Annual Review of Clinical Psychology - Volume 17, 2021

The impact of tobacco smoking treatment is determined by its reach into the smoking population and the effectiveness of its interventions. This review evaluates the reach and effectiveness of pharmacotherapy and psychosocial interventions for smoking. Historically, the reach of smoking treatment has been low, and therefore its impact has been limited, but new reach strategies such as digital interventions and health care system changes offer great promise. Pharmacotherapy tends to be more effective than psychosocial intervention when used clinically, and newer pharmacotherapy strategies hold great promise of further enhancing effectiveness. However, new approaches are needed to advance psychosocial interventions; progress has stagnated because research and dissemination efforts have focused too narrowly on skill training despite evidence that its core content may be inconsequential and the fact that its mechanisms are either unknown or inconsistent with supporting theory. Identifying effective psychosocial content and its mechanisms of action could greatly enhance the effectiveness of counseling, digital, and web interventions.

Empirical publications inspired by the network approach to psychopathology have increased exponentially in the twenty-first century. The central idea that an episode of mental disorder arises from causal interactions among its symptomatic elements has especially resonated with those clinical scientists whose disenchantment with traditional categorical and dimensional approaches to mental illness has become all too apparent. As the field has matured, conceptual and statistical concerns about the limitations of network approaches to psychopathology have emerged, inspiring the development of novel methods to address these concerns. Rather than reviewing the vast empirical literature, I focus instead on the issues and controversies regarding this approach and sketch directions where the field might go next.

Coinciding with the development and revision of conceptual models of psychopathology, there has been a proliferation in the number of self-report clinical questionnaires and studies evaluating their psychometric properties. Unfortunately, many clinical measures are constructed and evaluated using suboptimal methods. This review provides current guidelines for the conceptualization, development, and psychometric validation of clinical questionnaires using latent variable methods. A two-stage exploratory-confirmatory framework is provided. The exploratory stage includes item selection and revision, initial structural evaluation, and preliminary tests of concurrent validity (e.g., convergent and discriminant). The confirmatory stage involves replicating factor structure using a more restrictive model, identifying areas of model strain, conducting additional tests of concurrent and predictive validity, and evaluating measurement invariance. Recommendations are provided for (a) item generation, (b) how to use different types of exploratory and confirmatory factor models to determine structure, and (c) evaluating reliability and validity using a latent variable measurement model approach.

Traditional diagnostic systems went beyond empirical evidence on the structure of mental health. Consequently, these diagnoses do not depict psychopathology accurately, and their validity in research and utility in clinicalpractice are therefore limited. The Hierarchical Taxonomy of Psychopathology (HiTOP) consortium proposed a model based on structural evidence. It addresses problems of diagnostic heterogeneity, comorbidity, and unreliability. We review the HiTOP model, supporting evidence, and conceptualization of psychopathology in this hierarchical dimensional framework. The system is not yet comprehensive, and we describe the processes for improving and expanding it. We summarize data on the ability of HiTOP to predict and explain etiology (genetic, environmental, and neurobiological), risk factors, outcomes, and treatment response. We describe progress in the development of HiTOP-based measures and in clinical implementation of the system. Finally, we review outstanding challenges and the research agenda. HiTOP is of practical utility already, and its ongoing development will produce a transformative map of psychopathology.

Prolonged grief disorder (PGD) is a diagnostic entity now included in the International Classification of Diseases 11th Revision (ICD-11) and soon to appear in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). A characteristic feature of PGD is distressing, disabling yearning that persists a year or more after the loss. Other characteristic symptoms include disbelief and lack of acceptance of the loss, emotional detachment from others since the loss, loneliness, identity disturbance, and sense of meaninglessness. In this review, we detail psychiatric views on grief and their evolution over the twentieth century. We then discuss the development of diagnostic formulations for disordered grief, which culminated in PGD's status as a mental disorder in the DSM. After summarizing recent evidence that may suggest that PGD is linked to the neural reward system, we suggest further areas of research. In particular, we note the need for studies that extend the evidence base concerning PGD across cultural and sociodemographic boundaries and that investigate novel treatments.

Latinx immigrant families are greatly impacted by US policies and practices that limit immigrant families’ and children's rights. This article reviews the effects of such policies and the growing literature examining migration experiences. Latinx immigrant youth and parents may encounter multiple stressors across the stages of migration, including physical and structural violence, fear, poverty, and discrimination, which contribute to higher rates of mental health problems in this population. Despite significant trauma exposure, immigrants demonstrate incredible resilience within themselves, their families, and their communities and through movements and policies aimed at protecting their rights. Numerous culturally relevant universal, targeted, and intensive interventions were developed to magnify these protective factors to promote healing, advance immigration reform, and provide trauma-informed training and psychoeducation. Psychologistsplay a crucial role in implementing, evaluating, and advocating for accessible and collaborative approaches to care so that Latinx immigrant families have the resources to combat the harmful sequelae of immigration stress.

