C. Steven Richards1 and Lee M. Cohen2
1Department of Psyschological Sciences, Texas Tech University, Lubbock, TX, USA
2Department of Psychology, College of Liberal Arts, The University of Mississippi, Oxford, MS, USA
Clinical health psychology and behavioral medicine are interesting and important specialty areas where various healthcare fields intersect. In this entry, we briefly discuss seven trends, that we believe, are shaping these fields, including (a) methodological sophistication, (b) chronic diseases, (c) diversity and inclusiveness, (d) biological issues, (e) translation of health psychology knowledge, (f) chronic psychopathology that is comorbid with health problems and diseases, and (g) social justice. We conclude this entry with a brief discussion of recommendations regarding theory, research, and practice to consider for the future.
After a review of the research in clinical health psychology and behavioral medicine, it is clear that the intricacy of the studies being published has progressed significantly in multiple ways. For instance, many studies include large and diverse samples of participants. Sampling effectively is one of the cornerstones of sound research and certainly in any area involving human participants. An example of a recent study that includes a large and diverse sample was conducted by Polenick, Renn, and Birditt (2018), where they studied the dyadic effects of depression on medical morbidity among 992 middle‐aged and older‐adult couples. One of the major findings of this study was that depressive symptoms in this population have long‐term associations with medical morbidity, such as chronic health conditions.
Another indication of the current methodological sophistication in this area is an increased use of multi‐variable, multi‐trait, and multi‐method measures, with sound psychometric properties. Such methodology permits the collection of a more thorough picture of the cognitive, emotional, behavioral, biological, and other health outcome variables relevant to the research questions being studied.
An interesting example is a study that explored the longitudinal pathways to alcohol use and abuse among 426 adolescents who had genetic risk factors for addiction, by Trucco, Villafuerte, Hussong, Burmeister, and Zucker (2018). These investigators predicted that the pathways under investigation would be moderated by depression and depressive relapse during the last wave of the study, which included adolescents aged 15–17 years. More specifically, it was expected that depression would be related to more substance use and would essentially facilitate the expression of the genetic risk factors. Trucco et al. (2018) also predicted that ineffective coping methods for stress would be a moderator, related to greater substance use. The investigators' predictions were supported: ongoing depression (or depressive relapse) over time, along with ineffective coping methods, appears to be a pathway that allows genetic risk factors to influence substance use and abuse. This study represents multiple research trends toward excellence in clinical health psychology and behavioral medicine, such as including a large sample (N = 426, plus a comparison sample), which was followed longitudinally over many years (ages 3–17, in 5 waves), with diverse measures (multi‐method, multi‐trait, and multi‐source), and attention to both biological and psychological variables. Trucco et al. (2018) included measures of demographics, family history, temperament, coping, depression, aggression, substance use, and biological correlates such as gender, race, and genotyping. Data were obtained from multiple sources for the psychosocial variables. Moreover, this study provides a rich evidence base for future efforts at health promotion and intervention.
In summary, methodological sophistication is one of the important trends in research on clinical health psychology and behavioral medicine. Indeed, recent editorials by editors of some of the major journals in the field have boasted about this trend and called for it to continue (e.g., for discussions of methodological issues, see Appelbaum et al., 2018; Freedland, 2017; Lilienfeld, 2017).
Another trend in clinical health psychology and behavioral medicine is an emphasis on psychosocial variables in the context of chronic diseases. There is tremendous interest and concern regarding highly prevalent chronic diseases such as heart disease, cancer, stroke, diabetes, arthritis, flu and other pandemic diseases, and so forth. These diseases are often listed in the top 5 or 10 causes of death from disease among adults across the industrialized world. Furthermore, psychosocial variables have been established as having important mediating, moderating, and health‐promoting effects for the course and outcome of such diseases (e.g., for a readable review, see Taylor, 2018).
