Effect of transdiagnostic cbt for anxiety disorders on comorbid diagnoses

Secondary depression in transdiagnostic group cognitive behavioral therapy among individuals diagnosed with anxiety disorders

Anxiety and depression co-occur at high rates, and their comorbidity typically creates a more severe clinical presentation then either alone. The effect of comorbid depression appears to vary across anxiety and related disorders. Transdiagnostic treatments present a promising option to improve comorbid conditions by targeting shared factors (e.g., information processing biases). The purpose of this study was to examine the reciprocal effects of secondary depression in transdiagnostic group cognitive behavioral therapy for anxiety (TGCBT). 120 individuals diagnosed with a primary anxiety disorder, 42 of whom had a depressive diagnosis, were enrolled in 12 weeks of TGCBT. Depressed individuals were compared to those without a depressive diagnosis on both clinician-rated and self-reported anxiety and depression following TGCBT. Although depressed individuals scored higher on most indices of anxiety at pre-treatment, both groups improved similarly with some evidence of greater improvement among those with comorbid depression. All individuals improved in self-reported depressive symptoms and comorbid depression improved to subclinical levels. These results posit TGCBT as an effective, efficient option for treating patients with anxiety and comorbid depression.

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called "lumpers" and "splitters"-those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper "Toward a Unified Treatment for Emotional Disorders" reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

Rethinking the service delivery system of psychological interventions in low and middle income countries

BACKGROUND

Global mental health is a growing field intricately connected to broader health, violence and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75 % of those with need in lower resource settings do not receive intervention. Most studies to date have examined the effectiveness of single-disorder mental health treatments - an approach that may be a significant challenge to scale-up and sustainability in lower resource settings.

MAIN BODY

This paper presents a brief overview of the scientific progress in global mental health, and suggests consideration of an internal stepped care delivery approach. An internal stepped care model is one idea of a delivery system, utilizing a common elements approach, where the same provider could navigate between different elements based on severity and type of problems of the client. It is distinct from traditional stepped care models in that clients remain with the same provider, rather than relying on referral systems.

CONCLUSION

An internal stepped care delivery system based on a simplified common elements approach could be more efficient, scalable, sustainable, and reduce the loss of clients to referrals in lower resource settings.

Intolerance of uncertainty and transdiagnostic group cognitive behavioral therapy for anxiety

BACKGROUND

Recent evidence suggests intolerance of uncertainty (IU) is a transdiagnostic variable elevated across anxiety disorders. No studies have investigated IU's response to transdiagnostic group CBT for anxiety (TGCBT). This study evaluated IU outcomes following TGCBT across anxiety disorders.

METHODS

151 treatment-seekers with primary diagnoses of social anxiety disorder, panic disorder, or GAD were evaluated before and after 12 weeks of TGCBT and completed self-report questionnaires at pre-, mid-, and post-treatment.

RESULTS

IU decreased significantly following treatment. Decreases in IU predicted improvements in clinical presentation across diagnoses. IU interacted with time to predict improvement in clinical presentation irrespective of primary diagnosis. IU also interacted with time to predict improvement in clinical presentation although interactions of time with diagnosis-specific measures did not. IUS interacted with time to predict reduction in anxiety and fear symptoms, and inhibitory IU interacted with time to predicted reductions in anxiety symptoms but prospective IU did not.

CONCLUSION

IU appears to be an important transdiagnostic variable in CBT implicated in both initial presentation and treatment change. Further implications are discussed.

Randomized controlled trial of group cognitive behavioral therapy compared to a discussion group for co-morbid anxiety and depression in older adults

BACKGROUND

Co-morbid anxiety and depression in older adults is associated with worse physical and mental health outcomes and poorer response to psychological and pharmacological treatments in older adults. However, there is a paucity of research focused on testing the efficacy of the co-morbid treatment of anxiety and depression in older adults using psychological interventions. Accordingly, the primary objective of the current study was to test the effects of a group cognitive behavior therapy (CBT) program in treating co-morbid anxiety and depression in a sample of older age adults.

METHOD

A total of 133 community-dwelling participants aged ⩾60 years (mean age = 67.35, s.d. = 5.44, male = 59) with both an anxiety disorder and unipolar mood disorder, as assessed on the Anxiety Disorder Interview Schedule (ADIS), were randomly allocated to an 11-week CBT group or discussion group. Participants with Mini-Mental State Examination scores <26 were excluded. Participants were assessed pre-treatment, post-treatment and at 6 months follow-up on the ADIS, a brief measure of well-being, Geriatric Anxiety Inventory and Geriatric Depression Scale.

RESULTS

Both conditions resulted in significant improvements over time on all diagnostic, symptom and wellbeing measures. Significant group × time interaction effects emerged at post-treatment only for diagnostic severity of the primary disorder, mean severity of all anxiety disorders, mood disorders, and all disorders, and recovery rates on primary disorder.

