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The Psychological Sequelae of the COVID-19 Pandemic: Psychological Processes, Current Research Ventures, and Preparing for a Postpandemic World

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Abstract

The novel coronavirus disease, also known as COVID-19, has brought upon a wave of unprecedented change, fear, and uncertainty. There is an urgent need to understand the factors and mechanisms implicated in the spread of COVID-19 and associated emotional distress. Likewise, establishing and mobilizing resources to manage the anticipated pervasive surge of mental health problems is of significant importance. To this end, the current paper presents an overview of psychological traits and mechanisms involved in the spread of infectious disease, as well as the development of mental health concerns. A summary of the current state of the literature on psychological processes related to COVID-19 and our ongoing research program aimed at addressing gaps in the literature is provided. The paper concludes with a discussion of the post-pandemic period and implications for the delivery of cognitive-behavioral therapy to combat the COVID-19-related psychological phenomena. Keywords: COVID-19, coronavirus, pandemic, psychology, cognitive-behavioral therapy
158 the Behavior Therapist
THENOVEL CORONAVIRUS disease, known
as COVID-19, arose in Wuhan, China in
December of 2019. As of May 4, 2020, the
virus has infected over 3.4 million people
and led to over 239,000 deaths globally
(WorldHealth Organization, 2020a), and
the numberscontinuetoriseexponentially.
The World Health Organization declared
COVID-19apandemic on March 11, 2020.
In response to the COVID-19 pandemic,
governments have imposedunprecedented
changes, such as closures of all nonessen-
tial business and mandated self-isolation.
Health officials have also recommended
social distancing, avoidance of crowded
areas, and increased hygiene practices in
attempt to reduce the spread of COVID-19
(World Health Organization, 2020b). The
magnitudeofthe situation is further high-
lighted by the unabating news and media
revolving around COVID-19.
As aconsequence of the threat of infec-
tion, life has become characterized by
financial uncertainty, fear, stress, and other
substantial lifestyle changes (e.g., social
withdrawal, isolation) that may increase
risk for mental health problems. Indeed,
emerging empirical evidence from China
indicates that greaterthan 25% of the gen-
eral populationare currently experiencing
moderate to severe levels of anxiety in
response to COVID-19 (Qiu et al., 2020;
Wang et al., 2020). Although the full scale
of the psychological impact is not yet
known,basedonobservationsfrom prior
pandemics (Shultz et al., 2008; Taylor,
2019a), it is anticipated to be larger than the
physical impact of the COVID-19 pan-
demic. Efforts directed at minimizing the
spread of COVID-19 and managing its
psychologicalsequelae are timely and crit-
ical.
While much remains unknown about
responses to COVID-19, existing research
on past global outbreaks (e.g., SARS, Ebola,
swine flu), which is reviewed in detail by
Taylor (2019a), may be relevantand infor-
mative in this regard. Empirical evidence
from previous pandemics indicates that
psychological factors play an instrumental
role in infectious disease mitigation, social
disorder,and vulnerability to mentalhealth
problems associated with pandemics
(Taylor, 2019a). Investigating psychologi-
cal factors influencing behavioral and emo-
tional responses to COVID-19 is, there-
fore, key to reducing the impact of
COVID-19.
The current paper is structured to pro-
vide an overview of the potential influence
of mediabroadcasting, psychological
mechanisms involved in diseaseavoidance,
and psychological traitspotentially impli-
cated in responses to COVID-19. These
factors are discussed in greater detail by
Taylor (2019a).Wethen describe current
psychologicalresearchonCOVID-19 and
ourongoingresearch program aimed at
addressing gaps in understanding of psy-
chological processes and traits that influ-
ence behaviors and emotional distress
related to COVID-19. To conclude, adis-
cussion of expectations for the postpan-
demic period and implications for the
delivery of CBT is provided.
TheRole of Media
People are being inundated with infor-
mation related to COVID-19 through news
and social media outlets. Indeed, the World
Health Organization(2020c)has described
the current state of the COVID-19 pan-
demic as a“massive infodemic.” Mass
media, through the use of emotionally
charged language and images, can have a
profound influence in exaggerating the
perceived dangers associated with infec-
tious disease (Kilgo et al., 2018: Muzzati,
2005). Consequently, the media may then
exacerbate individual inclinations towards
fear or indifference. While it is important
that the publicremain informed about the
pandemic (e.g., currentgovernment regu-
lations, public health recommendations
and actions), prolonged media exposure
can also lead to “media fatigue,” in which
individuals become desensitized to the
media and potentially disregard important
information (Collinson et al., 2015). Fur-
ther compounding the issue is the abun-
dance of misinformation that may cause
increasedanxiety as people may not know
which sources of information are reliable
(Taylor, 2019a).
Government communication through
the media during apandemic is apowerful
source of influence (Devakumar et al.,
2020). On the one hand, transparent and
clear messaging can relieve anxiety and
uncertainty by providing the public with
accurate and up-to-date information on
the state of the pandemic (Eaton &Kalich-
man, 2020; Taylor 2019a). On the other
hand, the use of xenophobic language,
inconsistent information, and suggestion
of governmentconspiracies has the poten-
tial togive rise to public fear and division.It
is of the utmost importance that govern-
ments carefully construct messages in
coordination with other officials to deliver
an effective, cohesive messagetothe public
on COVID-19 (Kapiri&Ross, 2020).
Behavioral Immune System
Due to the microscopicnatureofviral
pathogens, an individual’s biological
immune systemisonly reactive to infection
and insufficient to prevent infection
(Duncan&Schaller, 2009; Taylor, 2019a).
