Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58-16.07) were significantly (p=0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96-8.16) and SAD (5.92 points; 95% CI: 4.64-7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT. We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.

The Effectiveness of Cognitive Bias Modification Interventions for Substance Addictions: A Meta-Analysis

Background and Aims

Cognitive bias modification (CBM) interventions, presumably targeting automatic processes, are considered particularly promising for addictions. We conducted a meta-analysis examining randomized controlled trials (RCTs) of CBM for substance addiction outcomes.

Methods

Studies were identified through systematic searches in bibliographical databases. We included RCTs of CBM interventions, alone or in combination with other treatments, for any type of addiction. We examined trial risk of bias, publication bias and possible moderators. Effects sizes were computed for post-test and follow-up, using a random-effects model. We grouped outcome measures and reported results for addiction (all related measures), craving and cognitive bias.

Results

We identified 25 trials, 18 for alcohol problems, and 7 for smoking. At post-test, there was no significant effect of CBM for addiction, g = 0.08 (95% CI -0.02 to 0.18) or craving, g = 0.05 (95% CI -0.06 to 0.16), but there was a significant, moderate effect on cognitive bias, g = 0.60 (95% CI 0.39 to 0.79). Results were similar for alcohol and smoking outcomes taken separately. Follow-up addiction outcomes were reported in 7 trials, resulting in a small but significant effect of CBM, g = 0.18 (95% CI 0.03 to 0.32). Results for addiction and craving did not differ by substance type, sample type, delivery setting, bias targeted or number of sessions. Risk of bias was high or uncertain in most trials, for most criteria considered. Meta-regression analyses revealed significant inverse relationships between risk of bias and effect sizes for addiction outcomes and craving. The relationship between cognitive bias and respectively addiction ESs was not significant. There was consistent evidence of publication bias in the form of funnel plot asymmetry.

Conclusions

Our results cast serious doubts on the clinical utility of CBM interventions for addiction problems, but sounder methodological trials are necessary before this issue can be settled. We found no indication that positive effects on biases translate into effects on addiction outcomes.

Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis

OBJECTIVE

Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted.

METHOD

Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem.

RESULTS

Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT. There was risk of bias as defined by the Cochrane Collaboration in the majority of studies. There was little indication that the presence of bias influenced outcome.

CONCLUSIONS

IPT is effective in the acute treatment of depression and may be effective in the prevention of new depressive disorders and in preventing relapse. IPT may also be effective in the treatment of eating disorders and anxiety disorders and has shown promising effects in some other mental health disorders.

PSYCHOLOGICAL TREATMENT OF DEPRESSION IN COLLEGE STUDENTS: A METAANALYSIS

BACKGROUND

Expanded efforts to detect and treat depression among college students, a peak period of onset, have the potential to bear high human capital value from a societal perspective because depression increases college withdrawal rates. However, it is not clear whether evidence-based depression therapies are as effective in college students as in other adult populations. The higher levels of cognitive functioning and IQ and higher proportions of first-onset cases might lead to treatment effects being different among college students relative to the larger adult population.

METHODS

We conducted a metaanalysis of randomized trials comparing psychological treatments of depressed college students relative to control groups and compared effect sizes in these studies to those in trials carried out in unselected populations of depressed adults.

RESULTS

The 15 trials on college students satisfying study inclusion criteria included 997 participants. The pooled effect size of therapy versus control was g = 0.89 (95% CI: 0.66∼1.11; NNT = 2.13) with moderate heterogeneity (I(2) = 57; 95% CI: 23∼72). None of these trials had low risk of bias. Effect sizes were significantly larger when students were not remunerated (e.g. money, credit), received individual versus group therapy, and were in trials that included a waiting list control group. No significant difference emerged in comparing effect sizes among college students versus adults either in simple mean comparisons or in multivariate metaregression analyses.

CONCLUSIONS

This metaanalysis of trials examining psychological treatments of depression in college students suggests that these therapies are effective and have effect sizes comparable to trials carried out among depressed adults.

