Mind the gap: Improving the dissemination of CBT

Outpatient CBT for Underweight Patients with Eating Disorders: Effectiveness Within a National Health Service (NHS) Eating Disorders Service

Background: Underweight eating disorders (EDs) are notoriously difficult to treat, although a growing evidence base suggests that outpatient cognitive behaviour therapy for EDs (CBT-ED) can be effective for a large proportion of individuals. Aims: To investigate the effectiveness of CBT-ED for underweight EDs in a ‘real-world’ settings. Method: Sixty-three adults with underweight EDs (anorexia nervosa or atypical anorexia nervosa) began outpatient CBT-ED in a National Health Service setting. Results: Fifty-four per cent completed treatment, for whom significant changes were observed on measures of ED symptoms, psychological distress and psychosocial impairment. There was also a large effect on body weight at end-of-treatment. Conclusions: The results suggest that good outcomes can be achieved by the majority of those who complete treatment, although treatment non-completion remains a significant barrier to recovery. Future studies should focus on improving treatment retention, as evidence suggests that CBT-ED in ‘real-world’ settings is effective.

Priming attachment security improves attitudes towards a range of therapies

We sought to understand how attachment orientation influenced attitudes towards different types of psychological therapies. In two studies, we (1) examined attachment orientation as a predictor of attitudes towards different therapies and (2) tested whether attachment security priming could improve attitudes. Study 1 (n = 339) found associations between attachment orientation and attitudes towards, and likelihood of using different therapies. Positive and negative attitudes about different therapies mediated the relationship between attachment avoidance and likelihood of use. Study 2 (n = 412) showed that primed security (vs. neutral prime) improved attitudes towards relational, non-relational and distanced-relational therapies for those with a fearful-avoidant attachment orientation. For relational and distanced-relational therapies, the mechanism of this effect was increased cognitive openness. Attachment orientation is a determinant of therapy attitudes and anticipated help-seeking behaviour. Priming security may promote open-minded decision-making about some therapies. Findings are discussed with relevance to attachment theory, research and clinical practice.

Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial

BACKGROUND

Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT.

METHODS

Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale.

RESULTS

After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%.

CONCLUSIONS

Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

The implementation and adherence to evidence-based protocols for psychotherapy for depression: the perspective of therapists in Dutch specialized mental healthcare

BACKGROUND

Although psychotherapy is an effective treatment for depression, a large number of patients still do not receive care according to the protocols that are used in clinical trials. Instead, patients often receive a modified version of the original intervention. It is not clear how and when treatment protocols are used or modified in the Dutch specialized mental health care and whether these changes lead to suboptimal adherence to treatment protocols.

METHODS

In the context of an ongoing multicenter trial that investigates whether twice-weekly sessions of protocolized interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) for depression lead to better treatment outcomes compared to once-weekly sessions, two focus groups using semi-structured interviews were organized. Aims were to increase insight in the adherence to and modifications of CBT and IPT protocols in the Dutch specialized mental health care for depression. Participants were fifteen therapists from seven mental health locations part of five mental health organizations. Verbatim transcripts were coded and analyzed using qualitative software.

RESULTS

Three themes emerged: modification as the common practice, professional and patient factors influencing the adherence to protocols and organizational boundaries and flexibility. Treatment modification appeared to happen on a frequent basis, even in the context of a trial. Definitions of treatment modifications were multiple and varied from using intuition to flexible use of the same protocol. Therapist training and supervision, the years of work experience and individual characteristics of the therapist and the patient were mentioned to influence the adherence to protocols. Modifications of the therapists depended very much on the culture within the mental health locations, who differed in terms of the flexibility offered to therapists to choose and modify treatment protocols.

CONCLUSIONS

Not all treatment modifications were in line with existing evidence or guidelines. Regular supervision, team meetings and a shared vision were identified as crucial factors to increase adherence to treatment protocols, whereas additional organizational factors, among which a change of mindset, may facilitate adequate implementation.

Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists

BACKGROUND

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence.

OBJECTIVE

The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit.

METHODS

A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks.

RESULTS

A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1).

CONCLUSIONS

Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis

Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.

"Association splitting" versus cognitive remediation in obsessive-compulsive disorder: A randomized controlled trial

Studies have confirmed the efficacy of the cognitive intervention Association Splitting (AS) in obsessive-compulsive disorder (OCD) when applied as a self-help technique. AS aims to alter symptom-provoking automated cognitive networks of OC-related stimuli by building new or strengthening established but weak neutral associations. The aim of this study was to investigate the acceptance and benefits of therapist-assisted AS as an add-on to cognitive behavioral therapy (CBT). One hundred and nine patients with OCD who were undergoing CBT were randomly assigned to either AS or cognitive remediation (CR). Both groups were assessed at baseline, 4 weeks and 6 months later. The primary measure was the Yale-Brown Obsessive Compulsive Scale. Although patients' acceptance of AS was good, AS was not better than CR regarding overall symptom severity. However, a larger decrease was found from baseline to 6 months follow-up in AS regarding avoidance. Moreover, subsidiary analyses excluding control patients who had obtained information about AS indicated its superiority. Because superiority of AS was found in post hoc analyses excluding control patients who had obtained information on AS, we suggest that contagion effects deserve consideration.

An internet-based intervention for people with psychosis (EviBaS): study protocol for a randomized controlled trial

BACKGROUND

Evidence shows that internet-based self-help interventions are effective in reducing symptoms for a wide range of mental disorders. To date, online interventions treating psychotic disorders have been scarce, even though psychosis is among the most burdensome disorders worldwide. Furthermore, the implementation of cognitive-behavioral therapy (CBT) for psychosis in routine health care is challenging. Internet-based interventions could narrow this treatment gap. Thus, a comprehensive CBT-based online self-help intervention for people with psychosis has been developed. The aim of this study is the evaluation of the feasibility and efficacy of the intervention compared with a waiting list control group.

