Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings?

Cognitive Behavioral Therapy for Anxiety Disorders

Cognitive behavioral therapy (CBT) is the front-line psychological intervention for the treatment of anxiety disorders. It is based on the cognitive behavioral model of anxiety disorders, which conceptualizes anxiety as caused by a pattern of maladaptive cognitive appraisals and avoidance behaviors that perpetuate pathologic fears. CBT includes core components that are relevant across anxiety disorders, including psychoeducation, cognitive restructuring, exposure therapy, and relapse prevention. CBT has a strong evidence base supporting its short-term and long-term efficacy and effectiveness. A case vignette is provided to illustrate the application of CBT principles. Clinical complexities, clinical recommendations, and future research directions are discussed.

Beyond the modified dot-probe task: A meta-analysis of the efficacy of alternate attention bias modification tasks across domains

Attention biases towards disease-relevant cues have been implicated in numerous disorders and health conditions, such as anxiety, cancer, drug-use disorders, and chronic pain. Attention bias modification (ABM) has shown that changing attention biases can change related emotional processes. ABM most commonly uses a modified dot-probe task, which has received increasing criticism regarding its reliability and inconsistent findings. The purpose of the present review was thus to systematically review and meta-analyse alternative tasks used in ABM research. We sought to examine whether alternative tasks significantly changed attention biases and emotional outcomes, and critically examined whether relevant sample, task and intervention characteristics moderated each of these effect sizes. Seventy-four (completer n = 15,294) study level comparisons were included in the meta-analysis. Overall, alternative ABM designs had a medium effect on changing biases (g = 0.488), and a small, but significant effect on improving clinical outcomes (g = 0.117). We found this effect to be significantly larger for studies which successfully changed biases compared to those that did not. Across all tasks, it appeared that targeting engagement biases results in the largest change to attention biases. Importantly, we found tasks incorporating gaze-contingency - encouraging engagement with non-biased stimuli - show the most promise for improving emotional outcomes.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Consultation as an Implementation Strategy to Increase Fidelity of Measurement-Based Care Delivery in Community Mental Health Settings: An Observational Study

Regularly administering outcome measures to clients to inform clinical decision making, referred to as measurement-based care (MBC), has the potential to improve mental health treatment due to its applicability across disorders and treatment settings. Given the utility of MBC, understanding predictors of high-fidelity MBC implementation is important. Training and consultation are widely used implementation strategies to increase the fidelity of evidence-based practice delivery but have rarely been studied with MBC. The current study will examine the relationship between time clinicians spent discussing a case in consultation ("dosage") and MBC fidelity. Thirty clinicians and 56 youth were in the MBC condition of a randomized controlled trial and completed baseline questionnaires. Consultation dosage was extracted from call notes. MBC fidelity was measured using the implementation index, which combines rates of administering and viewing questionnaires, using objective data from the online MBC system. Multi-level modeling was used. Greater consultation dosage significantly predicted a higher implementation index (ß = 0.27, SE = 0.06, p < .001). For every 30 min spent discussing a case in consultation, the case's MBC fidelity increased by 8.1%. Greater consultation dosage significantly predicted higher rates of administration (ß = 0.07, SE = 0.03, p = 0.033) and feedback report viewing (ß = 0.24, SE = 0.06, p < .001). More consultation at the case level predicts greater MBC fidelity using objective measures. The greatest impact was increasing the clinician feedback report viewing rate. The results of this study can help inform future efforts to increase the fidelity with which MBC is delivered and to make consultation as efficient and effective as possible.

Integrated behavioral treatments for comorbid anxiety and substance use disorders: A model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy

INTRODUCTION

Substance use disorders (SUD) and anxiety disorders are highly comorbid, and this comorbidity is associated with poor clinical outcomes. Emerging research in the last decade has shifted from addressing these problems separately to the development and evaluation of behavioral treatments that integrate care for anxiety disorders (or elevated symptoms of anxiety) and SUD.

METHODS

An extensive literature search revealed a sufficient number of studies (K=11) to conduct a meta-analysis comparing the efficacy of integrated SUD/anxiety disorder behavioral treatment to SUD treatment alone on substance use and anxiety symptom outcomes. Randomized clinical trials including those with SUD and either anxiety disorders or elevations in constructs implicated in the maintenance of anxiety disorder/SUD comorbidity were included. This study meta-analyzes the effects of these studies.

RESULTS

Integrated treatments outperformed SUD treatments alone on both substance use and anxiety outcomes, with small to moderate effects favoring integrated treatments. There was no significant heterogeneity across studies in the primary analyses, such that moderator analyses to identify variables that yielded differential patterns of effect sizes were not conducted.

DISCUSSION

Integrated treatments for SUD/anxiety disorders demonstrate an incremental but significant and clinically meaningful improvement over SUD treatment alone for SUD/anxiety disorder comorbidity. Implications for future research and clinical practice paradigm shifting are discussed.