CONCLUSION

Group CBT produced faster and sustained improvements in anxiety and depression on diagnostic severity and recovery rates compared to an active control in older adults.

Transdiagnostic cognitive behavioural treatment and the impact of co-morbidity: An open trial in a cohort of primary care patients

BACKGROUND

The development of initiatives to improve access to psychological therapies has been driven by the realization that untreated anxiety and depression are both very common and costly to individuals as well as society. Effective and efficient treatments, mostly in the form of cognitive behavioural therapies (CBT), can be used in ways which enhance their acceptability and accessibility. To date, numbers of group therapies have been developed to improve cost efficiency, but in spite of growing interest in transdiagnostic approaches, group therapies have so far mostly been diagnosis specific.

AIMS

This study is aimed at evaluating a brief transdiagnostic cognitive behavioural group therapy (TCBGT) designed to treat both anxiety and depression among patients in primary care.

METHOD

The participants were 287 adult patients in primary care with diagnoses of depression and/or anxiety disorders. They underwent a 5-week TCBGT. A mixed design ANOVA was used to evaluate differential effects of treatment according to diagnostic groups (anxiety versus depression) and number of diagnoses (co-morbidity).

RESULTS

Pre-post differences were significant and the treatment was equally effective for both anxiety disorders and depression. Number of diagnoses did not affect the outcome.

CONCLUSIONS

The study indicates feasibility of the brief transdiagnostic group therapy for a wide range of mood and anxiety disorders in primary care. The results indicate that low intensity, brief transdiagnostic group therapies may be a feasible way to improve access to psychological therapies for a large number of patients.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial

Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d ≥ 1.48; avg. reduction ≥ 50%) and comorbid major depressive disorder (Cohen's d ≥ 1.64; avg. reduction ≥ 45%), social anxiety disorder (Cohen's d ≥ 0.80; avg. reduction ≥ 29%) and panic disorder (Cohen's d ≥ 0.55; avg. reduction ≥ 33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.

Intensive weekend group treatment for panic disorder and its impact on co-occurring PTSD: A pilot study

This pilot study examines the feasibility, acceptability, and potential effectiveness of delivering an intensive weekend group treatment for panic disorder (PD) to Veterans returning from deployments to Iraq and Afghanistan with co-occurring posttraumatic stress disorder (PTSD). The treatment program lasted 6h each day and was delivered by two experienced therapists. Patients received core components of panic treatment, including psychoeducation, cognitive restructuring, and interoceptive exposure. The interoceptive exposure exercises directly targeted anxiety sensitivity, a psychological construct also implicated in the maintenance of PTSD. Eighty-nine percent of patients who expressed interest in the treatment attended a baseline evaluation, and 63% of those who were study eligible initiated treatment. Treatment retention was high, with all 10 patients who initiated treatment completing the program. Veterans reported finding the treatment and delivery format highly acceptable and reported high levels of satisfaction. Panic symptoms improved significantly following the treatment and were maintained at a 7-month follow-up, with 71.4% of the sample reporting being panic free. Co-occurring PTSD symptoms also improved along with symptoms of anxiety and depression. Preliminary findings suggest that brief and intensive group treatments for PD/PTSD are a promising method of delivering cognitive behavioral therapy that may rapidly improve symptoms. This innovative treatment delivery format also may be a cost-effective way of increasing treatment engagement through increased access to quality care.

Transdiagnostic Case Conceptualization of Emotional Problems in Youth with ASD: An Emotion Regulation Approach

Youth with autism spectrum disorder often struggle to cope with co-occurring anxiety, depression, or anger, and having both internalizing and externalizing symptoms is a common clinical presentation. A number of authors have designed cognitive-behavioral interventions to address transdiagnostic factors related to multiple emotional problems, although none have applied this focus to youth with ASD. The current review article describes how a transdiagnostic emotion regulation framework may inform cognitive-behavioral interventions for youth with ASD, which until now have focused almost exclusively on anxiety. Research is needed to empirically test how a transdiagnostic intervention can address the processes of emotion regulation and assist youth with ASD to cope with their emotional disorders.

Case-Series Evaluating a Transdiagnostic Cognitive-Behavioural Treatment for Co-occurring Anxiety Disorders

BACKGROUND

Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioural interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating co-occurring anxiety disorders.

AIMS

To evaluate the efficacy of a transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders.

METHOD

An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13-session modular transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD.

RESULTS

Five of the six participants completed treatment. At posttreatment assessment the five treatment completers achieved diagnostic and symptomatic change, with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the 3-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre to postintervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at 3-month follow-up.

