CBT intensity and outcome for panic disorder in a primary care setting

The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders

OBJECTIVES

Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis.

METHODS

A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only.

RESULTS

Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders.

CONCLUSIONS

These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

Patients' symptoms and strengths as predictors of long-term outcomes of CBT for generalized anxiety disorder - A three-level, multi-predictor analysis

Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual's symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients' strengths for clinical practice.

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

The benefits of a longer course of cognitive behavioral therapy for some patients with social anxiety disorder

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (n = 38) to those who continued treatment for a variable number of additional sessions (n = 34). We found no between-group differences in demographic characteristics, number of comorbid diagnoses, comorbid generalized anxiety disorder or major depressive disorder, or severity of depression at baseline. Patients who ended treatment after 20 sessions experienced greater improvements in SAD over those 20 sessions compared to those who continued treatment. Both groups experienced changes in depression and quality of life over the first 20 sessions. Those who continued treatment showed additional decreases in social anxiety beyond session 20. For those who initially appear to be non-responsive to CBT for SAD, a longer course of treatment may elicit significant improvements.

Evaluating the empirical evidence for three transdiagnostic mechanisms in anxiety and mood disorders

High co-morbidity among mental disorders indicates that common transdiagnostic mechanisms underlie various psychopathology, yet there has been little research effort to empirically explicate transdiagnostic processes. A few existing studies are limited in the number of transdiagnostic mechanisms and mental disorder categories explored. The current study addresses these limitations by examining the relationship between three transdiagnostic processes (experiential avoidance, rumination, and emotion dysregulation) and symptom severity of five mental disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and depression) in a college sample (N = 266). Applying Structural Equation Modeling (SEM), three transdiagnostic models were evaluated, with the five latent variables of mental disorder regressed onto each transdiagnostic process. The results showed that all transdiagnostic models-except the emotion dysregulation model-generally fit the data well. Among the tested models, the strongest evidence was found for experiential avoidance as a transdiagnostic mechanism underlying multiple disorders, suggesting the need for further research effort to reduce experiential avoidance in diverse clinical populations.

Not the exercise type? Personality traits and anxiety sensitivity as predictors of objectively measured physical activity and sedentary time

Personality traits have been investigated as predictors of sedentary behavior, while both personality traits and anxiety sensitivity have been investigated as predictors of physical activity; however, few studies employed objective measurement of these behaviors. The current study recruited 64 young adults who completed the Anxiety Sensitivity Index-3 and NEO-Personality Inventory-3, then wore accelerometers for 1 week. Results revealed that agreeableness and anxiety sensitivity were inversely associated with moderate intensity or greater physical activity; however, none of the investigated constructs predicted sedentary time. These results highlight the importance of objective measurement when studying these behaviors and clinical implications for the identification of individuals at risk for physical activity avoidance.

Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

Predictors of outcome in guided self-help cognitive behavioural therapy for common mental disorders in primary care

Cognitive behavioural therapy (CBT) can effectively treat common mental disorders (CMDs), but access to treatment is insufficient. Guided self-help (GSH) CBT has shown effects comparable to face-to-face CBT and may be a resource-efficient treatment alternative. However, not all patients respond to GSH. Learning more about predictors of outcome may increase knowledge regarding which patients respond to GSH. The aim of this study was to investigate predictors of outcome for GSH CBT for patients with CMDs in primary care. Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia or stress-related disorders were included. All patients received GSH CBT. Outcomes were remission status, reliable change and post-treatment depression ratings. Predictors investigated were clinical, demographic and therapy-related variables. Analyses were conducted using logistic and linear regression. Higher educational level predicted remission, higher quality of life ratings predicted remission and decreased depression, and higher age at onset predicted reliable change. Therapy-related variables, i.e. patient adherence to treatment and patients' and clinicians' estimation of treatment response, were all related to outcome. More large-scale studies are needed, but the present study points at the importance of therapy-related variables such as monitoring and supporting treatment adherence for an increased chance of remission.

Evaluating a Web-Based Social Anxiety Intervention Among Community Users: Analysis of Real-World Data

Background

Social anxiety is both harmful and prevalent. It also currently remains among the most undertreated major mental disorders, due, in part, to socially anxious individuals’ concerns about the stigma and expense of seeking help. The privacy and affordability of computer-aided psychotherapy interventions may render them particularly helpful in addressing these concerns, and they are also highly scalable, but most tend to be only somewhat effective without therapist support. However, a recent evaluation of a new self-guided, 7-module internet-delivered cognitive behavioral therapy intervention called Overcome Social Anxiety found that it was highly effective.

Objective

The initial evaluation of Overcome Social Anxiety revealed that it led to significant reductions in symptom severity among university undergraduates. The aim of this study was to extend the results of the initial study and investigate their generalizability by directly evaluating the intervention’s effectiveness among a general community sample.

