procrastination among university students - A randomized controlled trial study protocol.

Procrastination is a widespread problem that is highly prevalent among the young adult population and is associated with several negative consequences. However, current evidence on the effectiveness of e-health interventions for procrastination either lack a comparison to an inactive control, do not include a student population or are of poor quality. This protocol describes the design of a trial that will overcome these limitations and examine the effectiveness of a guided internet-based intervention (GetStarted) to reduce problematic procrastinating behaviors in college students compared to a waitlist control. This study will be a two-armed randomized controlled trial with a calculated sample size of N = 176. Participants will be students from seven universities in the Netherlands. The intervention group will receive a four-week e-coach-guided intervention for procrastination. The waitlist control group will get access to treatment four weeks after randomization. Assessments will take place at baseline, post-test (4 weeks post-baseline) and follow-up (6 months post-baseline). Data will be analyzed with an intent-to-treat principle. The primary outcome is change in procrastination behaviors measured on the Irrational Procrastination scale (IPS). Secondary outcomes are depression, anxiety, stress, and quality of life. Additionally, sociodemographic characteristics of the participants, satisfaction with treatment, program usability, satisfaction with e-coach and treatment adherence will be examined as potential moderators. The results from this study can build evidence for the effectiveness of a guided internet-based intervention for treating procrastination in college students. Should it be effective, GetStarted could provide a flexible, low-intense and cost-effective treatment for procrastination and prevent common mental health problems in college students. Trial registration: This trial is registered at ClinicalTrials.gov Protocol Registration and Results System (Trial number: NCT05478096).

Effects of psychological treatment for depression among people not actively seeking help: a meta-analysis.

Although psychological treatments have been found to be effective for depression in adults, many individuals with depression do not actively seek help. It is currently unclear whether psychological treatments are effective among those not actively seeking help. Besides, little is known about the proportion of patients who completed a screening questionnaire who end up in a clinical trial. Therefore, we conducted a meta-analysis of 52 randomized trials comparing psychotherapies for adults with a diagnosis or elevated symptoms of depression against control conditions (care-as-usual, waiting list, and other inactive treatment). Only studies recruiting participants who do not actively seek help (participants who have been recruited through screening instead of advertisements and clinical referrals) were included. To obtain an overall effect estimate of psychotherapy, we pooled all post-test differences with a random-effects model. We found that psychological treatments had a moderate to high effect on reducing depressive symptoms compared to control groups [g = 0.55; 95% confidence interval (CI) 0.41-0.69]. Heterogeneity was high (I2 = 75%; 95% CI 68-80). At 12 months' follow-up, the effects were small but significant (6-8 months: g = 0.33; 95% CI 0.14-0.52; 9-12 months: g = 0.24; 95% CI 0.11-0.37). As a secondary outcome, we found that 13% of patients who completed a screening questionnaire met the inclusion criteria for depression and agreed to be randomized in the trial. Based on the current evidence, psychological treatments for depression might be effective for depressed patients who are not actively seeking help.

Guided internet-based transdiagnostic individually tailored Cognitive Behavioral Therapy for symptoms of depression and/or anxiety in college students: A randomized controlled trial.

Common mental disorders, such as depression and anxiety, often emerge in college students during the transition into early adulthood. Mental health problems can seriously impact students' functioning, interpersonal relationships, and academic achievement. Actively reaching out to college students with mental health problems and offering them internet-based interventions may be a promising way of providing low-threshold access to evidence-based treatment in colleges. This randomized controlled trial aimed to assess the effectiveness of a guided web-based transdiagnostic individually tailored Cognitive Behavioral Therapy (iCBT) in treating college students with depression and/or anxiety symptoms. Through an online survey that screened college students' mental health, we recruited 100 college students aged ≥18 years who reported mild to moderate depression and/or anxiety symptoms and were attending colleges in the Netherlands. Participants were randomly allocated to guided iCBT (n = 48) or treatment as usual (TAU) control (n = 52). Primary outcomes were symptoms of depression and anxiety measured at post-treatment (7 weeks post-randomization). We also measured all outcomes at 6- and 12-months post-randomization. All analyses were based on the intention-to-treat principle and were repeated using the complete-case sample. We found no evidence of a difference between the effects of guided iCBT and TAU in any of the examined outcomes (i.e., symptoms of depression and anxiety, quality of life, educational achievement, and college dropout) across all time points (p > .05). There was no evidence that effects of iCBT were associated with treatment satisfaction and adherence. More research into transdiagnostic individually tailored iCBT is necessary. Further, future studies should recruit larger samples to investigate possible smaller but clinically relevant effects of internet-based interventions for college students with depression and/or anxiety.

