Faculty Bibliography

BACKGROUND:Complicated grief (CG) is characterized by persistent, impairing grief after losing a loved one. Little is known about sleep disturbance in CG. Baseline prevalence of subjective sleep disturbance, impact of treatment on sleep, and impact of mid-treatment sleep on CG and quality of life outcomes were examined in adults with CG in secondary analyses of a clinical trial. METHODS:Patients with CG (n = 395, mean age =53.0; 78% female) were randomized to CGT+placebo, CGT+citalopram (CIT), CIT, or placebo. Subjective sleep disturbance was assessed by a grief-anchored sleep item (Pittsburgh Sleep Quality Index: PSQI-1) and a four-item sleep subscale of the Quick Inventory of Depressive Symptomatology (QIDS-4). Sleep disturbance was quantified as at least one QIDS-4 item with severity ≥2 or grief-related sleep disturbance ≥3 days a week for PSQI-1. Outcomes included the Inventory of Complicated Grief (ICG), Work and Social Adjustment Scale (WSAS), and Clinical Global Impressions Scale. RESULTS:Baseline sleep disturbance prevalence was 91% on the QIDS-4 and 46% for the grief-anchored PSQI-1. Baseline CG severity was significantly associated with sleep disturbance (QIDS-4: p = .015; PSQI-1: p = .001) after controlling for comorbid depression and PTSD. Sleep improved with treatment; those receiving CGT+CIT versus CIT evidenced better endpoint sleep (p = .027). Mid-treatment QIDS-4 significantly predicted improvement on outcome measures (all p < .01), though only WSAS remained significant after adjustment for mid-treatment ICG (p = .02). CONCLUSIONS:Greater CG severity is associated with poorer sleep beyond PTSD and depression comorbidity. Additional research including objective sleep measurement is needed to optimally elucidate and address sleep impairment associated with CG.

Evidence exists for a negative influence of exercise/weight-loss television on explicit attitudes towards exercise. However, it is unclear if this is specific to viewing intense exercise or the overweight/obese status of the viewed exercisers. Additionally, exposure to exercise cues can induce people to eat more, reflecting compensatory eating in response to exercise cues rather than actual exercise. In this study, we examined the relative influence of viewing overweight/obese versus normal weight exercisers on eating (calories consumed) and attitudes towards exercise. 102 college students were randomized to view: 1) overweight/obese individuals engaging in vigorous exercise; 2) normal weight individuals engaging in vigorous exercise; or 3) no-exercise video with participants of various weight statuses (control condition). Participants subsequently completed a taste test assessing calories consumed; a computerized, implicit attitudes-towards-exercise task; and an explicit attitudes-towards-exercise questionnaire. Participants with higher BMIs and those viewing normal weight exercisers (vs. overweight/obese exercisers) ate significantly more. No significant effects were found for the interaction between BMI and video or for explicit or implicit attitudes towards exercise. This study extends findings of the impact of viewing vigorous exercise to eating behaviors. If replicated under naturalistic conditions, findings have implications for health promotion initiatives and television programming impacting overeating.