Methods

While signing up for Overcome Social Anxiety, users consented to the usage of their anonymized outcome data for research purposes. Before and after completing the intervention, users completed the Fear of Negative Evaluation Scale (FNE), which we employed as the primary outcome measure. Secondary outcome measures included the Depression Anxiety Stress Scales (DASS) and 2 bespoke questionnaires measuring socially anxious thoughts (Thoughts Questionnaire) and avoidance behaviors (Avoidance Questionnaire).

Results

Participants who completed the intervention (102/369, 27.7%) experienced significant reductions in the severity of their symptoms on all measures employed, including FNE (P<.001; Cohen d=1.76), the depression subscale of DASS (P<.001; Cohen d=0.70), the anxiety subscale of DASS (P<.001; Cohen d=0.74), the stress subscale of DASS (P<.001; Cohen d=0.80), the Thoughts Questionnaire (P<.001; Cohen d=1.46), and the Avoidance Questionnaire (P<.001; Cohen d=1.42).

Conclusions

Our results provide further evidence that Overcome Social Anxiety reduces the severity of social anxiety symptoms among those who complete it and suggest that its effectiveness extends to the general community. The completion rate is the highest documented for a fully automated intervention for anxiety, depression, or low mood in a real community sample. In addition, our results indicate that Overcome Social Anxiety reduces the severity of symptoms of depression, physiological symptoms of anxiety, and stress in addition to symptoms of social anxiety.

Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings

CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure); however, delivery of CBT for anxiety disorders in real-world community clinics is lacking. This study utilized surveys we developed with key stakeholder feedback (patient, provider, and administrator) to assess patient and provider/administrator perceptions of the barriers to delivering (or receiving) CBT for anxiety disorders. Providers/administrators from two counties in California (N = 106) indicated lack of training/competency as primary barriers. Patients in one large county (N = 42) reported their own symptoms most often impacted treatment receipt. Both groups endorsed acceptability of exposure but indicated that its use in treatment provided/received had been limited. Implications and recommendations are discussed.

Evaluating a Web-Based Social Anxiety Intervention Among University Students: Randomized Controlled Trial

BACKGROUND

Treatment rates for social anxiety, a prevalent and potentially debilitating condition, remain among the lowest of all major mental disorders today. Although computer-delivered interventions are well poised to surmount key barriers to the treatment of social anxiety, most are only marginally effective when delivered as stand-alone treatments. A new, Web-based cognitive behavioral therapy (CBT) intervention called Overcome Social Anxiety was recently created to address the limitations of prior computer-delivered interventions. Users of Overcome Social Anxiety are self-directed through various CBT modules incorporating cognitive restructuring and behavioral experiments. The intervention is personalized to each user's symptoms, and automatic email reminders and time limits are used to encourage adherence.

OBJECTIVE

The purpose of this study was to conduct a randomized controlled trial to investigate the effectiveness of Overcome Social Anxiety in reducing social anxiety symptoms in a nonclinical sample of university students. As a secondary aim, we also investigated whether Overcome Social Anxiety would increase life satisfaction in this sample.

METHODS

Following eligibility screening, participants were randomly assigned to a treatment condition or a wait-list control condition. Only those assigned to the treatment condition were given access to Overcome Social Anxiety; they were asked to complete the program within 4 months. The social interaction anxiety scale (SIAS), the fear of negative evaluation scale (FNE), and the quality of life enjoyment and satisfaction questionnaire-short form (Q-LES-Q-SF) were administered to participants from both conditions during baseline and 4-month follow-up lab visits.

RESULTS

Over the course of the study, participants assigned to the treatment condition experienced a significant reduction in social anxiety (SIAS: P<.001, Cohen d=0.72; FNE: P<.001, Cohen d=0.82), whereas those assigned to the control condition did not (SIAS: P=.13, Cohen d=0.26; FNE: P=.40, Cohen d=0.14). Additionally, a direct comparison of the average change in social anxiety in the 2 conditions over the course of the study showed that those assigned to the treatment condition experienced significantly more improvement than those assigned to the control condition (SIAS: P=.03, Cohen d=0.56; FNE: P=.001, Cohen d=0.97). Although participants assigned to the treatment condition experienced a slight increase in life satisfaction, as measured by Q-LES-Q-SF scores, and those assigned to the control condition experienced a slight decrease, these changes were not statistically significant (treatment: P=.35, Cohen d=-0.18; control: P=.30, Cohen d=0.18).

CONCLUSIONS

Our findings indicate that Overcome Social Anxiety is an effective intervention for treating symptoms of social anxiety and that it may have further utility in serving as a model for the development of new interventions. Additionally, our findings provide evidence that contemporary Web-based interventions can be sophisticated enough to benefit users even when delivered as stand-alone treatments, suggesting that further opportunities likely exist for the development of other Web-based mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02792127; https://clinicaltrials.gov/ct2/show/record/NCT02792127 (Archived by WebCite at http://www.webcitation.org/6xGSRh7MG).

Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trial

BACKGROUND

Maternal postnatal depression occurs following 10-15% of births and is associated with a range of negative child outcomes. Risks to children are particularly increased when postnatal depression is persistent. We aimed to examine whether a parenting video-feedback therapy (VFT) intervention versus a control treatment of progressive muscle relaxation (PMR), both added to cognitive behavioural therapy (CBT) for persistent postnatal depression, would lead to improved child outcomes at age 2 years.

METHODS

In this two-arm, parallel-design, individually randomised controlled trial, we recruited a community sample of women aged 18 years or older living within 50 miles of Oxford, UK, between 4·5 and 9·0 months post partum. All participants met diagnostic criteria for current major depressive disorder that had persisted for at least 3 months and had infants at 35 or more weeks of gestation, with a birthweight of 2000 g or greater, and without serious neonatal complications. Through a centralised service, women were randomly assigned by use of a minimisation algorithm, to receive either VFT or PMR, balanced for child sex, temperament, age, socioeconomic status, and severity of depression. Both groups also received CBT for depression. Primary outcomes were child cognitive development, language development, behaviour problems, and attachment security at age 2 years. There were 11 home-based treatment sessions before child age 1 year, followed by two booster sessions in the second year. Assessors were masked to treatment group allocation. All analyses were done according to the intention-to-treat principle. This trial is registered with the ISRCTN registry, number ISRCTN07336477.

FINDINGS

Between March 18, 2011, and Dec 9, 2013, we randomly assigned 144 women, 72 to each group. Primary outcome data were available for 62-64 (86-89%) VFT and 67-68 (93-94%) PMR participants. There were no group differences in child outcome (cognitive development, adjusted difference -1·01 [95% CI -5·11 to 3·09], p=0·63; language development, 1·33 [-4·16 to 6·82], p=0·63; behaviour problems, -1·77 [-4·39 to 0·85], p=0·19; attachment security, 0·02 [-0·06 to 0·10], p=0·58), with both groups achieving scores similar to non-clinical norms on all outcomes. There were six serious adverse events: five in the VFT group (in two participants) and one in the PMR group. None was treatment-related.

INTERPRETATION

The effect of persistent postnatal depression on children is a major public health issue. For both treatment groups there was sustained remission from depression, and child development outcomes were in the normal range. The precise mechanisms accounting for the observed positive child outcomes cannot be ascertained from this study.

FUNDING

Wellcome Trust.

Review: Prevention of anxiety among at-risk children and adolescents - a systematic review and meta-analysis

BACKGROUND

Anxiety disorders are common, often start in childhood and run a chronic course. As such there is a need for effective prevention.

METHODS

We conducted a systematic review and meta-analyses of randomized, controlled trials to prevent the onset of anxiety disorders in 'at risk' young people. Diagnostic and symptom outcomes were examined. Putative moderators were tested as was publication bias.

RESULTS

We included 16 trials (2545 young people). Two trials reported diagnostic outcomes, and significant effects were found for these at end-of-programme (RR = .09, 95%CI = .02 to .16), 6- (RR = .17, 95%CI = .06 to .27) and 12-month (RR = .31, 95%CI .17 to .45) follow-ups. Based on 16 trials, improved anxiety symptoms were significant compared to nonattention controls only, with small effect sizes reported by young people at the end-of-programmes, 6- and 12-month follow-ups; and by parents at the end of the programmes and 12-, but not 6-, month follow-ups. There was no evidence of significant moderation or publication bias.

CONCLUSIONS

Fourteen studies included children and young people who presented with elevated anxiety symptoms, but anxiety disorder was not ruled out in the participants in these studies. Hence, these studies might be reporting results of mixed prevention/early intervention programmes. Prevention programmes that target developmental risk factors, not only disorder maintaining factors, appear most promising. The clinically meaningful impact of anxiety disorder prevention programmes remains unknown.

Randomized Pilot of an Anxiety Sensitivity-Based Intervention for Individuals in a Substance Use Day Program

Anxiety sensitivity (AS), or the tendency to appraise physical symptoms as intolerable or dangerous, may maintain the cycle between co-occurring anxiety and substance use disorders. This study examined preliminary efficacy of a brief intervention targeting AS for individuals with heterogeneous substance use disorders. Forty-one patients with high AS entering an addictions day program were randomized to treatment as usual (TAU) or to TAU plus a nine-hour AS-focused intervention that consisted of interoceptive exposures, psychoeducation about the cycle of problematic substance use and anxiety, and a single session of cognitive challenging (e.g., reviewing common cognitive distortions and decatastrophizing anxiety symptoms). Mixed-effects intent-to-treat models suggested that participants in the AS condition showed greater decreases in AS at post-treatment, but this effect was lost at follow-up three months later. Intervention conditions did not differ in change in percent days abstinent or self-reported anxiety, with both conditions showing significant improvement at post-treatment. Results suggest that the nine-hour AS-focused intervention led to a short-term benefit over TAU alone, but this benefit was not sustained at three months' follow-up. Future AS interventions may need to target specific subconstructs of AS for selected populations, or target emotional distress tolerance more broadly.

