Anorexia nervosa is commonly treated using outpatient cognitive-behavioural therapy (CBT), but its effectiveness needs to be established. This systematic review and meta-analysis (PROSPERO CRD42023484924) assessed outpatient CBT's effectiveness for anorexia nervosa and explored potential moderators (pre-treatment Body Mass Index (BMI), age, illness duration, protocol duration of therapy, dropout). Searches (SCOPUS, PsycINFO, MEDLINE, grey literature) identified 26 studies reporting pre- to post-treatment outcomes for at least one primary measure (weight, eating disorder symptoms). Studies were medium to high quality. Secondary outcome data (depression, anxiety, quality of life) were also extracted. Meta-analyses (26 studies) found medium to large post-treatment effect sizes for weight (g = 0.87; 95% CI 0.67-1.08) and eating disorder symptoms (g = -0.74; 95% CI -0.93 - -0.54), with change starting early and increasing to follow-up. Effect sizes for secondary outcome measures were medium to large. Pre-treatment BMI moderated weight gain. This review was constrained by excluding non-English language papers and the limited number of papers reporting minimum data for inclusion. Overall, results suggest an optimistic picture for patients with anorexia nervosa treated with outpatient CBT. Clinicians can expect good outcomes using CBT, regardless of patients' starting weight, age, or illness duration.

Practice assignments (i.e. homework) are a key component in cognitive behavioral therapies that predict treatment outcomes for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) separately. However, research has not explored these variables among individuals with comorbid PTSD and MDD. This study evaluated whether practice assignment adherence and helpfulness predicted PTSD (Clinician-Administered PTSD Scale for DSM-5; CAPS-5) and MDD (Montgomery-Åsberg Depression Rating Scale; MADRS) outcomes at posttreatment and 3-month follow-up. Data were derived from a randomized clinical trial comparing cognitive processing therapy (CPT) and behavioral activation-enhanced CPT (BA+CPT) among 83 U.S. active duty service members with comorbid PTSD and MDD. Participants reported greater assignment adherence in BA+CPT than CPT ( = .008), primarily due to higher adherence to BA assignments within BA+CPT. Multilevel models indicated helpfulness ratings were significantly related to decreased CAPS-5 scores ( = .044) but not MADRS scores ( = .074); service members with the highest helpfulness ratings achieved the best outcomes. Adherence was not significantly related to CAPS-5 ( = .494) or MADRS ( = .114) outcomes. Findings provide clinical insights regarding compliance in integrated treatments and highlight the value in assessing helpfulness of practice assignments during treatment.

Low-intensity interventions, designed as accessible, scalable, and cost-effective, are increasingly adopted globally to address common mental health problems. Typically, based on Cognitive Behavioural Therapy (CBT), low-intensity interventions emphasise patient self-management techniques, practiced outside of sessions as between-session work (BSW). Although crucial for symptom improvement, task completion remains a challenge, and research on predictors of BSW engagement in low-intensity contexts is limited. This qualitative study employed interpretive description methodology and framework analysis to interview 24 patients from UK NHS Talking Therapies services, exploring barriers and facilitators to between-session engagement in low-intensity CBT-based interventions. Themes constructed emphasised the importance of prioritising BSW, where between-session activities are endorsed during sessions to cultivate favourable patient attitudes. Specific, tailored task planning, continuous practitioner review and proactive responses to non-completion were key to secure engagement. External support from patients' social networks also reinforced engagement and mitigated barriers such as time constraints. Findings highlight the need for targeted provider training to ensure consistent application of engagement-enhancing techniques, as well as adjustments to intervention delivery to better incorporate patient preferences and leverage social support. This study provides critical insights and actionable guidance that can enhance the global delivery and effectiveness of low-intensity interventions.

