BackgroundWeb-based cognitive-behavioral therapeutic (CBT) apps have demonstrated efficacy but are characterized by poor adherence. Conversational agents may offer a convenient, engaging way of getting support at any time.ObjectiveThe objective of the study was to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression.MethodsIn an unblinded trial, 70 individuals age 18-28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) (n=34) or were directed to the National Institute of Mental Health ebook, “Depression in College Students,” as an information-only control group (n=36). All participants completed Web-based versions of the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Positive and Negative Affect Scale at baseline and 2-3 weeks later (T2).ResultsParticipants were on average 22.2 years old (SD 2.33), 67% female (47/70), mostly non-Hispanic (93%, 54/58), and Caucasian (79%, 46/58). Participants in the Woebot group engaged with the conversational agent an average of 12.14 (SD 2.23) times over the study period. No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly reduced their symptoms of depression over the study period as measured by the PHQ-9 (F=6.47; P=.01) while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7 (F1,54= 9.24; P=.004). Participants’ comments suggest that process factors were more influential on their acceptability of the program than content factors mirroring traditional therapy.ConclusionsConversational agents appear to be a feasible, engaging, and effective way to deliver CBT.

T. E. Joiner's (2004, in press) theory of suicidal behavior suggests that past suicidal behavior plays an important role in future suicidality. However, the mechanism by which this risk is transferred and the causal implications have not been well studied. The current study provides evaluation of the nature and limits of this relationship across 4 populations, with varying degrees of suicidal behavior. Across settings, age groups, and impairment levels, the association between past suicidal behavior and current suicidal symptoms held, even when controlling for strong covariates like hopelessness and symptoms of various Axis I and II syndromes. Results provide additional support for the importance of past suicidality as a substantive risk factor for later suicidal behavior.

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Objective-There are limited data supporting specific treatments for adults with anorexia nervosa (AN). Randomized Clinical Trials (RCTs) for adults with AN are characterized by high attrition limiting the feasibility of conducting and interpreting existing studies. High dropout rates may be relatedt to the inflexible and obsessional cognitive style of AN patients. This study evaluated the feasibility of using Cognitive Remediation Therapy (CRT) to reduce attrition in RCTs for AN.Method-Forty-six participants (mean age of 22.7 years and mean duration of AN of 6.4 years) were randomized to receive 8 sessions of either CRT or CBT over 2 months followed by 16 sessions of CBT for 4 months.Results-During the two month CRT vs. CBT treatment, rates of attrition were lower in CRT (13%) compared to CBT (33%). There were greater improvements in cognitive inefficiencies in the CRT compared to the CBT group at the end of two months. There were no differences in other outcomes.Conclusion-These results suggest that CRT is acceptable and feasible for use in RCTs for outpatient treatment of AN. CRT may reduce attrition in the short term. Adequately powered future studies are needed to examine CRT as an outpatient treatment for AN. Keywordsanorexia nervosa; cognitive remediation; treatment; cognitive flexibility; attention to detail Anorexia Nervosa (AN) is a serious psychiatric disorder associated with high morbidity, mortality, and cost.(1, 2) Unfortunately, no treatments for adults with AN have been shown to be effective in systematic randomized studies.(3) This may be because treatment studies of adults with AN are plagued with difficulties recruiting and retaining participants.(3, 4) Most attrition occurs within the first two months of treatment and may reflect a mismatch between therapist and patient goals, especially in treatments emphasizing weight gain and changing eating related cognitions.(5)(6) However, many clinicians and researchers attribute

Objective Adolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40–50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT. Method 45 adolescents (12 – 18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups. Outcomes There were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early. Conclusions The results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

Objective Deficits in executive function (EF) --including inhibitory control, cognitive flexibility, decision-making, and working memory--may be risk or maintenance factors for binge eating disorder (BED). However, there is mixed evidence regarding EF deficits in individuals with BED. Significant methodological weaknesses (e.g., use of a single EF measure, omission of relevant covariates) in the current literature represent one reason for lack of consensus. Methods The current study compared EF in a sample of overweight women with (n=31) and without (n=43) full or sub-threshold BED, with the aim of conducting a multi-faceted investigation of the neurocognitive profile of BED. A neuropsychological battery of EF was administered to all participants. Results After controlling for IQ and age, individuals with binge eating displayed significantly poorer performance on tasks of problem-solving and inhibitory control, and displayed higher prioritization of immediate versus delayed rewards, but the two groups did not appear to differ on set-shifting, working memory, and risk taking. Differences in inhibitory control were no longer statistically significant when depressive symptomology was added as a covariate and correction for multiple comparisons was applied. Exploratory analyses indicated that full and sub-threshold BED groups did not differ in EF. Discussion Results partially support the hypothesis of relative EF deficits in individuals with BED, suggesting that binge eating may be maintained by cognitive factors distinct from those of obesity. Future research should aim to replicate with a larger sample, control for a wider range of psychiatric comorbidities, and examine whether EF deficits predict treatment outcome.

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