As such, the behavioral immune system
(BIS) has evolved to mobilize in response
to the threat of infection. The BIS is acom-
plex system involved in detecting and
responding to perceived indicators of the
presence of an infectious disease (e.g.,
someone coughing or sneezing; Ackerman
et al., 2018; Schaller&Park, 2011). The BIS
further elicits emotional reactions (e.g., dis-
gust, fear, anxiety) to facilitate behavioral
avoidance of virus-relevant cues and pre-
SCIENCE FORUM
The Psychological Sequelae of the COVID-19
Pandemic: Psychological Processes, Current
Research Ventures, and Preparing for a
Postpandemic World
Michelle M. Paluszek* and Caeleigh A. Landry,* University of Regina
Steven Taylor, University of British Columbia
Gordon J. G. Asmundson, University of Regina
*contributed equally to this article
160 the Behavior Therapist
paluszek et al.
vent contact with potential pathogens
(Schaller&Park).
The cues detected by the BIS are only
sometimes indicative of infection(Schaller
&Park, 2011). To ensure protection, the
BIS tends to generate false-positiveerrors
in that it may incorrectlyperceive acue to
indicate infection when it is not present.
Further, there are individual differences in
the sensitivity of the BIS (Duncan &
Schaller, 2009; Duncan et al., 2009). Some
individuals may be especially sensitive or
attentivetothe presenceofcues that may
suggest pathogens and such cues elicit a
more intense reaction. Individuals with
higher levels of perceived vulnerability to
infectionand disgust sensitivity reflect this
phenomenon.
Disgust Sensitivity
Disgust sensitivity—the extent to which
an individual experiences emotional dis-
tressand repulsion from disgust-inducing
stimuli—is proposed to be an indicator of a
sensitive BIS (Goetz et al., 2013; Taylor,
2019a). Disgust may be elicited through
taste, sight, or smell (Terrizzi et al., 2010).
Sick or unhygienicpeople, bodily content,
and dirty environments are examples of
proposed universal disgust-inducing stim-
uli (Curtis et al., 2011). Individuals with
heightened disgust sensitivity tend to react
more intensely to disgust-inducing stimuli.
Asimilarreaction may be elicited by stim-
uli that resemble, or come into contact
with, disgust-inducing stimuli (Curtis et
al.; Oaten et al., 2009; Rozin et al., 2008).
Disgust sensitivity has been found to be
involved in the developmentand mainte-
nance of certain phobias (e.g., spider
phobia, blood-injection-injury phobia;
Olatunji, 2006; Olatunji et al., 2006) as well
as contamination-based obsessive-com-
pulsive disorder (Olatunjietal., 2005).
Empirical evidenceimplicatingdisgust
sensitivity in pandemic-related reactions
has been emerging. Disgust sensitivity has
been foundtopredict greater fear of infec-
tious disease (e.g., Ebola; Blakey et al., 2015;
Brandetal., 2013; Wheatonetal., 2012). A
recentstudy also suggests that disgust sen-
sitivity may interact with thephysicalcon-
sequences factor of anxiety sensitivity(AS;
referred to below) to predict greater con-
cern of infection from an infectious disease
(McKay et al., in press). Disgust sensitivity
may be arelevanttrait to consider for dif-
ferentiating who may be at risk for greater
COVID-19-relatedanxiety or fear.
Perceived Vulnerability to Disease
Perceived vulnerability to disease
(PVD) refers to the individual’s belief of
how likely they would be to contract an
infectious disease(Taylor,2019a). The BIS
is particularly sensitiveinindividuals with
highPVD. An individual with high PVD is
more likely to perceive adisease as athreat
and have an anxiousemotional and behav-
ioral reaction. For this reason, it is believed
that those withelevated PVD arelikely to
experiencehigh levels of emotional distress
during apandemic(Taylor). The trait may
also partly account for the drive to avoid
groups who are perceived to be likely
infected with COVID-19.
As infectious diseases are often trans-
mitted through social contact, theorists
propose that the BIS evolved to influence
attitudes and social interactions in attempt
to avoid infection (Schaller &Park, 2011).
This influence may come in the form of
xenophobia (i.e., prejudice towards for-
eigners; Schaller &Park). Whenthreatened
by an outbreak, individualswho are highly
motivated to avoid infection may exhibit
xenophobia due to the belief foreigners are
sources of infection. Studies indicate that
individuals with elevated PVD are most
likely to endorse negative attitudes towards
foreigners and avoid contactwith foreign-
ers (e.g.,Aarøeetal., 2017;Duncan et al.,
2009; Faulkneretal., 2004).
The avoidance, stigmatization, and
blame of out-groups (i.e., groupsone does
not belong to) is not an uncommon reac-
tion to the threat of an infectious disease
(Makhanova et al., 2015; Taylor, 2019a).
Evidence of xenophobia was observed
during SARS and the Bubonic Plague
(Cohn, 2010; Washer,2004). Xenophobia
directed at individuals of Chinese ancestry
is being reported during the COVID-19
pandemic (e.g., Aguilera, 2020).Discrimi-
nation may not only hinder jointefforts to
mitigate the spread of infectious disease,
but also create undue distress for out-
groups (Taylor).Marginalized groups may
already find themselves vulnerableduring
the COVID-19pandemic for anumber of
reasons. For example,members of margin-
alized groups may be less likely to seek out
or afford health care services, may lack
financial resources to effectively self-isolate
as per recommendations, or may be more
likely to have preexisting chronic health
conditions that increase risk of COVID-
19-related complications (Eaton&Kalich-
man, 2020; Hutchins et al., 2009; Smith&
Judd, 2020; Yancy, 2020). The pandemic
may further drive social, financial, and
health care disparities experienced by mar-
ginalized groups, putting them at even
greaterrisk of physical and mental health
problems (Eaton &Kalichman; Yancy).
The implementation of comprehensive
interventions directed at addressing
COVID-19-related fear, xenophobia, and
socioeconomic inequalities are needed to
bolster the protection of vulnerable groups
duringthe COVID-19 pandemic.
