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Published in final edited form as: Psychiatr Clin North Am. 2024 Mar 19;47(2):433–444. doi: 10.1016/j.psc.2024.02.008

Improving Exposure Therapy: Rationale and Design of an International Consortium

Jasper A J Smits 1,*, Jonathan S Abramowitz 2, Joanna J Arch 3, Santiago Papini 4, Rebecca A Anderson 5, Laura J Dixon 6, Bronwyn M Graham 7, Stefan G Hofmann 8, Jürgen Hoyer 9, Jonathan D Huppert 10, Jolene Jacquart 11, David Johnson 12, Peter M McEvoy 13, Dean McKay 14, Jill Newby 15, Michael W Otto 16, Andre Pittig 17, Winfried Rief 18, David Rosenfield 19, Kiara R Timpano 20, Andre Wannemüller 21, for the Exposure Therapy Consortium
PMCID: PMC11082449  NIHMSID: NIHMS1980963  PMID: 38724129

1. Rationale

Exposure therapy is a clinical strategy that involves confronting cues that activate the thoughts, emotions, and behavioral urges central to patients’ presenting problems. Cues can be internal (e.g., thoughts, sensations, feelings, images, memories) and/or external (e.g., situations, people). By guiding patients to approach these cues and engage in response prevention (i.e., without efforts to escape, avoid, or mitigate perceived danger), exposure therapy aims to facilitate learning opportunities that can promote symptom reduction and wellbeing1–3. A core and effective strategy in many established interventions for the anxiety, trauma- and stress-related, and obsessive-compulsive and related disorders4, exposure therapy has also been applied in the treatment of substance use disorders5, eating disorders6, obesity7, and depression8.

Exposure therapy is derived from classic extinction learning approaches to altering the learned associations to stimuli, but the complexity of the learning process involved has been increasing as a result of research findings spanning the T0 (basic biomedical research) to T2 (clinical trials) translational research continuum9. For example, animal studies and animal-to-human translation efforts related to the fear- and anxiety-related disorders have shown that the degree to which the learning of safety in response to feared cues stands apart from, is integrated with, or competes with a pre-existing fear memory depends on the degree to which the original fear learning is activated prior to safety learning and the similarity between the new and old learning contingencies10–12. There is also controversy about the relative contributions of associative and declarative learning processes in extinction in humans, and ongoing clinical research has expanded the list of potential moderators of exposure therapy efficacy13. The result is the emergence of a complex matrix of factors that may influence exposure therapy success in the clinic; enhancement of patient care relies on the resolution of these questions about how best to engage the mechanisms of exposure therapy while understanding the contextual factors that moderate responses to this engagement. Systematic clinical research conducted with careful attention to the exact nature of exposure therapy cues and contexts holds the promise of aligning clinical intervention with advances in research on extinction. Conducting this research in a consortium allows for larger-scale studies by sharing study burden across multiple sites, refinement of design using team science, and replicability across labs. Moreover, larger-scale studies of this nature have the statistical power to consider the moderating role of individual difference factors that are often overlooked in basic research on extinction, where the focus has typically been on a homogenous group of rodents or human participants. Outcomes from T2 clinical research therefore have the potential to be backward translated to inform the questions being addressed in T0 basic research, and enhance the validity of basic research relevant to exposure therapy.

Echoing concerns about replicability in related literatures, initial initiatives to improve the rigor of research related to exposure therapy have included collaborations like the Research Network for the European Interdisciplinary Study of Fear and Extinction Learning as well as the Return of Fear (EIFEL-ROF) and their guidelines for the design and analysis of studies on human fear acquisition, extinction, and return of fear14. We aim to complement such initiatives by establishing a global Exposure Therapy Consortium (ETC). By centralizing resources and expertise, the ETC aims to facilitate (1) team science devoted to questions surrounding the mechanisms, moderators, and associated procedural variables useful for efficacious application of exposure therapy, (2) targeted large-scale research collaborations across the translational research stages that have the potential to yield better data faster; and (3) training and implementation efforts that have the potential to increase exposure therapy uptake.

In this paper, we describe the design of the ETC and provide an overview of (initial) activities. We hope that this overview encourages participation from researchers and clinicians who are interested in furthering research on and implementation of exposure therapy.

2. Organizational Structure

ETC has adopted an organizational structure that can promote collaboration, productivity and quality control, while ensuring inclusivity and equal opportunity to participate in ETC activities (see Figure 1). All members complete an application and agree to the terms of a Memorandum of Understanding (see https://exposure.la.utexas.edu).

