Background:The aim of this study was to explore the effectiveness of Internet-delivered cognitive-behavioral therapy (iCBT) in treating fibromyalgia (FM) compared with an identical protocol using conventional group face-to-face CBT.
Methods:Sixty participants were assigned to either (a) the waiting list group, (b) the CBT group, or (c) the iCBT group. The groups were assessed at baseline, after 10 weeks of treatment, and at 3-, 6-, and 12-month follow-ups. The primary outcome measured was the impact of FM on daily functioning, as measured by the Fibromyalgia Impact Questionnaire (FIQ). The secondary outcomes were psychological distress, depression, and cognitive variables, including self-efficacy, catastrophizing, and coping strategies.
Results: In post-treatment, only the CBT group showed improvement in the primary outcome. The CBT and iCBT groups both demonstrated improvement in psychological distress, depression, catastrophizing, and utilizing relaxation as a coping strategy. The iCBT group showed an improvement in self-efficacy that was not obtained in the CBT group. CBT and iCBT were dissimilar in efficacy at follow-up. The iCBT group members improved their post-treatment scores at their 6- and 12-month follow-ups. At the 12-month follow-up, the iCBT group showed improvement over their primary outcome and catastrophizing post-treatment scores. A similar effect of CBT was expected, but the positive results observed at the post-treatment assessment were not maintained at follow-up.
Conclusions: The results suggest that some factors, such as self-efficacy or catastrophizing, could be enhanced by iCBT. Specific characteristics of iCBT may potentiate the social support needed to improve treatment adherence.
Vallejo M. A., Ortega J., Rivera J., Comeche M.I. & Vallejo-Slocker L.(2015). Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial. J Psychiatr Res. 2015 Sep;68:106-13. doi: 10.1016/j.jpsychires.2015.06.006. Epub 2015 Jun 20.
This article is an introduction to the second issue of a two-part special series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.
Magidson, J. F., & Weisberg, R. B. (2014). Implementing cognitive behavioral therapy in specialty medical settings. Cognitive and Behavioral Practice, 21, 4, 367-371.
Cognitive Behavior Therapy (CBT) is usually short-term, goal-directed, and skills based. Therapists help patients identify and solve problems and learn specific skills to change their thinking and behavior so they can make lasting changes in their behavior and general functioning. At each session, patients record responses to their unhelpful and inaccurate thinking, along with steps they have committed to take in the coming week.
A growing body of literature has demonstrated the effectiveness of CBT for people with diabetes. For example, a randomized controlled trial published last year in Diabetes Care showed that CBT enhanced treatment adherence and decreased depression in type 2 diabetes patients. In this study, participants received either enhanced usual care or enhanced usual care plus a CBT intervention. Four months after treatment, the group receiving CBT intervention showed greater improvements in medication adherence, depressive symptoms, and diabetes control compared to the usual care group. At the 8-month follow up, the CBT intervention group maintained their gains in adherence and diabetes control.
As an example, a patient might react to a high blood glucose reading by thinking, “This is horrible! I’ll never get my diabetes under control. I’m a failure.” He may then feel sad, become discouraged, and give up on trying to manage his disease. In CBT treatment, therapists help patients identify and modify their automatic, negative thoughts and unhelpful behaviors. They teach them specific, empowering skills to help them manage their disease. Thus, with the help of CBT, instead of thinking “I’m a failure” and wanting to give up, the patient thinks, “This reading is high. I better take steps to get it under control.”
Safren, S. A., Gonzalez, J. S., Wexler, D. J., Psaros, C., Delahanty, L. M., Blashill, A. J., Margolina, A. I., … Cagliero, E. (February 20, 2014). A Randomized Controlled Trial of Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in Patients With Uncontrolled Type 2 Diabetes. Diabetes Care, 37, 3, 625-633.
OBJECTIVE: To examine the potential effectiveness of a multimodal rehabilitation program including an acceptance-oriented cognitive-behavioral therapy for highly distressed patients with rheumatic diseases.
METHODS: An observational study employing a one-group pre-post test design (N=25). The primary outcome was psychological distress. Secondary outcomes were quality of life, illness acceptance, and coping flexibility. Group pre-to-post and pre-to-12 months follow-up treatment changes were evaluated by paired-samples t-tests and Cohen’s effect sizes (d). Individual changes were evaluated by the reliable change index (RCI) and clinically significant change (CSC) parameters.
