Annual Review of Clinical Psychology - Volume 7, 2011

The past decade has witnessed a resurgence of interest in behavioral interventions for depression. This contemporary work is grounded in the work of Lewinsohn and colleagues, which laid a foundation for future clinical practice and science. This review thus summarizes the origins of a behavioral model of depression and the behavioral activation (BA) approach to the treatment and prevention of depression. We highlight the formative initial work by Lewinsohn and colleagues, the evolution of this work, and related contemporary research initiatives, such as that led by Jacobson and colleagues. We examine the diverse ways in which BA has been investigated over time and its emerging application to a broad range of populations and problems. We close with reflections on important directions for future inquiry.

We survey the utility of animal models of mental illness, based on the identification of possible neurocognitive or neurobehavioral endophenotypes. Three broad clusters of neuropsychiatric disorder are discussed: (a) impulsive-compulsive syndromes, comprising drug addiction, attention deficit/hyperactivity disorder, gambling, obsessive-compulsive disorder, and compulsive eating; (b) disorders at the cognitive-emotional interface, comprising anxiety, depression, and schizophrenia; and (c) disorders purely of cognition, which contribute to the third cluster, cognitive disorders. The emphasis is thus on modeling symptoms rather than disorders per se. We also distinguish between two main aspects of any validated model: the precise neurobehavioral or neurocognitive processes implicated from detailed study of the clinical phenotype, and the perturbations, whether typically genetic, environmental, pharmacological, or neurodevelopmental, that are designed to simulate relevant neural, neurochemical, or molecular aspects of particular neuropsychiatric disorders.

The functional significance of the brain's white matter was not fully appreciated until new imaging methods were developed to visualize fiber pathways and connections in the living brain. Rapid advances in diffusion tensor imaging (DTI) have led to substantial insights into human brain development and disease processes and have thrust white matter into the focus of researchers and clinicians alike. The full clinical potential of this relatively new technique remains to be determined, but early indicators suggest that DTI will be a significant new technology in mapping mechanisms of human health and disease. Here we review brain changes that have been studied with DTI over the human lifespan and findings in a variety of neuropsychiatric disorders. We also suggest future areas where DTI is likely to have significant impact.

The current review targets efforts to use outcome measures in routine care for the purpose of enhancing psychotherapy outcome, particularly for patients who are predicted to have a negative treatment outcome. The place of outcome measures in solving the negative effects problem is emphasized, with a narrow focus on one set of measures that is relatively well advanced in its clinical utility. This clinical innovation relies on research-based clinical decision tools that provide psychotherapists with timely warnings and problem-solving strategies when a patient deviates from an expected treatment response. Summary of a meta-analytic review using this patient feedback methodology suggests that measuring, monitoring, predicting treatment failure, and providing clinical support tools to clinicians enhance treatment outcome for patients who have an early negative treatment response. Other measures are then briefly reviewed before we turn to future directions. Clinicians are encouraged to employ these methods in routine practice.

Brain graphs provide a relatively simple and increasingly popular way of modeling the human brain connectome, using graph theory to abstractly define a nervous system as a set of nodes (denoting anatomical regions or recording electrodes) and interconnecting edges (denoting structural or functional connections). Topological and geometrical properties of these graphs can be measured and compared to random graphs and to graphs derived from other neuroscience data or other (nonneural) complex systems. Both structural and functional human brain graphs have consistently demonstrated key topological properties such as small-worldness, modularity, and heterogeneous degree distributions. Brain graphs are also physically embedded so as to nearly minimize wiring cost, a key geometric property. Here we offer a conceptual review and methodological guide to graphical analysis of human neuroimaging data, with an emphasis on some of the key assumptions, issues, and trade-offs facing the investigator.

A wave of new developments has occurred in the behavioral and cognitive therapies that focuses on processes such as acceptance, mindfulness, attention, or values. In this review, we describe some of these developments and the data regarding them, focusing on information about components, moderators, mediators, and processes of change. These “third wave” methods all emphasize the context and function of psychological events more so than their validity, frequency, or form, and for these reasons we use the term “contextual cognitive behavioral therapy” to describe their characteristics. Both putative processes, and component and process evidence, indicate that they are focused on establishing a more open, aware, and active approach to living, and that their positive effects occur because of changes in these processes.

