Mind the gap: Improving the dissemination of CBT

A questionnaire-based qualitative study of therapist views on computerized CBT

Few studies have explored therapists’ views on computerized cognitive behavioural therapy (cCBT) and this study aimed to provide an in-depth understanding of accredited therapists’ views on cCBT's role in treating depression. Twelve therapists constituted this self-selected sample (eight female, four male). Mean age was 52 years (range 46–61). The data obtained from a semi-structured questionnaire were analysed using thematic analysis. Three themes were identified and discussed: (1) the standardized nature of cCBT for depression, (2) the importance of the therapeutic relationship in cCBT, and (3) the pros and cons with cCBT as an alternative to CBT. The therapists in this study emphasized that innovations in CBT delivery formats (e.g. internet-based, computerized) show promise. However, participants expressed some views that clash with the evidence-based viewpoint. More work is needed to improve the implementation of evidence-based practice and policy.

Effects of online intervention for depression on mood and positive symptoms in schizophrenia

BACKGROUND

Depression is common in schizophrenia. Whereas the improvement of mood and self-esteem represents a subjective treatment priority for many patients, depression is rarely a primary target for clinical intervention. The present trial examined whether an online intervention for depression can ameliorate depressive symptoms in schizophrenia.

METHODS

A total of 58 individuals with schizophrenia were invited to participate in an online survey which encompassed the Center for Epidemiologic Studies-Depression Scale (CES-D, primary outcome), the Patient-Health-Questionnaire-9 (PHQ-9) and the Paranoia Checklist. Subsequently, telephone interviews were conducted to verify diagnostic status and assess symptoms (Positive and Negative Syndrome Scale, PANSS). Participants were randomized either to the experimental condition (online depression intervention) or to a waitlist control condition. Three months after inclusion, a reassessment was carried out (self-report and telephone interview blind for group condition). The trial was registered (registration: DRKS00007888).

RESULTS

Participants in the treatment group showed a significant decline of depressive symptoms at a medium-to-large effect size, as assessed with the CES-D and the PANSS depression item, in comparison to the waitlist control group (completer (CC) and intention-to-treat analyses (ITT)). For the PHQ-9 (CC and ITT) and the PANSS distress subscale (CC only) significance was bordered at a medium effect size. Completion at the post-assessment after three months was 84%.

DISCUSSION

Depression in schizophrenia is both underdiagnosed and undertreated. To reduce the large treatment gap in the disorder, low threshold strategies are urgently needed. Online treatment and bibliotherapy may represent valuable tools to address patients' needs beyond the treatment of the core positive syndrome.

Health related quality of life for young people receiving dialectical behaviour therapy (DBT): a routine outcome-monitoring pilot

PURPOSE

Adults presenting with borderline personality disorder (BPD) score poorly on measures of health related quality of life (HRQoL). Little is known about HRQoL in adolescents with BPD type presentations and how treatment impacts quality of life. Our primary aim was to use routinely collected quality-of-life outcome measures pre and post-treatment in dialectical behaviour therapy (DBT) for adolescents to address this gap. Secondary aims were to benchmark these data against EuroQol 5 dimensions (EQ-5D™) outcomes for clients treated in clinical trials and to assess the potential of the EQ-5D™ as a benchmarking tool.

METHOD

Four adolescent DBT teams, routinely collecting outcome data using a pseudonymised secure web-based system, supplied data from consecutive discharges.

RESULTS

Young people in the DBT programmes (n = 43) had severely impaired HRQoL scores that were lower at programme admission than those reported in published studies using the EQ-5D™ in adults with a BPD diagnosis and in one study of adolescents treated for depression. 40 % of adolescents treated achieved Reliable Clinical Change. HRQoL improved between admission and discharge with a large effect size. These results were not statistically significant when clustering in programme outcomes was accounted for.

CONCLUSION

Young people treated in NHS DBT programmes for BPD type presentations had poorer HRQoL than adults with a BPD diagnosis and adolescents with depression treated in published clinical trials. The EQ-5D™ detected reliable change in this group of adolescents. Programme outcome clustering suggests that both the measure and the web-based monitoring system provide a mechanism for benchmarking clinical programmes.

A sorrow shared is a sorrow halved? A three-arm randomized controlled trial comparing internet-based clinician-guided individual versus group treatment for social anxiety disorder

A growing body of evidence suggests that internet-based cognitive behavioural treatments (ICBT) are effective to treat social anxiety disorder (SAD). Whereas the efficacy of clinician-guided ICBT has been established, ICBT in a group format has not yet been systematically investigated. This three-arm RCT compared the efficacy of clinician-guided group ICBT (GT) with clinician guided individual ICBT (IT) and a wait-list (WL). A total of 149 individuals meeting the diagnostic criteria for SAD were randomly assigned to one of three conditions. Primary endpoints were self-report measures of SAD and diagnostic status taken at baseline, after the twelve-week intervention and at six-month follow-up. Secondary endpoints were symptoms of depression, interpersonal problems and general symptomatology. At post-treatment, both active conditions showed superior outcome regarding SAD symptoms (GT vs. WL: d = 0.84-0.74; IT vs. WL: d = 0.94-1.22). The two active conditions did not differ significantly in symptom reduction (d = 0.12-0.26, all ps > 0.63), diagnostic response rate or attrition. Treatment gains were maintained at follow-up. The group format reduced weekly therapist time per participant by 71% (IT: 17 min, GT: 5 min). Findings indicate that a clinician-guided group format is a promising approach in treating SAD.