Figure 1.

Figure 1.

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ETC Organizational Structure.

Note: The ETC has two organizational arms supporting its mission. Both the research and clinical arms are managed by committees and a Board of Directors oversees all ETC activities. The research arm Steering Committee approves all research activities; which is supported by a Rigor and Reproducibility Committee that is specifically tasked with providing guidance on methodology for proposed research projects. Research Working Groups develop and implement research projects and share data with consortium for possible follow-up (meta-) analyses. The clinical arm Steering Committee provides leadership to support implementation and outreach activities. It is supported by a Membership and Outreach Committee (MOC), which is tasked with facilitating membership engagement among clinicians and clinical outreach initiatives across the globe. The MOC is supported by regional working groups to provide input and address needs particular to their region. Clinical Working Groups develop and facilitate training and implementation projects.

3. Research Activities

We have established two research Working Groups to date. The first focuses on mechanisms of action. This group has reviewed extant research and (1) summarized putative mechanisms that have received empirical attention to date (e.g., extinction, self-efficacy, distress tolerance, experiential avoidance, instrumental learning) and (2) provided recommendations for future research focusing on five specific priority areas: conceptualization, measurement, study design/analysis, and individual/contextual differences13. The second Working Group focuses on threat extinction, a putative target for exposure therapy. This group has been piloting a standardized procedure for de novo threat conditioning studies to help ensure that variations across labs are not due to the procedural differences that are evident in the conditioning literature14. These activities complement the publication of a book that reviews the application of exposure procedures across presenting problems3.

To stimulate ETC involvement and the development of new Working Groups and research project proposals, we designed a proof-of-principle study. The major aim of this pilot project is to identify and problem-solve obstacles involved in large-scale collaborative research on exposure therapy. In this next section, we describe this proof-of-principle project, the various obstacles we have encountered (and the solutions we implemented), and the lessons we have learned.

3.1. Study Aims.

Recognizing that coming to a design for any study may require a small rather than a large group of investigators, four investigators participated in a series of meetings to develop study aims, hypotheses, and procedures. Leveraging successes with one-session large-group exposure therapy documented by Wannemüller and colleagues15,16, we decided on the aim of testing the efficacy of a one-session large-group exposure therapy protocol for reducing anxiety sensitivity - a risk and maintaining factor for fear- and anxiety-related disorders17,18. To address the question of whether adding post-session processing may optimize exposure therapy efficacy, we proposed comparing two variants of the protocol. The first variant (STANDARD) includes a combination of psychoeducation and interoceptive exposure therapy modeling and practice. The second variant (ENHANCED) is identical to the first but also includes post-exposure practice processing aimed at facilitating threat reappraisal (i.e., safety learning). We proposed to compare the two variants of the protocol and include a general stress reduction protocol as a control condition (CONTROL). In order to achieve the study aim, we will randomly assign individuals with elevated anxiety sensitivity to one of the three conditions. In addition to the anxiety sensitivity, we will measure demographic and clinical characteristics upon study entry, as well as in-session experiences relevant to safety learning. Assessments of outcome variables will occur at pre-treatment, post-treatment, and at 1-week and 1-month follow-up.

The pre-registered hypotheses for the primary end-point are: 1a) Reduction in anxiety sensitivity from pre-treatment to post-treatment will be greater in the two exposure conditions (combined) relative to the control condition. 1b) Reduction in anxiety sensitivity from pre-treatment to post-treatment will be greater in the enhanced exposure relative to the standard exposure condition. For the secondary end-point, hypotheses are: 2a) Reduction in anxiety sensitivity from pre-treatment to 1-month follow-up will be greater in the two exposure conditions (combined) relative to the control condition. 2b) Reduction in anxiety sensitivity from pre-treatment to 1-month follow-up will be greater in the enhanced exposure relative to the standard exposure condition.

3.2. Research Team.

After developing the aims and procedures for the study, we approached colleagues with relevant expertise to join the investigative team. Two researchers developed a data analytic plan and power analysis for the study, agreed to oversee the randomization and analysis, and pre-registered the study (see https://clinicaltrials.gov/study/NCT05225740 and https://osf.io/uw3zs). Ten other researchers agreed to participate by collecting data at their respective sites. These researchers involved other members of their team (e.g., faculty, graduate students, research staff) to help conduct the study. Formalizing the collaboration involved reliance and data sharing agreements. We selected the University of Texas at Austin (UT) as the primary site and worked with their research office to engage the single IRB mechanism and implement necessary confidential data control plans.