METHODS

The intervention includes modules on delusion, voice hearing, social competence, mindfulness, and seven other domains. Participants are guided through the program by a personal moderator. Usage can be amended by an optional smartphone app. In this randomized controlled trial, participants are allocated to a waiting list or an intervention of eight weeks. Change in positive psychotic symptoms of both groups will be compared (primary outcome) and predictors of treatment effects will be assessed.

DISCUSSION

To our knowledge, this project is one of the first large-scale investigations of an internet-based intervention for people with psychosis. It may thus be a further step to broaden treatment options for people suffering from this disorder.

TRIAL REGISTRATION

NCT02974400 (clinicaltrials.gov), date of registration: November 28th 2016.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

Patients’ Perspectives on Treatment with Metacognitive Training for OCD

Abstract. There is much room for improvement in the treatment of obsessive-compulsive disorder (OCD). The current study introduces a newly developed version of Metacognitive Training for OCD (MCT-OCD), inspired by the self-help intervention myMCT as well as by MCT group programs for other disorders. The current study examines the acceptability of the training. Forty-four patients with OCD received four sessions of MCT-OCD in addition to inpatient treatment. At post assessment, patients provided a subjective appraisal of the training. Analyses revealed high acceptability and added value of the MCT-OCD. The current, preliminary version of the MCT-OCD is promising in terms of patient acceptance. Results will be used to improve current shortcomings of the training and to develop a more comprehensive MCT-OCD.

Roadmap for optimizing the clinical utility of emotional stress paradigms in human neuroimaging research

The emotional stress response is relevant to a number of psychiatric disorders, including posttraumatic stress disorder (PTSD) in particular. Research using neuroimaging methods such as functional magnetic resonance imaging (fMRI) to probe stress-related neural processing have provided some insights into psychiatric disorders. Treatment providers and individual patients would benefit from clinically useful fMRI paradigms that provide information about patients' current brain state and responses to stress in order to inform the treatment selection process. However, neuroimaging has not yet made a meaningful impact on real-world clinical practice. This lack of clinical utility may be related to a number of basic psychometric properties that are often overlooked during fMRI task development. The goals of the current review are to discuss important methodological considerations for current human fMRI stress-related paradigms and to provide a roadmap for developing methodologically sound and clinically useful paradigms. This would include establishing various aspects of reliability, including internal consistency, test-retest and multi-site, as well as validity, including face, content, construct, and criterion. In addition, the establishment of standardized normative data from a large sample of participants would support our understanding of how any one individual compares to the general population. Addressing these methodological gaps will likely have a powerful effect on improving the replicability of findings and optimize our chances for improving real-world clinical outcomes.

Methylphenidate Has Superior Efficacy Over Parent-Child Interaction Therapy for Preschool Children with Disruptive Behaviors

OBJECTIVE

To compare the effectiveness between parent-child interaction therapy (PCIT) and methylphenidate in preschool children with attention-deficit/hyperactivity disorder (ADHD) symptoms and disruptive behaviors who had remaining significant behavior problems after previous behavioral parent training.

METHODS

We included 35 preschool children, ranging in age between 3.4 and 6.0 years. Participants were randomized to PCIT (n = 18) or methylphenidate (n = 17). Outcome measures were maternal ratings of the intensity and number of behavior problems and severity of ADHD symptoms. Changes from pretreatment to directly posttreatment were compared between groups using two-way mixed analysis of variance. We also made comparisons of both treatments to a nonrandomized care as usual (CAU) group (n = 17) regarding intensity and number of behavior problems. All children who started one of the treatments were included in the analyses.

RESULTS

Mothers reported a significantly more decreased intensity of behavior problems after methylphenidate (pre-post effect size d = 1.50) compared with PCIT (d = 0.64). ADHD symptoms reduced significantly over time only after methylphenidate treatment (d = 0.48) and not after PCIT. Changes over time of children in the CAU treatment were nonsignificant.

CONCLUSIONS

Although methylphenidate was more effective than PCIT, both interventions may be effective in the treatment of preschool children with disruptive behaviors. Our findings are preliminary as our sample size was small and the use of methylphenidate in preschool children lacks profound safety data as reflected by its off-label status. More empirical support is needed from studies with larger sample sizes.

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.

Costs and returns on training investment for empirically supported psychological interventions

Objective Financial costs are a significant barrier to the uptake of empirically supported psychological interventions in clinical settings. Training may be among the largest of these costs; however, the potential magnitude of these costs is unclear. The aim of the present study was to develop a hypothetical model of potential training costs associated with adopting a novel therapy using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income. Methods Direct and indirect costs were estimated for reference categories being cognitive behavioural therapy for social anxiety disorder delivered by registered psychologists. These were based on averages of 39 workshops and eight treatment manuals available in Australia identified through online searches. Results This model demonstrated that upper cost ranges for training can exceed A$55000, and even didactic training (reading manuals, attending workshops) may cost up to A$9000. Indirect costs of forfeited income account for a substantial proportion of these costs. Conclusions This hypothetical model highlights why training costs should be considered in decisions about disseminating and implementing novel empirically supported psychological interventions, particularly within private workforces. In addition, the direct return on training investment for practitioners in private practice is unclear, and may vary based on caseloads and current treatment modalities. Initiatives to track competence, support training and identify novel training solutions may be required to ensure the sustainability of high-quality mental healthcare. What is known about the topic? Financial costs are one of the leading factors determining whether empirically supported mental health treatments are adopted or sustained. Training costs may be one of the largest costs of disseminating and implementing novel psychological therapies within existing workforces, including both direct (e.g. workshop fees) and indirect (e.g. lost income) costs. However, little is understood about the potential magnitude of these costs. What does this paper add? This paper presents a hypothetical modelling of potential costs associated with adopting a novel therapy, with reference categories for an empirically supported treatment (cognitive behaviour therapy) for one mental disorder (social anxiety disorder) for one mental health profession (psychologist). This model was developed and populated using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income. What are the implications for practitioners? With potential costs for adopting one novel psychological intervention exceeding A$55000, we highlight why training costs and pathways should be a focal point for ensuring the sustainable provision of high-quality mental healthcare in Australia.