Negative Effects of Psychological Treatments: An Exploratory Factor Analysis of the Negative Effects Questionnaire for Monitoring and Reporting Adverse and Unwanted Events

Research conducted during the last decades has provided increasing evidence for the use of psychological treatments for a number of psychiatric disorders and somatic complaints. However, by focusing only on the positive outcomes, less attention has been given to the potential of negative effects. Despite indications of deterioration and other adverse and unwanted events during treatment, little is known about their occurrence and characteristics. Hence, in order to facilitate research of negative effects, a new instrument for monitoring and reporting their incidence and impact was developed using a consensus among researchers, self-reports by patients, and a literature review: the Negative Effects Questionnaire. Participants were recruited via a smartphone-delivered self-help treatment for social anxiety disorder and through the media (N = 653). An exploratory factor analysis was performed, resulting in a six-factor solution with 32 items, accounting for 57.64% of the variance. The derived factors were: symptoms, quality, dependency, stigma, hopelessness, and failure. Items related to unpleasant memories, stress, and anxiety were experienced by more than one-third of the participants. Further, increased or novel symptoms, as well as lack of quality in the treatment and therapeutic relationship rendered the highest self-reported negative impact. In addition, the findings were discussed in relation to prior research and other similar instruments of adverse and unwanted events, giving credence to the items that are included. The instrument is presently available in eleven different languages and can be freely downloaded and used from www.neqscale.com.

Using 'candidacy' as a framework for understanding access to mainstream psychological treatment for people with intellectual disabilities and common mental health problems within the English Improving Access to Psychological Therapies service

BACKGROUND

The Improving Access to Psychological Therapies (IAPT) service was established to address common mental health problems among the English population in a timely manner in order to counter the social and economic disadvantage accompanying such difficulties. Using the concept of candidacy, we examined how the legitimacy of claims by people with intellectual disabilities to use this service is facilitated or impeded.

METHOD

We used a sequential mixed methods design. We completed 21 interviews with a range of stakeholders, including people with intellectual disabilities and their carers. Themes from the interviews were used to design an online survey questionnaire that was returned by 452 staff from IAPT and specialist intellectual disability services.

RESULTS

Using the candidacy framework, we noted that eligibility and access to IAPT were achieved through dynamic and iterative processes of negotiation involving people with intellectual disabilities and their supporters on one side and IAPT staff and service structures on the other. Barriers and facilitators were apparent throughout the seven dimensions of candidacy (identification, navigation, permeability of services, appearances, adjudications, offers and resistance and operating conditions) and were linked to discourses relating to the character and purpose of IAPT and specialist intellectual disability services.

CONCLUSIONS

Opportunities exist for some people with intellectual disabilities to assert their candidacy for IAPT input, although there are barriers at individual, professional, organisational and structural levels. More attention needs to be paid to how principles of inclusiveness are operationalised within IAPT teams and to the mental health facilitation role of specialist intellectual disability staff.

Wise Additions Bridge the Gap between Social Psychology and Clinical Practice: Cognitive-Behavioral Therapy as an Exemplar

Progress in clinical science, theory, and practice requires the integration of advances from multiple fields of psychology, but much integration remains to be done. The current article seeks to address the specific gap that exists between basic social psychological theories and the implementation of related therapeutic techniques. We propose several "wise additions," based upon the principles outlined by Walton (2014), intended to bridge current social psychological research with clinical psychological therapeutic practice using cognitive behavioral therapy as an example. We consider how recent advances in social psychological theories can inform the development and implementation of wise additions in clinical case conceptualization and interventions. We specifically focus on self and identity, self-affirmation, transference, social identity, and embodied cognition, five dominant areas of interest in the field that have clear clinical applications.

A systematic review and meta-analysis of low intensity CBT for psychosis

Sixteen sessions of individual cognitive behavior therapy for people with psychosis (CBTp) is recommended. However, access to CBTp is poor, so the potential of low intensity CBTp (fewer than 16 sessions of face-to-face contact) is being explored. A systematic review and meta-analysis was conducted of 10 controlled trials evaluating low intensity CBTp. Significant between-group effects were found on the primary outcome, symptoms of psychosis, at post-intervention (d=-0.46, 95% CI: -0.06, -0.86) and follow-up (d=-0.40, 95% CI: -0.06, -0.74). Study quality did not moderate post-intervention psychosis outcomes, nor did contact time/number of sessions or therapy format (individual versus group). Between-group effects on secondary outcomes (depression, anxiety and functioning) were not significant at post-intervention, but became significant at follow-up for depression and functioning outcomes (but not for anxiety). Overall, findings suggest that low intensity CBTp shows promise with effect sizes comparable to those found in meta-analyses of CBTp more broadly. We suggest that low intensity CBTp could help widen access. Future research is called for to identify mechanisms of change and to ascertain moderators of outcome so that low intensity CBTp targets key mechanisms (so that scarce therapy time is used effectively) and so that interventions offered are matched to patient need.

Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial

The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n=85) or direct FtF CBT (n=88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients' access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.

New Developments in Cognitive-Behavioral Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that causes considerable psychosocial impairment. This article reviews recent changes in the definition of SAD in DSM-5 and summarizes the current evidence for effective cognitive-behavioral treatments in adults, children, and adolescents. Current data suggests that cognitive-behavioral therapy (CBT) is efficacious in the treatment of this condition. Among different CBT approaches, individual cognitive therapy may be associated with the largest effect sizes. In this review, interventions targeting dysfunctional cognitive processes that contribute to the effective treatment of SAD are discussed. Some recent findings from neuroimaging research and studies on the augmentation of CBT using neuroenhancers indicate that changes in emotion regulation as well as fear extinction are important psychological mediators of positive outcome. Furthermore, internet-delivered CBT is a promising field of technological innovation that may improve access to effective treatments. Despite the availability of effective treatments, treatment-resistant SAD remains a common problem in clinical practice that requires more research efforts. Finally, potential areas for further development of CBT as well as its dissemination in health care are summarized.

