Faculty Bibliography

Physical activity is a well-established intervention for improving mental health outcomes, yet its integration into psychological practice remains under-researched. Psychologists, as mental health professionals, are well-positioned to promote physical activity. This Short Communication describes the case for physical activity promotion within psychological practice. We explore both clinical and ethical considerations for incorporating physical activity promotion into psychological practice, practical strategies using the '5As model' and a case study to guide psychologists, addressing barriers to change and enhancing client motivation. Importantly, we discuss the need for further training and development for psychologists to ensure safe, impactful physical activity promotion is implemented in practice. By providing actionable recommendations, we aim to support psychologists in integrating physical activity promotion into their clinical practice, ultimately enhancing mental health care.

BACKGROUND:Self-compassion is recognized as important for psychological well-being and has been linked to reduced anxiety levels. Mindfulness-based interventions, such as the 8-week Mindfulness-Based Stress Reduction program (MBSR), have shown promise in treating anxiety disorders, but no studies to date have compared the effects of MBSR to the gold-standard medication treatment (escitalopram) on self-compassion or its subscales. The primary aim of this study was to examine the effects of MBSR versus escitalopram on self-compassion (total score and subscales) in adults with anxiety disorders. METHODS:We conducted a comparative effectiveness trial, delivering escitalopram versus MBSR virtually over 8 weeks for anxiety disorders in 198 adults. We assessed the impact of each treatment on self-compassion and its subscales using the Self-Compassion Scale. Baseline group differences were tested using chi-square tests for categorical variables and t-tests for continuous variables. We used longitudinal mixed-effects models to test whether MBSR produced greater improvements in self-compassion than escitalopram at each assessment point. RESULTS:Contrary to our hypothesis, MBSR did not demonstrate greater improvement in self-compassion compared to escitalopram at each assessment point. All domains of self-compassion improved over time when across treatment groups. Additionally, both treatment groups showed improvements in most subscales. Two of the subscales showed differences in response by treatment group. In the mixed model predicting the Common Humanity subscale, participants in the MBSR group evidenced an improvement in Common Humanity over time whereas the escitalopram group remained relatively unchanged in Common Humanity over time (Estimate = -0.34, t = -2.44, 95% CI = [-0.61, -0.06], p = 0.016). In the mixed effects model predicting Mindfulness, the MBSR group evidenced greater improvement in Mindfulness between baseline and post-treatment than the escitalopram group (Estimate = -0.26, t = -2.05, 95% CI = [-0.51, -0.01], p = 0.042). DISCUSSION/CONCLUSIONS:Although meditation was not generally superior to medication for improving self-compassion among individuals with anxiety disorders, several significant improvements were found across both interventions, and meditation may be more effective for promoting two self-compassion subscales-mindfulness and common humanity. MBSR's facet-specific benefits support its use where enhancing self-relational capacities is a treatment priority.

Childhood parental affection and abuse may shape vulnerability to generalized anxiety disorder (GAD) and major depressive disorder (MDD) in adulthood through personal mastery and perceived constraints. This three-wave 18-year longitudinal study tested whether sense-of-control dimensions mediated the effects of early parental experiences on later GAD and MDD symptoms (N = 3294; 54.9% women; mean age = 45.6 years, SD = 11.4, range = 20-74 years; 89.7% White compared to African American, Asian/Pacific Islander, Native American and other). Structural equation models showed that lower parental affection and higher abuse at Time 1 predicted greater perceived constraints at Time 2 (Cohen's d = -0.396 to 0.510), which in turn predicted greater GAD and MDD severity at Time 3 (d = 0.463 to 0.754). Perceived constraints significantly mediated the links between childhood parental experiences and adult symptom severity for both GAD (d = -0.269-0.319; percentage mediated: 30.0%-69.2%) and MDD (d = -0.343-0.422; 11.0%-44.9%), whereas mastery did not. Mediated effects were somewhat stronger for maternal (11.4%-69.2%) than paternal (11.0%-51.5%) experiences. These findings underscore perceived constraints as a critical mechanism linking childhood parental experiences to later anxiety and depression. Interventions that address maladaptive beliefs about sense of control may improve long-term outcomes for adults exposed to early adversity.