Psychological Traits
To slow the spread of infection, com-
munities will have to work collectively in
accordancewith publichealth recommen-
dations. Health officials are currently
encouraging social distancing and proper
hygienebehaviors(e.g., handwashing) and
will likely recommend all eligible individu-
als receive aCOVID-19vaccine when they
become available (World Health Organiza-
tion, 2020b);however, not everyone will be
willing to engage in such behaviors. Some
individualsmay magnifyinfection risk by
engaging in maladaptive behaviors (e.g.,
failingtowash hands, maintain social dis-
tancing,orreceive avaccine). Other indi-
viduals might react to COVID-19 with
moderate fear, motivating them to adhere
to recommendations, while others may
experience intense and debilitating fear.
Below we addressindividual difference fac-
tors that may influence anxietyand stress
responses and their possible downstream
effects on adaptive or maladaptive
COVID-19-related behaviors.
Unrealistic Optimism Bias
Unrealistic optimism bias is the ten-
dency to have overly positive beliefs about
one’s future (Taylor &Brown, 1988).
People who have an unrealistic optimism
bias tend to believe that positiveevents are
more likely to happen to them than to
othersand,assuch,underestimate thedan-
gers of disease and otherpotential threats
(Weinstein, 1980). During the SARS out-
break, those with unrealistic optimism bias
believed themselves to be less likely to con-
tract the infection than others (Ji et al.,
2004). Individuals with unrealistic opti-
mism bias may pose aserious societal
threat during pandemics as they are
unlikely to practice proper preventative
health behaviors, such as proper hand-
washing and vaccination (Taylor, 2019a).
Unwillingness to vaccinate, even in a
minority of individuals, can have sizeable
repercussions on the public(WorldHealth
Organization,2020d). Efforts to eradicate
thedisease through vaccine distribution
June 2020 161
psychological sequelae of covid-19 pandemic
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may be diminished. Contention arising
from opposing views on vaccine accept-
ability (e.g., potential use of “vaccination
certificates” to allow travel) could also
incite societal discord and strife. In addi-
tion to unrealistic optimism bias, other
psychological traits (discussed further
below) may influence vaccine hesitancy.
For example, individuals with high intoler-
ance of uncertainty (IU)orhealth anxiety
could be concerned about the potential
unknownside effectsofavaccine and, thus,
be unwilling to receive it (Petrie et al., 2004;
Taylor, 2019a).
Health Anxiety
The tendency to become distressed by
illness-related stimuli (e.g., fever, cough-
ing) is known as health anxiety
(Abramowitz &Braddock, 2011;Asmund-
son &Taylor, 2020a; Taylor &Asmund-
son, 2004). Both high and low levels of
health anxiety are associated with mal-
adaptive behaviors. Thosewith low health
anxiety are unlikely to engage in recom-
mended hygiene behaviors and are espe-
cially vulnerable to unrealistic optimism
bias (Gilles et al., 2011). Previous studies of
prior epidemics indicate that individuals
with low health anxiety are least likely to
adhere to social distancing and to wash
their hands as per recommendations
(Goodwin et al., 2009; Jones &Salathe,
2009; Rubin et al., 2009; Williams et al.,
2015; Wong &Sam, 2011). On the other
hand, those with elevated heath anxiety
tend to worry excessivelyabouttheir health
and can overestimate the degree of threat
posed by an illness (Hedman et al., 2016;
Taylor &Asmundson, 2004; Wheaton et
al.,2010), including COVID-19.
People with high health anxiety are
likely to overuse health care services and
experience high levels of impairment when
experiencing aperceived threat (Bobevski,
et al., 2016; Eilenberg et al., 2015; Sunder-
land et al., 2013). They are often hypervigi-
lant towards their bodily sensations and
more likely to interpret those symptoms as
dangerous (Tyrer &Tyrer, 2018). Due to
the widespread media coverage of COVID-
19, peoplemay begin paying closeratten-
tion to bodily sensations that they would
have previouslyignored.Self-isolation may
also worsen health anxiety, as environ-
ments with low external stimulimay facili-
tate awareness of internalstimuli (Taylor &
Asmundson, 2004).
Anxiety Sensitivity
Conceptually similar to healthanxiety,
AS is the fear of anxietyorarousal-related
reactions(e.g., rapidheartbeat, shortnessof
breath)based in the belief that these reac-
tions areharmful or bringaboutnegative
consequences (e.g., death; Reiss &
McNally, 1985; Taylor, 2019b). Healthanx-
iety and AS share an overarching fear of
bodily changes or sensations and misinter-
pretation of these changes or sensationsas
dangerous (Taylor, 2019a). Whenanindi-
vidual with heightened AS experiences
normal bodilysensations(e.g.,when anx-
ious), anxiety and the acquired fear
response to these sensations are magnified
(Taylor et al., 2007). AS is purported to
increase risk for arange of disorders,
including anxiety-related disorders(Bern-
stein et al., 2005; Schmidtetal., 2006; Tull
et al., 2009). Elevated AS, particularly relat-
ing to concern of physical consequences
(e.g., heart attack), may also increase risk
for pandemic-related anxiety and certain
behavioral patterns (Blakey et al., 2015;
Taylor, 2019a). The physical consequences
factor of AS has also been shown to medi-
ate the relationship between obsessive-
162 the Behavior Therapist
paluszek et al.
compulsive symptoms (e.g., checking,
washing) and fear of swine flu (Brand et al.,
2013).Further research is necessary to elu-
cidatethe potentialrole of AS in COVID-
19-related anxiety and disease-mitigating
behaviors.
Intolerance of Uncertainty
IU is another traitfactor that may have
important consequences for COVID-19-
related coping. IU refers to the individual’s
abilitytohandle missing information and
feelings of uncertainty that may accom-
pany it (Carleton, 2016). People with high
IU prefer predictability in their lives and
can feel paralyzed with indecision when
facedwith an unexpected situation (Birrell
et al., 2011). High IU has been found to
contribute to avariety of mental health
conditions and to be linked to the develop-
ment of excessive worry (Gentes &Ruscio,
2011; Rosser, 2018; Shihata et al., 2016).