Rethinking Research on Prediction and Prevention of Psychotherapy Dropout: A Mechanism-Oriented Approach

Dropout is a ubiquitous psychotherapy outcome in clinical practice and treatment research alike, yet it remains a poorly understood problem. Contemporary dropout research is dominated by models of prediction that lack a strong theoretical foundation, often drawing on data from clinical trials that report on dropout in an inconsistent and incomplete fashion. In this article, we assert that dropout is a critical treatment outcome that is worthy of investigation as a mechanistic process. After briefly describing the scope of the dropout problem, we discuss the many factors that limit the field's present understanding of dropout. We then articulate and illustrate a transdiagnostic conceptual framework for examining psychotherapy dropout in contemporary research, concluding with recommendations for future research. With a more comprehensive understanding of the factors affecting retention, research efforts can shift toward investigating key processes underlying treatment dropout, thus, boosting prediction and informing strategies to mitigate dropout in clinical practice.

Can psychological interventions prevent or reduce risk for perinatal anxiety disorders? A systematic review and meta-analysis

OBJECTIVE

Little is known about the extent to which interventions can prevent perinatal anxiety disorders. We conducted a systematic review and meta-analysis to examine whether interventions can decrease the onset and symptoms of perinatal anxiety among individuals without an anxiety disorder diagnosis.

METHOD

We conducted a comprehensive literature search across five databases related to key concepts: (1) anxiety disorders/anxiety symptom severity (2) perinatal (3) interventions (4) prevention. We included studies that examined a perinatal population without an anxiety disorder diagnosis, included a comparator group, and assessed perinatal anxiety. We included interventions focused on perinatal anxiety as well as interventions to prevent perinatal depression or influence related outcomes (e.g., physical activity).

RESULTS

Thirty-six studies were included. No study assessing the incidence of perinatal anxiety disorder (n = 4) found a significant effect of an intervention. Among studies assessing anxiety symptom severity and included in the quantitative analysis (n = 30), a meta-analysis suggested a small standardized mean difference of -0.31 (95% CI [-0.46, -0.16], p < .001) for anxiety at post intervention, favoring the intervention group. Both mindfulness (n = 6), and cognitive behavioral therapy approaches (n = 10) were effective.

CONCLUSIONS

Interventions developed for perinatal anxiety were more effective than interventions to prevent perinatal depression. Psychological interventions show promise for reducing perinatal anxiety symptom severity, though interventions specifically targeting anxiety are needed.

Introducing Braining-physical exercise as adjunctive therapy in psychiatric care: a retrospective cohort study of a new method

BACKGROUND

Patients with severe mental disorders suffer from higher rates of poor somatic health and have shorter life expectancy than the average population. Physical activity can treat and prevent several diseases, e.g. cardiovascular and metabolic disorders as well as psychiatric symptoms. It is therefore of utmost importance to develop effective methods to integrate physical activity into psychiatric care. To meet this need, the physical activity intervention Braining was developed. This study aims to describe Braining, to assess the number of patients reached during the first years of pilot testing, to analyze clinical data in the group of patients participating in Braining 2017-2020 and to assess the intervention.

METHODS

In this descriptive retrospective study we analyzed data from all patients participating in Braining training sessions ≥ 3 times (n = 239), the Braining Participants. Regular patients at the clinic served as a comparison. Furthermore, medical records were studied for a smaller cohort (n = 51), the Braining Pilot Cohort. Data was analyzed using Chi-square and Fisher's tests.

RESULTS

During the introduction period of Braining, 580 patients attended an information meeting about Braining, or at least one training session. 239 patients participated in ≥ 3 training sessions, considered to be participants of Braining. These Braining Participants (n = 239), ages 19 to 82, males 23.4%, attended between 3 and 308 training sessions (median 9). The main diagnoses were affective and anxiety disorders. Number of diagnoses ranged from 0 to 10 (median = 2). For the subsample, the Braining Pilot Cohort (n = 51), participants attended between 3 and 208 training sessions (median = 20). Twelve percent were working full-time, and symptom severity of depression and general anxiety was moderate. Two thirds had ≥ 3 different classes of medication. Regarding metabolic morbidity, 28 had been diagnosed with hypertension, though blood lipids, blood glucose as well as blood pressure were within the normal range. Thirty-seven percent were prescribed Physical Activity on Prescription during 2017-2020. One severe adverse event was reported.

CONCLUSIONS

The Braining intervention reached all age-groups and patients with a wide and representative diagnostic panorama, suggesting that Braining could be a promising and safe method for implementing physical activity in a psychiatric patient population.

Therapist perceptions of experiential training for exposure therapy

BACKGROUND

Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use.

AIMS

This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training.

METHOD

Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use.

