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Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention. To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life. Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873). The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress. The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.

Background Gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria experience social marginalization, discrimination and violence due to their sexual identity, which may negatively impact physical, mental, and sexual health outcomes. Studies on GBMSM in Africa utilize measurement scales developed largely for populations in the Global North. The validity and reliability of these instruments—to our knowledge—have never been thoroughly investigated among GBMSM in Nigeria. The aim of the current study was to determine the validity and reliability of the English versions of the Center for Epidemiologic Studies Depression Scale (CESD-R), Multidimensional Scale of Perceived Social Support (MSPSS), and LGBT Minority Stress Measure among a large multi-state sample of GBMSM Nigeria. Methods Between January and June 2019, we conducted cognitive interviews ( N  = 30) and quantitative assessments ( N  = 406) with GBMSM in Nigeria. The cognitive interviews assessed comprehension of scale items and elicited suggestions for scale modifications. The quantitative assessment was used to gather psychosocial health data and to evaluate psychometric properties and construct validity of the modified scales. We utilized confirmatory factor analysis to assess factor structure, correlation coefficients, and Cronbach’s alpha to examine scale validity and internal consistency. Results Based on participant feedback from the cognitive interviews, we made slight modifications (i.e., culturally appropriate word substitutions) to all three scales. Results of quantitative analyses indicated good psychometric properties including high factor loadings, internal consistency and construct validity among the CESD-R, MSPSS, and LGBT Minority Stress Measure among GBMSM in Nigeria. Conclusion These results suggests that modifying research scales to be more culturally relevant likely do not jeopardize their validity and reliability. We found that modified scales measuring depressive symptoms, perceived social support, and minority stress among GBMSM in Nigeria remained valid. More research is needed to explore whether the psychometric properties remain if the scales are translated into broken English (Pidgin) and other traditional Nigerian languages (Yoruba, Igbo and Hausa).

Abstract Introduction Most adolescent smokers report a desire to quit, and many have made several unsuccessful quit attempts; however, when adolescents attempt to quit, they often resume smoking quickly. This ecological study aimed to (1) characterize affective and situational precipitants of smoking lapses among adolescents and (2) explore the moderating influence of nicotine dependence severity on lapse precipitants. Methods Adolescent daily smokers (n = 166; ages 14–18 years) completed electronic diaries of cigarettes smoked, craving and affective states, and situational variables on handheld computers in their natural environment for 2 weeks following an unassisted quit attempt. On average, adolescents were moderately nicotine dependent (Modified Fagerström Tolerance Questionnaire [mFTQ] score = 4.9; SD = 1.6). Results Craving was a significant episodic cue for lapse and stable influence on lapse, relating to 44% and 15% increased odds of lapse, respectively. High-arousal affective states—regardless of valence—were associated with 12%–13% increased odds of lapse. Low-arousal positive affective states were associated with 17% decreased odds of lapse. A 1-unit difference in a teen’s mFTQ score related to 27% increased odds of lapse, but dependence severity did not moderate proximal lapse influences. Conclusions This report provides some of the first ecological data characterizing adolescent smoking lapses following a quit attempt. As in prior work with teens, lapses were nearly universal and quickly followed the quit attempt. Specific situational and affective contexts of smoking lapses for adolescents were implicated, indicating the need for cessation interventions to address craving and high-arousal affective states as precipitators of lapse in this high-risk group. Implications This report provides some of the first ecological data characterizing smoking lapses among teens attempting to quit smoking on their own. Like adults, adolescents face many barriers when making quit attempts. The present work provides ecological data to suggest that the experience of heightened arousal in teens’ daily lives interferes with their efforts to quit smoking. Thus, this work highlights the importance of affective dysregulation, or amplitude of emotional feelings, for teen smoking lapses. Moment-to-moment fluctuation in craving was also implicated as a dynamic precipitator of smoking lapse in this high-risk group.