An example of an excellent study illustrating this trend is a recent study by Manne, Siegel, Heckman, and Kashy (2016). This study included 302 female patients with early‐stage breast cancer, along with their spouses. For the most distressed patients, a couple‐focused and supportive version of group therapy appeared to be the more‐effective intervention for coping with psychosocial variables such as depression and anxiety. In contrast, for patients who were less distressed, a structured and skills‐based version of group therapy appeared to be the most effective for reducing depression and anxiety, and in an associated manner, also improving health‐promoting behaviors such as stronger adherence to medical regimens. This study successfully addressed some of the common research concerns among the psycho‐oncology research community, such as including a relatively large sample, a longitudinal and randomized controlled design, and use of a broad array of measures.
There are also numerous excellent examples of research examining combined psychosocial and medical interventions for post‐heart‐attack patients that are represented by the ENRICHD and CREATE randomized controlled trials (Berkman et al., 2003; Lespérance et al., 2007). These large trials (with beginning sample sizes of 2,481 and 284, respectively) randomized participants to combinations of SSRI antidepressant medications and either cognitive behavior therapy (ENRICHD) or interpersonal psychotherapy (CREATE) or usual care with brief supportive counseling from clinic and healthcare staff.
In addition to the standard goals of better heart health and medical improvement after a heart event, the treatment goals included improvement in depression and social support (Berkman et al., 2003; Lespérance et al., 2007). Numerous correlational studies have indicated clear relationships between these psychosocial variables and long‐term heart health in cardiac disease patients. Although a comprehensive summary of the results from the ENRICHD and CREATE trials is beyond the scope of this brief entry, a major finding was that the medication plus psychosocial intervention conditions indicated improvement in depression and social support over time. However, these psychosocial improvements were not associated with significantly fewer heart events or cardiac fatalities over time. Therefore, while the improvements observed during follow‐up visits on the psychosocial measures was encouraging, there was disappointment that improvements in depression and social support over time did not translate into improvement in physical cardiac health and avoidance of future heart attacks. Nonetheless, these heart disease studies stand as excellent examples of sophisticated research on psychosocial processes associated with disease.
In summary, there have been numerous excellent studies regarding clinical health psychology, behavioral medicine, and chronic disease. Chronic diseases are major killers, however, and we need to learn more. Fortunately, there appears to be movement in this direction, although the large randomized controlled trials like those noted above are expensive and thus vulnerable to the funding patterns of major national granting agencies and foundations/societies focused on health, such as the National Institutes of Health (United States), the National Health Service (United Kingdom), the American Heart Association, and the American Cancer Society.
We live in a diverse world and the benefits of inclusiveness are obvious. Therefore, many areas within clinical health psychology and behavioral medicine, as with other fields that engage in theory, research, and practice relevant to human beings, have witnessed a large increase in studies and interventions that focus on diversity and inclusiveness. From our perspective, this is one of the most important trends in clinical health psychology and behavioral medicine (e.g., see the editorial by Davila, 2017; and the special section overview, on sexual and gender minority health, by Davila & Safren, 2017).
An example of a determined effort to recruit a diverse sample is a study examining physical activity and depressive symptoms after treatment for breast cancer (Brunet, O'Loughlin, Gunnell, & Sabiston, 2018). The early research in this area was often limited to samples of entirely Caucasian women, within a small age range, who were relatively well educated and mostly married or living with a partner. In contrast, this large study of 201 women with breast cancer reflected efforts to recruit a more diverse sample, including a wider range of age, race, civil status, and education. This study also evidenced considerable diversity regarding medical variables such as stage of cancer, treatments received, and time since treatment completion. The investigators acknowledge, of course, that even more diverse samples will be helpful for future research. One of the major findings from this investigation is that more physical exercise was associated with less frequent depressive symptoms among participants after treatment for breast cancer; however, not all of the predicted relationships between depression and exercise were maintained longitudinally.
