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Yoshinaga N, Obara Y, Kawano N, Kondo K, Hayashi Y, Nakai M, Takeda R, Tanoue H. Real-World Effectiveness and Predictors of Nurse-Led Individual Cognitive Behavioral Therapy for Mental Disorders: An Updated Pragmatic Retrospective Cohort Study. Behav Sci (Basel) 2024; 14:604. [PMID: 39062427 PMCID: PMC11273469 DOI: 10.3390/bs14070604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/11/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
The importance of nurses integrating effective psychological techniques into their clinical practice is widely recognized. Nevertheless, further evidence from real-world settings is needed to establish nurse-led cognitive behavioural therapy (CBT) as an effective approach in clinical practice. This study aimed to examine the clinical effectiveness and predictors of individual CBT for mental disorders delivered by nurses in various routine clinical settings. This pragmatic retrospective cohort study collected data from participants who received nurse-led individual CBT at four institutions from different prefectures in Japan between April 2015 and March 2023. During the study period, 280 clients were referred to nurses for CBT, 240 of whom received nurse-led individual CBT of at least one session. The common primary diagnoses among participants were major depressive disorder (33.8%), social phobia (12.9%), and obsessive-compulsive disorder (10.0%). Of these, 23 participants were ongoing cases at the end of the observation period, and 217 who had completed the course of therapy or discontinued/dropped out from the therapy were included in the analysis (173 completed and 44 discontinued/dropped out (i.e., dropout rate = 20.3%)). Based on the clinical significance definition (primary outcome), 62.4% of the participants who completed the therapy were judged to demonstrate positive clinical significance (recovered or improved), with only a few participants (6.9%) demonstrating deterioration. Significant improvements were observed before and after nurse-led individual CBT across all secondary outcomes, including depression and anxiety symptoms, health-related quality of life, and functional disability (all ps ≤ 0.001). Univariate logistic regression revealed that clients with higher baseline severity of depression and anxiety symptoms were less likely to achieve positive clinical significance following nurse-led individual CBT. The real-world evidence gained through this study will encourage frontline nurses and motivate institutional/organizational leaders and policymakers to employ nurse-led individual CBT, especially for depression and anxiety-related disorders.
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Affiliation(s)
- Naoki Yoshinaga
- School of Nursing, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki City 889-1692, Miyazaki, Japan;
| | - Yoko Obara
- Graduate School of Nursing Science, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki City 889-1692, Miyazaki, Japan;
| | - Naohisa Kawano
- Cognitive Behavioral Therapy Office, Shigasato Hospital, 1-18-41, Shigasato, Otsu 520-0006, Shiga, Japan;
| | - Kazuki Kondo
- Department of Nursing, Gifu University Hospital, 1-1 Yanagido, Gifu City 501-1194, Gifu, Japan;
| | - Yuta Hayashi
- Department of Nursing, Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 654-0142, Hyogo, Japan;
| | - Michikazu Nakai
- Clinical Research Support Center, University of Miyazaki Hospital, 5200 Kihara, Kiyotake, Miyazaki City 889-1692, Miyazaki, Japan;
| | - Ryuichiro Takeda
- Health Care and Safety Center, University of Miyazaki, 1-1 Gakuen Kibanadai-Nishi, Miyazaki City 889-2192, Miyazaki, Japan;
| | - Hiroki Tanoue
- School of Nursing, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki City 889-1692, Miyazaki, Japan;
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Malivoire BL, Stewart KE, Cameron D, Rowa K, McCabe RE. Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting. Behav Cogn Psychother 2024; 52:440-455. [PMID: 38291658 DOI: 10.1017/s1352465823000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings. AIM This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic. METHOD Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly. RESULTS Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time. DISCUSSION These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.
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Affiliation(s)
- B L Malivoire
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - K E Stewart
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - D Cameron
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - K Rowa
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - R E McCabe
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
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Bergamaschi V, Baumann F, Warnke I, Corbisiero S, Ludwig F, Riedel A, Gabriel-Felleiter K, Schmidt SJ. Who Benefits from Acute Psychiatric Home Treatment? A Systematic Review. Community Ment Health J 2024:10.1007/s10597-024-01297-0. [PMID: 38940978 DOI: 10.1007/s10597-024-01297-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/13/2024] [Indexed: 06/29/2024]
Abstract
Home treatment (HT) treats patients in an acute crisis through an interdisciplinary team with daily appointments for a short treatment period. The effectiveness of HT has already been confirmed. However, only few studies addressed specific patient characteristics associated outcome of treatment. This study aimed to identify patient characteristics associated with successful outcomes of HT. A systematic literature search was conducted according to the PRISMA guidelines. A total of 13 studies were included in the systematic review. Being employed, having a regular income, having an anxiety disorder and family involvement were associated with a successful treatment outcome in HT. High symptom severity and former hospital admissions were associated with unsuccessful treatment outcome in HT in the selected studies. HT seems to be especially beneficial for patients with paid employment or regular income, patients with anxiety disorders, and patients with familial or other social support.
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Affiliation(s)
- Vera Bergamaschi
- Institue of Psychology, University of Bern, Bern, Switzerland.
- Luzerner Psychiatrie, Voltastrasse 42, 6005, Lucerne, Switzerland.
| | - Felix Baumann
- Institue of Psychology, University of Bern, Bern, Switzerland
- Luzerner Psychiatrie, Voltastrasse 42, 6005, Lucerne, Switzerland
| | - Ingeborg Warnke
- Luzerner Psychiatrie, Voltastrasse 42, 6005, Lucerne, Switzerland
| | | | - Fabian Ludwig
- Luzerner Psychiatrie, Voltastrasse 42, 6005, Lucerne, Switzerland
| | - Andreas Riedel
- Luzerner Psychiatrie, Voltastrasse 42, 6005, Lucerne, Switzerland
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Geiger Y, van Oppen P, Visser H, Eikelenboom M, van den Heuvel OA, Anholt GE. Long-term remission rates and trajectory predictors in obsessive-compulsive disorder: Findings from a six-year naturalistic longitudinal cohort study. J Affect Disord 2024; 350:877-886. [PMID: 38266929 DOI: 10.1016/j.jad.2024.01.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 11/29/2023] [Accepted: 01/14/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND This naturalistic study, utilizing data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) cohort, investigated the long-term remission rates and predictors of different trajectories of obsessive-compulsive disorder (OCD) within a clinical population. METHODS A sample of 213 participants was classified into three illness trajectories: "Chronic," "Episodic, "and "Remitted-OCD." Long-term remission rates were calculated based on three follow-up measurements over a 6-year period. A multinomial logistic regression model, incorporating five selected predictors with high explanatory power and one covariate, was employed to analyze OCD trajectory outcomes. RESULTS The long-term full remission rates, calculated from all the measurements combined (14%), were significantly lower than what was observed in earlier studies and when compared to assessments at each individual follow-up (∼30%). Moreover, high baseline symptom severity and early age of onset were identified as significant risk factors for a chronic course of OCD, while male sex and younger age predicted a more favorable trajectory. Notably, the likelihood of an episodic course remained high even without identified risk factors. LIMITATIONS The bi-annual data collection process is unable to capture participants' clinical conditions between assessments. Additionally, no data was collected regarding the specific type and duration of psychological treatment received. Regarding the type of treatment participants received. CONCLUSIONS Results suggest that long-term remission rates may be lower than previously reported. Consequently, employing multiple assessment points in longitudinal studies is necessary for valid estimation of long-term full remission rates. The results emphasize the importance of personalized clinical care and ongoing monitoring and maintenance for most OCD cases.
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Affiliation(s)
- Yuval Geiger
- Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Patricia van Oppen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Public Health research institute and GGZ inGeest Specialized Mental Health Care, the Netherlands.
| | - Henny Visser
- Innova Research Centre, Mental Health Care Institute GGZ Centraal, Ermelo, the Netherlands.
| | - Merijn Eikelenboom
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Public Health research institute and GGZ inGeest Specialized Mental Health Care, the Netherlands.
| | - Odile A van den Heuvel
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, Department of Anatomy and Neurosciences, Amsterdam Neuroscience, the Netherlands.
| | - Gideon E Anholt
- Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Keha E, Naftalovich H, Shahaf A, Kalanthroff E. Control your emotions: evidence for a shared mechanism of cognitive and emotional control. Cogn Emot 2024:1-13. [PMID: 38465905 DOI: 10.1080/02699931.2024.2326902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
The current investigation examined the bidirectional effects of cognitive control and emotional control and the overlap between these two systems in regulating emotions. Based on recent neural and cognitive findings, we hypothesised that two control systems largely overlap as control recruited for one system (either emotional or cognitive) can be used by the other system. In two experiments, participants completed novel versions of either the Stroop task (Experiment 1) or the Flanker task (Experiment 2) in which the emotional and cognitive control systems were actively manipulated into either a high or low emotional-load condition (achieved by varying the proportions of negative-valence emotional cues) and a high and a low cognitive control condition (achieved through varying the proportion of conflict-laden trials). In both experiments, participants' performance was impaired when both emotional and cognitive control were low, but significantly and similarly improved when one of the two control mechanisms were activated - the emotional or the cognitive. In Experiment 2, performance was further improved when both systems were activated. Our results give further support for a more integrative notion of control in which the two systems (emotional and cognitive control) not only influence each other, but rather extensively overlap.
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Affiliation(s)
- Eldad Keha
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Psychology, Achva Academic College, Arugot, Israel
| | - Hadar Naftalovich
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Shahaf
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eyal Kalanthroff
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
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Shahid S, Kelson J, Saliba A. Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review. JMIR Ment Health 2024; 11:e48916. [PMID: 38329804 PMCID: PMC10884902 DOI: 10.2196/48916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD. OBJECTIVE The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD. METHODS The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items. RESULTS The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria. CONCLUSIONS The findings showed that VR exposure therapy-based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues. TRIAL REGISTRATION PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891.
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Affiliation(s)
- Simon Shahid
- Faculty of Business, Justice, and Behavioural Sciences, Charles Sturt University, Bathurst, Australia
| | - Joshua Kelson
- Faculty of Business, Justice, and Behavioural Sciences, Charles Sturt University, Bathurst, Australia
| | - Anthony Saliba
- Faculty of Business, Justice, and Behavioural Sciences, Charles Sturt University, Bathurst, Australia
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Öst LG, Brattmyr M, Finnes A, Ghaderi A, Havnen A, Hedman-Lagerlöf M, Parling T, Welch E, Wergeland GJ. Cognitive behavior therapy for adult eating disorders in routine clinical care: A systematic review and meta-analysis. Int J Eat Disord 2024; 57:249-264. [PMID: 38098336 DOI: 10.1002/eat.24104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Cognitive behavior therapy (CBT) is a recommended treatment for eating disorders (ED) in adults given its evidence, mainly based on efficacy studies. However, little is known about how CBT works in routine clinical care. The goal of the present meta-analysis is to investigate how CBT works for various ED when carried out in routine clinical settings. METHOD Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until June 2023. The outcome of CBT, methodological quality, risk of bias (RoB), and moderators of treatment outcome were examined and benchmarked by meta-analytically comparing with efficacy studies for ED. Fifty studies comprising 4299 participants who received CBT were included. RESULTS Large within-group effect sizes (ES) were obtained for ED-psychopathology at post-treatment (1.12), and follow-up (1.22), on average 9.9 months post-treatment. Attrition rate was 25.5% and RoB was considerable in the majority of studies. The benchmarking analysis showed that effectiveness studies had very similar ESs as efficacy studies (1.20 at post-treatment and 1.28 at follow-up). CONCLUSION CBT for ED is an effective treatment when delivered in routine clinical care, with ESs comparable to those found in efficacy studies. However, the evidence needs to be interpreted with caution due to the RoB in a high proportion of studies. PUBLIC SIGNIFICANCE Eating disorders are common in the population and often lead to multiple negative consequences. CBT has been found effective for ED and is recommended in clinical guidelines. Since these recommendations are primarily based on university studies we wanted to investigate how CBT performs in routine clinical care. Our meta-analysis found that CBT worked as well in routine care as in university setting studies.