Baseline Depression Severity as Moderator of Depression Outcomes Between Cognitive Behavioral Therapy vs Pharmacotherapy: An Individual Patient Data Meta-analysis

IMPORTANCE

Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical trials as well as traditional meta-analyses have considerable limitations in testing for moderators of treatment outcomes.

OBJECTIVES

To conduct a systematic literature search, collect primary data from trials, and analyze baseline depression severity as a moderator of treatment outcomes between cognitive behavioral therapy (CBT) and antidepressant medication (ADM).

DATA SOURCES

A total of 14 902 abstracts were examined from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and Cochrane Registry of Controlled Trials from 1966 to January 1, 2014.

STUDY SELECTION

Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included.

DATA EXTRACTION AND SYNTHESIS

Study authors were asked to provide primary data from their trial. Primary data from 16 of 24 identified trials (67%), with 1700 outpatients (794 from the CBT condition and 906 from the ADM condition), were included. Missing data were imputed with multiple imputation methods. Mixed-effects models adjusting for study-level differences were used to examine baseline depression severity as a moderator of treatment outcomes.

MAIN OUTCOMES AND MEASURES

Seventeen-item Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI).

RESULTS

There was a main effect of ADM over CBT on the HAM-D (β = -0.88; P = .03) and a nonsignificant trend on the BDI (β = -1.14; P = .08, statistical test for trend), but no significant differences in response (odds ratio [OR], 1.24; P = .12) or remission (OR, 1.18; P = .22). Mixed-effects models using the HAM-D indicated that baseline depression severity does not moderate reductions in depressive symptoms between CBT and ADM at outcome (β = 0.00; P = .96). Similar results were seen using the BDI. Baseline depression severity also did not moderate the likelihood of response (OR, 0.99; P = .77) or remission (OR, 1.00; P = .93) between CBT and ADM.

CONCLUSIONS AND RELEVANCE

Baseline depression severity did not moderate differences between CBT and ADM on the HAM-D or BDI or in response or remission. This finding cannot be extrapolated to other psychotherapies, to individual ADMs, or to inpatients. However, it offers new and substantial evidence that is of relevance to researchers, physicians and therapists, and patients.

The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: A meta-analysis

BACKGROUND

It is not clear whether cognitive behavior therapy (CBT) works through changing dysfunctional thinking. Although several primary studies have examined the effects of CBT on dysfunctional thinking, no meta-analysis has yet been conducted.

METHOD

We searched for randomized trials comparing CBT for adult depression with control groups or with other therapies and reporting outcomes on dysfunctional thinking. We calculated effect sizes for CBT versus control groups, and separately for CBT versus other psychotherapies and respectively, pharmacotherapy.

RESULTS

26 studies totalizing 2002 patients met inclusion criteria. The quality of the studies was less than optimal. We found a moderate effect of CBT compared to control groups on dysfunctional thinking at post-test (g=0.50; 95% CI: 0.38-0.62), with no differences between the measures used. This result was maintained at follow-up (g=0.46; 95% CI: 0.15-0.78). There was a strong association between the effects on dysfunctional thinking and those on depression. We found no significant differences between CBT and other psychotherapies (g=0.17; p=0.31), except when restrict in outcomes to the Dysfunctional Attitudes Scale (g=0.29). There also was no difference between CBT and pharmacotherapy (g=0.04), though this result was based on only 4 studies.

DISCUSSION

While CBT had a robust and stable effect on dysfunctional thoughts, this was not significantly different from what other psychotherapies or pharmacotherapy achieved. This result can be interpreted as confirming the primacy of cognitive change in symptom change, irrespective of how it is attained, as well as supporting the idea that dysfunctional thoughts are simply another symptom that changes subsequent to treatment.

