Publications by authors named "Brandon A Gaudiano"

79 Publications

Mindfulness-based interventions for medication adherence: A systematic review and narrative synthesis.

J Psychosom Res 2021 Oct 26;149:110585. Epub 2021 Jul 26.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States. Electronic address:

Objective: Inadequate medication adherence is a significant limitation for achieving optimal health outcomes across chronic health conditions. Mindfulness-based interventions (MBIs) have been increasingly applied to promote medical regimen adherence as MBIs have been shown to improve patient-level barriers to adherence (i.e., depressive symptoms, cognitive impairment, stress). The purpose of this review is to investigate the state of research regarding MBIs targeting medication adherence in chronic illnesses and to identify evidence gaps to inform future studies.

Methods: The search reviewed 5 databases (e.g., PubMed, PsycINFO, Embase, CINAHL, Proquest Thesis/Dissertations) to identify trials that quantitatively evaluated the effect of MBIs on medication adherence. Study abstracts and full texts were screened identifying eligible studies, and findings were summarized using a narrative synthesis.

Results: A total of 497 studies were reviewed; 41 were eligible for full text review and 9 were included in narrative synthesis: seven were RCTs and two were pre-post designs. Study quality varied, with five rated moderate or high risk for bias. Clinical populations tested included living with HIV (k = 3), cardiovascular disease (k = 3), psychological disorders (k = 2), and men who underwent a radical prostatectomy (k = 1). Four studies found significant improvements in medication adherence, however only two of these studies had low risk of bias.

Conclusions: Research on MBI's for medication adherence is developing, but the effectiveness of MBIs remains unclear due to the nascent stage of evidence and methodological limitations of existing studies. Researchers should prioritize rigorous experimental designs, theory-driven investigations of behavioral mechanisms, and the use of objective measurements of adherence.
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http://dx.doi.org/10.1016/j.jpsychores.2021.110585DOI Listing
October 2021

Differences in Burden Severity in Adult-Child Family Caregivers and Spousal Caregivers of Persons with Dementia.

J Gerontol Soc Work 2021 Jul-Aug;64(5):518-532. Epub 2021 Apr 6.

Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA.

Researchers are continuing to focus on the nature and sources of burden of family caregivers of persons living with dementia. Caregiving stress and burden are assessed and addressed by social workers, including at high-risk times such as hospitalization. This study tested whether adult-child family caregivers experience greater perceived burden than spousal caregivers, accounting for risks of acute stress which can accompany hospitalization for their care recipient, where social workers may be meeting with family caregivers for the first time. Family caregivers (N = 76; n = 42 adult-child; n = 34 spouse) were recruited during care-recipient clinical treatment. The settings of care included an outpatient memory care program and an inpatient geriatric psychiatry service. Results showed that adult-child caregivers reported greater burden as compared with spousal caregivers, but no differences regarding depressive symptoms, perceived stress, or grief. After controlling for demographics and location of care, being an adult-child caregiver remained a predictor of greater burden severity. Being an adult-child family caregiver may place an individual at increased risk for experiencing high burden. These findings suggest socials workers should consider how adult-child caregivers may benefit from strategies to address and reduce burden, beyond those typically offered to spousal caregivers.
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http://dx.doi.org/10.1080/01634372.2021.1912242DOI Listing
April 2021

The Role of Medical Comorbidity in the Rapid Psychiatric Readmission of Patients With Schizophrenia-spectrum Disorders.

J Psychiatr Pract 2021 01 21;27(1):14-22. Epub 2021 Jan 21.

Objective: Inpatient admissions are common for individuals with schizophrenia-spectrum disorders, and difficulty transitioning from the hospital to the community results in these individuals being at high risk for hospital readmissions. Thus, psychotic disorders account for high rates of rapid readmission within 30 days of discharge. Increasing evidence highlights the role of comorbid medical conditions, such as circulatory and metabolic problems, in contributing to early readmission rates for these patients. This study examined the specific role of circulatory and metabolic problems in predicting psychiatric rehospitalizations while accounting for other medical conditions, psychiatric comorbidities, and preadmission medications.

Methods: The electronic medical records of 752 patients admitted to a psychiatric hospital were examined, with patients classified as having readmission within 30 days of their index hospitalization (n=79) or no readmission within 30 days (n=673). The 2 groups were compared on multiple variables in univariate and multivariate analyses.

Results: Male sex [odds ratio (OR)=2.02, P=0.019)], disability status (OR=1.96, P=0.027), and presence of a circulatory (but not a metabolic) condition (OR=3.43, P=0.003) were associated with significantly increased odds of being rehospitalized within 30 days, even when accounting for additional predictors, including age, substance use disorder, race, and other medical conditions.

Conclusions: These findings highlight the importance of considering circulatory, in addition to metabolic disorders, during inpatient stays. This comorbidity pattern may signify a subset of individuals with schizophrenia-spectrum disorders requiring more comprehensive discharge planning and support after an inpatient hospitalization to prevent rapid rehospitalization.
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http://dx.doi.org/10.1097/PRA.0000000000000517DOI Listing
January 2021

Feasibility and Preliminary Effects of Implementing Acceptance and Commitment Therapy for Inpatients With Psychotic-Spectrum Disorders in a Clinical Psychiatric Intensive Care Setting.