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Affiliation(s)
- Lars-Göran Öst
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Martin Brattmyr
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anna Finnes
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Care Center, Stockholm, Sweden
| | - Ata Ghaderi
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Audun Havnen
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
- Division of Psychiatry, St. Olavs Hospital, Trondheim, Norway
| | - Maria Hedman-Lagerlöf
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Parling
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm, Sweden
| | - Elisabeth Welch
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Rababa M, Al-Rawashdeh S, El Jarrah I, Abu Khait A. Nurses' Perception of Using Cognitive Behavior Therapy for Death Anxiety and Ageism. OMEGA-JOURNAL OF DEATH AND DYING 2023; 88:449-464. [PMID: 34541949 DOI: 10.1177/00302228211046798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the effectiveness of cognitive behavior therapy (CBT) in relieving death anxiety and ageism among nurses, there is not a complete consensus on its acceptability, adherence, credibility, and expectancy in the literature. Therefore, this descriptive-comparative study aimed to examine Jordanian nurses' perception of using CBT in relieving death anxiety and ageism. Most participants perceived CBT as a credible and adherable treatment for death anxiety and ageism. Significant differences were found in the CBT credibility and expectancy between nurses grouped according to levels of perceived treatment adherence and acceptability of CBT. The findings provide a promising avenue for adopting CBT to target death anxiety and its associated ageism among nurses and for improving CBT adherence, acceptability, credibility, and expectancy. A better understanding of participants' perception of CBT is crucial for optimal clinical practice.
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Affiliation(s)
- Mohammad Rababa
- Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Sami Al-Rawashdeh
- Department of Community and Mental Health- Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Imteyaz El Jarrah
- Maternal and Child Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Abdallah Abu Khait
- Department of Community and Mental Health- Faculty of Nursing, The Hashemite University, Zarqa, Jordan
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Tibi L, van Oppen P, van Balkom AJ, Eikelenboom M, Visser H, Anholt GE. Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study. Aust N Z J Psychiatry 2023; 57:1443-1452. [PMID: 37183408 DOI: 10.1177/00048674231173342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder. METHODS We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up. RESULTS The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits. CONCLUSION The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors.
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Affiliation(s)
- Lee Tibi
- Cognetica: The Israeli Center for Cognitive Behavioral Therapy, Tel-Aviv, Israel
| | - Patricia van Oppen
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center/GGZ InGeest, Amsterdam, The Netherlands
| | - Anton Jlm van Balkom
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center/GGZ InGeest, Amsterdam, The Netherlands
| | - Merijn Eikelenboom
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center/GGZ InGeest, Amsterdam, The Netherlands
| | - Henny Visser
- Mental Health Care Institute GGZ Centraal, Amsterdam, The Netherlands
| | - Gideon E Anholt
- Department of Psychology, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Oey LT, McDonald S, McGrath L, Dear BF, Wootton BM. Guided versus self-guided internet delivered cognitive behavioural therapy for diagnosed anxiety and related disorders: a preliminary meta-analysis. Cogn Behav Ther 2023; 52:654-671. [PMID: 37655553 DOI: 10.1080/16506073.2023.2250073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Abstract
Guided and self-guided internet-delivered cognitive-behavioural therapy (ICBT) has been demonstrated to be efficacious in the treatment of anxiety and related disorders (ARDs). The aim of the current study was to examine the efficacy of guided and self-guided ICBT for adults diagnosed with ARDs using a meta-analytic synthesis of randomised controlled trials directly comparing the two treatment approaches. Eleven studies (n = 1414) were included. There was a small, but significantly pooled between-group effect size at post-treatment (g = 0.16; 95% CI: 0.03-0.28) favouring guided ICBT. At follow-up, the between-group effect size was small and non-significant (g = 0.13; 95% CI: -0.04-0.30). Gender distribution moderated outcome at post-treatment (higher proportions of females resulted in a smaller between-group effect size). Type of support provided in the guided-treatment arm moderated treatment outcome at follow-up (those receiving synchronous support had a larger between-group effect size). Amount of guidance in the guided-treatment arm moderated effect sizes at post-treatment and follow-up (more guidance leading to larger between-group effect sizes). Automated reminders, disorder type, and treatment length did not moderate outcomes. The results suggest that guided and self-guided ICBT interventions result in similar outcomes, however guided interventions may be marginally more effective in the short term.
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Affiliation(s)
- Lilyan T Oey
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology, Sydney, NSW, Australia
| | - Sarah McDonald
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology, Sydney, NSW, Australia
| | - Laura McGrath
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology, Sydney, NSW, Australia
| | - Blake F Dear
- Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, NSW, Australia
| | - Bethany M Wootton
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology, Sydney, NSW, Australia
- Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, NSW, Australia
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11
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Wang C, Sheng Y, Yu L, Tian F, Xue Y, Zhai Q. Effects of cognitive behavioral therapy on mental health and quality of life in inflammatory bowel disease patients: A meta-analysis of randomized controlled trials. Behav Brain Res 2023; 454:114653. [PMID: 37657513 DOI: 10.1016/j.bbr.2023.114653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/28/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
We aim to assess the roles of cognitive behavioral therapy (CBT) in improving quality of life (QoL) and mental health in inflammatory bowel disease (IBD) patients. In this study, PubMed, Web of Science, PsycINfO, and the Cochrane Library databases were used for locating proper randomized controlled trials (RCTs) (to October 2022). IBD Questionnaire (IBDQ), Hospital Anxiety and Depression Scale-Anxiety Scale (HADS-A), and Hospital Anxiety and Depression Scale-Depression Scale (HADS-D) were selected for analysis. Finally, nine eligible RCTs were included in this study. The analysis of these RCTs showed that CBT significantly increased IBDQ scores (standardized mean difference (SMD): 0.26, 95% confidence interval (CI): [0.05, 0.47], p = 0.02), decreased HADS-A (SMD: -0.25, 95% CI: [-0.45, -0.05], p = 0.01), HADS-D (SMD: -0.17, 95% CI: [-0.31, -0.02], p = 0.02) scores. The result of subgroup analysis, based on treatment duration, showed that long-term CBT (≥ 12 weeks; SMD: 0.23, 95% CI: [0.05, 0.41]; p = 0.01; I2 = 28%) increased IBDQ scores. Thus, CBT is helpful for alleviating anxiety, depression and enhancing QoL in IBD patients.
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Affiliation(s)
- Chen Wang
- State Key Laboratory of Food Science and Resources, Jiangnan University, Wuxi, Jiangsu 214122, PR China; College of Food Science, Southwest University, Chongqing 400715, PR China
| | - Yingyue Sheng
- Department of Gastroenterology, Affiliated hospital of Jiangnan University, Wuxi, Jiangsu, PR China
| | - Leilei Yu
- State Key Laboratory of Food Science and Resources, Jiangnan University, Wuxi, Jiangsu 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Fengwei Tian
- State Key Laboratory of Food Science and Resources, Jiangnan University, Wuxi, Jiangsu 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China
| | - Yuzheng Xue
- Department of Gastroenterology, Affiliated hospital of Jiangnan University, Wuxi, Jiangsu, PR China.
| | - Qixiao Zhai
- State Key Laboratory of Food Science and Resources, Jiangnan University, Wuxi, Jiangsu 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, PR China.
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12
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Dale M, Eccles FJR, Melvin K, Khan Z, Jones L, Zarotti N, Kiani R, Johnson J, Wells R, Simpson J. Guided self-help for anxiety among Huntington's disease gene expansion carriers (GUIDE-HD) compared to treatment as usual: a randomised controlled feasibility trial. Pilot Feasibility Stud 2023; 9:159. [PMID: 37700320 PMCID: PMC10496323 DOI: 10.1186/s40814-023-01364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/15/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Huntington's disease (HD) is an adult-onset genetic neurodegenerative condition associated with cognitive decline, motor impairments, and emotional difficulties. Anxiety affects up to 71% of HD gene expansion carriers (i.e., those with the version of the gene that causes HD) and can negatively impact quality of life, worsen other HD symptoms, and increase suicide risk. Therefore, helping people with their anxiety should be a clinical priority. A significant evidence base now exists for low-cost talking therapies for anxiety, such as guided self-help, and with people with other neurodegenerative conditions (e.g., Parkinson's disease). However, this type of intervention has not been specifically assessed with HD gene expansion carriers. METHODS This protocol describes an exploratory randomised controlled feasibility study of a psychological intervention for anxiety for HD gene expansion carriers. The 10 session guided self-help intervention ('GUIDE-HD') is based on a blend of second and third wave cognitive behavioural models of anxiety (cognitive behaviour therapy [CBT] and acceptance and commitment therapy [ACT]) and is adapted to meet the specific needs of an HD population. This study will compare guided self-help with treatment as usual (TAU), with 15 HD gene expansion carriers randomly allocated to each group. Participants will be recruited across the UK. Quantitative data will be collected pre-intervention, immediately post-intervention, 3-month post-intervention and 6-month post-intervention. Qualitative data will be collected at one month post-intervention from participants, including HD carers. The data will be analysed to assess whether the current intervention and study design are feasible to progress to a larger randomised controlled trial. Feasibility has been defined in terms of recruitment rate, retention rate to both trial arms, intervention adherence, and acceptability of the intervention and measurement tools. DISCUSSION Given the lack of evidenced interventions to date to support the wellbeing of people with the expanded Huntington's gene, this study will assess the feasibility of progressing this particular intervention to a full trial. To try and increase the acceptability of the intervention, a number of stakeholders, including those affected by HD and in caring roles, have been fundamental to the creation of the intervention (e.g., therapy manual, planned therapy process) to date. TRIAL REGISTRATION Trial ID: ISRCTN47330596 . Date registered: 28/09/2022. Protocol version and date: Version 2, 09/06/22. Trial sponsor organisation and contact: Leicestershire Partnership NHS Trust (Dave Clarke). Role of sponsor: Overall responsibility for the conduct and governance of the trial. Role of funder: Review of initial research proposal.
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Affiliation(s)
- Maria Dale
- Leicestershire Partnership NHS Trust, Mill Lodge, Narborough, Leicestershire, LE19 4SL, Leicester, UK
| | - Fiona J R Eccles
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AH, UK
| | - Katie Melvin
- Leicestershire Partnership NHS Trust, Mill Lodge, Narborough, Leicestershire, LE19 4SL, Leicester, UK
| | - Zaynah Khan
- Leicestershire Partnership NHS Trust, Mill Lodge, Narborough, Leicestershire, LE19 4SL, Leicester, UK
| | - Lee Jones
- Leicestershire Partnership NHS Trust, Mill Lodge, Narborough, Leicestershire, LE19 4SL, Leicester, UK
| | - Nicolò Zarotti
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AH, UK
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, M6 8HD, UK
| | - Reza Kiani
- Leicestershire Partnership NHS Trust, Mill Lodge, Narborough, Leicestershire, LE19 4SL, Leicester, UK
| | | | | | - Jane Simpson
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AH, UK.
