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Strategies not accompanied by a mental health professional to address anxiety and depression in children and young people: a scoping review of range and a systematic review of effectiveness. Wolpert Miranda,Dalzell Kate,Ullman Roz,Garland Lauren,Cortina Melissa,Hayes Daniel,Patalay Praveetha,Law Duncan The lancet. Psychiatry This Review reports on a scoping review followed by a systematic review to consider interventions designed to address or manage depression or anxiety in children and young people up to the age of 25 years without the need to involve mental health professionals. The scoping review identified 132 approaches, 103 of which referred to children or young people (younger than 25 years). These approaches included social interaction, engagement with nature, relaxation, distraction, sensory stimulation, physical activity, altering perceptions, engaging in hobbies, self-expression, and exploration. A systematic review of effectiveness studies from the literature identified in the scoping review found only 38 studies on seven types of intervention that met the inclusion criteria. 16 studies were based on cognitive or behavioural principles (15 on digital interventions and one on bibliotherapy), ten focused on physical exercise, five on light therapy, three on dietary supplements, two on massage therapy, one on online peer support, and one on contact with a dog. Most studies focused on adolescents or young adults. Evidence suggested that light therapy could be effective for season depression and that digital interventions based on attention bias modification are ineffective for anxiety. Mixed evidence was available on the effectiveness of computerised cognitive behavioural therapy for depression and anxiety, and of physical exercise for depression. All other studies had insufficient certainty to obtain even tentative conclusions about effectiveness. These results highlight the disparity between the extensive range of approaches identified in the scoping review and the restricted number and focus found in the systematic review of effectiveness of these approaches. We call for an expanded research agenda that brings evaluation rigour to a wide range of self or community approaches. 10.1016/S2215-0366(18)30465-6
Modeling Avoidance in Mood and Anxiety Disorders Using Reinforcement Learning. Mkrtchian Anahit,Aylward Jessica,Dayan Peter,Roiser Jonathan P,Robinson Oliver J Biological psychiatry BACKGROUND:Serious and debilitating symptoms of anxiety are the most common mental health problem worldwide, accounting for around 5% of all adult years lived with disability in the developed world. Avoidance behavior-avoiding social situations for fear of embarrassment, for instance-is a core feature of such anxiety. However, as for many other psychiatric symptoms the biological mechanisms underlying avoidance remain unclear. METHODS:Reinforcement learning models provide formal and testable characterizations of the mechanisms of decision making; here, we examine avoidance in these terms. A total of 101 healthy participants and individuals with mood and anxiety disorders completed an approach-avoidance go/no-go task under stress induced by threat of unpredictable shock. RESULTS:We show an increased reliance in the mood and anxiety group on a parameter of our reinforcement learning model that characterizes a prepotent (pavlovian) bias to withhold responding in the face of negative outcomes. This was particularly the case when the mood and anxiety group was under stress. CONCLUSIONS:This formal description of avoidance within the reinforcement learning framework provides a new means of linking clinical symptoms with biophysically plausible models of neural circuitry and, as such, takes us closer to a mechanistic understanding of mood and anxiety disorders. 10.1016/j.biopsych.2017.01.017
School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis. The lancet. Psychiatry BACKGROUND:Rates of anxiety and depression are increasing among children and young people. Recent policies have focused on primary prevention of mental disorders in children and young people, with schools at the forefront of implementation. There is limited information for the comparative effectiveness of the multiple interventions available. METHODS:We did a systematic review and network meta-analysis, searching MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled trials for published and unpublished, passive and active-controlled randomised and quasi-randomised trials. We included educational setting-based, universal, or targeted interventions in which the primary aim was the prevention of anxiety and depression in children and young people aged 4-18 years. Primary outcomes were post-intervention self-report anxiety and depression, wellbeing, suicidal ideation, or self-harm. We assessed risk of bias following the Cochrane Handbook for Systematic Reviews of Interventions. We estimated standardised mean differences (SMD) using random effects network meta-analysis in a Bayesian framework. The study is registered with PROPSERO, number CRD42016048184. FINDINGS:1512 full-text articles were independently screened for inclusion by two reviewers, from which 137 studies of 56 620 participants were included. 