Depression in patients with hematologic malignancies: The current landscape and future directions.

Patients with hematologic malignancies experience high rates of depression. These patients are vulnerable to depression throughout the disease trajectory, from diagnosis to survivorship, and at the end of life. In addition to the distressing nature of depression, it has substantial downstream effects including poor quality of life, increased risk of treatment complications, and worse survival. Therefore, systematic screening for depression and integration of robust psychological interventions for affected patients is crucial. Although depression has been historically studied mostly in patients with solid malignancies, research focusing on patients with hematologic malignancies is growing. In this article, we describe what is known about depression in patients with hematologic malignancies, including its assessment, prevalence, risk factors, and implications. We also describe interventions to ameliorate depression in this population. Future research is needed to test effective and scalable interventions to reduce the burden of depression among patients with blood cancers.

Coping with racial discrimination: a preliminary examination of coping strategies in college students at a University in Northeastern U.S.

OBJECTIVE: We examined the associations between coping strategies in response to racism and distress symptoms. SAMPLE: One hundred forty-four racially minoritized students at a northeastern university completed an online survey. METHODS: Participants completed self-report active and emotion-focused coping and distress symptom (i.e., depression and anxiety) measures. Hierarchical regressions were conducted to test: 1) correlations between coping strategies in response to racism and distress symptoms, and 2) whether emotional acceptance moderates the association between active coping in response to racism and distress symptoms. RESULTS: Students' self-compassionate responses to their emotional reactions to discrimination uniquely predicted less distress. In contrast, reports of using resistance and education in response to discrimination were positively correlated with distress symptoms; however, these associations were no longer significant when accounting for emotional acceptance. CONCLUSIONS: Our findings suggest that emotional acceptance coping may be associated with lower distress symptoms. Active coping was associated with increased distress symptoms, except when accounting for emotional acceptance coping.

Mental health disorders and survival among older patients with diffuse large B-cell lymphoma in the USA: a population-based study.

BACKGROUND: Mental health disorders can potentially decrease quality of life and survival in patients with cancer. Little is known about the survival implications of mental health disorders in patients with diffuse large B-cell lymphoma (DLBCL). We aimed to evaluate the effect of pre-existing depression, anxiety, or both on survival in a US cohort of older patients with DLBCL. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients aged 67 years or older, diagnosed with DLBCL in the USA between Jan 1, 2001, and Dec 31, 2013. We used billing claims to identify patients with pre-existing depression, anxiety, or both before their DLBCL diagnosis. We compared 5-year overall survival and lymphoma-specific survival between these patients and those without pre-existing depression, anxiety, or both using Cox proportional analyses, adjusting for sociodemographic and clinical characteristics, including DLBCL stage, extranodal disease, and B symptoms. FINDINGS: Among 13 244 patients with DLBCL, 2094 (15·8%) had depression, anxiety, or both disorders; 6988 (52·8%) were female, and 12 468 (94·1%) were White. The median follow-up for the cohort was 2·0 years (IQR 0·4-6·9 years). 5-year overall survival was 27·0% (95% CI 25·1-28·9) for patients with these mental health disorders versus 37·4% (36·5-38·3) for those with no mental health disorder (hazard ratio [HR] 1·37, 95% CI 1·29-1·44). Although survival differences between mental health disorders were modest, those with depression alone had the worst survival compared with no mental health disorder (HR 1·37, 95% CI 1·28-1·47), followed by those with depression and anxiety (1·23, 1·08-1·41), and then anxiety alone (1·17, 1·06-1·29). Individuals with these pre-existing mental health disorders also had lower 5-year lymphoma-specific survival, with depression conferring the greatest effect (1·37, 1·26-1·49) followed by those with depression and anxiety (1·25, 1·07-1·47) and then anxiety alone (1·16, 1·03-1·31). INTERPRETATION: Pre-existing depression, anxiety, or both disorders present within 24 months before DLBCL diagnosis, worsens prognosis for patients with DLBCL. Our data underscore the need for universal and systematic mental health screening for this population, as mental health disorders are manageable, and improvements in this prevalent comorbidity might affect lymphoma-specific survival and overall survival. FUNDING: American Society of Hematology, National Cancer Institute, Alan J Hirschfield Award.