Individuals with elevated IU may perceive
COVID-19 as aparticularly distressing
time given its many unpredictable situa-
tions and unknowns, including, but not
limited to, contractingthe virus, perceiving
who is infected, what could be carrying the
virus, how to protect oneself or loved ones,
as wellaspotential job loss(Taylor,2019a).
Additionally, highIUhas been associated
with health-related checking and reassur-
ance seeking(Dugas &Robichaud, 2007).
Similar to health anxiety (Asmundson &
Taylor, 2020a, 2020b), the need for confir-
mation that one is free of infection may
motivate those with higher IU to contact
medical services even with relatively
benign symptoms and consequentlyover-
burden the health care system. There is
potential that the news media may further
fuel uncertainty, especially given that there
is still much to learn aboutCOVID-19.
CurrentFindings and
OngoingResearch
At present, limited research has been
published on the psychological factors
involved in the COVID-19 pandemic.
Cross-sectional population studies from
China suggest substantial anxiety and
depression during the initial stage of the
COVID-19 pandemic (Qiu et al., 2020;
Wang et al., 2020). One study on college
students in China indicated that 25% of the
students wereexperiencing mild to severe
levels of generalanxiety and that those who
knew someone infected with COVID-19
were particularly distressed (Cao et al.,
2020). Health care workers also appear to
be especially at risk of poorer mental health
outcomes.Significantlyhigh rates of mild
to severe symptoms of depression (50%),
anxiety (45%), and insomnia (34%) were
reported in one study (Lai et al., 2020).
Another study indicated that front-line
health care workers in China are more at
risk than nonclinical staff to experience
general fear and symptoms of anxiety and
depression (Lu et al., 2020). Studies
directed at understanding psychological
factors are still ongoingasthe COVID-19
pandemic continues to unfold; for exam-
ple, the Montreal Behavioural Medicine
Centre is conducting the International
COVID-19 Awareness and Responses
Evaluation, alongitudinal online study.
While there are anumber of research
groupsworking to understand the psycho-
logical impacts of COVID-19, the evidence
to date is limited by focus on general mea-
sures of anxiety or narrow conceptualiza-
tions of COVID-19-related fears. The
breadth of COVID-19-related distress may
prove to be quite expansive.
Our own international research team is
conducting alarge-scale populationrepre-
sentative study in Canadaand the United
States using online survey methodology
across three time points (baseline, 1month,
and 3months) to examinevarious psycho-
logical traits and COVID-19-related dis-
tress. Data from the first wave, comprising
6,854 respondents, has been used in the
development and initial validation of the
COVID Stress Scales (CSS; Taylor et al.,
2020), comprising 36 items on five scales
assessing COVID danger and contamina-
tion fears, COVID fears about economic
consequences, COVID xenophobia,
COVID compulsive checking, and COVID
traumaticstress symptoms.The CSS offer
promiseastools for better understanding
the psychopathology associated with
COVID-19 and for identifying people in
need of mental health services due to the
COVID-19 pandemic in particular and
future pandemics in general. We are also
developinganonline self-assessmentplat-
form that, based on feedback from CSS
self-assessment,individuals will be offered
tailored resources to help them bettercope
with pandemic-related distress. Future
waves of our data collection will give a
clearer indication of the mental health
landscape as the pandemic evolves over
time and will helpinformefforts to combat
COVID-19aswell as anticipated fallouts in
the postpandemic era.
Preparing for the Postpandemic Era
There are numerous ways in which life
may change as aresult of the COVID-19
pandemic, and there are currently many
uncertainties. It is not clear, for example,
whether COVID-19 will disappear from
the population, as did SARS, or whether
COVID-19 will become aseasonal infec-
tion, analogoustoseasonal influenza. But
we canbefairly certain that the current
pandemic will eventually end. There are
various subtle ways in which the lives of
many people will be changed by the pan-
demic. These are discussed in detail by
Taylor and Asmundson (2020). In the
remainder of the present article, we focus
on the implications for mental health prac-
titioners.
Although the staggering infectious
impact of COVID-19 may soon subside,
clinicians will be faced with the challenge of
managing the anticipated pervasive surge
of mental health concerns. Early evidence
from China at the onset of the pandemic
suggests an increase in general mental
health problems, including anxiety and
depression (Qiu et al., 2020; Wang et al.,
2020). Stressors related to COVID-19 (e.g.,
quarantine, unemployment, financial
hardship, marital strain, isolation, social
withdrawal, death of loved ones) will likely
initiate or exacerbate mental health prob-
lems(Brooks et al., 2020; Shultzetal., 2015;
Taylor, 2019a). Some individuals infected
with COVID-19 may suffer persistent psy-
chologicaldistress, as was found with SARS
(Hong et al., 2009). Among front-line
health care workers, there may be pro-
found distress from burnout due to an
excessive workload and moral injuries
during the pandemic (Williamson et al.,
2020). Further, front-line health care work-
ers may be at an elevated risk for experi-
encing traumatic stresssymptoms related
to exposure to illness and death (Shultz et
al., 2015; Taylor, 2017), as was the case with
SARS (Naushad et al., 2019; Wu et al.,
2009). As governments ease restrictions,
stressors will involvereadjusting lifestyles,
coping with the potential threat of another
wave of COVID-19, and residualanxiety in
the absence of an illness threat. While some
may attempt to resume their previous
lifestyle, others (e.g., those who are intro-
verted,health-anxious) may remain in
seclusion to shelterfrom the world, similar
to agoraphobia or hikikomori (i.e., social
withdrawal lastinggreater than 6months;
Teo, 2010).Atpresent, the current mental
health care structure is ill-prepared to deal
with the need for psychological services
June 2020 163
psychological sequelae of covid-19 pandemic
brought upon by COVID-19. There is an
urgent need for available, quality mental
health services tailored for the distress,
lifestyle changes, and needsofthe current
and postpandemic society.