This study investigates the feasibility and preliminary evidence for the efficacy of a single-session online metacognitive training (MCT-ED) among a population considered to be at-risk of developing an eating disorder. A total of  = 95 participants with high weight concerns were randomised to an MCT-ED condition ( = 43) or a waitlist control condition ( = 52). Participants completed measures of body image flexibility, perfectionism, weight and shape concerns and mood at baseline, post-treatment (one-week post-baseline), and 3-months post-treatment. The MCT-ED intervention consisted of content targeting cognitive flexibility and perfectionism. Treatment completion for MCT-ED was 93.62%, indicating that the intervention was feasible and acceptable. Participants also provided positive ratings on a feedback questionnaire indicating preliminary feasibility. At 1-week post-treatment, relative to the waitlist condition, the MCT-ED group had significantly lower personal standards ( = 0.64) and experienced a significantly greater decrease in concern over mistakes ( = 0.57). These improvements were not sustained at 3-month follow-up. Findings suggested that MCT-ED is a feasible brief intervention format for those with elevated weight concerns, but more research is required to produce longer, more meaningful effects that may impact weight and shape concerns.

Negative posttraumatic cognitions (NPCs) and cognitive emotion regulation (CER) strategies have both been proposed as predictors of change in evidence-based cognitive behavioral therapies for posttraumatic stress disorder (PTSD). However, they are rarely studied simultaneously, with only one study examining these predictors in a randomized clinical trial of prolonged exposure therapy. It remains to be tested how these variables predict improvements in PTSD severity in real world clinical settings or different delivery formats. Data from 487 military service members and veterans that participated in a 2-week nonrandomized, uncontrolled cognitive processing therapy-based intensive treatment program (ITP) for PTSD were used to evaluate NPCs and CER strategies as predictors of improvements in PTSD severity. Results showed that, in a model with both predictors, decreases in self-focused NPCs, world-focused NPCs, and catastrophizing (CER strategy) were associated with reductions in PTSD severity during treatment and at follow-up. However, these effects were small ( ranging from .005 to.04) relative to reductions in depression severity ( .40). Although NPCs and CER strategies significantly predicted reductions in PTSD severity, their overall impact was relatively small in this nonrandomized, uncontrolled ITP. Future research should continue to investigate these and other predictors in a variety of treatment settings.

Three decades of research indicate that intolerance of uncertainty (IU) plays a role in the maintenance of mental health conditions. In particular, the relationship between IU and worry is especially strong. The current study aimed to conduct a partial examination of the Intolerance of Uncertainty Model (IUM) of GAD as well as the Transdiagnostic Model of Intolerance of Uncertainty (TMIU), in a clinical sample of adults with GAD using path analysis. Participants with a primary diagnosis of GAD ( = 112) completed a range of measures that assessed IU, cognitive avoidance (CA), positive beliefs about worry (PBW), threat estimates, worry, and anxiety, with two path analysis models constructed for the IUM and TMIU. In a preliminary analysis of the IUM, path analysis found that CA and PBW did not have an indirect effect the relationship between IU and worry, however, CA (and not PBW) had an indirect effect on the relationship between IU and anxiety. For the TMIU, the first model demonstrated a poor fit. In an alternative model, threat estimates were found to indirect effect the relationship between IU and worry as well as anxiety. This suggests that threat appraisals do play a role in the relationship between IU, worry and anxiety in individuals with GAD.

Many veterans do not initiate trauma-focused evidence-based psychotherapy (TF-EBP) to treat posttraumatic stress disorder (PTSD). Instead, veterans receive other treatments prior to TF-EBP and the process of transitioning to TF-EBP is poorly understood. The goal of the current study was to understand clinicians' beliefs about and approaches to transitioning veterans into TF-EBP. Clinicians ( = 20) with any experience providing TF-EBP from across the national VA healthcare system participated in semi-structured qualitative interviews. Rapid qualitative analysis procedures were used to identify themes: (1) TF-EBP is rarely contraindicated; (2) there is no consensus on treatment alternatives after veterans decline TF-EBP; (3) unstructured therapy can be a barrier to TF-EBP; (4) data from non-TF-EBP can be used to encourage TF-EBP engagement; (5) veterans are poorly informed about PTSD referrals; (6) culturally responsive PTSD care involves asking questions throughout the treatment process; (7) TF-EBP was delivered with attention to how identity may impact treatment; (8) TF-EBP was among the first treatment option offered by all clinicians; (9) veterans initiate TF-EBP when willing; and (10) clinicians developed resources socialize veterans to structured treatment. Since non-TF-EBP approaches may be indicated (or requested) for some veterans, strategies to facilitate transitions to TF-EBP are needed.