J Cogn Psychother 2020 01;34(1):80-96

Alpert Medical School of Brown University.

The aim of this study was to adapt Acceptance and Commitment Therapy for Inpatients (ACT-IN) for implementation in a typical hospital setting to prepare for a larger clinical trial. The sample consisted of 26 inpatients diagnosed with psychotic-spectrum disorders. Using an open trial design, patients received individual and group ACT-IN sessions during their stay. We assessed the feasibility/acceptability of ACT-IN and preliminary changes on patient outcomes at baseline, discharge, and 4-month follow-up. We successfully recruited and retained participants as planned. Patients reported satisfaction with treatment, and routine hospital staff showed adoption and fidelity to the intervention. Relative to baseline, patients demonstrated significant improvements in symptoms and functioning across the 4-month follow-up. The current study shows that ACT-IN may be feasible and acceptable for inpatients with psychotic disorders in a psychiatric intensive care setting and should be tested in a future effectiveness-implementation trial.
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http://dx.doi.org/10.1891/0889-8391.34.1.80DOI Listing
January 2020

Development and Initial Testing of an mHealth Transitions of Care Intervention for Adults with Schizophrenia-Spectrum Disorders Immediately Following a Psychiatric Hospitalization.

Psychiatr Q 2021 03;92(1):259-272

Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, 02912, USA.

An important period in the care of patients with schizophrenia-spectrum disorders is when they transition from inpatient to outpatient services and are at increased risk for relapse and rehospitalization. Thus, we developed and examined the initial feasibility, acceptability, and clinical effects of an mHealth transitions of care intervention (Mobile After-Care Support; MACS) in an open trial. Ten adults with schizophrenia-spectrum disorders were recruited during their index psychiatric hospitalization and enrolled prior to discharge. Measures of feasibility, acceptability, and MACS targets were administered at baseline and a 1-month follow-up. Drawing on skills from Cognitive Behavioral Therapy for Psychosis (CBTp), MACS delivered brief assessments of clinically relevant variables, followed by just-in-time interventions for patients starting immediately post-discharge. Individuals completed about one session per day on average as expected. Overall, measures of MACS usability and satisfaction were positive. T-test analyses showed that dysfunctional coping strategies significantly decreased from baseline to 1-month follow-up. Results also revealed statistically significant reductions in psychiatric symptoms over 1-month follow-up. This study demonstrates the feasibility and acceptability of MACS, a new app-based intervention targeting transitions of care for patients with psychosis. The field is turning to the use of mobile technology as a means of augmenting service delivery and providing real-time assessment and intervention for patients at risk. MACS is a promising adjunctive intervention that warrants further testing in a randomized controlled trial.
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http://dx.doi.org/10.1007/s11126-020-09792-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775867PMC
March 2021

An adapted Delphi approach: The use of an expert panel to operationally define non-judgment of internal experiences as it relates to mindfulness.

Complement Ther Med 2020 Jun 17;51:102444. Epub 2020 May 17.

Alpert Medical School of Brown University, United States; Brown University School of Public Health, United States.

Objectives: There are several definitions of mindfulness throughout the literature, many of which suggest an attitude of non-judgmental awareness. However, the concept of "non-judgment" itself has not previously been systematically operationally defined. Our purpose was to use an expert panel to generate an operational definition of non-judgment of internal experiences, as it relates to mindfulness, to be used to inform the development of an implicit measure of the construct.

Design: We utilized an adapted Delphi survey method consisting of three survey rounds.

Setting: We employed in-person and online survey methods.

Results: We used three survey rounds with an adapted Delphi approach. Expert review panelists consisted of 18 mindfulness researchers or clinicians. Each round of survey results was assessed and discussed among the core team. A consensus was reached among the core team for an operational definition of non-judgment of internal experiences: "acknowledging our thoughts, feelings, and sensations, as they are, without applying valence (e.g., good, bad, right, wrong) to them."

Conclusions: An expert panel review process informed the generation of an operational definition of non-judgment of internal experiences. Our operational definition provides a foundation for the future development of an implicit task of non-judgment of internal experiences, with the aim of using this task to assess change in response to mindfulness-based treatments. To our knowledge, this is the first systematic definition of non-judgment of internal experiences within the mindfulness literature.
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http://dx.doi.org/10.1016/j.ctim.2020.102444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299277PMC
June 2020

Using ecological momentary assessment for patients with psychosis posthospitalization: Opportunities for mobilizing measurement-based care.

Psychiatr Rehabil J 2021 Mar 16;44(1):43-50. Epub 2020 Apr 16.

Department of Psychiatry and Human Behavior.

Objective: Ecological momentary assessment (EMA) via mobile devices offers a promising approach for collecting real-time data from psychiatric patients, potentially as an augment to traditional measurement-based care strategies. This study examined whether EMA had added value in collecting clinically important data from recently hospitalized adults with psychosis, relative to traditional assessments.

