Centre for Clinical Interventions

BACKGROUND: Depression and anxiety disorders are common and treatable with cognitive behavior therapy (CBT), but access to this therapy is limited. OBJECTIVE: Review evidence that computerized CBT for the anxiety and depressive disorders is acceptable to patients and effective in the short and longer term. METHOD: Systematic reviews and data bases were searched for randomized controlled trials of computerized cognitive behavior therapy versus a treatment or control condition in people who met diagnostic criteria for major depression, panic disorder, social phobia or generalized anxiety disorder. Number randomized, superiority of treatment versus control (Hedges g) on primary outcome measure, risk of bias, length of follow up, patient adherence and satisfaction were extracted. PRINCIPAL FINDINGS: 22 studies of comparisons with a control group were identified. The mean effect size superiority was 0.88 (NNT 2.13), and the benefit was evident across all four disorders. Improvement from computerized CBT was maintained for a median of 26 weeks follow-up. Acceptability, as indicated by adherence and satisfaction, was good. Research probity was good and bias risk low. Effect sizes were non-significantly higher in comparisons with waitlist than with active treatment control conditions. Five studies comparing computerized CBT with traditional face-to-face CBT were identified, and both modes of treatment appeared equally beneficial. CONCLUSIONS: Computerized CBT for anxiety and depressive disorders, especially via the internet, has the capacity to provide effective acceptable and practical health care for those who might otherwise remain untreated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000030077.

BACKGROUND: A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice. METHODS: Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted. RESULTS: 64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials. LIMITATIONS: Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field. CONCLUSIONS: The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

BACKGROUND: Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential. AIMS: To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety. METHOD: A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7). RESULTS: Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms. CONCLUSIONS: The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.

BACKGROUND: Anorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum. METHOD: A triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions. RESULTS: The evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained. CONCLUSIONS: The review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

BACKGROUND: Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders. METHODS: The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper. RESULTS: A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms. CONCLUSION: Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N=218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.

OBJECTIVE: The aims of this study were to report 12-month and lifetime prevalence for anxiety disorders in the Australian general population, identify sociodemographic and clinical correlates of anxiety disorders, and report the rates of comorbidity among anxiety, affective, and substance use disorders across the lifespan. METHOD: The 2007 National Survey of Mental Health and Wellbeing was a nationally representative, face-to-face household survey of 8841 (60% response rate) community residents aged between 16 and 85 years. Diagnoses for anxiety, affective and substance use disorders were made according to the DSM-IV using the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. RESULTS: 12-month and lifetime prevalence of anxiety disorders were 11.8% and 20.0%, respectively. Anxiety disorders had a similar median age of onset (19 years) compared to substance use disorders (20 years), but earlier than affective disorders (34 years). Social phobia was the earliest onset anxiety disorder (median 13 years), with generalized anxiety disorder the latest (median 33 years). Significant correlates of the presence of anxiety disorders included being female, single, not in the labour force, in the middle age groups, not having post-graduate qualifications, having a comorbid physical condition, and having a family history of mental disorders. Being in the oldest age ranges and being born in another non-English speaking country were associated with lower odds of having an anxiety disorder. Body mass index was not associated with the presence of an anxiety disorder. Anxiety disorders were highly comorbid, particularly with major depression, dysthymia, and alcohol dependence. Comorbidity with substance use disorders reduced with age. Comorbidity with affective disorders was high across the lifespan. CONCLUSIONS: Anxiety disorders are common, can have an early onset, and are highly comorbid. Prevention, early detection, and treatment of anxiety disorders should be a priority.

OBJECTIVE: This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention. METHOD: A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted. RESULTS: Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up. DISCUSSION: The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required. © 2016 Wiley Periodicals, Inc.

BACKGROUND: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. METHOD: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. RESULTS: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. CONCLUSION: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

OBJECTIVE: The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence-based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework. METHOD: Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive-behavioral therapy for eating disorders (CBT-ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians. RESULTS: A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT-ED methods. DISCUSSION: Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence-based practice. These are shared to assist clinicians over the period of changed practice.

BACKGROUND: Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality. METHODS: This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review. RESULTS: Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates. CONCLUSION: Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

Abstract Mindfulness training has been proposed as a potentially important new approach for the treatment of generalized anxiety disorder (GAD). However, to date only a few studies have investigated mindfulness training for GAD. The aim of this study was to further investigate symptom change and recovery in pathological worry after mindfulness-based cognitive therapy (MBCT) using an uncontrolled pre-post design. Twenty-three adults with a primary diagnosis of GAD participated in the study. The MBCT program involved 9 weekly 2-hour group sessions, a post-treatment assessment session, and 6-week and 3-month follow-up sessions. Intent-to-treat analysis revealed significant improvements in pathological worry, stress, quality of life, and a number of other symptoms at post-treatment, which were maintained at follow-up. Attrition was also low, and MBCT was perceived as a credible and acceptable intervention. However, when applying standardized recovery criteria to pathological worry scores, the rate of recovery at post-treatment was very small, although improved at follow-up. Overall, the findings suggest MBCT is definitely worthy of further investigation as a treatment option for GAD, but falls well short of outcomes achieved by past research. Possible reasons for the poor rate of recovery, implications, and limitations are briefly outlined.

