Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial

A One-Arm Pilot Trial of a Telehealth CBT-Based Group Intervention Targeting Transdiagnostic Risk for Emotional Distress

The COVID-19 pandemic had a significant impact on mental health, straining an already overburdened healthcare system. A modular, transdiagnostic approach to treating psychopathology may be ideal to target common transdiagnostic risk factors for emotional distress and related disorders likely to be impacted by circumstances related to this once-in-a-lifetime environmental stressor. Anxiety sensitivity (AS), or fear of anxious arousal, intolerance of uncertainty (IU), or distress when confronted with uncertainty, and loneliness are three transdiagnostic risk factors impacted by the pandemic and robust predictors of emotional distress beyond that. We completed a pilot feasibility, acceptability, and utility trial of Coping Crew, our group, telehealth-delivered transdiagnostic treatment protocol in 17 participants who completed the intervention (M age = 22.00, SD = 4.46; 71% female). The intervention and study protocol were feasible to deliver and were rated as acceptable and useful to address intervention targets. Evidence was mixed regarding feasibility, acceptability, and usefulness of the mobile app component. Sixteen of 17 participants (94%) completed at least one survey a day on 80% of the days but only 6 participants (35%) completed at least 80% of the mobile app surveys delivered over the course of the intervention. Most participants rated use of the app as acceptable and relevant to psychological improvements made due to the intervention. Sizeable effect size reductions in transdiagnostic risk factors were found at post-intervention and maintained at 1- and 3-month follow-up, supporting next steps in the development of this modular transdiagnostic treatment.

Hypnosis with depressed children and teens: Building skills, creating connection

Depression in children and teens has been on the rise for several years. Recent increases in anxiety and loneliness, both contributors to the development of depression, are putting more young people at risk for chronic and comorbid mental health struggles. The use of hypnosis with depressed children offers the opportunity to target the identified skills depressed and anxious children need and is a modality clinicians should embrace. This article describes how to create hypnotic interventions focusing on improved emotional and cognitive management, better sleep, and the ability to make positive social connections. Such interventions serve to not only build the resources depressed children need for recovery, but also support a paradigm shift toward prevention in children and families.

A systematic review and meta-analysis of transdiagnostic cognitive behavioural therapies for emotional disorders

Transdiagnostic cognitive behavioural psychotherapy (TD-CBT) may facilitate the treatment of emotional disorders. Here we investigate short- and long-term efficacy of TD-CBT for emotional disorders in individual, group and internet-based settings in randomized controlled trials (PROSPERO CRD42019141512). Two independent reviewers screened results from PubMed, MEDLINE, PsycINFO, Google Scholar, medRxiv and OSF Preprints published between January 2000 and June 2023, selected studies for inclusion, extracted data and evaluated risk of bias (Cochrane risk-of-bias tool 2.0). Absolute efficacy from pre- to posttreatment and relative efficacy between TD-CBT and control treatments were investigated with random-effects models. Of 56 identified studies, 53 (6,705 participants) were included in the meta-analysis. TD-CBT had larger effects on depression (g = 0.74, 95% CI = 0.57-0.92, P < 0.001) and anxiety (g = 0.77, 95% CI = 0.56-0.97, P < 0.001) than did controls. Across treatment formats, TD-CBT was superior to waitlist and treatment-as-usual. TD-CBT showed comparable effects to disorder-specific CBT and was superior to other active treatments for depression but not for anxiety. Different treatment formats showed comparable effects. TD-CBT was superior to controls at 3, 6 and 12 months but not at 24 months follow-up. Studies were heterogeneous in design and methodological quality. This review and meta-analysis strengthens the evidence for TD-CBT as an efficacious treatment for emotional disorders in different settings.

The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

Moderators of the cost-effectiveness of transdiagnostic CBT for anxiety disorders over an 8-month time horizon using a net-benefit regression framework

BACKGROUND

Access to evidence-based psychological treatment is a concern in many parts of the globe due to government-level financial constraints and patient-level barriers. Transdiagnostic cognitive behavioural therapy (tCBT) is an effective treatment approach that uses a single protocol for anxiety disorders which could enhance the dissemination of evidence-based psychotherapy. In a context of limited resources, the study of treatment moderators can allow to identify subgroups for which the cost-effectiveness of an intervention differs, information that could impact decision-making. So far, there has been no economic evaluation of tCBT for different subpopulations. The objectives of this study, using the net-benefit regression framework, were to explore clinical and sociodemographic factors as potential moderators of the cost-effectiveness of tCBT compared to treatment-as-usual (TAU).