Cognitive behavioural therapy for eating disorders: how do clinician characteristics impact on treatment fidelity?

BACKGROUND

Clinicians routinely report not practising evidence-based treatments with eating disorders. There has been limited research investigating the impact of adaptable clinician characteristics such as self-efficacy and therapeutic optimism in this area. This study evaluated if there is a relationship between clinician therapeutic optimism, self-efficacy and the provision of evidence-based practice in the treatment of bulimia nervosa and binge eating disorder.

METHOD

A survey developed for this study was administered to 100 psychologists who were recruited online via a range of organisations affiliated with psychology and/or eating disorders. The survey measured demographic factors, eating disorder treatment knowledge, treatment fidelity, the use of individual treatment components and a range of clinician characteristics including self-efficacy and therapeutic optimism.

RESULTS

Results demonstrated that clinician self-efficacy was positively associated with and predicted treatment fidelity. Therapeutic optimism had significant low correlations with treatment fidelity but did not predict treatment fidelity.

CONCLUSION

These findings would suggest that strengthening clinician self-efficacy is useful in improving evidence-based practice in the treatment of binge eating disorder and bulimia nervosa and may also have implications in the training of clinicians. The study also demonstrated that the use of a range of knowledge translation strategies are valuable in enhancing clinician adherence to evidence-based practice. Further research with direct measures of treatment fidelity is needed to clarify these findings.

A qualitative exploration of psychosocial specialists' experiences of providing support in UK burn care services

INTRODUCTION

A burn can have a significant and long-lasting psychosocial impact on a patient and their family. The National Burn Care Standards (2013) recommend psychosocial support should be available in all UK burn services; however, little is known about how it is provided. The current study aimed to explore experiences of psychosocial specialists working in UK burn care, with a focus on the challenges they experience in their role.

METHODS

Semi-structured telephone interviews with eight psychosocial specialists (two psychotherapists and six clinical psychologists) who worked within UK burn care explored their experiences of providing support to patients and their families.

RESULTS AND DISCUSSION

Thematic analysis revealed two main themes: burn service-related experiences and challenges reflected health professionals having little time and resources to support all patients; reduced patient attendance due to them living large distances from service; psychosocial appointments being prioritised below wound-related treatments; and difficulties detecting patient needs with current outcome measures. Therapy-related experiences and challenges outlined the sociocultural and familial factors affecting engagement with support, difficulties treating patients with pre-existing mental health conditions within the burn service and individual differences in the stage at which patients are amenable to support.

CONCLUSION

Findings provide an insight into the experiences of psychosocial specialists working in UK burn care and suggest a number of ways in which psychosocial provision in the NHS burn service could be developed.

Transdiagnostic Therapy

Transdiagnostic cognitive-behavioral (CBT) therapy is a modified form of CBT designed to be applicable with patients across the range of anxiety and related emotional disorders. Based on emerging genetic, neurologic, developmental, cognitive, and behavioral science, transdiagnostic CBT may alleviate barriers to dissemination and accessibility by providing a single treatment approach across diagnoses. Data from clinical trials and metaanalyses suggest treatment efficacy that is comparable with traditional CBT approaches, with possibly superior efficacy among patients with multiple comorbid anxiety and emotional diagnoses. Limitations in the evidence base and remaining areas for future research are discussed.

Therapist-Reported Features of Exposure Tasks That Predict Differential Treatment Outcomes for Youth With Anxiety

OBJECTIVE

Exposure tasks are recognized widely as a key component of cognitive-behavioral therapy (CBT) for child and adolescent anxiety. However, little research has examined specific exposure characteristics that predict outcomes for youth with anxiety and that may guide its application in therapy.

METHOD

This study draws on a sample of 279 children and adolescents (48.4% male; 79.6% white) with a principal anxiety disorder who received 14 sessions of CBT, either alone or in combination with medication, through the Child/adolescent Anxiety Multimodal treatment Study (CAMS). The present study examines therapist-reported quantity, difficulty level, compliance, and mastery of exposure tasks as they related to CBT response (i.e., Clinical Global Impressions-Improvement ratings). Secondary treatment outcomes included reduction in anxiety symptom severity on the Pediatric Anxiety Rating Scale, global impairment measured via the Children's Global Assessment Scale, and parent-report of anxiety-specific functional impairment on the Child Anxiety Impairment Scale.

RESULTS

Regression analyses indicated a dose-response relationship between therapist-reported quantity of exposure and independent evaluations of treatment outcome, with more time devoted to exposure linked to better outcomes. Similarly, greater time spent on more difficult (rather than mild or moderate) exposure tasks predicted better outcomes, as did therapist ratings of child compliance and mastery.

CONCLUSION

The present findings highlight the importance of challenging children and adolescents with difficult exposure tasks and of collaborating to ensure compliance and mastery.