RESULTS: Significant effects were found post-treatment and maintained at 12 months in psychological distress (d>0.80), illness acceptance (d=1.48) and the SF-36 subscales role physical, vitality, and mental health (d ? 0.65). No significant effects were found for coping flexibility and the SF-36 subscales physical functioning, bodily pain, social functioning, and role emotional. Both a reliable (RCI) and clinically significant (CSC) improvement was observed for almost half of the highly distressed patients.
CONCLUSION: The patients enrolled in the multimodal rehabilitation program showed improved psychological health status from pre to post-treatment.
PRACTICE IMPLICATIONS: A randomized clinical trial is needed to confirm or refute the added value of an acceptance-oriented
Vriezekolk, J. E., Eijsbouts, A. M., van, L. W. G., Beenackers, H., Geenen, R., & van, . E. C. H. (2013). An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: a pre-post test evaluation in highly distressed patients with rheumatic diseases. Patient Education and Counseling, 91, 3, 357-63.
OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.
METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.
RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.
CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.
Lumley, M. A., Keefe, F. J., Mosley-Williams, A., Rice, J. R., McKee, D., Waters, S. J., Partridge, R. T., … Kalaj, A. (2014). The Effects of Written Emotional Disclosure and Coping Skills Training in Rheumatoid Arthritis: A Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, 82, 4, 644-658.
OBJECTIVE: A sudden gain is defined as a large and stable individual improvement occurring between two consecutive treatment sessions. Sudden gains have been shown to predict better long-term improvement in several treatment studies, including cognitive behavioural therapy for depression and anxiety disorders, but have not been studied in the treatment of health anxiety or any form of internet-based cognitive behavioural therapy. The aim of this study was to investigate the role of sudden gains in internet-based cognitive behavioural therapy for severe health anxiety.
METHOD: We examined the occurrence and significance of sudden gains in measures of health anxiety in 81 participants receiving internet-based cognitive behavioural therapy. We compared patients with sudden gains, patients without sudden gains, and patients with gradual gains.
RESULTS: Thirteen participants (16%) experienced one sudden gain in health anxiety with individual sudden gains distributed across the treatment. As expected, patients with a sudden gain showed larger improvements than patients without a sudden gain at post-treatment (d = 1.04) and at one-year follow-up (d = 0.91) on measures of health anxiety.
CONCLUSIONS: Consistent with previous studies, sudden gains in internet-based cognitive behavioural therapy are associated with significantly larger and stable treatment effects up to one-year follow-up.
Hedman, E., Lekander, M., Ljotsson, B., Lindefors, N., Ru?ck, C., Hofmann, S. G., Andersson, E., … Schulz, S. M. (January 01, 2014). Sudden gains in internet-based cognitive behaviour therapy for severe health anxiety. Behaviour Research and Therapy, 54, 22-9.
OBJECTIVE:Many breast cancer patients experience (severe) menopausal symptoms after an early onset of menopause caused by cancer treatment. The aim of this study was to assess the cost-effectiveness of cognitive behavioral therapy (CBT) and physical exercise (PE), compared to a waiting list control group (WLC).
METHODS: We performed a cost-effectiveness analysis from a healthcare system perspective, using a Markov model. Effectiveness data came from a recent randomized controlled trial that evaluated the efficacy of CBT and PE. Cost data were obtained from relevant Dutch sources. Outcome measures were incremental treatment costs (ITCs) per patient with a clinically relevant improvement on a measure of endocrine symptoms, the Functional Assessment of Cancer Therapy questionnaire (FACT-ES), and on a measure of hot flushes, the Hot Flush Rating Scale (HFRS), and costs per quality-adjusted life years (QALY) gained over a 5-year time period.
RESULTS: ITCs for achieving a clinically relevant decline on the FACT-ES for one patient were 1,051 for CBT and 1,315 for PE, compared to the WLC. The corresponding value for the HFRS was 1,067 for CBT, while PE was not more effective than the WLC. Incremental cost-utility ratios were 22,502/QALY for CBT and 28,078/QALY for PE.
CONCLUSION: CBT is likely the most cost-effective strategy for alleviating treatment-induced menopausal symptoms in this population, followed by PE. The outcomes are sensitive to a reduction of the assumed duration of the treatment effect from 5 to 3 and 1.5 years.
IMPLICATIONS FOR CANCER SURVIVORS: Patients can be prescribed CBT or, based on individual preferences, PE.