METHODS

This is a secondary data analysis of a pragmatic randomized controlled trial opposing tCBT added to TAU (n = 117) to TAU only (n = 114). Data on costs from the health system and the limited societal perspectives, as well as anxiety-free days, an effectiveness measure based on the Beck Anxiety Inventory, were collected over an 8-month time horizon and used to derive individual net-benefits. The net-benefit regression framework was used to assess moderators of the cost-effectiveness of tCBT + TAU as opposed to TAU alone. Variables of sociodemographic and clinical nature were assessed.

RESULTS

Results showed that the number of comorbid anxiety disorders significantly moderated the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective.

CONCLUSIONS

The number of comorbid anxiety disorders was identified as a moderator affecting the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. More research is needed to strengthen the case of tCBT from an economic standpoint for large-scale dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02811458, 23/06/2016.

An examination of sudden gain prevalence across cognitive-behavioural therapy for anxiety and depressive disorders: A quantitative analysis and meta-analytic review

Sudden gains, incidences of unexpectedly large and stable session to session symptom reductions during psychotherapy, have been shown in samples of individuals receiving treatment for both anxiety and depressive disorders, although seemingly more frequently in sample receiving treatment for depressive disorders. This may suggest that sudden gains are a function of depression, but the high comorbidity between anxiety and depressive disorders makes this difficult to assess. Study One utilised a sample of 117 adults undergoing CBT for a principal anxiety disorder to explore the effect of comorbid depression on sudden gain prevalence. Results indicated that sudden gains were not more prevalent in the comorbid depression group; however, the frequency of sudden gains was significantly related to comorbid depressive disorder severity. Study Two involved a meta-analysis of 48 studies to compare sudden gain prevalence between trials of CBT for depressive disorders versus anxiety-related disorders. The results of the meta-analysis indicated significantly higher rates of sudden gains in samples with a principal depressive disorder diagnosis, compared to a principal anxiety disorder diagnosis. Sudden gains may therefore be driven by depression, but only at the more severe level.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data

BACKGROUND

This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone.

METHODS

This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included.

RESULTS

Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness.

CONCLUSIONS

From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

French adaptation and validation of the Panic Disorder Severity Scale-self-report

BACKGROUND

The aims of this study were to conduct a cross-cultural validation of the Panic Disorder Severity Scale - Self-Report (PDSS-SR) and to examine psychometric properties of the French-Canadian version.

METHODS

A sample of 256 adults were included in the validation study based on data from the baseline interview of a clinical trial on transdiagnostic cognitive-behavioral therapy for mixed anxiety disorders. Participants completed the Anxiety and Related Disorders Interview Schedule (ADIS-5), and self-report instruments including the PDSS-SR, Beck Anxiety Inventory (BAI), Mobility Inventory for Agoraphobia (MIA), Sheehan Disability Scale (SDS), Patient Health Questionnaire (PHQ-9), Social Phobia Inventory (SPIN), Insomnia Severity Index (ISI) and Penn State Worry Questionnaire (PSWQ). The cross-cultural adaptation in French of the PDSS-SR included a rigorous back-translation process, with an expert committee review. Sensitivity to change was also examined with a subgroup of patients (n = 72) enrolled in the trial.

RESULTS

The French version of the PDSS-SR demonstrated good psychometric properties. The exploratory factor analysis supported a one factor structure with an eigenvalue > 1 that explained 64.9% of the total variability. The confirmatory factor analysis (CFA) corroborated a one-factor model with a good model fit. Internal consistency analysis showed a .91 Cronbach's alpha. The convergent validity was adequate with the ADIS-5 clinical severity ratings for panic disorder (r = .56) and agoraphobia (r = .39), as well as for self-report instruments [BAI (r = .63), MIA (accompanied: r = .50; alone: r = .47) and SDS (r = .37)]. With respect to discriminant validity, lower correlations were found with the SPIN (r = .17), PSWQ (r = .11), ISI (r = .19) and PHQ-9 (r = .28). The optimal threshold for probable diagnosis was 9 for the PDSS-SR and 4 for the very brief 2-item version. The French version showed good sensitivity to change.

CONCLUSIONS

The French version of the PDSS-SR has psychometric properties consistent with the original version and constitutes a valid brief scale to assess the severity of panic disorder and change in severity over time, both in research and clinical practice.

The mediating role of emotion regulation in transdiagnostic cognitive behavioural therapy for emotional disorders in primary care: Secondary analyses of the PsicAP randomized controlled trial

BACKGROUND

Emotional disorders are highly prevalent in primary care. Transdiagnostic cognitive behavior therapy (TD-CBT) is a promising treatment of emotional disorders. In this study, we evaluated several emotion regulation strategies as potential mediators of treatment outcomes in a clinical sample of primary care.

METHODS

A total of 1061 primary care patients were included in a randomized clinical trial comparing treatment-as-usual (TAU) to TD-CBT+TAU. Of these, 631 (TAU=316; TD-CBT+TAU=315) completed the full treatment and all pre- and post-treatment scales to assess symptoms (anxiety, depression, somatization), emotion regulation strategies (worry, rumination, negative metacognition, suppression, cognitive reappraisal), overall functioning, and quality of life (QoL).