Metacognitive interventions have received increasing interest the last decade and there is a need to synthesize the evidence of these type of interventions. The current study is an updated systematic review and meta-analysis where we investigated the efficacy of metacognitive interventions for adults with psychiatric disorders. We included randomized controlled trials that investigated either metacognitive therapy (MCT; developed by Wells) or metacognitive training (MCTraining; developed by Moritz). Ovid MEDLINE, Embase OVID, and PsycINFO were searched for articles published until May 2024. The final analyses included 21 MCT- and 28 MCTraining studies (in total 3239 individuals). Results showed that MCT was more efficacious than both waiting-list control conditions ( = 1.84) as well as other forms of cognitive behavior therapies ( = 0.43). MCTraining was superior to treatment as usual ( = 0.45), other psychological treatments ( = 0.46) and placebo conditions ( = 0.15). Many of the included studies lacked data on blinding procedures, reporting of inter-rater reliability, treatment adherence, competence, treatment expectancy and pre-registration procedures. We conclude that both MCT and MCTraining are probably efficacious treatments but that future studies need to incorporate more quality aspects in their trial designs.

With the rising number of dementia cases, supporting family caregivers to maintain their well-being is crucial. Acceptance and Commitment Therapy (ACT) shows promise in promoting psychological flexibility and positive behaviour change. However, it is still developing in caregiving contexts. This study evaluated the preliminary efficacy of a fully online ACT intervention for caregivers of people with dementia. This study employed a pre-post design with two follow-up assessments at 3 and 6 months. A 9-week web-based self-help ACT program, including individual goal setting prior to the intervention, and minimal contact motivational coaching, was provided to 30 family caregivers in the Netherlands. Linear mixed-effect models based on a complete-case analysis showed significant changes in depressive symptoms (mean difference: -3.34, = -0.78). Significant and sustained improvements were observed in stress (mean difference: -6, = -1.13) and anxiety (mean difference: -5.55, = -1.38), both of which were clinically significant. Sense of competence increased (mean difference: 1.1, = 0.45). ACT-specific measures, including psychological flexibility, engaged living, and inflexibility, also showed significant improvements with medium-to-large effect sizes. This online intervention demonstrated promising preliminary evidence of ACT's potential efficacy on caregivers' well-being, warranting further research in larger-scale controlled trials.

The Bergen 4-day treatment (B4DT) for obsessive-compulsive disorder (OCD) is a concentrated form of exposure and response prevention that has been evaluated and implemented nationwide in Norway. Its effectiveness has yet to be fully established in other countries. A total of 86 patients with OCD underwent the treatment at the Icelandic Anxiety Centre (KMS) from 2018 to 2023. Of these, 61.6% were classified as having severe symptoms, and 38.4% with moderate symptoms. Of the sample, 72.1% had previously received psychological treatment for OCD and 86.0% had at least one comorbid disorder, depression being the most common (50.0%). Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was administered pre-treatment, posttreatment, and at 3-month follow-up, along with measures on general anxiety, depression, and occupational impairment. The mean score on Y-BOCS was 30.5 (SD = 3.6) pre-treatment, 10.6 (SD = 4.1) posttreatment and 10.9 (SD = 5.4) at 3-month follow-up. By the end of treatment, 94.9% of the patients had responded and 68.0% were in remission. At the 3-month follow-up, 92.5% were responders and 67.9% remitters. Participants were satisfied with the treatment and had improved in terms of occupational functioning, which was maintained at follow-up. These preliminary results suggest that the B4DT may be a swift and effective treatment format for OCD.