Simple or complex? A case study of physical and mental health co-morbidity

People with epilepsy are significantly more likely to have a mental health disorder than those without a chronic illness. The reasons for this are multiple but may include the mental health difficulties being perceived as complex due to the presence of a chronic illness. In part due to the apparent complexity of the co-occurring physical and mental illness, many are not offered evidence-based treatment (EBT) for the mental health disorder. There is little guidance to inform clinicians about the interventions to use to treat mental health disorders in people with epilepsy. The present paper reports a case of treatment for depression using a standard EBT in a young person with epilepsy. The patient also had clinically significant symptoms of anxiety and an eating disorder and would be considered ‘complex’ according to standard criteria. The intervention, however, was relatively simple and was delivered as guided self-help via 10 weekly telephone calls of approximately 30 minutes duration, and two follow-up calls at one month and three months post-intervention. Self-report and parent-report questionnaire measures were completed before and after the intervention, and at both follow-up time points. A blind-rated online diagnostic interview measure was also completed before and after the intervention. The young person and her family also completed a qualitative interview of their experiences of the intervention. This simple intervention was effective in working towards the client's goals, although pre–post measurement on standard measures was variable. This interesting case raises questions about whether patients with mental and physical comorbidities are complex, or just perceived as complex.

Implementation of internet-delivered CBT for children with anxiety disorders in a rural area: A feasibility trial

Child anxiety disorders are highly prevalent and cause significant impairment. Cognitive behavioral therapy (CBT) is recommended for child anxiety disorders, but access to CBT is limited, particularly in rural areas. Internet-delivered CBT (ICBT) can help increase the availability of evidence-based interventions and evidence is beginning to accumulate to indicate that ICBT is efficacious for children with anxiety disorders. However, whether the results of controlled trials are transferrable to real-world clinical settings is unclear. The objective of this study was to evaluate whether therapist-guided ICBT is feasible and potentially effective when implemented in an outpatient clinic in rural Sweden. Children (N = 19) aged 8-12 with anxiety disorders underwent a 12-week ICBT program called BiP Anxiety. Feasibility measures included treatment satisfaction, compliance and feedback from clinicians. Clinical outcome measures were clinician-, parent- and child ratings of anxiety symptoms and functional impairment. Overall, participants and clinicians were satisfied with the treatment content and format. There were statistically significant changes from pre- to post-treatment on the primary outcome measure (t = - 4.371, p < 0.001), as well as on all secondary outcome measures. Therapeutic gains were maintained for up to three months from the post-treatment assessment. At follow-up, 68% were no longer in need of treatment and could be discharged from the clinic. The study suggests the feasibility of implementing ICBT in regular health care. Implementation of ICBT could dramatically increase access to evidence based treatment for children with anxiety disorders who live far away from specialist clinics.

Internet interventions for depression: new developments

A wide range of Internet interventions, mostly grounded in methods of cognitive behavioral therapy, have been developed and tested for several mental disorders. The evidence to date shows that these interventions are effective in reducing symptoms of depression. Metaanalyses report small-to-medium effect sizes when Internet interventions are delivered as stand-alone self-help interventions (d=0.25-0.36), and medium-to-large effect sizes when delivered as therapist-guided interventions (d=0.58-0.78), both compared with usual care. Only a minority of people suffering from depression receive adequate treatment, and Internet interventions might help bridge the large treatment gap. This review summarizes the current body of evidence and highlights pros and cons of Internet interventions. It also outlines how they could be implemented in mental health care systems and points out unresolved questions, as well as future directions, in this research field.

Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial

BACKGROUND

Few studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health.

OBJECTIVE

To determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans.

DESIGN

Pragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC).

PARTICIPANTS

A total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics.

INTERVENTION

bCBT was delivered to 180 participants by staff mental health providers (n = 19). bCBT addressed physical and emotional health using a modular, skill-based approach. bCBT was delivered in person or by telephone over 4 months. Participants randomized to EUC (n = 122) received a mental health assessment documented in their medical record.

MAIN MEASURES

Primary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included health-related quality of life. Assessments occurred at baseline, posttreatment (4 months), and 8- and 12-month follow-up.

KEY RESULTS

Participants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4+ sessions). bCBT improved symptoms of depression (p = 0.004; effect size, d = 0.33) and anxiety (p < 0.001; d = 0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12 months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12 months.

CONCLUSIONS

Integrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent, and the impact on physical health outcomes was limited to shorter-term effects and COPD participants. Clinical trials.Gov identifier: NCT01149772.

Program ACTIVE: Cognitive Behavioral Therapy to Treat Depression in Adults With Type 2 Diabetes in Rural Appalachia

High rates of type 2 diabetes (T2DM) and depression exist in rural Appalachia with limited access to psychotherapeutic treatment. No manualized cognitive behavioral therapy (CBT) treatment materials exist that are culturally tailored for individuals in this region with T2DM. We describe the development of the Program ACTIVE CBT intervention for use with adults with T2DM and depression by mental health providers in rural Appalachia. Qualitative and quantitative methods were used to test the feasibility and acceptability of Program ACTIVE. Intervention materials were rated at the 6th-7th grade reading level. Key informant interviews evaluated materials as culturally sensitive and accessible. Participants indicated high levels of satisfaction with therapy (94%), support from their therapist (86%), and usefulness of therapy and depression improvement (80.3%). Program ACTIVE was found to be a feasible and acceptable culturally tailored manualized CBT treatment for adults with T2DM and depression living in rural Appalachia. Implementation of these materials on a regional scale needs to be assessed.

The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55-1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.