The recent shift from psychopathology to resilience and from diagnosis to functioning requires the construction of transdiagnostic markers of adaptation. This review describes a model of resilience that is based on the neurobiology of affiliation and the initial condition of mammals that mature in the context of the mother's body and social behavior. The model proposes three tenets of resilience—plasticity, sociality, and meaning—and argues that coordinated social behavior stands at the core sustaining resilience. Two lines in the maturation of coordinated social behavior are charted, across animal evolution and throughout human development, culminating in the mature human reciprocity of empathy, mutuality, and perspective-taking. Cumulative evidence across ages and clinical conditions and based on our behavioral coding system demonstrates that social reciprocity, defined by plasticity at the individual, dyadic, and group levels, denotes resilience, whereas the two poles of disengagement/avoidance and intrusion/rigidity characterize specific psychopathologies, each with a distinct behavioral signature. Attention to developmentally sensitive markers and to the dimension of meaning in human sociality may open new, behavior-based pathways to resilience.

Depression is a common and debilitating condition that adversely affects functioning and the capacity to work and establish economic stability. Women are disproportionately burdened by depression, and low-income pregnant and parenting women have particularly high rates of depression and often lack access to treatment. As depression can be treated, it is a modifiable risk factor for poor economic outcomes for women, and thus for children and families. Recent national and state health care policy changes offer the opportunity for community-based psychological and economic interventions that can reduce the number of pregnant and parenting women with clinically significant depressive symptoms. Moreover, there is strong evidence that in addition to benefiting women's well-being, such reforms bolster children's emotional and social development and learning and help families rise out of poverty. This review summarizes the mental health and economic literature regarding how maternal depression perpetuates intergenerational poverty and discusses recommendations regarding policies to treat maternal depression in large-scale social services systems.

The therapeutic onset of traditional antidepressants is delayed by several weeks and many depressed patients fail to respond to treatment altogether. In contrast, subanesthetic ketamine can rapidly alleviate symptoms of depression within hours of a single administration, even in patients who are considered treatment-resistant. Ketamine is thought to exert these effects by restoring the integrity of neural circuits that are compromised in depression. This hypothesis stems in part from preclinical observations that ketamine can strengthen synaptic connections by increasing glutamate-mediated neurotransmission and promoting rapid neurotrophic factor release. An improved understanding of how ketamine, and other novel rapid-acting antidepressants, give rise to these processes will help foster future therapeutic innovation. Here, we review the history of antidepressant treatment advances that preceded the ketamine discovery, critically examine mechanistic hypotheses for how ketamine may exert its antidepressant effects, and discuss the impact this knowledge has had on ongoing drug discovery efforts.

This article provides a critical review of existing research on intimate (marriage or marriage-like) relationship distress and risk for depression. Using the meta-framework of research triangulation, we seek to synthesize research evidence across several different methodologies and study designs and to draw the most reliable conclusion regarding a potential causal association between relationship distress and depression. Focusing on existing correlational (i.e., observational), genetically informed, and intervention (i.e., experimental) research on the association between relationship distress and depression, we conclude that the existing body of research evidence supports the claim that relationship distress is a causal risk factor for depression. A secondary aim of the article is to highlight a variety of effective methods that, when viewed from the perspective of triangulation, enhance the pursuit of causal inference, including propensity score matching, target trial emulation, directed acyclic graph approach, and Mendelian randomization.

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

Why does prenatal exposure to wars, natural disasters, urbanicity, or winter increase the risk for schizophrenia? Research from the last two decades has provided rich insight about the underlying chains of causation at play during environmental upheaval, from conception to early infancy. In this review, we appraise the evidence linking schizophrenia spectrum disorder to prenatal maternal stress, obstetric complications, early infections, and maternal nutrition and other lifestyle factors. We discuss putative mechanisms, including the maternal stress system, perinatal hypoxia, and maternal–offspring immune activation. We propose that gene–environment interactions, timing during development, and sex differentiate the neuropsychiatric outcomes. Future research should pursue the translation of animal studies to humans and the longitudinal associations between early exposures, intermediate phenotypes, and psychiatric disorders. Finally, to paint a comprehensive model of risk and to harness targets for prevention, we argue that risk factors should be situated within the individual's personal ecosystem.

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

Developmental approaches provide inclusive, universal, and methodologically rigorous frameworks for studying persons with intellectual disability (ID). This is an exceptionally heterogeneous group with regard to etiology, genotype, and phenotype that simply shares the traditional diagnostic criteria, typically a score of two standard deviations below the population mean of 100 on standardized IQ tests and deficits in adaptive behavior. We trace the foundational, conceptual, and methodological roots of developmental approaches and highlight ways that these and more recent iterations continue to be central to advances in the increasingly nuanced study of persons with ID. This work is premised on the consideration of specific etiological groupings and subgroupings across and between different domains of functioning within the context of familial and complex environments throughout the life span. We highlight the potential contributions of advances in behavioral methodologies, genomics, and neuroscience when considered within universal and hierarchic frameworks based on development.

