Economic Impact of Third-Wave Cognitive Behavioral Therapies: A Systematic Review and Quality Assessment of Economic Evaluations in Randomized Controlled Trials

Economic Evaluation of Videoconference Group Acceptance and Commitment Therapy and Behavioral Activation Therapy for Depression Versus Usual Care Among Adults With Chronic Low Back Pain Plus Comorbid Depressive Symptoms

Chronic pain and depression are frequently comorbid conditions associated with significant health care and social costs. This study examined the cost-utility and cost-effectiveness of videoconference-based group forms of Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD), as a complement to treatment-as-usual (TAU), for patients with chronic low back pain (CLBP) plus depressive symptoms, compared to TAU alone. A trial-based economic evaluation (n = 234) was conducted from a governmental and health care perspective with a time horizon of 12 months. Primary outcomes were the Brief Pain Inventory-Interference Scale (BPI-IS) and Quality Adjusted Life Year. Compared to TAU, ACT achieved a significant reduction in total costs (d = .47), and BATD achieved significant reductions in indirect (d = .61) and total costs (d = .63). Significant improvements in BPI-IS (d = .73 and d = .66, respectively) and Quality Adjusted Life Year scores (d = .46 and d = .28, respectively) were found in ACT and BATD compared to TAU. No significant differences in costs and outcomes were found between ACT and BATD. In the intention-to-treat analyses, from the governmental and health care perspective, no significant differences in cost reduction and incremental effects were identified in the comparison between ACT, BATD, and TAU. However, in the complete case analysis, significant incremental effects of ACT (∆BPI-IS = -1.57 and -1.39, respectively) and BATD (∆BPI-IS = -1.08 and -1.04, respectively) compared with TAU were observed. In the per-protocol analysis, only the significant incremental effects of ACT (∆BPI-IS = -1.68 and -1.43, respectively) compared to TAU were detected. In conclusion, ACT and BATD might be efficient options in the management of CLBP plus comorbid depression symptoms as compared to usual care. However, no clear difference was found in the comparison between the 2 active therapies regarding cost-effectiveness or cost-utility. PERSPECTIVE: The economic evaluation of psychological therapies for the management of complex conditions can be used in decision-making and resource allocation. This study provides evidence that ACT and BATD are more effective and involve a greater reduction in costs than usual care in the management of CLBP plus comorbid depressive symptoms. TRIAL NUMBER: NCT04140838.

Mindfulness-Based Stress Reduction Health Insurance Coverage: If, How, and When? An Integrated Knowledge Translation (iKT) Delphi Key Informant Analysis

Objectives

Hundreds of trials have evaluated Mindfulness-Based Stress Reduction (MBSR), but in the United States, it is generally not covered by health insurance. Consequently, the aims were to identify the following: (1) key questions to make decisions about if, how, and when MBSR should be covered by health insurance; (2a) barriers and (2b) facilitators to understand and resolve for MBSR to be covered by health insurance; and (3) highest priority evidence needed to inform health insurance coverage decisions.

Methods

Key informants (n = 26) included health insurers, healthcare administrators, policymakers, clinicians, MBSR instructors, and MBSR students. An initial pool of items related to the study aims was generated through qualitative interviews. Through the Delphi process, participants rated, discussed, and re-rated each item's relevance. Items were required to reach a consensus of ≥ 80% agreement to be retained for final inclusion.

Results

Of the original 149 items, 42 (28.2%) met the ≥ 80% agreement criterion and were retained for final inclusion. The most highly rated items informing whether MBSR should be covered by health insurance included research demonstrating that MBSR works and that it is not harmful. The most highly rated barriers to coverage were that MBSR is not a medical treatment and patient barriers to attendance. Highly rated facilitators included the potential of MBSR to address common mental health and psychosomatic problems. Finally, understanding what conditions are effectively treated with MBSR and the impact of MBSR on stress were rated as the highest priority evidence needed to inform health insurance coverage decisions.

Conclusions

Findings highlight priorities for future research and policy efforts to advance health insurance coverage of MBSR in the United States.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-024-02366-x.

A Digital Behavioral Activation Intervention (JuNEX) for Pregnant Women With Subclinical Depression Symptoms: Explorative Co-Design Study

BACKGROUND

Digital interventions are gaining increasing interest due to their structured nature, ready availability, and self-administered capabilities. Perinatal women have expressed a desire for such interventions. In this regard, behavioral activation interventions may be particularly suitable for digital administration.

OBJECTIVE

This study aims to exploratorily investigate and compare the feasibility of the internet-based self-help guided versus unguided version of the Brief Behavioral Activation Treatment for Depression-Revised, an empirically supported in-person behavioral activation protocol, targeting pregnant women with subclinical depression symptoms. A user-centered design is used, whereby data are collected with the intent of evaluating how to adjust the intervention in line with pregnant women's needs. Usability and user engagement were evaluated.

METHODS

A total of 11 Italian pregnant women with subclinical depressive symptoms based on the Patient Health Questionnaire-9 (scoring<15) participated in this study; of them, 6 (55%) women were randomly assigned to the guided group (age: mean 32.17, SD 4.36 years) and 5 (45%) to the unguided group (age: mean 31, SD 4.95 years). The Moodle platform was used to deliver the interventions in an e-learning format. It consisted of 6 core modules and 3 optional modules; the latter aimed at revising the content of the former. In the guided group, each woman had weekly chats with their assigned human guide to support them in the homework revisions. The intervention content included text, pictures, and videos. Semistructured interviews were conducted, and descriptive statistics were analyzed.