Evidence-Based Psychotherapy in Primary Care

The functional and financial effects of untreated psychiatric disorders within primary care have led to the development of novel service delivery models to improve access to high-quality, evidence-based mental health treatments. Cognitive-behavioral therapy (CBT) is an efficacious and effective psychotherapeutic approach for treating a broad range of mental health conditions. CBT is a practical, skill-building approach that emphasizes self-efficacy and self-management of symptoms while working toward defined and measurable treatment goals. Although significant barriers to the full dissemination of CBT remain, collaborative care and integrated behavioral health programs embedded within primary care clinics can enhance treatment outcomes by using CBT. Identifying core CBT principles used in the treatment of anxiety (e.g., exposure), depression (e.g., behavioral activation), and insomnia (e.g., stimulus control) is an important step toward improving the quality of care for these conditions. High-impact, low-intensity CBT programs hold promise in improving access to this evidence-based treatment across a broader population.

Efficacy of cognitive-behavioral therapy for childhood anxiety and depression

A review of meta-analyses of cognitive-behavioral therapy (CBT) for childhood anxiety and depression was conducted. A total of 36 meta-analyses were identified that met inclusion criteria for this review. In most cases, medium-to-large effect sizes for treatment reduction were observed when CBT was compared to non-active control conditions. Small-to-medium effects were observed when CBT was compared to active control treatments. The available meta-analyses generally did not examine, or data were not sufficient to evaluate, potential moderators of outcome, differential effects for parental involvement, or changes in quality of life or functional outcomes associated with treatment. Accordingly, while CBT should be broadly considered an effective treatment approach for childhood anxiety and depression, additional research is warranted in order to establish guidelines for service delivery for complicating factors in client presentation.

The PED-t trial protocol: The effect of physical exercise -and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder

BACKGROUND

Sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t). The therapeutic underpinnings of these separate treatment components are well-known, but their combination to treat BN and BED have never been previously tested. The purpose of this paper is to provide the rationale for this new treatment approach and to outline the specific methods and procedures.

METHODS

The PED-t trial uses a prospective randomized controlled design. It allocates women between 18 and 40 years (BMI range 17.5-35.0) to groups consisting of 5-8 members who receive either CBT or PED-t for 16 weeks. Excess participants are allocated to a waiting list control group condition. All participants are assessed at baseline, post-treatment, 6, 12 and 24 months' post-follow-up, respectively, and monitored for changes in biological, psychological and therapy process variables. The primary outcome relates to the ED symptom severity, while secondary outcomes relates to treatment effects on physical health, treatment satisfaction, therapeutic alliance, and cost-effectiveness. We aim to disseminate the results in high-impact journals, preferable open access, and at international conferences.

DISCUSSION

We expect that the new treatment will perform equal to CBT in terms of behavioral and psychological symptoms, but better in terms of reducing somatic symptoms and complications. We also expect that the new treatment will improve physical fitness and thereby, quality of life. Hence, the new treatment will add to the portfolio of evidence-based therapies and thereby provide a good treatment alternative for females with BN and BED.

TRIAL REGISTRATION

Prospectively registered in REC the 16th of December 2013 with the identifier number 2013/1871 , and in Clinical Trials the 17th of February 2014 with the identifier number NCT02079935 .

Randomised controlled trial of online continuing education for health professionals to improve the management of chronic fatigue syndrome: a study protocol

INTRODUCTION

Chronic fatigue syndrome (CFS) is a serious and debilitating illness that affects between 0.2%-2.6% of the world's population. Although there is level 1 evidence of the benefit of cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for some people with CFS, uptake of these interventions is low or at best untimely. This can be partly attributed to poor clinician awareness and knowledge of CFS and related CBT and GET interventions. This trial aims to evaluate the effect of participation in an online education programme, compared with a wait-list control group, on allied health professionals' knowledge about evidence-based CFS interventions and their levels of confidence to engage in the dissemination of these interventions.

METHODS AND ANALYSIS

A randomised controlled trial consisting of 180 consenting allied health professionals will be conducted. Participants will be randomised into an intervention group (n=90) that will receive access to the online education programme, or a wait-list control group (n=90). The primary outcomes will be: 1) knowledge and clinical reasoning skills regarding CFS and its management, measured at baseline, postintervention and follow-up, and 2) self-reported confidence in knowledge and clinical reasoning skills related to CFS. Secondary outcomes include retention of knowledge and satisfaction with the online education programme. The influence of the education programme on clinical practice behaviour, and self-reported success in the management of people with CFS, will also be assessed in a cohort study design with participants from the intervention and control groups combined.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Human Research Ethics Committee at The University of New South Wales (approval number HC16419). Results will be disseminated via peer-reviewed journal articles and presentations at scientific conferences and meetings.

TRIAL REGISTRATION

ACTRN12616000296437.

Die Relevanz der Ausbildung für den späteren Einsatz von Expositionsverfahren in der therapeutischen Praxis

Zusammenfassung. Theoretischer Hintergrund: Obwohl empirische Belege für Expositionsmethoden sprechen, werden diese in der Praxis zu wenig eingesetzt. Fragestellung: Es wurden Faktoren auf individueller und institutioneller Ebene identifiziert, welche für eine spätere Anwendung von Expositionsmethoden in der Praxis relevant sind und im deutschen Ausbildungssystem untersucht. Methode: Insgesamt wurden 20 Ausbildungsinstitute und 398 Absolvent_innen befragt. Mit einer Multilevelanalyse wurde die Relevanz verschiedener Faktoren geprüft. Ergebnisse: Auf individueller Ebene waren Ausbildungstyp (KiJu vs. Erwachsene) und inhaltliche Aspekte (z. B. die Einstellung zu Expositionsmethoden) für den späteren Expositionseinsatz wichtig. Auf institutioneller Ebene war eine universitäre Anbindung der Ausbildungsinstitute relevant. Schlussfolgerungen: Innerhalb der Ausbildung trägt die vermehrte Vermittlung von sowohl störungs- als auch methodenspezifischem Wissen zur Verwendung von Expositionsverfahren bei. Absolventen und deren spätere Patienten profitieren von praktischer Übung der Methodik, vor allem dann, wenn realistische Überzeugungen hinsichtlich der Wirksamkeit und Umsetzbarkeit der Methode entwickelt werden.