This article introduces the role economics can play in deciding whether programs designed to prevent mental disorders, which carry large disease and economic burdens, are a worthwhile use of limited healthcare resources. Fortunately, preventive interventions for mental disorders exist; however, which interventions should be financed is a common issue facing decision makers, and economic evaluation can provide answers. Unfortunately, existing economic evaluations of preventive interventions have limited applicability to local healthcare contexts. An approach to priority setting largely based on economic techniques—Assessing Cost-Effectiveness (ACE)—has been developed and used in Australia to answer questions regarding the economic credentials of competing interventions. Eleven preventive interventions for mental disorders and suicide, mostly psychological in nature, have been evaluated using this approach, with many meeting the criteria of good value for money. Interventions targeting the prevention of suicide, adult and childhood depression, childhood anxiety, and early psychosis have particular merit.

Disturbances in aspects of memory described in current learning and cognitive theories are much more strongly associated with the presence of psychiatric disorder than with mere exposure to traumatic events. In posttraumatic stress disorder (PTSD), there are numerous associated changes that involve memory capacity, the content of memories for trauma, and a variety of memory processes. Whereas some changes appear to reflect the effects of the disorder, other evidence supports a predictive or causal role for memory disturbance. The following aspects of memory are likely to play a causal role in the development or maintenance of PTSD: verbal memory deficits, negative conceptual knowledge concerning the self, overgeneral memory, avoidance or suppression of memories, and negative interpretation of memory symptoms. Other aspects of memory likely to play a causal role that are in addition specific to PTSD are the integration of the trauma with identity, impairment in retrieval of voluntary trauma memories, and increased incidence of sensation-based memories or flashbacks.

Obsessive compulsive disorder (OCD) is characterized by the presence of intrusive, anxiety-provoking thoughts, images, or impulses along with repetitive behaviors or mental acts designed to reduce obsessional distress. OCD is associated with significant functional impairment, psychiatric comorbidity, and compromised quality of life. Fortunately, substantive progress has been made in the past several decades in the development and empirical evaluation of treatments for OCD across the developmental spectrum. The current review begins with a discussion of the clinical presentation of OCD and psychological theories regarding its etiology and maintenance. A detailed discussion follows of exposure plus response prevention, the psychosocial treatment that has garnered the most evidence for its efficacy. A summary of the extant treatment outcome literature related to exposure plus response prevention as well as cognitive therapies, pharmacotherapies, and combined approaches is then presented. Recommendations for future clinical and research directions are then provided.

Acute stress disorder (ASD) was introduced into the Diagnostic and Statistical Manual (DSM) taxonomy in 1994 to address the lack of a specific diagnosis for acute pathological reactions to trauma and the role that dissociative phenomena play both in the short- and long-term reactions to trauma. In this review, we discuss the history and goals of the diagnosis and compare it with the diagnoses of acute stress reaction, combat stress reaction, and posttraumatic stress disorder (PTSD). We also evaluate the research on the validity and limitations of ASD as a diagnosis, the relationship between peritraumatic dissociation and other symptomatology, the extent to which PTSD is predicted by previous ASD or peritraumatic dissociation, and other important issues such as impairment and risk factors related to ASD. We conclude with our recommendations for changes in DSM-5 criteria and the development of more sophisticated research that considers ASD as but one of two or possibly three common acute posttraumatic syndromes.

Understanding the association between personality and depression has implications for elucidating etiology and comorbidity, identifying at-risk individuals, and tailoring treatment. We discuss seven major models that have been proposed to explain the relation between personality and depression, and we review key methodological issues, including study design, the heterogeneity of mood disorders, and the assessment of personality. We then selectively review the extensive empirical literature on the role of personality traits in depression in adults and children. Current evidence suggests that depression is linked to traits such as neuroticism/negative emotionality, extraversion/positive emotionality, and conscientiousness. Moreover, personality characteristics appear to contribute to the onset and course of depression through a variety of pathways. Implications for prevention and prediction of treatment response are discussed, as well as specific considerations to guide future research on the relation between personality and depression.

Evidence for the importance of sleep in the mood disorders has mushroomed over the past decade. Among adolescents and adults with a mood disorder, sleep disturbance is a risk factor for episodes, can contribute to relapse, has an adverse impact on emotion regulation, is critical for cognitive functioning, compromises health, and may contribute to substance use comorbidity and suicidality. This evidence has triggered a shift away from viewing sleep disturbance as an epiphenomenon, toward viewing sleep disturbance as an important but under-recognized mechanism in the multifactorial cause and maintenance of the mood disorders. Because the biology underpinning the sleep and circadian system is an open system, readily influenced by inputs from the environment, sleep in the mood disorders represents a unique and exciting domain for interdisciplinary research across behavioral, social, cognitive, and neurobiological levels of explanation. Together, the accumulated evidence has informed a range of novel, powerful, simple, and inexpensive treatments with potential for massive improvements to public health, including improving quality of life, reducing length and severity of episodes, and reducing the risk of subsequent episodes in the large number of individuals who suffer from mood disorders.