An intimate partner relationship is one of the most significant life goals for humans. Romantic relationships can promote healthy behavior and buffer against the development of psychiatric disorders. However, reliable and valid measures of relationship satisfaction are lacking. The Valentine scale is a freely available brief measure of relationship satisfaction (https://osf.io/fb72s), intended to provide an easily interpretable index of relationship satisfaction. Across two studies, we evaluated the reliability, validity, and factor structure of the Valentine scale. Study One ( = 851) explored the factor structure of the Valentine scale, assessed its test-retest reliability, and criterion-related validity. Study Two ( = 527) confirmed the factor structure of the Valentine scale, explored its measurement invariance, and further evaluated criterion-related validity. The results supported a unidimensional structure of the Valentine scale. Furthermore, the Valentine scale exhibited good internal reliability (Cronbach's alpha = .75 and .81 in Study One and Two, respectively), high test-retest reliability (ICC = .80 at a two-week follow-up in Study One), and appropriate criterion-related validity demonstrating positive correlations with other measures of relationship satisfaction and positive affect, as well as and negative correlations with measures of psychopathology. Together, these findings provide good support for the usage of the Valentine scale to quantify relationship satisfaction.

Perfectionism has been suggested as a risk factor relevant to multiple psychological disorders, including obsessive-compulsive disorder (OCD) and eating disorders (ED). However, it remains unclear how perfectionism contributes to general and specific psychopathology. Disorder-specific processes (e.g. body dissatisfaction, responsibility) between perfectionism and subsequent symptoms may offer an explanation. The current study examined longitudinal associations between perfectionism, body dissatisfaction or responsibility, and symptoms of ED or OCD. A community sample of 499 women (18-30) completed a three-wave online study, assessing perfectionism, ED and OCD symptoms, body dissatisfaction, and responsibility/threat overestimation. Temporal relations between perfectionism and symptoms were analyzed using a structural equation model. Effects of body dissatisfaction and responsibility/threat overestimation were analyzed using multiple hierarchical regressions. Results showed that perfectionism predicted subsequent OCD symptoms, but not ED symptoms. ED symptoms, but not OCD symptoms, predicted subsequent perfectionism. No interaction effects between perfectionism and the disorder-specific processes were found. Instead, body dissatisfaction independently contributed to both ED and OCD symptoms, whereas inflated responsibility/threat overestimation predicted specifically OCD symptoms. To conclude, perfectionism appears to increase the risk of psychological symptoms. However, in this sample this was specific to OCD symptoms. Given ED symptoms predicted later perfectionism, bidirectional effects need to be considered.

Loneliness has detrimental effects on physical and mental well-being, making relevant any systematic means of inhibiting its impact. Whereas interventions based on cognitive behavior therapies have shown efficacy, interventions based on Ellis's rational emotive behavior therapy (REBT) have not been systematically assessed. In 2019, Hyland et al. demonstrated that the REBT theoretic principles of psychopathology and psychological health significantly predict loneliness scores, providing an empirical justification for later intervention efforts. The Hyland et al. sample was small, with limited demographic and geographic diversity. This paper replicates the Hyland et al. analyses using a larger ( = 3,064) sample drawn from the United States, United Kingdom, Canada, Australia, and South Africa. The present results replicate Hyland et al.'s results for both the psychopathology and psychological health models, with minimal variation in model fit from country to country. Implications for the development of an REBT-based intervention to treat loneliness are discussed.

The network approach to psychopathology postulates that it is more helpful to think of psychiatric problems to be caused by each other, rather than by underlying diseases. Personalized networks can be created using questionnaires asking participants about their perceptions of the causal links between symptoms, which is time-efficient but has shown low test-retest reliability. The present study explores whether perceptions of causal links can instead be assessed using interviews. The study investigates the feasibility, acceptability and test-retest reliability of such an interview format. 21 adolescents were interviewed twice within one week. Results showed an average test-retest reliability for node centrality of  = .703 ( = .148), and for causal links  = .533 ( = .198). A majority of participating adolescents rated the interview as easy to understand. On a group level, the node both most central and frequent was negative emotions. Future studies should evaluate the clinical utility of networks created in interviews, both in terms of face-validity and to guide clinicians in treatment choices.