RESULTS

Treatment and direct effects showed that TD-CBT+TAU was superior to TAU alone. On the multivariate mediation analysis of indirect effects, three maladaptive strategies (worry, rumination and negative metacognition) had significant effects on all emotional symptoms. Suppression was also significant for depression. Rumination and negative metacognition were significant mediators of functioning, while only negative metacognition was significant for QoL. Reappraisal had no effect on any outcome.

LIMITATIONS

We focused mainly on maladaptive cognitive emotion regulation strategies and only studied one behavioural strategy (suppression) and one adaptive strategy (reappraisal).

CONCLUSIONS

Targeting certain maladaptive emotion regulation strategies (worry, rumination, suppression, negative metacognition) as mediators for treatment with TD-CBT could reduce emotional symptoms and improve well-being. Negative metacognition was the most transdiagnostic strategy, whereas an adaptive strategy such as reappraisal was not a mediator. Thus, maladaptive emotion regulation strategies are key mediators in transdiagnostic therapy for emotional disorders in primary care.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.

Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

Background

Strategies to improve access to evidence-based psychological treatments (EBPTs) include but are not limited to implementation strategies. No currently available framework accounts for the full scope of strategies available to allow stakeholders to improve access to EBPTs. Anxiety disorders are common and impactful mental conditions for which EBPTs, especially cognitive-behavioral therapies (CBT), are well-established yet often hard to access.

Objective

Describe and classify the various strategies reported to improve access to CBT for anxiety disorders.

Methods

Scoping review with a keyword search of several databases + additional grey literature documents reporting on strategies to improve access to CBT for anxiety disorders. A thematic and inductive analysis of data based on grounded theory principles was conducted using NVivo.

Results

We propose to classify strategies to improve access to CBT for anxiety disorders as either "Contributing to the evidence base," "Identifying CBT delivery modalities to adopt in practice," "Building capacity for CBT delivery," "Attuning the process of access to local needs," "Engaging potential service users," or "Improving programs and policies." Each of these strategies is defined, and critical information for their operationalization is provided, including the actors that could be involved in their implementation.

Implications

This scoping review highlights gaps in implementation research regarding improving access to EBPTs that should be accounted for in future studies.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BACKGROUND

The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.

METHODS/DESIGN

We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.

STATISTICAL ANALYSIS

Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.

DISCUSSION

This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Evidence-Based Pharmacotherapy of Generalised Anxiety Disorder: Focus on Agomelatine

Recent network meta-analyses support the use of pharmacotherapy in patients with generalised anxiety disorder (GAD). Compared with placebo, drug treatment can improve symptoms and quality of life, and is more effective in preventing relapse. Selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors are generally considered the first-line agents of choice in GAD, but in some patients, an alternative evidence-based treatment with a different mechanism of action may also be considered (e.g. those with severe GAD, inadequate response, adverse effects and/or contraindications). One example is agomelatine, a melatonin receptor agonist and serotonin 2C (5-HT_2C) receptor antagonist, which has been shown to have efficacy that is greater than placebo in patients with GAD, and to have a tolerability profile that compares favourably with that of escitalopram. Both agomelatine and escitalopram are efficacious in treating patients with GAD, including those with severe symptoms.

Impact of group transdiagnostic cognitive-behavior therapy for anxiety disorders on comorbid diagnoses: Results from a pragmatic randomized clinical trial in primary care

BACKGROUND

Anxiety and depressive disorders are the most common mental illnesses worldwide, with most individuals meeting criteria for more than one diagnosis. Most cognitive-behavioral therapy (CBT) approaches target only one disorder at a time, resulting in the need to treat comorbid diagnoses sequentially. Transdiagnostic CBT protocols have been developed that simultaneously treat principal and comorbid disorders.

METHOD

The current study reports on a secondary analysis of data from a pragmatic effectiveness randomized trial of group tCBT in comparison to treatment-as-usual (TAU) in primary care. Of the trial sample of 231 patients, 191 had at least one comorbid diagnosis of clinical severity at T0.

RESULTS

Overall rates of comorbidity decreased over time (82.0% at T0, 45.0% at T1, 45.7% at T3) and those receiving tCBT showed a significantly lower rate of comorbidity at T1 (33.7%) than TAU (55.7%) and at T3 (tCBT: 27.9%, TAU: 60.2%). Comorbid diagnosis severity ratings reduced to a significantly greater extent in tCBT than in TAU.

CONCLUSIONS

tCBT is effective in promoting remission of and reducing the severity of comorbid diagnoses. Implications for the treatment of whole persons as opposed to specific diagnoses is discussed.