Method: In a sample of 24 adults with psychosis, EMA data regarding psychotic symptoms, affect, alcohol and drug use, functioning, quality of life, and social support were collected starting immediately posthospital discharge and extending for up to one month during their transition to outpatient care. EMA data were compared with traditional retrospective assessments of the same constructs, administered at a 1-month follow-up assessment.

Results: Data from EMA and traditional retrospective assessments were correlated with each other in most cases. However, in some cases, participants were more likely to report drug use, medication nonadherence, and psychotic symptoms via EMA compared with traditional retrospective assessments.

Conclusions And Implications For Practice: Results suggest that the additional information obtained via frequent in-the-moment self-reports collected using smartphones can provide an expanded picture of individuals' symptomatic and functional experiences. Thus, monitoring patients' progress posthospitalization could be improved through the use of EMA. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8415125PMC
March 2021

Pilot randomized controlled trial of a video self-help intervention for depression based on acceptance and commitment therapy: Feasibility and acceptability.

Clin Psychol Psychother 2020 May 28;27(3):396-407. Epub 2020 Feb 28.

Psychosocial Research Program, Butler Hospital, Providence, Rhode Island.

A common setting where depression is identified and treated is in primary care, where there is a need for low-intensity and cost-effective interventions to be used as part of a stepped-care model. The current study involved a pilot, parallel-group, randomized controlled trial of a video self-help intervention for primary care patients based on acceptance and commitment therapy (ACT). The intervention, called LifeStories, consisted of storytelling vignettes of patients describing their use of ACT-consistent coping skills for depression. Primary care patients were recruited to determine feasibility, acceptability, and potential clinical effects of the intervention. Twenty-one participants were assigned to use LifeStories over a period of 4 weeks, and 19 participants were assigned to an attention-matched comparison group. Qualitative feedback indicated that participants using LifeStories found the intervention to be engaging and useful in transmitting key ACT principles. Furthermore, those receiving LifeStories rated their level of "transportation" or immersion in the videos higher than the control group. Both conditions showed large improvements in levels of depression at a 12-week follow-up. There were no significant differences in symptom outcomes between groups; however, because this was a pilot study, it was not powered to detect differences between interventions. Both conditions additionally showed smaller effect size changes in psychological flexibility, a key ACT mechanism. The results suggest LifeStories to be a feasible and acceptable psychological intervention that may improve depression, and further research is warranted to determine its effectiveness as part of a stepped-care approach to treating depression in primary care.
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http://dx.doi.org/10.1002/cpp.2436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322697PMC
May 2020

Corrigendum to 'Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: Pilot result' [Behaviour Research and Therapy 44 (2006) 415-437].

Behav Res Ther 2020 Jan 23;124:103534. Epub 2019 Dec 23.

Office of the President, University of New England, 11 Hills Beach Rd., Biddeford, ME, 04005, USA.

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http://dx.doi.org/10.1016/j.brat.2019.103534DOI Listing
January 2020

Corrigendum to 'Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: Pilot result' [Behaviour Research and Therapy 44 (2006) 415-437].

Behav Res Ther 2020 Jan 23;124:103534. Epub 2019 Dec 23.

Office of the President, University of New England, 11 Hills Beach Rd., Biddeford, ME, 04005, USA.

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http://dx.doi.org/10.1016/j.brat.2019.103534DOI Listing
January 2020

Predictors of 30-day rehospitalization in a sample of hospitalized patients with Bipolar I disorder.

Psychiatry Res 2019 11 7;281:112559. Epub 2019 Sep 7.

Warren Alpert Medical School of Brown University, Department of Psychiatry & Human Behavior, Box G-BH, Providence, RI 02912, USA; Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA.

The transition from psychiatric hospitalization to home is marked by high clinical vulnerability, characterized by risk of symptom rebound, exposure to preexisting stressors, and challenges with outpatient treatment linkage. Rates of rehospitalization during this post-discharge period, particularly for those with bipolar disorder, are reported to be high. This study evaluated demographic and clinical predictors of early rehospitalization (within 30 days) in a sample of hospitalized adults with Bipolar I disorder (BD-I). A chart review was conducted for 215 patients with BD-I admitted to an academically-affiliated psychiatric hospital within one calendar year. A computer algorithm was used to extract relevant demographic, clinical, and treatment information. Univariate and multivariate logistic regression models were used to examine predictors of early rehospitalization. Overall, 12% of participants were readmitted within 30 days of discharge. Controlling for other clinical and demographic variables, patient functioning and pre-admission psychiatric polypharmacy, but not comorbid psychiatric diagnoses, predicted early readmission in patients with BD-I. Findings highlight the relative importance of considering low psychosocial functioning, and medication regimens containing multiple psychiatric medications, during hospitalizations. These features may indicate a subset of patients with BD-I who require more comprehensive discharge planning and support to transition to the community following a psychiatric hospitalization.
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http://dx.doi.org/10.1016/j.psychres.2019.112559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924623PMC
November 2019

Impact of causal explanations for social anxiety disorder on stigma and treatment perceptions.

