The Bergen 4-day treatment for panic disorder: replication and implementation in a new clinic

BACKGROUND

Bergen 4-day treatment (B4DT) is a concentrated exposure-based treatment (cET), where the patient receives concentrated, individually tailored cognitive behavioral therapy (CBT) during four consecutive days. Previous findings have indicated that B4DT could be a promising treatment for panic disorder (PD).

AIM

The aim of the present study was to evaluate the implementation of B4DT for panic disorder with- and without agoraphobia, at a new clinic. This is the first replication study for B4DT on panic disorder.

METHOD

Thirty consecutively recruited patients with PD were included in an open trial design. Assessment of symptoms of panic disorder were measured with Panic Disorder Severity Scale (PDSS), while symptoms of generalized anxiety were assessed by Generalized Anxiety Disorder-7 (GAD-7) and depressive symptoms by Patient Health Questionnaire (PHQ-9) pre-treatment, post-treatment and at 3-month follow-up. Treatment satisfaction was measured with Client Satisfaction Questionnaire (CSQ-8) post-treatment.

RESULTS

The results showed a significant reduction in symptom severity from pre-treatment to post-treatment (d = 4.32), and at 3-month follow-up (d = 4.91). The proportion of patients classified as fulfilling the criteria for remission was 80.0% at post-treatment and 86.7% at follow up. There was a significant reduction in symptoms of depression and generalized anxiety. Treatment satisfaction was high and none of the patients dropped out.

CONCLUSION

The current study replicated the results from the original study and indicate that the treatment can be successfully implemented at new clinics. B4DT may be a promising treatment for panic disorder and comorbid symptoms of generalized anxiety and depression. Larger and more controlled studies are needed to establish the efficacy of B4DT for panic disorder.

Cognitive-Behavioral Therapy in the Digital Age: Presidential Address

Our field has come a long way in establishing cognitive-behavioral therapy as the empirically supported treatment of choice for a wide range of mental and behavioral health problems. Nevertheless, most individuals with mental disorders do not receive any care at all, and those who do often have difficulty accessing care that is consistently high in quality. Addressing these issues is complex and costly and thus progress has been slow. We are entering an exciting stage in which emerging technologies might offer novel solutions to the treatment gap. This paper discusses a number of technology-enabled solutions to our field's challenges, including Internet-based and smartphone-based cognitive-behavioral therapy. Nevertheless, we must remain attentive to potential pitfalls of these emerging technologies. The paper incorporates suggestions for how the field may approach these potential pitfalls and provides a vision for how we might develop powerful, scalable, precisely timed, personalized interventions to enhance global mental health.

A lack of differentiation in amygdala responses to fearful expression intensity in panic disorder patients

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.

Brief Therapist-Guided Exposure Treatment of Panic Attacks: A Pilot Study

A three-session therapist-guided exposure treatment was tested in a consecutive series of eight primary health care patients suffering from panic attacks who specifically used distraction techniques as their primary safety behavior. The Panic Disorder Severity Scale Self-Report (PDSS-SR) was administered at baseline (1-3 weeks before the first session), and 1, 2, and 3 weeks after treatment. Weekly ratings on the Body Sensations Questionnaire (BSQ) and the Agoraphobic Cognitions Questionnaire (ACQ) during treatment were undertaken to explore when reliable change took place on these measures. The results showed a large within-group effect size on PDSS-SR ( d = 1.63); six of the eight patients were classified as responders, and four of them showed remission. Large effect sizes ( ds between 1.17 and 3.00) were seen also on BSQ and ACQ, as well as on agoraphobic avoidance, general level of anxiety, and depression. The results on BSQ and ACQ suggest that the fear of body sensations in most cases was reduced before a change occurred in agoraphobic cognitions. These results indicate that a brief three-session exposure-based treatment may be sufficient for this subgroup of panic patients. The findings need to be replicated under controlled conditions with larger samples and different therapists before more firm conclusions can be drawn. Future research should also focus on the relevance of dividing patients into subgroups based on type of safety behavior.

Can Cognitive Behavioral Therapy for Anxiety and Depression Be Improved with Pharmacotherapy? A Meta-analysis

The present meta-analysis examined controlled trials of pharmacologic augmentation of cognitive-behavioral therapy (CBT) for patients with anxiety or depressive disorders. The additive effect of medications was small for both anxiety and depressive disorders at posttreatment, and there was no additive benefit after medications were discontinued. A small body of evidence suggested that antidepressant medications are an efficacious second-line treatment for patients failing to respond to CBT alone. In anxiety disorders, novel agents thought to potentiate the biological mechanisms of CBT showed small effects at posttreatment; after discontinuation, some of these agents were associated with an increasing effect.

Group psychotherapy for eating disorders: A meta-analysis

OBJECTIVE

In the current meta-analysis, we review the effect of group psychotherapy compared to both wait-list controls and other active treatments for adults with eating disorders (EDs).