Background: Complicated grief (CG) is hypothesized to include both attachment and traumatic distress symptoms, and a preliminary diagnosis has been placed in the trauma and stressor related DSM-5 category (APA, 2013). Posttraumatic stress disorder (PTSD) and CG often present comorbidly, and both result from a major stressor (Simon et al., 2007; Marques et al., 2013; Lenferink et al., 2018). Preliminary data suggest posttraumatic stress symptoms (PTSS) may be present across patients with CG, and not vary by whether the loss is violent or accidental in nature such as required for PTSD diagnoses (Simon et al., 2013; Kersting et al., 2011). Much less is known about how PTSS changes with CG targeted treatment, whether this change is impacted by the nature of the death, or whether it may be necessary to target PTSS separately from grief to improve functional outcomes.
Method(s): Participants were 395 individuals (mean age +/- SD = 53.0 +/- 14.5 years; 78.0% women) with a primary diagnosis of CG based on structured clinical interviews and an Inventory of Complicated Grief (ICG) score>=30. Data were derived from the previously published 20-week multi-center RCT of complicated grief therapy plus pill placebo (CGT + PLA), CGT plus citalopram (CGT + CIT), citalopram (CIT), or placebo (PLA) (Shear et al., 2016). DSM-IV PTSS were assessed using the 17-item self-report Davidson Trauma Scale (DTS). DTS total score of 40 was proposed by the developers of the scale as a cut-off for a diagnosis of PTSD, and has been frequently used as a threshold in previous studies (Davidson et al., 1997; Kastello et al., 2016; Khitab et al., 2013). Our primary analysis examined the adjusted mean difference from baseline in the DTS total and subscale scores (i.e., intrusion, avoidance-numbing, hyperarousal) over three follow-up periods (week 12, 16, and 20) by treatment arm using longitudinal mixed effects regression with participant specific random intercepts. In follow-up analyses, we investigated whether cause of death (violent vs. nonviolent) moderated the relationship between treatments and DTS total score by introducing interaction terms between cause of death and treatment arms in the mixed effects regression model.
Result(s): In the full sample, the mean DTS total score at baseline was 63.2 +/- 27.2, and 77.7% (n = 307) had DTS>=40. There was a general decreasing trend of mean DTS total scores over the 20-week period with a mean adjusted reduction of 27.4 points (d = 0.6) from baseline to week 12 (p < 0.001), and a reduction of 30.7 points (d = 0.7) from baseline to week 20 (p < 0.001). There was no significant difference in change in DTS total score at week 12 by treatment group. However, at weeks 16 and 20, CGT + PLA and CGT + CIT were each associated with a significant DTS reduction compared to placebo alone, while CIT was not. For CGT + PLA vs. PLA, there was 8.8 point (d = 0.14) greater reduction in DTS total score from baseline to week 16 (p = 0.01), and 12.5 point (d = 0.19) greater reduction from baseline to week 20 (p < 0.001). For CGT + CIT vs PLA, there was a 10.0 point (d = 0.15) greater reduction in adjusted DTS total score from baseline to week 16 (p < 0.001), and 10.7 point (d = 0.16) greater decrease from baseline to week 20 (p < 0.001). Similar trends were observed for DTS subscales-CGT + PLA and CGT + CIT demonstrated consistent reduction compared to PLA. In the model with interaction terms between treatments and cause of death, the decrease in DTS score for CGT + CIT compared to PLA was 9.5 points (d = 0.12) greater for those who had violent death compared to those who did not experience violent death (p = 0.04). For CGT + CIT vs CGT + PLA, however, the reduction in DTS total score was 4.2 points (d = 0.04) greater in those who experienced violent death compared to those who did not, but the difference was not statistically significant (p = 0.53).
Conclusion(s): Adults with primary CG assigned to CGT with or without medication demonstrated a significantly larger reduction in PTSS compared to pill placebo, whereas citalopram alone did not. These data parallel findings from the primary study findings for grief (Shear et al., 2016), and demonstrate that CGT may be an effective intervention for PTSS in those with CG. A high level of PTSS were present in this primary CG sample, and PTSS were comparable at baseline for those with violent and non-violent losses. For those who lost someone to violent death, while these data found initial support for greater PTSS reduction for combination therapy with CGT and citalopram compared to placebo, we did not find evidence for a significant benefit of combined therapy over CGT alone for CG due to violent loss. More research is needed to fully understand the role of traumatic distress and its optimal treatment in CG

BACKGROUND AND OBJECTIVES:The impaired ability to delay rewards, delay discounting (DD), is associated with several problematic conditions in which impulsive decision-making derails long-term goals. Working memory (WM), the ability to actively store and manipulate information, is associated with DD. The purpose of this study was to examine the effect of cognitive priming on DD and to identify moderation of this effect dependent on degree of WM capacity (WMC) and depressed mood. METHODS:A WM task (n-back) was used as a cognitive prime before assessment of DD (Monetary Choice Questionnaire) and was compared to a similar prime from an inhibition task in a factorial design in 183 community participants. All participants completed a DD task and assessment of depressive symptoms (Beck Depression Inventory-II). Priming effects were evaluated relative to WMC of participants. RESULTS:Higher WMC and lower depression scores were associated with greater relative preference for larger, delayed rewards. The effects of a WM prime were moderated by WMC; benefits of the prime were only evident for individuals with lower WMC. No effects were found for an alternative inhibition task. LIMITATIONS:Limitations included depression scores mainly in subclinical range, use of hypothetical instead of real rewards in the DD task, and no examination of the time course of effects. CONCLUSIONS:This study provides support for the effectiveness of a brief WM prime in enhancing ability to delay rewards. Priming may be a useful adjunctive intervention for individuals with WM dysfunction or conditions in which impulsive decision-making may derail long-term goals.