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Gavric D, Cameron D, Waechter S, Moscovitch DA, McCabe RE, Rowa K. Just do something: An experimental investigation of brief interventions for reducing the negative impact of post-event processing in social anxiety disorder. J Anxiety Disord 2023; 98:102744. [PMID: 37478698 DOI: 10.1016/j.janxdis.2023.102744] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/02/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
Post-Event Processing (PEP) is prevalent and problematic in Social Anxiety Disorder (SAD) but is typically not a direct target in evidence-based treatments such as cognitive behavioural therapy (CBT) for SAD. The primary aim of the current study was to examine the impact of several theoretically and empirically derived interventions for PEP in SAD, including concrete thinking, abstract thinking, and distraction in comparison to a control (i.e., do nothing) condition. Based on prior research, we hypothesized that the concrete and distract conditions would be associated with positive benefits, including reductions in PEP and improvements in self-perception, whereas the abstract and control conditions would not. The second aim of the study was to identify baseline variables that predict the trajectory of change in PEP over time. Participants (N=92) with a principal diagnosis of SAD completed a social stress task and were randomly assigned to one of four conditions. Participants completed measures at baseline, post-intervention/control, and at 1-week, and 1-month follow-up. Contrary to hypotheses, all three active conditions were similarly effective at reducing PEP and improving self-perceptions relative to the control condition. In the absence of an intervention, engagement in PEP remained high up to a month following the social stress task. Higher levels of baseline state anxiety, intolerance of uncertainty, and use of safety behaviours predicted greater PEP, even in the presence of an intervention. These results highlight the benefits of relatively brief interventions that disrupt the course of PEP for people with SAD. Such interventions can be easily incorporated into CBT protocols for SAD to enhance their effects.
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Affiliation(s)
- Dubravka Gavric
- Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada.
| | - Duncan Cameron
- Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada
| | - Stephanie Waechter
- Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - David A Moscovitch
- Department of Psychology and Centre for Mental Health Research and Treatment, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Randi E McCabe
- Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Karen Rowa
- Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada
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14
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Öst LG, Enebrink P, Finnes A, Ghaderi A, Havnen A, Kvale G, Salomonsson S, Wergeland GJ. Cognitive behavior therapy for adult post-traumatic stress disorder in routine clinical care: A systematic review and meta-analysis. Behav Res Ther 2023; 166:104323. [PMID: 37257304 DOI: 10.1016/j.brat.2023.104323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/25/2023] [Accepted: 04/26/2023] [Indexed: 06/02/2023]
Abstract
Although different cognitive behavioral therapies (CBT) have strong research support for treatment of adult post-traumatic stress disorder (PTSD) more knowledge is needed about the performance of CBT in routine clinical care. The present study is a systematic review and meta-analysis of CBT for PTSD in adults treated in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for studies published until the end of May 2022. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined, and benchmarked by meta-analytically comparing with efficacy studies for PTSD. Thirty-three studies, comprising 6482 participants, were included. The within-group effect sizes (ES) for PTSD-severity at post-treatment (1.75), and follow-up (1.70), on average 6 months post-treatment, were large. The effectiveness studies had very similar ESs as efficacy studies at post-treatment (1.75 vs. 1.72) and follow-up (1.70 vs. 2.02), based on the benchmarking analysis. As the heterogeneity was large, we can only cautiously consider CBT for PTSD an effective treatment when delivered in routine clinical care. The outcomes of effectiveness studies for PTSD seem to be comparable to the results obtained in efficacy studies. PROSPERO REGISTRATION ID: CRD42021228828.
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Affiliation(s)
- Lars-Göran Öst
- Department of Psychology, Stockholm University, Sweden; Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Pia Enebrink
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Finnes
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Academic Primary Care Center, Region Stockholm, Sweden
| | - Ata Ghaderi
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Audun Havnen
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Division of Psychiatry, St. Olavs Hospital, Trondheim, Norway
| | - Gerd Kvale
- Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Norway
| | - Sigrid Salomonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
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15
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Öst LG, Enebrink P, Finnes A, Ghaderi A, Havnen A, Kvale G, Salomonsson S, Wergeland GJ. Cognitive behavior therapy for adult depressive disorders in routine clinical care: A systematic review and meta-analysis. J Affect Disord 2023; 331:322-333. [PMID: 36894029 DOI: 10.1016/j.jad.2023.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/18/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Different cognitive behavioral therapies (CBT) have strong research support for treatment of adult depressive disorders (DD). Given the scarcity of knowledge about the performance of CBT in routine clinical care, a systematic review and meta-analysis of CBT for adults with DD treated in this context was conducted. METHODS Published studies until the end of September 2022, were systematically searched in Ovid MEDLINE, Embase OVID, and PsycINFO. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined, and benchmarked by meta-analytically comparing with efficacy studies for DD. RESULTS Twenty-eight studies, comprising 3734 participants, were included. Large within-group effect sizes (ES) were obtained for DD-severity at post-treatment, and follow-up, on average 8 months post-treatment. Benchmarking analysis showed that effectiveness studies had very similar ESs as efficacy studies at post-treatment (1.51 vs. 1.71) and follow-up (1.71 vs. 1.85). Remission rates were also very similar; effectiveness studies 44 % and 46 %, efficacy studies 45 % and 46 %, at post-treatment and follow-up, respectively. LIMITATIONS Only studies published in English-language peer-reviewed journals were included and the use of pre-post ES in the meta-analyses could contribute to biased outcomes. CONCLUSIONS CBT for DD is an effective treatment when delivered in routine clinical care and the outcomes of effectiveness studies for DD are comparable to the effects obtained in efficacy studies. PROSPERO REGISTRATION MASKED.
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Affiliation(s)
- Lars-Göran Öst
- Department of Psychology, Stockholm University, Sweden; Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Pia Enebrink
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Finnes
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Academic Primary Care Center, Region Stockholm, Sweden
| | - Ata Ghaderi
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Audun Havnen
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Division of Psychiatry, St. Olavs Hospital, Trondheim, Norway
| | - Gerd Kvale
- Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Norway
| | - Sigrid Salomonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
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Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting. PLoS One 2023; 18:e0282902. [PMID: 36897860 PMCID: PMC10004605 DOI: 10.1371/journal.pone.0282902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/25/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Numerous randomized controlled trials (RCTs) demonstrate the efficacy of cognitive behavioral therapy (CBT), metacognitive therapy (MCT), and methods to reduce intolerance of uncertainty (IU-CBT) in the treatment of generalized anxiety disorder (GAD). However, few studies have investigated these treatments under conditions of routine clinical care. The main objective of this study was to investigate the effectiveness of psychotherapy for GAD in an outpatient setting and to identify factors influencing treatment outcome. METHODS Fifty-nine GAD patients received naturalistic CBT (including MCT and IU-CBT) in an outpatient clinic and postgraduate training center for psychotherapy. Patients completed self-report questionnaires at the beginning and end of therapy regarding the main outcome worry as well as metacognitions, intolerance of uncertainty, depression, and general psychopathology. RESULTS Worry, negative metacognitions, intolerance of uncertainty, depression, and general psychopathology decreased significantly (p's < .001) with large effect sizes for all symptoms (d = 0.83-1.49). A reliable change in the main outcome worry was observed in 80% of patients, and recovery occurred in 23%. Higher worry scores at posttreatment were predicted by higher pretreatment scores, female sex, and less change in negative metacognitive beliefs during treatment. CONCLUSIONS Naturalistic CBT for GAD appears to be effective in routine clinical care for worry as well as depressive symptoms, with particular benefits associated with altering negative metacognitions. However, a recovery rate of only 23% is lower than the rates reported in RCTs. Treatment needs to be improved, especially for patients with more severe GAD and for women.
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17
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Hamlett GE, Foa EB, Brown LA. Exposure Therapy and Its Mechanisms. Curr Top Behav Neurosci 2023; 64:273-288. [PMID: 37532963 DOI: 10.1007/7854_2023_428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Exposure therapy is the gold-standard treatment approach for pathological anxiety. This therapeutic approach builds on principles of extinction training from traditional fear conditioning and extinction protocols. In this chapter, we discuss principles of exposure therapy in the clinic and the laboratory experimental results that guide our decisions in the therapy. We discuss emotional processing theory and inhibitory learning principles, with a focus on expectation violation. We conclude with future research directions needed to improve exposure therapy outcomes among patients with anxiety-related disorders.
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Affiliation(s)
- Gabriella E Hamlett
- Department of Psychiatry, Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, PA, USA
| | - Edna B Foa
- Department of Psychiatry, Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, PA, USA
| | - Lily A Brown
- Department of Psychiatry, Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, PA, USA.
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18
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Öst LG, Enebrink P, Finnes A, Ghaderi A, Havnen A, Kvale G, Salomonsson S, Wergeland GJ. Cognitive behavior therapy for obsessive-compulsive disorder in routine clinical care: A systematic review and meta-analysis. Behav Res Ther 2022; 159:104170. [PMID: 36302283 DOI: 10.1016/j.brat.2022.104170] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/11/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022]
Abstract
Cognitive behavioral therapy (CBT) has strong research support for obsessive-compulsive disorder (OCD). However, less is known about how CBT performs when delivered in routine clinical care. A systematic review and meta-analysis was conducted of CBT for OCD in adults treated in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for studies published until July 2021. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined, and benchmarked by meta-analytically comparing with efficacy studies for OCD. Twenty-nine studies (8 randomized controlled trials) were included, comprising 1669 participants. Very large within-group effect sizes (ES) were obtained for OCD-severity at post-treatment (2.12), and follow-up (2.30), on average 15 months post-treatment. Remission rates were 59.2% post-treatment and 57.0% at follow-up. Attrition rate was 15.2%. Risk of bias was considerable in the majority of studies. The benchmarking analysis showed that effectiveness studies had almost exactly the same ES as efficacy studies at post-treatment and somewhat higher at follow-up. Furthermore, effectiveness studies had significantly higher remission rates than efficacy studies, both at post- and follow-up assessment. CBT for OCD is an effective treatment when delivered in routine clinical care, with ES comparable to those found in efficacy studies. However, the evidence needs to be interpreted with caution because of the risk of bias in a high proportion of studies. PROSPERO REGISTRATION ID: CRD42021228828.