J Ment Health 2020 Feb 9;29(1):84-91. Epub 2019 Feb 9.

Butler Hospital/Brown University Warren Alpert School of Medicine, Providence, RI, USA.

: There is evidence to suggest that biogenetic explanations for symptoms of mental disorders have become increasingly popular. Research suggests that such explanations provokes mixed blessings: biological explanations may reduce blame but also encourage prognostic pessimism and promote perceptions of pharmacological treatment over psychotherapy. The goal of this study was to evaluate the impact of different causal explanations on social anxiety disorder.: About 205 adults completed an experiment where they read a vignette describing an individual with social anxiety disorder and were randomly assigned to a symptom explanation that was: (1) biological, (2) biopsychosocial, (3) psychosocial, or (4) no explanation.: The psychosocial condition yielded the highest perceived credibility and lowest attributions of blame. The biological condition promoted positive expectations for medication effectiveness compared to other conditions. Conditions did not differ on prognostic expectations.: Calls attention to the risk of generalizing from previous research to mental disorders as a whole.
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http://dx.doi.org/10.1080/09638237.2018.1487543DOI Listing
February 2020

Time-lagged predictors of daily medication nonadherence beliefs during the month post-hospital discharge in patients with psychotic-spectrum disorders.

Psychiatry Res 2018 12 21;270:253-256. Epub 2018 Sep 21.

Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA.

We used ecological momentary assessment (EMA) to examine the period following hospitalization when risk for medication nonadherence is highest among patients with psychotic-spectrum disorders. EMA data were collected daily via smartphones from 23 patients with psychotic-spectrum disorders (totaling 1149 surveys) in the month immediately following discharge. Nonadherence beliefs significantly correlated with percentage of medication doses. Time-lagged increases in irritability, sadness, life dissatisfaction, functional impairment, and previous day missed medication dose predicted subsequent increases in nonadherence beliefs over time. Future research should study mobile interventions that target the factors found to predict nonadherence beliefs to improve post-hospital recovery.
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http://dx.doi.org/10.1016/j.psychres.2018.09.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292726PMC
December 2018

Comorbid Cannabis and Tobacco Use Disorders in Hospitalized Patients with Psychotic-Spectrum Disorders.

J Dual Diagn 2018 Jul-Sep;14(3):171-180. Epub 2018 Sep 28.

a Butler Hospital, Psychosocial Research Program, Providence , Rhode Island , USA.

Objective: Individuals with psychotic-spectrum disorders use tobacco and cannabis at higher rates than the general population and individuals with other psychiatric disorders, which may contribute to increased rates of medical problems and mortality. The present study examined whether individuals with psychosis and comorbid tobacco and/or cannabis use disorders exhibit differing clinical characteristics in terms of their sociodemographic, mental health, substance use, physical health, and medication use patterns. Elucidation of these profiles, and determining their relative severity, has important implications for treatment, including offering more targeted interventions based on type of comorbidity pattern.

Methods: We examined the electronic medical records of 829 patients with psychotic-spectrum disorders admitted to a psychiatric hospital and categorized them as having: (1) cannabis use disorder (CUD); (2) tobacco use disorder (TUD); (3) comorbid cannabis and tobacco use disorders (CUD + TUD); or (4) neither disorder (no CUD/TUD). Multinomial logistic regression was used to compare the aforementioned groups on multiple variables controlling for age and sex.

Results: Alcohol and stimulant use disorder diagnoses were each related to higher odds of having a CUD and CUD + TUD, relative to no CUD/TUD. Stimulant and polysubstance use disorder diagnoses were each related to higher odds of having a TUD compared to no CUD/TUD. Greater number of prescribed psychotropic medications was related to higher odds of a TUD compared to no CUD/TUD.

Conclusions: Although several differences between groups were accounted for by age of cannabis versus tobacco users, findings point to the importance of considering comorbid alcohol and substance use disorders among those with psychosis and CUD/TUD, as these comorbidities have important implications for screening and treatment selection during and following acute hospitalization.
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http://dx.doi.org/10.1080/15504263.2018.1470359DOI Listing
September 2019

Experiential Avoidance and Mood State in Bipolar Disorder.

J Cogn Psychother 2018 Jun;32(2):88-96

Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Experiential avoidance (EA) has been linked to various negative psychological outcomes and is believed to play a key role in many forms of psychopathology. While EA has been studied in the context of depression, anxiety, posttraumatic stress disorder, and other diagnoses, this study is the first to investigate the role of EA in bipolar disorder (BD). Eight participants in treatment for BD answered questions about mood state and EA twice per day for 60 days, using an ecological momentary assessment (EMA) design. Within-person hierarchical linear modeling analyses revealed that EA was negatively correlated with mood. Although EA did not predict subsequent mood, the reverse was true; EA increased following reports of blunted positive mood. Clinical implications, study limitations, and future research directions are discussed.
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http://dx.doi.org/10.1891/0889-8391.32.2.88DOI Listing
June 2018

Complex Polypharmacy in Patients With Schizophrenia-Spectrum Disorders Before a Psychiatric Hospitalization: Prescribing Patterns and Associated Clinical Features.

