Imagine a brighter future: Development of a school-based positive imagery intervention to target anhedonia in adolescents.

Children and Young People PhD Scholarship 2019 : Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London.

Supervisor: Jennifer Lau, Victoria Pile

Lay Summary:

Depression is common, distressing and costly. Depression that starts in youth is associated with worse outcomes. Yet many young people with depression face difficulties accessing treatments. This project aims to develop an intervention that encourages positive future thinking, as a way to uplift positive mood, in young people with high levels of depression. Learning how to deploy this effectively in youth could be a valuable and empowering experience. To assess how possible it is to administer our intervention, we will gather data on how many young people (their schools and parents) are willing to take part in the research, how many complete the intervention, how helpful they find it, whether they respond negatively, and areas for improvement. These data are a first necessary step for assessing whether this intervention would be acceptable and safe in this population before we can plan larger studies in the future. Consistent with the views of many young people and teachers, our intervention is designed to be easily deliverable in a school environment by a practitioner without the need for extensive clinical training.

Research Student Student: Taryn Hutchinson

Hi, I’m Taryn. I started my PhD at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London in October 2019, under the supervision of Dr Jennifer Lau, Dr Katherine Young and Dr Victoria Pile.

Prior to starting my PhD, I completed my MSc in Clinical and Health Psychology at the University of Manchester, my PGCert for Evidence-Based Psychological Treatments (IAPT Pathway) at the University of Reading and my BSc in Psychology at the University of Exeter. During this time, I also worked as a Psychological Wellbeing Practitioner in two Child and Adolescent Mental Health Services. The majority of my clinical experience has been working with young people experiencing difficulties with depression, anxiety and emotion regulation and delivering evidence-based interventions to young people and their parents. I thoroughly enjoy working with young people and am passionate about furthering the development of early-intervention support for them. From my experiences, I have seen the challenges that young people face in accessing early mental health support and the barriers they can be up against in getting treatment from more specialist services. I am therefore delighted to be a part of this project, which aims to develop a school-based intervention for anhedonia in depression, and I am thoroughly enjoying this opportunity. I would like to thank Mental Health Research UK for funding this fantastic opportunity.

Scientific goal: The goal of the project is to develop a brief, manualised intervention for adolescent depression that targets anhedonia through harnessing the ability to imagine positive events. This intervention is designed to be delivered in the school environment by practitioners without extensive training. A case series and a feasibility randomised controlled trial will be conducted by the doctoral student in the proposed project to assess the acceptability of this intervention in schools.

Progress Report Year 4, 2023

IMAGINE-Positive Intervention

Following completing the case series for our positive mental imagery intervention, IMAGINE-Positive, I analysed the results and wrote up the findings, which I have now submitted for publication:

Hutchinson, T., Lau, J., Smith, P., & Pile, V. [Submitted] Targeting anhedonia in adolescents: A single case series of a positive imagery-based early intervention

For the next phase of the project, we had originally planned to conduct a feasibility randomised controlled trial, however unfortunately due to several logistical challenges and the delays due to the COVID-19 pandemic, it would not have been possible to finish this study in the time remaining in my PhD. Whilst this was initially disappointing, with support from my supervisors we designed another study which I believe still valuably contributes to this project and my overall thesis. We decided to extend the findings of our first case series study, by conducting qualitative interviews with participants who completed IMAGINE-Positive, across two schools in London. We hoped to understand participants’ perspectives of the barriers and facilitators to accessing IMAGINE-Positive in schools, and what they perceive to be the active ingredients of the intervention. I have analysed the findings from this study and written them up. These two studies will be the final empirical chapters of my thesis. I would like to thank Mental Health Research for supporting me with a travelcard which allowed me to commute to the schools in London for both of these studies.

COVID-19 online survey:

Using the data that we collected from an online survey investigating how young people were managing their emotions during the COVID-19 pandemic, I explored the role of future mental imagery in young people’s symptoms of depression, specifically negative affect and anhedonia. In our first paper, I explored these associations in young people, predominately based in the UK, at one time point. Earlier this year this paper was published in Cognitive Therapy and Research:

Hutchinson, T., Riddleston, L., Pile, V., Meehan, A., Shukla, M., & Lau, J. (2023). Is Future Mental Imagery Associated with Reduced Impact of the COVID-19 Pandemic on Negative Affect and Anhedonic Symptoms in Young People? Cognit Therapy and Research, 47(2), 168-180. https://doi.org/10.1007/s10608-023-10352-1

In the second paper from this study, I aimed to extend our previous findings in a different population, adolescents from Israel, and across time. I have submitted this paper for publication:

Hutchinson, T., Riddleston, Lavi, R., L., Pile, V., Meehan, A., Shukla, M., & Lau, J. [Submitted] Does prospective mental imagery predict symptoms of negative affect and anhedonia in young people?