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Affiliation(s)
- Lars-Göran Öst
- Department of Psychology, Stockholm University, Sweden; Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Pia Enebrink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Finnes
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Academic Primary Care Center, Region Stockholm, Sweden
| | - Ata Ghaderi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Audun Havnen
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Division of Psychiatry, St. Olavs Hospital, Trondheim, Norway
| | - Gerd Kvale
- Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Norway
| | - Sigrid Salomonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
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19
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Cassel M, Blom K, Gatzacis J, Renblad P, Kaldo V, Jernelöv S. Clinical feasibility of cognitive behavioural therapy for insomnia in a real-world mixed sample at a specialized psychiatric outpatient clinic. BMC Psychiatry 2022; 22:600. [PMID: 36085009 PMCID: PMC9461101 DOI: 10.1186/s12888-022-04231-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A majority of psychiatric patients suffer from insomnia or insomnia-like problems. In addition to impairing quality of life, sleep problems can worsen psychiatric conditions, such as depression and anxiety, and can make treatment of various psychiatric conditions less successful. Several international guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first line treatment. However, patients in psychiatric care are rarely offered this treatment, and there is a lack of studies evaluating the treatment in regular psychiatric settings. In this pilot study, we aimed to determine the clinical feasibility of a group-based CBT-I intervention in an outpatient clinical setting for patients with depression, bipolar disorder, anxiety disorders and PTSD. We also aimed to investigate if symptoms of insomnia, depression and anxiety changed after CBT-I. METHODS Seventeen patients at an out-patient psychiatric clinic for mixed psychiatric problems of anxiety, affective disorders and PTSD, were enrolled in a six-week long group-based CBT-I intervention. Primary outcomes were pre-defined aspects of treatment feasibility. Secondary outcomes were changes in self-reported symptoms of insomnia severity, depression, and anxiety between pre - and post intervention. Assessment of insomnia severity was also performed 3 months after treatment. Feasibility data is reported descriptively, changes in continuous data from pre- to post-treatment were analysed with dependent t-tests. RESULTS All feasibility criteria were met; there were enough patients to sustain at least one group per semester (e.g., minimum 8), 88% of included patients attended the first session, mean of attended sessions was 4.9 of 6, and drop-out rate was 5.9%. Therapists, recruited from clinical staff, found the treatment manual credible, and possible to use at the clinic. Symptoms of insomnia decreased after treatment, as well as symptoms of depression and anxiety. CONCLUSION CBT-I could prove as a clinically feasible treatment option for insomnia in a psychiatric outpatient setting. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT05379244. Retrospectively registered 18/05/2022.
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Affiliation(s)
- Maria Cassel
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Kerstin Blom
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Jannis Gatzacis
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Peter Renblad
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Viktor Kaldo
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden ,grid.8148.50000 0001 2174 3522Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Susanna Jernelöv
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden. .,Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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20
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Smith ORF, Sæther SMM, Haug E, Knapstad M. Long-term outcomes at 24- and 36-month follow-up in the intervention arm of the randomized controlled trial of Prompt Mental Health Care. BMC Psychiatry 2022; 22:598. [PMID: 36076192 PMCID: PMC9461100 DOI: 10.1186/s12888-022-04227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Whether long-term symptom improvement is maintained after treatment in services such as the Norwegian Prompt Mental Health Care (PMHC) and the English Improving Access to Psychological Therapies is not yet known. In this prospective study, we investigate whether improvements observed at 6-month follow-up are maintained at 24- and 36-month follow-up among clients who received PMHC. METHOD Data from the treatment arm of the randomized controlled trial of PMHC were used (n = 459). The main outcomes were (reliable) recovery rate and symptoms of depression (PHQ-9) and anxiety (GAD-7). Primary outcome data at 24- and 36-months follow-up were available for 47% and 39% of participants, respectively. Secondary outcomes were work participation, functional status, health-related quality of life, and positive mental well-being. Sensitivity analyses with regard to missing data assumptions were conducted for the primary continuous outcomes. RESULTS Improvements were maintained at 24- and 36-month follow-up for symptoms of depression and anxiety, (reliable) recovery rate, and health-related quality of life. Small linear improvements since 6-month follow-up were observed for work participation, functional status, and positive mental well-being. Sensitivity analyses did not substantially alter the findings for symptoms of depression and anxiety mentioned above. CONCLUSIONS Our findings support the long-term effectiveness of PMHC, but results should be interpreted with caution due to lacking follow-up data at 24- and 36-month in the control group, and substantial attrition.
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Affiliation(s)
- Otto R. F. Smith
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway ,grid.418193.60000 0001 1541 4204Centre for Evaluation of Public Health Measure, Norwegian Institute of Public Health, Bergen, Norway ,grid.458561.b0000 0004 0611 5642Department of Teacher Education, NLA University College, Pb 74 Sandviken, 5812 Bergen, Norway
| | - Solbjørg M. M. Sæther
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway
| | - Ellen Haug
- grid.458561.b0000 0004 0611 5642Department of Teacher Education, NLA University College, Pb 74 Sandviken, 5812 Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Health Promotion and Development, University of Bergen, 5020 Bergen, Norway
| | - Marit Knapstad
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway
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21
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Ji NN, Xia M. Enriched environment alleviates adolescent visceral pain, anxiety- and depression-like behaviors induced by neonatal maternal separation. Transl Pediatr 2022; 11:1398-1407. [PMID: 36072545 PMCID: PMC9442205 DOI: 10.21037/tp-22-410] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Neonatal maternal separation (NMS), a major kind of early life stress, increases the risk of visceral pain, anxiety- and depression-like behaviors in adulthood. An enriched environment (EE) has been shown to successfully rescue the brain from various early life psychological stressors. Therefore, this study aimed to investigate whether NMS induces visceral pain, anxiety- and depression-like behaviors in adolescents and to evaluate the impact of EE in infancy on these symptoms. METHODS Male C57BL/6 J mice that had been subjected to NMS were used in this study. The visceral pain threshold test (PTT), open field test (OFT), and sucrose preference test (SPT) were conducted to evaluate visceral pain, anxiety- and depression-like behaviors in mice, respectively. An enzyme linked immunosorbent assay (ELISA) for tumor necrosis factor-α (TNF-α), interleukin-1β, (IL-1β), and interleukin-10 (IL-10) was performed to assess neuroinflammatory responses. Then, the effects of EE (free-turning running wheels, pipes, stairs, and various colored ocean balls, etc.) on NMS-induced behaviors and neuroinflammatory factors were examined. RESULTS The impacts of NMS included adolescent visceral pain, anxiety- and depression-like behaviors. The medial prefrontal cortex (mPFC), basolateral amygdala (BLA), and paraventricular nucleus (PVN) were biased towards pro-inflammatory features. Further, EE alleviated adolescent visceral pain, anxiety- and depression-like behaviors. The application of EE up-regulated the expression of IL-10, and down-regulated the expression of IL-1β and TNF-α in mPFC, BLA, and PVN. CONCLUSIONS The effects of NMS include adolescent visceral pain, anxiety- and depression-like behaviors, accompanied by an imbalance of neuroinflammation. Intervention with EE in pediatric mice relieved these symptoms by reducing neuroinflammation in the central nervous system.
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Affiliation(s)
- Ning-Ning Ji
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Ming Xia
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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22
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Xian-Yu CY, Deng NJ, Zhang J, Li HY, Gao TY, Zhang C, Gong QQ. Cognitive behavioral therapy for children and adolescents with post-traumatic stress disorder: meta-analysis. J Affect Disord 2022; 308:502-511. [PMID: 35460743 DOI: 10.1016/j.jad.2022.04.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/27/2022] [Accepted: 04/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Children and adolescents who experience traumatic events may develop post-traumatic stress disorder (PTSD), which is often associated with other psychiatric disorders, including depression and anxiety. Cognitive behavioral therapy (CBT) is widely used in psychotherapy to treat PTSD in children and adolescents. This meta-analysis evaluated previous studies on the effectiveness of CBT in the treatment of PTSD in children and adolescents. METHODS Randomized controlled trials (RCTs) published before July 25, 2021, were retrieved from seven databases. All RCTs of CBT compared to control, including conventional treatment or other treatments, in children or adolescents with PTSD. Random effect models were employed for all outcomes. Risk of bias was performed by Cochrane Collaboration's tool. The publication bias was evaluated using the Egger's regression analysis. RESULTS Nineteen RCTs were included in the meta-analysis. Compared with control, CBT was effective in reducing the symptoms of PTSD in children and adolescents, with a variety of scales used to measure the overall PTSD symptoms: CAPS (SMD = -0.41, 95%CI [-0.71, -0.12]), CPSS (SMD = -0.88, 95%CI [-1.42, -0.34]) and UCLA-PTSD RI (SMD = -1.70, 95%CI [-2.98, -0.42]). Furthermore, CBT also improved the comorbidities of depression (SMD = -0.43, 95%CI [-0.70, -0.17]) and anxiety (SMD = -0.29, 95%CI [-0.56, -0.03]) associated with PTSD. However, CBT was not effective in reducing avoidance symptoms (SMD = 0.38, 95%CI [-0.55, 1.31]). CONCLUSION CBT can reduce the severity of PTSD in children and adolescents and improve the symptoms of depression and anxiety, as evident in the treatment of PTSD victims of sexual abuse and war and in patients aged more than 7 years.
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Affiliation(s)
- Chen-Yang Xian-Yu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Nian-Jia Deng
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Jin Zhang
- Department of Information Resources, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Hao-Yang Li
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Teng-Yu Gao
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China.
| | - Qin-Qin Gong
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China; Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan 420000, China.
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Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder: The Results of a Naturalistic Outcomes Study. J Clin Med 2022; 11:jcm11102762. [PMID: 35628888 PMCID: PMC9145175 DOI: 10.3390/jcm11102762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022] Open
Abstract
Cognitive−behavioral therapy is a well-established treatment for obsessive−compulsive disorder (OCD). There are a variety of cognitive and behavioral strategies, and it is necessary to analyze the outcomes of the treatments. The aim of the present study is to verify the effectiveness of a treatment that combines evidence-based procedures and specific cognitive interventions highlighting the issue of acceptance. Forty patients with OCD were recruited and underwent a specific treatment procedure. All patients had a psychodiagnostic assessment for OCD using the Y−BOCS (Yale−Brown obsessive−compulsive scale) performed twice: before treatment (t0) and after nine months (t1). Data analysis showed a decrease in the scores between t0 and t1 according to the Y−BOCS in terms of the interference, severity, and impairment of obsessive−compulsive symptoms. A repeated-measures ANOVA showed a significant reduction in symptoms after treatment, with values of F (1, 39) = 137.56, p < 0.001, and η2 = 0.78. The ANOVA results were corroborated by a Wilcoxon signed-rank test. A reliable change index analysis indicated that 33 participants reported improvements in symptoms, of which 23 were clinically significant. The results showed clinical relevance for OCD treatment and highlighted how this cognitive procedure favored positive outcomes.
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Kathmann N, Jacobi T, Elsner B, Reuter B. Effectiveness of Individual Cognitive-Behavioral Therapy and Predictors of Outcome in Adult Patients with Obsessive-Compulsive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:123-135. [PMID: 35034016 DOI: 10.1159/000520454] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cognitive-behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) has proven its efficacy in randomized controlled trials (RCTs). OBJECTIVE To test generalizability to routine care settings, we conducted an effectiveness study to provide naturalistic outcome data and their predictors. METHODS Pre-post changes in symptoms and impairment as well as response rates were determined in a naturalistic OCD sample (intention-to-treat, ITT, n = 393). Patients received individual CBT for OCD adopting an exposure-based, non-manualized treatment format. Linear and logistic regression analyses were applied to identify associations of sociodemographic and clinical variables with symptom change. RESULTS Effect size in ITT patients amounted to d = 1.47 in primary outcome (Yale-Brown Obsessive-Compulsive Scale, Y-BOCS). Remission rates were 46.3% (ITT), 52.0% (completers), and 18.2% (non-completers). The rates of treatment response without remission, no change, and deterioration in the ITT sample were 13.2, 38, and 3%, respectively. Initial symptom severity, comorbid personality disorder, and unemployment were associated with a poorer outcome, and previous medication with a better outcome. Comorbid depressive and anxiety disorders as well as other clinical or sociodemographic variables showed no effects on symptom change. CONCLUSIONS Outcomes in this large observational trial in a naturalistic setting correspond to available RCT findings suggesting that CBT for OCD should be strongly recommended for dissemination in routine care. Targets for further research include early prediction of non-response and development of alternative treatment strategies for patients who respond insufficiently.