Anxiety disorders

Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.

The effect of Korean-group cognitive behavioural therapy among patients with panic disorder in clinic settings

WHAT IS KNOWN ON THE SUBJECT?: Panic disorder patients display various panic-related physical symptoms and catastrophic misinterpretation of bodily sensations, which lower their quality of life by interfering with daily activities. Cognitive behavioural therapy (CBT) is a useful strategy for panic disorder patients to manage symptoms associated with inaccurate cognitive interpretation of situations resulting from the patient's cognitive vulnerability. In South Korea, however, despite the increasing prevalence of panic disorder, CBT is not a common element of nursing care plans for panic disorder patients. Moreover, few Korean researchers have attempted to assess the effects of CBT on such patients. WHAT THIS PAPER ADD TO EXISTING KNOWLEDGE?: In a strategy combining CBT and routine treatments, patients with panic disorder can experience greater positive effects in the acute treatment phase than those they experience when receiving only routine treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals, especially psychiatric nurses in local clinics who operate most special mental health programmes for panic disorder patients, should apply a panic disorder management programme that integrates CBT and routine treatments. The integrated approach is more effective for reducing the number of panic attacks and cognitive misinterpretation in patients than providing routine treatment alone. For patients with panic disorder, the objective of CBT is to understand the relationship between psychological panic disorder sensations, emotions, thoughts and behaviours. Therefore, nurses can help patients address and improve biological, social and psychological aspects of physical health problems as well as help them improve their coping skills in general.

ABSTRACT

Introduction In panic disorder, sensitivity to bodily sensations increases due to the patient's cognitive vulnerability. Cognitive behavioural therapy (CBT) can help to decrease sensitivity to bodily sensations by correcting these cognitive distortions by controlling negative thoughts and panic attacks. Aims This study verified whether group CBT is more effective than treatment as usual (TAU) in South Korean patients with panic disorder. Methods The study participants consisted of 76 panic disorder patients. Patients in the therapy condition attended sessions once a week for a total of 12 sessions in addition to drug treatment. Results In the therapy condition, there were significant decreases in panic-related bodily sensations and ranking and belief scores for catastrophic misinterpretation of external events. Discussion Group CBT, in comparison to TAU, decreases panic and agoraphobia symptom severity in South Korean patients with panic disorder. Our study provides evidence for the effectiveness of a panic disorder management programme that integrates group CBT and traditional pharmacotherapeutic treatment for patients with panic disorder. Implications for Practice The cognitive behavioural approach is needed to reduce panic and agoraphobia symptoms for hospitalized patients with panic disorder more than activity therapies, medications and supportive counselling by doctors and nurses.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders

The present article uses meta-analysis to examine treatment components related to outcome within 35 randomized controlled trials (RCTs) for childhood anxiety disorders (CADs) and eight RCTs for childhood obsessive compulsive disorder (OCD). Examination of the RCTs of cognitive behavioral therapy (CBT) for CADs suggested that adding relaxation and delaying exposures until after the introduction of other anxiety management strategies does not increase the efficacy of exposure-based treatment. In addition, compared to the large effect size (ES) associated with exposure and response prevention (ERP) for OCD (k = 9, mean ES = 1.93), the effect size associated with CBT for CADs (k = 44, mean ES = 0.89) did not differentiate from attention placebo (k = 11, mean ES = 0.55), although it was more effective than waitlist control (k = 24, mean ES = 0.22). Instructively, ERP for OCD involved more exposure initiated earlier and less relaxation than CBT for CADs. In addition, RCTs of ERP were more likely to use clinician-administered measures as opposed to self-report and to be conducted in clinical versus recruited samples. These results suggest that dismantling studies using a gold-standard clinician-rated outcome measure to compare the value of adding anxiety management strategies to exposure will be necessary to increase the efficacy of CBT for CADs to levels achieved by ERP for OCD.

Mobile Device-Based Applications for Childhood Anxiety Disorders

OBJECTIVE

Given that childhood anxiety disorders are common and frequently undertreated, novel treatment platforms are needed. The current article explores the potential for mobile device-based (m-health) applications, to expand access to evidence-based treatment.

METHODS

This article reviews the relevant literature regarding barriers to disseminating evidence-based treatment, the potential benefits of the m-health platform, standards for evaluating m-health interventions, and currently available applications.

RESULTS

Although a large number of m-health applications for anxiety are available, the vast majority of them are inconsistent with therapy protocols supported by the child anxiety treatment literature. The relatively few m-health applications based on evidence-based practice have not yet been examined empirically.