RESULTS

Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures.

DISCUSSION

Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

The first steps in facing your fears: The acceptability of virtual reality and in vivo exposure treatment for specific fears

Phobic individuals are often reluctant to engage in exposure in vivo (IVE). We examined whether providing exposure in virtual reality (VRE) can increase the acceptability. In Study 1, we provided 186 fearful participants with (hypothetical) VRE and IVE treatment offers and examined their willingness to engage in treatment, estimated success, negative beliefs, acceptance/refusal and their preference. Almost 70 % preferred VRE over IVE and acceptance rates were higher for the VRE offer (58 %) than for IVE (35 %). Although participants held fewer negative beliefs about VRE, they did rate IVE as slightly more successful. In Study 2, we examined whether VRE can serve as a stepping stone to IVE in a sample of 102 spider fearful individuals. Willingness to engage, estimated success and negative beliefs about IVE were assessed before and after VRE. After VRE, participants rated IVE as more successful, but were not more willing to engage in IVE, nor were they more inclined to accept an IVE offer. No decreases in negative beliefs were observed. In conclusion, VRE is deemed more acceptable than IVE and could lower refusal rates, hereby resulting in more phobic individuals receiving treatment. Future research should shed light on underlying motivations and associations.

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping

Background

Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved.

Methods

Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes.

Results

Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms.

Conclusion

A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Primary Outcomes for Adults Receiving the Unified Protocol after Hurricane Harvey in an Integrated Healthcare Setting

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy for treating anxiety and depression. However, there are limited effectiveness data when conducted in real-world settings with diverse populations, including those with trauma. We evaluated treatment outcomes in a naturalistic, community setting among 279 adults who received UP following Hurricane Harvey. We examined change in overall clinical severity, depression and anxiety symptoms, functional impairment, and baseline outcome predictors (i.e., demographic characteristics, impact from Hurricane Harvey, co-occurrence of depression and anxiety symptoms). Global clinical severity, depression and anxiety symptoms, and functional impairment decreased by end-of-treatment. Participants experienced global symptom improvement to a lesser degree than demonstrated in efficacy trials. Participants who experienced greater storm impact reported larger reductions in anxiety symptoms than those less impacted by Harvey. Further studies evaluating the effectiveness of the UP post-disaster and with diverse samples are needed.

Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation's low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.

Effectiveness and Efficacy of Therapeutic Interventions Performed by Nurses for Anxiety Disorders: A Systematic Review

BACKGROUND: Anxiety disorders are characterized by excessive anxiety, fear, and behavioral disorders that can lead the individual to have losses in daily, social, and work activities, generating a negative impact on their quality of life. AIM: To evaluate the quality of evidence of the therapeutic interventions performed by nurses for anxiety disorders. METHOD: An analysis of the quality of evidence was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The systematic review protocol was registered in the Prospective Register of Systematic Reviews (Prospero), CRD420202939. RESULTS: The interventions performed by nurses were effective (d = 0.44), with significant improvement in reducing anxiety levels, reducing drug use, and improving self-control. CONCLUSIONS: The study indicates that therapeutic interventions performed by nurses are beneficial for individuals who suffer from anxiety disorders, with significant improvement in reducing anxiety levels, reducing medication use, improving self-control, and remission of anxiety symptoms.

The development and usability of a video game to attenuate pandemic-related stress using an equity lens

Background

The emergence of the novel coronavirus (COVID-19) has introduced additional pressures on an already fragile mental health care system due to a significant rise in depression, anxiety, and stress among Canadians. Although cognitive behavioral therapy (CBT) is known to be an efficacious treatment to reduce such mental health issues, few people have access to CBT in an engaging and sustainable manner. To address this gap, a collaboration between the Centre for Addiction and Mental Health (CAMH) and the National Research Council of Canada (NRC) developed CBT-based self-led, online, clinician-tested modules in the form of a video game, named Legend of Evelys, and evaluated its usability in the attenuation of a COVID-19–related increase in stress.

Objective

We here present the conceptualization and design of new self-care modules in the form of a video game, its implementation in a technological infrastructure, and inclusivity and privacy considerations that informed the development. A usability study of the modules was performed to assess the video game’s usability, user engagement, and user perceptions.

Methods

The development of the video game involved establishment of a technology infrastructure for secure implementation of the software for the modules and a clinician-led assessment of the clinical utility of these modules through two “whiteboard” sessions. The usability study was informed by a mixed methods sequential explanatory design to evaluate the intervention of the mobile app through two distinct phases: quantitative data collection using in-app analytics data and two surveys, followed by qualitative data collection by semistructured interviews.