Therapist Training on Cognitive Behavior Therapy for Anxiety Disorders Using Internet-Based Technologies

This study investigated a technology-enhanced training protocol to facilitate dissemination of therapist training on cognitive behavior therapy (CBT) for anxiety disorders. Seventy community clinicians received an online tutorial followed by live remote observation of clinical skills via videoconference. Impact of training on patient outcomes was also assessed. Training resulted in a significant increase in both trainee knowledge of CBT concepts and techniques and therapist competence in applying these skills. Patients treated by trainees following training had significant reductions in anxiety and depression. Ratings of user satisfaction were high. Results provide support for the use of these technologies for therapist training in CBT.

Internet-Delivered Acceptance-Based Cognitive-Behavioral Intervention for Social Anxiety Disorder With and Without Therapist Support: A Randomized Trial

Social anxiety disorder (SAD) is one of the most prevalent psychiatric disorders in the United States. Although evidenced-based behavioral treatments are available, less than 20% of those with SAD receive treatment. Internet-based interventions can address barriers to treatment access, and guided Internet-based treatments have been demonstrated to be effective for SAD. However, the optimal role (if any) of the therapist in such programs remains unclear. We examined the acceptability and efficacy of a novel Internet-based cognitive-behavior therapy for SAD that utilizes traditional behavioral interventions (e.g., exposure) within the context of a model emphasizing mindfulness and psychological acceptance. Forty-two participants were randomized to an eight-module self-help intervention with ( n = 20) or without ( n = 22) adjunctive therapist support; the therapist support was delivered through 10 to 15 min of weekly videoconferencing and daily text messages. Both groups experienced a significant reduction in SAD symptoms and improvements in functioning and quality of life, with no significant differences between groups in both completer-only and intent-to-treat analyses. However, the therapist support group evidenced lower attrition than the minimal support group (20% vs. 50%). Implications for dissemination and future directions are discussed.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis

Research evaluating transdiagnostic CBT (tCBT) demonstrates its efficacy. Some evidence suggests equivalence between tCBT and diagnosis-specific CBT (dxCBT), however more investigations are necessary to clarify any difference in efficacy. This meta-analysis was conducted to compare tCBT and dxCBT, and to investigate the differential impact of comorbidity on effect sizes. Pre and post scores from primary anxiety measures in 83 treatment conditions, taken from studies primarily targeting anxiety disorders, were summarised and compared. Meta-regression analyses were then used to test the effects of comorbidity. DxCBT and tCBT meta-effects were found to be large, where g=0.951, 95% CI: 0.874-1.027, and g=1.059, 95% CI: 0.876-1.242, respectively. While statistically different (p=0.008), overlap of confidence intervals indicated a lack of clinical significance. Furthermore, no relationship between comorbidity rate and tCBT outcome was observed. These results were discussed in the context of previous findings in the transdiagnostic CBT literature.

Internet-Delivered Cognitive Behavior Therapy for Adolescents With Irritable Bowel Syndrome: A Randomized Controlled Trial

OBJECTIVES

Few treatments have been able to effectively manage pediatric irritable bowel syndrome (IBS). Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure for abdominal symptoms is effective for adult IBS. The objective of this study was to evaluate the efficacy of Internet-CBT based on behavioral exposure for adolescents with IBS.

METHODS

Adolescents with IBS fulfilling the Rome III criteria were randomized to either Internet-CBT or a wait-list control. The Internet-CBT was a 10-week intervention where the main component was exposure to IBS symptoms by reduction of avoidance of abdominal symptoms and instead stepwise provocation of symptoms. The primary outcome was total score on Gastrointestinal Symptoms Rating Scale for IBS (GSRS-IBS). Secondary outcomes included adolescent- and parent-rated quality of life and parent-rated gastrointestinal symptoms. Difference between groups was assessed from pretreatment to posttreatment and the Internet-CBT group was also evaluated at 6 months after treatment completion.

RESULTS

A total of 101 adolescents with IBS (13-17 years of age) were included in this study. Dropout rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on mixed effects models. Analyses showed a significant larger pretreatment to posttreatment change on the primary outcome GSRS-IBS (B=-6.42, P=0.006, effect size Cohen's d=0.45, 95% confidence interval (0.12, 0.77)) and on almost all secondary outcomes for the Internet-CBT group compared with the control group. After 6 months, the results were stable or significantly improved.

CONCLUSIONS

Internet-CBT based on exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life.

Borderline Personality Disorder: Treatment from the Contextual Perspective

In relation to the psychotherapy of borderline personality disorder (BPD), the contextual model embraces the subjective components that operate alongside the more readily objectifiable elements of the medical model. The latter include the guidelines of the various psychodynamic and cognitive approaches, the randomized control trials of these approaches, follow-up studies, and data from MRI and other neurophysiological tests. The contextual model focuses on less easily measurable factors that comprise the real relationship between therapist and patient, including the heterogeneity in the BPD domain. Another component consists of patient expectations at the outset, the placebo effect of having an ally in the person of the therapist, and the nature of the patient's primary unconscious conflicts. These combined elements exert a major influence vis-à-vis the efficacy of treatment, such that the precise nature of the therapeutic method emerges as of less importance in the eventual outcome-so long as the method is a bona fide theory-driven intervention, conducted by therapists with sufficient knowledge of alternative approaches and with the flexibility to utilize other approaches temporarily, in accordance with the exigencies of the patient's current life. This amounts to an integrated approach.

