Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.     

An empirical review of cognitive therapy for late life depression: does research evidence suggest adaptations are necessary for cognitive therapy with older adults?

This paper describes the treatment of depression in older adults using cognitive behaviour therapy (CBT) as first developed by Beck and colleagues. Evidence for the validity and effectiveness of this form of treatment is considered by reference to published outcome research and meta‐analysis studies. Attempts to compare CBT approaches with other forms of psychotherapy have indicated minimal differences in outcome with all therapy modalities reporting beneficial effects in comparison to no treatment or placebo. It is clear that an empirical evaluation of cognitive‐behaviour therapy for late life depression is still in its early stages as evidenced by the small number of published studies. The clinical issue of whether therapeutic adaptations are necessary in order for cognitive therapy to be effective with older adults is briefly discussed with reference to the literature from outcome research. Copyright © 2001 John Wiley & Sons, Ltd.     

Modified Cognitive Behavior Therapy for Severe,Treatment‐Resistant Obsessive‐Compulsive Disorder in an Adolescent With Autism Spectrum Disorder

There is a high rate of comorbidity between obsessive‐compulsive disorder (OCD) and autism spectrum disorders (ASD). Standard cognitive‐behavior therapy (CBT) protocols have been shown to be less effective in treating OCD in young people with ASD than in typically developing youth. This case study describes the treatment of an adolescent boy with severe, treatment‐resistant OCD and ASD using a modified CBT approach. Modifications to a standard evidence‐based CBT for OCD protocol included extended psychoeducation about anxiety; regular home‐based sessions; and increased involvement of systems, including family and school. Multi‐informant outcome data indicated significant improvements in OCD symptoms over the course of treatment with gains being maintained over a 12‐month follow‐up period. These findings demonstrate the potential efficacy of modified CBT for pediatric OCD in the context of ASD.     

Psychotherapy for depression: A randomized clinical trial comparing schema therapy and cognitive behavior therapy

Background

The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.

Methods

In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.

Results

ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders. Limitations: This study needs replication.

Conclusions

This preliminary research indicates that ST may provide an effective alternative therapy for depression.     

Treatment of major depression in the context of panic disorder.

BACKGROUND: Individuals with major depression frequently have panic attacks, and often panic disorder, but rarely have researchers studied the impact of comorbidity of panic on the outcome of psychological treatment of depression. METHODS: In this study, patients with comorbid panic and depression were first treated with cognitive-behavioral therapy (CBT) for panic. Depression symptoms in this treated group were compared to a group of patients with major depression who were on a minimal therapist contact waitlist. In the second phase of the study, patients in both groups (comorbid and depression-only) were treated with CBT for depression. RESULTS: CBT for panic had little effect on co-existing depression, suggesting a specificity of action for CBT directed at different disorders. In addition, the presence of current or recently remitted panic attacks or agoraphobic avoidance did not interfere with the outcome of CBT for depression. CONCLUSION: These findings stand in contrast to previous studies showing greater linkage between depression and panic in treatment outcome. LIMITATIONS: While there are implications for treatment planning, these conclusions may be limited by the exclusion criteria and the highly structured treatment approach of separating treatment for panic from treatment for depression.     

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.     

A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care

Panic disorder and agoraphobia is a prevalent clinical condition which places heavy demands on treatment resources in primary care. The efficient delivery of evidence‐based psychological treatment for this disorder is therefore important. Previous research has investigated both individual and group treatment formats for cognitive behaviour therapy (CBT) for panic disorder and agoraphobia. These two modalities of treatment delivery are, however, rarely compared within the same study format. Also little is known of patients' preferences regarding treatment delivery formats. The present study investigated the relative efficacy of a group treatment CBT and an individual treatment CBT in comparison with a waiting list control group in the treatment of panic disorder with or without agoraphobia in primary care. Ninety‐seven patients suffering from DSM‐IV panic disorder with or without agoraphobia were randomly allocated to receive either group CBT, individual CBT, or waiting list control. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response was measured by blind assessor, therapist and patient‐rated measures of anxiety, depression, and agoraphobic avoidance, and was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end‐point, in terms of traditional statistical significance, both the group and individual CBT were significantly superior to waiting list control but did not differ significantly from each other. When clinical significance of outcome at treatment end‐point was considered, individual CBT showed a significant advantage over both group CBT and waiting list control. At 3‐month follow‐up, however, the individual CBT treatment group showed significant superiority to the group CBT treatment on clinical significance of outcome on one outcome measure only. This was principally due to a reduction in the proportion of patients achieving criteria of clinically significant change in the individual CBT treatment group over the 3‐month follow‐up period. When given a free choice of group or individual CBT at the end of the waiting list period, the overwhelming majority (95%) of the waiting list patients chose individual CBT. The implications of these findings for future research and for wider clinical practice are discussed. Copyright © 2004 John Wiley & Sons, Ltd.     