Practitioner Review: Cognitive bias modification for mental health problems in children and adolescents: a meta-analysis

BACKGROUND

Despite accumulating research and bold claims about the efficacy of cognitive bias modification (CBM) for young populations, no meta-analysis has attempted to synthesize the research literature so far. We examined whether there was empirical evidence for the clinical efficacy of CBM interventions in youths, while also considering the methodological quality of this evidence.

METHODS

Studies were identified through systematic searches in bibliographical databases (PubMed, PsychInfo, Cochrane Library and EMBASE to June 2014). We included randomized controlled trials of CBM interventions, and considered both clinical outcomes and targeted biases. We examined the quality of the trials, as well as potential publication bias and possible moderators.

RESULTS

We identified 23 trials that reported on four types of outcomes: mental health, anxiety, depression and bias. Effect sizes were small and nonsignificant for all symptom outcomes considered. We found a moderate significant effect size for bias outcomes (Hedges' g of 0.53), with significant heterogeneity. There were no differences between types of CBM interventions, or between one versus multiple-session applications. A small but significant effect size for mental health problems arose when the intervention was delivered in schools. The quality of almost all of the included studies was suboptimal and the vast majority did not include information needed for allowing quality assessment.

CONCLUSIONS

We conducted the first meta-analysis of CBM interventions for children and adolescents and found no effects for mental health outcomes, but we did find moderate and significant effects on the targeted biases. Our results cast serious doubts on CBM interventions having any clinical utility for nonadult populations. Demand characteristics might play an important part in CBM research.

Characterizing psychological dimensions in non-pathological subjects through autonomic nervous system dynamics

The objective assessment of psychological traits of healthy subjects and psychiatric patients has been growing interest in clinical and bioengineering research fields during the last decade. Several experimental evidences strongly suggest that a link between Autonomic Nervous System (ANS) dynamics and specific dimensions such as anxiety, social phobia, stress, and emotional regulation might exist. Nevertheless, an extensive investigation on a wide range of psycho-cognitive scales and ANS non-invasive markers gathered from standard and non-linear analysis still needs to be addressed. In this study, we analyzed the discerning and correlation capabilities of a comprehensive set of ANS features and psycho-cognitive scales in 29 non-pathological subjects monitored during resting conditions. In particular, the state of the art of standard and non-linear analysis was performed on Heart Rate Variability, InterBreath Interval series, and InterBeat Respiration series, which were considered as monovariate and multivariate measurements. Experimental results show that each ANS feature is linked to specific psychological traits. Moreover, non-linear analysis outperforms the psychological assessment with respect to standard analysis. Considering that the current clinical practice relies only on subjective scores from interviews and questionnaires, this study provides objective tools for the assessment of psychological dimensions.

Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis

BACKGROUND

Cognitive bias modification (CBM) interventions are strongly advocated in research and clinical practice.

AIMS

To examine the efficiency of CBM for clinically relevant outcomes, along with study quality, publication bias and potential moderators.

METHOD

We included randomised controlled trials (RCTs) of CBM interventions that reported clinically relevant outcomes assessed with standardised instruments.

RESULTS

We identified 49 trials and grouped outcomes into anxiety and depression. Effect sizes were small considering all the samples, and mostly non-significant for patient samples. Effect sizes became non-significant when outliers were excluded and after adjustment for publication bias. The quality of the RCTs was suboptimal.

CONCLUSIONS

CBM may have small effects on mental health problems, but it is also very well possible that there are no significant clinically relevant effects. Research in this field is hampered by small and low-quality trials, and by risk of publication bias. Many positive outcomes are driven by extreme outliers.

Autonomic effects of cognitive reappraisal and acceptance in social anxiety: evidence for common and distinct pathways for parasympathetic reactivity

Few studies investigated the effects of emotion regulation strategies on autonomic parameters in socially anxious individuals. We asked 99 socially anxious participants to give an impromptu speech in front of an audience in a virtual reality environment. In the anticipation phase, they practiced an emotion regulation strategy: negative functional reappraisal, acceptance, negative dysfunctional reappraisal. All strategies led to decreases in parasympathetic activity and increases in heart rate during anticipation. Parasympathetic activity remained low in the recovery phase, while heart rate increased, indicating a possible rebound effect of social performance. Exploratory moderation analysis revealed that for subjects with higher social anxiety, acceptance led to increased parasympathetic activity in the anticipation and recovery phases than negative functional reappraisal. Our results indicate that although globally parasympathetic reactivity seems to be a more general marker of simply attempting to regulate emotions, it could help distinguish between emotion regulation strategies for some participant subgroups.