3.3. Study Procedures.

Critical to a quality international multi-site site study involving the evaluation of a treatment protocol is removing unnecessary variability in procedures within and across sites. We have standardized procedures across aspects and phases of the proposed study and outline these next.

3.3.1. Sample size determination.

Power and sample size calculations were based on the ability to detect a small effect (i.e., a mean difference of 0.2 standard deviation between ENHANCED and STANDARD on the primary outcome) using a cluster randomized design with a 0.1 coefficient of variation of cluster size to account for differences in recruitment across sites, an intraclass correlation of 0.02, and cluster and individual auto-correlations of 0.80 (allowing for correlations to decay across time points). With these parameters, an average group size of 20 per treatment would yield 81% power with 10 sites (i.e., 200 per treatment), and 92% power with 14 sites (i.e., 280 per treatment) at the .05 significance level. Note that these sample size targets provide even greater power to detect differences between the combined exposure groups and the control condition, where effect sizes are expected to be medium to large. Calculations were made using an online power and sample size calculator for cluster randomized trials19.

3.3.2. Enrollment.

Because this is a non-funded feasibility study, we decided to limit enrollment to university students who receive course credit for research participation. Entry criteria included ages 18–70, elevated anxiety sensitivity, (i.e., Anxiety Sensitivity Index-3 [ASI-3]20 total score ≥23), and no history of respiratory or cardiovascular conditions, neurological disorders, pregnancy, or other medical problems that may interfere with an ability to complete interoceptive exposure procedures. These criteria will be assessed through self-report and eligibility will require an ASI-3 score ≥ 23 on two administrations21. All sites will use existing data acquisition platforms (e.g., Sona Systems, REDCap) to obtain written consent, screen, and enroll participants.

3.3.3. Randomization.

We will use cluster randomization: groups of participants will be randomized to one of the three study conditions. Cluster randomization sequences (blocks of 3 stratified by site) will be computer generated such that each block of 3 sequential groups includes one of each study condition (i.e., conditions do not repeat within each block). Participants will sign up to attend a group without knowing what study condition will be randomly assigned. Study condition allocation will be concealed from the study biostatistician until analyses are completed.

3.3.4. Interventions.

All interventions will be implemented in large-group format (targeted n ≥ 25 participants) in a classroom setting by a team of clinicians trained in exposure therapy. Aiding standardization, clinicians will deliver the interventions using a series of videos featuring one of the investigators providing instructions, education, and modeling.

STANDARD.

The STANDARD protocol includes an orientation and psychoeducation phase (approximately 20 min), an exposure practice phase (approximately 75 min), and a task to control for the extra intervention time in the ENHANCED condition (15 min).

Orientation/Psychoeducation phase:

Following general orientation, participants will watch a video which provides (1) information about anxiety sensitivity and its role in anxiety and related disorders, as well as the rationale for interoceptive exposure practice and (2) an overview of the intervention. Participants will then watch a video which shows a clinician and patient discussing the rationale for interoceptive exposure followed by the practice of three symptom induction exercises, namely (1) spinning; (2) straw breathing, and (3) voluntary hyperventilation. All exercises are safe strategies to produce feared bodily sensations allowing for effective exposure therapy22. Following the video, participants will be asked to respond to a series of questions (with corrective feedback offered by clinicians) to help ensure that psychoeducation resulted in an understanding of the model of exposure therapy and its procedures.

Exposure practice phase:

Participants will rotate in smaller subgroups through three group-based exposure exercises (30 seconds of spinning, 1 min of straw breathing, 1 min of hyperventilation), each led by a team of clinicians using separate classrooms. Each exposure exercise involves 5 repeated trials interspersed with ratings of anticipated and actual perceived threat and fear.

Control task:

To control for the time involved in the post-processing exercise in the ENHANCED condition, participants will complete a set of questions regarding the exercises (without a specific attempt to highlight the discrepancy between anticipated and actual outcomes). Following completion of the control task, all participants will reconvene in the main classroom for a group-based debriefing. The clinicians will be available to offer assistance with regulating the distress resulting from exposure practice should that be needed.

ENHANCED.

Participants assigned to ENHANCED will receive an intervention that is identical to STANDARD with the addition of a 15-minute post-processing exercise that precedes the group-based debriefing. This exercise starts with a brief video which shows a clinician and patient discussing the learning that had occurred during exposure practice. Following the video, participants will be asked to write out responses to a series of questions aimed at facilitating safety learning. Clinicians will engage the group in a brief discussion to aid processing.