METHOD

Twenty-seven randomized controlled trials (RCTs) that provide direct comparisons with a total of 1,853 participants were included.

RESULTS

Group psychotherapy is significantly more effective than wait-list controls at achieving abstinence rates of binge eating and/or purging (RR = 5.51, 95% CI: 3.73, 8.12), decreasing the frequency of binge eating and/or purging (g = 0.70, 95% CI: 0.51, 0.90), and reducing related ED psychopathology (g = 0.49, 95% CI: 0.32, 0.66) after treatment. The effects of group psychotherapy and other active treatments (e.g., behavioral weight loss, self-help, individual psychotherapy) did not differ on any outcome at post-treatment or at follow-ups. Group cognitive behavioral therapy (CBT) and other forms of group psychotherapy did not differ significantly on outcomes at any time point.

DISCUSSION

Additional research is needed to evaluate other group psychotherapy approaches, along with CBT, to provide more evidence-based treatment options for individuals with an ED. Group psychotherapy appears as effective as other common treatments and is perhaps more cost-effective than the most popular treatment, individual psychotherapy. Only 8.33% of comparisons in the current meta-analysis had at least 80% power to detect a moderate effect (d = .50) and we recommend that future RCTs be adequately powered.

Separate and combined effects of genetic variants and pre-treatment whole blood gene expression on response to exposure-based cognitive behavioural therapy for anxiety disorders

OBJECTIVES

Exposure-based cognitive behavioural therapy (eCBT) is an effective treatment for anxiety disorders. Response varies between individuals. Gene expression integrates genetic and environmental influences. We analysed the effect of gene expression and genetic markers separately and together on treatment response.

METHODS

Adult participants (n ≤ 181) diagnosed with panic disorder or a specific phobia underwent eCBT as part of standard care. Percentage decrease in the Clinical Global Impression severity rating was assessed across treatment, and between baseline and a 6-month follow-up. Associations with treatment response were assessed using expression data from 3,233 probes, and expression profiles clustered in a data- and literature-driven manner. A total of 3,343,497 genetic variants were used to predict treatment response alone and combined in polygenic risk scores. Genotype and expression data were combined in expression quantitative trait loci (eQTL) analyses.

RESULTS

Expression levels were not associated with either treatment phenotype in any analysis. A total of 1,492 eQTLs were identified with q < 0.05, but interactions between genetic variants and treatment response did not affect expression levels significantly. Genetic variants did not significantly predict treatment response alone or in polygenic risk scores.

CONCLUSIONS

We assessed gene expression alone and alongside genetic variants. No associations with treatment outcome were identified. Future studies require larger sample sizes to discover associations.

Cost-effectiveness of interventions for treating anxiety disorders: A systematic review

BACKGROUND

Anxiety disorders are highly prevalent mental disorders that constitute a major burden on patients and society. As a consequence, economic evaluations of the interventions have become increasingly important. However, no recent overview of these economic evaluations is currently available and the quality of the published economic evaluations has not yet been assessed. Therefore, the current study has two aims: to provide an overview of the evidence regarding the cost-effectiveness of interventions for anxiety disorders, and to assess the quality of the studies identified.

METHODS

A systematic review was conducted using PubMed, PsycINFO, NHS-EED, and the CEA registry. We included full economic evaluations on interventions for all anxiety disorders published before April 2016, with no restrictions on study populations and comparators. Preventive interventions were excluded. Study characteristics and cost-effectiveness data were collected. The quality of the studies was appraised using the Consensus on Health Economic Criteria.

RESULTS

Forty-two out of 826 identified studies met the inclusion criteria. The studies were heterogeneous and the quality was variable. Internet-delivered cognitive behavioural therapy (iCBT) appeared to be cost-effective in comparison with the control conditions. Four out of five studies comparing psychological interventions with pharmacological interventions showed that psychological interventions were more cost-effective than pharmacotherapy.

LIMITATIONS

Comparability was limited by heterogeneity in terms of interventions, study design, outcome and study quality.

CONCLUSIONS

Forty-two studies reporting cost-effectiveness of interventions for anxiety disorders were identified. iCBT was cost-effective in comparison with the control conditions. Psychological interventions for anxiety disorders might be more cost-effective than pharmacological interventions.

Small Group Process and Outcome Research Highlights: A 25-Year Perspective

We summarize major research findings from the past 25 years within the larger evolution of group psychotherapy. Small group process findings are highlighted from a group-as-a-whole, interpersonal relation, subgroup, individual member characteristics, and leader perspective. Special emphasis is given to cohesion and the significant correlation between cohesion and outcome. We note that group therapy is an empirically well-supported treatment for a large number of psychiatric disorders and describe evidence supporting the outcome of various theoretical orientations. Key studies showing outcome equivalence for group and individual therapy are reviewed, followed by a high-level summary of group therapy's efficacy research for depression, bipolar, social phobia, panic disorder, obsessive compulsive, bulimia nervosa, binge-eating, substance-related, trauma-related, HIV/AIDS, breast cancer, chronic pain, schizophrenia, and borderline personality. We conclude with the promise of recent advances for moving the field forward over the next 25 years.