These two studies will form the first two empirical chapters of my thesis.

Conferences:

In September 2022, I presented our findings from the online COVID-19 surveys as part of a symposium at the European Association for Behavioural and Cognitive Therapies conference in Barcelona. I was very grateful to have been awarded a Conference Travel grant from the IoPPN Psychology Department (£500) and the Centre for Doctoral Studies (£200) at King’s College London, which enabled me to attend this conference.

In July 2023, I presented our findings from the case series study in a symposium at the International Conference on Early Intervention in Mental Health (IEPA14) in Lausanne, Switzerland. I was again very grateful to have been awarded a Conference Travel grant from the IoPPN Psychology Department (£1000) at King’s College London, in order to attend this conference.

Plans for the future:

I am currently finalising the write up of my thesis and aim to submit at the beginning of September, with my viva hopefully in November 2023. I have been very fortunate to gain a place on the Doctorate of Clinical Psychology at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, and will begin my training in October 2023. I am very grateful to Mental Health Research UK for the opportunity to undertake this PhD and the skills and experiences that I have gained along the way, all of which I believe have helped me toward the next stage of my career. It has been a privilege to be a part of the Mental Health Research UK community between the scholars, trustees, volunteers and supporters and I would like to wish everyone the best for the future. I would also like to thank my supervisors, Professor Jennifer Lau, Dr Victoria Pile and Dr Patrick Smith, for their on-going support during this PhD. It’s been a truly wonderful experience to work with them and I would not have been able to navigate this journey without them.

Progress Report year 3, 2022

IMAGINE-Positive Intervention

Case series:

Although two years later than initially planned (due to the COVID-19 pandemic), I am pleased to report that I have completed the case series for IMAGINE-Positive. In March 2021, we attempted to complete the case series online, but unfortunately due to on-going school closures and difficulties with online recruitment, we were unable to complete it. In March 2022, we were able to recruit and deliver the intervention in person, as originally planned. 10 young people started the intervention and 8 completed it. The purpose of the case series was to refine the intervention ahead of the feasibility randomised controlled trial (RCT). Feedback from the participants has been positive and most participants said they would recommend the intervention to a friend. I am currently writing up our findings from the case series and plan to submit this paper for publication.

Feasibility Randomised Controlled Trial (RCT):

We are due to start recruitment for the feasibility RCT in September 2022. The purpose of this trial is to investigate whether it is feasible and acceptable to deliver IMAGINE-P in a school setting, compared to a control intervention. We will also be collecting pilot data on clinical measures for symptoms of depression and anhedonia, as well as on measures for the proposed underlying mechanisms (e.g. vividness of mental imagery and memory specificity). We are aiming to recruit 32 participants. Once recruitment has finished, I plan to write up the findings for publication, as well as for my thesis.

COVID-19 online survey:

In response to the COVID-19 pandemic in 2020, we developed on online survey that investigated how young people, aged 12-25 years, were manging their emotions during lockdown. We teamed up with researchers around the world, including the UK, India, Israel and Nepal, and asked young people to complete surveys every two weeks, over a 16-week period (up to a total of 8 surveys). My collaborators and I have begun publishing some of our findings from these surveys and I have been working on two papers exploring the role of mental imagery in symptoms of depression in young people, as explained below:

Cross-sectional paper:

The first paper investigated the simultaneous relationships between the vividness of negative and positive future mental imagery and symptoms of depression, specifically negative affect (the low mood symptoms of depression) and anhedonia (the loss of pleasure and enjoyment symptoms of depression). We also explored whether negative and positive future imagery changed the way stress of COVID-19 impacted young people’s symptoms of depression. 2602 young people completed this survey and we found that increased vividness of negative future imagery and reduced vividness of positive future imagery were associated with increased negative affect, whereas only reduced vividness of positive future imagery were associated with increased symptoms of anhedonia. Increased vividness of negative future images amplified the relationship between stress associated with COVID-19 and negative affect, while increased vividness of positive future images reduced the association between stress associated with COVID-19 and anhedonia. These results are important because if we can understand how negative and positive future mental imagery are differentially associated with negative affect and anhedonia, we may be able to target novel mechanisms in psychological treatments for young people. A limitation of this paper, however, is that because it only focuses one data from one time point, we cannot determine the directions of these relationships identified, i.e., whether vividness of imagery leads to these symptoms or whether these symptoms of depression change the vividness of imagery. We are therefore writing a second paper that looks at these relationships across time using the data from our follow-up surveys. This cross-sectional paper has been submitted for publication.