Telehealth, also referred to as telemedi-
cine, and online psychotherapy are well-
poised to respond to the growing demand
for services that are accessible from home.
Videoconferencing psychotherapy may be
an efficacious alternative to face-to-face
therapy (Berryhill et al., 2019). Likewise,
there is strong empiricalevidence to sup-
port therapist-guided and unguidedinter-
net-delivered CBT for general mental
health issues as well as arange of mental
disorders (Andersson, 2016; Andrews et
al., 2018; Hadjistavropoulos et al., 2016;
Karyotaki et al., 2017). There is anticipa-
tion that COVID-19 may serve as the cata-
lyst forthe widespread acceptance and pro-
vision of online- or telehealth-delivered
psychotherapy (Wind et al., 2020). How-
ever, it is very likely that currently online
programs will require tailoring to address
the mental health impacts specific to
COVID-19, at least in the most severely
impacted.For example, it may be necessary
to provide mental health services in a
stepped- or blended-care approach
whereby those with minorissues receive an
online or app-delivered COVID-19-spe-
cific healthinformation intervention,those
with moderate issues receive asimilarly
focused and delivered self-managed inter-
vention, and the most severely impacted
are treated with asimilarly focused inter-
vention that also includes individual
coaching via telephone or text. Suchinter-
ventions for COVID-19-specific distress
are currently in the development and test-
ing stages.
Conclusion
The COVID-19 pandemic is antici-
pated to have apervasive impact on the
actions and well-being of society as acon-
sequence of acombination of substantial,
widespread individual and societal
changes, mediaexposure, and preexisting
psychological traits and mechanisms.
Research is needed to not only assess the
extent of this concern, but also to inform
recommendations that ensure appropriate
treatment. Fortunately, this research is
under way in variouscountries.Clinicians
are urged to adapt and reform current
practice in line with evidence-based, acces-
sibleclinical practice. Government officials
and health care practitioners should make
efforts to prepare for the unknown and
potentially long-standing imprint of
COVID-19 on the mental health and well-
being of the current generation.
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...
Preparation forthispaperwas supported in
part by theCanadian Institutes of Health
ResearchCanadian2019 Novel COVID-19
RapidResearch Funding Opportunityand
the UniversityofRegina. Dr.Taylor receives
financial supportthrough payments from
various bookpublishersand as partofhis
work as Associate Editor of the Journalof
Obsessive-Compulsiveand Related Disorders.
Dr. Asmundsonisthe Editor-in-Chief of the
JournalofAnxietyDisorders and Develop-
mentEditor of Clinical Psychology Review.
He receives financial support throughpay-
ments forhis editorial work on the afore-
mentioned journalsand royaltiesfrom vari-
ous bookpublishers.
Correspondence to Gordon J. G. Asmund-
son,Ph.D., DepartmentofPsychology, Uni-
versity of Regina, Regina, Saskatchewan, S4S
0A2; gordon.asmundson@uregina.ca
... Identification of additional psychological vulnerabilities, beyond heightened prepandemic psychological distress, would also be helpful in tailoring interventions. Intolerance of LIVING IN UNCERTAIN TIMES 7 uncertainty (IU) and perceived threat are two such vulnerabilities that might predict mental health problems during the COVID-19 pandemic Daly & Robinson, 2021;Fang et al., 2020;Glowacz & Schmits, 2020;Paluszek et al., 2020;Rettie & Daniels, 2020;Satici et al., 2020;Tull et al., 2020;Wheaton et al., 2021). ...
... However, this previous study was conducted in the early days of the first pandemic wave, prior to the onslaught of media attention, governmental messaging and misinformation that presented to the public conflicting messaging regarding the seriousness of COVID-19. It is possible that prolonged exposure to conflicting information and misinformation increased stress and uncertainty, which could exacerbate mental health problems, especially among those with pre-pandemic vulnerabilities (Holman et al., 2020;Mertens et al., 2020;Paluszek et al., 2020). However, prolonged media exposure could also result in "media fatigue," in which people become desensitized and less responsive to messaging over time (Collinson et al., 2015;Paluszek et al., 2020). ...
... It is possible that prolonged exposure to conflicting information and misinformation increased stress and uncertainty, which could exacerbate mental health problems, especially among those with pre-pandemic vulnerabilities (Holman et al., 2020;Mertens et al., 2020;Paluszek et al., 2020). However, prolonged media exposure could also result in "media fatigue," in which people become desensitized and less responsive to messaging over time (Collinson et al., 2015;Paluszek et al., 2020). In combination, "media fatigue" and repeated exposure to messaging from governmental officials, media, and informal social networks downplaying the severity of the pandemic may have reduced perceived threat among some individuals, including those at higher objective risk. ...
Preprint
Amidst the ongoing COVID-19 pandemic, people are facing heightened uncertainty about the future and increasing rates of psychological distress. Intolerance of uncertainty (IU) and perceived COVID-19 threat may be contributing to mental health problems. This study investigated changes in mental health problems prior to and during the first two pandemic waves in the U.S., and the extent to which IU and perceived COVID-19 threat predicted these problems. MTurk participants (n=192; 50% women) were recruited from a pre-pandemic study in December 2019/January 2020 for a follow-up study on COVID-19 experiences, across five timepoints between April and August 2020. IU, perceived COVID-19 threat, and mental health problems (i.e., worry, COVID-19 fear, and trauma symptoms) were assessed. On average, mental health problems were not elevated, relative to pre-pandemic levels, and remained stable across time. Heightened IU and perceived COVID-19 threat were associated with more mental health problems. Surprisingly, objective measures of COVID-19 threat (e.g., state case rates) showed no associations with IU, and were slightly negatively correlated with psychological distress and perceived threat. Pre-existing mental health symptoms, IU and perceived COVID-19 threat may foster vulnerability to mental health problems during the pandemic, more so than objective threat levels.