Results

A total of 32 participants trialed the app for 2 weeks. They used the video game an average of six times and rated the game as “good” based on the Systems Usability Scale score. In terms of stress reduction, the study demonstrated a significant difference in the participants’ Perceived Stress Scale score at baseline (mean 22.14, SD 6.187) compared with that at the 2-week follow-up (mean 18.04, SD 6.083; t₂₇=3.628, P=.001). Qualitative interviews helped participants identify numerous functionality issues and provided specific recommendations, most of which were successfully integrated into the video game for future release.

Conclusions

Through this collaboration, we have established that it is possible to incorporate CBT exercises into a video game and have these exercises adopted to address stress. While video games are a promising strategy to help people with their stress and anxiety, there is a further need to examine the real-world effectiveness of the Legend of Evelys in reducing anxiety.

The impact of implementation climate on community mental health clinicians’ attitudes toward exposure: An evaluation of the effects of training and consultation

Background:

Most evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) and anxiety disorders include exposure; however, in community settings, the implementation of exposure lags behind other EBT components. Clinician-level determinants have been consistently implicated as barriers to exposure implementation, but few organizational determinants have been studied. The current study examines an organization-level determinant, implementation climate, and clinician-level determinants, clinician demographic and background factors, as predictors of attitudes toward exposure and changes in attitudes following training.

Method:

Clinicians (n = 197) completed a 3-day training with 6 months of twice-monthly consultation. Clinicians were trained in cognitive behavioral therapy (CBT) for anxiety, depression, behavior problems, and trauma-focused CBT (TF-CBT). Demographic and background information, implementation climate, and attitudes toward exposure were assessed in a pre-training survey; attitudes were reassessed at post-consultation. Implementation climate was measured at the aggregated/group-level and clinician-level.

Results:

Attitudes toward exposure significantly improved from pre-training to post-consultation (t(193) = 9.9, p < .001; d = 0.71). Clinician-level implementation climate scores did not predict more positive attitudes at pre-training (p > .05) but did predict more positive attitudes at post-consultation (ß = −2.46; p < .05) and greater changes in those attitudes (ß = 2.28; p < .05). Group-level implementation climate scores did not predict attitudes at pre-training, post-consultation, or changes in attitudes (all ps > .05). Higher frequency of self-reported CBT use was associated with more positive attitudes at pre-training (ß = −0.81; p < .05), but no other clinician demographic or background determinants were associated with attitudes at post-consultation (all p > .05) or with changes in attitudes (all p > .05).

Conclusions:

Clinician perceptions of implementation climate predicted greater improvement of attitudes toward exposure following EBT training and consultation. Findings suggest that organizational determinants outside of training impact changes in clinicians’ attitudes. Training in four EBTs, only two of which include exposure as a component, resulted in positive changes in clinicians’ attitudes toward exposure, which suggests non-specialty trainings can be effective at changing attitudes, which may enable scale-up.

Exposure is highly effective for treating trauma symptoms and anxiety-based disorders, but it is not commonly used in community mental health settings. Clinicians who endorsed higher expectations, support, and rewards for using exposure in their agency had more positive attitudes toward exposure after training and consultation. Additionally, clinicians who endorsed that exposure is expected, supported, and rewarded in their agency showed a greater improvement in attitudes throughout the training process. Organizational culture can affect clinicians’ attitude changes in the training process, and therefore should become a focus of training efforts.

Development and Initial Pilot Testing of a fully integrated treatment for comorbid social anxiety disorder and alcohol use disorder in a community-based SUD clinic setting

OBJECTIVES

Social anxiety disorder (SAD) and alcohol use disorder (AUD) are highly comorbid and this comorbidity is associated with poorer clinical outcomes. Integrating exposure-based treatment for SAD into the context of typical AUD treatment programs should improve engagement and treatment outcomes for this population.

METHODS

After initial development of a fully integrated, intensive outpatient program (IOP) for individuals with comorbid SAD and AUD, patients with SAD and AUD were recruited from a community-based SUD specialty clinic (N = 56) and randomized to either (a) usual care (UC), consisting of the evidence-based Matrix Model of Addiction IOP; or (b) the Fully Integrated Treatment (FIT) for comorbid SAD and AUD IOP. Participants were assessed on indices of social anxiety and alcohol use.

RESULTS

By the 6-month follow-up, those in FIT showed superior improvement to UC on number of drinking days in the past 30 days and social anxiety severity at follow-up, but there were no differences between groups on quantity of alcohol consumed on drinking days. Alcohol-related problems improved in both groups, with no statistically significant differences. Within-group improvement was observed in FIT (but not in UC) on drinking to cope with social anxiety and avoidance of social situations without alcohol, but between-group effects were non-significant. In sum, the integrated treatment of SAD and AUD led to greater reductions in both the frequency of drinking and in social anxiety symptoms than usual care.

CONCLUSIONS

Targeting social anxiety in the context of AUD treatment is a promising approach to improving the treatment of this common comorbidity.