Treatment engagement in the early phase of cognitive-behavior therapy for panic disorder: A grounded theory analysis of patient experience

Exposure-based cognitive-behavior therapy (EBCBT) is the treatment of choice for panic disorder (PD). However, little is known about early treatment processes that facilitate retention in treatment and positive outcomes of PD treatment. We studied the development of early treatment process with semi-structured individual in-depth interviews with 12 patients with PD, conducted post session 3. Grounded theory was used to analyze the transcripts. The development of early treatment process was captured by four thematic categories: approaching the problem, easing in and opening up, building trust and bonding, and making sense of panic. The developmental scheme culminated to the core category: Jointly Engaging in PD Therapy versus Awaiting Relief, capturing early engagement or disengagement from PD therapy respectively. The emergent core category was cross-validated against distal treatment outcome. Emergent processes can be replicated and incorporated in early treatment procedures of EBCBT for PD. Clinical practice recommendations are discussed.

Treatment-resistant panic disorder: clinical significance, concept and management

Panic disorder is commonly prevalent in the population, but the treatment response for panic disorder in clinical practice is much less effective than that in our imagination. Increasing evidence suggested existence of a chronic or remitting-relapsing clinical course in panic disorder. In this systematic review, we re-examine the definition of treatment-resistant panic disorder, and present the potential risk factors related to the treatment resistance, including the characteristics of panic disorder, other psychiatric and physical comorbidities, and psychosocial stresses. Furthermore, we summarize the potential pathophysiologies, such as genetic susceptibility, altered brain functioning, brain-derived neurotrophic factor, and long-term inflammation, to explain the treatment resistance. Finally, we conclude the current therapeutic strategies for treating treatment-resistant panic disorder from pharmacological and non-pharmacological views.

RANDOMIZED TRIAL OF D-CYCLOSERINE ENHANCEMENT OF COGNITIVE-BEHAVIORAL THERAPY FOR PANIC DISORDER

BACKGROUND

Initial studies have provided a mixed perspective of the efficacy of d-cycloserine (DCS) for augmenting the efficacy of exposure-based cognitive behavioral therapy (CBT) for panic disorder. In this multicenter trial, we examine the magnitude of DCS augmentation effects for an ultra-brief program of CBT.

METHODS

We conducted a double-blind, controlled trial at three treatment sites, randomizing 180 adults with a primary diagnosis of panic disorder to five sessions of treatment, with study pill (50 mg DCS or matching placebo) administered 1 hr prior to the final three sessions. Two booster sessions were subsequently provided, and outcome was assessed at posttreatment and 1-month, 2-month, and 6-month follow-up assessments. The primary outcome was the degree of reduction in the Panic Disorder Severity Scale. Additional analyses examined the role of severity and current antidepressant or benzodiazepine use as moderators of DCS augmentation effects.

RESULTS

DCS augmentation resulted in significant benefit only early in the trial, with no beneficial effects of DCS augmentation evident at follow-up evaluations. We did not find that baseline severity or antidepressant or benzodiazepine use moderated DCS efficacy, but benzodiazepine use was associated with lower efficacy of CBT regardless of augmentation condition.

CONCLUSIONS

Consistent with other recent multicenter trials, the benefit of DCS was less than indicated by pilot study and reflected an acceleration of treatment response evident at treatment endpoint, but no advantage in response over follow-up evaluation. Our results did not support severity or concomitant medication moderators observed in previous trials of DCS augmentation.

Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials

Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by findings from primary studies and earlier meta-analyses. However, a comprehensive summary of the recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171 patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quantitative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled trials for specific symptomatology: g=0.84, 95% CI [0.72; 0.97] and general psychopathology: g=0.62, 95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alleviating symptoms of SAD, but not in improving general psychopathology. No differences appeared for direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence, group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT (ICBT) on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) to 16 March 2015. The CCDANCTR includes relevant randomised controlled trials from MEDLINE, EMBASE, PsycINFO and CENTRAL. We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate additional trials.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1736 citations and selected 38 studies (3214 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (5 trials), post-traumatic stress disorder (2 trials), obsessive compulsive disorder (2 trials), and specific phobia (2 trials). Eight remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (18 trials), Australia (14 trials), Switzerland (3 trials), the Netherlands (2 trials), and the USA (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, therapist-supported ICBT versus waiting list control, therapist-supported versus unguided ICBT, and therapist-supported ICBT versus face-to-face CBT.Low quality evidence from 11 studies (866 participants) contributed to a pooled risk ratio (RR) of 3.75 (95% CI 2.51 to 5.60; I(2) = 50%) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. The SMD for disorder-specific symptoms at post-treatment (28 studies, 2147 participants; SMD -1.06, 95% CI -1.29 to -0.82; I(2) = 83%) and general anxiety symptoms at post-treatment (19 studies, 1496 participants; SMD -0.75, 95% CI -0.98 to -0.52; I(2) = 78%) favoured therapist-supported ICBT; the quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (5 studies, 312 participants; SMD -0.22, 95% CI -0.56 to 0.13; I(2) = 58%; very low quality evidence) or general anxiety symptoms (2 studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; I(2) = 0%; very low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; I(2) = 0%; low quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (7 studies, 450 participants; SMD 0.06, 95% CI -0.25 to 0.37; I(2) = 60%; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; I(2) = 78%; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT were low quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should explore heterogeneity among studies which is reducing the quality of the evidence body, involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.

