Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland

OBJECTIVES

To establish the long-term outcome of participants in clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders and psychosis, examining the effectiveness and cost-effectiveness associated with receiving CBT in comparison with alternative treatments.

DESIGN

An attempt was made to contact and interview all of the participants in eight randomised, controlled, clinical trials of CBT for anxiety disorders and two randomised, controlled, clinical trials of CBT for schizophrenia conducted between 1985 and 2001. Case note reviews of healthcare resources used in the 2 years prior to entering the trials and the 2 years prior to follow-up interview were undertaken.

SETTING

Mixed rural and urban settings in five localities in central Scotland. Anxiety disorder trials were conducted mainly in primary care and included three with generalised anxiety disorder, four with panic disorder and one with post-traumatic stress disorder (PTSD). The psychosis studies (one on relapse prevention and one with chronic disorder) were conducted in secondary care.

PARTICIPANTS

Of the 1071 entrants to the 10 studies, 489 agreed to participate (46% of original entrants, 52% of those available to contact).

INTERVENTIONS

Follow-up interviews took place between 1999 and 2003, 2-14 years after the original treatment. Interviews for Trials 1-8 were conducted by a research psychologist blind to original treatment condition. Interviews for Trials 9 and 10 were conducted by community psychiatric nurses also blind to treatment condition. Case note reviews were completed following the interview.

MAIN OUTCOME MEASURES

For Trials 1-8 the main interview-based outcome measures were: Anxiety Disorders Interview Schedule-DSM-IV for diagnosis and co-morbidity, Clinical Global Severity (0-8) and the Hamilton Anxiety Rating Scale. The main patient-rated measures were: Brief Symptom Inventory, SF-36 II, Clinical Global Improvement (1-7), and the Positive and Negative Affect Scale. For Trials 9 and 10 the primary outcome measure was the interview-based Positive and Negative Syndrome Scale (PANSS).

RESULTS

For the anxiety disorder studies (Trials 1-8), over half of the participants (52%) had at least one diagnosis at long-term follow-up, with significant levels of co-morbidity and health status scores comparable to the lowest 10% of the general population. Only 36% reported receiving no interim treatment for anxiety over the follow-up period with 19% receiving almost constant treatment. Patients with PTSD did particularly poorly. There was a 40% real increase in healthcare costs over the two time periods, mainly due to an increase in prescribing. A close relationship was found between poor mental and physical health for those with a chronic anxiety disorder. Treatment with CBT was associated with a better long-term outcome than non-CBT in terms of overall symptom severity but not with regard to diagnostic status. The positive effects of CBT found in the original trials were eroded over longer time periods. No evidence was found for an association between more intensive therapy and more enduring effects of CBT. Long-term outcome was found to be most strongly predicted by the complexity and severity of presenting problems at the time of referral, by completion of treatment irrespective of modality and by the amount of interim treatment during the follow-up period. The quality of the therapeutic alliance, measured in two of the studies, was not related to long-term outcome but was related to short-term outcome. The cost-effectiveness analysis showed no advantages of CBT over non-CBT. The cost of providing CBT in the original trials was only a very small proportion (6.4%) of the overall costs of healthcare for this population, which are high for both physical and mental health problems. In the psychosis studies (Trials 9 and 10), outcome was generally poor with only 10% achieving a 25% reduction in total PANSS scores from pretreatment to long-term follow-up, also cost-effectiveness analysis showed no advantages of CBT over non-CBT, although healthcare costs fell over the two time periods mainly owing to a reduction in inpatient costs.

CONCLUSIONS

Psychological therapy services need to recognise that anxiety disorders tend to follow a chronic course and that good outcomes with CBT over the short term are no guarantee of good outcomes over the longer term. Clinicians who go beyond standard treatment protocols of about 10 sessions over a 6-month period are unlikely to bring about greater improvement. Poor outcomes over the long term are related to greater complexity and severity of presenting problems at the time of referral, failure to complete treatment irrespective of modality and the amount of interim treatment during the follow-up period. The relative gains of CBT are greater in anxiety disorders than in psychosis. Longitudinal research designs over extended periods of time (2-5 years), with large numbers of participants (500+), are required to investigate the relative importance of patient characteristics, therapeutic alliance and therapist expertise in determining the cost-effectiveness of CBT in the longer term.

Risk adjustment of Florida mental health outcomes data: concepts, methods, and results

This article discusses outcome evaluation systems for mental health programs. It reviews and critically evaluates design and analysis methods for strengthening the validity of such uncontrolled comparisons. The article examines methods for statistically adjusting preexisting groups, now referred to as risk adjustment or case-mix adjustment, and offers guidelines for determining when this procedure is appropriate. Then, analyses on two dependent variables--a global rating of functioning and a consumer satisfaction measure--available from an outcomes evaluation system currently underway in Florida are used to demonstrate the proposed method of risk adjustment. Results for 24 providers of mental health services showed that while risk adjustment only made a small difference in the overall provider rankings, the ranking of some specific providers changed considerably. The article concludes with a discussion of the implications of this research.

