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Interventions

Interventions consisted of 15 weekly, 1-on-1 manualized treatment sessions delivered via telehealth: module 1 (sessions 2-7) emphasized behavioral change, module 2 (sessions 8-10) introduced cognitive strategies, module 3 (sessions 11-14) centered on either intentional cultivation of positive emotional states (PAT) or reducing arousal (NAT). Session 1 covered psychoeducation, and session 15 focused on relapse prevention. Therapists were randomly assigned to clients and intervention conditions, and both therapists and clients were blinded to intervention assignments until the first session.

PAT was designed to enhance key components of reward processing in individuals with low positive mood.59,60 Reward anticipation-motivation is addressed by guiding individuals to plan pleasurable activities and envision positive future experiences. Reward consumption is facilitated through active engagement in enjoyable activities; vivid, present-focused mental rehearsal (savoring); cognitive strategies that redirect attention toward positive aspects of experience; and structured practices to cultivate positive emotions, such as loving-kindness and generosity. Reward learning is promoted by strengthening the association between positive behaviors and enhanced mood and by encouraging self-attribution for positive outcomes.

NAT was designed as a mechanistically distinct comparison condition to improve negative affect and threat responses. NAT incorporates several elements drawn from established evidence-based therapies for anxiety and depression, including exposure to feared or avoided situations, cognitive restructuring of distorted appraisals (eg, probability overestimation and self-blame), and respiratory training to reduce hypocapnia and physiological arousal, while intentionally excluding other components (eg, pleasant events scheduling) to maintain focus on targeting threat reactivity.