Background Smoking cessation following hospitalization for Acute Coronary Syndrome (ACS) significantly reduces subsequent mortality. Depressed mood is a major barrier to cessation post-ACS. Although existing counseling treatments address smoking and depression independently in ACS patients, no integrated treatment addresses both. We developed an integrated treatment combining gold standard cessation counseling with behavioral activation-based mood management; Behavioral Activation Treatment for Cardiac Smokers (BAT-CS). The purpose of this pilot randomized controlled trial was to test feasibility, acceptability, and preliminary efficacy of BAT-CS vs. Standard of Care (SC). Methods Participants were recruited during hospitalization for ACS and were randomly assigned to BAT-CS or SC. The nicotine patch was offered in both conditions. Smoking, mood, and stress outcomes were collected at end-of-treatment and 24-week follow-up. Results Fifty-nine participants (28 BAT-CS, 31 SC) were recruited over 42 weeks, and assessment completion was above 80% in both conditions. Treatment acceptability and fidelity were high. At 24 week follow-up adjusted odds ratios favoring BAT-CS were 1.27 (95% CI: 0.41–3.93) for 7-day point prevalence abstinence and 1.27 (95% CI: 0.42–3.82) for continuous abstinence. Time to first smoking lapse was significantly longer in BAT-CS (62.4 vs. 31.8 days, p  = 0.03). At 24-weeks, effect sizes for mood and stress outcomes ranged from η 2 partial of.07–.11, with significant between treatment effects for positive affect, negative affect, and stress. Conclusions The design of this study proved feasible and acceptable. Results provide preliminary evidence that combining behavioral activation with standard smoking cessation counseling could be efficacious for this high risk population. A larger trial with longer follow-up is warranted. Trial registration NCT01964898 . First received by clinicaltrials.gov October 15, 2013.

IntroductionUnhealthy alcohol use is associated with a range of adverse outcomes among people with HIV (PWH). Testing the efficacy and promoting the availability of effective interventions to address unhealthy alcohol use among PWH is thus a priority. Alcohol use outcomes in intervention studies are often measured by self-report alone, which can lead to spurious results due to information biases (eg, social desirability). Measuring alcohol outcomes objectively through biomarkers, such as phosphatidylethanol (PEth), in addition to self-report has potential to improve the validity of intervention studies. This protocol outlines the methods for a systematic review and individual participant data meta-analysis that will estimate the efficacy of interventions to reduce alcohol use as measured by a combined categorical self-report/PEth variable among PWH and compare these estimates to those generated when alcohol is measured by self-report or PEth alone.Methods and analysisWe will include randomised controlled trials that: (A) tested an alcohol intervention (behavioural and/or pharmacological), (B) enrolled participants 15 years or older with HIV; (C) included both PEth and self-report measurements, (D) completed data collection by 31 August 2023. We will contact principal investigators of eligible studies to inquire about their willingness to contribute data. The primary outcome variable will be a combined self-report/PEth alcohol categorical variable. Secondary outcomes will include PEth alone, self-report alone and HIV viral suppression. We will use a two-step meta-analysis and random effects modelling to estimate pooled treatment effects; I2 will be calculated to evaluate heterogeneity. Secondary and sensitivity analyses will explore treatment effects in adjusted models and within subgroups. Funnel plots will be used to explore publication bias.Ethics and disseminationThe study will be conducted with deidentified data from completed randomised controlled trials and will be considered exempt from additional ethical approval. Results will be disseminated through peer-reviewed publications and international scientific meetings.PROSPERO registration numberCRD42022373640.

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use. The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP. In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data. Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site's content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website's esthetics to the participants' engagement with it and its credibility in prompting genuine reflection. GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

