Effects of behavioural activation with and without citalopram on emotional cognition and mood

大量研究文献表明，抑郁症患者在他们的自动认知过程中往往倾向于负面刺激。例如，抑郁症与相对增加对消极词语和面部表情的注意和记忆有关(Roiser&Sahakian，2013)，以及在健康样本中发现的对模糊刺激的积极偏见的减少(Milders等人，2010年)。证据表明，这些偏见不仅是一种偶然现象，而且可能是抑郁症发病的危险因素(Joormann，Talbot，&Gotlib，2007)以及复发的可能预测因素(Bouhuys，Geerts&Gordijn，1999)。重要的是，这些自动偏见的积极变化与抗抑郁药物治疗的早期阶段有关(Harmer等人，2003)。Harmer，Goodwin和Cowen(2009)提出了抗抑郁药物机制的认知神经心理学模型，根据该模型，情绪刺激的自动处理的早期变化发生在情绪的有意识变化之前。与此相一致的是，Tranter et al.(2009)发现证据表明，在药物治疗两周时，面部表情识别自动偏向的早期变化可能预示着六周后的治疗成功。然而，尚不清楚为什么这种情感偏见的早期变化并不适用于每个人，而且许多人对一线抗抑郁药治疗没有反应。(2017)，药物治疗引起的情感偏差的早期认知变化有望与积极的环境强化相互作用，最终改善情绪。如果积极的环境强化是必要的，以与药物诱导的积极偏见相互作用，从而增强药物疗效，这可以解释患者对抗抑郁药物反应的差异。事实上，有几条证据表明了环境强化在抗抑郁治疗中的重要性。例如，Shiroma等人。(2014)发现，在接受抗抑郁药物治疗后，社会支持水平较高的患者的积极偏见增加更大。这也与动物研究的证据一致，在动物研究中，环境更好的动物对抗抑郁药物表现出更好的反应，以及更高的脑源性神经营养因子水平(Branchi等人，2006年)。据我们所知，抗抑郁效果和环境强化之间的相互作用还没有在人体上进行实验测试。DPHIL的目的是使用行为激活(BA)检测环境强化对认知偏差的作用，包括添加和不添加抗抑郁药物治疗。这是一种NICE推荐的抑郁症治疗方法(国家健康与护理卓越研究所，[NICE]，2009)，旨在通过帮助患者在感到有动力之前重新开始被放弃的活动来增加他们的活动和环境回报。这是通过活动监测、循序渐进的目标设定和教练式的支持的结构化方案实现的。第一项研究的目的是测试BA干预对情绪认知和情绪的早期影响。我们的目标是招募90名参与者，并将他们随机分为1)4周BA，2)4周活动监测(主动控制组)或3)被动对照组，同时收集干预开始、中期和结束时的数据。DPhil的第二个实验将联合BA和抗抑郁药物治疗2周，以检验其对认知偏差的早期影响。我们的目标是招募120名患有抑郁症的参与者，并将他们随机分为四组(BA使用抗抑郁药物，BA使用安慰剂，仅使用抗抑郁药物和仅使用安慰剂)。总体而言，这应该有助于我们理解不同抑郁症治疗类型中早期认知变化的开始。

A body of research literature has shown that patients with depression tend to have a bias towards negative stimuli in their automatic cognitive processes. For example, depression is linked to a relative increase in attention to and memory for negative words and facial expressions (Roiser & Sahakian, 2013) as well as a decrease in the positive bias for ambiguous stimuli that is found in healthy samples (Milders et al., 2010). Rather than just being an epiphenomenon, evidence suggests that these biases might play a causal role by being a risk factor for depression onset (Joormann, Talbot, & Gotlib, 2007) as well as a possible predictor of relapse (Bouhuys, Geerts & Gordijn, 1999).Importantly, positive changes in these automatic biases have been linked to the early phase of antidepressant drug treatment (Harmer et al., 2003). Harmer, Goodwin and Cowen (2009) have proposed a cognitive neuropsychological model of antidepressant drug mechanism whereby early changes in automatic processing of emotional stimuli occur before conscious changes in mood. In line with this, Tranter et al. (2009) found evidence that early changes in the automatic bias for facial expression recognition at two weeks of drug treatment may be predictive of treatment success at six weeks. However, it is not clear why this early change in affective bias does not occur for everyone and many people don't respond to their first line antidepressant treatment.As suggested by Harmer et al. (2017), the early cognitive changes in affective bias induced by drug treatment are expected to interact with positive environmental reinforcement to eventually improve mood. If positive environmental reinforcement is necessary for interacting with the drug-induced positive bias and thus potentiating drug efficacy, this could explain variability in how patients respond to antidepressant drugs. Indeed, several lines of evidence suggest the importance of environmental reinforcement in antidepressant treatment. For instance, Shiroma et al. (2014) found that increase in positive bias after antidepressant administration was greater in patients with higher levels of social support. This is also consistent with evidence from animal research wherein animals in better environments show a better response to antidepressant drugs, as well as higher brain BDNF levels (Branchi et al., 2006). To our knowledge, the interaction between antidepressant effects and environmental reinforcement has not been experimentally tested in humans. The aim of this DPhil is to examine the role of environmental reinforcement on cognitive biases with and without added antidepressant treatment, using behavioural activation (BA). This is a NICE-recommended depression treatment (National Institute of Health and Care Excellence, [NICE], 2009), which aims to increase patients' activity and environmental reward by helping them get back to abandoned activities before they feel motivated for it. This is achieved through a structured programme of activity monitoring, gradual goal setting and coach-like support. The purpose of the first study is to test the early effects of a BA intervention on emotional cognition and mood. We aim to recruit 90 participants and randomise them into either 1) 4 weeks of BA, 2) 4 weeks of activity monitoring (active control group) or 3) passive control group, while collecting data at the beginning, middle and end of the intervention. The second experiment of this DPhil will combine BA with antidepressant drug treatment for 2 weeks to examine the early effects on cognitive biases. We aim to recruit 120 participants experiencing depression and randomise them into four groups (BA with antidepressants, BA with placebo, antidepressants alone and placebo alone). Overall, this should aid our understanding of the onset of early cognitive changes in different depression treatment types.