The Associations of Common Psychological Problems With Mental Disorders Among College Students.

Psychological problems like procrastination, perfectionism, low self-esteem, test anxiety and stress are common among college students. There are evidence-based interventions available for these problems that not only have direct effects on these problems, but also indirect effects on mental disorders such as depression and anxiety disorders. Targeting these psychological problems may offer new opportunities to prevent and treat mental disorders in a way that is less stigmatizing to students. In this study we examined the association of five psychological problems with five common mental disorders (panic, generalized anxiety, bipolar, major depressive, and substance use disorder) in a sample of 2,449 students from two Dutch universities. Psychological problems were measured with one item for each problem and mental disorders were measured with the Composite International Diagnostic Interview Screening Scales. Associations were examined with Poisson regression models as relative risks (RR) of the disorders as a function of the psychological problems. The population attributable fraction (PAF) indicates by what percentage the prevalence of the mental disorder would be reduced if the psychological problem was addressed successfully by an intervention. Especially generalized anxiety disorder was strongly associated with psychological problems (strong associations with stress and low self-esteem and moderately with test anxiety). The group with three or more psychological problems had a strongly increased risk for generalized anxiety (RR = 11.25; 95% CI: 7.51-16.85), and a moderately increase risk for major depression (RR = 3.22; 95% CI: 2.63-3.95), panic disorder (RR = 3.19; 95% CI: 1.96-5.20) and bipolar disorder (RR = 3.66; 95% CI: 2.40-5.58). The PAFs for having any of the psychological problems (one or more) were considerable, especially for generalized anxiety (60.8%), but also for panic disorder (35.1%), bipolar disorder (30.6%) and major depression (34.0%). We conclude that common psychological problems are associated with mental disorders and with each other. After adjustment, psychological problems are associated with different patterns of mental disorders. If the impact of the psychological problems could be taken away, the prevalence of several mental disorders would be reduced considerably. The psychological problems may provide a promising target to indirectly prevent and intervene in psychopathology in hard to reach college students with mental disorders.

Psychological risk factors and the course of depression and anxiety disorders: A review of 15 years NESDA research.

BACKGROUND: The Netherlands Study of Depression and Anxiety (NESDA; Nbaseline=2981) is an ongoing longitudinal, multi-site, naturalistic, cohort study examining the etiology, course, and consequences of depression and anxiety. In this article we synthesize and evaluate fifteen years of NESDA research on prominent psychological risk factors for the onset, persistence, recurrence, and comorbidity of affective disorders. METHODS: A narrative review of 62 NESDA articles examining the specificity and predictive value of neuroticism, behavioral inhibition, repetitive negative thinking, experiential avoidance, cognitive reactivity, locus of control, (implicit) self-esteem, (implicit) disorder-specific self-associations, and attentional bias for the course of affective disorders. RESULTS: All self-reported risk factors showed cross-sectional relationships with singular and comorbid affective disorders, and prospective relationships with the development and chronicity of depression and anxiety disorders. High neuroticism, low self-esteem, and negative repetitive thinking showed most prominent transdiagnostic relationships, whereas cognitive reactivity showed most pronounced depression-specific associations. Implicit self-esteem showed predictive validity for the persistence and recurrence of anxiety and depression over and above self-reported risk factors. Automatic approach-avoidance behavior and attentional bias for negative, positive, or threat words showed no relationship with affective disorders. CONCLUSION: NESDA identified both (a) transdiagnostic factors (e.g., neuroticism, low implicit self-esteem, repetitive negative thinking) that may help explain the comorbidity between affective disorders and overlap in symptoms, and (b) indications for disorder-specific risk factors (e.g., cognitive responsivity) which support the relevance of distinct disorder categories and disorder-specific mechanisms. Thus, the results point to the relevance of both transdiagnostic and disorder-specific targets for therapeutic interventions.

Feasibility and acceptability of a guided internet-based stress management intervention for university students with high levels of stress: Protocol for an open trial.