Another recent example of a study that included ambitious efforts to recruit a large and diverse sample is a study that examined the associations between pharmacotherapy for diabetes and immigrant status in the United States; this study was conducted by Hsueh et al. (2018). While a complete discussion regarding the many variables in this study that examined diversity is beyond the scope of this entry, if we focus solely on the race, ethnicity, and education variables used, there were numerous participants across several racial and ethnicity groups, including 28% non‐Hispanic Black, 18% Mexican American, 8% other Hispanic, 6% multiracial, and 40% non‐Hispanic White. Educational level completed was also quite diverse, ranging from ninth grade or lower to college graduate or above. One of the major findings included a clinically significant result that being foreign born was associated with significantly reduced odds of receiving insulin treatment (Hsueh et al., 2018). There were also some differential patterns of associations with treatment offerings and different racial/ethnic group membership. These results suggest that perhaps integrating diversity information about a patient's immigration status and racial/ethnic identity would allow for a more culturally sensitive care of diabetes.
In summary, we live in a diverse world, and additional research like the studies noted above is needed. It is essential that future studies make it a priority to recruit and assess diverse participants and consider relevant diversity variables.
Traditional research on chronic health problems and diseases has characteristically paid considerable attention to biological factors. More recently, social scientists are paying increasingly more attention to such variables. Specifically, the fields of clinical health psychology and behavioral medicine appear to be moving toward a stronger biological focus (e.g., see editorials by Freedland, 2017; Lilienfeld, 2017). Furthermore, this increased focus on a biological emphasis is facilitated and enhanced by recent technology, such as MRI, PET, and CT scans. The sophistication and options available for biological assays of blood, urine, hormones, neurotransmitters, and so forth have expanded and become more accessible. Moreover, the ability to evaluate, store, and reexamine biological samples has grown tremendously (e.g., see discussions in Taylor, 2018).
An interesting example of a health psychology study that incorporates biological variables is the Trucco et al. study (2018), mentioned earlier in this entry. Trucco et al. (2018) included measures of genotyping, focusing on the polymorphisms from four genes, which were predicted to be relevant to the substance use variables being studied. A major finding was that depression and ineffective coping methods appear to be a pathway that allows genetic risk factors to influence substance use and abuse.
Another example of biological measures being utilized in recent clinical health psychology research is an investigation by Bakhshaie et al. (2018). The authors used a carbon monoxide analysis of breath samples as a method to verify the participants' smoking status. Similar biochemical verification methods have been used in numerous smoking cessation research studies, along with other studies on nicotine and tobacco use. One of the investigators' primary findings was that teaching the participants strategies to more effectively manage symptoms of anxiety and depression appeared to be associated with fewer withdrawal symptoms, and thus better outcomes, in a smoking cessation study (Bakhshaie et al., 2018).
In summary, the inclusion of biological variables in clinical health psychology and behavioral medicine research is becoming more common, more sophisticated, and more central to the questions being asked.
Research studies conducted in laboratories, with carefully controlled variables, under almost perfect conditions are important. However, it is also critical that findings be applicable in real‐world situations. These real‐world situations often involve imperfect conditions, limited resources, overworked healthcare providers, underserved patients, and numerous other challenges. Practical and cost‐effective translations have found encouraging effectiveness in real‐world settings, in part, by using mobile and online technologies, public health education campaigns, social service agencies, charitable organizations, and religious organizations (e.g., see the journal editorial in Translational Behavioral Medicine by Miller‐Halegoua, Bowen, Diefenbach, & Tercyak, 2016).
O'Hara and his colleagues have conducted several randomized controlled trials and more naturalistic, low‐cost intervention trials in healthcare clinics with depressed postpartum women. Their findings indicate that interpersonal psychotherapy interventions in the acute phase of depression treatment, and/or during maintenance treatment, are helpful for depressive relapse prevention among women who often had numerous health challenges and who were also caring for young children (e.g., Nylen et al., 2010; O'Hara, Stuart, Gorman, & Wenzel, 2000; Serge, Brock, & O'Hara, 2015). Moreover, these studies showed a transition themselves, from efficacy‐like studies as seen in O'Hara et al. (2000) to more translational studies as seen in Serge et al. (2015). Thus, even in economically challenged and underserved populations being treated in real‐world healthcare settings with limited resources, interpersonal psychotherapy has potential as both an acute and maintenance treatment for depression and as a treatment that can be translated into real‐world settings (e.g., see Serge et al., 2015 for the most translational study in this series of investigations).