The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists

Although client preferences are an integral component of evidence-based practice in psychology (American Psychological Association, 2006), relatively little research has examined what potential mental health consumers value in the psychotherapy they may receive. The present study was conducted to examine community members' preferences for the scientific and relational aspects of psychotherapy for different types of presenting problems, and how accurately therapists perceive these preferences. Community members (n = 200) were surveyed about the importance of scientific (e.g., demonstrated efficacy in clinical trials) and relational (e.g., therapist empathy) characteristics of psychotherapy both for anxiety disorders (e.g., obsessive-compulsive disorder) and disorder-nonspecific issues (e.g., relationship difficulties). Therapists (n = 199) completed the same survey and responded how they expected the average mental health consumer would. Results showed that although community members valued relational characteristics significantly more than scientific characteristics, the gap between these two was large for disorder-nonspecific issues (d = 1.24) but small for anxiety disorders (d = .27). Community members rated scientific credibility as important across problem types. Therapists significantly underestimated the importance of scientific characteristics to community members, particularly in the treatment of disorder-nonspecific issues (d = .74). Therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to community members. The implications of the present findings for understanding the nature of client preferences in evidence-based psychological practice are discussed.

Investigating the efficacy of an individualized metacognitive therapy program (MCT+) for psychosis: study protocol of a multi-center randomized controlled trial

BACKGROUND

Psychological interventions are increasingly recommended as adjunctive treatments for psychosis, but their implementation in clinical practice is still insufficient. The individualized metacognitive therapy program (MCT+; www.uke.de/mct_plus ) represents a low-threshold psychotherapeutic approach that synthesizes group metacognitive training (MCT) and cognitive behavioral therapy for psychosis, and addresses specific cognitive biases that are involved in the onset and maintenance of psychosis. It aims to "plant the seed of doubt" regarding rigid delusional convictions and to encourage patients to critically reflect, extend and change their approach to problem solving. Its second edition also puts more emphasis on affective symptoms. A recent meta-analysis of metacognitive interventions (MCT, MCT+) indicate small to moderate effects on positive symptoms and delusions, as well as high rates of acceptance. Nonetheless, no long-term studies of MCT+ involving large samples have been conducted.

METHODS

The goal of the present multi-center, observer-blind, parallel-group, randomized controlled trial is to compare the efficacy of MCT+ against an active control (cognitive remediation; MyBrainTraining(©)) in 328 patients with psychosis at three time points (baseline, immediately after intervention [6 weeks] and 6 months later). The primary outcome is change in psychosis symptoms over the 6-month follow-up period as assessed by the delusion subscale of the Psychotic Symptom Rating Scale. Secondary outcomes include jumping to conclusions, other positive symptoms of schizophrenia, depressive symptoms, self-esteem, quality of life, and cognitive insight. The study also seeks to elucidate mediating factors that promote versus impede symptom improvement across time.

DISCUSSION

This is the first multi-center randomized controlled trial to test the efficacy of individualized MCT+ in a large sample of patients with psychosis. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.

TRIAL REGISTRATION

The trial is registered through the German Clinical Trials Register ( www.drks.de ) as DRKS00008001 . Registered 6 May 2015.

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems

BACKGROUND

Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings.

OBJECTIVE

This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning.

METHOD

Narrative review.

RESULTS AND CONCLUSIONS

Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

How to Train Experienced Therapists in a New Method: A Qualitative Study into Therapists' Views

BACKGROUND

Implementation of new effective treatments involves training, supervision and quality control of therapists, who are used to utilize other methods. Not much is known about therapists' views on how new psychotherapy methods should be taught.

OBJECTIVE

The purpose of this study is to get insight in how experienced therapists experience the training in a new method so that training methods for experienced therapists can be improved.

METHOD

Qualitative research using focus groups. For an RCT on the effectiveness of schema therapy (ST) for six personality disorders more than 80 therapists were trained in ST. They applied the ST-protocol after 4-day training, with peer supervision and limited expert supervision. Sixteen of these trained ST therapists from seven health institutions participated in the focus groups. The transcripts and records of the focus groups were analyzed on repeating themes and subthemes and in terms of higher order categories.

RESULTS

Therapists appreciated didactical learning methods but particularly valued experiential learning. Especially, novice ST therapists missed role plays, feedback to learn required skills and attitudes, and attention to their resistance to new techniques (e.g., empathic confrontation and imagery). Peer supervision gave emotional recognition, but therapists lacked regular advice from an ST-expert.

CONCLUSIONS

In teaching a new therapeutic method didactic teaching is necessary, but experiential learning is decisive. Experiential learning includes practicing the new therapy and reflecting on one's experiences, including resistance against new methods. Emphatic confrontation, case conceptualization, role play, peer supervision and opportunities to ask an expert supervisor during peer supervision are found to be helpful. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Especially by Eperiential learning besides didactic learning. By practicing with many role plays including feedback. By reflecting on one's experiences including resistance against ingredients of the new method. By peer supervision with opportunities to ask an expert supervisor.

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.

Online CBT Is Effective in Overcoming Cultural and Language Barriers in Patients With Depression

OBJECTIVE

The goal of this study was to evaluate the efficacy of weekly email in delivering online cognitive behavioral therapy (CBT) to treat mild to moderately depressed individuals. The effectiveness of the online CBT was measured following treatment and then again at a 6-month follow-up and was compared with outcomes in a waitlist control group.

METHODS

Participants were recruited through announcements on psychology Web sites, Iranian organization Web sites, and weblogs and flyers. Ninety-three individuals who met inclusion criteria, including a score >18 on the Beck Depression Inventory (BDI), participated in the study, with 47 randomly assigned to the CBT group and 46 to the control group. The CBT group received 10 to 12 sessions of online CBT conducted by a psychiatrist and a psychiatry resident. Following completion of the CBT, a second BDI was sent to participants. Another BDI was then sent to participants 6 months after the completion of treatment.