OBJECTIVE:During the COVID-19 pandemic, telemental health (TMH) use rapidly increased. Though patients report satisfaction with TMH, acceptability among different psychiatric providers (inpatient, outpatient, nurses) and for various diagnoses is less understood. This study aimed to expand understanding by examining TMH acceptability, benefits, and barriers for providers and patients during the early transition to TMH in the COVID-19 pandemic. METHODS:Online anonymous surveys evaluated patient (n = 64) and provider (n = 39) satisfaction with and perceived benefits and challenges to TMH from October-December 2020 on 5-point Likert scales. Qualitative data was collected and themes identified. RESULTS:Outpatient (3.97 ± 1.05) and inpatient (3.11 ± 1.6) providers, including nurses, reported high satisfaction with TMH, despite over 50% never having used TMH prior to the pandemic. TMH was viewed as acceptable across diagnoses, including serious mental illness and substance use. Provider-rated benefits of outpatient TMH versus in-person visits included COVID safety (mean difference[MD] = 3.05), travel (MD = 2.95), and reduced cancellations (MD = 1.81). Inpatient TMH similarly included COVID safety benefits (MD = 3.31), but also challenges related to team-based service provision (MD = 1.68) and working with trainees (MD = 1.19). Qualitative themes identified TMH challenges (e.g., technological: 56.7% patients, 66.7% providers) and benefits (e.g., convenience/flexibility: 80% patients, 81.5% providers). CONCLUSIONS:TMH was associated with high satisfaction for patients and across provider types and patient diagnoses. This study provides further support that TMH across clinical settings allows for greater flexibility and accessibility to evidence-based care, and ongoing benefits even outside the context of the COVID-19 pandemic. It suggests the benefits of ongoing training of staff and trainees in TMH.

Numerous relationship process variables are positively associated with psychotherapy outcomes, but less is known about the therapeutic relationship in mind-body interventions (e.g., yoga). This study examined components of the therapeutic relationship (alliance, credibility/expectations) for patients with generalized anxiety disorder randomized to 12-weeks of group Kundalini Yoga (yoga), cognitive behavior therapy (CBT), or stress education (SE) in groups of 3-6. 147 participants (71% women, M age=33.2±13.3) completed the Working Alliance Inventory (WAI) and Credibility and Expectancy Questionnaire (CEQ) (yoga: n=56, CBT: n=65, SE: n=26) and outcome measures of worry, anxiety, and depression. WAI included subscales of goal, task, and bond. ANOVA assessed differences in WAI and CEQ scores by treatment at midpoint (Week 6) and endpoint (Week 12). Longitudinal linear mixed effects models assessed effects of midpoint WAI by treatment on self-report outcomes. Mean WAI and CEQ scores were significantly higher for CBT than SE by midpoint. The largest differences in WAI subscale scores compared to SE were in task for both CBT and yoga. No significant differences emerged between CBT and yoga. WAI at midpoint was not a significant predictor of midpoint to posttreatment change in worry, anxiety, or depression, nor was the effect of WAI on change in these outcomes different between treatment groups. Results suggest patient ratings of relationship process variables were similar between yoga and CBT, but different from SE in group treatment for anxiety, and that components of the relationship may be optimized within yoga by augmenting goal and task, perhaps by borrowing elements from CBT-based treatments.

Homework is a potential contributor to treatment response in cognitive-behavioral therapy (CBT) for anxiety, but less is known regarding the importance of yoga homework for generalized anxiety disorder (GAD). This study examined the impact of homework engagement on treatment response within a randomized controlled trial (RCT) of 12 weeks of group CBT, Kundalini Yoga (KY), or stress education (SE) in a subsample of 190 adults with GAD (71% female, Mean age = 33 ± 13) who attended ≥2 sessions and submitted ≥1 homework log. Participants in CBT and KY showed greater overall homework engagement than those in SE (ps < .05). Across treatment arms, staff-rated homework compliance (p = .002, OR = 1.74), but not participant-reported days per week engaged in homework (p = .108), predicted clinical response at post-treatment ("response"). Greater staff-rated homework compliance was related to a greater response for those in CBT (p = .005, OR = 2.49) and KY (p = .049, OR = 1.66), but not SE. Greater participant-reported homework days per week was only marginally related to response to CBT (p = .054, OR = 1.71), and was not related to response to KY or SE. These findings highlight the importance of homework engagement in CBT for GAD. More research is needed to further elucidate the role of homework engagement in yoga for GAD.TRIAL REGISTRATION: clinicaltrials.gov: NCT01912287; https://clinicaltrials.gov/ct2/show/NCT01912287.

BACKGROUND:During the pandemic, a randomized controlled trial (RCT) of Mindfulness-Based Stress Reduction (MBSR) versus the antidepressant, escitalopram (ESC) added a second phase using a synchronous, videoconference (VC) format for both interventions, enabling randomized and naturalistic comparisons. The original in-person RCT demonstrated non-inferiority of MBSR to ESC. In the second phase, we hypothesized that MBSR-VC would be non-inferior to ESC-VC, and that MBSR-VC would be non-inferior to in-person MBSR (MBSR-IN). METHODS:Adults with anxiety disorders were recruited for a 3-center RCT. Primary (Clinical Global Impression of Severity: CGIS) and secondary outcomes (satisfaction, other measures for anxiety subtypes) were compared between MBSR-IN vs MBSR-VC, ESC-IN vs ESC-VC and MBSR-VC vs ESC-VC. RESULTS:MBSR-VC (n = 100) and ESC-VC (n = 102) did not significantly differ in mean CGI-S change at endpoint (1.39 vs 1.51, p = 0.17) but non-inferiority of MBSR-VC was not supported. MBSR did not vary by delivery format (VC: 1.3 vs. IN: 1.3, p = 0.77) and MBSR-VC's non-inferiority to MBSR-IN was demonstrated within the pre-specified margin of -0.40 (95 % CI: -0.34 to 0.25). ESC-IN and ESC-VC were not significantly different in CGI-S change in unadjusted comparisons (1.4 vs 1.5, p = 0.53), but the average CGI-S at endpoint was significantly lower in the ESC-VC group in a multivariable longitudinal model. Other findings included in-person treatments having a greater impact on social anxiety compared to their VC version, ESC-VC having higher satisfaction ratings and a greater impact on panic symptoms than MBSR-VC. CONCLUSIONS:Remotely delivered MBSR demonstrated comparable effectiveness to in-person MBSR for anxiety disorders, providing support for this delivery approach. Social anxiety symptoms improved more with in-person care. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov: NCT03522844.