Using 360-degree videos for virtual reality exposure in CBT for panic disorder with agoraphobia: a feasibility study

BACKGROUND

Cognitive behavioural therapy (CBT) is an effective treatment for panic disorder with agoraphobia (PDA). However, implementation of some of the procedures involved, particularly in vivo exposure, can be time consuming and taxing for routine health care services. CBT with exposure taking place in virtual reality (VR-CBT) is a more time-efficient option and has shown promising results in the treatment of PDA. However, VR-CBT requires expensive equipment and appropriate virtual environments, which historically has been costly and cumbersome to produce. Thus, access to VR-CBT has been sparse in regular care environments.

AIMS

The aim of this study was to investigate whether VR-CBT using filmed virtual environments produced with a low-cost 360-degree film camera can be a feasible and acceptable treatment for PDA when implemented in a primary care context.

METHOD

This was an open feasibility trial with a within-group design, with assessments conducted at pre-test, post-test, and 6-month follow-up. Participants (n = 12) received a 10-12 week treatment programme of VR-CBT and PDA-related symptoms were assessed by the primary outcome measure The Mobility Inventory for Agoraphobia (MIA) and the Panic-Disorder Severity Scale-Self Rated (PDSS-SR).

RESULTS

The results showed that treatment satisfaction was high and participants were significantly improved on PDA-related measures at post-treatment and at 6-month follow-up with large effect sizes (Cohen's d range = 1.46-2.82). All 12 participants completed the treatment.

CONCLUSIONS

These findings suggest that VR-CBT with 360-degree video virtual environments delivered to primary care patients with PDA is feasible, acceptable, and potentially efficacious.

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.

A Randomized Trial of Brief Online Interventions to Facilitate Treatment Seeking for Social Anxiety

This study developed and evaluated a brief, single-session online intervention designed to facilitate treatment seeking among adults with clinically significant social anxiety (SA) symptoms, who generally seek treatment at exceptionally low rates. Adults (N = 267) reporting significant SA symptoms were recruited online and randomized to a brief, single-session online intervention: Education consisted of brief psychoeducation and treatment resources, or Education+Motivation which added treatment seeking-focused motivational content adapted from Motivational Interviewing and Acceptance and Commitment Therapy. Attitudes, intentions, perceived control, and treatment seeking were assessed at Pre, Post, and 1-month follow-up (FU). Both interventions were feasible (90% completion) and improved all outcomes. At FU, 70% reported engaging in one or more SA treatment-seeking behaviors. Education+Motivation was more effective than Education at improving treatment-seeking attitudes and behaviors. A brief online intervention with educational and motivational content is a promising direction for promoting treatment seeking for adults with SA symptoms.

Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy

OBJECTIVE

Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization.

METHOD

Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization.

RESULTS

Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization.

CONCLUSION

Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.

Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82-1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55-2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master's degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AIM

To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.

METHODS

Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.

RESULTS

Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.

CONCLUSIONS

Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.

Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression

OBJECTIVE

Respiratory abnormalities are a hallmark of anxiety symptomatology and may serve as clinically useful modifiers for alleviating anxiety symptoms. However, gold-standard anxiety treatments (e.g., cognitive-behavioral interventions) often do not directly address respiratory components despite their theoretical utility and clinical accessibility. This review examined the clinical effectiveness of respiratory interventions, interventions that directly target respiration abnormalities and processes, in treating trait anxiety symptoms.

METHODS

The final analysis included 40 randomized controlled trials including at least one measure of trait anxiety, a respiratory-focused intervention group, and a non-respiratory control-group (active or inactive treatment). Overall effects of respiratory focused interventions were examined, as well as the effect of hypothesized moderators.

RESULTS

Respiratory component interventions yielded significantly greater improvements (moderate to large effect) in anxiety symptoms than controls, with the stronger effects observed in comparison to inactive, rather than active, control conditions. Significant heterogeneity in findings suggests that variability in intervention design, population, and control comparison may obfuscate interpretation of findings.

CONCLUSIONS

Evidence supports the clinical utility of respiratory interventions as either an independent anxiety treatment, or as an adjunct to other interventions. Clinical and research implications of findings along with recommendations for ongoing investigations in this domain are discussed.

Cost-effectiveness of Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care

IMPORTANCE

Youth anxiety and depression are common and undertreated. Pediatric transdiagnostic interventions for anxiety and/or depression may be associated with improved access to treatment among youths.

OBJECTIVE

To evaluate the cost-effectiveness of a pediatric transdiagnostic brief behavioral therapy (BBT) program for anxiety and/or depression compared with assisted referral to community outpatient mental health care (ARC).

DESIGN, SETTING, AND PARTICIPANTS

In this economic evaluation, an incremental cost-effectiveness analysis was performed from the societal perspective using data from a randomized clinical trial of youths with full or probable diagnoses of anxiety or depression who were recruited from pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania. The trial was conducted from October 6, 2010, through December 5, 2014, and this analysis was performed from January 1, 2019, through October 20, 2020.