J Clin Psychopharmacol 2018 Jun;38(3):180-187

Background: Current evidence-based guidelines provide unclear support for many common polypharmacy practices in schizophrenia. Excessive or complex polypharmacy (≥4 psychotropics) has been studied in patients with bipolar disorder, but not in schizophrenia to date.

Methods: We conducted a digital medical record data extraction of 829 patients consecutively admitted to a psychiatric hospital and diagnosed as having schizophrenia-spectrum disorders.

Results: In those prescribed psychiatric medication preadmission, 28.1% (n = 169) met the criteria for complex polypharmacy. Complex polypharmacy patients were older, female, white, and disabled, and had more comorbidities compared with those without complex polypharmacy. In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy patients.

Conclusions: Although there is little evidence to support complex polypharmacy in schizophrenia, rates were relatively high in patients requiring hospitalization, especially when they are also diagnosed as having comorbid psychiatric and medical conditions. Future research is needed to study the risk-benefit profile for these patients, especially considering their higher medical burden and related health risks.
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http://dx.doi.org/10.1097/JCP.0000000000000876DOI Listing
June 2018

Development of a Storytelling Video Self-Help Intervention Based on Acceptance and Commitment Therapy for Major Depression: Open Trial Results.

Behav Modif 2019 01 1;43(1):56-81. Epub 2017 Nov 1.

1 Butler Hospital, Providence, RI, USA.

This study involved the initial development and testing of a video self-help intervention called LifeStories, which features real patients describing their use of coping strategies for depression based on Acceptance and Commitment Therapy. We conducted a baseline-controlled open trial (AB design) of 11 individuals diagnosed with major depressive disorder. Participants reported high levels of satisfaction and transportation (i.e., engagement) after watching LifeStories. No significant changes were observed during the 4-week baseline period in terms of interviewer-rated depression severity (primary outcome), but a significant and large effect size improvement was observed at Week 8 postintervention. The majority of participants (54.5%) showed a reliable and clinically significant posttreatment response. Significant improvements also were observed during the intervention period only for self-reported depressive symptoms and aspects of mindfulness (nonreactivity). Qualitative data analysis of participant interviews identified additional areas for improvement and refinement. Future testing in a randomized trial is warranted based on these encouraging results.
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http://dx.doi.org/10.1177/0145445517738932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624846PMC
January 2019

Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement.

Behav Res Ther 2017 10 29;97:259-272. Epub 2017 May 29.

Department of Psychology, University of Nevada, Reno, NV 89557-0062, USA.

Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.
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http://dx.doi.org/10.1016/j.brat.2017.05.016DOI Listing
October 2017

Acceptance and Commitment Therapy for Inpatients with Psychosis (the REACH Study): Protocol for Treatment Development and Pilot Testing.

Healthcare (Basel) 2017 May 5;5(2). Epub 2017 May 5.

Butler Hospital, Providence, RI 02906, USA.

Patients with schizophrenia-spectrum disorders frequently require treatment at inpatient hospitals during periods of acute illness for crisis management and stabilization. Acceptance and Commitment Therapy (ACT), a "third wave" cognitive-behavioral intervention that employs innovative mindfulness-based strategies, has shown initial efficacy in randomized controlled trials for improving acute and post-discharge outcomes in patients with psychosis when studied in acute-care psychiatric hospitals in the U.S. However, the intervention has not been widely adopted in its current form because of its use of an individual-only format and delivery by doctoral-level research therapists with extensive prior experience using ACT. The aim of the Researching the Effectiveness of Acceptance-based Coping during Hospitalization (REACH) Study is to adapt a promising acute-care psychosocial treatment for inpatients with psychosis, and to pilot test its effectiveness in a routine inpatient setting. More specifically, we describe our plans to: (a) further develop and refine the treatment and training protocols, (b) conduct an open trial and make further modifications based on the experience gained, and
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http://dx.doi.org/10.3390/healthcare5020023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5492026PMC
May 2017

Valued Living and Its Relationship to Medication Adherence in Patients with Bipolar and Comorbid Substance Use Disorders.

J Nerv Ment Dis 2017 03;205(3):178-181

*Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University; †Psychosocial Research, Butler Hospital, Providence, RI; and ‡Department of Psychology, Lafayette College, Easton, PA.

Bipolar disorder with comorbid substance abuse is associated with high rates of treatment nonadherence. Adherence interventions developed to date have had mixed effects in this population. Valued living (i.e., the consistency between a patient's personal values and daily actions) represents a potentially useful treatment target that may improve adherence. We investigated the relationship between valued living, medication adherence, symptoms, and functioning in a sample of 39 patients diagnosed with bipolar disorder and a comorbid substance use disorder. Results showed that greater values-action consistency explained a unique amount of variance (R change = 15.2%) in medication adherence even after controlling for symptom severity, functional impairment, and other reported reasons for nonadherence. Drug use and treatment beliefs also predicted nonadherence. Findings suggest that valued living should be investigated further as a potentially malleable treatment target in future adherence intervention research.
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http://dx.doi.org/10.1097/NMD.0000000000000533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327790PMC
March 2017

Feasibility and acceptability of post-hospitalization ecological momentary assessment in patients with psychotic-spectrum disorders.