Disaster Mental Health Epidemiology: Methodological Review and Interpretation of Research Findings

Worldwide, disasters are increasing in frequency and severity. Mental health consequences of disasters are extensive, and knowledge of anticipated mental health effects is needed for effective disaster response. Difficulties inherent in conducting disaster research have limited the understanding of research findings. This article presents and interprets disaster mental health research findings in the context of research methods. A brief history of the disaster mental health research field is provided, and the presentation of findings is ordered into topical areas of disaster mental health consequences and timing and prediction of mental health outcomes. Results of different studies varied greatly by several main characteristics of research methods, especially methods of psychiatric assessment, sampling and exposure group determination, and consideration of confounding variables. In conclusion, many complexities in conducting disaster mental health research have limited the understanding and interpretation of available knowledge needed to inform efforts to plan and carry out effective mental health responses to disasters. Thoughtful interpretation of findings in the context of research design and methods is vital to accurate understanding of the types, prevalence, and predictors of anticipated mental health effects of disasters. A wealth of knowledge from disaster mental health research has accumulated in recent decades, but more research is still needed to resolve inconsistent findings through methodological refinements.

Treatment of Anxiety Disorders in a Psychology Clinic

People with anxiety disorders demand psychological attention most often. Therefore, it seems important to identify both the characteristics of the patients who demand help and the clinical variables related to that demand and its treatment. A cohort of 292 patients who requested help at a university clinical facility was studied. The typical profile of the patient was: being female, young, unmarried, with some college education, and having previously received treatment, especially pharmacological one. The three most frequent diagnoses of anxiety, which include 50% of the cases, were: Anxiety Disorder not otherwise specified, Social Phobia, and Panic Disorder with Agoraphobia. Regarding the characteristics of the intervention, the average duration of the assessment was 3.5 sessions (SD = 1.2), and the duration of the treatment was 14 sessions (SD = 11.2). The percentage of discharges was 70.2%. The average cost of treatment was around €840. The results are discussed, underlining the value of empirically supported treatments for anxiety disorders.

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialized Register (CCDANCTR) to 12 April 2013. The CCDANCTR includes relevant randomised controlled trials from EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate further trials. An update of an initial search (April 2013), conducted in September 2014, identified seven new completed studies, seven previously ongoing studies now completed, and four new ongoing studies. This is a fast-moving area; we plan to update this review shortly, incorporating these new studies.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1000 citations and selected 30 studies (2181 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (4 trials), post-traumatic stress disorder (1 trial), and specific phobia (1 trial). Five remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (15 trials), Australia (12 trials), Switzerland (2 trials), and the Netherlands (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, experimental versus waiting list control, experimental versus unguided ICBT, and experimental versus face-to-face CBT.Moderate quality evidence from 9 studies (644 participants) contributed to a pooled RR of 4.18 (95% CI 2.42 to 7.22) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. Similarly, the SMD for disorder-specific symptoms at post-treatment (22 studies, 1573 participants; SMD -1.12, 95% CI -1.39 to -0.85) and general anxiety symptoms at post-treatment (14 studies, 1004 participants; SMD -0.79, 95% CI -1.10 to -0.48) favoured therapist-supported ICBT. The quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (4 studies, 253 participants; SMD -0.24, 95% CI -0.69 to 0.21; low quality evidence) or general anxiety symptoms (two studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; moderate quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (6 studies, 424 participants; SMD 0.09, 95% CI -0.26 to 0.43; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was low to very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT was low to moderate quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.