INTERVENTIONS

In the randomized clinical trial, youths were randomized to BBT (n = 95) or ARC (n = 90). The BBT program consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level therapists. Families randomized to ARC received personalized referrals to mental health care and telephone calls to support access to care.

MAIN OUTCOMES AND MEASURES

Anxiety-free days, depression-free days, quality-adjusted life-years (QALYs), and costs based on incremental cost-effectiveness ratios from intake through 32-week follow-up. A cost-effectiveness acceptability curve for QALYs was used to assess the probability that BBT was cost-effective compared with ARC over a range of amounts that a decision-maker might be willing to pay for an additional outcome.

RESULTS

Enrolled patients included 185 youths (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] White; and 38 [20.7%] Hispanic). Youths who received BBT experienced significantly more anxiety-free days (difference, 28.63 days; 95% CI, 5.86-50.71 days; P = .01) and QALYs (difference, 0.026; 95% CI, 0.009-0.046; P = .007) compared with youths who received ARC. Youths who received BBT experienced more depression-free days than did youths who received ARC (difference, 10.52 days; 95% CI, -4.50 to 25.76 days; P = .18), but the difference was not statistically significant. The mean incremental cost-effectiveness ratio was -$41 414 per QALY (95% CI, -$220 601 to $11 468). The cost-effectiveness acceptability curve analysis indicated that, at a recommended willingness-to-pay threshold of $50 000 per QALY, the probability that BBT would be cost-effective compared with ARC at 32 weeks was 95.6%.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, BBT in primary care was significantly associated with better outcomes and a greater probability of cost-effectiveness at 32 weeks compared with ARC. The findings suggest that transdiagnostic BBT may be associated with improved youth anxiety and functioning at a reasonable cost.

Clinical considerations in designing brief exposure interventions for primary care behavioral health settings

INTRODUCTION

Prevalence rates of anxiety disorders and symptoms in primary care (PC) settings are very high. Behavioral health consultants in primary care behavioral health (PCBH) settings enable increased access to evidence-based anxiety treatment. Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms.

METHODS

The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤ 30 min), time-limited (4-6 visit) approached are presented.

RESULTS

Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings.

DISCUSSION

Exposure may offer promise in improving the quality of anxiety treatment in PC. Future work documenting both effectiveness and implementation outcomes of exposure in PC in clinical work and research trials is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Training with tarantulas: A randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training

BACKGROUND

Although exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness.

METHODS

Participants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation.

RESULTS

Experiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up.

CONCLUSIONS

A one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions.

Improving the reach of clinical practice guidelines: An experimental investigation of message framing on user engagement

Despite strong evidence for the efficacy of PTSD treatments, most affected individuals are not receiving these treatments, in part because they may not know that evidence-based treatments exist. The American Psychological Association published a website to disseminate information about their Clinical Practice Guideline for treating PTSD. In Study 1, Google Optimize was used in a field study to examine whether altering the subheadings to three of the website pages would increase site visitor engagement. On the main page and page describing treatments, no subheading alterations improved engagement. On the Patients and Families page, the subheading "say goodbye to symptoms" improved engagement on three outcome variables, including clicking a link to find a psychologist (though there were a small number of clicks). In a preregistered conceptual replication in a sample not actively seeking information about the PTSD guideline (N=578), results did not replicate. Results highlight challenges of evidence-based treatment information dissemination.

A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way Through Anxiety Workbook

Effective interventions for generalized anxiety exist, but barriers to treatment prevent their broad dissemination. Commercially available self-help materials may help bridge this gap, but few have been empirically evaluated. This study compared self-reported change in generalized anxiety symptomology and associated problems between community members with excessive worry who were randomly assigned to receive the Worry Less, Live More: The Mindful Way through Anxiety Workbook (n = 35) and those in a delayed condition (n = 29). Participants in the workbook condition reported significantly greater reductions between baseline and 11-week follow-up in self-reported worry (η ² =.15), general anxiety/tension (η ² =.13), and anxiety (η ² =.24) than those in the delayed condition, although no statistically significant differences across condition on changes in depression, functional impairment or acceptance were detected. This pilot study provides support for continued research examining the efficacy of acceptance-based behavioral therapy delivered in a self-help format.

Anxiety interventions delivered in primary care behavioral health routine clinical practice

INTRODUCTION

Although anxiety is highly prevalent in primary care and a top reason for referral to primary care behavioral health (PCBH) services, there are limited data on which anxiety interventions are used in routine PCBH practice. The objective of this study was to identify interventions delivered when treating anxiety in PCBH practice.