RESULTS

Email-based CBT significantly reduced BDI scores compared with results in a waitlist control group following 10 to 12 weeks of treatment and at 6-month follow-up.

CONCLUSIONS

Email is a viable method for delivering CBT to individuals when face-to-face interaction is not possible. Limitations and future directions are discussed.

Exposing therapists to trauma-focused treatment in psychosis: effects on credibility, expected burden, and harm expectancies

BACKGROUND

Despite robust empirical support for the efficacy of trauma-focused treatments, the dissemination proves difficult, especially in relation to patients with comorbid psychosis. Many therapists endorse negative beliefs about the credibility, burden, and harm of such treatment.

OBJECTIVE

This feasibility study explores the impact of specialized training on therapists' beliefs about trauma-focused treatment within a randomized controlled trial.

METHOD

Therapist-rated (n=16) credibility, expected burden, and harm expectancies of trauma-focused treatment were assessed at baseline, post-theoretical training, post-technical training, post-supervised practical training, and at 2-year follow-up. Credibility and burden beliefs of therapists concerning the treatment of every specific patient in the trial were also assessed.

RESULTS

Over time, therapist-rated credibility of trauma-focused treatment showed a significant increase, whereas therapists' expected burden and harm expectancies decreased significantly. In treating posttraumatic stress disorder (PTSD) in patients with psychotic disorders (n=79), pre-treatment symptom severity was not associated with therapist-rated credibility or expected burden of that specific treatment. Treatment outcome had no influence on patient-specific credibility or burden expectancies of therapists.

CONCLUSIONS

These findings support the notion that specialized training, including practical training with supervision, has long-term positive effects on therapists' credibility, burden, and harm beliefs concerning trauma-focused treatment.

Does Collaborative Case Conceptualisation enhance engagement and outcome in the treatment of anorexia nervosa? Rational, design and methods

BACKGROUND

Anorexia Nervosa (AN) is a severe and potentially chronic disorder characterised by low body weight and persistent behaviours that interfere with weight gain. Individuals with AN are often difficult to engage in treatment and display high rates of drop out. The Collaborative Case Conceptualisation (CCC) assessment approach was developed to target proposed AN maintaining factors with the aim of improving treatment motivation and engagement and consequently treatment outcomes in individuals with AN. The proposed study aims to examine the efficacy of CCC in improving a range of outcomes including Body Mass Index, eating disorder symptomatology, general psychopathology, quality of life and future treatment motivation and participation. Potential mediators will also be explored.

METHODS/DESIGN

Thirty-two participants will be recruited from Melbourne based specialist eating disorder services, community and university clinics, and health practitioner networks. Participants will be randomised to three individual sessions of either CCC or a standardised assessment condition (assessment as usual; AAU). The AAU assessment will include; a mental status examination, assessment of current disordered eating behaviours and cognitions, assessment of clinical history, and a physical examination. The CCC condition combines the AAU assessment components with shared collaborative formulation and tailored psychoeducation highlighting the consequences of the eating disorder on wellbeing and future goals in a supportive and motivating way.

IMPLICATIONS

This intervention may provide an effective and feasible method of improving treatment engagement and outcomes for individuals suffering from AN, with the ultimate outcome of reducing the negative biopsychosocial impacts of this potentially severe and chronic disorder.

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation

OBJECTIVE

Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials.

METHOD

Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology.

RESULTS

Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables.

DISCUSSION

Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data.

A RANDOMIZED CONTROLLED TRIAL IN COMMUNITY MENTAL HEALTH CENTERS OF COMPUTER-ASSISTED COGNITIVE BEHAVIORAL THERAPY VERSUS TREATMENT AS USUAL FOR CHILDREN WITH ANXIETY

OBJECTIVE

This study aims to examine the real-world effectiveness of a computer-assisted cognitive behavioral therapy (CBT) protocol relative to treatment as usual (TAU) among anxious children presenting at community mental health centers.

METHODS

One hundred children (7-13 years) with clinically significant anxiety were randomized to receive either 12 weekly computer-assisted CBT sessions or TAU for an equivalent duration. Assessments were conducted by independent evaluators at screening/baseline, midtreatment, posttreatment, and 1-month followup (for computer-assisted CBT treatment responders).

RESULTS

There were significant between-group effects favoring the computer-assisted CBT condition on primary anxiety outcomes. Thirty of 49 (61.2%) children randomized to computer-assisted CBT responded to treatment, which was superior to TAU (6/51, 11.8%). Relative to TAU, computer-assisted CBT was associated with greater reductions in parent-rated child impairment and internalizing symptoms, but not child-rated impairment and anxiety and depressive symptoms. Treatment satisfaction and therapeutic alliance in those receiving computer-assisted CBT was high. Treatment gains in computer-assisted CBT responders were maintained at 1-month followup.

CONCLUSIONS

Within the limitations of this study, computer-assisted CBT is an effective and feasible treatment for anxious children when used in community mental health centers by CBT-naïve clinicians.

Training mental health professionals in suicide practice guideline adherence: Cost-effectiveness analysis alongside a randomized controlled trial

BACKGROUND

There is a lack of information on the cost-effectiveness of suicide prevention interventions. The current study examines the cost-effectiveness of a multifaceted structured intervention aiming to improve adherence to the national suicide practice guideline in comparison with usual implementation.

METHODS

In the intervention condition, professionals of psychiatric departments were trained using an e-learning supported Train-the-Trainer program. Newly admitted suicidal patients were assessed as soon as their department was trained and at 3 months follow-up. The primary outcome was improvement in suicide ideation. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes were plotted, and cost-effectiveness acceptability curves were estimated.