Precancer and cancer-associated depression and anxiety among older adults with blood cancers in the United States.

For patients with blood cancers, comorbid mental health disorders at diagnosis likely affect the entire disease trajectory, as they can interfere with disease information processing, lead to poor coping, and even cause delays in care. We aimed to characterize the prevalence of depression and anxiety in patients with blood cancers. Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients ≥67 years old diagnosed with lymphoma, myeloma, leukemia, or myelodysplastic syndromes between 2000 and 2015. We determined the prevalence of precancer depression and anxiety and cancer-associated (CA) depression and anxiety using claims data. We identified factors associated with CA-depression and CA-anxiety in multivariate analyses. Among 75 691 patients, 18.6% had at least 1 diagnosis of depression or anxiety. Of the total cohort, 13.7% had precancer depression and/or precancer anxiety, while 4.9% had CA-depression or CA-anxiety. Compared with patients without precancer anxiety, those with precancer anxiety were more likely to have subsequent claims for CA-depression (odds ratio [OR] 2.98; 95% CI 2.61-3.41). Other factors associated with a higher risk of CA- depression included female sex, nonmarried status, higher comorbidity, and myeloma diagnosis. Patients with precancer depression were significantly more likely to have subsequent claims for CA-anxiety compared with patients without precancer depression (OR 3.01; 95% CI 2.63-3.44). Female sex and myeloma diagnosis were also associated with CA-anxiety. In this large cohort of older patients with newly diagnosed blood cancers, almost 1 in 5 suffered from depression or anxiety, highlighting a critical need for systematic mental health screening and management for this population.

Mindfulness and Valued Living in the Face of Racism­Related Stress.

Objectives: Racism-related stress is associated with significant mental health costs, necessitating the development of coping strategies to mitigate the negative sequelae. Mindfulness and valued living (MVL)-based strategies may be uniquely beneficial in addressing the negative effects of racism-related stress for people of color (POC) by decreasing internalized messages, while increasing self-compassion, coping flexibility, and engagement in values-based actions. It is imperative that clinicians applying or recommending MVL strategies to POC for coping with racism-related stress understand the complex nature of racism and, given that complexity, consider how MVL may need to be adapted to be effective. This paper offers guidance to clinicians seeking to use MVL strategies with clients of color to cope with racism-related stress. Methods: We provide a brief contextual literature review on the nature of racism, mental health impacts of racism-related stress for POC, and selected models of coping with racism-related stress. We also review existing mindfulness literature in relation to coping with racism-related stress, while offering considerations for adapting MVL strategies specifically for coping with racism-related stress. Results: Altogether, the research points to the promise of MVL strategies as beneficial interventions for coping with racism-related stress, although more research is warranted. We recommend that clinicians consider the suggestions outlined to present MVL strategies to clients in culturally responsive, validating ways. Conclusions: Further research is needed to evaluate links between MVL strategies and mental health, and to evaluate whether discrimination-specific adaptations are beneficial in mitigating the mental health impacts of racism-related stress.

The role of experiential avoidance in the relation between racial discrimination and negative mental health outcomes.

Objective Racial discrimination has been shown to be associated with negative mental health outcomes among people of color (POC), and students of color (SOC) specifically. The current study examines experiential avoidance (EA) as a potential moderator in the relation between discrimination and mental health outcomes. Sample: Two-hundred students of color at a large, public university in Northeastern United States. Methods: We evaluated the associations between racial discrimination frequency and stress appraisal (GEDS and GEDS-A), EA (AAQ), and the Depression, Anxiety, and Stress Scales (DASS). Results: Discrimination frequency and appraised stress were associated with each DASS subscale. EA moderated the relation between GEDS and depression, and between GEDS-A and the stress subscale. Conclusions: Discrimination frequency and appraised stress were positively associated with DASS subscales, and at low EA scores, frequency and appraised stress of discrimination were no longer associated with depressive or stress symptoms, respectively.

Learning gains from a one-day training in acceptance-based behavior therapy.