METHOD

We conducted an online survey of PCBH providers regarding their clinical practice with patients who present for treatment of anxiety symptoms. The final sample comprised 209 PCBH providers recruited from e-mail listservs of national professional organizations (59.3% psychologists, 23.4% social workers, 12.4% counselors, 4.8% other). Providers reported on use (yes/no) of 17 interventions in their most recent session with their most recent adult patient presenting with a primary concern of non-trauma-related anxiety.

RESULTS

On average, patients were reported to be 42.2 (14.73) years old, White (73.7%), and male (56.5%) with anxiety symptoms of moderate severity (65.6%). Most reportedly had comorbid sleep difficulties (63.6%), depressive symptoms (58.4%), and/or stress/adjustment (56.0%). Providers reported delivering an average of 5.77 (2.05, range: 1-15) interventions, with psychoeducation (94.7%), relaxation training (64.1%), and supportive therapy (60.8%) being most common. Several highly efficacious evidence-based interventions for anxiety, including cognitive therapy (45.0%) and exposure (21.1%), were less common.

DISCUSSION

While PCBH providers delivered numerous brief interventions for anxiety, cognitive therapy and exposure were underutilized. Furthermore, PCBH patients with anxiety symptoms were complex, with significant severity and comorbidity. These results suggest implications for research, clinical training, intervention design, and future implementation efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A meta-analysis of dropout rates from exposure with response prevention and pharmacological treatment for youth with obsessive compulsive disorder

OBJECTIVE

Beliefs that exposure with response prevention (ERP) is excessively distressing and will result in client dropout from treatment are commonly-cited reasons for clinicians not providing evidence-based treatment. This meta-analysis examined treatment attrition for ERP for youth with obsessive compulsive disorder (OCD) compared with other treatment modalities.

METHOD

A systematic literature search identified 11 randomized controlled trials (RCTs) comparing ERP to active or waitlist control conditions, 9 comparing pharmacotherapy to control, and 3 comparing ERP to pharmacotherapy for youth with OCD.

RESULTS

Attrition rates were low for ERP (10.24%) compared to pharmacotherapy (17.29%), active control (e.g., relaxation, metacognitive therapy; 20.63%), and pill placebo (23.49%). ERP had lower risk of attrition compared to active control conditions (RR = 0.60; p = .02), and was not significantly different to waitlist (RR = 0.80; p = .59). In head-to-head trials, there was no difference between the risk of attrition from ERP and pharmacotherapy (RR = 1.26; p = .74). Of the pharmacotherapy trials, risk of attrition from serotonin reuptake inhibitors treatment was not significantly different compared to placebo (RR = 0.94; p = .76), with no difference between antidepressants and clomipramine (p = .19). Attrition from ERP was primarily for logistical reasons, compared to lack of efficacy for relaxation and/or adverse reactions from pharmacotherapy.

CONCLUSIONS

Attrition from ERP is low, and is generally lower than non-ERP interventions. Given favorable attrition and efficacy data, there is little justification for appropriately-trained clinicians not to offer ERP as a first-line treatment for youth with OCD.

Use of Guideline-Recommended Treatments for PTSD Among Community-Based Providers in Texas and Vermont: Implications for the Veterans Choice Program

Implementation of the Veterans Choice Program (VCP) allows Veterans to receive care paid for by the Department of Veterans Affairs (VA) in community settings. However, the quality of that care is unknown, particularly for complex conditions such as posttraumatic stress disorder (PTSD). A cross-sectional survey was conducted of 668 community primary care and mental health providers in Texas and Vermont to describe use of guideline-recommended treatments (GRTs) for PTSD. Relatively, few providers reported using guideline-recommended psychotherapy or prescribing practices. More than half of psychotherapists reported the use of at least one guideline-recommended psychotherapy for PTSD, but fewer reported the use of core treatment components, prior training in the GRT(s) they use, or adherence to a treatment manual. Suboptimal prescribing for PTSD patients was reported more commonly than optimal prescribing. Findings raise critical questions regarding how to ensure veterans seeking PTSD care in community settings receive psychotherapy and/or prescribing consistent with clinical practice guidelines.

A systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) was designed to be a flexible, evidence-based intervention that could treat a wide range of emotional disorders. The purpose of this systematic review is to summarize (1) the range of presenting problems to which the UP has been applied with adult patients, and (2) the settings in which the protocol has been used, as well as any modifications made to it. Using PRISMA guidelines, we conducted a literature search of PsychInfo, PubMed, Proquest Dissertations and Theses, and Web of Science. The 77 studies included in this review indicated the UP has been applied to a wide range of presenting problems including anxiety, depressive, bipolar, traumatic-stressor, substance use, eating, borderline personality, insomnia, and physical health disorders. Additionally, the UP has been applied to non-diagnosable problems such as non-suicidal self-injury, subclinical presentations, and sexual minority stress. The strongest base of evidence for the UP is among Caucasian females in the United States with anxiety-related or depressive disorders. Numerous adaptions of the UP were present in the literature. Overall, results suggest the UP can be flexibly applied to a range of diagnostic presentations. However, many studies reviewed were preliminary and further research is needed.