Compr Psychiatry 2017 04 7;74:204-213. Epub 2017 Feb 7.

Department of Psychiatry and Behavioral Sciences. University of Washington, Seattle, WA 98195 USA.

Background: Up to 50% of patients with psychotic-spectrum disorders are medication nonadherent. The use of real-time assessment via ecological momentary assessment (EMA) on mobile devices might offer important insights into adherence behaviors that cannot be measured in the clinic. However, existing EMA studies have only studied acutely ill patients during hospitalization or more stable patients in the community.

Methods: Feasibility and acceptability of EMA in 65 patients with psychotic-spectrum disorders who were recently discharged from the hospital were assessed. EMA was administered for four weeks via study-provided mobile devices. Feasibility was measured by study recruitment/retention rates, patients' connectivity, and completion rates. Quantitative and qualitative acceptability data were collected.

Results: Participants completed 28-31% of offered EMA assessments. The only significant predictor of reduced EMA completion was recent cannabis use. EMA completion was maintained from weeks 1 to 3 but significantly dropped at the fourth week. Patient acceptability feedback was generally positive; negative comments related primarily to technological problems.

Conclusions: This was the first study to use EMA in recently discharged patients with psychotic-spectrum disorders. EMA is feasible and acceptable in this population, but completion rates were lower than in more stable samples. Future research should consider limiting the assessment period, screening for substance use, and integrating assessment with intervention elements to increase EMA engagement.
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http://dx.doi.org/10.1016/j.comppsych.2017.01.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369417PMC
April 2017

An Open Trial of a Smartphone-assisted, Adjunctive Intervention to Improve Treatment Adherence in Bipolar Disorder.

J Psychiatr Pract 2016 11;22(6):492-504

WENZE: Department of Psychology, Lafayette College, Easton, PA, and Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI ARMEY, WEINSTOCK, GAUDIANO, and MILLER: Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, and Psychosocial Research Program, Butler Hospital, Providence, RI.

We evaluated the feasibility and acceptability of a novel, 12-week, adjunctive, smartphone-assisted intervention to improve treatment adherence in bipolar disorder. Eight participants completed 4 in-person individual therapy sessions over the course of a month, followed by 60 days of twice-daily ecological momentary intervention (EMI) sessions, with a fifth in-person session after 30 days and a sixth in-person session after 60 days. Perceived credibility of the intervention and expectancy for change were adequate at baseline, and satisfaction on completion of the intervention was very high. Participants demonstrated good adherence to the intervention overall, including excellent adherence to the in-person component and fair adherence to the smartphone-facilitated component. Qualitative feedback revealed very high satisfaction with the in-person sessions and suggested a broad range of ways in which the EMI sessions were helpful. Participants also provided suggestions for improving the intervention, which primarily related to the structure and administration of the EMI (smartphone-administered) sessions. Although this study was not designed to evaluate treatment efficacy, most key outcome variables changed in the expected directions from pretreatment to posttreatment, and several variables changed significantly over the course of the in-person sessions or during the EMI phase. These findings add to the small but growing body of literature suggesting that EMIs are feasible and acceptable for use in populations with bipolar disorder.
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http://dx.doi.org/10.1097/PRA.0000000000000196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5119543PMC
November 2016

Feasibility and challenges of inpatient psychotherapy for psychosis: lessons learned from a veterans health administration pilot randomized controlled trial.

BMC Res Notes 2016 Jul 30;9:376. Epub 2016 Jul 30.

Serious Mental Illness Treatment Resource and Evaluation Center, VA Office of Mental Health Operations, Ann Arbor, MI, USA.

Background: In large health care systems, decision regarding broad implementation of psychotherapies for inpatients with psychosis require substantial evidence regarding effectiveness and feasibility for implementation. It is important to recognize challenges in conducting research to inform such decisions, including difficulties in obtaining consent from and engaging inpatients with psychosis in research. We set out to conduct a feasibility and effectiveness Hybrid Type I pilot randomized controlled trial of acceptance and commitment therapy (ACT) and a semi-formative evaluation of barriers and facilitators to implementation.

Findings: We developed a training protocol and refined an ACT treatment manual for inpatient treatment of psychosis for use at the Veterans Health Administration. While our findings on feasibility were mixed, we obtained supportive evidence of the acceptability and safety of ACT. Identified strengths of ACT included a focus on achievement of valued goals rather than symptoms. Weaknesses included that symptoms may limit patient's understanding of ACT. Facilitators included building trust and multi-stage informed consent processes. Barriers included restrictive eligibility criteria, rigid use of a manualized protocol, and individual therapy format. Conclusions are limited by our randomization of only 18 patient participants (with nine completing all aspects of the study) out of 80 planned.