Factors related to psychotherapists' self-assessment when treating anxiety and other disorders

The aim of the study was to replicate and extend recent findings regarding therapists' self-assessment biases. This study examined clinicians' estimates of their abilities when working with general clinical groups and with anxious patients, and of the recovery/improvement rates of their clients. It also considered what clinician personality traits and clinical practice elements were associated with such estimates. A total of 195 out 801 clinicians completed a survey regarding self-ratings, team ratings, therapy outcomes for their clients, and their own personality traits. The great majority of clinicians rated themselves and their teams as being better clinicians than their peers, though not to as extreme a level as in the previous study. They also reported exceptionally positive therapy outcomes. Due to the large proportion of non-responders, it is possible that these findings do not reflect actual self-assessment bias, but a greater willingness to participate among clinicians who are more skilled and with particular personality styles. However, the data suggest that perceptions of skill and therapy outcome might be associated with clinician personality characteristics, though not with other clinical practice variables. These interpretations should be treated with caution due to the limited response rate. Different possible explanations for these patterns of self-assessment are outlined, including conscious and unconscious processes. Methods for enhancing accurate skill perception are discussed, including self-monitoring and supervision.

Empirically supported treatments for panic disorder with agoraphobia in a Spanish psychology clinic

The aim of this work is to study the sociodemographic and clinical characteristics of patients diagnosed with Panic Disorder with Agoraphobia (PD/Ag), as well as the characteristics of the treatment and its results and cost in a University Psychology Clinic. Fifty patients demanded psychological assistance for PD/Ag; 80% were women, with an average age of 29.22 years (SD = 9.03). Mean number of evaluation sessions was 3.26 (SD = 1.03), and of treatment sessions, 13.39 (SD = 9.237). Of the patients, 83.33% were discharged (that is, questionnaire scores were below the cut-off point indicated by the authors, and no PD/Ag was observed at readministration of the semistructured interview), 5.5% refused treatment, and 11% were dropouts. The average number of treatment sessions of patients who achieved therapeutic success was 15.13 (SD = 8.98). Effect sizes (d) greater than 1 were obtained in all the scales. Changes in all scales were significant (p < .05). The estimated cost of treatment for patients who achieved therapeutic success was 945.12€. The treatment results are at least similar to those of studies of efficacy and effectiveness for PD/Ag. The utility of generalizing treatments developed in research settings to a welfare clinic is discussed.

Predicting rapid response to cognitive-behavioural treatment for panic disorder: the role of hippocampus, insula, and dorsolateral prefrontal cortex

Although cognitive-behavioural therapy (CBT) is an effective first-line intervention for anxiety disorders, treatments remain long and cost-intensive, difficult to access, and a subgroup of patients fails to show any benefits at all. This study aimed to identify functional and structural brain markers that predict a rapid response to CBT. Such knowledge will be important to establish the mechanisms underlying successful treatment and to develop more effective, shorter interventions. Fourteen unmedicated patients with panic disorder underwent 3 T functional and structural magnetic resonance imaging (MRI) before receiving four sessions of exposure-based CBT. Symptom severity was measured before and after treatment. During functional MRI, patients performed an emotion regulation task, either viewing negative images naturally, or intentionally down-regulating negative affect by using previously taught strategies of cognitive reappraisal. Structural MRI images were analysed including left and right segmentation and volume estimation. Improved response to brief CBT was predicted by increased pre-treatment activation in bilateral insula and left dorsolateral prefrontal cortex (dlPFC) during threat processing, as well as increased right hippocampal gray matter volume. Previous work links these regions to improved threat processing and fear memory activation, suggesting that the activation of such mechanisms is crucial for exposure-based CBT to be effective.

Incremental cost-effectiveness of pharmacotherapy and two brief cognitive-behavioral therapies compared with usual care for panic disorder and noncardiac chest pain

The aim of this study was to assess the incremental cost-effectiveness ratios (ICERs) of two brief cognitive-behavioral therapy (CBT)-based interventions and a pharmacological treatment, compared with usual care, initiated in the emergency department (ED) for individuals with panic disorder (PD) with a chief complaint of noncardiac chest pain. A total of 69 patients were followed up to 6 months. The primary outcome variables were direct and indirect costs of treatment and PD severity. Panic management (PM) had an ICER of $124.05, per the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, severity score change (95% confidence interval [CI], $54.63-$314.57), compared with pharmacotherapy (paroxetine), with an ICER of $213.90 (95% CI, $133.51-$394.94), and brief CBT, with an ICER of $309.31 (95% CI, $151.27-$548.28). The pharmacological and CBT interventions were associated with a greater clinical improvement compared with usual care at posttest. PM presented a superior ICER, suggesting that it may be a promising treatment option to implement in EDs.

Changes in automatic threat processing precede and predict clinical changes with exposure-based cognitive-behavior therapy for panic disorder

BACKGROUND

Cognitive behavioral therapy (CBT) is an effective treatment for emotional disorders such as anxiety or depression, but the mechanisms underlying successful intervention are far from understood. Although it has been a long-held view that psychopharmacological approaches work by directly targeting automatic emotional information processing in the brain, it is usually postulated that psychological treatments affect these processes only over time, through changes in more conscious thought cycles. This study explored the role of early changes in emotional information processing in CBT action.

METHODS

Twenty-eight untreated patients with panic disorder were randomized to a single session of exposure-based CBT or waiting group. Emotional information processing was measured on the day after intervention with an attentional visual probe task, and clinical symptoms were assessed on the day after intervention and at 4-week follow-up.

