Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (prevent): A randomised controlled trial

New Study (1)Abstract:

Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months.

In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654.

Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial.

We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life.

Kuyken, Willem et al. (2015) Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet (386) 9988, p. 63 – 73.

Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial

New Study (1)Abstract:

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.

Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial

New Study (1)Abstract:

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ?30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p<0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD=12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm S, Phillips K. A., Didie E., Buhlmann U., Greenberg J.L., Fama J.M., Keshaviah A., & Steketee G. (2013) Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther. 2014 May;45(3):314-27. doi: 10.1016/j.beth.2013.12.007. Epub 2013 Dec 29.

Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between veteran and community participants

New Study (1)Abstract:

Cognitive–behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Barrera, T. L., Cully, A. J., Amspoker B. A., Wilson, L. N., Kraus-Schuman, C., Wagener, D. P., Calleo, S. J., Teng, E. J., Rhoades, H. M. & Mosozera, N. (2015)9. Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants  Journal of Anxiety Disorders, Volume 33, Issue null, Pages 72-80

Developing and using a case formulation to guide cognitive-behavior therapy

New Study (1)Abstract:

This article describes a case formulation-driven approach to cognitive-behavior therapy (CBT) that draws on the formulations and interventions in the ESTs while helping the therapist make many of the clinical decisions that are not directly addressed in the ESTs. We begin the article with an overview of case formulation-driven CBT. Then we describe each of the steps of case formulation-driven CBT, giving special attention to the step of developing a case formulation. We conclude with a brief discussion of alternate approaches to case formulation in CBT, and a brief review of evidence supporting the use of a case formulation approach to CBT.

Persons, B. J., & Lisa, S. T. (2015). Developing and Using a Case Formulation to Guide Cognitive-Behavior Therapy. Journal of Psychology & Psychotherapy 5(2)

Identical symptomology but different diagnoses: Treatment implications of an OCD versus schizophrenia diagnosis

New Study (1)Abstract
Background: Individuals with identical symptomatology may receive conflicting diagnoses, potentially leading to different treatments. The aims of this study were to assess diagnostic impressions and treatment recommendations for obsessive–compulsive disorder (OCD) versus schizophrenia-spectrum disorders (SSD).
Methods: Participants (N = 82) were recruited from accredited doctoral programs. All participants were randomized to assess diagnostic impressions and treatment recommendations for 15 vignettes. These were measured across three separate testing sessions.
Results: Large discrepancies in treatment recommendations were found. All participants who selected OCD recommended psychotherapy while only 15.4% of participants who identified the same vignette as schizophrenia suggested psychotherapy. More than half the participants who reported schizophrenia selected antipsychotics as the primary response; medication was not a primary recommendation when the vignette was identified as OCD.
Conclusion: Symptoms conceptualized as SSDs were recommended medication; those same symptoms conceptualized as OCD were recommended psychotherapy. Greater awareness regarding the efficacy of psychosocial treatments for SSDs is needed.

Hunter, N., Glazier, K., & McGinn, L. K. (2015). Identical symptomology but different diagnoses: Treatment implications of an OCD versus schizophrenia diagnosis. Psychosis: Psychological, Social and Integrative Approaches. doi:10.1080/17522439.2015.1044462

Implementing a web-based intervention to train community clinicians in an evidence-based psychotherapy: A pilot study

New Study (1)Abstract:

Objective: The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health systems.

Methods: Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques.

Results: Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques.

Conclusions: Internet-supported e-learning by community clinicians was found to be feasible and led to uptake of an evidence-based psychotherapy comparable to that by clinicians who received face-to-face training.

Stein, D. B., Celedonia, K.L.,  Swartz, A. H., DeRosier, E. M., Sorbero, J. M., Brindley, A. R., Burns, M. R., Dick, W. A.,  & Frank, E. (2015) Implementing a Web-Based Intervention to Train Community Clinicians in an Evidence-Based Psychotherapy: A Pilot Study. Psychiatric Services, 66(9). doi.org/10.1176/appi.ps.201400318

Ethical considerations in exposure therapy with children

New Study (1)Abstract:

Despite the abundance of research that supports the efficacy of exposure therapy for childhood anxiety disorders and OCD, negative views and myths about the harmfulness of this treatment are prevalent. These beliefs contribute to the underutilization of this treatment and less robust effectiveness in community settings compared to randomized clinical trials. Although research confirms that exposure therapy is efficacious, safe, tolerable, and bears minimal risk when implemented correctly, there are unique ethical considerations in exposure therapy, especially with children. Developing ethical parameters around exposure therapy for youth is an important and highly relevant area that may assist with the effective generalization of these principles. The current paper reviews ethical issues and considerations relevant to exposure therapy for children and provides suggestions for the ethical use of this treatment.