CONTROL.

Participants assigned to this condition will receive the same amount in minutes of stress management training (SMT), which is designed to help people better cope with feelings of anxiety that accompany high levels of anxiety sensitivity. SMT will involve video-delivered group instruction, facilitated by clinicians, in healthy ways to experience and cope with stress whenever difficult situations arise. Participants will learn about the components of the stress response, including both its positive and negative consequences. SMT will also teach participants ways to maintain a healthy lifestyle, targeting things like nutrition, exercise, and sleep hygiene.

3.4. Assessment.

Data collection and entry procedures were standardized across sites. Specifically, the prescreens and follow-up surveys will be collected electronically, while data collected during the session (baseline, within-session, and post-intervention measures) will be recorded via paper and pencil and entered into REDCap by research teams following the session. To ensure data entry integrity, the primary outcome measure (ASI-3) will be double coded, and all data entered from the paper and pencil measures will be checked by multiple research team members.

To facilitate standardization, the REDCap database was developed and pilot-tested at the primary site before deployment to collaborating institutions. Once the database was deemed reliable, REDCap XML files were sent to research teams so that each site would have the identical database structure. The standardized REDCap database included additional sections for Institutional Review Board (IRB) reporting, participant tracking, and post-session reporting. These supplemental sections provided ways for research teams to keep track of participation, compensation, and any potential adverse events. Once all sessions are completed by a collaborating site, de-identified REDCap data will be sent to the relying institution and stored on secure, encrypted cloud servers. All data entered manually will be checked for inaccuracies prior to data analysis.

3.4.1. Primary Outcome Measure.

The ASI-3 is an 18-item self-report used to assess concern associated with possible negative consequences of anxiety-related symptoms. Responses are rated on a 5-point Likert scale ranging from 0 (very little) to 4 (very much) and summed to create a total score. Total scores range from 0 to 72. We selected this measure because of its sound psychometric properties20. We refer readers to a supplement (https://osf.io/7u6ef) that describes measures included in this protocol for screening and to achieve secondary aims.

3.5. Data Analysis.

The pre-registered analysis plan and any subsequent modifications are publicly available on the Open Science Framework (https://osf.io/uw3zs). Following intention-to-treat principles, all participants that attend their group will be included in the analyses. All analyses will use mixed effects (multilevel) modeling to account for the nested structure of the data: repeated measures (level 1) nested within participants (level 2) nested within groups (level 3) nested within sites (level 4). The primary outcome model (ASI-3) will include fixed effects of phase (pre-treatment, post-treatment, 1-week follow-up, 1-month follow-up), condition (exposure-enhanced, exposure-standard, control) and a condition-by-phase interaction. Helmert coding will be used for the conditions to make the comparisons necessary to test the hypotheses (i.e., both exposure conditions vs control; exposure-enhanced vs exposure standard). We will also fit alternative models (e.g., piecewise growth curves) and select the best-fitting model based on AIC/BIC. Primary end-point hypotheses will be tested by comparing changes in ASI-3 from pre-treatment to post-treatment. Secondary end-point hypotheses will be tested by comparing changes in ASI-3 from pre-treatment to 1-month-follow-up. Across all analyses, group differences will be considered significant at the standard p < .05 level. Each estimate will include a 95% confidence interval and a Cohen’s D effect size. Analyses will be conducted using the open-source statistical software R. After completion of the trial and publication of results, de-identified data, analysis code and output will be posted on the OSF repository for this project (https://osf.io/h4875/).

3.6. Training.

To minimize variability in study administration and implementation, we generated brief training modules for staff and clinicians and made these available on a study website (https://exposure.la.utexas.edu/research/projects/project-1/etc-training-modules). Each of these modules provides an overview of and education in procedures (e.g., screening, assessment, treatment) and systems (REDCap). The training for clinicians also includes a brief video-recorded workshop. Site-investigators will be responsible to ensure that staff and clinicians have completed the relevant training and are prepared to participate in the study.