RESULTS

Collectively, the data suggest that the guided intervention was better accepted than the unguided one. However, the high rates of dropout (at T6: guided group: 3/6, 50%; unguided: 4/5, 80%) suggest that a digital replica of Behavioral Activation Treatment for Depression-Revised may not be feasible in an e-learning format. The reduced usability of the platform used was reported, and homework was perceived as too time-consuming and effort-intensive. Moreover, the 6 core modules were deemed sufficient for the intervention's goals, suggesting that the 3 optional modules could be eliminated. Nevertheless, participants from both groups expressed satisfaction with the content and found it relevant to their pregnancy experiences.

CONCLUSIONS

Overall, the findings have emphasized both the intervention's merits and shortcomings. Results highlight the unsuitability of replicating an in-person protocol digitally as well as of the use of nonprofessional tools for the implementation of self-help interventions, ultimately making the intervention not feasible. Pregnant women have nonetheless expressed a desire to receive psychological support and commented on the possibilities of digital psychosocial supports, particularly those that are app-based. The information collected and the issues identified here are important to guide the development and co-design of a more refined platform for the intervention deployment and to tailor the intervention's content to pregnant women's needs.

Cost-effectiveness of providing university students with a mindfulness-based intervention to reduce psychological distress: economic evaluation of a pragmatic randomised controlled trial

OBJECTIVE

Increasing numbers of young people attending university has raised concerns about the capacity of student mental health services to support them. We conducted a randomised controlled trial (RCT) to explore whether provision of an 8 week mindfulness course adapted for university students (Mindfulness Skills for Students-MSS), compared with university mental health support as usual (SAU), reduced psychological distress during the examination period. Here, we conduct an economic evaluation of MSS+SAU compared with SAU.

DESIGN AND SETTING

Economic evaluation conducted alongside a pragmatic, parallel, single-blinded RCT comparing provision of MSS+SAU to SAU.

PARTICIPANTS

616 university students randomised.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the university counselling service. Costs relate to staff time required to deliver counselling service offerings. QALYs were derived from the Clinical Outcomes in Routine Evaluation Dimension 6 Dimension (CORE-6D) preference based tool, which uses responses to six items of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM; primary clinical outcome measure). Primary follow-up duration was 5 and 7 months for the two recruitment cohorts.

RESULTS

It was estimated to cost £1584 (2022 prices) to deliver an MSS course to 30 students, £52.82 per student. Both costs (adjusted mean difference: £48, 95% CI £40-£56) and QALYs (adjusted mean difference: 0.014, 95% CI 0.008 to 0.021) were significantly higher in the MSS arm compared with SAU. The incremental cost-effectiveness ratio (ICER) was £3355, with a very high (99.99%) probability of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY.

CONCLUSIONS

MSS leads to significantly improved outcomes at a moderate additional cost. The ICER of £3355 per QALY suggests that MSS is cost-effective when compared with the UK's National Institute for Health and Care Excellence thresholds of £20 000 per QALY.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry, ACTRN12615001160527.

Third-wave cognitive behavioral therapies for caregivers of cancer patients: a scoping review

BACKGROUND

Cancer caregivers extend comprehensive support covering all aspects of patients' daily lives. It has been reported that a significant proportion of cancer caregivers experience emotional distress. As one way to solve this problem, third-wave cognitive behavioral therapies (CBT), which involves integrating acceptance and mindfulness into cognitive‒behavioral therapy, has been applied to improve caregiver outcomes.

METHODS

A scoping review was conducted based on the scoping review guidelines proposed by the Jonna Briggs Institute (JBI). The population was caregivers of cancer patients, the concept was third-wave CBT, and the context remained open. English and Korean publications published from 2001 to June 2022 were identified from PubMed, Embase, CINAHL, PsycINFO, Cochrane, Korea Med, and RISS.

RESULTS

A total of 12 studies were included in this scoping review. Mindfulness-Based Stress Reduction (MBSR) and Acceptance and Commitment Therapy (ACT) was the most frequently applied intervention (n = 3, each). Among the components of third-wave CBT, 'mindfulness' was identified in all the studies reviewed (n = 12). Dyadic interventions comprised the majority (n = 9). Interventions using digital technologies such as mobile application/web page (n = 3), telephone (n = 3), and FaceTime (n = 2) have increased since 2017. Depression was the most frequently evaluated outcome (n = 8), followed by anxiety and mindfulness (n = 6, each).

CONCLUSIONS

The current review explored available third-wave CBT intervention studies for cancer caregivers and targeted outcomes. Most of the interventions were dyadic interventions and utilized mindfulness. Delivery methods were continuously updated with digital technologies. Further RCTs with robust research designs and a synthesis of the results of the trials would provide evidence about how to effectively apply third-wave CBTs for cancer caregivers.

Management protocols of chronic Orofacial Pain: A Systematic Review

Objective

Chronic orofacial pain (CP) is a persistent and debilitating condition that affects the face, mouth, and jaw and can have a significant impact on an individual's quality of life by posing problems to eat, speak, and perform everyday activities. By the means of this narrative review, we aim to assess different types of management modalities that exist to combat chronic orofacial pain.

Design

Various databases were explored with MeSH keywords of chronic orofacial pain, orofacial pain, and interventions and treatment protocols for eligible articles. After an extensive literature search, it was ascertained that this review identified four major categories of treatment modalities for the management of chronic orofacial pain, namely pharmacological management, psychological management, lifestyle interventions-based management, and current stimulation-based management.

Results

Of the four categories discussed, although pharmacological intervention offered the most immediate relief-especially from orofacial pain that was of a sudden, stab-like in nature-psychological management demonstrated a remarkable ability to reduce/alleviate the more serious aspect of chronic orofacial pain and was deemed better in comparison to the rest. Lifestyle-based techniques and current stimulation-based management were of limited use since they tended to focus more on the causal and not the symptomatic aspect of orofacial pain.

Conclusions

Many patients with persistent orofacial discomfort can experience notable improvements in their symptoms and general well-being by all the treatment modalities evaluated.