A vast share of the population-attributable risk for autism relates to inherited polygenic risk. A growing number of studies in the past five years have indicated that inherited susceptibility may operate through a finite number of early developmental liabilities that, in various permutations and combinations, jointly predict familial recurrence of the convergent syndrome of social communication disability that defines the condition. Here, we synthesize this body of research to derive evidence for a novel developmental substructure for autism, which has profound implications for ongoing discovery efforts to elucidate its neurobiological causes, and to inform future clinical and biomarker studies, early interventions, and personalized approaches to therapy.

Childhood conduct disorders, a serious mental health concern, put children at risk for significant mental health problems throughout development. Elevations on callous-unemotional (CU) traits designate a subgroup of youth with conduct disorders who have unique causal processes underlying their problem behavior and are at a particularly high risk for serious impairment relative to others with these disorders. As a result, these traits have recently been integrated into major diagnostic classification systems for conduct disorders. Given that CU traits are partly defined by deficits in empathy, we review research on empathy development in typically developing children and use this research to (a) advance theories on the specific emotional deficits that may be associated with CU traits, (b) explain the severe pattern of aggressive behavior displayed by children with elevated CU traits, and (c) suggest possible ways to enhance prevention and treatment for children with conduct disorders and elevated CU traits.

Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN) and for binge eating disorder (BED), although interpersonal psychotherapy appears to be equally effective for BED. Evidence for the effectiveness of CBT-ED for the persistent (adult) form of anorexia nervosa (AN) is insufficient at present and is essentially absent for AN in adolescents except for some evidence from uncontrolled trials. This article begins with an overview of the early studies in the development of CBT-ED that showed a similar effectiveness of other symptom-focused psychotherapies—a finding that was neglected at the time. Later developments are then considered, including comparisons of CBT-ED with other psychotherapies, efforts to develop Internet-based training and treatment, and electronic applications for treatment. Finally, implications of the findings for future short- and long-term research and for clinical practice are considered.

Meta-analytic, population cohort, prospective, and clinical studies provide systematic evidence that child sexual abuse accounts for unique variation in several deleterious outcomes. There is strong evidence for psychiatric disorders, including posttraumatic stress disorder and mood, anxiety, and substance use disorders, and mixed evidence for personality disorders. Evaluation of sex-specific outcomes shows strong evidence for teenage childbearing, sexual revictimization, and sexual dysfunction and mixed evidence for heightened sexual behaviors and sexual offending. This review further demonstrates not only that survivors suffer the noxious impact of traumatic sexualization but that additional transdiagnostic mechanisms, including the biological embedding of stress, emotion dysregulation, avoidance, and insecure attachment, converge to compound risk for deleterious outcomes. A road map to enhance the rigor of future research is outlined, and specific recommendations for evidence-based policy making to boost prevention efforts and increase access to treatment are discussed.

The last three decades in psychological research have been marked by interdisciplinary science. Addiction represents a prime example of a disorder marked by a complex interaction among psychosocial and biological factors. This review highlights critical findings in the basic neuroscience of addiction and translates them into clinical language that can inform clinical psychologists in their research, teaching, and practice. From mechanisms of reward processing, learning and memory, allostasis, incentive-sensitization, withdrawal, tolerance, goal-directed decision making, habit learning, genetics, inflammation, and the microbiome, the common theme of this review is to illustrate the clinical utility of basic neuroscience research and to identify opportunities for clinical science. The thoughtful integration of basic and clinical science provides a powerful tool to fulfill the scientific mission of improving health care. Clinical psychologists have a crucial role to play in the translational science of addiction.

Initially designed for the treatment of phobias, the use of virtual reality in phobic disorders has expanded to other mental health disorders such as posttraumatic stress disorder, substance-related disorders, eating disorders, psychosis, and autism spectrum disorder. The goal of this review is to provide an accessible understanding of why this approach is important for future practice, given its potential to provide clinically relevant information associated with the assessment and treatment of people suffering from mental illness. Most of the evidence is available for the use of virtual reality exposure therapy in anxiety disorders and posttraumatic stress disorder. There is hardly any evidence that virtual reality therapy is effective in generalized anxiety disorder and obsessive-compulsive disorder. There is increasing evidence that cue exposure therapy is effective in addiction and eating disorders. Studies into the use of virtual reality therapy in psychosis, autism spectrum disorder, and attention deficit hyperactivity disorder (ADHD) are promising.