Conclusions: Future studies should include (1) multi-stage informed consent processes to build trust and alleviate patient fears, (2) relaxation of restrictions associated with obtaining efficacy/effectiveness data, and (3) use of Hybrid Type II and III designs.
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http://dx.doi.org/10.1186/s13104-016-2179-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967502PMC
July 2016

A Randomized Survey of the Public's Expectancies and Willingness to Participate in Clinical Trials of Antidepressants Versus Psychotherapy for Depression.

Prim Care Companion CNS Disord 2016;18(1). Epub 2016 Feb 25.

McLean Hospital/Harvard Medical School, Belmont, Massachusetts.

Background: Expectancies and treatment preferences are known to affect the outcomes of patients enrolled in clinical trials for depression, but there is little research on their influence when the public is considering participation in these trials.

Method: We conducted an online survey (May 2013) in which participants (N = 615) were randomly assigned to read hypothetical descriptions of clinical trials for depression based on 1 of the following study designs: medication versus placebo, medication versus medication, psychotherapy versus placebo, or psychotherapy versus psychotherapy. Afterward, individuals rated willingness to participate in the trial, logic and credibility of the treatments, and expected success and improvement in symptoms.

Results: There were no differences in expectancies for ratings of credibility and logic or success and improvement among clinical trial designs. However, self-reported willingness to participate in the study was rated significantly higher in the 2 psychotherapy trial designs (active-comparator and placebo-controlled) compared with the active-comparator medication design (P < .05). Psychiatric treatment history, general treatment preferences, and depression severity were positively correlated with willingness to participate primarily in the active-comparator medication design.

Conclusions: Consistent with the broader treatment preference literature, individuals reported a greater willingness to participate in psychotherapy compared with antidepressant studies. Thus, people's perceptions of different treatments are likely to influence not only the outcomes of clinical trials for depression but also decisions to participate in these trials in the first place.
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http://dx.doi.org/10.4088/PCC.15m01879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874763PMC
April 2018

A Randomized Survey of the Public's Expectancies and Willingness to Participate in Clinical Trials of Antidepressants Versus Psychotherapy for Depression.

Prim Care Companion CNS Disord 2016;18(1). Epub 2016 Feb 25.

McLean Hospital/Harvard Medical School, Belmont, Massachusetts.

Background: Expectancies and treatment preferences are known to affect the outcomes of patients enrolled in clinical trials for depression, but there is little research on their influence when the public is considering participation in these trials.

Method: We conducted an online survey (May 2013) in which participants (N = 615) were randomly assigned to read hypothetical descriptions of clinical trials for depression based on 1 of the following study designs: medication versus placebo, medication versus medication, psychotherapy versus placebo, or psychotherapy versus psychotherapy. Afterward, individuals rated willingness to participate in the trial, logic and credibility of the treatments, and expected success and improvement in symptoms.

Results: There were no differences in expectancies for ratings of credibility and logic or success and improvement among clinical trial designs. However, self-reported willingness to participate in the study was rated significantly higher in the 2 psychotherapy trial designs (active-comparator and placebo-controlled) compared with the active-comparator medication design (P < .05). Psychiatric treatment history, general treatment preferences, and depression severity were positively correlated with willingness to participate primarily in the active-comparator medication design.

Conclusions: Consistent with the broader treatment preference literature, individuals reported a greater willingness to participate in psychotherapy compared with antidepressant studies. Thus, people's perceptions of different treatments are likely to influence not only the outcomes of clinical trials for depression but also decisions to participate in these trials in the first place.
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http://dx.doi.org/10.4088/PCC.15m01879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874763PMC
April 2018

Clinical characteristics and medication use patterns among hospitalized patients admitted with psychotic vs nonpsychotic major depressive disorder.

Ann Clin Psychiatry 2016 Feb;28(1):56-63

Butler Hospital, Providence, Rhode Island, USA, Alpert Medical School of Brown University, Providence, Rhode Island, USA. E-mail:

Background: In routine practice, major depressive disorder (MDD) with psychotic features often goes under-recognized and undertreated. Previous research has specified several demographic and clinical differences in MDD patients with psychotic features compared with those without psychosis in routine outpatient practice, but there is little systematic research in modern routine hospital settings.

Methods: We conducted a retrospective electronic medical records chart review of 1,314 patients diagnosed with MDD who were admitted consecutively to a major psychiatric hospital over a 1-year period. We examined the prevalence of psychotic features in the sample and investigated the differences in demographic variables, clinical characteristics, and medication use patterns among patients with and without psychosis.

Results: The prevalence of psychotic features was 13.2% in the current hospital sample. Patients with psychotic depression were more likely to be older, male, a member of a racial/ethnic minority, and have more medical comorbidities and certain Axis I disorders compared with nonpsychotic patients. In addition, patients with psychotic depression were more likely to be prescribed antipsychotics and hypnotics before admission.