Perfectionism is a transdiagnostic process associated with multiple mental health disorders. Perfectionism can moderate the effectiveness of Cognitive Behavioural Therapy (CBT) for depression, but it remains unclear whether perfectionism is associated with CBT outcomes for anxiety disorders. This study investigated the relationship between perfectionism, treatment outcomes and adherence for individuals seeking internet-based CBT (iCBT) for Generalised Anxiety Disorder (GAD). A total of 1,904 adults from the general Australian community commenced an iCBT GAD program and completed measures of perfectionism, generalised anxiety, depression and psychological distress at baseline, mid-treatment, and post-treatment. Regression analyses were used to examine relationships between baseline perfectionism, post-treatment symptom reductions and treatment completion. Baseline perfectionism was significantly associated with pre-treatment GAD symptom severity, but not treatment completion or reductions in GAD severity post-iCBT. Significant reductions in generalised anxiety symptom severity (Hedges' g = 1.32), depression symptoms (g = 0.97), distress (g = 1.34) and perfectionism (both striving and evaluative concerns, g = 0.49 and g = 0.37, respectively) were observed with treatment. These findings suggest that iCBT for GAD is effective in reducing perfectionism, despite not directly targeting this process. Given there was no significant relationship between baseline perfectionism and treatment outcomes, it may not be necessary to specifically target perfectionism when delivering iCBT for GAD.

While most psychotherapy methods are about equally effective, it is unclear if (1) different methods of psychotherapy differ in the severity of negative effects, (2) negative effects impact outcome and (3) this impact is moderated by psychotherapy method. We analyzed data from an observational study of 141 patients from a day treatment program for depression. Based on shared decision-making, patients were treated with either Cognitive Behavioral Analysis System of Psychotherapy (CBASP) or Metacognitive Therapy (MCT). Negative effects were assessed with the Negative Effects Questionnaire (NEQ), severity of depressive symptoms with the Quick Inventory of Depressive Symptomatology (QIDS-SR). Treatment groups were propensity score matched to account for baseline differences. Severity of negative effects did not differ between CBASP and MCT. The association between negative effects and outcome was moderated by treatment method. For patients treated with CBASP, negative effects were associated with outcome: those experiencing the lowest severity of negative effects had the greatest improvement in symptoms during treatment. Treatments were equally tolerated but differed in their association between negative effects and outcome. Results need to be considered with caution due to the considerable drop-out rate during the follow-up period and the non-controlled nature of our study.

Social anxiety is a prevalent mental health concern that impacts approximately 12% of the US population. There is a need for targeted mechanism-focused interventions for social anxiety that are also highly scalable. Using a recently developed naturalistic paradigm with simulated teleconferencing interactions as the central treatment element, we developed a new self-guided internet-based intervention for social anxiety called iExposure. This randomized clinical trial aimed at testing two mechanism-driven exposure augmentation strategies for social anxiety. Participants ( = 53) were randomized to four sessions of either (a) standard iExposure ( = 18), (b) iExposure +Attention Control ( = 22), or (c) iExposure + Attention Guidance ( = 13) and administered over two weeks. At follow-up across conditions, there were large reductions in communication anxiety d = -1.51 and moderate reductions in social anxiety d = -0.60. The attention control condition led to larger reductions in social anxiety compared to standard iExposure d = -0.81 and attention guidance did not enhance iExposure for general symptoms of social anxiety, d = -0.27. These findings provide preliminary support for the utility of iExposure. Further research is needed with a larger sample to understand its efficacy with regard to the role of attention augmentation strategies.