The primary method of training for individual licensed mental health professionals is continuing education (CE). Despite the promise of CE as a vehicle for training clinicians in evidence-based practices, only a handful of studies have examined the efficacy of trainings delivered in the CE context. Moreover, these studies have focused on a few very specific therapeutic approaches. There is a growing body of evidence supporting Acceptance-based Behavior Therapy (ABBT) as a treatment for generalized anxiety disorder (GAD) and related disorders. Training workshops aimed at disseminating ABBT are regularly conducted across and outside the United States, yet the effectiveness of these trainings is unknown. The goal of this study was to examine learning outcomes among licensed mental health professionals following a six-hour CE training in ABBT. Data were collected at baseline, post-training, and at three-month follow-up. Participants demonstrated a statistically significant increase in learning on an ABBT Knowledge Questionnaire and in their coded responses to client scenarios from baseline to follow-up, although there was a significant decline in knowledge between post and follow-up. Beyond baseline ABBT knowledge, attitude towards evidence-based practice was the only predictor of change in knowledge over time.

A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way Through Anxiety Workbook.

Effective interventions for generalized anxiety exist, but barriers to treatment prevent their broad dissemination. Commercially available self-help materials may help bridge this gap, but few have been empirically evaluated. This study compared self-reported change in generalized anxiety symptomology and associated problems between community members with excessive worry who were randomly assigned to receive the Worry Less, Live More: The Mindful Way through Anxiety Workbook (n = 35) and those in a delayed condition (n = 29). Participants in the workbook condition reported significantly greater reductions between baseline and 11-week follow-up in self-reported worry (η2 =.15), general anxiety/tension (η2 =.13), and anxiety (η2 =.24) than those in the delayed condition, although no statistically significant differences across condition on changes in depression, functional impairment or acceptance were detected. This pilot study provides support for continued research examining the efficacy of acceptance-based behavioral therapy delivered in a self-help format.

Cultural and service factors related to mental health beliefs among post-9/11 veterans.

BACKGROUND AND AIMS: The primary purpose of this study was to examine cultural and demographic predictors of dimensions of anticipated stigma and negative mental health beliefs, known barriers to mental health care utilization, among post-9/11 veterans. METHODS: A cross-sectional survey methodology was used to assess 132 post-9/11 veterans. Bivariate correlations were used to examine associations between military cultural values (self-reliance and emotional control), demographic variables (gender and service characteristics) and dimensions of anticipated stigma and negative beliefs about mental health. Descriptive statistics were used to examine item-level agreement on scales of stigma, mental health beliefs and cultural values to more fully describe these beliefs in this population. RESULTS: Descriptive findings revealed that the most highly endorsed dimension of stigma was anticipated stigma from coworkers. Correlational findings indicated that only exaggerated self-reliance, not emotional control, was positively associated with higher negative beliefs about treatment and treatment-seeking, and not other dimensions of negative beliefs about mental health. Active duty service members and those who deployed reported higher negative beliefs about treatment-seeking, emotional control and self-reliance. In addition, men reported higher negative beliefs about treatments, treatment-seeking and self-reliance than women. CONCLUSION: These results highlight the importance of addressing concerns about self-reliance and mental health treatment in stigma-reduction interventions especially among male, deployed, and active duty service members to reduce stigma and stigma-related barriers to care.

Surviving and Thriving During Stress: A Randomized Clinical Trial Comparing a Brief Web-Based Therapist-Assisted Acceptance-Based Behavioral Intervention Versus Waitlist Control for College Students.

The high rates of anxiety in college students and the many barriers to accessing evidence-based care in communities and on campuses indicate a clear need to explore ways to increase access to evidence-based treatments. Web-based interventions and preventions are one way to bridge this gap; they hold the potential to decrease mental health disparities and enhance student functioning. The current RCT examined the acceptability and efficacy of a 3-session web-based therapist-assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress) for college students versus a waitlist (WL) control condition, in a sample of racially and ethnically diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-effects regression models (MRMs) were run in SPSS to examine the effects of time, condition, and Condition × Time on outcomes and hypothesized mechanisms. Significant Condition × Time interactions for general anxiety, depression, and quality of life (QOL) emerged, suggesting that SATDS participants reported significantly greater changes on these outcomes from pre- to posttreatment versus WL. However, interaction effects were nonsignificant for anxious arousal and social anxiety. MRMs examining hypothesized mechanisms revealed significant Condition × Time interactions for experiential avoidance, decentering, and values-based living. However, interaction effects were nonsignificant for mindfulness. All significant gains were maintained at 1-month follow-up, with the exception of QOL. Results contribute to the growing literature on the acceptability and efficacy of web-based approaches, and suggest these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care.