More than half of university students have high levels of stress. Stress management programs can help students improve coping skills and prevent psychological distress. However, studies have generally targeted all university students regardless of whether they experience high levels of stress or not, and thus more studies are needed to examine the feasibility and acceptability of e-health interventions for students with elevated stress. The present open trial aims to examine the feasibility and acceptability of a guided internet-based stress management program for university students with high levels of stress. In this study, participants are recruited via e-mail, newsletters, and flyers from four universities in the Netherlands to participate in a guided internet-based stress management program. Guidance is delivered by e-coaches who provide weekly asynchronous text-based motivational feedback after each module is completed. Primary outcomes are satisfaction with the intervention, assessed by the Client Satisfaction Scale (CSQ-8), and usability, assessed by the System Usability Scale (SUS-10). Secondary outcomes are perceived stress, quality of life, and depression, assessed by the Perceived Stress Scale (PSS-10), the EuroQol- 5 Dimension- 5 Level Scale (EQ- 5D- 5L), and the Patient Health Questionnaire (PHQ-9) respectively. Adherence rates to the program are assessed by examining the number of completed modules, time spent on the platform, and completed exercises. The Caring Universities Project was funded in (September 2019). In June 2020, the project was officially announced to the students and recruitment began immediately. As of October 2020, recruitment continues. The expected date of the publication of the results is in 2021. It is expected that the results of the proposed study will be informative for designing and implementing e-health interventions in higher education. Moreover, it is assumed that the findings will contribute to the growing literature on internet interventions by yielding preliminary evidence related to the feasibility and acceptability of an online stress management program. TRIAL REGISTRATION: Netherlands Trial Register NL8686; https://www.trialregister.nl/trial/8686.

Psychological interventions to prevent the onset of depressive disorders: A meta-analysis of randomized controlled trials.

PURPOSE: Depressive disorders are common and have a considerable impact on patients and societies. Several treatments are available, but their effects are modest and reduce the burden only to a limited extent. Preventing the onset of depressive disorders may be one option to further reduce the global disease burden. METHODS: We conducted a meta-analysis of randomized controlled trials in participants without a diagnosis of depression at baseline, who were assigned to a preventive psychological intervention, or a care-as-usual, or comparable control group and in which incident cases of depression at follow-up were ascertained with a diagnostic interview. RESULTS: Our systematic searches resulted in 50 trials (14,665 participants) with relatively high quality, in high risk groups of all ages. The psychological interventions were mostly based on cognitive behavioral interventions. One year after the preventive interventions, the relative risk of developing a depressive disorder was RR = 0.81 (95% CI: 0.72-0.91), indicating that those who had received the intervention had 19% less chance to develop a depressive disorder. Given the average control event rate of 30%, twenty-one people had to participate in the intervention to prevent one depressive disorder compared to people in the control conditions. CONCLUSIONS: Prevention is a promising approach to reduce the global disease burden of depression in addition to treatments.

Temporal stability of symptoms of affective disorders, cognitive vulnerability and personality over time.

BACKGROUND: Signs and symptoms of psychopathology can be chronic but are generally regarded as less stable over time than markers of cognitive vulnerability and personality. Some findings suggest that these differences in temporal stability are modest in size but a rigorous examination across concepts is lacking. The current study investigated the temporal stability of affective symptoms, cognitive vulnerability markers and personality traits at various assessments over nine years. METHODS: Participants of the Netherlands Study of Depression and Anxiety were assessed at baseline and reassessed after 2, 4, 6 and 9 years. They were grouped on the basis of waves of depression and anxiety CIDI-diagnoses into stable healthy (n = 768), stable patients (n = 352) and unstable patients (n = 821). We determined temporal stability by calculating intraclass correlation coefficients (ICC) and consistency indices of latent state-trait analyses (LST). RESULTS: Temporal stability was moderate to high for symptoms (range ICC's 0.54-0.73; range consistency 0.64-0.74), cognitive vulnerability (range ICC's 0.53-0.76; range consistency 0.60-0.74) and personality (range ICC's 0.57-0.80; range consistency.60 -0.75). Consistency indices for all measures were on average a bit lower in the unstable group (ICC = 0.54) compared to the stable groups (ICC = 0.61). Overall stability was similarly high after 2, 4, 6 and 9 years. CONCLUSION: The 9-year stability over time of symptoms of affective disorders and that of indices of cognitive vulnerability and personality are remarkably similar and relatively high.

The predictive specificity of psychological vulnerability markers for the course of affective disorders.

High scores on markers of psychological vulnerability have been associated with a worse course of affective disorders. However, little is known about the specificity of those associations in predicting the course of different depressive and anxiety disorders. We examined the impact of psychological vulnerability on the short- and long-term course of depressive and anxiety disorders. Participants from the Netherlands Study of Depression and Anxiety with a current diagnosis of depression or anxiety (n = 1256) were reassessed after 2 and 6 years. Diagnostic status and chronic duration (>85% of the time) of symptoms were the outcomes. Predictors were neuroticism, extraversion, locus of control, cognitive reactivity (rumination and hopelessness reactivity), worry and anxiety sensitivity. High neuroticism, low extraversion and external locus of control predicted chronicity of various affective disorders. Rumination, however, predicted chronicity of depressive but not anxiety disorders. Worry specifically predicted chronicity of GAD and anxiety sensitivity predicted chronicity of panic disorder and social anxiety disorder. These patterns were present both at short-term and at long-term, without losing predictive accuracy. Psychological vulnerabilities that are theoretically specific to certain disorders indeed selectively predict the course of these disorders. General markers of vulnerability predicted the course of multiple affective disorders. This pattern of results supports the notion of specific as well as transdiagnostic predictors of the course of affective disorders and is consistent with hierarchical models of psychopathology.