RESULTS

For the total group of suicidal patients (n=566), no effect of the intervention on suicide ideation or costs was found. For a subgroup of depressed suicidal patients (n=154, intervention=75, control=79), mean level of suicide ideation decreased with 2.7 extra points in the intervention condition, but this was not statistically significant. For this subgroup, the intervention may be considered cost-effective in comparison with usual implementation if society is willing to pay≥€ 6100 per unit of effect on the suicide ideation scale extra.

LIMITATIONS

Considering the cost outcomes, we had almost no cases that were complete, and heavily relied on statistical techniques to impute the missing data. Also, diagnoses were not derived from structured clinical interviews.

CONCLUSIONS

We presented the first randomized trial (trial registration: The Netherlands Trial Register (NTR3092 www.trialregister.nl)) on cost-effectiveness of a suicide practice guideline implementation in mental health care. The intervention might be considered cost-effective for depressed suicidal patients if society is willing to make substantial investments.

Development of a smartphone application for eating disorder self-monitoring

OBJECTIVE

This case report aims to (1) describe the development and refinement of a smartphone application for eating disorder self-monitoring; (2) characterize its users in terms of demographic and clinical characteristics; and (3) explore its feasibility and utilization as a self-monitoring tool.

METHOD

We developed a mobile phone application through which people with eating disorders can self-monitor meals, emotions, behaviors, and thoughts. The application also included positive reinforcement, coping skill suggestions, social support, and feedback components. The app was made available on two Internet app stores. Data include number of downloads and subsequent usage statistics, consumer ratings on app-stores are used as indicators of satisfaction, anonymous aggregate demographic data and Eating Disorder Examination Questionnaire scores from 57,940 individuals collected over a two-year period.

RESULTS

The app demonstrated population-level utilization with over 100,000 users over a two-year period. Almost 50% percent of users stated that they are not currently receiving clinical treatment and 33% reported they had not told anyone about their eating disorder. A surprising number of people with severe problems are using the app.

DISCUSSION

Smartphone apps have the capacity to reach and engage traditionally underserved individuals with eating disorders at a large scale. Additional work is indicated for the evaluation of the clinical effectiveness of applications for specific user groups and in clinical treatment contexts.

From training to practice: a survey study of clinical challenges in implementing cognitive behavioural therapy in Norway

This study examines potential barriers to the implementation of CBT as perceived by therapists participating in the training programmes of the Norwegian Association for Cognitive and Behavioural Therapy (NACBT). Based on a questionnaire to members of the NACBT, a factor analysis identified five underlying dimensions of implementation barriers. A one-way analysis of variance was conducted to examine differences in how barriers were perceived by therapists working in medicine, mental health and social services. A multiple regression analysis was performed to examine the relationship between the barriers and the therapists’ global satisfaction with CBT. The five factor-based barriers identified were related to Therapeutic skills, Aspects of the workplace, Supervision, Training, and Clients. Problems related to Supervision and Therapeutic skills were reported to be the most important obstacles. Nurses and others working at psychiatric wards reported the largest number, and psychologists and others working with outpatients, reported the lowest number of barriers. The study highlights the importance of implementation quality in the process of linking training and practice of CBT in Norway. Even if aspects of the training programmes were perceived to be among the smallest threats to implementation, training was not sufficient in order for candidates to implement CBT in clinical practice.

On the use of exposure therapy in the treatment of anxiety disorders: a survey among cognitive behavioural therapists in the Netherlands

BACKGROUND

Although research has shown exposure therapy to have earned its rank among empirically supported treatments (ESTs) for anxiety disorders, several US-based studies suggest it to be underused in clinical practice. Data on exposure use in Europe is mainly lacking, whereas its state of dissemination in countries such as the Netherlands has remained uncharted. Therefore, this study examined the use of exposure therapy among members of the Dutch Association for Behavioural and Cognitive Therapy (VGCt), as well as explored therapist, educational and contextual variables that could facilitate its dissemination in clinical practice.

METHODS

Respondents (n = 490) were surveyed on clinical interventions used in their treatment for social anxiety disorder, phobia, OCD and panic disorder. Data was collected on the use of (disorder) specific interventions, therapists' attitudes on exposure, treatment experience, current educational status, educational background and workplace characteristics.

RESULTS

Analysis of the data showed that most therapists implemented exposure frequently, but that exposure use still warrants improvement, specifically for certain (disorder-specific) interventions that were accordingly underused. Confirming our hypothesis, we found that clinicians who practiced exposure regularly also reported a greater willingness to use the treatment, perceived the method as more credible, and saw fewer barriers for its usage than those who did so less. The use of (disorder-) specific interventions, such as in vivo exposure (therapist as well as self-directed), exposure and response prevention for OCD, and interoceptive exposure for panic disorder, was positively related to level of education. While most were satisfied with the training they had received, therapists did report a need for additional instruction in targeted practical, empirical, and diagnostic skills.

CONCLUSIONS

Our findings support the conclusion that the dissemination of exposure therapy in the Netherlands progresses well, but that education in certain (disorder-specific) techniques merits augmentation. To bridge the gap between research and clinical practice, future research should therefore focus on new, preferably blended approaches to training clinicians in exposure techniques.