Panic disorder symptoms are persistent for 50-80% of cases even after treatment, resulting in experiences of disability and dissatisfaction in life. Previous research has focused on anxiety sensitivity (AS) and its dimensions as contributing to symptoms of panic disorder; however, recent research has suggested that intolerance of uncertainty (IU)-the tendency for a person to consider the possibility of a negative event occurring as threatening, irrespective of the actual probability of its occurrence-may also play a critical role. The current study was designed to assess the specific relationships between dimensions of IU (i.e. prospective IU and inhibitory IU) and the fear and avoidance symptoms associated with panic disorder. Participants included 122 community members (81% women) with a history of at least one panic attack who participated in a larger study on fear. Participants completed measures of AS, IU, and panic disorder symptoms. Correlation and regression analyses supported a significant and substantial relationship between AS, inhibitory IU, and panic disorder symptoms. Inhibitory IU accounted for relatively more variance in avoidance symptoms related to panic disorder than did the fears of physical sensations dimension of AS. As such, further investigation of the role of IU in panic disorder symptoms appears warranted. Comprehensive results, implications, and directions for future research are discussed.

Homework or between-session learning has long been considered an essential aspect of effective cognitive behaviour therapy. However, it has received relatively less empirical attention than other components of cognitive behaviour therapy. In general, studies have found that homework completion is predictive of outcome in psychotherapy. However, the amount of homework completed by a patient represents only one aspect of this important therapeutic component. This study investigated both the quantity and the quality of homework completed during a 10-week group cognitive and behavioural treatment program for anxious and depressed patients. It explored the relationship between various aspects of homework completion and outcomes on several different variables. A total of 94 patients were included in the analysis. It was found that both quantity and quality of homework completed predicted outcome on measures of depression, anxiety and quality of life at post-treatment and at 1-month follow-up. The results were strongest for the amount of homework completed, suggesting that clinicians should encourage patients to complete homework even if the homework content is not entirely accurate. The results of this study highlight the importance of homework as a central part of effective cognitive and behavioural treatment.

AIM: To investigate the effects of 60 minutes delivery room skin-to-skin contact (DR-SSC) compared with 5 minutes visual contact (VC) on mother-child interaction (MCI), salivary cortisol, maternal depression, stress and bonding at 6 months corrected age. METHODS: A single-centre randomized controlled trial conducted in a German level III NICU. Eighty-eight preterm infants (25-32 weeks of gestational age) were randomized after initial stabilization to either 60 minutes DR-SSC or 5 minutes VC. Forty-five infants were allocated to DR-SSC, 43 to VC. RESULTS: Delivery room skin-to-skin contact dyads showed a higher quantity of maternal motoric (18 vs 15, P = .030), infant's vocal (7 vs 5, P = .044) and motoric (20 vs 15, P = .032) responses. Moreover, the combined score of maternal and infant responsive behaviour was higher (86 vs 71, P = .041) in DR-SSC dyads. DR-SSC mothers had lower risk of both, early postpartum depression (15% vs 45%, P = .003) and impaired bonding (Score 3 vs 5, P = .031). CONCLUSION: In addition to regular intermittent kangaroo mother care, DR-SSC promotes MCI and decreases risk of maternal depression and bonding problems. Thus, DR-SSC may have positive effects on preterm development.

Intolerance of uncertainty (IU) has been most heavily implicated in the development and maintenance of generalised anxiety disorder; however, recent research has supported the transdiagnostic conceptualisation of IU by demonstrating that IU contributes to a broad array of symptoms associated with multiple anxiety and depressive disorders. The aim of this study was to examine IU firstly as a trait variable and secondly in reference to a regularly occurring, diagnostically relevant situation in a large clinical sample (N = 218). A measure of situation-specific IU (the Intolerance of Uncertainty Scale-Situation-Specific Version; IUS-SS) is presented. The IUS-SS was found to have a unitary factor structure and high internal consistency. Participants reported significantly more situation-specific IU compared to trait IU. Discriminant validity was indicated by lack of significant relationships with measures of extraversion and alcohol use. Supporting the convergent validity and transdiagnostic nature of the scale, the IUS-SS was positively associated with neuroticism and symptoms of generalised anxiety disorder and social phobia, and explained unique variance in symptoms of depression and panic disorder above and beyond trait IU. Theoretical and clinical implications are discussed.