Mewes, J. C., Steuten, L. M. G., Duijts, S. F. A., Oldenburg, H. S. S., Van, B. M., Stuiver, M. M., Hunter, M. S., … Aaronson, N. K. (2014). Cost-Effectiveness of Cognitive-Behavioral Therapy and Physical Exercise for Alleviating Treatment-Induced Menopausal Symptoms in Breast Cancer Patients. Journal of Cancer Survivorship: Research and Practice. Epub ahead of print.
OBJECTIVE: Daily preexposure prophylaxis (PrEP) is an effective HIV prevention strategy, but adherence is required for maximum benefit. To date, there are no empirically supported PrEP adherence interventions. This article describes the process of developing a PrEP adherence intervention and presents results on its impact on adherence.
METHODS: The Partners PrEP Study was a placebo-controlled efficacy trial of daily oral tenofovir and emtricitabine/tenofovir PrEP among uninfected members of HIV-serodiscordant couples. An ancillary adherence study was conducted at 3 study sites in Uganda. Participants with <80% adherence as measured by unannounced pill count received an additional adherence counseling intervention based on Lifesteps, an evidence-based HIV treatment adherence intervention, based on principles of cognitive-behavioral theory.
FINDINGS: Of the 1147 HIV-seronegative participants enrolled in the ancillary adherence study, 168 (14.6%) triggered the adherence intervention. Of participants triggering the intervention, 62% were men; median age was 32.5 years. The median number of adherence counseling sessions was 10. Mean adherence during the month before the intervention was 75.7% and increased significantly to 84.1% in the month after the first intervention session (P < 0.001). The most frequently endorsed adherence barriers at session 1 were travel and forgetting.
INTERPRETATION: A PrEP adherence intervention was feasible in a clinical trial of PrEP in Uganda and PrEP adherence increased after the intervention. Future research should identify PrEP users with low adherence for enhanced adherence counseling and determine optimal implementation strategies for interventions to maximize PrEP effectiveness.
Psaros, C., Haberer, J. E., Katabira, E., Ronald, A., Tumwesigye, E., Campbell, J. D., Wangisi, J., … Safren, S. A. (January 01, 2014). An Intervention to Support HIV Preexposure Prophylaxis Adherence in HIV-Serodiscordant Couples in Uganda. Journal of Acquired Immune Deficiency Syndromes (1999), 66, 5, 522-9.
Depression is a common comorbidity of diabetes, undesirably affecting patients’ physical and mental functioning. Psychological interventions are effective treatments for depression in the general population as well as in patients with a chronic disease. The aim of this study was to assess the efficacy of individual mindfulness-based cognitive therapy (MBCT) and individual cognitive behavior therapy (CBT) in comparison with a waiting-list control condition for treating depressive symptoms in adults with type 1 or type 2 diabetes. In this randomized controlled trial, 94 outpatients with diabetes and comorbid depressive symptoms (i.e., Beck Depression Inventory-II [BDI-II] ?14) were randomized to MBCT (n = 31), CBT (n = 32), or waiting list (n = 31). All participants completed written questionnaires and interviews at pre- and postmeasurement (3 months later). Primary outcome measure was severity of depressive symptoms (BDI-II and Toronto Hamilton Depression Rating Scale). Anxiety (Generalized Anxiety Disorder 7), well-being (Well-Being Index), diabetes-related distress (Problem Areas In Diabetes), and HbA1clevels were assessed as secondary outcomes. Results showed that participants receiving MBCT and CBT reported significantly greater reductions in depressive symptoms compared with patients in the waiting-list control condition (respectively, P = 0.004 and P < 0.001; d = 0.80 and 1.00; clinically relevant improvement 26% and 29% vs. 4%). Both interventions also had significant positive effects on anxiety, well-being, and diabetes-related distress. No significant effect was found on HbA1c values.
CONCLUSIONS: Both individual MBCT and CBT are effective in improving a range of psychological symptoms in individuals with type 1 and type 2 diabetes.
Tovote, K. A., Fleer, J., Snippe, E., Peeters, A. C. T. M., Emmelkamp, P. M. G., Sanderman, R., … Schroevers, M. J. (2014). Individual Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) for Treating Depressive Symptoms in Patients with Diabetes: Results of a Randomized Controlled Trial. Diabetes Care, doi: 10.2337/dc13-2918 1935-5548.
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