CONCLUSIONS

Realizing the potential of m-health for child anxiety will require addressing the uncertainty around the necessary and sufficient components of cognitive-behavioral therapy (CBT), as well as the common challenges associated with delivering interventions via information and communication technology. Mayo Clinic Anxiety Coach is an m-health application designed by the author and colleagues to be consistent with exposure-based CBT and principles for effective intervention delivery via information and communication technology. Recommendations for identifying, using, and developing m-health applications for childhood anxiety disorders are presented.

Patient experience of computerised therapy for depression in primary care

OBJECTIVE

To explore patient experience of computerised cognitive behaviour therapy (cCBT) for depression in a pragmatic randomised controlled trial (Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy, REEACT).

DESIGN

Qualitative semistructured interviews with 36 participants.

PARTICIPANTS

Depressed patients with a Patient Health Questionnaire 9 of 10 or above recruited into the REEACT randomised controlled trial.

SETTING

Primary care settings in England.

RESULTS

Participant experience was on a continuum, with some patients unable or unwilling to accept psychological therapy without interpersonal contact while others appreciated the enhanced anonymity and flexibility of cCBT. The majority of patients were ambivalent, recognising the potential benefits offered by cCBT but struggling with challenges posed by the severity of their illness, lack of support and limited personalisation of programme content. Low completion rates were commonly reported, although more positive patients reported greater engagement. Both positive and ambivalent patients perceived a need for monitoring or follow-up to support completion, while negative patients reported deliberate non-adherence due to dissatisfaction with the programme. Patients also reported that severity of depression impacted on engagement, and viewed cCBT as unsuitable for patients undergoing more severe depressive episodes.

CONCLUSIONS

The study demonstrates both the unique demands and benefits of computerised therapy. cCBT was preferred by some patients and rejected by others, but the majority of patients were ambivalent about the therapy. cCBT could be offered within a menu of options in stepped care if matched appropriately to individual patients or could be offered with enhanced support to appeal to a greater number of patients.

TRIAL REGISTRATION NUMBER

ISRCTN91947481.

Stepped care versus face-to-face cognitive behavior therapy for panic disorder and social anxiety disorder: Predictors and moderators of outcome

OBJECTIVE

To investigate predictors and moderators of treatment outcome by comparing immediate face-to-face cognitive behavioral therapy (FtF-CBT) to a Stepped Care treatment model comprising three steps: Psychoeducation, Internet-delivered CBT, and FtF-CBT for panic disorder (PD) and social anxiety disorder (SAD).

METHOD

Patients (N = 173) were recruited from nine public mental health out-patient clinics and randomized to immediate FtF-CBT or Stepped Care treatment. Characteristics related to social functioning, impairment from the anxiety disorder, and comorbidity was investigated as predictors and moderators by treatment format and diagnosis in multiple regression analyses.

RESULTS

Lower social functioning, higher impairment from the anxiety disorder, and a comorbid cluster C personality disorder were associated with significantly less improvement, particularly among patients with PD. Furthermore, having a comorbid anxiety disorder was associated with a better treatment outcome among patients with PD but not patients with SAD. Patients with a comorbid depression had similar outcomes from the different treatments, but patients without comorbid depression had better outcomes from immediate FtF-CBT compared to guided self-help.

CONCLUSIONS

In general, the same patient characteristics appear to be associated with the treatment outcome for CBT provided in low- and high-intensity formats when treated in public mental health care clinics. The findings suggest that patients with lower social functioning and higher impairment from their anxiety disorder benefit less from these treatments and may require more adapted and extensive treatment. CLINICALTRIALS.GOV: Identifier: NCT00619138.

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

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

Introduction to the special issue: new methods in exposure therapy

Exposure-based interventions have been shown to significantly reduce anxiety and avoidance. The efficacy of the approach is robust, and recent efforts have been made to expand the use of exposure as well as identify more effective ways to implement the procedure. This article introduces the special issue devoted to recent novel approaches to the dissemination and implementation of exposure.

The role of anxiety sensitivity in daily physical activity and eating behavior

Anxiety sensitivity (AS), or the fear of somatic arousal, has been linked to both maladaptive eating behavior as well as exercise avoidance in both self-report and laboratory-based experiments. The current pilot study sought to extend these finding to the naturalistic setting. A sample of 32 adults completed affect and dietary monitoring and wore actigraphs across a three-day monitoring period. Results indicated that high AS was associated with greater calorie consumption overall in women and less consumption in men, and high AS predicted an increase in calories consumed following participants' greatest increase in negative affect in both sexes. For physical activity, results indicated an AS by BMI interaction such that obese individuals with high AS engaged in less moderate-intensity physical activity, whereas the opposite was true for normal weight individuals. These results indicate that AS may represent a double-edged risk factor for obesity contributing to both exercise avoidance and calorie consumption.

The effectiveness of booster sessions in CBT treatment for child and adolescent mood and anxiety disorders

BACKGROUND

To investigate the effects of booster sessions in cognitive behavioral therapy (CBT) for children and adolescents with mood or anxiety disorders, whereas controlling for youth demographics (e.g., gender, age), primary diagnosis, and intervention characteristics (e.g., treatment modality, number of sessions).