Repetitive negative thinking (RNT) is an established transdiagnostic process associated with multiple emotional disorders. Brief transdiagnostic measures of RNT uncontaminated with diagnosis-specific symptoms, terminology, and instructions are required for (a) research investigating the process of RNT and (b) clinical practice to guide case formulations, treatment plans, and to assess change. The aim of this study was to examine the psychometric properties of a 10-item trait version of the Repetitive Thinking Questionnaire (RTQ-10) in undergraduate (N = 386) and clinical (N = 400) samples. The undergraduate sample completed the RTQ-10, and the clinical sample completed the RTQ-10 as well as measures of worry, rumination, anxiety- and depression-related cognitions, and positive and negative affect. Results demonstrated that the RTQ-10 has a unitary structure, high internal reliability, distinguishes between clinical and non-clinical cases, assesses RNT similarly in men and in women, and accurately assesses RNT along its full continuum. RTQ-10 scores were positively associated with worry and rumination, anxiety and depression symptoms and cognitions, and with the higher order vulnerability factor of negative affect, adding to its transdiagnostic credentials. The RTQ-10 was negatively but weakly associated with positive affect, providing some divergent validity. The RTQ-10 appears to be a brief and clinically useful transdiagnostic measure of RNT.

OBJECTIVE: To assess the factor structure of the Eating Disorder Examination (EDE) in three different samples and to compare the goodness-of-fit of five models of EDE data. METHOD: The EDE was administered to eating disordered (n = 158), treatment-seeking obese (n = 170) and non-eating disordered community-based (n = 329) participants. Confirmatory factor analysis was used to compare the validity of the original four-factor EDE model with that of three-, two-, and one-factor models. RESULTS: None of the tested models provided a "good fit" to the data in any sample, with the exception of a brief one-factor model in the eating disorder group. Estimations of internal consistency, reliability, and validity were superior for the one-, two-, and three-factor models compared to the four-factor model in all samples. DISCUSSION: Overall, there was more support for a one-factor model of EDE data than for a multi-factorial model. It may be more appropriate to use Global EDE scores than individual subscale scores for research purposes.

BACKGROUND: A recent paper reported the outcomes of a study examining a new self-guided internet-delivered treatment, the Wellbeing Course, for symptoms of anxiety or depression. This study found the intervention resulted in significant symptom reductions. It also found that automated emails increased treatment completion and clinical improvements in a subsample with elevated anxiety and depression. AIMS: To examine the clinical outcomes and the effect of automated emails at 12 months post-treatment. METHOD: Participants, who were randomly allocated to a Treatment Plus Automated Emails Group (TEG; n = 100), a standard Treatment Group (TG; n = 106) or delayed-treatment Waitlist Control Group (Control; n = 51), were followed up at 12 months post-treatment. Eighty-one percent, 78% and 87% of participants in the TEG, TG and treated Waitlist Control Group provided symptom data at 12-month follow-up, respectively. The primary outcome measures were the Patient Health Questionnaire-9 Item Scale (PHQ-9) and the Generalized Anxiety Disorder-7 Item Scale (GAD-7). RESULTS: Significant improvements in symptoms of anxiety and depression were observed over time in both the TEG and TG (Fs >69, ps <.001) these were sustained from post-treatment to 12-month follow-up (ps >.05), and were associated with large effect sizes. No statistically significant differences in symptoms were found between the TEG and TG at post-treatment, 3-month or 12-month follow-up. Previously reported symptom differences between TEG and TG participants with comorbid symptoms were no longer present at 12-month follow-up (ps >.70). CONCLUSIONS: The overall benefits of the Wellbeing Course were sustained at 12-month follow-up. Although automated emails facilitated Course completion and reductions in symptoms for participants with comorbid anxiety and depression from pre-post treatment, these differences were no longer observed at 12-month follow-up. The results indicate that automated emails promote more rapid treatment response for people with elevated and comorbid symptoms, but may not improve longer term outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.

Repetitive negative thinking (RNT) is a transdiagnostic process associated with numerous emotional disorders. Most measures of RNT are disorder-specific, limiting utility in comorbid populations. Transdiagnostic measures of RNT have been developed in adults and are associated with anxiety and depression. However, a transdiagnostic measure is needed to assess RNT in adolescents as a potential vulnerability factor for emotional disorders. This study validates a transdiagnostic measure of RNT—Repetitive Thinking Questionnaire–10 (RTQ-10)—in adolescents ( N = 840, M age = 15.7 years). Exploratory and confirmatory factor analyses supported a unidimensional structure. The RTQ-10 manifested good internal consistency and measurement invariance across genders and age. RNT was equally associated with anxiety and depression symptoms irrespective of gender or age. Convergent validity was demonstrated by correlations with disorder-specific measures of RNT. These findings support the RTQ-10 as a reliable and valid transdiagnostic measure of RNT in adolescents.