... Studies have shown that COVID-19 mitigation strategies are linked to the onset of posttraumatic stress symptoms, anxiety, depression, and other psychological stress across culturally diverse populations (George & Thomas, 2020;Khan et al., 2020;Kisely et al., 2020;Liang et al., 2020;Paluszek et al., 2020) and college students worldwide (Somma et al., 2021). In addition, recent studies with US samples have identified a threefold increase in the prevalence of anxiety and depression symptoms during the pandemic compared to pre-pandemic rates (Santabárbara et al., 2021). ...
Article
Full-text available
Young adults and racial/ethnic minorities report the worst mental health outcomes during the COVID19 pandemic, according to the Center for Disease Control (2020). The objectives of this study were (1) to identify common mental health symptoms among Latin American, US Hispanic, and Spanish college students, and (2) to identify clinical features predictive of higher post-traumatic stress symptoms (PTSS) among this population. The study sample included 1,113 college students from the USA, Mexico, Chile, Ecuador, and Spain who completed an online survey containing demographic questions and mental health screeners. Findings revealed higher scores of depression, suicidality, and PTSS compared to pre-pandemic levels and current scores by non-Spanish speaking college students ; however, less than 5% of participants endorsed clinical levels of anxiety. After controlling for demographic profiles and sociocultural values, clinical symptoms of depression , loneliness, perceived stress, anxiety, and coping strategies explained 62% of the PTSS variance. Age, history of mental illness, perceived social support, and familism were not significant predictors. This sample of college students revealed higher mental health symptoms during the COVID-19 pandemic. The high prevalence of PTSS highlights the need to develop pragmatic, cost-effective, and culturally sensitive prevention and intervention strategies to mitigate these symptoms. Implications for college administrators and clinicians are discussed.
... 11e14 IU has been identified as an important trait-like factor that may affect behaviour, including vaccination, while facing the threat of infection. 17 IU is defined as an inability to endure uncertain situations and the emotional reactions provoked by the perceptions of uncertainty. 18 Finally, not every type of distress experienced during the pandemic seems to be related to vaccination attitudes; 10 therefore, we wanted to explore whether vaccine acceptance was limited to distress related to the perception of a particular threat (e.g. the SARS-CoV-2 virus) or whether vaccine acceptance was also related to general distress. ...
Article
Objectives Previous research has shown that the COVID-19 Stress Scale (CSS), a measure assessing various dimensions of distress related to the COVID-19 pandemic, is associated with self-protective behaviours; however, it remains unknown whether this distress can be used to predict attitudes towards vaccination. The purpose of this study was to validate the Serbian CSS (Serbian-CSS) and to explore its predictive power over and above certain sociodemographic characteristics, individual difference variables (attitudes and personality) and general distress in relation to COVID-19 vaccine acceptance. Study design An online cross-sectional study was conducted that targeted users of different social network groups at the beginning of the public COVID-19 vaccination programme in Serbia. Methods A large, online study sample (N = 3129) provided self-reported data on COVID-19 related distress, health and sociodemographic indicators, individual difference variables and attitudes towards vaccination. Results The Serbian-CSS is a valid and reliable instrument that assesses six dimensions of COVID-19 distress. The strongest predictors of vaccine acceptance were attitudes towards immigrants (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] 0.31, 0.41), followed by education (AOR = 1.51, 95% CI 1.27, 1.88) and pre-pandemic mental health issues (AOR = 1.61, 95% CI 1.30, 2.01). Conclusions The level of distress measured by the CSS had a non-substantial contribution to vaccine acceptance, which is probably due to the mild level of distress that was observed at the time of assessment. Public health messaging that relies on the distribution of information is not sufficient to address strongly held beliefs against vaccination. The study provides a benchmark for future cross-cultural research regarding negative affective states associated with the COVID-19 pandemic.
... Additional traits associated with increased vulnerability to stress, such as neuroticism and other related more specific traits that also amplify the perceived degree of threat (e.g. health-anxiety and intolerance to uncertainty) have been suggested to be associated with the COVD-19 psychological sequelae (Paluszek et al., 2020). All these traits and the consequent dysfunctional coping strategies are related to perfectionism (Stoeber & Corr, 2015). ...
Article
Psychological reactions to pandemics and their constraints depend heavily on personality. Although perfectionism is consistently associated to depression, anxiety and stress, its role in the pandemics’ psychological impact has not been yet empirically studied. Our aim was to analyze the role of perfectionism in psychological distress during the pandemic of COVID-19, testing whether it is mediated by fear of COVID-19 and repetitive negative thinking/RNT. Participants (N=413 adults; 269.2% women) were recruited from September until December 2020, via social networks. They completed self-report validated questionnaires to evaluate perfectionism dimensions (self-critical, rigid and narcissistic perfectionism), fear of COVID-19, RNT and psychological distress (sum of anxiety, depression and stress symptoms). As women had significantly higher levels of self-critical perfectionism, RNT, fear of COVID-19 and psychological distress, gender was controlled in mediation analysis. The three perfectionism dimensions correlated with RNT, fear of COVID-19 and psychological distress. The effect of self-critical perfectionism on psychological distress was partially mediated by fear of COVID-19 and RNT whereas the effect of rigid and narcissistic perfectionism was fully mediated. Perfectionism influences emotional and cognitive responses to the COVID-19 and therefore should be considered both in the prevention and psychological consequences of the pandemic.
... Early evidence from Chinese university students indicates that delays in academic activities, loss of social support, economic strain (e.g., loss of steady family income), and having family or acquaintances infected with the COVID-19 virus were primary sources of anxiety during the COVID-19 pandemic (Cao et al., 2020). These and other adjustments are likely to negatively impact the educational growth and psychological well-being of millions of students world-wide (Paluszek et al., 2020;. ...
