Although an evidence-based treatment for most types of mental illness has been developed, there is substantial room for improvement. The effect sizes of most available treatments are small to moderate, gains may not persist, and there are too many patients who derive little or no benefit. Even under optimal conditions, treatment failure is alarmingly common.
Traditionally the development of psychological treatments has involved consensus between groups of skilled clinician researchers and many medication treatments have been discovered by serendipity. Hence, there have been calls for ‘increased attention to science’ in the treatment development process (Aronson, 2005; Insel, 2009; Salkovskis, 2002).
We have a 15-year track record in treatment development research. We are currently running NIH-funded treatment research: for teens who are ‘night owls’ (go to bed late and wake late), adults with severe mental illness and adults with depression. Our collaborators include Dan Buysse (Pittsburgh), Steve Hollon (Vanderbilt) Amy Kilbourne (Michigan), Steve Hinshaw (UC Berkeley), Qing Zhou (UC Berkeley), Susan Michie (University College, London), Greg Clarke (Kaiser, Oregon), Charles Morin (University Laval, Quebec), Tom Neylan (UCSF) and Emily Ozer (UC Berkeley).
Our approach to treatment development is to use a multi-systems and mechanisms-focused framework in which (a) cognitive, affective, biological, behavioral and developmental contributors are emphasized as the source for deriving novel interventions and (b) intervention research is used to develop hypotheses about and/or confirm mechanisms.
A theme that runs across all our research is a deep interest in the Science of Behavior Change: https://commonfund.nih.gov/behaviorchange
Treatment development teams often need to take on the challenge of retooling in the emerging flourishing science of dissemination and implementation (D&I) to ensure the investments made in developing new treatments can be accessed by the people who most need them. Indeed, over the past decade we have been developing expertise in D&I via an R01 treatment study based in a CMHC (RO1MH105513). Also, Dr. Harvey was very fortunate to participate in the Training Institute for Dissemination and Implementation Research in Health (TIDIRH) in 2017 conducted by the National Cancer Institute. We are particularly interested in collaborating with community mental health centers, which are major publicly funded providers of services to individuals with a severe mental illness.
Harvey, A. C. & Gumport, N. B. (2015). Evidence-based psychological treatments for mental disorders: modifiable barriers to access and possible solutions. Behavior Research and Therapy, 68, 1-12.
Harvey, A.G., Hein, K., Dong, L., Smith, F.L., Lisman, M., Yu, S., Rabe-Hesketh, S., & Buysse, D.J. (2016). A transdiagnostic sleep and circadian treatment to improve severe mental illness outcomes in a community setting: study protocol for a randomized controlled trial. Trials, 17, 606.
Our interest in transdiagnostic processes arose as we worked across a range of mental disorders. We were so struck by the similarities in the processes that maintain different disorders. These so-called ‘transdiagnostic processes’ refer to processes that are in common across more than one mental illness. The potential advantages of studying, and intervening on, transdiagnostic processes are at least threefold. First, if a transdiagnostic process contributes to the maintenance of symptoms across multiple disorders, then one powerful approach is to focus treatment on that process rather than on the large number of discrete disorders currently listed in the DSM. Second, comorbidity among mental illness is the norm. Hence, a significant clinical dilemma is which disorder/s to prioritize for treatment. Targeting treatment at a transdiagnostic process provides one path forward. Third, a transdiagnostic approach may reduce the heavy burden on clinicians, who must learn multiple disorder-focused protocols, with common theoretical underpinnings and interventions (Harvey et al., 2004). Indeed, this approach may help solve the ‘too many empirically supported treatments problem’ (p. 68) that impedes the dissemination and up-take of treatments (Weisz, Ng, & Bearman, 2014).
We have highlighted sleep and circadian problems as biologically and theoretically plausible transdiagnostic contributors to mental and physical health difficulties. Our ‘treatment experiments’ involve carefully devising a set of procedures to improve sleep and circadian functioning and observing if these procedures improve mental and physical outcomes. Over an iterative process spanning more than 15 years, this process of ‘devising a set of procedures’ has resulted in the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C). TranS-C has been used in the following two research programs.
- Sleep in Adults with a Serious Mental Illness (SMI). Dysregulated sleep and circadian rhythms are prominent transdiagnostic features of SMI. Previous treatments for comorbid sleep and psychiatric problems have been disorder-focused—they have treated specific sleep disorders (e.g., insomnia) comorbid with specific psychiatric diagnoses (e.g., major depression). However, real life disorders are not so neatly categorized. The goal of this research program is to test TranS-C for a wide range of sleep and circadian problems experienced by adults with a wide range of SMI. The hypothesis tested is that TranS-C will improve functional impairment, disorder-focused symptoms and sleep and circadian functioning. We are recruiting participants across DSM diagnoses and across common sleep and circadian problems.