Longitudinal paper:

In this paper, we wanted to explore the relationships between negative future imagery and negative affect and positive future imagery and anhedonia over time. Using data from survey 1 (Time 1) and survey 8 (Time 8) from our Israel population, we found that correlations between negative future imagery and negative affect; and positive future imagery and anhedonia, were significant over time. However, when all of these variables were put into the same model these relationships were no longer significant. I am now in the process of writing this paper and plan to submit it for publication soon.

Conferences:

In September 2022, I will be presenting our findings from the COVID-19 online surveys as part of a symposium at the European Association for Behavioural and Cognitive Therapies conference in Barcelona.

Plans for the fourth year of my PhD:

Complete the feasibility RCT
Write up my thesis and submit

I would like to thank Mental Health Research UK and my supervisors, Jennifer Lau, Victoria Pile and Patrick Smith, for another year of great support, particularly during these challenging times.

Progress Report year 2, 2021

Anhedonia intervention

Case series:

Following the first national lockdown due to COVID-19, I worked with my supervisors to adapt the IMAGINE-PA therapy manual for online delivery via video-conferencing. Initially, we hoped this would be a straightforward adaptation that could help with recruitment, such as by potentially allowing us to deliver the intervention during the summer holidays. However, the unpredictable nature of the pandemic and several logistical challenges meant that recruitment for the case series was delayed longer than we hoped. Despite these challenges, I have learnt a lot of lessons on how to facilitate online recruitment, screening, and intervention delivery, as well as ways to manage potential challenges in the future. Positively, we were able to start recruitment in May 2021 and no doubt, the experiences I have had so far will be valuable for when we begin recruitment in September 2021. Positively, we have been able to maintain relationships with schools/ colleges who are interested in the project and willing to participant in the future when circumstances are right for them.

Thesis chapter:

I have started writing a chapter of my thesis on the recruitment strategy for IMAGINE-PA. In this chapter, I detail the methods of recruitment (including study advertisement) and success rate (in terms of how many schools expressed interest versus took up the intervention), as well as the practical challenges that have impeded recruitment thus far. The purpose of this chapter is to serve a rationale for the recruitment strategy moving forward, to ensure recruitment is as efficient as possible by building on the lessons learnt previously.

Narrative Review:

With my supervisors, I have been writing a narrative review on the treatments for anhedonia in depression. As the literature on this topic is extremely broad, I have been working with my supervisors on how to define treatments for anhedonia in depression, to decide which studies to include and exclude. I have selected and written about the treatments that are in the scope of my review and have identified approaches that these treatment use to target anhedonia. The next step in my review is to investigate experimental studies using these approaches to understand which underlying mechanisms these approaches may target.

COVID-19 online survey

In response to the COVID-19 pandemic, my supervisor and I developed an online survey with international collaborators in the UK, India, Israel and Nepal to investigate how young people were managing their emotions during lockdown. We invited participants to complete the survey up to 8 times, over a 16-week period, and we finished data collect in December 2020. Over 3000 young people completed the baseline survey. With this data I have been working on my first paper, which has been exploring the role of future mental imagery in adolescent depression, particularly the relationships with positive and negative future imagery and negative affect and anhedonia. This has been incredibly exciting to write up, as currently (in comparison to adult studies) there is little research into the role of mental imagery in adolescent depression. I am due to submit this paper for publication very soon and already have plans for a second paper exploring the relationships between positive and negative future imagery and negative affect and anhedonia using the longitudinal (8 surveys) data. In this paper, I may also look at the role of other cognitive predictors (e.g., attentional control and positive reappraisal) in adolescent depression. I also hope to write a third paper exploring any cross-cultural differences with the data that my collaborators in Israel and India collected. Whilst this study was born out of disruptions to my original project due to COVID-19, it has given me the opportunity to collect important data in a large sample that I otherwise would not have collected, and I am grateful to Mental Health Research UK and my supervisors for supporting me with this research.