Nondaily smoking is a widespread and increasingly prevalent pattern of use. To date, no effective treatment approach for nondaily smoking has been identified. This study aimed to conduct an unblinded randomized controlled trial to evaluate proof-of-concept markers of the Smiling instead of Smoking (SiS) app, a smartphone app for smoking cessation, designed specifically for people who smoke less than daily, within the framework of positive psychology. Overall, 226 adults who smoke less than daily were recruited on the web and asked to undertake a quit attempt while using assigned smoking cessation support materials. Participants were randomly assigned to 1 of 3 materials: the SiS smartphone app, the National Cancer Institute's smartphone app QuitGuide (QG), or the National Cancer Institute's smoking cessation brochure, \"Clearing the Air\" (CtA). All participants engaged in a 15-minute scripted onboarding phone call and were introduced to their support materials to use for the next 7 weeks. Follow-up self-assessment web surveys were sent 2, 6, 12, and 24 weeks after participants' initially chosen quit date (ie, 1 week after onboarding). The primary outcome for this study was self-efficacy to remain abstinent from smoking at treatment end. Secondary outcomes assessed treatment acceptability, treatment feasibility (eg, number of days of app use, time spent using app, and use of smoking cessation strategies), and secondary proof-of-concept efficacy outcomes (eg, positive affect, craving, and attitudes toward smoking). Smoking outcomes (ie, 30-day point prevalence abstinence and smoking reduction) were also assessed. Results indicated a significant effect of treatment on the primary outcome, where SiS participants (n=80) reported higher self-efficacy to abstain from smoking at the end of treatment than the 2 control groups (QG: n=75; P=.02; Cohen d=0.40 and CtA: n=71; P=.007; Cohen d=0.50). This effect was also significant on both self-efficacy subscales (ie, internal cues and external cues) with effect sizes ranging from Cohen d=0.34 to 0.50 across the pairwise comparisons. The SiS app group also reported lower craving (QG: P=.005; Cohen d=-0.57 and CtA: P=.005; Cohen d=-0.57) and higher positive affect than QG (QG: P=.01; Cohen d=0.44 and CtA: P=.05; Cohen d=0.38); attitudes toward smoking were largely similar across groups. Treatment acceptability was comparable across groups (P values for all groups >.05; Cohen d range 0.06-0.23). Treatment feasibility measures indicated that participants used the SiS app on 33 out of 49 days, for 35 to 40 minutes per week, resulting in greater use of smoking cessation strategies than QG (QG: P=.04; Cohen d=0.38 and CtA: P=.16; Cohen d=0.24). These findings provide strong evidence for the conceptual underpinnings of the SiS app, and thereby provide compelling justification for conducting a large-scale randomized controlled trial that can test the effectiveness of the SiS app on smoking cessation. ClinicalTrials.gov NCT04672239; https://clinicaltrials.gov/study/NCT04672239. RR2-10.2196/40867.

Introduction A growing literature suggests that anhedonia-an affective dimension related to the inability to experience pleasure-is associated with poor smoking cessation outcomes. Despite these findings, research of the motivational mechanisms linking anhedonia and smoking has been limited. Accordingly, the present study examined (a) relationships between anhedonia and motivationally relevant smoking characteristics and (b) whether anhedonia moderated the effects of tobacco deprivation on appetitive and aversive aspects of smoking urges. Methods Smokers (N = 212; ≥5 cigarettes/day) first attended a baseline session during which measures of anhedonia and smoking characteristics were completed. Prior to a subsequent experimental session, a portion of participants were randomized to one of two groups: (a) 12-hr tobacco deprivation before the session (n = 51) and (b) ad libitum smoking (n = 69). Results Smokers with higher levels of anhedonia reported a greater number of past failed quit attempts and a higher proportion of quit attempts that ended in rapid relapse within 24 hr, rs > .20, ps < .05. Anhedonia did not consistently correlate with smoking heaviness, chronicity, and dependence motives. Anhedonia significantly moderated the influence of tobacco deprivation on appetitive smoking urges, such that deprivation effects on appetitive urges were stronger in high anhedonia smokers (β = .64) than in low anhedonia smokers (β = .23). Anhedonia did not moderate deprivation effects on aversive smoking urges. This pattern of results remained robust when controlling for baseline negative affect. Discussion These findings elucidate anhedonia's link with smoking relapse and could be useful for developing cessation interventions for anhedonic smokers.