Mindfulness-based intervention improves residual negative symptoms and cognitive impairment in schizophrenia: a randomized controlled follow-up study

BACKGROUND

Residual negative symptoms and cognitive impairment are common for chronic schizophrenia patients. The aim of this study was to investigate the efficacy of a mindfulness-based intervention (MBI) on negative and cognitive symptoms of schizophrenia patients with residual negative symptoms.

METHODS

In this 6-week, randomized, single-blind, controlled study, a total of 100 schizophrenia patients with residual negative symptoms were randomly assigned to the MBI or control group. The 6-week MBI group and the control group with general rehabilitation programs maintained their original antipsychotic treatments. The scores for the Positive and Negative Syndrome Scale (PANSS), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and the Symptom Checklist 90 (SCL-90) were recorded at baseline and week 6 to assess psychotic symptoms, cognitive performance, and emotional state, respectively.

RESULTS

Compared with general rehabilitation programs, MBI alleviated the PANSS-negative subscore, general psychopathology subscore, and PANSS total score in schizophrenia patients with residual negative symptoms (F = 33.77, p_Bonferroni < 0.001; F = 42.01, p_Bonferroni < 0.001; F = 52.41, p_Bonferroni < 0.001, respectively). Furthermore, MBI improved RBANS total score and immediate memory subscore (F = 8.80, p_Bonferroni = 0.024; F = 11.37, p_Bonferroni = 0.006), as well as SCL-90 total score in schizophrenia patients with residual negative symptoms (F = 18.39, p_Bonferroni < 0.001).

CONCLUSIONS

Our results demonstrate that MBI helps schizophrenia patients with residual negative symptoms improve clinical symptoms including negative symptom, general psychopathology symptom, and cognitive impairment.

TRIAL REGISTRATION

ChiCTR2100043803.

The Efficacy of Digital Cognitive–Behavioral Interventions in Supporting the Psychological Adjustment and Sleep Quality of Pregnant Women with Sub-Clinical Symptoms: A Systematic Review and Meta-Analysis

The present meta-analysis investigated the overall and differential efficacy of digital cognitive–behavioral therapies (CBTs) vs. third-generation CBTs deployed to pregnant women in reducing sub-clinical depression, anxiety, and stress symptoms while fostering sleep quality and quality of life. A PRISMA-guided systematic search was used, including randomized controlled trials (RCTs) evaluating the above-mentioned interventions. Data were pooled using either the mean difference (MD) or standardized MD (SMD). Sub-group analyses were carried out when appropriate. The primary outcomes were depression, anxiety, and stress symptoms, as well as sleep quality and quality of life. The interventions’ acceptability was evaluated through the odds ratio (OR) of drop-out rates. Seven RCTs were included, comprising 1873 pregnant women. The results showed the interventions’ efficacy in terms of reducing depression symptoms (SMD = −0.36, CI = 0.61, −0.11, k = 9) at the endpoint, although it was not maintained at follow-up during the postpartum period. The interventions’ efficacy in terms of reducing anxiety symptoms (SMD = 1.96, CI = −2.72, −1.21, k = 3) at the endpoint was also significant, while having no effect on sleep quality. The interventions were well accepted (OR = 1.68; 95% CI = 0.84, 3.35; k = 7). Although no sound conclusions can be drawn concerning the joint or differential efficacy of the considered interventions, this study was useful in highlighting the need to develop evidence-based digital prevention programs for pregnant women with sub-clinical symptoms.

The role of the acceptance and commitment therapy in the treatment of social anxiety: An updated scoping review

BACKGROUND

Social Anxiety Disorder (SAD) or Social Phobia is characterized by fear and anxiety of social circumstances that negatively impact an individual's occupational and relational life. There are several treatment options for this disorder ranging from pharmacological therapy to psychotherapies. In particular, the Acceptance and Commitment Therapy (ACT), a form of cognitive-behavioral therapy that practices acceptance and awareness strategies with behavior change strategies in order to increase an individual's mental flexibility, has been found to be effective. In this review, we aimed to provide an overview of recent studies that examined ACT's efficacy in SAD, also taking into consideration the comparison with traditional Cognitive-behavioral Therapy (CBT) interventions.

METHODS

A bibliographic search on PubMed, EMBASE and Scopus was conducted from inception to the 3rd of February 2022 of all studies investigating the effect of ACT in SAD individuals without any comorbidity. Among the articles retrieved, 11 met the inclusion criteria.

RESULTS

From the reviewed studies, ACT may be considered a promising treatment of social phobia by improving attentional bias, awareness, emotion regulation, and safety/avoidance behaviors; however, the results have not yet demonstrated a valid alternative to the CBT.

LIMITATIONS

Only four studies considered a follow-up evaluation, which is paramount to exploring the effectiveness of ACT and several studies have a very small sample size. Concerning the review itself we only considered original English articles and we did not measure the risk of publication bias and the risk of bias between studies.

CONCLUSIONS

The results of this study suggest that ACT can be a promising treatment for improving selective psychological problems often observed in SAD. However, larger longitudinal studies further exploring the effectiveness of the behavioral and cognitive "third-wave" psychotherapies, based mainly on acceptance of SAD, are necessary.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.

Cost-effectiveness and cost-utility of an Acceptance and Commitment Therapy intervention vs. a Cognitive Behavioral Therapy intervention for older adults with anxiety symptoms: A randomized controlled trial

BACKGROUND

A previous randomized controlled trial in older adults with anxiety symptoms found no differences between a brief blended Acceptance and Commitment Therapy (ACT) intervention and brief face-to-face Cognitive Behavior Therapy (CBT) regarding anxiety symptom severity at posttreatment and 12-month follow-up. A health-economic evaluation comparing these interventions has not yet been conducted.