Training Models for Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers

IMPORTANCE

Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed.

OBJECTIVE

To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists.

INTERVENTIONS

Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members.

MAIN OUTCOMES AND MEASURES

The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome.

RESULT

A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P < .001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P < .001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P < .001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P = .03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P = .005; expert, 0.69 [95% CI, 0.38-1.01]; P < .001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P = .048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P = .048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P = .03).

CONCLUSIONS AND RELEVANCE

Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02079142.

Evaluating approaches to marketing cognitive behavioral therapy: does evidence matter to consumers?

Direct-to-consumer marketing initiatives may improve utilization of evidence-based therapy.  An important decision in such marketing efforts is how to effectively present scientific evidence supporting these treatments to potential consumers (if at all). This OSF preregistered study experimentally tested whether the language used to describe research evidence supporting cognitive behavioral therapy (CBT) for anxiety disorders affected consumer treatment attitudes and intentions. Adult participants (N = 303) recruited via mTurk were first assessed for their understanding of the term "evidence-based." They were then randomized to read a description of CBT employing either: formal research language (e.g., "large-scale clinical trials have demonstrated…"), informal language about research support derived from prior qualitative work (e.g., "people have better results…"), or no information about research. Perceptions of CBT (including credibility and expectancy) and likelihood of pursuing CBT (pull demand) were assessed. Results indicated that only half the sample understood the meaning of the term "evidence-based." The conditions that discussed research support outperformed the control condition on CBT perceptions, credibility, general expectancies, and perceived effectiveness. Post-hoc comparisons provided some evidence that qualitatively-derived language was more effective than formal research language for promoting positive perceptions of CBT. Implications for marketing content are discussed.

Therapist beliefs about exposure therapy implementation

Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client.

Key learning aims

(1)

Factors Influencing the Use of Cognitive-Behavioral Therapy with Autistic Adults: A Survey of Community Mental Health Clinicians

Cognitive-behavioral therapy (CBT) can improve anxiety and depression in autistic adults, but few autistic adults receive this treatment. We examined factors that may influence clinicians' use of CBT with autistic adults. One hundred clinicians completed an online survey. Clinicians reported stronger intentions (p = .001), more favorable attitudes (p < .001), greater normative pressure (p < .001), and higher self-efficacy (p < .001) to start CBT with non-autistic adults than with autistic adults. The only significant predictor of intentions to begin CBT with clients with anxiety or depression was clinicians' attitudes (p < .001), with more favorable attitudes predicting stronger intentions. These findings are valuable for designing effective, tailored implementation strategies to increase clinicians' adoption of CBT for autistic adults.

Internet-delivered cognitive behavioral therapy for panic disorder with or without agoraphobia: a systematic review and meta-analysis

The current systematic review and meta-analysis examined the efficacy and effectiveness of internet-delivered cognitive behavioral therapy (iCBT) on panic disorder and agoraphobia symptom severity. Twenty-seven studies were identified. Results from nine randomised controlled trials (RCTs) showed that iCBT outperformed waiting list and information controls for panic (g = 1.22) and agoraphobia (g = .91) symptoms, but the quality of RCTs varied and heterogeneity was high. Results from three RCTs suggested iCBT may have similar outcomes to face-to-face CBT in reducing panic and agoraphobia symptoms. Within-group effect sizes between baseline and post-treatment were large for panic (n = 29, g = 1.16) and medium for agoraphobia symptom severity (n = 18, g = .73). Subgroup analyses of within-group pre/post treatment effect sizes showed larger within-group effect sizes for efficacy studies (n = 15) compared to effectiveness studies (n = 14) for panic severity (g = 1.38 vs. g = .98) but not agoraphobia severity. There was no impact of program length, inclusion or arousal reduction techniques, or degree of clinician support. Within-group effects of iCBT suggest the reduction in panic and agoraphobia symptom severity is maintained at 3-6 month follow-up (n = 12).

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.

The role of the individual in the coming era of process-based therapy

For decades the development of evidence-based therapy has been based on experimental tests of protocols designed to impact psychiatric syndromes. As this paradigm weakens, a more process-based therapy approach is rising in its place, focused on how to best target and change core biopsychosocial processes in specific situations for given goals with given clients. This is an inherently more idiographic question than has normally been at issue in evidence-based therapy over the last few decades. In this article we explore methods of assessment and analysis that can integrate idiographic and nomothetic approaches in a process-based era.

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.

Exposure therapy for youth with anxiety: Utilization rates and predictors of implementation in a sample of practicing clinicians from across the United States

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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