Another excellent translational study explored how to improve adherence to cognitive behavior therapy for insomnia (CBT‐I; Dolsen et al., 2017). In this randomized trial for 188 adults with persistent insomnia, the investigators found strong support for the hypothesis that effective sleep the night before and the night after a treatment session will improve patients' adherence to many aspects of the treatment regimen. Additionally, it was found that CBT‐I interventions usually improve the patient's sleep before and after a treatment session. Such sleep improvement, in turn, will improve treatment adherence, based on their findings. Given that adherence to treatment is a huge challenge for most psychosocial and medical interventions, this study is an example of a methodologically sophisticated study that may be generalizable to many healthcare environments, help clinicians and patients to improve treatment adherence, and make a significant difference in public health.
In summary, research in the fields of clinical health psychology and behavioral medicine is continuing to improve upon translating findings into practical methods that have clear applications in the real world.
Patients suffering from comorbid chronic psychopathology and physical health concerns commonly present in healthcare settings. As such, gaining a better understanding of the relationships between physical and mental health is essential if treatments are to advance. One example of a study that has examined this complicated relationship was conducted by Stice, Gau, Rohde, and Shaw (2017). This research team (as well as their colleagues in numerous related studies) investigated the risk factors that predict the various DSM‐5 eating disorders (American Psychiatric Association, 2013). Stice et al. (2017) evaluated a rich array of variables that might predict the future onset of each DSM‐5 eating disorder. These disorders included anorexia nervosa, bulimia nervosa, binge eating disorder, and purging disorder. With a sample of 1,272 young women (M age of 18.5 years), the investigators conducted diagnostic interviews every year for 3 years of follow‐up assessment, following a series of their own prevention trials. In addition, they collected a vast amount of self‐report and weight, height, and health data. It was found that the strongest predictors leading to the development of eating disorders were related to negative affect, such as depressive symptoms, and interpersonal difficulties. As with much of the research literature on eating disorders, pursuit of a “thin ideal” and the associated body dissatisfaction that often accompanies this goal was strongly correlated with extreme dieting, unhealthy weight control behaviors, and the negative affect and interpersonal difficulties mentioned above. Therefore, the investigators note that incorporating interventions for depression and interpersonal discord into prevention efforts for eating disorders may be an effective strategy.
In summary, some types of chronic psychopathology, such as depression, are frequently observed with a large number of physical health concerns and diseases. The best research and clinical work accounts and plans for such comorbidity.
Given that health concerns (both physical and mental) can be influenced greatly by the distribution of wealth and opportunities for personal activity, it is our opinion that issues related to social justice should be of concern to everyone. Research and practice in the fields of clinical health psychology and behavioral medicine, therefore, should reflect these concerns. Fortunately, much of the recent work in these fields has begun to consider such concerns, and the emphasis is increasing enough to justify calling it a “trend.”
A good example is the work of Yang, Chen, and Park (2016), who examined perceived housing discrimination and self‐reported health. With a sample of 9,842 adults in 830 neighborhoods across Philadelphia, PA, the investigators were interested in whether certain neighborhood features matter in terms of overall health. Specifically, associations of increased perceived housing discrimination, and more negative self‐reported health, were strengthened in neighborhoods with relatively high housing values; however these associations were weakened in neighborhoods with a broader range of housing values and diversity (i.e., income, parenthood, and ethnic minority status). Another interesting finding of this large study was that the statistical models for illustrating a negative relationship between perceived housing discrimination and self‐reported health generally underestimate the relationship, unless the models also incorporate neighborhood features such as economic level, family diversity, and ethnic minority status. This large, sophisticated study by Yang et al. (2016) is an excellent example of research on the intersection of clinical health psychology, social justice, and multicultural issues.
In summary, there has been important research on social justice, health psychology, behavioral medicine, and a broad range of multicultural and diversity issues. This research area is growing rapidly, and it should help guide our future efforts in assessment, intervention, and follow‐up.