OBJECTIVE

This study examined the one-year cost-effectiveness and cost-utility of blended ACT compared to face-to-face CBT for older adults with anxiety symptoms.

METHODS

The economic evaluation was embedded in a randomized controlled trial comparing blended ACT to CBT in 314 older adults with mild to moderately severe anxiety symptoms. Data were collected at baseline and 3, 6 and 12 months post baseline. For the cost-effectiveness analysis, treatment response was defined as a reliable improvement in anxiety symptom severity (measured with the Generalized Anxiety Disorder-7) between baseline and 12-month follow-up. To assess cost-utility, quality-adjusted life years (QALYs) were computed using EuroQol-5 Dimensions-5 Levels-5 utility scores. Analyses took the societal perspective, including both healthcare costs and productivity costs. Incremental cost-effectiveness ratios were calculated using 2500 bootstraps of seemingly unrelated regression equations of costs and effects. Sensitivity analyses were performed to assess the robustness of the findings.

RESULTS

Differences between the blended ACT group and CBT group in treatment response and QALYs were statistically insignificant and clinically irrelevant. The ACT intervention was associated with an average per-participant cost reduction of €466 ($593) compared to CBT, which resulted from lower productivity costs in the blended ACT group. From a healthcare perspective, the ACT intervention was associated with higher costs (by €71 ($90)) than CBT.

CONCLUSIONS

The results do not indicate that from a health-economic perspective blended ACT should be preferred over CBT in the treatment of older adults with anxiety symptoms. The findings support a model of shared decision making, where clinicians and patients collaboratively decide on the preferred intervention, based on ethical-medical, practical and personal considerations.

TRIAL REGISTRATION

Netherlands Trial Register: TRIAL NL6131 (NTR6270); https://www.trialregister.nl/trial/6131.

The Effectiveness of Mindfulness-Based Cognitive Therapy in Primary Care and the Role of Depression Severity and Treatment Attendance

Objectives

Evidence suggests the efficacy of mindfulness-based cognitive therapy (MBCT) to prevent depression relapse and decrease depressive symptoms during the acute phase. However, the effectiveness of MBCT in real-world heterogeneous samples treated in clinical health settings, including primary care, has received little attention. This study had two aims: (1) to evaluate the effectiveness of MBCT delivered in primary care considering pre-treatment depression scores and (2) to explore the role of participants' characteristics on symptom improvement.

Methods

Data were obtained from 433 individuals who received MBCT. Participants completed the Personality Inventory for ICD-11 (PiCD) pretreatment and the Beck Depression Inventory (BDI-II) pre- and post-treatment.

Results

Sixty percent presented moderate-to-severe depression according to scores on the BDI-II, 18.1% presented mild depression, and 21.7% were in the non-depressed range. The severity of pre-treatment depressive symptoms was associated with outcomes. Most individuals who lacked depressive symptoms at baseline remained in the non-clinical range after the treatment. Those in the severe group benefited the most from the intervention, since 35.6% were considered recovered. Rates of deterioration ranged from 2.1 to 2.7%, depending on the depression-baseline scores. Depression severity at the entrance, attendance, and age, but not personality traits, appear to be related to symptom improvement.

Conclusions

According to our results, MBCT can be effectively and safely delivered in primary care.

Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies

Cognitive–behavioral therapy (CBT) helps individuals to eliminate avoidant and safety-seeking behaviors that prevent self-correction of faulty beliefs, thereby facilitating stress management to reduce stress-related disorders and enhance mental health. The present review evaluated the effectiveness of CBT in stressful conditions among clinical and general populations, and identified recent advances in CBT-related techniques. A search of the literature for studies conducted during 1987–2021 identified 345 articles relating to biopsychosocial medicine; 154 (45%) were review articles, including 14 systemic reviews, and 53 (15%) were clinical trials including 45 randomized controlled trials. The results of several randomized controlled trials indicated that CBT was effective for a variety of mental problems (e.g., anxiety disorder, attention deficit hypersensitivity disorder, bulimia nervosa, depression, hypochondriasis), physical conditions (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, breast cancer), and behavioral problems (e.g., antisocial behaviors, drug abuse, gambling, overweight, smoking), at least in the short term; more follow-up observations are needed to assess the long-term effects of CBT. Mental and physical problems can likely be managed effectively with online CBT or self-help CBT using a mobile app, but these should be applied with care, considering their cost-effectiveness and applicability to a given population.

Psychological impact of COVID-19 lockdowns among adult women: the predictive role of individual differences and lockdown duration

COVID-19 pandemic has altered women's mental health as a consequence of the global threat and the lockdown measures adopted by public health policies. It has been suggested that women are at a higher risk for mood alterations, but most of the studies are cross-sectional or have only considered the first days of the confinement in their longitudinal designs. The present study was aimed at evaluating temporal changes in anxiety and depression in a general sample of 155 non-infected adult Spanish women after a complete quarantine. It also explored the predictive role of personality, the establishment of new routines and physical activity during lockdown in a pre-post design assessing temporal and clinical mood changes after 5 weeks of lockdown. Logistic regression analyses showed that higher neuroticism and depressive levels at baseline, lower routines engagement, and lower physical activity during lockdown predicted depression caseness, whereas anxiety caseness was best predicted by higher neuroticism, more days of lockdown and greater anxiety symptoms at baseline. It is concluded that lockdown duration, increased neuroticism and baseline levels of anxiety and depression are risk factors for women's mental health, while routines and physical activity emerge as protective factors for managing psychological wellbeing during the pandemic lockdowns.

The Effect of Psychological Interventions on the Prevention of Chronic Pain in Adults: A Systematic Review and Meta-analysis

OBJECTIVE

Up to 50% of patients develop high-impact chronic pain after an acute care experience and many psychological variables have been identified in this process. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the effect of psychological interventions within 3 months after pain onset.