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Affiliation(s)
- Norbert Kathmann
- Department of Psychology and Outpatient Clinical Care Unit, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tanja Jacobi
- Department of Psychology and Outpatient Clinical Care Unit, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Björn Elsner
- Department of Psychology and Outpatient Clinical Care Unit, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Benedikt Reuter
- Department of Psychology and Outpatient Clinical Care Unit, Humboldt-Universität zu Berlin, Berlin, Germany
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Ahrens J, Shao R, Blackport D, Macaluso S, Viana R, Teasell R, Mehta S. Cognitive -behavioral therapy for managing depressive and anxiety symptoms after stroke: a systematic review and meta-analysis. Top Stroke Rehabil 2022; 30:368-383. [PMID: 35352629 DOI: 10.1080/10749357.2022.2049505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Post-stroke anxiety and depression can be disabling and result in impaired recovery. Cognitive-behavioral therapy (CBT) has been demonstrated to be effective for anxiety and depression; however, determining its efficacy among those with stroke is warranted. Our objectives to evaluate CBT for anxiety and depression post-stroke . METHODS This review was registered with PROSPERO (REG# CRD42020186324). Medline, PsycInfo, and EMBR Cochrane were used to locate studies published before May 2020, using keywords such as stroke and CBT. A study was included if: (1) interventions were CBT-based, targeting anxiety and/or depression; (2) participants experienced a stroke at least 3 months previous; (3) participants were at least 18 years old. Standardized mean differences ± standard errors and 95% confidence intervals were calculated, and heterogeneity was determined. The Cochrane Risk of Bias tool was used. RESULTS The search yielded 563 articles, of which 10 (N = 672) were included;6 were randomized controlled trials. Primary reasons for exclusion included: (1) wrong population (2) insufficient data provided for a meta-analysis; (3) wrongoutcomes. CBT showed large effects on reducing overall anxiety (SMD ± SE: 1.01 ± 0.32, p < .001) and depression (SMD ± SE: 0.95 ± 0.22, p < .000) symptoms at the end of the studies. CBT moderately maintained anxiety (SDM ± SE: 0.779 ± 0.348, p ˂.025) and depression (SDM ± SE: 0.622 ± 0.285, p ˂ .029) scores after 3-months. Limitations included small sample size, limited comparators, and lack of follow-up data. CONCLUSION The results of this meta-analysis provide substantial evidence for the use of CBTto manage post-stroke anxiety and depression.
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Affiliation(s)
- Jessica Ahrens
- Lawson Health Research Institute, Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
| | - Richard Shao
- Lawson Health Research Institute, Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
| | - Daymon Blackport
- Lawson Health Research Institute, Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
| | - Steven Macaluso
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Ricardo Viana
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Robert Teasell
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Swati Mehta
- Lawson Health Research Institute, Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph’s Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
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Ritola V, Lipsanen JO, Pihlaja S, Gummerus EM, Stenberg JH, Saarni S, Joffe G. Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study. J Med Internet Res 2022; 24:e29384. [PMID: 35323119 PMCID: PMC8990365 DOI: 10.2196/29384] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/30/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022] Open
Abstract
Background Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care. Objective In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care. Methods We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale. Results Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery. Conclusions This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.
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Affiliation(s)
- Ville Ritola
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jari Olavi Lipsanen
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Satu Pihlaja
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero-Matti Gummerus
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jan-Henry Stenberg
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Suoma Saarni
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Grigori Joffe
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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27
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Arnfred B, Bang P, Hjorthøj C, Christensen CW, Stengaard Moeller K, Hvenegaard M, Agerskov L, Krog Gausboel U, Soe D, Wiborg P, Smith CIS, Rosenberg N, Nordentoft M. Group cognitive behavioural therapy with virtual reality exposure versus group cognitive behavioural therapy with in vivo exposure for social anxiety disorder and agoraphobia: a protocol for a randomised clinical trial. BMJ Open 2022; 12:e051147. [PMID: 35110313 PMCID: PMC8811551 DOI: 10.1136/bmjopen-2021-051147] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Anxiety disorders have a high lifetime prevalence, early-onset and long duration or chronicity. Exposure therapy is considered one of the most effective elements in cognitive behavioural therapy (CBT) for anxiety, but in vivo exposure can be challenging to access and control, and is sometimes rejected by patients because they consider it too aversive. Virtual reality allows flexible and controlled exposure to challenging situations in an immersive and protected environment. AIM The SoREAL-trial aims to investigate the effect of group cognitive behavioural therapy (CBT-in vivo) versus group CBT with virtual reality exposure (CBT-in virtuo) for patients diagnosed with social anxiety disorder and/or agoraphobia, in mixed groups. METHODS AND ANALYSIS The design is an investigator-initiated randomised, assessor-blinded, parallel-group and superiority-designed clinical trial. Three hundred two patients diagnosed with social anxiety disorder and/or agoraphobia will be included from the regional mental health centres of Copenhagen and North Sealand and the Northern Region of Denmark. All patients will be offered a manual-based 14-week cognitive behavioural group treatment programme, including eight sessions with exposure therapy. Therapy groups will be centrally randomised with concealed allocation sequence to either CBT-in virtuo or CBT-in vivo. Patients will be assessed at baseline, post-treatment and 1-year follow-up by treatment blinded researchers and research assistants. The primary outcome will be diagnosis-specific symptoms measured with the Liebowitz Social Anxiety Scale for patients with social anxiety disorder and the Mobility Inventory for Agoraphobia for patients with agoraphobia. Secondary outcome measures will include depression symptoms, social functioning and patient satisfaction. Exploratory outcomes will be substance and alcohol use, working alliance and quality of life. ETHICS AND DISSEMINATION The trial has been approved by the research ethics committee in the Capital Region of Denmark. All results, positive, negative as well as inconclusive, will be published as quickly as possible and still in concordance with Danish law on the protection of confidentially and personal information. Results will be presented at national and international scientific conferences. The trial has obtained approval by the Regional Ethics Committee of Zealand (H-6-2013-015) and the Danish Data Protection Agency (RHP-2014-009-02670). The trial is registered at ClinicalTrial.gov as NCT03845101. The patients will receive information on the trial both verbally and in written form. Written informed consent will be obtained from each patient before inclusion in the trial. The consent form will be scanned and stored in the database system and the physical copy will be destroyed. It is emphasised that participation in the trial is voluntary and that the patient can withdraw his or her consent at any time without consequences for further and continued treatment. TRIAL REGISTRATION NUMBER NCT03845101.
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Affiliation(s)
- Benjamin Arnfred
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Bang
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Clas Winding Christensen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Stengaard Moeller
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Hvenegaard
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lone Agerskov
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik Krog Gausboel
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ditte Soe
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Wiborg
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christopher Ian Schøler Smith
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicole Rosenberg
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department for Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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Elsner B, Jacobi T, Kischkel E, Schulze D, Reuter B. Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy. BMC Psychiatry 2022; 22:66. [PMID: 35086513 PMCID: PMC8793233 DOI: 10.1186/s12888-022-03701-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome. METHOD In a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions. RESULTS In a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings. CONCLUSIONS The results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.
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Affiliation(s)
- Björn Elsner
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Tanja Jacobi
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Eva Kischkel
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Daniel Schulze
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
- Department of Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany
| | - Benedikt Reuter
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
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Domhardt M, Nowak H, Engler S, Baumel A, Grund S, Mayer A, Terhorst Y, Baumeister H. Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials. Clin Psychol Rev 2021; 90:102084. [PMID: 34610493 DOI: 10.1016/j.cpr.2021.102084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/13/2021] [Accepted: 09/08/2021] [Indexed: 01/14/2023]
Abstract
While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.
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Affiliation(s)
- Matthias Domhardt
- Department of Clinical Psychology and Psychotherapy, Ulm University, Germany.
| | - Hannah Nowak
- Department of Clinical Psychology and Psychotherapy, Ulm University, Germany
| | - Sophie Engler
- Department of Clinical Psychology and Psychotherapy, Ulm University, Germany
| | - Amit Baumel
- Department of Community Mental Health, University of Haifa, Israel
| | - Simon Grund
- IPN - Leibniz Institute for Science and Mathematics Education, Kiel, Germany
| | - Axel Mayer
- Department of Psychological Methods and Evaluation, Bielefeld University, Germany
| | - Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Ulm University, Germany; Department of Psychological Research Methods, Ulm University, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Ulm University, Germany
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Silfee V, Williams K, Leber B, Kogan J, Nikolajski C, Szigethy E, Serio C. Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study. JMIR Form Res 2021; 5:e28538. [PMID: 34529583 PMCID: PMC8512194 DOI: 10.2196/28538] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/13/2021] [Accepted: 09/13/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. OBJECTIVE This study assessed providers' views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. METHODS Participating providers included BH and physical health (PH) providers from a women's health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. RESULTS A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. CONCLUSIONS Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow.
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Affiliation(s)
| | - Kelly Williams
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Brett Leber
- UPMC Health Plan, Pittsburgh, PA, United States
| | - Jane Kogan
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
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Anton MT, Greenberger HM, Andreopoulos E, Pande RL. Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study. JMIR Form Res 2021; 5:e27570. [PMID: 34546170 PMCID: PMC8493460 DOI: 10.2196/27570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context. OBJECTIVE The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching. METHODS In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated. RESULTS Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (β=-1.2; P<.001), generalized anxiety (β=-1.1; P<.001), and social anxiety (β=-2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=-2.1; P=.03). CONCLUSIONS This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program.
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Rechenberg K, Koerner R. Cognitive Behavioral Therapy in Adolescents with Type 1 Diabetes: An Integrative Review. J Pediatr Nurs 2021; 60:190-197. [PMID: 34224937 DOI: 10.1016/j.pedn.2021.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/24/2021] [Indexed: 12/19/2022]
Abstract
PROBLEM Type 1 Diabetes (T1D) is a complex chronic condition that impacts physiologic and psychosocial outcomes in adolescents. Adolescents with T1D experience anxiety and depressive symptoms at 2 to 3 times the rate of the general adolescent population. Anxiety and depressive symptoms negatively impact disease management. Cognitive behavioral therapy (CBT) is considered the gold standard therapeutic technique for treating anxiety and depressive symptoms. The aim of this integrative review was to examine and synthesize the extant literature exploring the effect of CBT on physiologic and psychosocial outcomes in adolescents with T1D. ELIGIBILITY CRITERIA Electronic databases were searched with the terms "type 1 diabetes" and "cognitive behavioral therapy." Studies were included if they were published between 2000 and 2020, evaluated a pediatric population (≤18 years of age), and included individuals with diagnosed T1D. SAMPLE 475 articles were identified in our initial search, and after removal of duplicates 353 articles remained. 339 did not meet inclusion criteria. A total of 14 papers met inclusion criteria. RESULTS All studies included CBT, but differed in delivery methods. Several studies demonstrated evidence of the feasibility and acceptability; however, there were mixed results regarding improvement of physiologic and psychosocial outcomes. CONCLUSIONS CBT is a feasible and acceptable intervention in adolescents with T1D. It may be a method of improving psychologic and psychosocial outcomes for this high-risk population. IMPLICATIONS In adolescents with T1D, screening and treatment for psychosocial comorbidities should occur regularly at endocrinology visits. CBT can be operationalized to fill this gap.
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Affiliation(s)
- Kaitlyn Rechenberg
- University of South Florida College of Nursing, FL, United States of America.
| | - Rebecca Koerner
- University of South Florida College of Nursing, FL, United States of America.