3.7. Challenges.

Team science brings with it a series of challenges that are interpersonal and organizational in nature and reflect the complexities inherent in having highly-productive people from disparate institutions agree on common research methods that may nonetheless intersect with institution-specific barriers to completion. Fortunately, guidance is available for anticipating and addressing some of these challenges23. Significant challenges can also arise from outside the collaborative network. For example, after multiple delays caused by the COVID-19 pandemic, we have observed several challenges implementing the study as planned. First, obtaining IRB approval has required high levels of organization and communication from all sites. In some instances, slower communication between review boards or with lawyers about data sharing has resulted in minor delays in startups at collaborating sites. Utilizing the single IRB mechanism where possible aids efficiency; yet, the burden and responsibilities of managing documentation for multiple sites befalls the primary institution. Second, the decision to require REDCap presented challenges for some sites. Institutions that do not have a REDCap license must access REDCap at the primary site, which requires formal appointments at this site and the necessary training for new users of the REDCap system. The materials that we have posted on the study training website and providing opportunities to consult with primary site researchers have helped remedy this obstacle. Third, this study involves sites across different continents and thus required translation of study materials. To date, all study materials are available in English, German, Arabic and Hebrew; yet this required considerable effort, including extra piloting of the protocols to ensure the translations were understood as intended. At the same time, the ubiquitousness of English (e.g. in movies and shows) made subtitling the English videos quite feasible.

Perhaps because of the COVID-19 pandemic, we also observed changes in student participation in research studies. Specifically, across sites, enrollment rates for in-person studies have decreased relative to before the pandemic. Credit points toward study course requirements may also be insufficient to motivate large numbers of university students to participate in exposure groups, compared to clients presenting to mental health clinics due to distress and disability resulting from their anxiety sensitivity and associated panic symptoms. Thus, although university students were targeted due to their accessibility, it has been more difficult than anticipated to engage them in group therapy sessions. This can result in substantial delays and rescheduling of sessions, which results in additional administrative burden for research coordinators and poses continuity issues when students involved in facilitating projects are required to meet deadlines for thesis submissions and graduations. As a result, we have made the following changes to the protocol. First, although keeping 25 as the minimum target group size, all sites will run all scheduled sessions regardless of group size. Second, depending on the group size, sites can either rotate subgroups of participants through the three exposure tasks or complete all three with the full group. For the former option, sites can form three exposure practice “stations” in separate classrooms and assign clinicians to run these for three subgroups. Sites are instructed to use the same approach across the STANDARD and ENHANCED conditions at their site. Third, to maintain a reasonable clinician to participant ratio, sites can employ as many as two clinicians per exposure practice station to as few as one clinician for smaller groups. Fourth, because of the unexpected reduced participant flow, sites have the option to complete data collection (running three groups) across multiple semesters. Secondary analyses may be designed to test whether treatment delivery parameters (e.g., group size, use of subgroups, number of clinicians, date of the session) predict treatment outcome or moderate the between-group effects.

4. Clinical Activities

We have established one Clinical Working Group to date focused on creating a resource repository to support clinician training and delivery of exposure therapy for a wide range of presenting concerns. The Evidence-Based Practice Resource Repository (https://exposure.la.utexas.edu/clinical/resources) is a database of peer-reviewed research articles, empirically supported clinical guides and treatment manuals, educational videos and tools, that allow clinicians to easily locate useful information and tools to aid the delivery of effective exposure therapy. In addition, this Working Group group has developed several worksheets (e.g., exposure lists, monitoring distress during exposures, tracking out-of-session exposure practice) and made these available in multiple languages.

5. Benefits of Engagement in ETC

ETC was organized to provide benefit to the field by facilitating larger-scale studies that can be conducted with lower burden across multiple collaborating sites (with lower sample size demand at each of the participating sites). This strategy has the additional benefit of engaging multiple minds in the design and honing of proposed projects and affords automatic replication across sites using a standardized protocol. In addition to the enhanced research productivity and potentially higher impact of papers associated with team science collaborations24, investigators in ETC can reap the benefits of being exposed to: (1) a broader set of research measures, methods, and technical skills within one’s area of study, (2) the unique issues and proposed solutions faced by researchers at each site, (3) the automatic assumptions and well-thought theoretical conceptualizations held by multiple researchers within a subfield, (4) the potential to by-pass early stage funding needs as projects and protocols are developed, tested, and replicated across sites, (5) the opportunity to conduct larger sample size studies on detailed questions that may not be ready for large-scale funding requests, (6) international leaders to build local capacity for clinicians (e.g., clinical skills), researchers (e.g., trial methodology and coordination), and students, and (7) potential for competitiveness for research funding locally, nationally, and internationally.