METHODS

We searched databases for articles published from databases inceptions until July 2019. We used standardized mean differences with 95% confidence intervals to assess treatment effect.

RESULTS

In all, 18 trials were found eligible; 11 of which were included in the meta-analyses. Trials were mainly performed in back pain patients in the middle to late adulthood. Regarding pain intensity, the effect of psychological interventions compared with standard treatments was nonsignificant at 3, 6, and 12 months. We found a moderate significant effect size in favor of psychological interventions compared with standard treatments with regard to disability at 12 months and a small significant effect with regard to coping with pain at 3 months when compared with information alone. Most of meta-analysis findings were associated with a low level of evidence.

DISCUSSION

This systematic review and meta-analysis showed no significant effect of psychological interventions on pain intensity. A positive and significant trend related to these interventions was shown on disability and coping with pain, when compared with standard treatment and information, respectively. However, these findings must be interpreted with caution considering the limited sample of trials. More rigorous randomized controlled trials performed in patients with a high-risk psychological profile are required to elucidate the efficacy of psychological interventions in preventing chronic pain.

Impulsive behaviors and clinical outcomes following a flexible intensive inpatient treatment for eating disorders: findings from an observational study

PURPOSE

The aim of the study was to assess the differences between impulsive and non-impulsive patients in response to a multidisciplinary intensive inpatient treatment for eating disorders (EDs).

METHODS

320 patients with EDs were consecutively recruited in an eating disorders unit (EDU). They were assessed by clinical interviews and self-reported questionnaires. The treatment was characterized by a patient-centric approach and included both an intensive and comprehensive standardized multidisciplinary program based on cognitive-behavioral therapy and a flexible and personalized component according to the needs and the history of each patient.

RESULTS

Impulsive ED patients showed greater improvement in specific psychopathological areas, in particular: interpersonal sensitivity of Symptom Checklist-90 (SCL-90) (p = 0.007); Eating Disorder Examination Questionnaire (EDE-Q) Global Score (p = 0.009), EDE-Q eating concern (p < 0.001) and EDE-Q shape concern (p = 0.025). The two groups also showed a different pattern on the Body Uneasiness Test, with impulsive patients uniquely showing improvement on Global Severity Index (p = 0.006), body image concern (p = 0.008), compulsive self monitoring (p = 0.002), and weight phobia (p = 0.037).

DISCUSSION

Results support the hypothesis that patients with impulsive behaviors might benefit from treatments characterized by a standardized cognitive behavioral therapy implemented by third-wave interventions according to each patient's clinical profile. Personalized treatment approaches could be an answer to the complexity of ED, addressing individual psychopathology. Further studies are needed to confirm these preliminary findings.

LEVEL OF EVIDENCE

III, cohort or case-control analytic studies.

A randomized controlled efficacy trial of mindfulness-based stress reduction compared with an active control group and usual care for fibromyalgia: the EUDAIMON study

Fibromyalgia (FM) syndrome represents a great challenge for clinicians and researchers because the efficacy of currently available treatments is limited. This study examined the efficacy of mindfulness-based stress reduction (MBSR) for reducing functional impairment as well as the role of mindfulness-related constructs as mediators of treatment outcomes for people with FM. Two hundred twenty-five participants with FM were randomized into 3 study arms: MBSR plus treatment-as-usual (TAU), FibroQoL (multicomponent intervention for FM) plus TAU, and TAU alone. The primary endpoint was functional impact (measured with the Fibromyalgia Impact Questionnaire Revised), and secondary outcomes included "fibromyalginess," anxiety and depression, pain catastrophising, perceived stress, and cognitive dysfunction. The differences in outcomes between groups at post-treatment assessment (primary endpoint) and 12-month follow-up were analyzed using linear mixed-effects models and mediational models through path analyses. Mindfulness-based stress reduction was superior to TAU both at post-treatment (large effect sizes) and at follow-up (medium to large effect sizes), and MBSR was also superior to FibroQoL post-treatment (medium to large effect sizes), but in the long term, it was only modestly better (significant differences only in pain catastrophising and fibromyalginess). Immediately post-treatment, the number needed to treat for 20% improvement in MBSR vs TAU and FibroQoL was 4.0 (95% confidence interval [CI] = 2.1-6.5) and 5.0 (95% CI = 2.7-37.3). An unreliable number needed to treat value of 9 (not computable 95% CI) was found for FibroQoL vs TAU. Changes produced by MBSR in functional impact were mediated by psychological inflexibility and the mindfulness facet acting with awareness. These findings are discussed in relation to previous studies of psychological treatments for FM.

Cost-Utility Analysis of Mindfulness-Based Cognitive Therapy Versus Antidepressant Pharmacotherapy for Prevention of Depressive Relapse in a Canadian Context: Analyse coût-utilité de la thérapie cognitive basée sur la pleine conscience contre la pharmacothérapie antidépressive pour prévenir la rechute de la dépression en contexte canadien

OBJECTIVE

Patients suffering from major depressive disorder (MDD) experience impaired functioning and reduced quality of life, including an elevated risk of episode return. MDD is associated with high societal burden due to increased healthcare utilization, productivity losses, and suicide-related costs, making the long-term management of this illness a priority. The purpose of this study is to evaluate the cost-effectiveness of mindfulness-based cognitive therapy (MBCT), a first-line preventative psychological treatment, compared to maintenance antidepressant medication (ADM), the current standard of care.

METHOD

A cost-utility analysis was conducted over a 24-month time horizon to model differences between MBCT and ADM in cost and quality-adjusted life years (QALY). The analysis was conducted using a decision tree analytic model. Intervention efficacy, utility, and costing data estimates were derived from published sources and expert consultation.