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Lervik LV, Hoffart A, Knapstad M, Smith ORF. Exploring the temporal associations between avoidance behavior and cognitions during the course of cognitive behavioral therapy for clients with symptoms of social anxiety disorder. Psychother Res 2021; 32:195-208. [PMID: 34142636 DOI: 10.1080/10503307.2021.1930243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges. METHOD We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested. RESULTS The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤ β ≤ .42 for T2-T5, p < .05), but not vice versa. In addition, AB, but not COG, predicted clients' general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions. CONCLUSION Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed.Trial registration: ClinicalTrials.gov identifier: NCT03238872.
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Affiliation(s)
- Linn Vathne Lervik
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
| | - Asle Hoffart
- Modum Bad Psychiatric Center, Vikersund, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Marit Knapstad
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Otto R F Smith
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
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Richter J, Pané-Farré CA, Gerlach AL, Gloster AT, Wittchen HU, Lang T, Alpers GW, Helbig-Lang S, Deckert J, Fydrich T, Fehm L, Ströhle A, Kircher T, Arolt V, Hamm AO. Transfer of exposure therapy effects to a threat context not considered during treatment in patients with panic disorder and agoraphobia: Implications for potential mechanisms of change. Behav Res Ther 2021; 142:103886. [PMID: 34023593 DOI: 10.1016/j.brat.2021.103886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2021] [Accepted: 05/04/2021] [Indexed: 01/07/2023]
Abstract
Further developments of exposure-based therapy (EBT) require more knowledge about transfer of treatment to non-trained everyday contexts. However, little is known about transfer effects of EBT. Using a standardized EBT protocol in 275 patients with panic disorder and agoraphobia we investigated the transfer of EBT to a highly standardized context during a Behavioral Avoidance Test (BAT; being entrapped in a small and dark test chamber) and not part of the exposure sessions. Patients of a treatment group underwent the BATs before treatment (t1), after a preparatory treatment phase (t2), and after an agoraphobic exposure phase (t3) and were compared with wait-list control patients, who repeated BAT assessments across the same time period. We found stronger reductions in avoidance behavior, reported fear, and autonomic arousal during the BAT from t1 to t3 in the treatment group patients who were anxious during t1 relative to the anxious but untreated patients. Fear reduction was related to treatment outcome indicating the contribution of transfer effects to successful EBT. Interestingly, reduction varied for different fear response systems suggesting different processes to may be involved in transfer effects. Importantly, final BAT assessment still evoked residual fear in the treatment group as compared to BAT non-anxious control patients, suggesting limited transfer effects - one possible reason for the return of symptoms in new situations.
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Affiliation(s)
- Jan Richter
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany.
| | - Christiane A Pané-Farré
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany; Department of Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Alexander L Gerlach
- Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany
| | - Andrew T Gloster
- Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Thomas Lang
- Christoph-Dornier-Foundation for Clinical Psychology, Institute for Clinical Psychology Bremen, Bremen, Germany; Department for Psychology & Methods, Jacobs University Bremen, Bremen, Germany
| | - Georg W Alpers
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
| | - Sylvia Helbig-Lang
- Department of Psychology and Psychotherapy, University of Hamburg, Hamburg, Germany
| | - Jürgen Deckert
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Thomas Fydrich
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lydia Fehm
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Volker Arolt
- Department of Psychiatry and Psychotherapy, University of Münster, Münster, Germany
| | - Alfons O Hamm
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany
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Abstract
Psychotherapy research aims to investigate predictors and moderators of treatment outcome, but there are few consistent findings. This study aimed to investigate cytokines in patients undergoing treatment for anxiety disorders and whether the level of cytokines moderated the treatment outcome. Thirty-seven patients with comorbid and treatment-resistant anxiety disorders were investigated using multilevel modelling. Serum cytokine levels were measured three times: pretreatment, in the middle of treatment, and at the end of treatment. Anxiety and metacognitions were measured weekly throughout treatment by self-report. The levels of monocyte chemoattractant protein-1, tumour necrosis factor-alpha, and interleukin-1 receptor antagonist did not change during therapy or were not related to the level of anxiety. Metacognitive beliefs predicted anxiety, but the relationship between metacognitions and anxiety was not moderated by cytokines. Limitations of the study include that the patients were not fasting at blood sampling, and we did not assess body mass index, which may affect cytokine levels. The lack of significance for cytokines as a predictor or moderator may be due to a lack of power for testing moderation hypotheses, a problem associated with many psychotherapy studies. Cytokines did not predict the outcome in the treatment of comorbid anxiety disorders in our sample. Furthermore, cytokines did not moderate the relationship between metacognitions and anxiety.
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Knapstad M, Smith ORF. Social anxiety and agoraphobia symptoms effectively treated by Prompt Mental Health Care versus TAU at 6- and 12-month follow-up: Secondary analysis from a randomized controlled trial. Depress Anxiety 2021; 38:351-360. [PMID: 33393688 PMCID: PMC7986705 DOI: 10.1002/da.23132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/17/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prompt Mental Health Care (PMHC, Norwegian adaption of Improving Access to Psychological Therapies) has shown effects on symptoms of anxiety and depression compared to treatment as usual (TAU). In this secondary analysis, we examine the effectiveness of PMHC among clients presenting with symptoms of social anxiety disorder (SAD) and/or agoraphobia on core symptoms at 6- and 12-month follow-up. METHODS Randomized controlled trial in two PMHC sites (70:30 ratio PMHC:TAU). Of participants, 61.3% (n = 472) scored at caseness for SAD and 47.7% (n = 367) for agoraphobia (40% both). Effects on SAD avoidance and physiological discomfort (SPIN-9), SAD cognitions (ATQ-SA), agoraphobic avoidance (MIA-8), and agoraphobic cognitions (ATQ-AP) were examined in piecewise growth models. RESULTS The PMHC group showed substantially greater symptom reduction than the TAU group for all outcomes: At 6-month follow-up, the between-group effect sizes were d -0.60 (95% CI: -0.94 to -0.26) for SPIN-9, -0.45 (95% CI: -0.70 to -0.20) for ATQ-SA, -0.50 (95% CI: -0.87 to -0.13) for MIA-8, and -0.61 (95% CI: -0.92 to -0.31) for ATQ-AP. All effects were sustained at similar level at a 12-month follow-up. CONCLUSION PMHC effectively alleviated SAD and agoraphobia symptoms, and individuals struggling with such symptoms constituted a large proportion of clients. Although results should be interpreted with caution due to risk of attrition bias, they lend further support for a scale-up of PMHC and similar initiatives. Individuals struggling with SAD and/or agoraphobia stood out as relatively high burdened, whereas only one of five had sought help the last 12 months, underscoring the need for the PMHC service.
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Affiliation(s)
- Marit Knapstad
- Department of Health PromotionNorwegian Institute of Public HealthBergenNorway,Department of Clinical PsychologyUniversity of BergenBergenNorway
| | - Otto R. F. Smith
- Department of Health PromotionNorwegian Institute of Public HealthBergenNorway
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Hoyer J, Lueken U. [Psychotherapy of anxiety disorders: state of the art]. DER NERVENARZT 2021; 92:441-449. [PMID: 33575834 DOI: 10.1007/s00115-021-01069-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alongside depression, anxiety disorders are the most frequent reason for consulting a psychotherapist. OBJECTIVE This article describes the recent progress in understanding basic learning processes in anxiety treatment, the resulting therapeutic procedures, the current state of knowledge on the efficacy of the various psychotherapeutic procedures and on the moderators of the success of treatment. MATERIAL AND METHODS The English and German language literature was reviewed and compiled, with an emphasis on the last 10 years. RESULTS Cognitive-behavioral therapy (CBT) achieves the best and broadest level of evidence across all anxiety disorders. Initial studies have also provided emerging evidence for the efficacy of manualized short-term psychodynamic treatment. The most discussed mechanism of action is that of inhibitory learning. Augmentation strategies and personalized treatment approaches are gaining in relevance. CONCLUSION Current models of inhibitory learning are rooted in basic research and foster a deeper understanding of the underlying neurobiological mechanisms. In order to optimize success of exposure treatment in vulnerable subgroups of patients, many procedural, device-based and pharmacological augmentation strategies are currently under investigation, whereby the latter are mostly still in the stage of (pre)clinical testing.
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Affiliation(s)
- J Hoyer
- Klinische Psychologie und Psychotherapie, TU Dresden, Hohe Str. 53, 01187, Dresden, Deutschland.
| | - U Lueken
- Institut für Psychologie, Humboldt-Universität zu Berlin, Berlin, Deutschland
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Lan T, Cao Z, Zhao F, Perham N. The Association Between Effectiveness of Tinnitus Intervention and Cognitive Function-A Systematic Review. Front Psychol 2021; 11:553449. [PMID: 33488438 PMCID: PMC7815700 DOI: 10.3389/fpsyg.2020.553449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 11/27/2020] [Indexed: 11/13/2022] Open
Abstract
Tinnitus refers to the perception of sound in the absence of an external stimulus. This can be problematic and can lead to health problems in some sufferers, including effects on cognitive functions such as attention and memory. Although several studies have examined the effectiveness of tinnitus interventions, e.g., cognitive behavioral therapy and sound therapy, it is still unclear as to the overall quality and limitations of these studies and whether their results could be generalized. Clarification is also needed as to whether poor cognitive function will lead to a less favorable intervention outcome in tinnitus patients. The present systematic review was therefore designed to critically appraise and synthesize findings from randomized controlled trials (RCTs) of tinnitus intervention and its effects on cognition. The methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Medline (PubMed), Embase, and PsycINFO were searched. Only RCTs that compared the effectiveness of a tinnitus intervention and a measure of cognitive function in adult participants with tinnitus were included. A total of 8 studies involving 610 participants tested using 11 cognitive function assessment tools (e.g., Stroop Color and Word Test and Visual Continuous Performance Task) and 5 tinnitus intervention outcome measurements (e.g., Tinnitus Handicap Inventory and Tinnitus Questionnaire) were included and analyzed. The outcomes of the review suggest that tinnitus intervention not only facilitates tinnitus management but also improves cognitive functions. It is likely that cognition and emotion play an important role in a patient's adjustment to tinnitus. Whether cognition can predict treatment outcomes is unclear due to insufficient evidence. Future research is needed using a standardized assessment protocol focusing on the effect of sound-based interventions on tinnitus severity and cognitive functions. Studies on whether cognitive function measurement can be used as a predictor for the effectiveness of tinnitus therapy are also needed.