The predictive value of Approach and Avoidance tendencies on the onset and course of depression and anxiety disorders.

BACKGROUND: Trait and automatic approach-avoidance (AA) tendencies are central concepts in research on affective disorders. We longitudinally examined the associations of trait and automatic AA tendencies with the risk of onset and chronicity of anxiety and depressive disorders. METHODS: Participants were subdivided into those with (n = 766) versus without (n = 1,636) a current anxiety or depression diagnosis at baseline. Clinical diagnoses were reassessed after 2-year follow-up. Automatic AA tendencies in reaction to facial expressions were assessed using the Approach-Avoidance Task, whereas self-reported trait AA tendencies were assessed using the Behavioral Inhibition System and the Behavioral Activation System scales. Analyses were adjusted for socio-demographics (basic adjustment) and for severity and history of psychopathology (full adjustment). RESULTS: Stronger trait avoidance tendencies predicted both increased risk of onset and increased risk of a chronic course of anxiety disorders after full adjustment (Odds ratioonset  = 1.55, P < .001, and Odds ratiochronicity  = 1.31, P = .03). The associations between stronger trait avoidance tendencies and increased risk of onset and chronicity of depressive disorders were no longer significant after full adjustment. In contrast, trait approach tendencies and automatic AA tendencies were not related to onset or chronicity of disorders. CONCLUSIONS: Increased trait avoidance tendencies are a risk factor for affective disorders in general, with possibly a slightly more pronounced role in anxiety than depressive disorders. This underlines the importance of addressing trait avoidance tendencies in both the treatment and aftercare of affective disorders.

Approach and avoidance tendencies in depression and anxiety disorders.

Anxiety is linked to increased avoidance and inhibition, whereas depression is linked to decreased approach and diminished behavioral activation. Although these notions are widely recognized, systematic investigation of approach-avoidance tendencies is lacking across these diagnostic groups. Participants (mean age = 45.6; 65.8% female) were subdivided in healthy controls (405), remitted patients (877) and currently anxious (217), depressed (154) or comorbid (154) patients. Automatic approach-avoidance tendencies in reaction to facial expression were assessed using the Approach-Avoidance-Task (AAT). Self-reported trait approach and avoidance tendencies were assessed using the BIS/BAS scale. Severity of psychopathology was assessed to examine dose-response relationships. We did not find any consistent associations of automatic approach-avoidance tendencies with psychiatric variables. In contrast, medium to large differences in BIS scores showed increased trait avoidance tendencies in all patient groups relative to healthy controls. Overall, it seems that increased trait avoidance, rather than decreased approach, is a characteristic of affective disorders. This holds for both depressed and anxious patients and more strongly so in severe and chronic patients. It underlines the importance to address trait avoidance tendencies in the treatment of affective disorders.

Cognitive vulnerability differentially predicts symptom dimensions of depression.

BACKGROUND: We examined the association of cognitive vulnerability to depression with changes in homogeneous measures of depressive symptoms. METHODS: Baseline and 1-year follow-up data were obtained from 2981 participants of the Netherlands study of depression and anxiety. Multivariate regression analyses were carried out on cognitive reactivity, locus of control and implicit and explicit self-depressive associations in combination with negative life events. The purpose of this analysis was to predict changes on the mood/cognition and anxiety/arousal subscales of the inventory of depressive symptomatology - self report. RESULTS: Cognitive reactivity, locus of control and explicit self-depressive associations were independently associated with changes in depressive symptoms after adjustment for covariates and baseline severity (all p<0.01). Negative life-events interacted with cognitive vulnerability to depression to predict depressive symptoms. Locus of control (b1=0.16, SE=0.02, η(2)=0.01; b2=0.10, SE=0.02, η(2)=0.004, F=8.69, p<0.01) and explicit self-depressive associations (b1=0.10, SE=0.03, η(2)=0.02; b2=0.02, SE=0.04, F=7.50, p<0.01) were more strongly associated with the cognitive (b1) than the somatic (b2) symptom dimension of depression. LIMITATIONS: The study sample is over-inclusive of depressed patients. Therefore it might be problematic generalizing the findings to the general population. CONCLUSION: Cognitive etiological factors may play a role in a "cognitive" subtype of depression. The findings strengthen the notion that homogeneous measures of depressive symptoms enable a greater degree of discrimination between subtypes than a multidimensional conception of depression.