METHODS

Electronic databases were searched for CBT interventions for youth with mood and anxiety disorders. Fifty-three (k = 53) studies investigating 1,937 youth met criteria for inclusion. Booster sessions were examined using two case-controlled effect sizes: pre-post and pre-follow-up (6 months) effect sizes and employing weighted least squares (WLSs) regressions.

RESULTS

Meta-analyses found pre-post studies with booster sessions had a larger effect size r = .58 (k = 15; 95% CI = 0.52-0.65; P < .01) than those without booster sessions r = .45 (k = 38; 95% CI = 0.41-0.49; P < .001). In the WLS regression analyses, controlling for demographic factors, primary diagnosis, and intervention characteristics, studies with booster sessions showed larger pre-post effect sizes than those without booster sessions (B = 0.13, P < .10). Similarly, pre-follow-up studies with booster sessions showed a larger effect size r = .64 (k = 10; 95% CI = 0.57-0.70; P < .10) than those without booster sessions r = .48 (k = 20; 95% CI = 0.42-0.53; P < .01). Also, in the WLS regression analyses, pre-follow-up studies showed larger effect sizes than those without booster sessions (B = 0.08, P < .01) after accounting for all control variables.

CONCLUSIONS

Result suggests that CBT interventions with booster sessions are more effective and the effect is more sustainable for youth managing mood or anxiety disorders than CBT interventions without booster sessions.

Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement

OBJECTIVE

The present study explored treatment dose and patient engagement as predictors of treatment outcome in cognitive behavioral therapy (CBT) for anxiety disorders.

METHOD

Measures of high versus low treatment dose and high versus low patient engagement in CBT were compared as predictors of 12- and 18-month outcomes for patients being treated for anxiety disorders with CBT (with or without concurrent pharmacotherapy) in primary care settings as part of a randomized controlled effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention. Measures of dose (attendance, exposure completion) and engagement in CBT (homework adherence, commitment) were collected throughout treatment, and blinded follow-up phone assessments of outcome measures (12-item Brief Symptom Inventory, Patient Health Questionnaire 8, Sheehan Disability Scale) were completed at 12 and 18 months. Propensity score weighting controlled for baseline differences in demographics and symptom severity between patients with high and low dose and engagement. These analyses included the 439 patients who selected CBT as treatment modality.

RESULTS

Completing exposures, having high attendance, and being more adherent to completing homework predicted better outcomes across all measures at 12 and 18 months, and high CBT commitment predicted better outcomes on all measures at 18 months.

CONCLUSIONS

This study found that higher treatment dose and patient engagement in CBT for anxiety disorders were stable and robust predictors of greater reductions in anxiety symptoms, depression symptoms, and functional disability.

Are exposure-based cognitive behavioral therapies safe during pregnancy?

Anxiety disorders during pregnancy are highly prevalent and associated with serious and enduring consequences for both mother and child. Exposure-based cognitive behavioral (CBT) and behavioral therapies (BT) represent the most empirically supported psychosocial treatments for anxiety disorders in general adult samples. Pregnant women, however, generally have been excluded from this body of research. Evidence that pregnant women inhabit a unique biological context combined with untested assumptions that exposure would unduly stress or harm the fetus have likely prohibited inquiry. This paper seeks to remedy this gap by integrating findings from obstetric, psychiatric, and psychological research to inform central questions regarding exposure-based treatment of anxiety disorders during pregnancy. Based on available evidence, we consider the potential risks and benefits of CBT/BT for anxiety disorders during pregnancy relative to other currently available treatment options. From a multidisciplinary research perspective, we argue that exposure-based therapies are likely to be safe during pregnancy, particularly relative to the alternatives. However, we also highlight critical questions for future research to directly test the biopsychological impact of exposure-based therapies among pregnant women.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders

OBJECTIVE

Randomized comparisons of acceptance-based treatments with traditional cognitive behavioral therapy (CBT) for anxiety disorders are lacking. To address this gap, we compared acceptance and commitment therapy (ACT) to CBT for heterogeneous anxiety disorders.

METHOD

One hundred twenty-eight individuals (52% female, mean age = 38, 33% minority) with 1 or more DSM-IV anxiety disorders began treatment following randomization to CBT or ACT; both treatments included behavioral exposure. Assessments at pre-treatment, post-treatment, and 6- and 12-month follow-up measured anxiety-specific (principal disorder Clinical Severity Ratings [CSRs], Anxiety Sensitivity Index, Penn State Worry Questionnaire, Fear Questionnaire avoidance) and non-anxiety-specific (Quality of Life Index [QOLI], Acceptance and Action Questionnaire-16 [AAQ]) outcomes. Treatment adherence, therapist competency ratings, treatment credibility, and co-occurring mood and anxiety disorders were investigated.