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Affiliation(s)
- Tianxiang Lan
- Centre for Speech and Language Therapy and Hearing Sciences, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Zuwei Cao
- Center for Rehabilitative Auditory Research, Guizhou Provincial People's Hospital, Guiyang, China
| | - Fei Zhao
- Centre for Speech and Language Therapy and Hearing Sciences, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
- Department of Hearing and Speech Science, Xinhua College, Sun Yat-sen University, Guangzhou, China
| | - Nick Perham
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
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Wu J, Sun Y, Zhang G, Zhou Z, Ren Z. Virtual Reality-Assisted Cognitive Behavioral Therapy for Anxiety Disorders: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:575094. [PMID: 34366904 PMCID: PMC8342859 DOI: 10.3389/fpsyt.2021.575094] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: We aim to explore the effectiveness of virtual reality-assisted cognitive behavioral therapy (VRCBT) in the treatment of anxiety and depression in patients with anxiety disorders. We further compare the therapeutic effect of VRCBT with that of standard cognitive behavioral therapy (CBT), as well as investigate the long-term efficacy of VRCBT. Methods: As of March 3, 2020, a total of four databases (Web of Science, PubMed, PsycINFO, and Scopus) were retrieved, and two researchers independently conducted literature retrieval and research selection and performed data extraction. Methodological quality assessment was performed using the Cochrane risk of bias tool and Grading of Recommendation, Assessment, Development, and Evaluation tool (GRADE). Results: A total of 11 studies were included (n = 626; range, 25.3-43.8), and six randomized controlled trials were quantitatively analyzed. The main outcome was anxiety and depression, and the secondary outcome was the withdrawal rate and long-term effects. Meta-analysis showed that the therapeutic effect of VRCBT on anxiety was better than that of the waiting list group (WLG) (SMD = -0.92; 95% CI: -1.34, -0.50; p = 0.005, I 2 = 66%, n = 276), while the therapeutic effect of VRCBT on anxiety was similar to that of standard CBT treatment (SMD = -0.26; 95% CI: -0.50, -0.01; p = 0.77, I 2 = 0%, n = 150). We further found that the therapeutic effect of VRCBT on depression was better than that of the WLG (SMD = -1.29; 95% CI: -2.26, -0.32; p = 0.09, I 2 = 58%, n = 74), while the effect of VRCBT was similar to that of standard CBT (SMD = -0.30; 95% CI: -0.67, -0.07; p = 0.39, I 2 = 1%, n = 116). Of the five studies that reported withdrawal rates of patients during the VRCBT and CBT treatment process, the withdrawal rates of the VRCBT group and CBT group did not reach statistical significance (OR = 0.70, 1.48, p > 0.05); only two studies reported the long-term effectiveness of VRCBT in anxiety and depression on patients with anxiety disorders. Conclusion: VRCBT treatment has a specific positive effect on patients with anxiety disorders (anxiety and depression). Compared with standard CBT, similar therapeutic effects can be achieved in the treatment of anxiety disorders. However, limited randomized controlled trials were included, requiring that these results be treated with caution.
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Affiliation(s)
| | - Yi Sun
- College of Physical Education, Jilin University, Changchun, China
| | - Gongwei Zhang
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
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Cognitive behavior therapy for internalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis. Clin Psychol Rev 2020; 83:101918. [PMID: 33186776 DOI: 10.1016/j.cpr.2020.101918] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 08/13/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023]
Abstract
Cognitive behavioral therapy (CBT) has received considerable empirical support for internalizing disorders including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and adolescents. However, there is less knowledge regarding how CBT performs when delivered in routine clinical care. A systematic review and meta-analysis was conducted of CBT for internalizing disorders in children and adolescents in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until October 2019. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined. The effects of CBT in routine clinical care were benchmarked by comparing with efficacy studies for the same disorders. Fifty-eight studies were included, comprising 4618 participants. Large effect sizes for outcome were detected at post-treatment (g = 1.28-2.54), and follow-up (g = 1.72-3.36). Remission rates across diagnoses ranged from 50.7% - 77.4% post-treatment, to 53.5% -83.3% at follow-up. Attrition rate across the disorders was 12.2%. Quality of the included studies was fair, and heterogeneity was high. Similarities between the effectiveness and efficacy studies were greater than the differences in outcome. CBT delivered in routine clinical care is efficacious in reducing internalizing disorders and symptoms. The outcomes are comparable with results obtained in efficacy studies. PROSPERO registration: ID CRD42019128709.
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Orock A, Louwies T, Yuan T, Greenwood-Van Meerveld B. Environmental enrichment prevents chronic stress-induced brain-gut axis dysfunction through a GR-mediated mechanism in the central nucleus of the amygdala. Neurogastroenterol Motil 2020; 32:e13826. [PMID: 32084303 PMCID: PMC7906280 DOI: 10.1111/nmo.13826] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cognitive behavioral therapy (CBT) improves quality of life of patients with irritable bowel syndrome (IBS), a disorder characterized by chronic visceral pain and abnormal bowel habits. Whether CBT can actually improve visceral pain in IBS patients is still unknown. The aim of this study is to evaluate whether environment enrichment (EE), the animal analog of CBT, can prevent stress-induced viscero-somatic hypersensitivity through changes in glucocorticoid receptor (GR) signaling within the central nucleus of the amygdala (CeA). METHODS Rats were housed in either standard housing (SH) or EE for 7 days before and during daily water avoidance stress (WAS) exposure (1-h/d for 7 days). In the first cohort, visceral and somatic sensitivity were assessed via visceromotor response to colorectal distention and von Frey Anesthesiometer 24 hous and 21 days after WAS. In another cohort, the CeA was isolated for GR mRNA quantification. KEY RESULTS Environment enrichment for 7 days before and during the 7 days of WAS persistently attenuated visceral and somatic hypersensitivity when compared to rats placed in SH. Environment enrichment exposure also prevented the WAS-induced decrease in GR expression in the CeA. CONCLUSION & INFERENCES Pre-exposure to short-term EE prevents the stress-induced downregulation of GR, and inhibits visceral and somatic hypersensitivity induced by chronic stress. These results suggest that a positive environment can ameliorate stress-induced pathology and provide a non-pharmacological therapeutic option for disorders such as IBS.
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Affiliation(s)
- A Orock
- Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - T Louwies
- Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - T Yuan
- Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - B Greenwood-Van Meerveld
- Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK,,Department of Veterans Affairs Health Care System, Oklahoma City, OK.,Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Asnaani A, Benhamou K, Kaczkurkin AN, Turk-Karan E, Foa EB. Beyond the Constraints of an RCT: Naturalistic Treatment Outcomes for Anxiety-Related Disorders. Behav Ther 2020; 51:434-446. [PMID: 32402259 PMCID: PMC8246650 DOI: 10.1016/j.beth.2019.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
Abstract
Despite considerable data from randomized controlled trials supporting use of behavioral therapies for anxiety disorders and anxiety-related disorders, there is a relative scarcity of data demonstrating that such findings are generalizable to patients in nonresearch settings, and a lack of standardized repeated outcome measurement in such settings. Using one of the largest examinations of naturalistic outcomes of behavioral therapies in treatment-seeking patients (N = 489), we examined the clinical characteristics and treatment outcomes of patients seeking treatment for anxiety and anxiety-related disorders in the past 3 years. Patients seeking treatment at a clinic specializing in cognitive-behavioral therapy (CBT) completed self-report questionnaires via an electronic data capture system and diagnostic interview at baseline, and were reassessed at mid- and posttreatment. Patients with anxiety and related disorders were assessed for changes in symptom severity and secondary outcomes (impairment/functioning, quality of life, and depression) over the course of therapy. Patients showed clinically significant and statistically reliable improvement in anxiety symptom severity scores over treatment (p < .001), after controlling for number of sessions received. Patients also showed significant improvement in depression, quality of life, and functioning (p values ≤ .001). We also found significant improvement in disorder-specific symptoms, including obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder (p values ≤ .001). Importance of, and ways to facilitate, integration of more routine assessment of a broader range of symptoms via online assessment systems and methods to better determine the effectiveness of CBT in naturalistic clinics are discussed.
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Asnaani A, Tyler J, McCann J, Brown L, Zang Y. Anxiety sensitivity and emotion regulation as mechanisms of successful CBT outcome for anxiety-related disorders in a naturalistic treatment setting. J Affect Disord 2020; 267:86-95. [PMID: 32063577 DOI: 10.1016/j.jad.2020.01.160] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/08/2019] [Accepted: 01/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Numerous randomized controlled trials (RCTs) have examined the efficacy of cognitive behavioral therapy (CBT) in reducing anxiety symptoms. However, relatively fewer studies have examined the effectiveness of CBT in naturalistic treatment settings. There is even less known about the mechanisms underlying successful outcomes in naturalistic samples receiving CBT. This study aimed to examine the absolute and relative mediation of emotion regulation (ER) difficulties and anxiety sensitivity (AS) on anxiety symptom reduction. METHODS Participants were treatment-seeking patients (N = 247) at an outpatient anxiety clinic. Measures of difficulties in ER, AS, and disorder specific symptoms were administered at baseline, mid, and post-treatment. A composite anxiety score was calculated to measure anxiety disorder symptom severity across anxiety-related diagnoses. RESULTS Individual mediation models revealed that both AS and ER significantly mediated the reduction in anxiety-related symptoms over the course of treatment. A multiple mediation model found that ER was the strongest mediator (indirect effect = -1.030, 95% CI = -2.172 to -0.153). Further analyses revealed that the ER subscale of impulse control difficulties (e.g., the tendency to avoid when confronted with a feared stimulus) was the strongest mediator (indirect effect = -0.849, 95% CI = -1.913 to -0.081). LIMITATIONS This study relied solely on self-report measures of ER, AS, and anxiety pathology, and did not have a control group. CONCLUSIONS These results suggest that improvement in the ability to control impulses may act as a mechanism of anxiety symptom reduction and may be important to target in CBT with naturalistic samples.
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Affiliation(s)
- Anu Asnaani
- University of Utah, Department of Psychology, 380 S 1530 E Behavioral Sciences Building, Salt Lake City, UT, United States 84112.
| | - Jeremy Tyler
- University of Pennsylvania, Department of Psychiatry, Center for the Treatment and Study of Anxiety, 3535 Market St, Suite 600 North, Philadelphia, PA, United States 19104
| | - Jesse McCann
- University of Pennsylvania, Department of Psychiatry, Center for the Treatment and Study of Anxiety, 3535 Market St, Suite 600 North, Philadelphia, PA, United States 19104
| | - Lily Brown
- University of Pennsylvania, Department of Psychiatry, Center for the Treatment and Study of Anxiety, 3535 Market St, Suite 600 North, Philadelphia, PA, United States 19104
| | - Yinyin Zang
- Peking University, School of Psychological and Cognitive Sciences, Beijing Key Laboratory of Behavior and Mental Health, No. 5 Yiheyuan Road, Haidian District, Beijing, China 100871.
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Long-term stability of benefits of cognitive behavioral therapy for obsessive compulsive disorder depends on symptom remission during treatment. CLINICAL PSYCHOLOGY IN EUROPE 2020; 2:e2785. [DOI: 10.32872/cpe.v2i1.2785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/04/2020] [Indexed: 01/09/2023] Open
Abstract
Background
Cognitive behavioral therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) and may afford stable long-term improvements. It is not clear, however, how stability or symptom recurrence can be predicted at the time of termination of CBT.
Method
In a 1-year follow-up intention-to-treat study with 120 OCD patients receiving individual CBT at a university outpatient unit, we investigated the predictive value of international consensus criteria for response only (Y-BOCS score reduction by at least 35%) and remission status (Y-BOCS score ≤ 12). Secondly, we applied receiver-operating characteristic (ROC) curves in order to find an optimal cut-off score to classify for deterioration and for sustained gains.
Results
Response only at post-treatment increased the likelihood of deterioration at follow-up compared to remission at an odds ratio of 8.8. Moreover, ROC curves indicated that a post-treatment score of ≥ 13 differentiated optimally between patients with and without symptom deterioration at follow-up assessment. The optimal cut-off score to classify for any sustained gains (response, remission, or both) at follow-up relative to baseline was 12. Importantly, previous findings of generally high long-term symptom stability after treatment in OCD could be replicated.
Conclusion
The findings highlight the clinical importance of reaching remission during CBT, and suggest that a recently published expert consensus for defining remission has high utility.