Article
The psychological effect of the pandemic and measures taken in response to control viral spread are not yet well understood in university students; in-depth qualitative analysis can provide nuanced information about the young adult distress experience. Undergraduate students ( N = 624) in an early US outbreak “hotspot” completed an online narrative writing about the impact and distress experienced due to the COVID-19 pandemic. Data were collected April-May 2020. A random selection of 50 cases were sampled for thematic analysis. Nine themes were identified: viral outbreak distress, fear of virus contraction/transmission, proximity to virus, dissatisfaction with public response, physical distancing distress, social distancing distress, academic and school-related distress, disruptive changes in health behavior and routines, financial strain and unemployment, worsening of pre-existing mental health problems, and social referencing that minimizes distress. Future work is needed to understand the persistence of the distress, in addition to developing methods for assessment, monitoring, and mitigation of the distress.
... The COVID-19 pandemic has spread worldwide since December 2019, leading to unprecedented changes in daily life (e.g., stay-at-home orders, business closures, and mask mandates) [11]. The changes have contributed to widespread fear and uncertainty regarding the pandemic [12]. Research from previous pandemics suggests that the psychological impact of the COVID-19 pandemic will be greater than the physical impact of the virus [13,14]. ...
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Public safety personnel (PSP) experience unique occupational stressors and suffer from high rates of mental health problems. The COVID-19 pandemic has impacted virtually all aspects of human life around the world and has introduced additional occupational stressors for PSP. The objective of this study was to explore how PSP, especially those seeking digital mental health services, have been affected by the pandemic. Our research unit, PSPNET, provides internet-delivered cognitive behavioral therapy to PSP in the Canadian province of Saskatchewan. When the pandemic spread to Saskatchewan, PSPNET began inquiring about the impact of the pandemic on prospective clients during the eligibility screening process. We used content analysis to analyze data from telephone screening interviews (n = 56) and descriptive statistics to analyze data from a questionnaire concerning the impacts of COVID-19 (n = 41). The results showed that most PSP reported facing several novel emotional challenges (e.g., social isolation, boredom, anger, and fear) and logistical challenges (e.g., related to childcare, finances, work, and access to mental healthcare). Most participants indicated they felt at least somewhat afraid of contracting COVID-19 but felt more afraid of their families contracting the virus than themselves. However, few participants reported severe challenges of any kind, and many (40%) indicated that they had not been significantly negatively impacted by the pandemic. Overall, the results suggest that PSP are not expressing significant concern at this time in meeting the novel challenges posed by COVID-19. Continued research will be required to monitor how diverse PSP populations and treatment outcomes are affected by the pandemic as the situation evolves.
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Objective Despite the abundance of studies linking fear and anxiety to COVID-19, there are limited studies that examine how these elements impact psychological behavioral responses, especially in Iran. The aim of this study was to investigate the relationship between anxiety and fear of COVID-19 with psychological behavior response, whether this relationship is mediated by role of perceived stress among Iranian population during the COVID-19 pandemic.MethodsA predictive cross-sectional study was used to investigate the relationships between COVID-19 anxiety syndrome, fear of COVID-19 with psychological behavioral responses due to the pandemic, and the mediating role of the COVID-19 perceived stress in these relationships.ResultsThe current study revealed that during the COVID-19 pandemic, fear and anxiety of COVID-19 can influence the psychological behavioral responses of individuals; however, this can be explained through perceived stress.Conclusion As such, the current study points out that the individuals who perceived high stress due to COVID-19 were more likely to comply with guidelines, which has given new insight into this field. The current study findings are applicable for health policymakers in order to help them in understanding human behavior for developing health promotion programs and also for fostering resilience among the general population.
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Background: The coronavirus disease pandemic disrupted the normal social and economic activities of the people resulting in over 3 million deaths worldwide. Piece of literature depicted that predictors of vaccine acceptance are complex, multiple, and vary depending on the type of vaccine involved. Objective: The study aimed at assessing the COVID-19 acceptance and its predictors among college students in Addis Ababa, Ethiopia, 2021. Methods: A multi-center-institutional-based cross-sectional study was conducted among 407 participants from three institutions in Addis Ababa selected based on a simple random sampling method from May 01 to July 30, 2021. A self-administered structured questionnaire was used for the collection of data, after which informed consent was obtained from all the included study participants. Descriptive statistics was used for the summarization of the data. Binary (bivariate and multivariate) logistic regression was applied for the identification predictors of vaccine acceptance with their respective 95% confidence interval and less than 5% p-value for the ascertainment of presence of association. Results: The level of vaccine acceptance was 39.8% (95% CI: 35.0-44.7%). Being male (AOR: 0.463, 95% CI: 0.284-0.755, P < 0.001), living with children under the age of five (AOR: 2.295; 95% CI: 1.416-3.721, P < 0.05), living with an elderly (AOR: 1.609, 95% CI: 1.016-2.548, P < 0.05) and having had poor knowledge (AOR: 2.187, 95% CI: 1.391-3.438, P < 0.001) were predictors significantly associated with an increased level of vaccine acceptance. Conclusion and Recommendation: The level of vaccine acceptance among college students in Ethiopia was lower than necessary to achieve herd immunity. Sex, living with under-five children, and elderly, and knowledge were predictors of COVID-19 acceptance. Concerned bodies were suggested to work over the identified predictors of vaccine acceptance in the study settings.
Article
Excessive fear and worry in response to the COVID-19 pandemic (e.g., COVID stress syndrome) is prevalent and associated with various adverse outcomes. Research from the current and past pandemics supports the association between transdiagnostic constructs-anxiety sensitivity (AS), disgust, and intolerance of uncertainty (IU)-and pandemic-related distress. Recent research suggests a moderating effect of disgust on the relationship of AS-physical concerns and COVID-19-related distress, suggesting that transdiagnostic constructs underlie individual differences in activation of the behavioral immune system (BIS). No previous study has examined the independent and conjoint effects of pre-COVID-19 AS-physical concerns, disgust propensity (DP), disgust sensitivity (DS), and IU in this context; thus, we did so using longitudinal survey data (N = 3,062 Canadian and American adults) with simple and moderated moderations controlling for gender, mental health diagnosis, and COVID-19 diagnosis. Greater AS-physical concerns, DP, and DS predicted more severe COVID stress syndrome assessed one month later. Either DP or DS further amplified the effect of AS-physical concerns on COVID stress syndrome, except danger and contamination fears. IU did not interact with AS-physical concerns and DS or DP. Theoretical and clinical implications pertaining to delivery of cognitive behavioural therapy for pandemic-related distress are discussed.