Web-Based Training for an Evidence-Supported Treatment: Training Completion and Knowledge Acquisition in a Global Sample of Learners

The purpose of this investigation is to describe the characteristics of professional and preprofessional learners who registered for and completed TF-CBTWeb, a modular, web-based training program designed to promote the dissemination of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and to demonstrate the feasibility of this method of dissemination. Between October 1, 2005, and October 1, 2012, a total of 123,848 learners registered for TF-CBTWeb, of whom 98,646 (79.7%) initiated the learning activities by beginning the first module pretest. Of those, 67,201 (68.1%) completed the full training. Registrants hailed from 130 countries worldwide, and they had varied educational backgrounds, professional identities (both professional and preprofessional), and a range of experience working with child trauma victims. Learners who were from the United States, students, those with master's degrees, and those with fewer years of experience working with child trauma victims tended to have the highest course completion rates. Learners displayed significant increases in knowledge about each component of TF-CBT, based on module pretest and posttest scores. The advantages and limitations of this web-based training program evaluation are discussed, while important implications for the use of web-based trainings are reviewed.

Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness

The past 40 years have generated numerous insights regarding errors in human reasoning. Arguably, clinical practice is the domain of applied psychology in which acknowledging and mitigating these errors is most crucial. We address one such set of errors here, namely, the tendency of some psychologists and other mental health professionals to assume that they can rely on informal clinical observations to infer whether treatments are effective. We delineate four broad, underlying cognitive impediments to accurately evaluating improvement in psychotherapy-naive realism, confirmation bias, illusory causation, and the illusion of control. We then describe 26 causes of spurious therapeutic effectiveness (CSTEs), organized into a taxonomy of three overarching categories: (a) the perception of client change in its actual absence, (b) misinterpretations of actual client change stemming from extratherapeutic factors, and (c) misinterpretations of actual client change stemming from nonspecific treatment factors. These inferential errors can lead clinicians, clients, and researchers to misperceive useless or even harmful psychotherapies as effective. We (a) examine how methodological safeguards help to control for different CSTEs, (b) delineate fruitful directions for research on CSTEs, and (c) consider the implications of CSTEs for everyday clinical practice. An enhanced appreciation of the inferential problems posed by CSTEs may narrow the science-practice gap and foster a heightened appreciation of the need for the methodological safeguards afforded by evidence-based practice.

Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis

Introduction

Self-help is increasingly accepted for the treatment of mental disorders, including psychosis, as both a provisional first step and a way to bridge the large treatment gap. Though mindfulness-based interventions do not belong to first line treatment strategies in psychosis and randomized controlled trials are lacking, encouraging preliminary findings speak for the usefulness of this approach. For the present study, we examined whether patients with psychosis benefit from mindfulness bibliotherapy.

Methods

A sample of 90 patients with psychosis (including a subsample with a verified diagnosis of schizophrenia) took part in the study via the Internet. Following baseline assessment, participants were randomized to either a mindfulness group or a Progressive Muscle Relaxation (PMR) control group and received the respective self-help manual including accompanying audio files. Symptom change was measured six weeks after the baseline assessment with self-rating scales including the Paranoia Checklist. The retention rate was 71%. The quality of the online dataset was confirmed by various strategies (e.g., psychosis lie scale; examination of response biases). The trial was registered at the ISRCTN registry (ISRCTN86762253).

Results

No changes across time or between groups were noted for the Paranoia Checklist. Both conditions showed a decline in depressive and obsessive-compulsive symptoms at a medium effect size (per protocol and intention to treat analyses).

Discussion/conclusion

The study provided partial support for the effectiveness of self-help mindfulness and PMR for depression in psychosis. Whether mindfulness delivered by a licensed therapist might lead to improved treatment adherence and a superior outcome relative to PMR remains to be established. The results underscore that bibliotherapy is a worthwhile approach to narrow the large treatment gap seen in psychosis.

Improving access to psychological therapies (IAPT) and treatment outcomes: epistemological assumptions and controversies

Cognitive behaviour therapy (CBT) is recommended as a primary treatment choice in England, for anxiety and depression, by the National Institute for Health and Care Excellence (NICE). It has been argued that CBT has enjoyed political and cultural dominance and this has arguably led to maintained government investment in England for the cognitive and behavioural treatment of mental health problems. The government programme 'Improving Access to Psychological Therapies' (IAPT) aims to improve the availability of CBT. The criticism of the NICE evidence-based guidelines supporting the IAPT programme, has been the dominance of the gold standard randomized controlled trial methodology, with a focus on numerical outcome data, rather than a focus on a recovery narrative. RCT-based research is influenced by a philosophical paradigm called positivism. The IAPT culture is arguably influenced by one research paradigm and such an influence can skew services only towards numerical outcome data as the only truth of 'recovery'. An interpretative paradigm could assist in shaping service-based cultures, alter how services are evaluated and improve the richness of CBT research. This paper explores the theory of knowledge (epistemology) that underpins the evidence-based perspective of CBT and how this influences service delivery. The paper argues that the inclusion of service user narrative (qualitative data) can assist the evaluation of CBT from the user's perspective and can understand the context in which people live and how they access services. A qualitative perspective is discussed as a research strategy, capturing the lived experience of under-represented groups, such as sexual, gender and ethnic minorities. Cognitive behaviour therapy (CBT) has enjoyed political and cultural dominance within mental healthcare, with renewed government investment in England for the'Improving Access to Psychological Therapies' (IAPT) programme. The criticism of the evidence-based guidelines, published by the National Institute for Health and Care Excellence (NICE), which supports the IAPT programme has been the dominance of the gold standard randomized controlled trial methodology. The definition of 'recovery' used by IAPT is based on a positivist position, with a focus on numerical outcome data garnered through psychometric measures. An interpretative perspective of recovery, which would include a subjective individual patient/service user narrative and would include a collaborative qualitative dialogue, is arguably absent from the IAPT programme. The challenge inherent in the IAPT programme is the high demand/high turnover culture, and psychometric measures are quick to administer; however, this culture is driven from one research paradigm. An interpretative paradigm may assist in shaping service-based cultures, alter how services are evaluated, and improve the richness of CBT research.

Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations

The efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been the subject of much study over the past fifteen years. Building on a foundation of case studies and open clinical trials, the literature now contains many methodologically sound studies that have compared full CBT protocols to waitlist controls, pill placebo, psychosocial comparison conditions, active medication, combined treatments, and brief CBT. This review is part of a series commissioned by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) in an effort to publish in one place what is known about the efficacy of treatments for OCD. A total of fourteen studies were identified; collectively their findings support the efficacy of CBT for youth with OCD. CBT protocols that emphasized either strictly behavioral or cognitive conceptualizations have each been found efficacious relative to waitlist controls. Efforts to enhance CBT׳s efficacy and reach have been undertaken. These trials provide guidance regarding next steps to be taken to maximize efficacy and treatment availability. Findings from studies in community clinics suggest that significant treatment benefits can be realized and are not reported only from within academic contexts. These findings bode well for broader dissemination efforts. Recommendations for future research directions are provided.

Specialized psychological and pharmacological treatments for obsessive-compulsive disorder throughout the lifespan: a special series by the Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD, www.ciocd.ca)

The World Health Organization ranks obsessive compulsive disorder (OCD) among the leading causes of worldwide medical disability. Affecting approximately 3% of the population, OCD, with its damaging effect on psychosocial function, is among the most severe and impairing of mental disorders. In Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), OCD and related disorders form a separate classification, consistent with convergent research that indicates OCD is distinct from anxiety disorders in psychopathology and treatment requirements. Although evidence-based treatments have been developed for OCD, these are not accessible to many sufferers. Timely evidence-based treatment is recommended to avoid unnecessary progression to chronicity, disability, and intransigence of symptoms. Improvement in existing training models is needed to disseminate advanced specialty clinical skills to optimize illness recovery. This special series by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) Accreditation Task Force (ATF) critically reviews evidence-based psychological and pharmacological treatments for OCD throughout the lifespan. The ATF mandate is to establish specialty OCD certification/accreditation standards and competencies. This pioneering initiative aims to achieve transformational change in accessibility to evidence-based clinical care so urgently needed for young people and adults suffering from OCD.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy (CT), has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

Alternative Models of the Outcome Questionnaire-45

The Outcome Questionnaire-45 (OQ) reliably quantifies level of psychological functioning and change during treatment. The three subscales, however, are not well validated. Could alternative scales, based on personality dimensions or other groupings of psychological problems better explain patterns of response? In Study 1, the intended structure and four alternative models were compared using EFA and CFA in random thirds of a community clinic intake sample (N = 1,822). Oblique and bi-level models were compared. Preferred models were tested for stability in samples from later time points. In Study 2, the models were compared in a nonclinical sample (N = 589). Most bi-level models provided adequate fit per standards previously established for the Outcome Questionnaire-45. A seven-factor model of psychological problems provided better fit than any yet reported for this inventory.

Automated Internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial

Osteoarthritis (OA) places a significant burden on worldwide public health because of the large and growing number of people affected by OA and its associated pain and disability. Pain coping skills training (PCST) is an evidence-based intervention targeting OA pain and disability. To reduce barriers that currently limit access to PCST, we developed an 8-week, automated, Internet-based PCST program called PainCOACH and evaluated its potential efficacy and acceptability in a small-scale, 2-arm randomized controlled feasibility trial. Participants were 113 men and women with clinically confirmed hip or knee OA and associated pain. They were randomized to a group completing PainCOACH or an assessment-only control group. Osteoarthritis pain, pain-related interference with functioning, pain-related anxiety, self-efficacy for pain management, and positive and negative affect were measured before intervention, midway through the intervention, and after intervention. Findings indicated high acceptability and adherence: 91% of participants randomized to complete PainCOACH finished all 8 modules over 8 to 10 weeks. Linear mixed models showed that, after treatment, women who received the PainCOACH intervention reported significantly lower pain than that in women in the control group (Cohen d = 0.33). Intervention effects could not be tested in men because of their low pain and small sample size. Additionally, both men and women demonstrated increases in self-efficacy from baseline to after intervention compared with the control group (d = 0.43). Smaller effects were observed for pain-related anxiety (d = 0.20), pain-related interference with functioning (d = 0.13), negative affect (d = 0.10), and positive affect (d = 0.24). Findings underscore the value of continuing to develop an automated Internet-based approach to disseminate this empirically supported intervention.

Evidence-based psychological treatments for mental disorders: modifiable barriers to access and possible solutions

The prevalence of mental disorders is high and appears to be growing, yet the majority of individuals who meet diagnostic criteria for a mental disorder are not able to access an adequate treatment. While evidence-based psychological treatments (EBPTs) are effective single or adjunctive treatments for mental disorders, there is also evidence that access to these treatments is diminishing. We seek to highlight modifiable barriers to these problems at the patient, therapist, treatment, organization and government-levels of analysis. A range of solutions to each set of contributors is offered and domains for future research are highlighted. In particular, we focus on the need to continue to work toward innovation in treatment development while also solving the difficulties relating to the dissemination of EBPTs. Several relatively new concepts in the field will be discussed (implementation cliff, program drift, voltage drop and deployment treatment development) and we contrast America and England as examples of government-level processes that are in the process of major change with respect to EBPTs. We conclude that there is a need for people in our field to become more knowledgeable about, and get involved in, shaping public policy.