- Adolescent ‘Night-Owls’. We noticed that a prevalent sleep problem that adolescents experience is a circadian phase that is delayed relative to societal norms. These evening chronotype (‘night-owl’) adolescents follow a delayed sleep-wake schedule, increasing mental and/or physical activity later in the day, compared to morning chronotypes (‘larks’). Indeed, the onset of puberty triggers an evening preference among approximately 40% of youth, which is compounded by social changes such as less parental control and access to technology. Eveningness, particularly among youth who have an early school start time, results in sleep deprivation. This is of concern because sleep is important for brain development. Eveningness is also important because there are well documented adverse consequences across emotional, cognitive, behavioral, social and physical domains.
We recently completed another ‘treatment experiment’ where we aimed to reduce eveningness in 176 10-18 year olds to determine if this reduces risk across emotional, cognitive, behavioral, social and physical domains. The method to reduce eveningness was the youth version of TranS-C. Consistent with our hypothesis, a Journal of the American Academy of Child and Adolescent Psychiatry paper reports that TranS-C is associated with improvement on selected sleep, circadian, and health outcomes, relative to Psychoeducation. In other words, at-risk youth who are ‘night-owls’ benefit, on selected sleep, circadian and health outcomes, from a short (6 session) psychosocial intervention. This study points to eveningness as an important contributor to risk in adolescence. Additional papers derived from this data are in preparation.
Inspired by this study, and supported by the NIH Science of Behavior Change Initiative, we are working on a new direction. Given that parents have profound impacts on teen risk and vulnerability. Yet parents receive minimal training in the elements of conversations that optimally inspire their children toward healthy behaviors. In the R21, I proposed to utilize a theoretically grounded and reliable taxonomy of behavior change techniques (BCTs) to scientifically derive the conversational elements, or micro-mechanisms, that reduce parent-teen coercion and conflict and facilitate upward spirals of healthy behavior change.
To read more take a look at:
Harvey, A. G. (2016). A Transdiagnostic Intervention for Youth Sleep and Circadian Problems. Cognitive and Behavioral Practice, 23, 341-355.
Harvey, A.G., & Buysse, D. J. (2017). Treating Sleep Problems: A Transdiagnostic Approach. New York: Guilford Press.
Clarke, G., McGlinchey, E., Hein, K., Gullion, C., Dickerson, J., Leo, M.C., & Harvey, A.G. (2015). Cognitive-Behavioral Treatment of Insomnia and Depression in Adolescents: A Pilot Randomized Trial. Behavior Research and Therapy, 69, 111-118.
Harvey, A. G., Hein, K., Dolsen, M. R., Dong, L., Rabe-Hesketh, S., Gumport, N. B., … & Smith, R. L. (2018). Modifying the impact of eveningness chronotype (“night-owls”) in youth: a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 57, 742-754.
Harvey, A.G., Watkins, E., Mansell, W. & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press.
This line of research arises from a long-term interest in memory and cognitive science. The specific idea was triggered by our clinical observation that patient memory for treatment can be poor. We were concerned that poor memory for treatment may contribute to poorer outcome. Consistent with these observations, we empirically established that memory for treatment is poor and that better recall for treatment is associated with better outcome. We also developed an intervention designed to improve memory for treatment. Distilled from the cognitive science and education literatures and based on carefully honed criteria, the Memory Support Intervention is comprised of eight powerful memory promoting strategies. Although this new intervention—the Memory Support Intervention—has potential to be added to a broad range of treatment types, such as psychosocial treatments and physician visits for medication management (‘pantreatment’) for a broad range of mental and physical disorders (‘transdiagnostic’), we are focusing on major depressive disorder (MDD) and cognitive therapy (CT) to create a ‘platform’ for the next step in investigating this approach.
To read more:
Zieve, G. G., Dong, L., & Harvey, A. G. (2019). Patient Memory for Psychological Treatment Contents: Assessment, Intervention, and Future Directions for a Novel Transdiagnostic Mechanism of Change. Behaviour Change, 1-11.
Harvey, A. G., Dong, L., Lee, J. Y., Gumport, N. B., Hollon, S. D., Rabe-Hesketh, S., … & Martinez, A. (2017). Can integrating the Memory Support Intervention into cognitive therapy improve depression outcome? Study protocol for a randomized controlled trial. Trials, 18(1), 539.
Dong, L., Lee, J. Y., & Harvey, A. G. (2017). Memory support strategies and bundles: A pathway to improving cognitive therapy for depression?. Journal of consulting and clinical psychology, 85(3), 187.