Predictors of well-being in the lives of student service members and veterans.

OBJECTIVE: The current study examined predictors of well-being, including quality of life and academic engagement, in a sample of student service members and veteran college students. METHODS: Eighty-seven student service members/veterans (SSM/V) completed an online survey containing questions about post-deployment social support, emotion regulation skills, psychological distress, academic engagement, quality of life, and demographics. Participants were recruited from September 2012 through May 2014. RESULTS: Results provided partial support for the proposed bi-directional mediational relations between post-deployment social support and emotion regulation predicting to quality of life and academic engagement. Path models indicated that both post-deployment social support and emotion regulation skills partially mediated the relation with quality of life while accounting for the effect of psychological distress, and that emotion regulation skills fully mediated the relation between social support and academic engagement. CONCLUSIONS: These findings suggest that both social support and emotion regulation skills may be useful targets for health promotion and intervention efforts for this population. Limitations and clinical implications for the development of on-campus SSM/V focused health promotion services are discussed.

Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder.

As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007). Identifying these mechanisms would help streamline evidence-based approaches, increase treatment response rates, and aid in the dissemination and implementation of evidence-based approaches in diverse contexts. The current study examined reductions in experiential avoidance (EA; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, as a potential mechanism of change in participants with a principal diagnosis of generalized anxiety disorder (GAD) receiving either acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Participants' EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions. Greater change in EA across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches.

The mediating role of internalized racism in the relationship between racist experiences and anxiety symptoms in a Black American sample.

OBJECTIVES: The current study explores the potential mediating role of internalized racism in the relationship between racist experiences and anxiety symptomology in a Black American sample. METHOD: One hundred and 73 Black American participants, between 18 and 62 years of age, completed a questionnaire packet containing measures of anxious arousal and stress symptoms, internalized racism, and experiences of racist events. RESULTS: Results indicated that internalized racism mediated the relationship between past-year frequency of racist events and anxious arousal as well as past-year frequency of racist events and stress symptoms. CONCLUSIONS: Internalized racism may be 1 mechanism that underlies the relationship between racism and anxious symptomology for Black Americans. These preliminary findings suggest that internalized racism may be an avenue through which clinicians can target the anxiety elicited by racist experiences. The clinical implications of these findings and future research directions are discussed. (PsycINFO Database Record

Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder.

OBJECTIVE: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. METHOD: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. RESULTS: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. CONCLUSIONS: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.

Decentering as a potential common mechanism across two therapies for generalized anxiety disorder.

OBJECTIVE: The purpose of this study was to examine decentering as a potential mechanism of action across 2 treatments for generalized anxiety disorder: an acceptance-based behavioral therapy (ABBT) and applied relaxation (AR). METHOD: Sixty-four individuals who completed at least half of the 16 total sessions of either ABBT or AR (65.6% female; 79.7% identified as White; average age = 34.41 years) completed measures of decentering (Experiences Questionnaire) and of symptoms of anxiety (Depression Anxiety Stress Scale-Stress subscale) at 5 time points over the course of therapy, and a measure of worry (Penn State Worry Questionnaire) at pre- and posttreatment. RESULTS: Initial growth curve models showed that decentering increased significantly over therapy (z = 7.09), and this increase was associated with a decrease in worry symptoms (Penn State Worry Questionnaire) at posttreatment (z = -8.51). The rate of change did not significantly vary across treatments, Δχ2/Δdf = 0.16/1, p = .69. Further, a series of bivariate latent difference score models indicated that the best-fitting model was one in which decentering was a leading indicator of change in symptoms (DASS-Stress). Allowing this coupling to vary across treatments did not significantly improve the fit of the model, Δχ2/Δdf = 0.71/1, p = .40. CONCLUSIONS: In this sample, results suggest that increased decentering was associated with decreases in anxiety and that changes in decentering appear to precede changes in symptoms within both ABBT and AR, indicating that decentering may be an important common mechanism of action. (PsycINFO Database Record

Relationships Between Amount of Post-Intervention of Mindfulness Practice and Follow-up Outcome Variables in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder: The Importance of Informal Practice.