Exposure therapy is an efficacious treatment for anxiety-related disorders. Yet, fear often returns after treatment. Occasional reinforcement, in which the feared stimulus is intermittently presented during extinction, increases safety learning and slows fear renewal in conditioning paradigms and analogue samples, but no studies to date have examined this strategy in clinical samples. The present study examined the effects of vicarious occasional reinforcement on fear renewal in a snake-phobic sample across multiple levels of analysis. Fear was intermittently reinforced by providing reminders of the feared outcome (a snake bite) throughout a two-session analogue video exposure manipulation. Snake-phobic adults were randomized to one of three conditions: a single-cue [S], multiple-cue [M], or multiple-cue+fear-outcome [M+FO] exposure group. Results showed the three groups did not significantly differ in threat expectancy or attentional bias for threat at follow-up. Despite sustained anxiety, however, the M+FO condition completed significantly more steps on a visual avoidance task at follow-up than the M and S conditions and heightened mean distress during exposure mediated this effect. The M and S groups did not significantly differ in visual avoidance at follow-up. These findings suggest incorporating reminders of the feared outcome into exposure may be an effective strategy for increasing inhibitory retrieval.

Insomnia is a common and debilitating disorder that is often undiagnosed and untreated. Cognitive behavioral therapy for insomnia (CBTI) is the first-line treatment for insomnia, though the lack of trained providers is a major barrier to accessibility. To address this issue, an online provider training platform, CBTI, was launched in April 2020. The objective of this study was to determine the knowledge and implementation practices of providers 1 year after their successful completion of CBTI. An online survey was sent to 569 providers who completed CBTI training within 3 months of launch. Providers were asked about knowledge retention, use of CBTI with patients, barriers, and facilitators to the use of CBTI and acceptability, feasibility, and intervention appropriateness of CBTI. Two hundred and thirty-three providers completed the survey. Results revealed that most of the providers retained knowledge gained during CBTI and that self-efficacy for CBTI was positively associated with CBTI use with their patients. Common barriers endorsed by providers were primarily related to difficulty promoting patient-buy-in for CBTI and difficulty finding CBTI supervision and consultation. Helpful facilitators included access to patient and therapist materials. Results also indicate very high acceptability (93.1%), agreeableness (94.3%), and feasibility (88.1%) of CBTI.

Interoceptive exposure (IE) exercises are underused, especially in people with chronic physical health problems. Secondary data analyses were conducted to examine the use of and acute responses to IE exercises in individuals with and without a history of chronic physical health problem(s). Participants ( = 413; Mage = 38.6, 56.1% with chronic physical health problems) enrolled in a 6-month randomized controlled trial that aimed to reduce anxiety and depression. Participants had access to a smartphone-based intervention that included on-demand access to IE exercises: head rush, straw breathing, chair spinning, fast breathing, and running in place. Utilization of the IE exercises and acute responses to the exercises were evaluated in the context of chronic physical health problem history. Participants with versus without a chronic physical health problem completed statistically significantly more IE exercises. Acute effects of IE exercises on distress and physical sensations were similar for those with and without a history of chronic physical health problems, as well as those who were versus were not taking medication. There is no evidence that chronic disease history influences the acute response to IE exercises. Continued research is needed to further assess the safety of IE exercises in people with various medical conditions.

Exercise directly improves mood and cognition. Providing exercise immediately before cognitive behavior therapy (CBT) sessions may therefore enhance the clinical responsiveness to CBT. The present pilot study examined the feasibility and direction of effect of exercise+CBT versus CBT in depressed outpatients using a stepped wedged design. Thirty-three patients received either group-based CBT (12-16 weeks) or group-based exercise+CBT within specialized mental healthcare settings. Weekly therapist-supervised exercise sessions (45 min, moderate intensity, running/indoor cycling) were provided directly before the CBT sessions, with encouragement for home-exercise. Feasibility was assessed through recruitment, retention, and safety, alongside treatment adherence and treatment effects on clinically relevant outcomes. Recruitment yielded 37% of eligible patients with similar retention rates across conditions. No adverse events were reported. The exercise+CBT condition attended 63% of supervised exercise sessions (72% at moderate/vigorous intensity) and fewer CBT sessions (42%) compared to the CBT condition (54%). The conditions showed similar improvements in depressive symptoms, rumination, and CBT skills over time. Our study shows in a specialized mental health care routine practice population that providing exercise before CBT sessions is feasible, warranting a future randomized controlled trial.