What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review

Prior meta-analytic reviews have indicated that cognitive and behavioral treatments are efficacious in treating child and adolescent depression and anxiety. Further, a meta-analysis has suggested that behavioral treatments are superior to nonbehavioral treatments for treating anxiety and depression in youth. However, the prior meta-analysis did not examine direct comparisons between cognitive and behavioral treatments (CBT) and non-CBT treatments, leaving open the possibility that their results were artifactual. The present meta-analysis aggregated results of studies in which CBT treatments were compared with either other bona fide treatments (including other CBT therapies) or non-bona fide therapies. The heterogeneity of the distribution of differences between bona fide treatments as well as a comparison of full (e.g. CBT+Parent training) versus component treatments (e.g., CBT only) were examined. The results indicated that: (a) CBT was more efficacious than non-bona fide therapies; (b) CBT was no more efficacious than bona fide non-CBT treatments (c) the differences between bona fide treatments were homogenously distributed around zero; and (d) full CBT treatments offered no significant benefit over their components. The results strongly suggest that the theoretically purported critical ingredients of CBT are not specifically ameliorative for child and adolescent depression and anxiety.     

Post‐stroke depression: the case for augmented,individually tailored cognitive behavioural therapy

In this review, we begin by considering why post‐stroke depression (PSD) is so prevalent. We then examine the current evidence base to support cognitive behavioural therapy (CBT) as a treatment approach for the condition. While there is limited evidence currently, we demonstrate that much remains to be established with regard to PSD and the efficacy of CBT. We argue there is every reason to believe CBT should be an effective treatment, but that clinicians must augment and individually tailor this approach to ensure effectiveness. We set out our rationale for a novel augmented, individually tailored CBT protocol, and describe five key components that we believe once incorporated, and tested using randomized controlled methods, should enhance treatment outcome of PSD. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: ? Depression is a common consequence of stroke. ? Despite a lack of clear evidence, there is reason to believe cognitive behavioural therapy (CBT) for post‐stroke depression should be effective, if it is adapted and tailored to the specific needs of stroke survivors. ? Augmented and individually tailored therapy using motivational interviewing techniques, grief resolution, selection optimization compensation, cognitive deficits adaptations and executive skills training is recommended. ? It is important to individualize augmented CBT, based on principles of case formulation.     

Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care

BACKGROUND: Patients frequently present with unexplained fatigue in primary care, but there have been few treatment trials in this context. We aimed to test cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for patients presenting to their family doctor with fatigue. Secondly, we described the outcome for a cohort of patients who presented to the same doctors with fatigue, who received standard care, plus a booklet. METHOD: This was a randomized trial, followed by a prospective cohort study. Twenty-two practices in SE England referred 144 patients aged 16 to 75 years with over 3 months of unexplained fatigue. Self-rated fatigue score, the hospital anxiety and depression rating scale, functional impairment, physical step-test performance and causal attributions were measured. In the trial six sessions of CBT or GET were randomly allocated. RESULTS: In the therapy groups the mean fatigue score decreased by 10 points (95% confidence interval (CI) = -25 to -15), with no significant difference between groups (mean difference = -1.3; CI = -3.9 to 1.3). Fewer patients attended for GET. At outcome one-half of patients had clinically important fatigue in both randomized groups, but patients in the group offered CBT were less anxious. Twenty-seven per cent of the patients met criteria for CFS at baseline. Only 25% of this subgroup recovered, compared to 60% of the subgroup that did not meet criteria for CFS. CONCLUSIONS: Short courses of GET were not superior to CBT for patients consulting with fatigue of over 3 months in primary care. CBT was easier 'to sell'. Low recovery in the CFS subgroup suggests that brief treatment is too short.     

