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Acceptance-Oriented CBT with Highly Distressed Rheumatic Disease Patients

CBT studyOBJECTIVE: 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.

Telephone-CBT is Effective for Adolescents with OCD

OBJECTIVE: Many adolescents with obsessive-compulsive disorder (OCD) do not have access to evidence-based treatment. A randomized controlled non-inferiority trial was conducted in a specialist OCD clinic to evaluate the effectiveness of telephone cognitive-behavioral therapy (TCBT) for adolescents with OCD compared to standard clinic-based, face-to-face CBT.

METHOD: Seventy-two adolescents, aged 11 through 18 years with primary OCD, and their parents were randomized to receive specialist TCBT or CBT. The intervention provided differed only in the method of treatment delivery. All participants received up to 14 sessions of CBT, incorporating exposure with response prevention (E/RP), provided by experienced therapists. The primary outcome measure was the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Blind assessor ratings were obtained at midtreatment, posttreatment, 3-month, 6-month, and 12-month follow-up.

RESULTS: Intent-to-treat analyses indicated that TCBT was not inferior to face-to-face CBT at posttreatment, 3-month, and 6-month follow-up. At 12-month follow-up, there were no significant between-group differences on the CY-BOCS, but the confidence intervals exceeded the non-inferiority threshold. All secondary measures confirmed non-inferiority at all assessment points. Improvements made during treatment were maintained through to 12-month follow-up. Participants in each condition reported high levels of satisfaction with the intervention received.

CONCLUSION: TCBT is an effective treatment and is not inferior to standard clinic-based CBT, at least in the midterm. This approach provides a means of making a specialized treatment more accessible to many adolescents with OCD. Clinical trial registration information-Evaluation of telephone-administered cognitive-behaviour therapy (CBT) for young people with obsessive-compulsive disorder (OCD); http://www.controlled-trials.com; ISRCTN27070832.

Turner, C. M., Mataix-Cols, D., Lovell, K., Krebs, G., Lang, K., Byford, S., & Heyman, I. (2014). Telephone Cognitive-Behavioral Therapy for Adolescents with Obsessive-Compulsive Disorder: A Randomized Controlled Non-inferiority Trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 12, 1298-1307.

CBT Alleviates Treatment-Induced Menopausal Symptoms in Breast Cancer Patients

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.

Preexposure Prophylaxis Adherence Intervention in HIV-Serodiscordant Couples in Uganda

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.

Internet-Based CBT is Effective for Panic Disorder

OBJECTIVE: Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care.

METHOD: We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR).

RESULTS: Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen’s d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up.

CONCLUSIONS: This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

Hedman, E., Ljo?tsson, B., Ru?ck, C., Bergstro?m, J., Andersson, G., Kaldo, V., Jansson, L., … Lindefors, N. (January 01, 2013). Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica, 128, 6, 457-67.

Group CBT for Social Anxiety Disorder: A Meta-Analysis

OBJECTIVE: A few meta-analyses have examined psychological treatments for a social anxiety disorder (SAD). This is the first meta-analysis that examines the effects of cognitive behavioural group therapies (CBGT) for SAD compared to control on symptoms of anxiety.

METHOD: After a systematic literature search in PubMed, Cochrane, PsychINFO and Embase was conducted; eleven studies were identified that met the inclusion criteria. The studies had to be randomized controlled studies in which individuals with a diagnosed SAD were treated with cognitive-behavioural group therapy (CBGT) and compared with a control group. The overall quality of the studies was moderate.

RESULTS: The pooled effect size indicated that the difference between intervention and control conditions was 0.53 (96% CI: 0.33-0.73), in favour of the intervention. This corresponds to a NNT 3.24. Heterogeneity was low to moderately high in all analyses. There was some indication of publication bias.

CONCLUSIONS: It was found that psychological group-treatments CBGT are more effective than control conditions in patients with SAD. Since heterogeneity between studies was high, more research comparing group psychotherapies for SAD to control is needed.

Wersebe, H., Sijbrandij, M., & Cuijpers, P. (January 01, 2013). Psychological group-treatments of social anxiety disorder: a meta-analysis. Plos One, 8, 11.)

CBT is Effective for Pathological Gambling

OBJECTIVE: Clinicians lack adequate data on the effectiveness of treatment for pathological gambling in low- and middle-income countries.

METHODS: We evaluated a manualized treatment program that included components of cognitive-behavioral therapy, motivational interviewing, and imaginal exposure in a sample of 128 participants diagnosed with pathological gambling. Our team recruited participants via the helpline of the National Responsible Gambling Program (NRGP) of South Africa between May 2011 and February 2012. Eligible participants, who met the DSM-IV-TR criteria for pathological gambling as assessed by the Structured Clinical Interview for Pathological Gambling (SCI-PG), were referred to practitioners who had been trained in the intervention technique. We then compared pre- and post-treatment scores obtained on the Yale-Brown Obsessive-Compulsive Scale Adapted for Pathological Gambling (PG-YBOCS), the primary outcome measure, and the Sheehan Disability Scale (SDS), the secondary outcome measure.

RESULTS: Scores obtained on the PG-YBOCS and the SDS both decreased significantly from the first to the final session (t[127] = 23.74, P < .001, r = .9; t[127] = 19.23, P < .001, r = .86, respectively).

CONCLUSIONS: The urges and disability symptoms related to pathological gambling were significantly reduced among participants completing treatment. These preliminary results hold promise for individuals with pathological gambling in South Africa and other low- and middle-income countries.

Pasche, S. C., Stein, D. J., Sinclair, H., Sinclair, H., Collins, P., Pretorius, A., & Grant, J. E. (January 01, 2013). The effectiveness of a cognitive-behavioral intervention for pathological gambling: A country-wide study. Annals of Clinical Psychiatry, 25, 4, 250-256.