RESULTS

MBCT was found to be cost-effective compared to maintenance ADM over a 24-month time horizon. Antidepressant pharmacotherapy resulted in 1.10 QALY and $17,255.37 per patient on average, whereas MBCT resulted in 1.18 QALY and $15,030.70 per patient on average. This resulted in a cost difference of $2,224.67 and a QALY difference of 0.08, in favor of MBCT. Multiple sensitivity analyses supported these findings.

CONCLUSIONS

From both a societal and health system perspective, utilizing MBCT as a first-line relapse prevention treatment is potentially cost-effective in a Canadian setting. Future economic evaluations should consider combined treatment (e.g., ADM and psychotherapy) as a comparator and longer time horizons as the literature advances.

Efficacy, cost-utility and physiological effects of Acceptance and Commitment Therapy (ACT) and Behavioural Activation Treatment for Depression (BATD) in patients with chronic low back pain and depression: study protocol of a randomised, controlled trial including mobile-technology-based ecological momentary assessment (IMPACT study)

INTRODUCTION

The IMPACT study focuses on chronic low back pain (CLBP) and depression symptoms, a prevalent and complex problem that represents a challenge for health professionals. Acceptance and Commitment Therapy (ACT) and Brief Behavioural Activation Treatment for Depression (BATD) are effective treatments for patients with persistent pain and depression, respectively. The objectives of this 12 month, multicentre, randomised, controlled trial (RCT) are (i) to examine the efficacy and cost-utility of adding a group-based form of ACT or BATD to treatment-as-usual (TAU) for patients with CLBP and moderate to severe levels of depressive symptoms; (ii) identify pre-post differences in levels of some physiological variables and (iii) analyse the role of polymorphisms in the FKBP5 gene, psychological process measures and physiological variables as mediators or moderators of long-term clinical changes.

METHODS AND ANALYSIS

Participants will be 225 patients with CLBP and moderate to severe depression symptoms recruited at Parc Sanitari Sant Joan de Déu (St. Boi de Llobregat, Spain) and Hospital del Mar (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs TAU+ACT versus TAU+BATD. A comprehensive assessment to collect clinical variables and costs will be conducted pretreatment, post-treatment and at 12 months follow-up, being pain interference the primary outcome measure. The following physiological variables will be considered at pretreatment and post-treatment assessments in 50% of the sample: immune-inflammatory markers, hair cortisol and cortisone, serum cortisol, corticosteroid-binding globulin and vitamin D. Polymorphisms in the FKBP5 gene (rs3800373, rs9296158, rs1360780, rs9470080 and rs4713916) will be analysed at baseline assessment. Moreover, we will include mobile-technology-based ecological momentary assessment, through the Pain Monitor app, to track ongoing clinical status during ACT and BATD treatments. Linear mixed-effects models using restricted maximum likelihood, and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the Fundació Sant Joan de Déu and Hospital del Mar. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities.

TRIAL REGISTRATION NUMBER

NCT04140838.

Cost-Utility of Attachment-Based Compassion Therapy (ABCT) for Fibromyalgia Compared to Relaxation: A Pilot Randomized Controlled Trial

A recent study has supported the efficacy of Attachment-Based Compassion Therapy (ABCT) compared to relaxation (REL) for the management of fibromyalgia (FM). The main objective of this paper is to examine the cost-utility of ABCT compared to REL in terms of effects on quality-adjusted life years (QALYs) as well as healthcare costs. Forty-two Spanish patients with FM received 8 weekly group sessions of ABCT or REL. Data collection took place at pre- and 3-month follow-up. Cost-utility of the two treatment groups (ABCT vs. REL) was compared by examining treatment outcomes in terms of QALYs (obtained with the EQ-5D-3L) and healthcare costs (data about service use obtained with the Client Service Receipt Inventory). Data analyses were computed from a completers, ITT, and per protocol approach. Data analysis from the healthcare perspective revealed that those patients receiving ABCT exhibited larger improvements in quality of life than those doing relaxation, while being less costly 3 months after their 8-week treatment program had ended (completers: incremental cost M, 95% CI = €−194.1 (−450.3 to 356.1); incremental effect M, 95% CI = 0.023 QALYs (0.010 to 0.141)). Results were similar using an ITT approach (incremental cost M, 95% CI = €−256.3 (−447.4 to −65.3); incremental effect M, 95% CI = 0.021 QALYs (0.009 to 0.033)). A similar pattern of results were obtained from the per protocol approach. This RCT has contributed to the evidence base of compassion-based interventions and provided useful information about the cost-utility of ABCT for FM patients when compared to relaxation. However, the small sample size and short follow-up period limited the generalizability of the findings.

Acceptance and commitment therapy to reduce eating disorder symptoms and body image problems in patients with residual eating disorder symptoms: A randomized controlled trial

Body image problems are central aspects of eating disorders (ED), and risk factors both for the development of and relapse into an ED. Acceptance and commitment therapy (ACT) aims at helping patients accept uncomfortable internal experiences while committing to behaviors in accordance with life values. The aim of the present study was to compare the effectiveness of a group intervention, consisting of 12 sessions, based on ACT to treatment as usual (TAU) for patients with residual ED symptoms and body image problems. The study was a randomized controlled superiority trial. Patients with residual ED symptoms and body image problems were recruited from a specialized ED clinic in Sweden. The final sample consisted of 99 women, randomized to ACT or TAU. At the two-year follow-up, patients who received ACT showed a significant greater reduction in ED symptoms and body image problems and received less specialized ED care than patients in TAU. In conclusion, ACT was superior in reducing ED symptoms and body image problems.