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Intolerance of uncertainty (IU) is proposed to be a transdiagnostic causal mechanism of psychological difficulties. The systematic review sought to evaluate the status of evidence pertaining to IU’s proposed causal influence upon symptoms of psychological conditions. The review collated evidence from studies involving experimental manipulation and assessment of temporal precedence to ensure direct assessment of causality. The search strategy and eligibility screening identified 12 articles, detailing 15 eligible studies (experimental manipulations: n = 10; temporal precedence studies: n = 5). Available evidence comprised symptoms of anxiety- and mood-related conditions, including obsessive–compulsive disorder (OCD). The greatest support for IU as a causal mechanism was evident for anxiety-related difficulties and, to a lesser extent, negative affect; limited support was found for OCD-related difficulties. However, notable inconsistency across study findings for all difficulty types precludes absolute conclusions. Implications and recommendations are discussed.
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Introduction: Depression is the leading cause of disability in the world. Despite the prevalence of depression, a small proportion of individuals seek mental health services. A cost-effective method for increasing access to mental health services is the implementation of telemental-health programs. This review aims to summarize the state of the field on the efficacy and effectiveness of videoconferencing psychotherapy (VCP) for the treatment of depression. Materials and methods: Systematic literature searches were performed using PsychINFO, PubMed, and EMBASE. Specific inclusion criteria were used to identify controlled and uncontrolled studies evaluating VCP for the treatment of depression. Data extraction included study assessment quality, research design, sample size, intervention details, outcome results, intervention effect size, and statistical differences between VCP and in-person (IP) therapy. Results: Of the 1,424 abstracts screened, 92 articles were critically reviewed. Thirty-three articles were included in the review, with 14 randomized controlled studies, 4 controlled nonrandomized studies, and 15 uncontrolled studies. Sample size ranged from 1 to 243 participants. Twenty-one studies reported statistically significant reductions in depressive symptoms following VCP, and the median effect size for studies ranged from medium to the very large range. Most controlled studies reported no statistical differences between VCP and IP groups receiving the same intervention. Conclusions: VCP for the treatment of depression is a promising method for delivering mental health services. More rigorous research is needed to evaluate VCP on depression in various contexts and participants.
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Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n = 458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17 to 1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.
Article
Introduction Medical responders are at-risk of experiencing a wide range of negative psychological health conditions following a disaster. Aim Published literature was reviewed on the adverse psychological health outcomes in medical responders to various disasters and mass casualties in order to: (1) assess the psychological impact of disasters on medical responders; and (2) identify the possible risk factors associated with psychological impacts on medical responders. Methods A literature search of PubMed, Discovery Service, Science Direct, Google Scholar, and Cochrane databases for studies on the prevalence/risk factors of posttraumatic stress disorder (PTSD) and other mental disorders in medical responders of disasters and mass casualties was carried out using pre-determined keywords. Two reviewers screened the 3,545 abstracts and 28 full-length articles which were included for final review. Results Depression and PTSD were the most studied outcomes in medical responders. Nurses reported higher levels of adverse outcomes than physicians. Lack of social support and communication, maladaptive coping, and lack of training were important risk factors for developing negative psychological outcomes across all types of disasters. Conclusions Disasters have significant adverse effects on the mental well-being of medical responders. The prevalence rates and presumptive risk factors varied among three different types of disasters. There are certain high-risk, vulnerable groups among medical responders, as well as certain risk factors for adverse psychological outcomes. Adapting preventive measures and mitigation strategies aimed at high-risk groups would be beneficial in decreasing negative outcomes.
Article
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.
Article
The current paper presents a future research agenda for intolerance of uncertainty (IU), which is a transdiagnostic risk and maintaining factor for emotional disorders. In light of the accumulating interest and promising research on IU, it is timely to emphasize the theoretical and therapeutic significance of IU, as well as to highlight what remains unknown about IU across areas such as development, assessment, behavior, and relationships to emotional disorders. The present paper was designed to provide a synthesis of what is known and unknown about IU, and, in doing so, proposes broad and novel directions for future research to address the remaining uncertainties in the literature.
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Cultures of Plague discloses a new chapter in the history of medicine. Neither the plague nor the ideas it stimulated were static, fixed in a timeless Galenic vacuum over five centuries, as historians and scientists commonly assume. As plague evolved in its pathology, modes of transmission, and the social characteristics of its victims, so did medical thinking about it. With over 600 plague imprints of the sixteenth century this study highlights the century's most feared and devastating epidemic that threatened Italy top to toe from 1575 to 1578, unleashing an avalanche of plague writing. From erudite definitions, remote causes, cures and recipes, physicians now directed their plague writings to the prince and discovered their most 'valiant remedies' in public health: strict segregation of the healthy and ill, cleaning streets, latrines, and addressing the long-term causes of plague-poverty. Those outside the medical profession joined the chorus. Relying on health board statistics and dramatized with eyewitness descriptions of bizarre happenings, human misery, and suffering, they created the structure for the plague classics of the eighteenth century and by tracking the contagion's complex and crooked paths anticipated trends of nineteenth-century epidemiology. In the heartland of Counter-Reformation Italy, physicians, along with those outside the profession, questioned the foundations of Galenic and Renaissance medicine, even the role of God. Such developments did not need to await the Protestant-Paracelsian alliance of seventeenth-century northern Europe. Instead, creative forces planted by the pandemic of 1575-8 sowed seeds of doubt and unveiled new concerns and ideas within that supposedly most conservative form of medical writing, the plague tract.
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During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapistguided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.