Modified Illness Perceptions Questionnaire Predicts Response to CBT for Psychosis

OBJECTIVE: Clinical responsiveness to cognitive behavioural therapy for psychosis (CBTp) varies. Recent research has demonstrated that illness perceptions predict active engagement in therapy, and, thereby, better outcomes. In this study, we aimed to investigate the psychometric properties of a modification of the Illness Perceptions Questionnaire (M-IPQ) designed to predict response following CBTp.

METHODS: Fifty-six participants with persistent, distressing delusions completed the M-IPQ; forty before a brief CBT intervention targeting persecutory ideation and sixteen before and after a control condition. Additional predictors of outcome (delusional conviction, symptom severity and belief inflexibility) were assessed at baseline. Outcomes were assessed at baseline and at follow-up four to eight weeks later.

RESULTS: The M-IPQ comprised two factors measuring problem duration and therapy-specific perceptions of Cure/Control. Associated subscales, formed by summing the relevant items for each factor, were reliable in their structure. The Cure/Control subscale was also reliable over time; showed convergent validity with other predictors of outcome; predicted therapy outcomes; and differentially predicted treatment effects.

LIMITATIONS: We measured outcome without an associated measure of engagement, in a small sample. Findings are consistent with hypothesis and existing research, but require replication in a larger, purposively recruited sample.

CONCLUSIONS: The Cure/Control subscale of the M-IPQ shows promise as a predictor of response to therapy. Specifically targeting these illness perceptions in the early stages of cognitive behavioural therapy may improve engagement and, consequently, outcomes.

Marcus, E., Garety, P., Weinman, J., Emsley, R., Dunn, G., Bebbington, P., Freeman, D., … Jolley, S. (December 01, 2014). A pilot validation of a modified Illness Perceptions Questionnaire designed to predict response to cognitive therapy for psychosis. Journal of Behavior Therapy and Experimental Psychiatry, 45, 4, 459-466.

Mental Imagery in Bipolar Affective Disorder versus Unipolar Depression during Times of ‘Positive’ Mood

OBJECTIVE: Compared to unipolar depression (UD), depressed mood in bipolar disorder (BD) has been associated with amplified negative mental imagery of the future (‘flashforwards’). However, imagery characteristics during positive mood remain poorly explored. We hypothesise first, that unlike UD patients, the most significant positive images of BD patients will be ‘flashforwards’ (rather than past memories). Second, that BD patients will experience more frequent (and more ‘powerful’) positive imagery as compared to verbal thoughts and third, that behavioural activation scores will be predicted by imagery variables in the BD group.

METHOD: BD (n=26) and UD (n=26) patients completed clinical and trait imagery measures followed by an Imagery Interview and a measure of behavioural activation.

RESULTS: Compared to UD, BD patients reported more ‘flashforwards’ compared to past memories and rated their ‘flashforwards’ as more vivid, exciting and pleasurable. Only the BD group found positive imagery more ‘powerful’, (preoccupying, ‘real’ and compelling) as compared to verbal thoughts. Imagery-associated pleasure predicted levels of drive and reward responsiveness in the BD group.

CONCLUSIONS: This study reveals BD patients experience positive ‘flashforward’ imagery in positive mood, with more intense qualities than UD patients. This could contribute to the amplification of emotional states and goal directed behaviour leading into mania, and differentiate BD from UD.

Ivins, A., Di, S. M., Close, H., Goodwin, G. M., & Holmes, E. (September 01, 2014). Mental imagery in bipolar affective disorder versus unipolar depression: Investigating cognitions at times of ‘positive’ mood. Journal of Affective Disorders, 166, 12, 234-242.

Computer-Assisted CBT (CBT4CBT) is Effective for Cocaine-Dependent Individuals on Methadone

OBJECTIVE: A previous pilot trial evaluating computer-based training for cognitive-behavioral therapy (CBT4CBT) in 77 heterogeneous substance users (alcohol, marijuana, cocaine, and opioids) demonstrated preliminary support for its efficacy in the context of a community-based outpatient clinic. The authors conducted a more definitive trial in a larger, more homogeneous sample.

METHOD: In this randomized clinical trial, 101 cocaine-dependent individuals maintained on methadone were randomly assigned to standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT, with seven modules delivered within an 8-week trial.

RESULTS: Treatment retention and data availability were high and comparable across the treatment conditions. Participants assigned to the CBT4CBT condition were significantly more likely to attain 3 or more consecutive weeks of abstinence from cocaine (36% compared with 17%; p<0.05, odds ratio=0.36). The group assigned to CBT4CBT also had better outcomes on most dimensions, including urine specimens negative for all drugs, but these reached statistical significance only for individuals completing the 8-week trial (N=69). Follow-up data collected 6 months after treatment termination were available for 93% of the randomized sample; these data indicate continued improvement for those assigned to the CBT4CBT group, replicating previous findings regarding its durability.

CONCLUSIONS: This trial replicates earlier findings indicating that CBT4CBT is an effective adjunct to addiction treatment with durable effects. CBT4CBT is an easily disseminable strategy for broadening the availability of CBT, even in challenging populations such as cocaine-dependent individuals enrolled in methadone maintenance programs.

Carroll, K. M., Kiluk, B. D., Nich, C., Gordon, M. A., Portnoy, G. A., Marino, D. R., & Ball, S. A. (April 01, 2014). Computer-assisted delivery of cognitive-behavioral therapy: Efficacy and durability of cbt4cbt among cocaine-dependent individuals maintained on methadone. American Journal of Psychiatry, 171, 4, 436-444.