Consistent evidence suggests that exercise leads to improvements in subjective sleep quality and also objective sleep metrics in non-psychiatric adult populations. However, the degree to which exercise provides sleep benefits for adults with psychiatric disorders is less known, despite the potential benefits given that sleep disturbance is prevalent in these populations. In this narrative review, we synthesize results of randomized controlled trials examining the influence of aerobic and/or resistance exercise interventions on sleep outcomes in adult psychiatric populations. We specifically focus on populations with elevated symptoms or diagnoses of depression, anxiety, or posttraumatic stress disorder. A systematic search through June 2024 yielded 26 relevant trials. Overall, most trials reported improvement of subjective sleep quality after aerobic and/or resistance exercise programs in samples with depression. Similar effects were observed for posttraumatic stress; however, larger trials are needed. Further research is needed to examine the impact of exercise on sleep in anxiety populations as only one trial with mixed results was identified. Results were more equivocal for the subpopulation of adult women with perinatal or postpartum depression, demonstrating the importance of understanding exercise effects on sleep in specific subpopulations. Few studies examined objective sleep outcomes, impact of acute exercise on next day sleep, or the interplay between exercise, sleep, and psychiatric symptom changes, all important areas of future research. Other implications and future directions are discussed, including potential moderators and mechanisms of action that warrant further study to better understand how exercise interventions may optimally target sleep in psychiatric populations.

Anxiety disorders are highly comorbid with sleep disturbance and have also been associated with deficits in emotion regulation, the ability to control and express emotions. However, the extent to which specific dimensions of sleep disturbance and emotion regulation are associated with anxiety diagnosis is not well-explored. This study examined dimensions of emotion regulation and sleep disturbance that may predict greater likelihood of anxiety diagnosis using novel machine learning techniques. Participants (Mean(SD) age= 28.6(11.3) years, 62.7% female) with primary anxiety disorders (n = 257), including generalized anxiety disorder (n = 122) and social anxiety disorder (n = 135), and healthy controls (n = 89) completed the Difficulties in Emotion Regulation Scale and Pittsburgh Sleep Quality Index. A conditional inference tree was fit to classify likelihood of current anxiety diagnosis based on predictors. The best model fit included 4 split nodes and 5 terminal nodes. Worse scores on two emotion regulation subscales, strategies directed to manage negative emotions and nonacceptance of negative emotions, were the best predictors of current anxiety diagnosis (99.3% probability of diagnosis). For those with better emotion regulation, poor sleep quality and worse daytime functioning due to sleep were important predictors of anxiety diagnosis. Good emotion regulation and non-disturbed sleep predicted high likelihood of being a non-psychiatric control (88.2%). Limitations include cross-sectional design precluding designating directionality of effects of sleep and emotion regulation on anxiety onset; limited sample size; and self-reported sleep. Facets of emotion regulation and sleep disturbance may be important early targets for brief intervention for anxiety disorders.

The COVID-19 pandemic was an unparalleled stressor that enhanced isolation. Loneliness has been identified as an epidemic by the US Surgeon General. This study aimed to: (1) characterize longitudinal trajectories of loneliness during the acute phase of the COVID-19 pandemic; (2) identify longitudinal mediators of the relationship of loneliness with anxiety and depression; and (3) examine how loneliness naturally clusters and identify factors associated with high loneliness. Two hundred and twenty-nine adults (78% female; mean age = 39.5 ± 13.8) completed an abbreviated version of the UCLA Loneliness Scale, Perceived Stress Scale, Emotion Regulation Questionnaire, State Anxiety Inventory, and Patient Health Questionnaire-8 longitudinally between April 2020 and 2021. Trajectory analyses demonstrated relatively stable loneliness over time, while anxiety and depression symptoms declined. Longitudinal analyses indicated that loneliness effects on anxiety and depression were both partially mediated by perceived stress, while emotion regulation capacity only mediated effects on anxiety. Three stable clusters of loneliness trajectories emerged (high, moderate, and low). The odds of moderate or high loneliness cluster membership were positively associated with higher perceived stress and negatively associated with greater cognitive reappraisal use. Our results demonstrate the important interconnections between loneliness and facets of mental health throughout the early phases of the pandemic and may inform targeted future interventions for loneliness work.