CONCLUSIONS

Results suggest that transdiagnostic cognitive behavioural interventions can be of benefit to patients with co-occurring anxiety disorders.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated promising results among patients with heterogeneous anxiety and comorbid depressive disorders when delivered on an individual basis, but greater efficiencies may be achieved with group-based applications. The aim of the present study was to provide a preliminary exploration of the UP when delivered in a group format. Among diagnostically diverse patients ( N = 11), the UP group treatment resulted in moderate to strong effects on anxiety and depressive symptoms, functional impairment, quality of life, and emotion regulation skills, as well as good acceptability and overall satisfaction ratings from patients. Three clinical cases are presented in detail to illustrate the group-based UP delivery, followed by a critical discussion of associated challenges and proposed guidelines for group administration, as well as directions for future research.

The expanding cognitive-behavioural therapy treatment umbrella for the anxiety disorders: disorder-specific and transdiagnostic approaches

Cognitive-behavioural therapy (CBT) is an empirically supported treatment for anxiety disorders. CBT treatments are based on disorder-specific protocols that have been developed to target individual anxiety disorders, despite that anxiety disorders frequently co-occur and are comorbid with depression. Given the high rates of diagnostic comorbidity, substantial overlap in dimensional symptom ratings, and extensive evidence that the mood and anxiety disorders share a common set of psychological and biological vulnerabilities, transdiagnostic CBT protocols have recently been developed to treat the commonalities among the mood and anxiety disorders. We conducted a selective review of empirical developments in the transdiagnostic CBT treatment of anxiety and depression (2008-2013). Preliminary evidence suggests that theoretically based transdiagnostic CBT approaches lead to large treatment effects on the primary anxiety disorder, considerable reduction of diagnostic comorbidity, and some preliminary effects regarding the impact on the putative, shared psychological mechanisms. However, the empirical literature remains tentative owing to relatively small samples, limited direct comparisons with disorder-specific CBT protocols, and the relative absence of the study of disorder-specific compared with shared mechanisms of action in treatment. We conclude with a treatment conceptualization of the new transdiagnostic interventions as complementary, rather than contradictory, to disorder-specific CBT.

Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: a systematic review and meta-analysis of published outcome studies

Transdiagnostic approaches to cognitive behaviour therapy (TCBT) of anxiety disorders have drawn increasing interest and empirical testing over the past decade. In this paper, we review evidence of the overall efficacy of TCBT for anxiety disorders, as well as TCBT efficacy compared with wait-list, treatment-as-usual, and diagnosis-specific cognitive behaviour therapy (CBT) controls. A total of 11 studies reporting 12 trials (n = 1933) were included in the systematic review. Results from the meta-analysis of 11 trials suggest that TCBT was generally associated with positive outcome; TCBT patients did better than wait-list and treatment-as-usual patients, and treatment gains were maintained through follow-up. The pooled estimate showed a moderate treatment effect, however with large heterogeneity suggesting differences in treatment effects between the studies. Also, all the included trials, apart from one, were judged to be associated with a high risk of bias. Only one study compared TCBT with diagnosis-specific CBT suggesting treatment effect of TCBT to be as strong as diagnosis-specific CBT. This study not only cautiously supports evidence for the efficacy of TCBT, but also suggests the need for more high-quality, large-scaled studies in this area. Transdiagnostic treatments offer great clinical promise as an affordable and pragmatic treatment for anxiety disorders and as a specialized treatment for co-morbid and other-specified anxiety disorders.

Predictors of length of stay among OEF/OIF/OND veteran inpatient PTSD treatment noncompleters

High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.

Transdiagnostic versus diagnosis-specific cbt for anxiety disorders: a preliminary randomized controlled noninferiority trial

BACKGROUND

Transdiagnostic cognitive-behavioral treatments for anxiety disorders have been gaining increased attention and empirical study in recent years. Despite this, research on transdiagnostic anxiety treatments has, to date, relied on open trials, or comparisons to waitlist conditions, published benchmarks, or relaxation-based interventions.

METHODS

The current study was a randomized clinical trial examining the efficacy of a 12-week transdiagnostic cognitive-behavioral group treatment in comparison to 12-week diagnosis-specific group Cognitive-Behavioral Therapy (CBT) protocols for panic disorder, social anxiety disorder, and generalized anxiety disorder.

RESULTS

Results from 46 treatment initiators suggested significant improvement during treatment, strong evidence for treatment equivalence across transdiagnostic and diagnosis-specific CBT conditions, and no differences in treatment credibility.

CONCLUSIONS

This study provides evidence supporting the efficacy of transdiagnostic CBT by comparison to current gold-standard diagnosis-specific CBT for social anxiety disorder, generalized anxiety disorder, and panic disorder. Transdiagnostic group CBT has the benefit of potentially easing dissemination and increasing access to evidence-based treatments for anxiety without sacrificing efficacy.