Faculty Bibliography

IMPORTANCE:Anxiety disorders have a lifetime prevalence of approximately 34% in the US, are often chronic, and significantly impair quality of life and functioning. OBSERVATIONS:Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors. Generalized anxiety disorder (6.2% lifetime prevalence), social anxiety disorder (13% lifetime prevalence), and panic disorder (5.2% lifetime prevalence) with or without agoraphobia are common anxiety disorders seen in primary care. Anxiety disorders are associated with physical symptoms, such as palpitations, shortness of breath, and dizziness. Brief screening measures applied in primary care, such as the Generalized Anxiety Disorder-7, can aid in diagnosis of anxiety disorders (sensitivity, 57.6% to 93.9%; specificity, 61% to 97%). Providing information about symptoms, diagnosis, and evidence-based treatments is a first step in helping patients with anxiety. First-line treatments include pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs, eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, eg, venlafaxine extended release) remain first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder. Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo (eg, generalized anxiety disorder: standardized mean difference [SMD], -0.55 [95% CI, -0.64 to -0.46]; social anxiety disorder: SMD, -0.67 [95% CI, -0.76 to -0.58]; panic disorder: SMD, -0.30 [95% CI, -0.37 to -0.23]). Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders compared with psychological or pill placebo (eg, generalized anxiety disorder: Hedges g = 1.01 [large effect size] [95% CI, 0.44 to 1.57]; social anxiety disorder: Hedges g = 0.41 [small to medium effect] [95% CI, 0.25 to 0.57]; panic disorder: Hedges g = 0.39 [small to medium effect[ [95% CI, 0.12 to 0.65]), including in primary care. When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care. CONCLUSIONS AND RELEVANCE:Anxiety disorders affect approximately 34% of adults during their lifetime in the US and are associated with significant distress and impairment. First-line treatments for anxiety disorders include cognitive behavioral therapy, SSRIs such as sertraline, and SNRIs such as venlafaxine extended release.

Consistent evidence indicates that exercise improves cognition and mood, with preliminary evidence suggesting that brain-derived neurotrophic factor (BDNF) may mediate these effects. The aim of the current meta-analysis was to provide an estimate of the strength of the association between exercise and increased BDNF levels in humans across multiple exercise paradigms. We conducted a meta-analysis of 29 studies (N = 1111 participants) examining the effect of exercise on BDNF levels in three exercise paradigms: (1) a single session of exercise, (2) a session of exercise following a program of regular exercise, and (3) resting BDNF levels following a program of regular exercise. Moderators of this effect were also examined. Results demonstrated a moderate effect size for increases in BDNF following a single session of exercise (Hedges' g = 0.46, p < 0.001). Further, regular exercise intensified the effect of a session of exercise on BDNF levels (Hedges' g = 0.59, p = 0.02). Finally, results indicated a small effect of regular exercise on resting BDNF levels (Hedges' g = 0.27, p = 0.005). When analyzing results across paradigms, sex significantly moderated the effect of exercise on BDNF levels, such that studies with more women showed less BDNF change resulting from exercise. Effect size analysis supports the role of exercise as a strategy for enhancing BDNF activity in humans, but indicates that the magnitude of these effects may be lower in females relative to males.

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.

BackgroundFew studies have examined which patients with migraine might be responders for mind-body interventions. Thus, we examined whether certain baseline mindfulness traits and interest in physical exercise might predict response to treatment.MethodsThis is a planned exploratory analysis of a phase 2 randomized controlled study (N  =  50; 25 per arm) comparing a 6-week physical therapist (PT)-delivered biofeedback-assisted relaxation (BAR) program vs. an Enhanced Usual Care (EUC) migraine self-management program (diary tracking and emailed migraine-related educational materials). We conducted moderation analyses to determine whether the Multidimensional Assessment of Interoceptive Awareness (MAIA), Difficulties in Emotion Regulation Scale (DERS) and Physical Activity Enjoyment Scale (PACES) at baseline influenced the effect of BAR on migraine-related outcomes (Migraine-Specific Quality of Life Role Function Restrictive (MSQv2.1-RFR) and Migraine-Related Disability (MIDAS)) at 6 months.ResultsAmong the n = 40 participants (BAR = 19; EUC = 21), the majority were female (95%), non-Hispanic (77.5%) and white (67.5%). Mean (SD) age was 45.6 (11.2) years. For the MAIA Not-Worrying subscale, BAR produced the greatest improvement in 6-month MSQv2.1-RFR scores among participants with low baseline Not-Worrying scores (those who tended to worry about bodily sensations/discomfort more) (BAR = 77.1 ± 6.6 vs. EUC = 48.9 ± 5.0; p = 0.002, g = 4.75). The benefit diminished at average levels (p = 0.060, g = 2.72) and was absent at high baseline Not-Worrying (p = 0.528, g =  -0.91). For the MAIA Self-Regulation subscale, BAR was most effective among those low in baseline self-regulation (BAR = 71.7 ± 5.3 vs. EUC = 44.3 ± 7.2; p = 0.004, g = 4.27). The DERS total score showed that BAR demonstrated little benefit among participants with better baseline emotion regulation (i.e. lower DERS score; p = 0.907, g = 0.17) but was more effective as baseline emotion regulation difficulties increased, showing a moderate benefit at average levels (BAR = 69.2 ± 4.2 vs. EUC = 55.8 ± 4.0, p = 0.027, g = 3.25) and a large, significant difference at high levels (BAR = 70.6 ± 6.3 vs. EUC = 44.7 ± 5.7; p = 0.004, g = 4.22). The PACES total score indicated that BAR benefits were strongest among those with low (BAR = 76.1 ± 7.0 vs. EUC = 47.1 ± 5.3, p = 0.002, g = 4.60) to average (BAR = 71.2 ± 4.2 vs. EUC = 58.6 ± 4.0, p = 0.035, g = 3.07) enjoyment of physical activity.ConclusionsWe found subgroups of individuals with migraine who may be better responders to PT-delivered BAR, specifically those who tend to worry more about bodily sensations (lower MAIA Not-Worrying score), those with low self-regulation (lower MAIA Self-Regulation score), those with worse emotion regulation (higher DERS score) and those with lower levels of physical activity enjoyment (lower PACES score) at baseline. This may help us determine who may benefit most from BAR.Trial RegistrationClinicalTrials.gov Identifier: NCT06077812.

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.