Conferences

In May 2020, I attended the MQ Mental Health Science Summit which was held virtually. I submitted a poster abstract of my research on future mental imagery and adolescent depression during COVID-19 and was fortunate to be offered the opportunity to display my poster at the two poster sessions of the conference. Using a platform called ‘Spatial Chat’, I was able to interact with fellow researchers in near enough the same was as you would in person by virtually moving myself to different posters. This was my first time presenting my PhD research at a conference, so it was a wonderful experience to be able to share my research and get feedback from fellow researchers.

Plans for the third year of my PhD:

Write my second paper using the longitudinal data from the COVID-19 survey data
Continue recruitment for the case series
Begin recruitment for the RCT
Complete the narrative review

Progress Report Year 1, 2020

During the first year of my PhD, I have been working on a number of exciting projects including: developing the therapy manual for our intervention to treat anhedonia in adolescent depression, preparing for the case series to fine tune the intervention, starting a systematic review of treatments for anhedonia and conducting an online survey of how young people are managing their emotions over time during the COVID-19 pandemic.

Anhedonia intervention:

Therapy manual:

With my supervisors, Dr Jennifer Lau and Dr Victoria Pile, I have been adapting our existing manual which uses mental imagery techniques to treat adolescent depression (IMAGINE), to focus on treating anhedonia more specifically by increasing positive emotions using positive future imagery. To distinguish these two interventions, we have titled this new intervention IMAGINE-PA, which stands for IMAGINE targeting positive affect. Anhedonia is thought to be caused by problems with the system that regulates positive emotions (positive affect), so the purpose of this intervention is to increase positive affect using positive future mental imagery. We have chosen this technique as a review of existing research suggests that generating positive future mental images may be more beneficial for increasing positive emotions than just talking about positive future events. Furthermore, using imagery techniques is thought to be developmentally appropriate for adolescents, as this is a time of rapid brain development. The intervention consists of four sessions and will be delivered to young people aged 16-18. Dr Pile and I presented an overview of the intervention at the Young People's Mental Health Advisory Group and, positively, the young people were interested in the intervention and reported it was not something they had received before.

Case series:

The purpose of the case series is to get you people’s feedback on the intervention and make any necessary changes ahead of a randomised controlled trial (RCT). The RCT which will compare the effectiveness of IMAGINE-PA with a control intervention. For the case series, we will only deliver IMAGINE-PA to 10 young people. I was due to start recruitment from a local school in March 2020 but unfortunately due to COVID-19, the schools shut as the country went into lockdown. Fast forward four months, I have now amended the therapy manual for delivery via videoconferencing and am hoping to recruit a school for delivery of the intervention over the summer holidays.

Systematic review:

Treatments into anhedonia (lack of positive affect) specifically are relatively new compared to traditional interventions for depression, which tend to focus on sadness and low mood (negative affect). The aim of the systematic review is to identify and evaluate existing treatments for anhedonia in depression. So far, I have identified my research question and defined my inclusion and exclusion criteria of which studies to include in the review. I am now working on what search terms I will use to find the relevant papers.

COVID-19 online survey:

As the intervention was originally developed to be delivered in schools, we feared that I may have to wait until at least September to begin the case series. Consequently, we used this opportunity to develop an online survey investigating how young people, aged 12-25, are managing their emotions during lockdown, as research suggests that young people can be particularly vulnerable to mental health problems as a result of quarantine. We are particularly interested in what strategies young people are using to stay resilient during the pandemic and are asking participants to complete a survey every two weeks over a 16 week period (8 surveys in total). A grant received from Rosetrees Trust has allowed us to reimburse UK-based participants for their time and effort. We have joined up with researchers around the world (including Germany, India, Israel and Nepal) to see how young people around the world are managing their emotions. So far, we have over 1000 participants from the UK taking part. We look forward to being able to share our findings with you in the future.

Three Minute Thesis Competition (3MT)

In April 2020, I entered the Institute of Psychiatry, Psychology and Neuroscience heat for the 3MT competition. Much to my surprise (but also joy) I won the heat and took part in the King’s 3MT Grand Final. Though I was very nervous, it was a really great opportunity to learn about the fascinating research that is being done at KCL in a variety of subject areas. It was a fantastic opportunity to consolidate all the work I had been doing and bring it all together in a short presentation that other people felt was accessible and easy to understand.

Plans for the second year of my PhD:

· Complete the case series and fine tune the intervention

· Analyse the data from the COVID-19 online survey and write it up

· Register the systematic review with Prospero and complete it

· Begin recruitment for the RCT