Because most behavioral treatments are time-limited, skills and practices that foster long-term maintenance of gains made during treatment are of critical importance. While some studies have found mindfulness practice to be associated with improvements in outcome variables over the course of treatment (Vettese et al., 2009), very little is known about the effects of continued mindfulness practice following treatment termination. The current study examined the relationships between separate single item measurements of three types of mindfulness practices (formal, informal, and mindfulness of breath in daily life) and longer-term outcomes in worry, clinician-rated anxiety severity, and quality of life following treatment with an acceptance-based behavior therapy (ABBT) for Generalized Anxiety Disorder (GAD) in two separate treatment studies. Results from Study 1 showed that at 9-month follow-up, amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry, clinician-rated anxiety severity, and quality of life. Similarly, in Study 2, at 6-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for anxiety severity and worry, and at 12-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life and worry, and mindfulness of breath was significantly related to quality of life. When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life. Formal practice was not significantly related to outcomes in either study, or in the combined sample. These findings support the further study of informal mindfulness practices as important tools for continued beneficial clinical outcomes following treatment for people with a principal diagnosis of GAD.

Mindfulness and acceptance-based behavioral therapies for anxiety disorders.

This article presents a brief conceptual overview of acceptance-based behavioral therapies (ABBTs) for anxiety disorders, followed by a review and summary of the recent efficacy studies of ABBTs for anxiety and comorbid disorders. We discuss clinical implications, including the importance of targeting reactivity and experiential avoidance in interventions for anxiety disorders through the use of mindfulness and other acceptance-based strategies, as well the encouragement of engagement in meaningful activities or valued action. We also address future directions for research, such as expanding research to include more randomized control trials comparing ABBTs for specific anxiety disorders to other active treatments, examining mechanisms of change, exploring adaptations in different care-delivery contexts, as well as determining the applicability of these approaches to clients from marginalized or non-dominant statuses.

A contemporary view of applied relaxation for generalized anxiety disorder.

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.

A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder.

OBJECTIVE: To examine whether an empirically and theoretically derived treatment combining mindfulness- and acceptance-based strategies with behavioral approaches would improve outcomes in generalized anxiety disorder (GAD) over an empirically supported treatment. METHOD: This trial randomized 81 individuals (65.4% female, 80.2% identified as White, average age 32.92) diagnosed with GAD to receive 16 sessions of either an acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Assessments at pretreatment, posttreatment, and 6-month follow-up included the following primary outcome measures: GAD clinician severity rating, Structured Interview Guide for the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Depression Anxiety Stress Scale, and the State-Trait Anxiety Inventory. Secondary outcomes included the Beck Depression Inventory-II, Quality of Life Inventory, and number of comorbid diagnoses. RESULTS: Mixed effect regression models showed significant, large effects for time for all primary outcome measures (ds = 1.27 to 1.61) but nonsignificant, small effects for condition and Condition × Time (ds = 0.002 to 0.20), indicating that clients in the 2 treatments improved comparably over treatment. For secondary outcomes, time was significant (ds = 0.74 to 1.38), but condition and Condition × Time effects were not (ds = 0.004 to 0.31). No significant differences emerged over follow-up (ds = 0.03 to 0.39), indicating maintenance of gains. Between 63.3 and 80.0% of clients in ABBT and 60.6 and 78.8% of clients in AR experienced clinically significant change across 5 calculations of change at posttreatment and follow-up. CONCLUSION: ABBT is a viable alternative for treating GAD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

An Acceptance-Based Behavioral Therapy for Individuals with Generalized Anxiety Disorder.

In response to clinical observations and research findings that individuals with Generalized Anxiety Disorder are reactive to their internal experiences, avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities, an Acceptance Based Behavioral Therapy (ABBT) was developed to specifically target these responses. ABBT incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT uses mindfulness and acceptance approaches as an alternate response to the rigid, avoidant responses characteristic of GAD. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client rather than engaging in actions that are motivated by avoidance of anxiety. This article provides a case conceptualization from an ABBT perspective for "William," the composite client presented in Robichaud (this issue). The article goes on to demonstrate how an ABBT approach to treatment may unfold session-by-session for "William."