Conclusions: Several demographic and clinical characteristics differentiate MDD patients with psychosis from those without psychosis in hospital settings that may be helpful in identifying these patients. Comparisons with outpatient samples and treatments implications are discussed.
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February 2016

Demographic and clinical characteristics associated with comorbid cannabis use disorders (CUDs) in hospitalized patients with bipolar I disorder.

Compr Psychiatry 2016 Feb 23;65:57-62. Epub 2015 Oct 23.

Alpert Medical School of Brown University Department of Psychiatry and Human Behavior, Providence, RI, USA; Butler Hospital Psychosocial Research Program, Providence, RI, USA.

Background: Published data suggest that cannabis use is associated with several negative consequences for individuals with bipolar disorder (BD), including new manic episode onset, psychosis, and functional disability. Yet much less is known about cannabis use disorders (CUDs) in this population, especially in more acutely symptomatic groups.

Methods: To evaluate correlates of CUD comorbidity in BD, a retrospective chart review was conducted for 230 adult patients with bipolar I disorder (BDI) who were admitted to a university-affiliated private psychiatric hospital. Using a computer algorithm, a hospital administrator extracted relevant demographic and clinical data from the electronic medical record for analysis.

Results: Thirty-six (16%) had a comorbid CUD. CUD comorbidity was significantly associated with younger age, manic/mixed episode polarity, presence of psychotic features, and comorbid nicotine dependence, alcohol use disorder (AUD), and other substance use disorders, but was associated with decreased likelihood of anxiety disorder comorbidity. With the exception of manic/mixed polarity and AUD comorbidity, results from multivariate analyses controlling for the presence of other SUDs were consistent with univariate findings.

Conclusion: Patients with BD and comorbid CUDs appear to be a complex population with need for enhanced clinical monitoring. Given increasing public acceptance of cannabis use, and the limited availability of evidenced-based interventions targeted toward CUDs in BD, psychoeducation and other treatment development efforts appear to be warranted.
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http://dx.doi.org/10.1016/j.comppsych.2015.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4715863PMC
February 2016

The Promises and Challenges of Ecological Momentary Assessment in Schizophrenia: Development of an Initial Experimental Protocol.

Healthcare (Basel) 2015 Sep 15;3(3):556-73. Epub 2015 Jul 15.

Butler Hospital and Warren Alpert Medical School of Brown University, 345 Blackstone Blvd., Providence, RI 02906, USA.

Severe mental illnesses, including schizophrenia and other psychotic-spectrum disorders, are a major cause of disability worldwide. Although efficacious pharmacological and psychosocial interventions have been developed for treating patients with schizophrenia, relapse rates are high and long-term recovery remains elusive for many individuals. Furthermore, little is still known about the underlying mechanisms of these illnesses. Thus, there is an urgent need to better understand the contextual factors that contribute to psychosis so that they can be better targeted in future interventions. Ecological Momentary Assessment (EMA) is a dynamic procedure that permits the measurement of variables in natural settings in real-time through the use of brief assessments delivered via mobile electronic devices (i.e., smart phones). One advantage of EMA is that it is less subject to retrospective memory biases and highly sensitive to fluctuating environmental factors. In the current article, we describe the research-to-date using EMA to better understand fluctuating symptoms and functioning in patients with schizophrenia and other psychotic disorders and potential applications to treatment. In addition, we describe a novel EMA protocol that we have been employing to study the outcomes of patients with schizophrenia following a hospital discharge. We also report the lessons we have learned thus far using EMA methods in this challenging clinical population.
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http://dx.doi.org/10.3390/healthcare3030556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4683929PMC
September 2015

Acceptance-based Behavior Therapy for Depression With Psychosis: Results From a Pilot Feasibility Randomized Controlled Trial.

J Psychiatr Pract 2015 Sep;21(5):320-33

GAUDIANO, EPSTEIN-LUBOW, MILLER, BUSCH, and WENZE: Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI GAUDIANO, EPSTEIN-LUBOW, and MILLER: Psychosocial Research Program, Butler Hospital, Providence, RI BUSCH: The Miriam Hospital, Centers for Behavioral and Preventive Medicine, Providence, RI WENZE: Lafayette College, Easton, PA NOWLAN: University of North Carolina, Chapel Hill, NC.

Acceptance-based depression and psychosis therapy (ADAPT), a mindfulness/acceptance-based behavioral activation treatment, showed clinically significant effects in the treatment of depression with psychosis in a previous open trial. The goal of the current study was to further test the feasibility of ADAPT to determine the utility of testing it in a future clinical trial, following a stage model of treatment development. Feasibility was determined by randomizing a small number of patients (N=13) with comorbid depression and psychosis to medication treatment as usual plus enhanced assessment and monitoring versus ADAPT for 4 months of outpatient treatment. Both conditions were deemed acceptable by patients. Differences in between-subjects effect sizes favored ADAPT posttreatment and were in the medium to large range for depression, psychosocial functioning, and experiential avoidance (ie, the target mechanism). Thus ADAPT shows promise for improving outcomes compared with medications alone and requires testing in a fully powered randomized trial.
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http://dx.doi.org/10.1097/PRA.0000000000000092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4704101PMC
September 2015
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