RESULTS

CBT and ACT improved similarly across all outcomes from pre- to post-treatment. During follow-up, ACT showed steeper linear CSR improvements than CBT (p < .05, d = 1.26), and at 12-month follow-up, ACT showed lower CSRs than CBT among completers (p < .05, d = 1.10). At 12-month follow-up, ACT reported higher AAQ than CBT (p = .08, d = 0.42; completers: p < .05, d = 0.56), whereas CBT reported higher QOLI than ACT (p < .05, d = 0.42). Attrition and comorbidity improvements were similar; ACT used more non-study psychotherapy at 6-month follow-up. Therapist adherence and competency were good; treatment credibility was higher in CBT.

CONCLUSIONS

Overall improvement was similar between ACT and CBT, indicating that ACT is a highly viable treatment for anxiety disorders.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders

OBJECTIVE

To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting.

METHODS

In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence.

RESULTS

Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups.

CONCLUSIONS

We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

Online CBT I: Bridging the Gap Between Eliza and Modern Online CBT Treatment Packages

Reviews have demonstrated large effect sizes when using computerised cognitive behaviour therapy (CBT) protocols for treating anxiety, depression and health related concerns. However, the amount of therapist contact per user seems to be the most significant prognostic indicator. Thus, in some ways current online interventions can be viewed primarily as an extension of one-on-one therapy. The present article provides guidelines for targeting this limitation of online psychological interventions. The goal is to mimic the therapeutic relationship using a computer, without having any therapist involved. Consequently, thousands of users would be able to receive treatment simultaneously, reaching a wider audience, which was the initial goal of the online model. The development of a treatment program using file audit data is suggested as an alternative to having an individual therapist for each user. This is done by allowing the ‘computer psychologist’ to tailor individualised treatments for each user based on their psychological profile. The user is provided with individualised corrective feedback based on a set of prewritten responses to common faulty thoughts. A new paradigm is proposed for online treatment delivery.

Online CBT II: A Phase I Trial of a Standalone, Online CBT Treatment Program for Social Anxiety in Stuttering

This paper introduces a novel approach to internet treatment for social anxiety. The goal of this treatment was to address key limitations of current standalone treatments (Helgadottir, Menzies, Onslow, Packman, & O'Brian, 2009). The ‘computer psychologist’ designed for this study used fully automated, prewritten individualised sample answers in order to simulate a human–human interaction through a human–computer interface. Two males who sought treatment for stuttering and met the diagnosis for social phobia according to the DSM-IV and ICD-10 criteria were selected for this study. After receiving the treatment, both users no longer met criteria for social phobia. Also, significant improvements were observed on other psychometric tests, including measures of unhelpful cognitions, behavioural avoidance, quality of life, and low mood. The quality of the interaction appeared to be similar to face-to-face therapy, indicating that the ‘computer psychologist’ established an effective therapeutic relationship, and the automated techniques used were sufficiently engaging to prompt users to log on regularly and complete the treatment program.

Effectiveness of cognitive behavioural therapy in primary health care: a review

BACKGROUND

Depression and anxiety are highly prevalent disorders causing substantial impairment in daily life. Cognitive behavioural therapy (CBT) delivered face-to-face or as self-help has shown to be an effective treatment for these disorders. Such treatments may be suitable for delivery in primary health care.

AIM

The aim of the article was to review research on the effectiveness of CBT for depression and anxiety disorders delivered in primary care by primary care therapists.

METHODS

A literature search of quantitative studies of the effectiveness of CBT delivered in primary care was conducted on multiple electronic databases. A total of 17 studies were included in the review.

RESULTS

Eight studies of supported Internet- or computer-based CBT, six of which were randomized controlled trials (RCTs), indicate that this treatment is effective for mild to moderate depression and anxiety. Five studies suggest that this treatment may be more effective than usual care for mild to moderate but not for more severe symptoms. Results of four RCTs of brief therapies using written self-help material suggest that while such interventions are effective, no particular approach outperformed any other, including usual care. Five RCTs of CBT delivered face-to-face show that this treatment can be effective when delivered by therapists highly educated in the mental health field. However, many primary care therapists may find such interventions too time consuming.

CONCLUSIONS

CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists.

Treating Panic in a Veteran With Comorbid Combat-Related Posttraumatic Stress Disorder

Research indicates that psychiatric comorbidity can limit the effectiveness of evidence-based psychotherapy interventions. Panic disorder (PD) can be effectively treated with panic control treatment. However, the effectiveness of this intervention with comorbid posttraumatic stress disorder (PTSD) is not well established. This case is about a 57-year-old Vietnam Veteran diagnosed with PD with agoraphobia and comorbid PTSD and depression. The veteran participates in 10 sessions of panic control treatment after limited success with pharmacotherapy. He completed a structured clinical interview and self-report measures at pretreatment, 1-week posttreatment and 3-month follow-up. The veteran’s panic attacks were eliminated prior to completing the protocol. He remained panic free at posttreatment and follow-up but continued to meet criteria for PTSD and depression. These findings indicate that comorbid PTSD and depression do not limit the success of panic control treatment for PD. However, treatment effects do not generalize across anxiety disorders. Implications and recommendations are presented.

Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings

In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.

Treatment for anxiety disorders: Efficacy to effectiveness to implementation

Anxiety disorders are common, costly and debilitating, and yet often unrecognized or inadequately treated in real world, primary care settings. Our group has been researching ways of delivering evidence-based treatment for anxiety in primary care settings, with special interest to preserving the fidelity of the treatment while at the same time promoting its sustainability once the research is over. In this paper, we describe the programs we have developed and our directions for future research. Our first study evaluated the efficacy of CBT and expert pharmacotherapy recommendations for panic disorder in primary care, using a collaborative care model of service delivery (CCAP). Symptom, disability and mental health functioning measures were superior for the intervention group compared to treatment as usual both in the short term and the long term, although also more costly. In our ongoing CALM study, we have extended our population to include panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic disorder, while at the same time utilizing clinicians with limited mental health care experience. In addition to pharmacotherapy management, we developed a computer-assisted CBT that guides both novice clinician and patient, thereby contributing to sustainability once the research is over. We have also incorporated a measurement based approach to treatment planning, using a web-based tracking system of patient status. To date, the computer-assisted CBT program has been shown to be acceptable to clinicians and patients. Clinicians rated the program highly, and patients engaged in the program. Future directions for our research include dissemination and implementation of the CALM program, testing potential alternations to the CALM program, and distance delivery of CALM.

First-line treatment: a critical appraisal of cognitive behavioral therapy developments and alternatives

In this article, the authors assess the successes, remaining challenges, and new developments in cognitive behavioral therapy (CBT) for anxiety disorders. They define CBT, examine treatment components, review treatment efficacy, and discuss the challenges of attrition, long-term follow-up, co-occurring/comorbid disorders, limited treatment comparisons, treatment mediators, and broader implementation. In addition, they present recent developments in cognitive behavioral therapy for anxiety disorders, including linking exposure therapy to basic science, mindfulness and acceptance-based treatments, and unified or transdiagnostic treatment protocols.

[Cognitive-behavioral therapy in panic disorder]

OBJECTIVE

Panic disorder is a chronic and recurrent condition that impairs an individual's psychosocial functioning and quality of life. Despite the efficacy of psychopharmacological treatment in reducing panic attacks, many patients fail to respond adequately to these interventions. Cognitive behavioral therapy provides an alternative and efficacious method for treating panic disorder and agoraphobic avoidance. The objective of the study is to describe the use of cognitive behavioral therapy for panic disorder.

METHOD

Narrative review of data collected from Medline, SciELO and PsycInfo and specialized textbooks.

RESULTS

We describe the cognitive-behavioral model for the treatment of panic disorder, and review both short and long-term efficacy findings. We also discuss the role of combined treatment (cognitive behavioral therapy and psychopharmacology).

CONCLUSIONS

Cognitive behavioral therapy, either individual or in group, can be used as first-line therapy for panic disorder. This treatment modality can also be indicated as a next step for patients failing to respond to other treatments.

Psychosocial interventions for low back pain in primary care: lessons learned from recent trials

STUDY DESIGN

Workshop discussion and literature overview.

OBJECTIVE

To give an overview of the main lessons learnt from recent trials on the effectiveness of psychosocial interventions for back pain in primary care.

SUMMARY OF BACKGROUND DATA

Recently, there has been a move to provide early psychosocial interventions in primary care to prevent chronic back pain. The results of most of the randomized trials, however, show only small differences between the psychosocial intervention and active control treatments in function or other outcome measures.

METHODS

During Low Back Pain Forum 2006 in Amsterdam 3 subgroups debated possible explanations for these "negative" findings, focusing on (1) patient selection, (2) the intervention, or (3) assessment. These discussions were illustrated with evidence from the literature and with data from 2 randomized trials.

RESULTS

The workshop participants highlighted the importance of better targeting psychosocial interventions at those who are at high risk of chronic back pain, and are likely to respond to treatment. Interventions should focus on modifiable prognostic factors, and address somatic, psychological, and social aspects of the pain problem. The general consensus was that, depending on the complexity of the condition, primary care providers can be involved in the psychosocial management of back pain, but should be adequately trained. Competencies of care providers and adherence to treatment protocols should be investigated in a process evaluation. Finally, although trials have included relevant instruments to measure back pain and disability, patient assessment might be improved by measuring other factors that may mediate or modify the effects of treatment.

CONCLUSION

Despite the publication of recent "negative" results of psychosocial interventions for back pain, workshop participants remained optimistic about the importance of this line of research. Suggestions are given for a refocused research agenda on the effectiveness of psychosocial interventions for back pain in primary care.