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

The 35-year progression of multisystemic therapy (MST) from modest university-based efficacy studies to large-scale transport to community practice settings is described in this review. The success of early efficacy research led to effectiveness trials, and their success in decreasing rates of youth rearrest and incarceration led to multisite transportability trials and adaptations of the MST model for treating youth presenting other types of challenging clinical problems. To support the transport of MST programs to community settings, an intensive quality improvement system modeled after that used in clinical trials has been implemented in community-based MST programs for the past 15 years. With the association between therapist treatment fidelity and youth outcomes well established, transportability research has demonstrated the significant roles played by clinical supervisors, expert consultants, and provider organizations in supporting therapist adherence and youth outcomes. This body of work has been facilitated by federal and state initiatives to support evidence-based services.

There has been an explosion of interest in studying gene-environment interactions (GxE) as they relate to the development of psychopathology. In this article, I review different methodologies to study gene-environment interaction, providing an overview of methods from animal and human studies and illustrations of gene-environment interactions detected using these various methodologies. Gene-environment interaction studies that examine genetic influences as modeled latently (e.g., from family, twin, and adoption studies) are covered, as well as studies of measured genotypes. Importantly, the explosion of interest in gene-environment interactions has raised a number of challenges, including difficulties with differentiating various types of interactions, power, and the scaling of environmental measures, which have profound implications for detecting gene-environment interactions. Taking research on gene-environment interactions to the next level will necessitate close collaborations between psychologists and geneticists so that each field can take advantage of the knowledge base of the other.

Psychological treatment has emerged as a common component of a multidimensional and interdisciplinary plan of pain care for many persons with persistent pain. Treatments are informed by a biopsychosocial model of pain and a long history of psychological research that has identified the central role of behavioral, cognitive, and emotional factors that are believed to contribute to the perpetuation, if not the development, of chronic pain and pain-related disability and emotional distress. Empirically supported self-regulatory, behavioral, cognitive-behavioral, and acceptance and commitment interventions are reviewed, and current and future interventions are highlighted. Important issues related to individual differences and disparities in the experience of pain and pain treatment are discussed. In particular, race and ethnicity are considered, and special considerations for the management of pain in children and older adults are discussed.

Sleep disturbance is intricately entwined with our sense of well-being, health, emotion regulation, performance and productivity, memory and cognitive functioning, and social interaction. A longitudinal perspective underscores the conclusion that persistent sleep disturbance, insomnia, at any time during the life span from infancy to old age has a lasting impact. We examine how insomnia develops, the evidence for competing explanations for understanding insomnia, and the evidence about psychological and behavioral treatments that are used to reduce insomnia and change daytime consequences. There are new directions to expand access to treatment for those who have insomnia, and thus a critical analysis of pathways for dissemination is becoming increasingly important.

After the 9-11 terrorist attacks, U.S. psychologists faced hard choices about what roles, if any, were appropriate for psychologists in the detainee interrogations conducted in settings such as the Bagram Airbase, the Abu Ghraib Prison, and the Guantanamo Bay Detention Camps. The American Psychological Association (APA) sparked intense controversy with its policies and public statements. This article reviews APA decisions, documents, and public statements in this area, in the context of major criticisms and responses to those criticisms. The review focuses on key issues: how the APA created and reported policies in the areas of ethics and national security; transparency; psychologists' professional identities; psychologists' qualifications; ethical-legal conflicts; policies opposing torture; interpretations of avoiding harm; and effective interrogations. It suggests lessons learned, missed opportunities, and questions in need of a fresh approach.

Gambling-related research has advanced rapidly during the past 20 years. As a result of expanding interest in pathological gambling (PG), stakeholders (e.g., clinicians, regulators, and policy makers) have a better understanding of excessive gambling, including its etiology (e.g., neurobiological/neurogenetic, psychological, and sociological factors) and trajectory (e.g., initiation, course, and adaptation to gambling exposure). In this article, we examine these advances in PG-related research and then consider some of the clinical implications of these advances. We consider criteria changes for PG recently proposed by the DSM-V Impulse Control Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). We also review how clinicians can more accurately and efficiently diagnose clients seeking help for gambling-related problems by utilizing brief screens. Finally, we consider the importance of future research that can identify behavioral markers for PG. We suggest that identifying these markers will allow clinicians to make earlier diagnoses, recommend targeted treatments, and advance secondary prevention efforts.