Cost-utility of individual internet-based and face-to-face Mindfulness-Based Cognitive Therapy compared with treatment as usual in reducing psychological distress in cancer patients

Objective

It was previously determined that group‐based face‐to‐face Mindfulness‐Based Cognitive Therapy (MBCT) and individual internet‐based MBCT (eMBCT) are equally efficacious compared with treatment as usual (TAU) in reducing psychological distress. In this study, the incremental cost‐utility of both interventions compared with TAU was assessed.

Methods

This cost‐utility study included 245 self‐referred heterogeneous cancer patients with psychological distress who were randomized to MBCT, eMBCT or TAU. Healthcare costs and (informal) work‐related productivity losses were assessed by interview. Outcomes were expressed in EuroQol‐5D‐3L utility scores and quality‐adjusted life years (QALY). An economic evaluation with a time‐horizon of 3 months was conducted from the societal perspective in the intention‐to‐treat sample. In addition, secondary explorative analyses of costs and quality of life during the 9‐month follow‐up were conducted based on linear extrapolation of TAU.

Results

Paid work‐related productivity losses and societal costs were lower in both intervention conditions compared with TAU during the 3‐month intervention period. Moreover, quality of life (utility scores) improved in eMBCT versus TAU (Cohen's d: .54) and MBCT versus TAU (.53). At a willingness to pay of €20000 per QALY, the mean incremental net monetary benefit was €1916 (SD=€783) in eMBCT and €2365 (SD=€796) in MBCT versus TAU. Exploration of costs demonstrated an equal pattern of eMBCT and MBCT being superior to TAU. Quality of life at 9‐month follow‐up remained improved in both interventions.

Conclusions

Results indicate that eMBCT and MBCT are cost‐saving treatments whilst simultaneously improving quality of life for distressed cancer patients.

'Mind the gaps': the accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: learning from mindfulness-based cognitive therapy through a mixed-methods study

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is an evidence-based approach for people at risk of depressive relapse to support their long-term recovery. However, despite its inclusion in guidelines, there is an 'implementation cliff'. The study objective was to develop a better explanation of what facilitates MBCT implementation.

SETTING

UK primary and secondary care mental health services.

DESIGN, PARTICIPANTS AND METHODS

A national two-phase, multi-method qualitative study was conducted, which was conceptually underpinned by the Promoting Action on Research Implementation in Health Services framework. Phase I involved interviews with stakeholders from 40 service providers about current provision of MBCT. Phase II involved 10 purposively sampled case studies to obtain a more detailed understanding of MBCT implementation. Data were analysed using adapted framework analysis, refined through stakeholder consultation.

RESULTS

Access to MBCT is variable across the UK services. Where available, services have adapted MBCT to fit their context by integrating it into their care pathways. Evidence was often important to implementation but took different forms: the NICE depression guideline, audits, evaluations, first person accounts, experiential taster sessions and pilots. These were used to build a platform from which to develop MBCT services. The most important aspect of facilitation was the central role of the MBCT implementers. These were generally self-designated individuals who 'championed' grass-roots implementation. Our explanatory framework mapped out a prototypical implementation journey, often over many years with a balance of bottom-up and top-down factors influencing the fit of MBCT into service pathways. 'Pivot points' in the implementation journey provided windows of either challenge or opportunity.

CONCLUSIONS

This is one of the largest systematic studies of the implementation of a psychological therapy. While access to MBCT across the UK is improving, it remains patchy. The resultant explanatory framework about MBCT implementation provides a heuristic that informed an implementation resource.

A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community

BACKGROUND/AIMS

This paper investigates the cost-effectiveness of dialectical behaviour therapy (DBT) for treating individuals with borderline personality disorder (BPD) in a community setting in Ireland, in the short term.

METHODS

Resource utilisation and effectiveness data were collected as part of the National DBT Project, Ireland, and are incorporated into a cost-effectiveness analysis. The perspective taken was that of the service provider and payer. Direct health resources were included and effectiveness was measured using the EQ-5D-5L questionnaire. To examine cost-effectiveness, incremental costs are compared with incremental quality-adjusted life years, to estimate an incremental cost-effectiveness ratio. A probabilistic sensitivity analysis was employed to investigate parameter uncertainty. Scenario analyses are employed to investigate cost-effectiveness of DBT with varying assumptions around effectiveness and costs.

RESULTS

The baseline analysis reveals that DBT is more expensive and more effective than routine clinical care (without DBT). The low incremental cost-effectiveness ratio suggests DBT can be considered cost effective in the short term. In each scenario analyses considered, the probability that DBT is cost effective is greater than 50%.

CONCLUSIONS

Mental health care provision, including that of DBT, varies across jurisdictions, necessitating economic evaluations of current practice in community-based services, on a country-by-country basis, to inform resource allocation decisions. In line with previous research, the analysis here indicates DBT can be considered cost effective in the short term. Future data collection on alternative comparators and long-term outcomes associated with DBT is warranted to investigate the longer term cost-effectiveness of DBT.