Secondary analyses were performed on data from two randomized controlled trials of a cognitive behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) in individuals with severe mental illness (SMI) to examine the feasibility, tolerability, and effectiveness for individuals with borderline personality disorder (BPD). In Study 1, 27 participants received CBT or treatment as usual. In Study 2, 55 participants received CBT or a Brief treatment. Feasibility and tolerability of CBT, PTSD symptoms, and other mental health and functional outcomes were examined, with assessments at baseline, post-treatment, and two follow-up time points. CBT was feasible and tolerable in this population. Study 1 participants in CBT improved significantly more in PTSD symptoms, depression, and self-reported physical health. Study 2 participants in both CBT and Brief improved significantly in PTSD symptoms, posttraumatic cognitions, depression, and overall functioning, with those in CBT acquiring significantly more PTSD knowledge, and having marginally significantly greater improvement in PTSD symptoms. CBT for PTSD was feasible and tolerated in individuals with SMI, BPD, and PTSD, and associated with improvements in PTSD symptoms and related outcomes. Prospective research is needed to evaluate CBT in individuals with BPD, including comparing it with staged interventions for this population.

PURPOSE OF THE REVIEW/OBJECTIVE:The purpose of this review is to critically assess the evidence for exercise as an adjunct intervention for major depressive disorder and bipolar disorder, chronic conditions characterized by frequent comorbid conditions as well as interepisodic symptoms with poor quality of life and impaired functioning. Individuals with these mood disorders are at higher risk of cardiovascular disease and premature death in part because of increased rates of obesity, inactivity, and diabetes mellitus compared to the general population. Exercise may not only mitigate the increased risk of cardiovascular disease, but could also potentially improve the long term outcomes of mood disorders. RECENT FINDINGS/RESULTS:We conducted a literature review on the impact of exercise on mood disorders and associated comorbid conditions as well as possible biological mechanisms. We found that exercise impacts both the physical health parameters of mood disorders as well as mental health outcomes. Exercise also positively impacts conditions frequently comorbid with mood disorders (i.e. anxiety, pain, and insomnia). There are multiple candidate biomarkers for exercise, with brain-derived neurotrophic factor and oxidative stress as two main promising components of exercise's anti-depressant effect. SUMMARY/CONCLUSIONS:Exercise appears to be a promising adjunct treatment for mood disorders. We conclude with recommendations for future research of exercise as an adjunct intervention for mood disorders.

BACKGROUND:A recent factor analysis of Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) data in a sample of schizophrenia-spectrum patients described a three factor model representing processing speed, attention/working memory, and learning; the social cognition measure was excluded from the analysis. The current analyses sought to replicate a three factor structure of the MCCB in a larger, more diagnostically diverse sample of participants. METHODS:Confirmatory factor analyses were performed to evaluate the factor structure of the MCCB in 300 outpatients with severe mental illness (54.3% schizophrenia-spectrum diagnoses) who were participants in three studies of cognitive remediation. Exploratory analyses were conducted to evaluate the concurrent prediction of symptoms from MCCB factor scores. RESULTS:The three factor structure of the MCCB demonstrated stronger model fit (χ(2)=14.53, p=0.75, SRMR=0.02, RMSEA=0.0, CFI=1.00, NNFI=1.01) than the unifactoral structure. Poorer cognitive performance across all three MCCB factors was significantly correlated with more severe overall and disorganization symptoms from the PANSS and BPRS, and less severe affective symptoms (e.g., depression, anxiety) in the overall sample. CONCLUSIONS:A three factor structure of the MCCB-composed of processing speed, attention/working memory, and learning-was replicated in a heterogeneous sample of persons with severe mental illness. Cognitive performance on the MCCB factors is associated with clinical symptoms.

Individuals with elevated levels of anxiety sensitivity (AS) may be motivated to avoid aversive emotional or physical states, and therefore may have greater difficulty achieving healthy behavioral change. This may be particularly true for exercise, which produces many of the somatic sensations within the domain of AS concerns. Cross-sectional studies show a negative association between AS and exercise. However, little is known about how AS may prospectively affect attempts at behavior change in individuals who are motivated to increase their exercise. We recruited 145 young adults who self-identified as having a desire to increase their exercise behavior. Participants completed a web survey assessing AS and additional variables identified as important for behavior change-impulsivity, grit, perceived behavioral control, and action planning-and set a specific goal for exercising in the next week. One week later, a second survey assessed participants' success in meeting their exercise goals. We hypothesized that individuals with higher AS would choose lower exercise goals and would complete less exercise at the second survey. AS was not significantly associated with exercise goal level, but significantly and negatively predicted exercise at Time 2 and was the only variable to offer significant prediction beyond consideration of baseline exercise levels. These results underscore the importance of considering AS in relation to health behavior intentions. This is particularly apt given the absence of prediction offered by other traditional predictors of behavior change.