The trends discussed in this entry (while not all inclusive) appear to be among the most prominent, consistent, and frequently cited developments in the fields of clinical health psychology and behavioral medicine. While staying close to the data and what is recently published, we offer a few cautious recommendations about these trends.
The importance of the trend of sophisticated methodology cannot be exaggerated. The history of science suggests that it is only as good as its methods. Therefore, we applaud improvements in methodology such as larger and more diverse samples, multi‐method and multi‐source measures, and longitudinal data collection. This kind of ambitious, large, and sophisticated research, along with translation to the real world, requires skill, resources, and determination. We hope that the research and practice infrastructures will continue to support this important work.
The trend of an emphasis on chronic diseases is expected and necessary, especially considering the significant impact behavioral and emotional factors play on overall health status. Some very important research and translational efforts have been accomplished in this area, and we hope that this important work continues.
Our world is diverse. Therefore, our research, clinical work, and translational efforts should reflect diversity, broadly defined. In our opinion, the fields of clinical health psychology and behavioral medicine have made a considerable amount of progress on this issue. However, we would like these efforts to continue and expand.
Biology has been strongly associated with how we behave (including our personality traits). Moreover, the explosion in biological technology allows for more sophisticated assessments of biological variables. As such, over the past couple of decades, it has become increasingly more common in clinical health psychology and behavioral medicine research to incorporate more biological variables and to include more biological measures in clinical and translational efforts. This trend toward a stronger biological focus can be expensive, and the technical demands can be daunting, but we believe the benefits make it worthwhile. We predict that the incorporation of biological variables in health psychology research will become expected in the foreseeable future, moving the emphasis on biology from a trend to a centerpiece of the field.
The translation of health psychology knowledge into the real world of healthcare settings is an important trend in clinical health psychology and behavioral medicine. After all, if the results we read about in academic journals do not apply to actual clinical populations in typical healthcare settings, then the utility of these findings holds less meaning. Clearly, researchers in these fields are interested in improving the health status of as many people as possible, not just the “ideal candidate.”
Chronic psychopathology is often comorbid with health problems and diseases. Depression is a good example, as it is associated with almost every health problem and disease on record. Depressive comorbidity is not helpful when it comes to our health, as, for example, the association of long‐term depression with heart disease has many negative implications, including increased disability, disrupted close relationships, poorer adherence to medical and psychological regimens, increased problems at work and at home, further heart events, and increased rates of death from heart disease. Therefore, we can no longer afford to consider psychological and medical issues in isolation.
Last but not least, we discussed the importance of considering variables related to social justice. While progress has been made regarding the inclusion of variables relevant to social justice concerns as part of more traditional clinical health psychology and behavioral medicine studies, more emphasis regarding social justice variables clearly needs to be done. This work is exciting and important, and we need it if we are going to make progress for everyone.
C. Steven Richards, PhD, is a professor of psychological sciences at Texas Tech University. His research interests include depression, clinical health psychology and behavioral medicine, comorbidity of health problems and psychopathology, self‐control, and relapse prevention for depression. He has held 15 administrative positions during his faculty appointments at Texas Tech University, Syracuse University, and the University of Missouri–Columbia. Dr. Richards earned his PhD in clinical psychology at the State University of New York at Stony Brook (now Stony Brook University).
Lee M. Cohen, PhD, is dean of the College of Liberal Arts and professor in the Department of Psychology at the University of Mississippi. Dr. Cohen came to the University of Mississippi from Texas Tech University, where he served in a number of administrative roles including the director of the nationally accredited doctoral program in clinical psychology and the chair of the Department of Psychological Sciences. As a faculty member, he received several university‐wide awards for his teaching and academic achievement. As a researcher, he received more than $1.5 million from funding agencies, including the US Department of Health and Human Services, the National Science Foundation, and the National Institutes of Health/National Institute on Drug Abuse. His research program examines the behavioral and physiological mechanisms that contribute to nicotine use, and he worked to develop optimal smoking cessation treatments. Dr. Cohen is a Fellow of the American Psychological Association and the Society of Behavioral Medicine. He received his PhD in clinical psychology from Oklahoma State University.