20 studies were assessed as being at low risk of bias for both random sequence generation and allocation concealment. There was weak evidence to suggest that cognitive behavioural interventions might reduce anxiety in primary and secondary settings. In universal secondary settings, mindfulness and relaxation-based interventions showed a reduction in anxiety symptoms relative to usual curriculum (SMD -0·65, 95% credible interval -1·14 to -0·19). There was a lack of evidence to support any one type of intervention being effective to prevent depression in universal or targeted primary or secondary settings. Comparison-adjusted funnel plots suggest the presence of small-study effects for the universal secondary anxiety analysis. Network meta-analysis was not feasible for wellbeing or suicidal ideation or self-harm outcomes, and results are reported narratively. INTERPRETATION:Considering unclear risk of bias and probable small study effects for anxiety, we conclude there is little evidence that educational setting-based interventions focused solely on the prevention of depression or anxiety are effective. Future research could consider multilevel, systems-based interventions as an alternative to the downstream interventions considered here. FUNDING:UK National Institute for Health Research. 10.1016/S2215-0366(19)30403-1
Face Perception in Social Anxiety: Visuocortical Dynamics Reveal Propensities for Hypervigilance or Avoidance. McTeague Lisa M,Laplante Marie-Claude,Bulls Hailey W,Shumen Joshua R,Lang Peter J,Keil Andreas Biological psychiatry BACKGROUND:Theories of aberrant attentional processing in social anxiety, and anxiety disorders more broadly, have postulated an initial hypervigilance or facilitation to clinically relevant threats and consequent defensive avoidance. However, existing objective measurements utilized to explore this phenomenon lack the resolution to elucidate attentional dynamics, particularly covert influences. METHODS:We utilized a continuous measure of visuocortical engagement, the steady-state visual evoked potential in response to naturalistic angry, fearful, happy, and neutral facial expressions. Participants were treatment-seeking patients with principal diagnoses of social anxiety circumscribed to performance situations (n = 21) or generalized across interaction contexts (n = 42), treatment-seeking patients with panic disorder with agoraphobia (n = 25), and 17 healthy participants. RESULTS:At the principal disorder level, only circumscribed social anxiety patients showed sustained visuocortical facilitation to aversive facial expressions. Control participants as well as patients with panic disorder with agoraphobia and generalized social anxiety showed no bias. More finely stratifying the sample according to clinical judgment of social anxiety severity and interference revealed a linear increase in visuocortical bias to aversive expressions for all but the most severely impaired patients. This group showed an opposing sustained attentional disengagement. CONCLUSIONS:Rather than shifts between covert vigilance and avoidance of aversive facial expressions, social anxiety appears to confer a sustained bias for one or the other. While vigilant attention reliably increases with social anxiety severity for the majority of patients, the most impaired patients show an opposing avoidance. These distinct patterns of attentional allocation could provide a powerful means of personalizing neuroscience-based interventions to modify attention bias and related impairment. 10.1016/j.biopsych.2017.10.004
Association of Childhood Irritability and Depressive/Anxious Mood Profiles With Adolescent Suicidal Ideation and Attempts. Orri Massimiliano,Galera Cedric,Turecki Gustavo,Forte Alberto,Renaud Johanne,Boivin Michel,Tremblay Richard E,Côté Sylvana M,Geoffroy Marie-Claude JAMA psychiatry Importance:Suicidal ideation and suicide attempt (suicidality) are common in adolescence and a public health concern. Childhood depression is a key risk factor for later suicidality and often co-occurs with irritability. No study to date has examined the joint association of depressive mood and irritability during childhood with later suicidality. Objective:To investigate the association of childhood irritability and depressive/anxious mood profiles with adolescent suicidality. Design, Setting, and Participants:This population-based cohort study included 1430 participants in the Québec Longitudinal Study of Child Development. Participants underwent assessment yearly or bi-yearly (5 months to 17 years). Data were collected from March 16, 1998, through July 17, 2015. Exposures:Profiles defined by the joint developmental trajectories of irritability and depressive/anxious mood at 6 to 12 years of age. Main Outcomes and Measures:Self-reported past-year suicidality (ie, serious suicidal ideation or suicide attempt) at 13, 15, and 17 years of age. Irritability and depressive/anxious mood were assessed using teacher report 5 times from 6 to 12 years of age. Results:The study included 1430 participants (676 boys [47.3%] and 754 girls [52.7%]) followed up to 17 years of age. Group-based multitrajectory modeling identified the following profiles: combined no irritability and low depressive/anxious mood with low irritability and low depressive/anxious