Gola, A. J., Beidas, S. R., Antinoro-Burke, D., Kratz, E. H. & Fingerhut, R. (2015). Ethical considerations in exposure therapy with children.  Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2015.04.003

Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: A randomized controlled trial

New Study (1)Abstract:

Major depressive disorder (MDD) is prevalent after traumatic brain injury (TBI); however, there is a lack of evidence regarding effective treatment approaches. We conducted a choice-stratified randomized controlled trial in 100 adults with MDD within 10 years of complicated mild to severe TBI to test the effectiveness of brief cognitive behavioral therapy administered over the telephone (CBT-T) (n = 40) or in-person (CBT-IP) (n = 18), compared with usual care (UC) (n = 42). Participants were recruited from clinical and community settings throughout the United States. The main outcomes were change in depression severity on the clinician-rated, 17-item Hamilton Depression Rating Scale (HAMD-17) and the patient-reported Symptom Checklist-20 (SCL-20) over 16 weeks. There was no significant difference between the combined CBT and UC groups over 16 weeks on the HAMD-17 (treatment effect = 1.2, 95% CI: -1.5-4.0; p = 0.37) and a nonsignificant trend favoring CBT on the SCL-20 (treatment effect = 0.28, 95% CI: -0.03-0.59; p = 0.074). In follow-up comparisons, the CBT-T group had significantly more improvement on the SCL-20 than the UC group (treatment effect = 0.36, 95% CI: 0.01-0.70; p = 0.043) and completers of eight or more CBT sessions had significantly improved SCL-20 scores compared with the UC group (treatment effect = 0.43, 95% CI: 0.10-0.76; p = 0.011). CBT participants reported significantly more symptom improvement (p = 0.010) and greater satisfaction with depression care (p < 0.001), than did the UC group. In-person and telephone-administered CBT are acceptable and feasible in persons with TBI. Although further research is warranted, telephone CBT holds particular promise for enhancing access and adherence to effective depression treatment.

Fann, J.R., Bombardier, C.H., Vannoy, S., Dyer, J., Ludman, E., Dikmen, S., Marshall, K., Barber, J. & Temkin, N. (2015). Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: A randomized controlled trial. J Neurotrauma. 2015 Jan 1;32(1):45-57. doi: 10.1089/neu.2014.3423.

Focusing on Long-Term Weight Loss: The Art of the Possible

Judith Beck_Deborah Beck Busis_2014-2015.jpgDeborah Beck Busis, LCSW

Diet Program Coordinator

Beck Institute for Cognitive Behavior Therapy

A recent article in the American Journal of Public Health (Fildes et al., 2015) reiterates the disheartening statistics on weight loss. This study and many others have shown that most obese people who lose weight gain it back.  In our experience, a major reason for this outcome is that dieters make changes that they are unable to sustain. For example, they reduce their calories too much, eliminate favorite foods, decline social events that include food, or set exercise goals that are too strenuous or time-consuming. When they inevitably return to previous eating, social, and exercise habits, they regain weight, feel helpless, become hopeless and stop their weight loss efforts altogether.


To reverse this trend, we ensure that every change we suggest is reasonable and maintainable. This means that dieters usually do not lose weight as quickly as they have in the past or lose as much weight as they would like. But they are much more likely to keep off the weight (plus about five pounds or so) that they do lose. Our philosophy is that successful weight loss entails figuring out the art of the possible.


One of our dieters, for example, had a very busy schedule and disliked cooking. Through a variety of standard cognitive therapy techniques, we helped her prioritize exercise and healthy eating and then did problem solving. She committed to exercise 30 minutes three to four times a week, which meant reducing (but not eliminating) the time she spent watching television and reading for pleasure. She also chose not to cook dinner at home, so we created a list of healthy take out and frozen options and planned when she could make the time to pick up her food.  Could we have persuaded her to commit to several hours of shopping and cooking every Sunday to prepare healthy meals for the week? Probably. But as she disliked cooking, it seemed likely that at some point she would stop prioritizing and scheduling cooking and be left unprepared with no healthy food for the week.


Another dieter really loved pizza but believed, like many people, that he had to stop eating it altogether to lose weight.  Dieters frequently try to eliminate certain foods or entire food groups, but they almost always revert at some point to eating their favorite foods again (which is fine, as long as it is in moderation). Once they begin eating the “forbidden” food again, though, they overdo it, because they haven’t learned to plan when and how much they’re going to eat nor how to stick to this plan. They interpret their abstinence violation as a sign that they are off track and then have difficulty regaining control over their eating overall.


We taught this dieter a combination of cognitive and behavioral skills so he could stay in control around pizza. First we made a plan. He would go to a pizza shop several times and order two large slices to take out. We identified likely thoughts that would interfere with this plan and created strong responses that he read before he went. He practiced this plan several times, bringing the pizza home so he wouldn’t have immediate access to more. Once he gained confidence in his ability to eat a reasonable amount of pizza in a controlled environment, he practiced eating pizza in more difficult circumstances–when he went out to dinner and to a party. Each time we predicted the thoughts he might have that could lead him off track and developed coping cards for him to read. He was able to gain the skills and confidence to control himself around pizza, which significantly increased the probability of his keeping weight off long-term.


It just doesn’t work for most dieters long term to make changes they can sustain only in the short term. We believe that reversing the dismal statistics on weight loss starts first with a focus on the art of the possible and is predicated on two words: reasonable and maintainable.