Moderating effects of empathic concern and personal distress on the emotional reactions of disaster volunteers

This study examines stress and mood outcomes in community volunteers who undertook one week's worth of post-disaster relief work in L'Aquila, Italy, which had been hit by an earthquake four months earlier. The study team obtained pre- and post-relief work data from 130 volunteers involved in activities such as preparing food for the displaced, cleaning the camps and distributing clean linen. The Perceived Stress Scale, the State-Trait Anxiety Inventory and the Profile of Mood States were administered at the start and at the end of the aid activities. Psychopathological symptoms and empathy were assessed in the beginning, using the Symptom Checklist 90 Revised and the Interpersonal Reactivity Index, respectively. The results show that, following the assistance work, volunteers displayed decreases in perceived stress, general distress, anxiety and anger, as well as increases in positive emotions. The empathy facets empathic concern and personal distress showed different patterns in modulating the post-disaster relief work adaptation for some of the mood outcomes.

Single nucleotide polymorphisms of tumor necrosis factor-alpha and the susceptibility to bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease of infancy. A "New" BPD has been characterized in preterm infants that may begin in utero, and then progress post-natally, resulting in arrested lung development and alveolar hypoplasia. Foundations for this "New" BPD may be derived from pro-inflammatory genes including tumor necrosis factor-alpha (TNFalpha). The hypothesis of the current study is that single nucleotide polymorphisms (SNPs) of the pro-inflammatory TNFalpha gene place preterm infants at increased risk for BPD. Preterm infants (105 in number) with birthweights <or=1 kg, who survived to at least 36 weeks postmenstrual age (PMA) or discharge were enrolled into this study. They were stratified for BPD according to their need for supplemental oxygen at 28 days and at 36 weeks PMA (non-, mild-, moderate-, or severe-BPD). DNA was extracted from these infants and subjected to analyses for the TNFalpha SNPs: -1,031, -863, -857, -308, and -238. The PHASE software (version 2.1) was used to reconstruct haplotypes and estimate their frequencies within the study population. Differences in birth weight (P < 0.001) and gestational age (P < 0.001), but not in racial distribution between the groups were found. Haplotype-specific analysis revealed no significant association between BPD severity and any of the 5-marker common haplotypes with 10 or more copies in this study population. Additionally, no significant association was observed in any three SNP haplotypes at -1,031, -863, and -857, and two SNP haplotypes at -308 and -238. We observed no association between BPD severity and the five TNFalpha SNPs investigated.

The genetic basis for bronchopulmonary dysplasia

While the 'original' bronchopulmonary dysplasia (BPD) was attributed to the iatrogenic effects of oxygen and barotrauma on the preterm lung, analyses of the 'new' BPD suggests that these environmental effects may contribute to arrested pulmonary development, and that there may also be genetic foundations for the susceptibility to BPD. Twinning, family and population studies implicate heritable factors in the evolution of BPD. The candidate genes examined for their potential role in BPD include surfactant apoprotein and inflammatory genes. With the identification and mapping of single nucleotide polymorphisms (SNPs), an explosion of testing for these genetic components that may contribute to a number of complex, multigenic disease conditions-including BPD-have been initiated. Sophisticated multiplex analyses are now available to link candidate SNPs to conditions such as BPD. However, there continues to be wide variation in the expression of BPD throughout neonatal units. Differentiating the effects caused by environmental and environmental-genetic interactions from isolated genetic etiologies is still problematic and will require carefully designed genetic analyses of preterm infant groups and their families.