A transdiagnostic sleep and circadian treatment to improve severe mental illness outcomes in a community setting: study protocol for a randomized controlled trial

BACKGROUND

Severe mental illness (SMI) is common, chronic and difficult to treat. Sleep and circadian dysfunctions are prominent correlates of SMI, yet have been minimally studied in ways that reflect the complexity of the sleep problems experienced. Prior treatment studies have been disorder-focused-they have treated a specific sleep problem in a specific diagnostic group. However, real life sleep and circadianproblems are not so neatly categorized, particularly in SMI where features of insomnia overlap with hypersomnia, delayed sleep phase and irregular sleep-wake schedules. Accordingly, the aim of this studyprotocol is to test the hypothesis that a Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) will improve functional impairment, disorder-focused symptoms and sleep and circadian functioning. Participants across DSM diagnoses and across common sleep and circadian problems are eligible. The elements of TranS-C are efficacious across SMI in research settings with research-based providers. The next step is to test TranS-C in a community setting. Accordingly, this study is being conducted within Alameda County Behavioral Health Care Services (ACBHCS), the Community Mental Health Centre (CMHC) for Alameda County.

METHODS/DESIGN

120 adults diagnosed with SMI and sleep and circadian dysfunction within ACBHCS will be randomly allocated to TranS-C (n = 60) or 6-months of Usual Care followed by Delayed Treatment with TranS-C (UC-DT; n = 60). TranS-C is modularized and delivered across eight to twelve 50-minute, weekly, individual sessions. All participants will be assessed before and immediately following treatment and again 6 months later. Primary analysis will examine whether TranS-C significantly improves functional impairment, disorder-specific symptoms and sleep and circadian functioning, relative to UC-DT. Exploratory analysis will examine whether improvements in sleep and circadian functioning predict reduction in functional impairment and disorder-specific symptoms, and whether the intervention effects are mediated by improved sleep and circadian functioning and moderated by previously reported risk factors (demographics, symptom severity, medications, psychiatric and medical comorbidity).

DISCUSSION

This trial tests an important and understudied mechanism-dysregulated sleep and circadian rhythms-in SMI, a novel transdiagnostic treatment approach, in a community setting so as to contribute to the goal of bridging the gap between research and practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02469233 . Registered on 9 June 2015.

The Role of Lean Process Improvement in Implementation of Evidence-Based Practices in Behavioral Health Care

To effectively implement evidence-based practices (EBP) in behavioral health care, an organization needs to have operating structures and processes that can address core EBP implementation factors and stages. Lean, a widely used quality improvement process, can potentially address the factors crucial to successful implementation of EBP. This article provides an overview of Lean and the relationship between Lean process improvement steps, and EBP implementation models. Examples of how Lean process improvement methodologies can be used to help plan and carry out implementation of EBP in mental health delivery systems are presented along with limitations and recommendations for future research and clinical application.

Blended CBT versus face-to-face CBT: a randomised non-inferiority trial

BACKGROUND

Internet based cognitive behavioural therapy (iCBT) has been demonstrated to be cost- and clinically effective. There is a need, however, for increased therapist contact for some patient groups. Combining iCBT with traditional face-to-face (ftf) consultations in a blended format (B-CBT) may produce a new treatment format with multiple benefits from both traditional CBT and iCBT such as individual adaptation, lower costs than traditional therapy, wide geographical and temporal availability, and possibly lower threshold to implementation. The primary aim of the present study is to compare directly the clinical effectiveness of B-CBT with face-to-face CBT for adult major depressive disorder.

METHODS/DESIGN

The study is designed as a two arm randomised controlled non-inferiority trial comparing blended CBT for adult depression with treatment as usual (TAU). In the blended condition six sessions of ftf CBT is alternated with six to eight online modules (NoDep). TAU is defined as 12 sessions of ftf CBT. The primary outcome is symptomatic change of depressive symptoms on the patient-health questionnaire (PHQ-9). Additionally, the study will include an economic evaluation. All participants must be 18 years of age or older and meet the diagnostic criteria for major depressive disorder according to the Diagnostic and Statistical Manual of Mental disorders 4th edition. Participants are randomised on an individual level by a researcher not involved in the project. The primary outcome is analysed by regressing the three-month follow-up PHQ-9 data on the baseline PHQ-9 score and a treatment group indicator using ancova. A sample size of 130 in two balanced groups will yield a power of at least 80% to detect standardised mean differences above 0.5 on a normally distributed variable.

DISCUSSION

This study design will compare B-CBT and ftf CBT in a concise and direct manner with only a minimal of the variance explained by differences in therapeutic content. On the other hand, while situated in routine care, ecological validity is somewhat compromised by the controlled manner in which the study is conducted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02796573 . Registered June 1st 2016. Currently recruiting participants.