Why has our recovery rate dropped? An audit examining waiting times, starting scores and length of treatment in relation to recovery within an IAPT service

The Improving Access to Psychological Therapies (IAPT) initiative was created to provide mental health services for those experiencing mild to moderate depression and anxiety. IAPT is commissioned on the basis that it achieves adequate performance on a number of ‘key performance indicators’, one of which is the proportion of clients who ‘move towards recovery’ following treatment. The impetus for the current evaluation was a significant reduction in the proportion of clients recovering within an IAPT service. Data for this clinical audit was obtained from IAPT electronic records (IAPTus). Three factors (waiting times, clinical contact and starting scores on the PHQ-9 and GAD-7) were examined and explored separately for each level of care (i.e. steps 2 and 3). These factors were analysed in relation to recovery and compared between periods of low and high recovery within the service. Results reveal that there was little change in the severity of clients’ starting scores between the periods of low and high recovery. Increased waiting time in the period of low recovery was not associated with recovery status. The amount of clinical contact was related to recovery at both time periods. Limitations and implications of the findings are discussed.

The effect of an e-learning supported Train-the-Trainer programme on implementation of suicide guidelines in mental health care

BACKGROUND

Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline.

METHODS

45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments.

RESULTS

Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found.

LIMITATIONS

The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study.

CONCLUSIONS

Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients.

TRIAL REGISTRATION

Netherlands Trial Register (NTR3092 www.trialregister.nl).

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy, has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

An adaptationist perspective on the etiology of depression

Major depressive disorder (MDD) presents with a variety of symptoms and responds to a wide range of treatment interventions. Diagnostic criteria collapse multiple syndromes with distinct etiologies into the same disorder. MDD is typically understood as a malfunction of neurotransmission or brain circuitry regulating mood, pleasure and reward, or executive function. However, research from an evolutionary perspective suggests that the "normal" functioning of adaptations may also generate symptoms meeting diagnostic criteria. Functioning adaptations may be an underappreciated etiological pathway to MDD. Many adaptive functions for depressive symptoms have been suggested: biasing cognition to avoid losses, conserving energy, disengaging from unobtainable goals, signaling submission, soliciting resources, and promoting analytical thinking. We review the potential role of these adaptive functions and how they can lead to specific clusters of depressive symptoms. Understanding MDD from such a perspective reduces the heterogeneity of cases and may help to select the best intervention for each patient. We discuss the implications of different adaptive and maladaptive etiological pathways for the use of antidepressants and various modes of psychotherapy. In particular, instances of MDD caused by functioning adaptations may benefit most from treatments that support the adaptive function, or that target the precipitating causal stressor. We conclude that an evolutionary approach to the study of MDD may be one of the more promising approaches to reduce its heterogeneity and to better match patients and treatment.

Medication and psychotherapy in eating disorders: is there a gap between research and practice?

BACKGROUND

Little research has investigated the use of evidence-based guidelines by eating disorder (ED) therapists, or prescribing of psychotropic medication. Moreover, people with EDs have rarely been surveyed on these topics, and their clinical and demographic features have not been presented. This study investigated perception of psychotherapy, psychotropic medication and the clinical characteristics of a community sample of people with EDs.

METHOD

An online survey methodology was used to recruit 253 people with eating disorders in the community. Where feasible, comparisons were made between four types of eating disorder, anorexia nervosa, bulimia nervosa, and two types of atypical or 'sub-threshold' eating disorder.

RESULTS

Unlike medication, reported psychotherapy showed some congruence with evidence based and other guidance. Most participants were currently receiving either psychotherapy, medication or both, and most had a severe and chronic ED.

CONCLUSIONS

Findings are considered in light of use of evidence-based treatment for EDs, calls for greater dissemination of cognitive behaviour therapy (CBT); indications that much may be poor quality; and the importance of what treatments to offer those who are chronically and severely ill. Development of theory and novel treatments is considered a priority.

Integrating technology into cognitive behavior therapy for adolescent depression: a pilot study

BACKGROUND

Rapid advances in information technology and telecommunications have resulted in a dramatic increase in the use of mobile devices and the internet to enhance and facilitate access to treatment. Cognitive behavior therapy (CBT) is an empirically based treatment that is well suited for enhancement by new technologies, particularly with youth. To facilitate the dissemination of this evidence-based treatment, we developed a technology-enhanced CBT intervention for the treatment of adolescent depression consisting of (1) online therapist training (2) in-session use of tablets for teaching clients CBT concepts and skills, and (3) text messaging for between session homework reminders and self-monitoring.

METHODS

Eighteen licensed clinicians (social workers n = 7, psychologists n = 9) were randomized to have their patients receive either the intervention (CBT) or treatment as usual (TAU). Each clinician treated four adolescents for 12 weeks. Clinicians in the CBT arm completed an online tutorial on CBT treatment of adolescent depression, then received an iPad with access to patient education materials for teaching CBT concepts to patients during sessions. Individualized text messages were integrated into treatment for homework reminders, support, and outcomes measurement. Outcome measures included a 49-item multiple choice test for tutorial effectiveness; the system usability scale (SUS) for user satisfaction; quick inventory of depressive symptomatology-adolescent version (QIDS-A-Pat); and clinician and patient ratings on the therapeutic alliance scale for adolescents (TASA).

RESULTS

A significant increase in knowledge of CBT concepts was found after completing the tutorial, t(8) = 7.02, p < 0.001. Clinician and patient ratings of user satisfaction were high for both the iPad teaching tools, and the text messaging. Ninety-five percent of teens said reviewing their text messages with their therapist was helpful, and all said they would use text messaging in treatment again. Ratings of the therapeutic alliance were higher in the CBT arm t(131) = 4.03, p = 0.001. A significant reduction in depression was found in both groups [t(34) = 8.453, p < 0.001 and t(29) = 6.67, p < 0.001 for CBT and TAU, respectively). Clinical ratings of improvement were greater on all outcome measures for the CBT arm; however, none reached statistical significance. Effect sizes (Cohen's d) ranged from small (QIDS-A) to large (TASA).

CONCLUSIONS

Results support the feasibility of this technology-enhanced CBT intervention as a means of improving CBT treatment of adolescent depression and may help address the critical shortage of therapists trained on empirically based treatments.