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Meyer HC, Odriozola P, Cohodes EM, Mandell JD, Li A, Yang R, Hall BS, Haberman JT, Zacharek SJ, Liston C, Lee FS, Gee DG. Ventral hippocampus interacts with prelimbic cortex during inhibition of threat response via learned safety in both mice and humans. Proc Natl Acad Sci U S A 2019; 116:26970-26979. [PMID: 31822612 PMCID: PMC6936350 DOI: 10.1073/pnas.1910481116] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Heightened fear and inefficient safety learning are key features of fear and anxiety disorders. Evidence-based interventions for anxiety disorders, such as cognitive behavioral therapy, primarily rely on mechanisms of fear extinction. However, up to 50% of clinically anxious individuals do not respond to current evidence-based treatment, suggesting a critical need for new interventions based on alternative neurobiological pathways. Using parallel human and rodent conditioned inhibition paradigms alongside brain imaging methodologies, we investigated neural activity patterns in the ventral hippocampus in response to stimuli predictive of threat or safety and compound cues to test inhibition via safety in the presence of threat. Distinct hippocampal responses to threat, safety, and compound cues suggest that the ventral hippocampus is involved in conditioned inhibition in both mice and humans. Moreover, unique response patterns within target-differentiated subpopulations of ventral hippocampal neurons identify a circuit by which fear may be inhibited via safety. Specifically, ventral hippocampal neurons projecting to the prelimbic cortex, but not to the infralimbic cortex or basolateral amygdala, were more active to safety and compound cues than threat cues, and activity correlated with freezing behavior in rodents. A corresponding distinction was observed in humans: hippocampal-dorsal anterior cingulate cortex functional connectivity-but not hippocampal-anterior ventromedial prefrontal cortex or hippocampal-basolateral amygdala connectivity-differentiated between threat, safety, and compound conditions. These findings highlight the potential to enhance treatment for anxiety disorders by targeting an alternative neural mechanism through safety signal learning.
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Affiliation(s)
- Heidi C. Meyer
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065
| | - Paola Odriozola
- Department of Psychology, Yale University, New Haven, CT 06511
| | | | - Jeffrey D. Mandell
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT 06511
| | - Anfei Li
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065
| | - Ruirong Yang
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065
| | - Baila S. Hall
- Department of Psychology, Brain Research Institute, University of California, Los Angeles, CA 90095
| | | | | | - Conor Liston
- Sackler Institute for Developmental Psychobiology, Weill Cornell Medicine, New York, NY 10065
- Feil Family Brain & Mind Research Institute, Weill Cornell Medicine, New York, NY 10065
| | - Francis S. Lee
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065
- Sackler Institute for Developmental Psychobiology, Weill Cornell Medicine, New York, NY 10065
| | - Dylan G. Gee
- Department of Psychology, Yale University, New Haven, CT 06511
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Leeuwerik T, Cavanagh K, Strauss C. Patient adherence to cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. J Anxiety Disord 2019; 68:102135. [PMID: 31704633 DOI: 10.1016/j.janxdis.2019.102135] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 07/15/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
Whilst cognitive behavioural therapy (CBT) is the treatment of choice for obsessive-compulsive disorder (OCD), around half of the participants do not experience remission following treatment. As yet, there is no comprehensive systematic review of the extent to which patient non-adherence presents a challenge to the overall benefit of CBT for OCD. The aim of this systematic review and meta-analysis was to identify the magnitude, moderators and reasons for poor patient adherence to CBT for OCD in terms of: (1) treatment refusal, (2) treatment dropout, (3) session attendance/module completion, and (4) between-session CBT task adherence. Sociodemographic and clinical variables, treatment and study design characteristics were examined as moderators of adherence. The systematic search identified 123 studies including 5627 participants taking part in CBT or control conditions. A pooled rate of 15.6% of eligible patients refused CBT and a further 15.9% of treatment starters dropped out from treatment. Group CBT had significantly lower dropout rates than individually-delivered CBT. No other significant moderators were found. Most studies reported moderate to good adherence to between-session CBT tasks, which had a significant medium to large association with post-treatment OCD symptom reduction. Recommendations for enhanced measurement and reporting of patient adherence to CBT for OCD are made along with clinical implications of findings.
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Affiliation(s)
- Tamara Leeuwerik
- School of Psychology, University of Sussex, Falmer, East Sussex, BN1 9QH, UK
| | - Kate Cavanagh
- School of Psychology, University of Sussex, Falmer, East Sussex, BN1 9QH, UK
| | - Clara Strauss
- School of Psychology, University of Sussex, Falmer, East Sussex, BN1 9QH, UK; Sussex Partnership NHS Foundation Trust, R&D Department, Sussex Education Centre, Nevill Avenue, Hove BN3 7HZ, UK.
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Kaldewaij R, Reinecke A, Harmer CJ. A lack of differentiation in amygdala responses to fearful expression intensity in panic disorder patients. Psychiatry Res Neuroimaging 2019; 291:18-25. [PMID: 31357097 DOI: 10.1016/j.pscychresns.2019.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
Patients with panic disorder show abnormalities in threat processing and regulation, both on a behavioural and neural level. Better understanding of the underlying mechanisms could help to develop new treatment strategies. In this study, we investigated brain region activation in 18 patients with untreated panic disorder (PD) and 17 healthy controls (HC) during the processing of emotional faces with fearful, happy and neutral expressions, using functional MRI. The intensity of the expressions was either prototypically high, medium or low. PD patients showed significantly increased activity in the dorso-medial prefrontal cortex (dmPFC) in response to faces in general and specifically for happy faces. While HC showed a decreased amygdala response to medium/low fearful versus high fearful faces, this effect was not present in PD: amygdala activation was stable across all fearful faces in this group. Psycho-physiological interaction analyses indicated more negative connectivity between the amygdala and prefrontal areas in the PD group during the task. Amygdala activation in panic patients appears to be less sensitive to decreasing intensities of fearful facial expressions and salience monitoring areas were less active during fearful faces in general in this group. This suggests PD patients might avoid more extensive processing of fearful faces.
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Affiliation(s)
- Reinoud Kaldewaij
- Department of Psychiatry, University of Oxford, United Kingdom; Currently at Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Cognitive Neuro-imaging, Radboud University Nijmegen, the Netherlands.
| | - Andrea Reinecke
- Department of Psychiatry, University of Oxford, United Kingdom; Oxford Health NHS foundation Trust, Warneford Hospital, United Kingdom
| | - Catherine J Harmer
- Department of Psychiatry, University of Oxford, United Kingdom; Oxford Health NHS foundation Trust, Warneford Hospital, United Kingdom
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Factores de predisposición genéticos y epigenéticos de los trastornos de ansiedad. REVISTA IBEROAMERICANA DE PSICOLOGÍA 2019. [DOI: 10.33881/2027-1786.rip.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Los trastornos de ansiedad constituyen un grupo de alteraciones psicológicas y neurológicas que representan varias formas de miedo y ansiedad anormales o patológicas (Orozco & Baldares, 2012). Aun cuando alrededor del 14% de la población del planeta ha sufrido algún trastorno de ansiedad, las causas que desencadenan el mismo no son del todo claras (Posada, 2013). La aproximación clásica de los estudios para la identificación de los factores de predisposición de estos trastornos neuropsiquiátricos se ha orientado a las teorías de la personalidad como la Teoría de Eysenck (Mitchell & Kumari, 2016) y la Teoría Bio-Psicológica de la personalidad (Knyazev, Pylkova, Slobodskoj-Plusnin, Bocharov, & Ushakov, 2015). Sin embargo, a partir de estos estudios, han surgido nuevas propuestas involucrando los aspectos neuroanatómicos y neurofuncionales. La transmisión eléctrica y química de la información y como esta se asocia a distintas conductas demuestran la relevación de la regulación de la producción y recaptación de neurotransmisores en sistema nervioso central (SNC). Aunque esta regulación se encuentra directamente relacionada con la expresión genética, em tanto se han identificado ciertos genes candidatos que aportan un porcentaje a esta predisposición, estos no son totalmente determinantes. Actualmente, dado a este vacío, se ha comenzado a investigar la influencia de factores epigenéticos que en conjunto con los factores genéticos permitirían ampliar la explicación de los factores de predisposición de ciertos trastornos neuropsiquiátricos que anteriormente eran considerados de etiología ambiental.
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Tiemens B, Kloos M, Spijker J, Ingenhoven T, Kampman M, Hendriks GJ. Lower versus higher frequency of sessions in starting outpatient mental health care and the risk of a chronic course; a naturalistic cohort study. BMC Psychiatry 2019; 19:228. [PMID: 31340791 PMCID: PMC6657162 DOI: 10.1186/s12888-019-2214-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 07/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND An adequate frequency of treatment might be a prerequisite for a favorable outcome. Unfortunately, there is a diversity of factors that interfere with an adequate frequency of sessions. This occurs especially in the first phase of treatment, while the first phase seems vital for the rest of treatment. The aim of this naturalistic study was to explore the impact of the initial frequency of treatment sessions on treatment outcome in a diverse mental health care population. METHODS Anonymized data were analyzed from 2,634 patients allocated for anxiety disorders, depressive disorders, and personality disorders to outpatient treatment programs in a large general mental health care facility. Patients' treatment outcome was routinely monitored with the Outcome Questionnaire-45 (OQ-45.2), every 12 weeks. Frequency of sessions was assessed for the first three months of treatment. Using Cox-proportional-hazard models, we explored the associations between initial frequency and improvement (reliable significant change) and recovery (reliable and clinically significant change). RESULTS Improvement and recovery were associated with symptom severity and functional impairment at start of treatment, the year the treatment started, number of measurements, the treatment program (anxiety disorders, depressive disorders, and personality disorders) and receiving group therapy other than psychotherapy. In all diagnostic groups, both improvement and recovery were associated with a higher frequency of sessions during the first three months of treatment. For improvement, this effect diminished after three years in treatment; however, for recovery this association was sustained. CONCLUSIONS In addition to severity at start of treatment and other predictors of outcome, a low frequency of initial treatment sessions might lead to a less favorable outcome and a more chronic course of the mental disorder. This association seems not to be limited to a specific diagnostic group, but was found in a large group of patients with common mental disorders (depression and anxiety disorders) and patients with a personality disorder. Despite organizational obstacles, more effort should be made to start treatment quickly by an effective frequency of session.
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Affiliation(s)
- Bea Tiemens
- Pro Persona Research, Renkum, The Netherlands.
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.
| | | | - Jan Spijker
- Pro Persona Research, Renkum, The Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Depression Expertise Centre, Pro Persona Mental Health Care, Nijmegen, The Netherlands
| | - Theo Ingenhoven
- Personality disorder Expert Centre, Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Mirjam Kampman
- Pro Persona Research, Renkum, The Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Pro Persona Mental Health Care, Nijmegen, The Netherlands
| | - Gert-Jan Hendriks
- Pro Persona Research, Renkum, The Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Pro Persona Mental Health Care, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
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Johnson SU, Hoffart A. Moderators and predictors of outcome in metacognitive and cognitive behavioural therapy for co‐morbid anxiety disorders. Clin Psychol Psychother 2019; 26:399-408. [DOI: 10.1002/cpp.2361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/18/2019] [Accepted: 02/21/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Asle Hoffart
- Research InstituteModum Bad Psychiatric Center Vikersund Norway
- Department of PsychologyUniversity of Oslo Oslo Norway
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