Reducing risk for anxiety and depression in adolescents: Effects of a single-session intervention teaching that personality can change

Efforts to reduce youth mental health problems have advanced greatly but have not lowered overall rates of youth mental illness. Thus, a need exists for disseminable, mechanism-targeted approaches to reducing risk of youth psychopathology. Accordingly, we conducted a randomized-controlled trial testing whether a single-session intervention teaching growth personality mindsets (the belief that personality is malleable) reduced known risk factors for anxiety and depression in adolescents experiencing or at risk for internalizing problems (N = 96, ages 12-15). Compared to a supportive-therapy control, a 30-min computer-guided mindset intervention strengthened adolescents' perceived control; this improvement was associated with increases in growth mindsets. Further, electrodermal activity recovery slopes showed that youths receiving the mindset intervention recovered from a lab-based social stressor over three times as fast as control group youths. Improvements in growth mindsets and perceived control were linked with faster stress recovery. Results suggest a disseminable strategy for reducing internalizing problem risk among adolescents.

Treatment engagement in the early phase of cognitive-behavior therapy for panic disorder: A grounded theory analysis of patient experience

Exposure-based cognitive-behavior therapy (EBCBT) is the treatment of choice for panic disorder (PD). However, little is known about early treatment processes that facilitate retention in treatment and positive outcomes of PD treatment. We studied the development of early treatment process with semi-structured individual in-depth interviews with 12 patients with PD, conducted post session 3. Grounded theory was used to analyze the transcripts. The development of early treatment process was captured by four thematic categories: approaching the problem, easing in and opening up, building trust and bonding, and making sense of panic. The developmental scheme culminated to the core category: Jointly Engaging in PD Therapy versus Awaiting Relief, capturing early engagement or disengagement from PD therapy respectively. The emergent core category was cross-validated against distal treatment outcome. Emergent processes can be replicated and incorporated in early treatment procedures of EBCBT for PD. Clinical practice recommendations are discussed.

Guided Internet-based cognitive behavioral therapy for mild and moderate depression: A benchmarking study

Major depression is among the most common and debilitating disorders worldwide, associated with large societal and individual costs. Effective treatments exist, but accessibility is scarce. Guided Internet-Based Cognitive Behavioral Therapy (guided iCBT) is a promising approach to reach more people in need of help. In the present pilot study, we investigated the outcome of a guided iCBT program for mild and moderate depression when disseminated from Sweden to Norway. The guided iCBT intervention was implemented within a university-based outpatient clinic by six student therapists under supervision. Twenty-two participants with mild and moderate depression were included in the study. Large treatment effects were found for depressive symptoms, whereas small to medium effects were observed for anxiety symptoms. More than half (55%) of the participants were classified as recovered at post-treatment and more than a third (41%) at follow-up. No participants had a significant deterioration from pre- to post-treatment, but two reported a significant deterioration from post-treatment to 6-month follow-up. Benchmarking the present results against those reported in the four original Swedish studies, we found that the treatment effect in the Norwegian study was slightly higher at post-treatment and slightly lower at 6-month follow-up compared to the outcome in the Swedish studies. The results should be interpreted with caution, as our sample was small and had no control group.

Bridging the Gap Between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research

Twenty years after Sobell's (1996) influential call to integrate advances in behavior therapy into clinical settings, significant progress has been made in implementation science. In this narrative review, we provide an overview of implementation research findings and highlight recent findings that can inform efforts to bridge the gap between research and practice in mental health service settings. Key findings are summarized, organized according to levels of influence described in two implementation frameworks: The Exploration, Planning, Implementation, and Sustainment Framework (EPIS; Aarons et al., 2011) and the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Important levels of influence to consider when implementing new treatments include the outer context, inner context, characteristics of the individual, and characteristics of the innovation. Research on strategies to prepare clinicians to deliver evidence-based psychosocial treatments (EBPTs) and to address contextual barriers to implementation at each level is described, with discussion of implications for the implementation of EBPTs and next steps for research.

What Did They Learn? Effects of a Brief Cognitive Behavioral Therapy Workshop on Community Therapists' Knowledge

Knowledge gain has been identified as necessary but not sufficient for therapist behavior change. Declarative knowledge, or factual knowledge, is thought to serve as a prerequisite for procedural knowledge, the how to knowledge system, and reflective knowledge, the skill refinement system. The study aimed to examine how a 1-day workshop affected therapist cognitive behavioral therapy declarative knowledge. Participating community therapists completed a test before and after training that assessed cognitive behavioral therapy knowledge. Results suggest that the workshop significantly increased declarative knowledge. However, post-training total scores remained moderately low, with several questions answered incorrectly despite content coverage in the workshop. These findings may have important implications for structuring effective cognitive behavioral therapy training efforts and for the successful implementation of cognitive behavioral therapy in community settings.

The challenge of training supervisors to use direct assessments of clinical competence in CBT consistently: a systematic review and exploratory training study

Evaluating and enhancing supervisee competence is a key function of supervision and can be aided by the use of direct assessments of clinical competence, e.g. the Cognitive Therapy Scale – Revised (CTS-R). We aimed to review the literature regarding inter-rater reliability and training on the CTS and CTS-R to present exploratory data on training raters to use this measure. We employed a systematic review. An exploratory study evaluated the outcomes of a CTS-R supervisor training workshop (n = 34), including self-reported familiarity with and confidence in using the tool, and inter-rater consistency on three CTS-R subscales, pre- and post-training. CTS and CTS-R inter-rater reliability was variable, with evidence of rater training enhancing reliability, although the form, duration and frequency of such training is unclear. The exploratory study found that supervisors rated themselves as more familiar with and confident in using the CTS-R at the end of training compared to at the beginning. However, inter-rater reliability was poor at the beginning and end of the training. Rating competence requires supervisors to make qualitative judgements, which is inherently variable. Training raters has been shown to improve rater reliability, although this was not demonstrated in the exploratory study. Practice implications and future research priorities are identified.