mood (831 [58.1%]; reference group), moderate irritability and low depressive/anxious mood (353 [24.7%]), high depressive/anxious mood only (94 [6.6%]), and high irritability and depressive/anxious mood (152 [10.6%]). Children with high irritability and high depressive/anxious mood reported higher rates of suicidality (25 of 152 [16.4%]) compared with the group with the lowest symptom levels (91 of 831 [11.0%]). In logistic regression analyses, the high irritability and depressive/anxious mood profile (odds ratio [OR], 2.22; 95% CI, 1.32-3.74; number needed to be exposed [NNE], 18) was associated with suicidality. To a lesser extent, the moderate irritability and low depressive/anxious mood profile was also associated with suicidality (OR, 1.51; 95% CI, 1.02-2.25; NNE = 48). The high depressive/anxious mood only profile was not associated with later suicidality (OR, 0.96; 95% CI, 0.47-1.95; NNE = -320). The high irritability and depressive/anxious mood profile was associated with a higher suicidal risk compared with the depressive/anxious mood only profile (OR, 2.28; 95% CI, 1.02-5.15). Girls with the high irritability and high depressive/anxious mood profile had higher risk for suicidality (OR, 3.07; 95% CI, 1.54-6.12; NNE = 5). Conclusions and Relevance:Children with high irritability and depressive/anxious mood and, to a lesser extent, with moderate irritability only had a higher suicidal risk during adolescence compared with children with low symptom levels. Early manifestation of chronic irritability during childhood, especially when combined with depressive/anxious mood, may be associated with an elevated risk for adolescent suicidality. The putatively causal role of irritability should be investigated. 10.1001/jamapsychiatry.2018.0174
The Unpredictive Brain Under Threat: A Neurocomputational Account of Anxious Hypervigilance. Cornwell Brian R,Garrido Marta I,Overstreet Cassie,Pine Daniel S,Grillon Christian Biological psychiatry BACKGROUND:Anxious hypervigilance is marked by sensitized sensory-perceptual processes and attentional biases to potential danger cues in the environment. How this is realized at the neurocomputational level is unknown but could clarify the brain mechanisms disrupted in psychiatric conditions such as posttraumatic stress disorder. Predictive coding, instantiated by dynamic causal models, provides a promising framework to ground these state-related changes in the dynamic interactions of reciprocally connected brain areas. METHODS:Anxiety states were elicited in healthy participants (n = 19) by exposure to the threat of unpredictable, aversive shocks while undergoing magnetoencephalography. An auditory oddball sequence was presented to measure cortical responses related to deviance detection, and dynamic causal models quantified deviance-related changes in effective connectivity. Participants were also administered alprazolam (double-blinded, placebo-controlled crossover) to determine whether the cortical effects of threat-induced anxiety are reversed by acute anxiolytic treatment. RESULTS:Deviant tones elicited increased auditory cortical responses under threat. Bayesian analyses revealed that hypervigilant responding was best explained by increased postsynaptic gain in primary auditory cortex activity as well as modulation of feedforward, but not feedback, coupling within a temporofrontal cortical network. Increasing inhibitory gamma-aminobutyric acidergic action with alprazolam reduced anxiety and restored feedback modulation within the network. CONCLUSIONS:Threat-induced anxiety produced unbalanced feedforward signaling in response to deviations in predicable sensory input. Amplifying ascending sensory prediction error signals may optimize stimulus detection in the face of impending threats. At the same time, diminished descending sensory prediction signals impede perceptual learning and may, therefore, underpin some of the deleterious effects of anxiety on higher-order cognition. 10.1016/j.biopsych.2017.06.031
Anxious, threatened, and also unethical: how anxiety makes individuals feel threatened and commit unethical acts. Kouchaki Maryam,Desai Sreedhari D The Journal of applied psychology People often experience anxiety in the workplace. Across 6 studies, we show that anxiety, both induced and measured, can lead to self-interested unethical behavior. In Studies 1 and 2, we find that compared with individuals in a neutral state, anxious individuals are more willing (a) to participate in unethical actions in hypothetical scenarios and (b) to engage in more cheating to make money in situations that require truthful self-reports. In Studies 3 and 4, we explore the psychological mechanism underlying unethical behaviors when experiencing anxiety. We suggest and find that anxiety increases threat perception, which, in turn, results in self-interested unethical behaviors. Study 5 shows that, relative to participants in the neutral condition, anxious individuals find their own unethical actions to be less problematic than similar actions of others. In Study 6, data from subordinate-supervisor dyads demonstrate that experienced anxiety at work is positively related with experienced threat and unethical behavior. We discuss the theoretical and practical implications of our findings. 10.1037/a0037796