Darwin's Other Dilemmas and the Theoretical Roots of Emotional Connection

Modern scientific theories of emotional behavior, almost without exception, trace their origin to Charles Darwin, and his publications On the Origin of Species (1859) and The Expression of the Emotions in Man and Animals (1872). The most famous dilemma Darwin acknowledged as a challenge to his theory of evolution through natural selection was the incomplete Sub-Cambrian fossil record. However, Darwin struggled with two other rarely referenced theoretical and scientific dilemmas that confounded his theories about emotional behavior. These included (1) the origin of social instincts (e.g., altruism, empathy, reciprocity and cooperation) and the reasons for their conservation in evolution and (2) the peripheral control of heart rate vis-à-vis emotional behavior outside of consciousness. Darwin acknowledged that social instincts are critical to the survival of some species, but had difficulty aligning them with his theory of natural selection in humans. Darwin eventually proposed that heart rate and emotions are controlled via one's intellect and cortical mechanisms, and that instinctive behavior is genetically programmed and inherited. Despite ongoing efforts, these two theoretical dilemmas are debated to this day. Simple testable hypotheses have yet to emerge for the biological mechanisms underlying instinctive behavior or the way heart rate is controlled in infants. In this paper, we review attempts to resolve these issues over the past 160 years. We posit that research and theories that supported Darwin's individualistic brain-centric and genetic model have become an "orthodox" Western view of emotional behavior, one that produced the prevailing behavioral construct of attachment as developed by John Bowlby. We trace research and theories that challenged this orthodoxy at various times, and show how these challenges were repeatedly overlooked, rejected, or misinterpreted. We review two new testable theories, emotional connection theory and calming cycle theory, which we argue resolve the two dilemmas We show emerging scientific evidence from physiology and a wide variety of other fields, as well from clinical trials among prematurely born infants, that supports the two theories. Clinical implications of the new theories and possible new ways to assess risk and intervene in emotional, behavioral and developmental disorders are discussed.

A guided and unguided internet- and mobile-based intervention for chronic pain: health economic evaluation alongside a randomised controlled trial

OBJECTIVE

This study aims at evaluating the cost-effectiveness and cost-utility of a guided and unguided internet-based intervention for chronic pain patients (ACTonPain_guided and ACTonPain_unguided) compared with a waitlist control group (CG) as well as the comparative cost-effectiveness of the guided and the unguided version.

DESIGN

This is a health economic evaluation alongside a three-arm randomised controlled trial from a societal perspective. Assessments were conducted at baseline, 9 weeks and 6 months after randomisation.

SETTING

Participants were recruited through online and offline strategies and in collaboration with a health insurance company.

PARTICIPANTS

302 adults (≥18 years, pain for at least 6 months) were randomly allocated to one of the three groups (ACTonPain_guided, ACTonPain_unguided, CG).

INTERVENTIONS

ACTonPain consists of seven modules and is based on Acceptance and Commitment Therapy. ACTonPain_guided and ACTonPain_unguided only differ in provision of human support.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes of the cost-effectiveness and the cost-utility analyses were meaningful change in pain interference (treatment response) and quality-adjusted life years (QALYs), respectively. Economic evaluation estimates were the incremental cost-effectiveness and cost-utility ratio (ICER/ICUR).

RESULTS

At 6-month follow-up, treatment response and QALYs were highest in ACTonPain_guided (44% and 0.280; mean costs = €6,945), followed by ACTonPain_unguided (28% and 0.266; mean costs = €6,560) and the CG (16% and 0.244; mean costs = €6,908). ACTonPain_guided vs CG revealed an ICER of €45 and an ICUR of €604.ACTonPain_unguided dominated CG. At a willingness-to-pay of €0 the probability of being cost-effective was 50% for ACTonPain_guided (vs CG, for both treatment response and QALY gained) and 67% for ACTonPain_unguided (vs CG, for both treatment response and QALY gained). These probabilities rose to 95% when society's willingness-to-pay is €91,000 (ACTonPain_guided) and €127,000 (ACTonPain_unguided) per QALY gained. ACTonPain_guided vs ACTonPain_unguided revealed an ICER of €2,374 and an ICUR of €45,993.

CONCLUSIONS

Depending on society's willingness-to-pay, ACTonPain is a potentially cost-effective adjunct to established pain treatment. ACTonPain_unguided (vs CG) revealed lower costs at better health outcomes. However, uncertainty has to be considered. Direct comparison of the two interventions does not indicate a preference for ACTonPain_guided.

TRIAL REGISTRATION NUMBER

DRKS00006183.

The Future of Intervention Science: Process-Based Therapy

Clinical science seems to have reached a tipping point. It appears that a new paradigm is beginning to emerge that is questioning the validity and utility of the medical illness model, which assumes that latent disease entities are targeted with specific therapy protocols. A new generation of evidence-based care has begun to move toward process-based therapies to target core mediators and moderators based on testable theories. This could represent a paradigm shift in clinical science with far-reaching implications. Clinical science might see a decline of named therapies defined by set technologies, a decline of broad schools, a rise of testable models, a rise of mediation and moderation studies, the emergence of new forms of diagnosis based on functional analysis, a move from nomothetic to idiographic approaches, and a move toward processes that specify modifiable elements. These changes could integrate or bridge different treatment orientations, settings, and even cultures.

Current status of acceptance and commitment therapy for chronic pain: a narrative review

It is well known that chronic pain is prevalent, complex to manage, and associated with high costs, in health care and society in general. Thanks to advances in new forms of cognitive behavioral therapy (known as third-wave CBT), currently clinicians and researchers have an empirically validated psychological treatment with increasing research support for the treatment of chronic pain. This treatment is called acceptance and commitment therapy (ACT). The main aim of this paper is to provide a narrative review that summarizes and integrates the current state of knowledge of ACT in the management of chronic pain as well as discuss current challenges and opportunities for progress. Based on the psychological flexibility model, ACT extends previous forms of CBT and integrates many CBT-related variables into six core therapeutic processes. ACT is a process-based therapy that fosters openness, awareness, and engagement through a wide range of methods, including exposure-based and experiential methods, metaphors, and values clarification. To our knowledge, there are three published systematic reviews and meta-analyses that support the effectiveness of ACT for chronic pain and many studies focused on specific processes derived from the psychological flexibility model. There is also promising support for the cost-effectiveness of ACT; however, the current evidence is still insufficient to establish firm conclusions about cost-effectiveness and the most efficient means of delivery. Additional well-designed economic evaluations are needed. Other research aims include delineating the neurobiological underpinnings of ACT, refining available outcome and process measures or develop new ones for ACT trials, and meeting the challenge of wide dissemination and implementation in real-world clinical practice.