6. Conclusions and Future Directions

In conclusion, ETC has successfully implemented an organizational structure aimed at fostering collaboration, productivity, and quality control. The establishment of research working groups targeting specific areas such as mechanisms of action and fear extinction signifies an organized and focused approach to tackling complex issues in exposure therapy. These groups have not only developed research agendas but have also contributed to the academic community through peer-reviewed articles and books. A proof-of-principle study has been initiated to further encourage collaborative research by identifying and resolving challenges related to large scale projects. Additionally, a Clinical Working Group has been set up to bolster clinician training and practice, featuring an extensive Evidence-Based Practice Resource Repository and a range of useful clinical tools available in multiple languages.

Despite the strides we have made, challenges remain. ETC has made use of technology to facilitate global collaboration while adopting a pragmatic approach of initiating projects within smaller, more localized groups. This strategy has proven effective in addressing logistical issues while maintaining the momentum of the consortium’s various activities. Overall, ETC has laid a robust foundation for advancing exposure therapy research and clinical practice through collaborative efforts, thereby making significant contributions to the field. Relatedly, although restrictions on in-person research have eased, difficulties in recruiting participants are ongoing and likely to persist. While challenging, these difficulties also present opportunities for innovation.

Looking to the future, the ETC could focus on expanding its working groups to cover more specialized areas within exposure therapy, potentially leading to additional multi-site trials for robust and generalizable findings. Technology integration, such as developing a dedicated platform for asynchronous collaboration, could alleviate the challenges of coordinating across time zones. The ETC is also well positioned to develop and test the feasibility of digital delivery of exposure therapy, which could enhance participant recruitment rates and aid in the democratization of access to exposure therapy globally. Another key area could be forming a world-wide conference on exposure therapy, international partnerships, and localized hubs to facilitate easier collaboration and to expand the consortium’s reach. This international focus could also extend to offering specialized training to clinicians worldwide, localizing clinical resources into additional languages, and engaging in policy advocacy to standardize exposure therapy protocols globally. Further, the consortium could capitalize on its data accumulation by employing advanced analytics for deeper insights and predictive modeling. Public awareness campaigns could be another avenue to combat negative beliefs associated with exposure therapy (and stigma of psychotherapy more broadly) and to disseminate evidence-based information. By pursuing these directions, the ETC has the potential to not only deepen its existing research but also expand its impact in advancing both the science and practice of exposure therapy on a global scale.

Key Points.

  • The Exposure Therapy Consortium (ETC) aims to facilitate team science devoted to questions surrounding the mechanisms, moderators, and associated procedural variables useful for efficacious clinical application of exposure therapy;

  • ETC can promote targeted large-scale research collaborations across the translational research stages that have the potential to yield better data faster;

  • ETC will facilitate training and implementation efforts that have the potential to increase exposure therapy uptake and effectiveness.

Synopsis.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, we describe the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. We discuss directions for expanding the consortium’s activities and its impact on a global scale.

Funding Support:

Author effort was supported as follows: Dr. Smits (NIMH R01MH125951), Dr. Hofmann (Alexander von Humboldt Foundation and Hessische Ministerium für Wissenschaft und Kunst), Dr. Newby (NHMRC 2008839), and Dr. Otto (NIMH R01 MH125949). These funding sources had no role in the content or the decision to publish this article.

Conflicts of Interest:

Dr. Smits receives funding from National Institute on Drug Abuse (NIDA R01DA047933), the National Cancer Institute (NCI R01CA273221), and Department of Defense (TP220002), and compensation and royalties from various publishers. Dr. Arch receives current research funding from the National Institutes of Health/ National Institute of Nursing Research (R01NR018479). Dr. Hofmann receives financial support by the Alexander von Humboldt Foundation (as part of the Alexander von Humboldt Professur) and the Hessische Ministerium für Wissenschaft und Kunst (as part of the LOEWE Spitzenprofessur). He also receives compensation for his work as editor from SpringerNature and royalties and payments for his work from various publishers. Dr. McEvoy receives compensation from The Guilford Press, Elsevier, Cambridge University Press, and McGraw-Hill Education. Dr. Newby receives funding from the Australian National Medical Research Council, and the Medical Research Future Fund. Dr. Otto receives compensation as an advisor to Big Health and receives grant support from National Institute of Mental Health, NIDA, and Big Health. Dr. Rosenfield reports funding from NIMH, NCI, National Center for Complementary and Integrative Health, and the Patient-Centered Outcomes Research Institute. He also receives compensation from several scientific journals and from Rosenfield Analytics. Dr. Rief received honoraria from Boehringer Ingelheim for talks on Post Covid, and he receives royalties from book publications from different publishers. All other authors report no conflicts of interest.

Footnotes

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