RESULTS

Vigilance for threat information was decreased in the treated group, compared with the waiting group, the day after intervention, before reductions in clinical symptoms. The magnitude of this early effect on threat vigilance predicted therapeutic response after 4 weeks.

CONCLUSIONS

Cognitive behavioral therapy rapidly affects automatic processing, and these early effects are predictive of later therapeutic change. Such results suggest very fast action on automatic processes mediating threat sensitivity, and they provide an early marker of treatment response. Furthermore, these findings challenge the notion that psychological treatments work directly on conscious thought processes before automatic information processing and imply a greater similarity between early effects of pharmacological and psychological treatments for anxiety than previously thought.

Case study of cognitive behavioural therapy awareness educational programme using blended learning, UK

This paper examined the opportunities as well as challenges in relation to the use of cognitive behavioural therapy (CBT). The opportunities include the increased range of mental health conditions and other disorders where CBT (in isolation or with other interventions) could be effective to address them, as well as policies around workforce education and training that support the expansion of psychological therapies, particularly CBT services. The challenges include the urgent need of heightened awareness among the wider platform of health and social care workers about CBT principles, structure, framework, methods of delivery, wider applications, evaluation and appropriate referral of clients, and stepped model of care. In response to such needs, the paper described CBT awareness educational award at the University of Gloucestershire, UK: the Certificate of Professional Studies in Awareness of Cognitive and Behavioural Therapies Practice delivered at Level III and M level. The challenges associated with the initiation and running of such educational programmes are highlighted, as well as suggestions for the way forward considering the learners', employers' and educational providers' perspectives.

What makes a quality therapy? A consideration of parsimony, ease, and efficiency

Evaluations of psychotherapy have traditionally focused on symptom reduction as the primary standard by which their value is determined. This has contributed to the appearance of equivalence between many therapies that may differ considerably in complexity, feasibility, amount of homework and therapist contact required, expected cost, speed of symptom decline, and transdiagnostic utility. In the current paper, I make the case that these are fundamental features related to quality that should be considered in psychotherapy development, randomized controlled trials, and dissemination efforts. Empirically supported treatments for different disorders are evaluated based on these criteria, and special consideration is given to cognitive-behavioral treatments for anxiety disorders. Specific recommendations for a quality-oriented clinical research agenda are also provided.

Five sessions and counting: considering ultra-brief treatment for panic disorder

BACKGROUND

Brief cognitive-behavioral therapy for panic disorder has the potential to lower health care costs and enhance dissemination of evidence-based interventions to clinical practice. This manuscript evaluates the utility of brief cognitive-behavioral therapy for panic disorder.

METHODS

A narrative review of studies examining the efficacy of cognitive-behavioral brief treatment of panic disorder, with a specific focus on an ultra-brief, 5-session, intervention developed by our group.

RESULTS

Brief cognitive-behavioral therapy for panic disorder is associated with clinically meaningful symptom improvement reflecting large effect sizes, comparable to those observed for standard protocols.

CONCLUSIONS

Growing evidence encourages the further evaluation and application brief cognitive-behavioral therapy for panic disorder. Controlled trials of cognitive-behavioral therapy have established the dramatic benefit that can be offered by brief treatment (often 12-15 sessions) approaches for Axis I disorders. Yet, as the field advances and core mechanisms of change are identified, there is the potential for offering efficacy in even briefer treatment protocols. In this manuscript, we describe the elements and initial efficacy estimates, based on published studies, for an ultra-brief treatment approach for panic disorder. We also discuss the potential impact, and such brief treatment can have relative to dissemination issues and the desire for the timely end to psychological suffering.

Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs

BACKGROUND

Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention.

METHODS

Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in.

RESULTS

The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes.

CONCLUSIONS

These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.

Group cognitive-behavioral therapy for patients with epilepsy and comorbid depression and anxiety

Clinical Practice Guidelines for depression and anxiety recommend cognitive-behavioral therapy (CBT) as an equivalent and sometimes more effective treatment than medication. The limited research investigating CBT for anxiety and depression in epilepsy demonstrates mixed results. Described here is a pilot project using an existing group CBT intervention for symptoms of depression and/or anxiety, CBT Basics II, in patients with epilepsy. Eighteen patients with epilepsy, referred by neurologists to address depression and/or anxiety symptoms, completed the 10-week group. Results demonstrated improvements in depression, anxiety, negative automatic thoughts, and cognitive therapy knowledge and skills. The group was generally acceptable to patients as indicated by good attendance rates and only one dropout. This pilot project demonstrates that group CBT is a feasible, acceptable, and promising intervention for patients with epilepsy and comorbid depression and anxiety symptoms.