HIV risk factors for persons with serious mental illness

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Assisting clients of community mental health centers to secure SSI benefits: a controlled evaluation

The entire caseloads of three Community Mental Health Centers were screened on variables normally assessed in the SSI application process. These data were then used to classify each individual as Possibly Eligible for SSI benefits, or as Probably Not Eligible. The Possibly Eligible subjects were randomly assigned to either the Experimental condition, in which subjects were helped to apply for SSI, or the Control condition, in which no intervention was provided. Results showed that the Experimental subjects were almost twice as likely to secure SSI benefits as the Control subjects. The usefulness of the screening form was supported in that control subjects were almost five times more likely to be awarded SSI, compared with subjects who had been classified as Probably Not Eligible.

Attributional, perceptual, and affective responses to depressed and nondepressed marital partners

Husbands of wives with (n = 22) or without (n = 23) a history of a depressive disorder indicated their attributions about and affective reactions to real and hypothetical positive and negative events occurring to their wives, rated their wives on personality traits categorized as depression-related and depression-neutral, and reported their own marital satisfaction. Husbands of depressed, relative to nondepressed, wives made more dispositional attributions, reported more negative affect in reaction to negative events, and indicated less marital satisfaction. Depressed wives were rated more negatively on both depression-related and depression-neutral personality traits. Results are interpreted as suggesting that spouses of depressed wives have a generalized negative view of their wives, which may also be operating within distressed marriages.

Attributional, perceptual, and affective responses to depressed and nondepressed marital partners

Husbands of wives with (n = 22) or without (n = 23) a history of a depressive disorder indicated their attributions about and affective reactions to real and hypothetical positive and negative events occurring to their wives, rated their wives on personality traits categorized as depression-related and depression-neutral, and reported their own marital satisfaction. Husbands of depressed, relative to nondepressed, wives made more dispositional attributions, reported more negative affect in reaction to negative events, and indicated less marital satisfaction. Depressed wives were rated more negatively on both depression-related and depression-neutral personality traits. Results are interpreted as suggesting that spouses of depressed wives have a generalized negative view of their wives, which may also be operating within distressed marriages.

Knowledge of AIDS and HIV among various groups

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Training psychiatric patients to discuss medication issues. Effects on patient communication and knowledge of medications

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Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes

Mental health and substance abuse treatment staff completed a set of measures assessing their attitudes, knowledge, and beliefs concerning AIDS. Results indicated that while most staff were aware of basic information about the disease, approximately one-third were not aware of the neuropsychological and psycho-behavioural concomitants of the disorder. Those surveyed were aware of the main transmission routes, but overgeneralized their concern to casual contact. Most staff indicated willingness to work with HIV-infected individuals, although 29% stated they would try to avoid working with them. Interestingly, mental health staff expressed greater hesitancy than substance abuse staff. These and other results are interpreted to suggest that some desensitization of concern may have already occurred among those who have worked with HIV-positive clients. Individuals who had worked with an HIV-positive client had greater knowledge, less discomfort, and were less likely to want to avoid those who are HIV-positive. Questions attempting to identify sources of discomfort in working with AIDS or HIV-positive clients suggested that fear of contagion may be the primary concern, followed by discomfort of working with the terminally ill, and then discomfort with IV drug users and homosexuals. The implications of these results for continuing education activities and staff readiness are discussed.

Administrative challenges to working with HIV-positive clients: experiences of mental health and substance abuse program directors in Florida

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A controlled study of combined hormonal and psychological treatment for sexual unresponsiveness in women

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Neurological features of HIV-related disease in Glasgow

The neurological features of 10 patients with HIV-related disease seen in Glasgow between July 1984 and May 1988 are described. Two of these patients presented with ARC and eight with AIDS. Six patients showed features consistent with a diagnosis of AIDS-dementia complex, one had cerebral toxoplasmosis, one had CNS lymphoma, one had a probable drug-induced encephalopathy and one patient had a meningoencephalitis of undetermined cause. Seven of these patients have now died. The implications of these findings are discussed.

Psychosocial characteristics of "double depression"

Thirty-nine patients with "double depression" (major depression and dysthymia) were compared to 38 patients with recurrent major depression without dysthymia on a number of severity of illness, psychosocial, and biological variables. No significant differences were found on any psychosocial or biological measure.

Hormonal treatments of sexual unresponsiveness in postmenopausal women: a comparative study

Forty postmenopausal women, referred for hormone replacement therapy and all of whom reported a significant concern about a decline in their sexual interest, were randomly allocated to one of two hormone implant treatment groups: either oestradiol (50 mg) alone, or oestradiol (50 mg) and testosterone (100 mg). Comparison between the two groups as a whole revealed no significant differences on any measure, both treatments being associated with a significant reduction in the severity of psychological, somatic and vasomotor symptoms, and with a significant improvement in sexual interest and responsiveness. Similar effects were also observed in patients who denied, pretreatment, any concurrent dyspareunia. Although it is not possible to identify the reasons for change, the results indicate no advantages of supplementary testosterone administration over oestradiol alone for sexually unresponsive postmenopausal women.

Retarded ejaculation as a function of non-aversive conditioning and discrimination: a hypothesis

Learning theory formulations of the development of retarded ejaculation have, so far, been confined to the conditioning of anxiety as the principal aetiological factor. A preliminary study of nine patients with ejaculatory failure suggests that positive reinforcement associated with self-masturbation may play a more central role. Some preliminary clinical observations consistent with this hypothesis, and the implications for treatment are discussed.

The usefulness of the semantic differential with "mild grade' mental defectives

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