Background:Smoking cessation smartphone apps have emerged as highly accessible tools to support smoking cessation efforts. It is unknown how specific app features contribute to user engagement over time and relate to smoking outcomes.Objective:To provide a feature-level analysis of the Smiling Instead of Smoking app (version 2) and to link feature use to subsequent smoking cessation.Methods:Nondaily smokers (N=100) used the app for a period of 49 days (1 week before quitting and 6 weeks after quitting). Participants self-reported 30-day point-prevalence abstinence at the end of this period and at a 6-month follow up (the survey response rate was 94% and 89% at these points, respectively). Self-reported 30-day point prevalence abstinence rates were 40% at the end of treatment and 56% at the 6-month follow up. The app engaged users in both positive psychology content and traditional behavioral smoking cessation content. The app sent push notifications to prompt participants to complete prescribed content (ie, a “happiness exercise” every day and a “behavioral challenge” to use the app’s smoking cessation tools on 15 out of 49 days). Actions that participants took within the app were timestamped and recorded.Results:Participants used the app on 24.7 (SD 13.8) days out of the 49 prescribed days, interacting with the happiness content on more days than the smoking content (23.8, SD 13.8 days vs 17.8, SD 10.3 days; t99=9.28 [2-tailed]; P<.001). The prescribed content was frequently completed (45% of happiness exercises; 57% of behavioral challenges) and ad libitum tools were used on ≤7 days. Most participants used each ad libitum smoking cessation tool at least once, with higher use of personalized content (≥92% used “strategies,” “cigarette log,” “smoke alarms,” and “personal reasons”) than purely didactic content (79% viewed “benefits of quitting smoking”). The number of days participants used the app significantly predicted 30-day point-prevalence abstinence at the end of treatment (odds ratio [OR] 1.05, 95% CI 1.02-1.09; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.008-1.07; P=.01). The number of days participants engaged with the happiness content significantly predicted smoking abstinence at the end of treatment (OR 1.05, 95% CI 1.02-1.08; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.007-1.07; P=.02). This effect was not significant for the number of days participants engaged with the smoking cessation content of the app, either at the end of treatment (OR 1.04, 95% CI 0.996-1.08, P=.08) or at the 6-month follow up (OR 1.02, 95% CI 0.98-1.06; P=.29).Conclusions:Greater app usage predicted greater odds of self-reported 30-day point-prevalence abstinence at both the end of treatment and over the long term, suggesting that the app had a therapeutic benefit. Positive psychology content and prescriptive clarity may promote sustained app engagement over time.Trial Registration:ClinicalTrials.gov NCT03951766; https://clinicaltrials.gov/ct2/show/NCT03951766

Recent evidence highlights the significant detrimental impact of nondaily smoking on health and its disproportionate prevalence in underserved populations; however, little work has been done to develop treatments specifically geared toward quitting nondaily smoking. This study aims to test the feasibility, acceptability, and conceptual underpinnings of version 2 of the Smiling Instead of Smoking (SiS2) smartphone app, which was developed specifically for nondaily smokers and uses a positive psychology approach. In a prospective, single-group study, nondaily smokers (N=100) were prescribed use of the SiS2 app for 7 weeks while undergoing a quit attempt. The app assigned daily positive psychology exercises and behavioral tasks every 2 to 3 days, which guided smokers through using the smoking cessation tools offered in the app. Participants answered surveys at baseline and at 2, 6, 12, and 24 weeks postquit. Feasibility was evaluated based on app use and acceptability based on survey responses. The underlying conceptual framework was tested by examining whether theorized within-person changes occurred from baseline to end of treatment on scales measuring self-efficacy, desire to smoke, and processing of self-relevant health information (ie, pros and cons of smoking, importance of the pros and cons of quitting, and motivation). Participants used the SiS2 app on an average of 24.7 (SD 13.8) days out of the 49 prescribed days. At the end of treatment, most participants rated the functions of the app as very easy to use (eg, 70/95, 74% regarding cigarette log and 59/95, 62% regarding happiness exercises). The average score on the System Usability Scale was 79.8 (SD 17.3; A grade; A+ ≥84.1, B+ <78.8). Most participants reported that the app helped them in their quit attempt (83/95, 87%), and helped them stay positive while quitting (78/95, 82%). Large effects were found for within-person decreases in the desire to smoke (b=-1.5, 95% CI -1.9 to -1.1; P<.001; g =1.01), the importance of the pros of smoking (b=-20.7, 95% CI -27.2 to -14.3; P<.001; g =0.83), and perceived psychoactive benefits of smoking (b=-0.8, 95% CI -1.0 to -0.5; P<.001; g =0.80). Medium effects were found for increases in self-efficacy for remaining abstinent when encountering internal (b=13.1, 95% CI 7.6 to 18.7; P<.001; g =0.53) and external (b=11.2, 95% CI 6.1 to 16.1; P<.001; g =0.49) smoking cues. Smaller effects, contrary to expectations, were found for decreases in motivation to quit smoking (P=.005) and the perceived importance of the pros of quitting (P=.009). Self-reported 30-day point prevalence abstinence rates were 40%, 56%, and 56% at 6, 12, and 24 weeks after the quit day, respectively. The SiS2 app was feasible and acceptable, showed promising changes in constructs relevant to smoking cessation, and had high self-reported quit rates by nondaily smokers. The SiS2 app warrants testing in a randomized controlled trial.