Les études de coûts-efficacité des traitements pharmacologiques et psychologiques des troubles anxieux : une recension des écrits

Cet article porte sur une recension des écrits sur l’évaluation économique des traitements éprouvés cognitivo-comportementaux et pharmacologiques des troubles anxieux. La recherche des articles pertinents s’échelonne de 1980 à 2008, à partir des bases de données électroniques du milieu médical et psychologique. Sept études sont recensées et portent sur le trouble panique, le trouble d’anxiété généralisée, la phobie spécifique et la phobie sociale. Les traitements pharmacologiques et la psychothérapie cognitive-comportementale présentent un rapport coûts-efficacité avantageux, particulièrement lorsque comparés aux soins usuels. Les auteurs concluent que malgré le besoin de renforcer l’état des connaissances sur le rapport coûts-efficacité des interventions, il semble avantageux pour la société d’accroître l’accès aux traitements éprouvés des troubles anxieux.

Stepped care for depression in primary care: what should be offered and how?

Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of "watchful waiting", as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.

Stepped care for obsessive-compulsive disorder: An open trial

This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N=14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n=5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate.

From assessment reactivity to aftercare for adolescent substance abuse: are we there yet?

This article addresses less developed areas of clinical research that are of great importance for better understanding the therapeutic process along the continuum of care in youth with alcohol and other substance use disorders (AOSUD). These include the rationale, design, mechanisms of behavior change (MBCs), implementation, monitoring, and outcome-based modification of treatment continuum for youth with AOSUD. The specific objectives are: (1) present current knowledge pertaining to the pretreatment phase including the effect of baseline assessment on treatment outcome; (2) address potential MBCs in treatment; (3) discuss the importance of aftercare, also known as continued care, to prevent postintervention relapse; (4) consider how reconceptualization of therapeutic paradigms might advance the field, in particular treatment algorithm or adaptive treatment strategies addressing poor response to treatment.

Internet-based treatment for panic disorder: does frequency of therapist contact make a difference?

Internet-based interventions with therapist support have proven effective for treating a range of mental health conditions. This study examined whether frequency of therapist contact affected treatment outcomes. Fifty-seven people with panic disorder (including 32 with agoraphobia) were randomly allocated to an 8-week Internet-based cognitive behavioural treatment intervention (Panic Online) with either frequent (three e-mails per week) or infrequent (one e-mail per week) support from a psychologist. Posttreatment, intention-to-treat analyses revealed that both treatments were effective at improving panic disorder and agoraphobia severity ratings, panic-related cognitions, negative affect, and psychological and physical quality of life domains, with no differences between conditions. High end-state functioning was achieved by 28.6% of the frequent and infrequent participants, respectively. Therapist alliance, treatment credibility, and satisfaction also did not differ between groups, despite significantly greater therapist time invested in the frequent contact condition. The results provide evidence that the effectiveness of Internet-based mental health interventions may be independent of the frequency of therapist support and may, therefore, be more cost-effective than previously reported.

Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: Further evaluation

Despite its acute efficacy for the treatment of panic disorder, benzodiazepines (BZs) are associated with a withdrawal syndrome that closely mimics anxiety sensations, leading to difficulty with treatment discontinuation and often disorder relapse. An exposure-based cognitive-behavioral treatment for BZ discontinuation, Panic Control Treatment for BZ Discontinuation (CBT) targets the fear of these sensations and has demonstrated efficacy in preventing disorder relapse and facilitating successful BZ discontinuation among patients with panic disorder. In this randomized controlled trial, CBT was compared to taper alone and a taper plus a relaxation condition to control for the effect of therapist contact and support among 47 patients with panic disorder seeking taper from BZs. Based on the primary outcome of successful discontinuation of BZ use, results indicate that adjunctive CBT provided additive benefits above both taper alone and taper plus relaxation, with consistently medium and large effect sizes over time that reached significance at the six month follow-up evaluation. The efficacy of CBT relative to either of the other taper conditions reflected very large and significant effect sizes at that time. These findings suggest that CBT provides specific efficacy for the successful discontinuation from BZs, even when controlling for therapist contact and relaxation training.

Predictors of relapse in the second follow-up year post cognitive-behavior therapy for panic disorder

OBJECTIVE: To investigate predictors of relapse two years after a brief cognitive-behavior group therapy in patients with panic disorder who had failed to respond to pharmacologic treatment. METHOD: A total of 56 patients with panic disorder were followed who had met remission criteria at 1 year evaluation after 12 sessions of cognitive-behavior group therapy. Demographic and clinical features and life stressors were investigated as predictors of relapse. RESULTS: At the 2 year assessment, 39 (70%) patients maintained remission status and use of medication was reduced significantly, such that 36 (64%) patients were not undergoing any psychiatric treatment. Among all independent variables investigated, only "conflict" as a stressful life event, RR = 3.20 (CI95% 1.60; 7.20 - p = 0.001), and the severity or residual anxiety symptoms, RR = 3.60 for each scale point (CI95% 1.02; 1.08 - p < 0.001), emerged as nonredundant predictors. CONCLUSION: In spite of the high treatment gains across two years of follow-up, clinicians should pay attention to stress management and to the role of residual symptoms during this period. Results were discussed in the context of treatment cost-efficacy and potential strategies to prolong treatment gains from cognitive-behavior group therapy.

Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access

Cognitive-behavioral therapies for anxiety disorders are highly efficacious (e.g., Butler, Chapman, Forman, & Beck, 2006; Deacon & Abramowitz, 2004). These treatments nevertheless remain underutilized and difficult to access for many of the patients who suffer from these conditions (e.g., Norton & Hope, 2005). We identify various barriers to the wide-scale dissemination of these treatments, including those that are applicable to empirically supported treatments more generally (e.g., lack of training opportunities, failure to address practitioner concerns) as well as those that may be relatively specific to CBT for anxiety disorders (e.g., practitioner concerns around using exposure interventions). We offer suggestions for overcoming these barriers, including specific guidance about continued accumulation of a supportive research base, making the appeals that are necessary to obtain required funding and organizational support, and the training of practitioners to deliver these treatments. Advocates of CBT for anxiety disorders will need to demonstrate that these treatments are cost effective, if wide-scale dissemination is to occur. In the United States, advocacy with third party payers will also be necessary. Although providing such steps may prove to be a difficult endeavour, the patients who stand to benefit from this work deserve nothing less.

Empirically supported treatments for panic disorder

This article provides an empirical review of the elements and efficacy of both pharmacologic and psychosocial treatments for panic disorder. Both monotherapies and combination treatment strategies are considered. The available evidence suggests that both cognitive behavioral therapy (CBT) and pharmacotherapy (prominently, selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors) are effective first-line agents and that CBT offers particular cost efficacy relative to both pharmacotherapy alone and combined pharmacotherapy and CBT. Predictors of non-response and mechanisms of action are considered, as are novel treatment strategies, including the use of memory enhancers to improve CBT outcome.

Sexual rehabilitation after localized prostate cancer: current interventions and future directions

Many published articles have documented the impact of prostate-cancer treatment on sexual functioning in men treated for localized disease. Surprisingly, the literature on interventions to rehabilitate men's sexual functioning is much more limited. In this article, we review the sexual-rehabilitation interventions for prostate-cancer patients and identify a number of common themes across interventions. We also identify areas where further research is needed and propose a conceptual model based on psychologic and nursing theories and informed by the published research.

Cost-of-illness studies and cost-effectiveness analyses in anxiety disorders: a systematic review

AIMS

To review cost-of-illness studies (COI) and cost-effectiveness analyses (CEA) conducted for anxiety disorders.

METHODS

Based on a database search in Pubmed, PsychINFO and NHS EED, studies were classified according to various criteria. Cost data were inflated and converted to 2005 US-$ purchasing power parities (PPP).

RESULTS

We finally identified 20 COI and 11 CEA of which most concentrated on panic disorder (PD) and generalized anxiety disorder (GAD). Differing inclusion of cost categories limited comparability of COI. PD and GAD tended to show higher direct costs per case, but lower direct cost per inhabitant than social and specific phobias. Different measures of effectiveness severely limited comparability of CEA. Overall CEA analysed 26 therapeutic or interventional strategies mostly compared to standard treatment, 8 of them resulting in lower better effectiveness and costs than the comparator.

CONCLUSIONS

Anxiety disorders cause considerable costs. More research on phobias, more standardised inclusion of cost categories in COI and a wider use of comparable effectiveness measures (like QALYs) in CEA is needed.

Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care

The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective-disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional-economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions. Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so. Clinical psychologists' failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today's clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student-faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge. A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands high-quality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer high-quality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.

Finding the ideal place for a psychotherapeutic intervention in a stepped care approach--a brief overview of the literature and preliminary results from the Project PREDICT

AIMS

To provide an overview over empirical evidence regarding stepped care approaches that include psychotherapies. To present own preliminary study results in alcohol dependent patients.

METHODS

Publications were searched in the databases Medline, PsycINFO and the internet search engine Google Scholar. Inclusion criteria were psychosocial treatment and psychiatric disorders. Our own study consists of two steps. In step 1 patients receive anti-craving medication or placebo and Medical Management (MM). After a relapse to heavy drinking patients can step up and after randomization they either continue with the same treatment or they receive additional alcoholism specific psychotherapy (ASP).

RESULTS

Evidence suggests that stepped care might be efficacious in patients with obsessive-compulsive behavior and depression. There is no evidence for efficacy in problem drinkers. Results of our own study show that the completer rate in MM alone is higher than in ASP with MM, but there are no significant differences concerning age, sex and disease severity between completer and non-completer in both study arms.

CONCLUSIONS

Further research with regard to stepped care in alcohol dependent patients is needed. An introduction of the psychotherapy at earlier stages might be sensible.