Treatment of depression and anxiety in infertile women: cognitive behavioral therapy versus fluoxetine

BACKGROUND: Infertility is a stressful event that can give rise to psychological difficulties. Both psychotherapy and pharmacotherapy are well-established treatments for depression and anxiety. The aim of this study was to compare the effectiveness of cognitive behavioral therapy with fluoxetine in the resolution or decreasing of depression and anxiety in infertile women. METHOD: In a randomized controlled clinical trial, 89 mild to moderate depressed infertile women (Beck scores 10-47) were recruited into three groups; cognitive behavior therapy (CBT), antidepressant therapy, and a control group. Twenty-nine participants in the CBT method received relaxation training, restructuring, and eliminating of negative automatic thoughts and dysfunctional attitudes to depression for 10 sessions. Thirty participants in the pharmacotherapy group took 20 mg fluoxetine daily for 90 days. Thirty control subjects did not receive any intervention. All participants completed the Beck Depression Inventory and Cattell Anxiety Inventory at the beginning and end of the study. Chi2 test, paired t-test, and ANOVA were used to analyze the data. RESULTS: The resolution of depression in the three groups was: fluoxetine group 50%, CBT 79.3%, and control 10%. The mean of the Beck scores at the beginning and end of the study was respectively: fluoxetine 23.2+/-8.6 versus 14.3+/-8.5(p<0.001), CBT 20.1+/-7.9 versus 7.7+/-4.8 (p<0.001), and control 19.8+/-8.5 versus 19.7+/-8.4 (p=0.9). Although both fluoxetine and CBT decreased significantly the mean of BDI scores more than that of the control group, the decrease in the CBT group was significantly more than fluoxetine group. The CBT method decreased significantly the mean of the Cattell scores more than the fluoxetine and control groups, but the decrease in the anxiety mean scores of that fluoxetine group was no more than that of control group. CONCLUSION: CBT was not only a reliable alternative to pharmacotherapy but also was superior to fluoxetine in the resolution or reducing of depression and anxiety of infertile women. Fluoxetine was superior to no therapy in the treatment of depression but not anxiety.     

Components Analyses of a School-Based Cognitive Behavioral Treatment for Youth Depression

The current study sought to build upon research on cognitive behavioral therapy (CBT) as the first-line treatment for depressed youth by investigating the effects of the various components of a CBT treatment on changes in depressive symptoms in young female participants. Female participants 9–14 years of age (n = 40; M age = 10.58 years) with a diagnosis of a depressive disorder from the CBT-only treatment condition of a larger randomized clinical trial were included in the current study. Participants engaged in a 20-session, 11-week, school-based CBT group intervention (ACTION Treatment; Stark et al., 2006). Depressive symptoms were assessed pre- and posttreatment, and intervention components were coded based on review of audio recordings of treatment sessions. Data were examined using two-level mixed-effects models using hierarchical linear modeling with full maximum likelihood estimation. Results indicated that higher quality behavioral intervention components were associated with greater improvement in posttreatment depression scores, higher quality cognitive intervention components were marginally associated with worsening posttreatment depression scores, and relational intervention components were not associated with depression outcome. Age significantly moderated the relationships between intervention components and depression outcome, with younger female participants benefiting most from higher quality behavioral and relational intervention components. These findings provide preliminary evidence about the differential impact of CBT components on depression treatment outcome for young female participants, with consideration of age as a moderator. This study highlights the importance of continuing to dismantle CBT treatment components for youth depression, as such findings can be used to design more potent, developmentally tailored interventions.     

The relationship between expected engagement and talking therapy outcome

The aim of the study was to investigate whether client‐reported expected engagement with therapy predicted therapy outcome. It was hypothesized that higher expected engagement with cognitive behavioural therapy (CBT) or person‐centred experiential therapy (PCET) would predict more symptomatic improvement following therapy and higher likelihood of therapy completion. The Sheffield Expected Engagement with Therapy Scale was administered to 96 clients at pre‐therapy assessment with all meeting a diagnosis of moderate or severe depression with 53 receiving CBT and 43 receiving PCET. Higher expected engagement predicted more symptomatic improvement in CBT but not PCET. Expected engagement only predicted improvement in CBT when clients rated the credibility of CBT as low or moderate. Expected engagement did not predict therapy completion in either therapy. Assessment of expected engagement could be a useful tool in prediction of symptomatic improvement in CBT.     

Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating,Improving, and Transporting What Works

Pediatric obsessive-compulsive disorder is a chronic and impairing condition that often persists into adulthood. This review refreshes the state of support for psychosocial treatments and the predictors or moderators that relate to their efficacy and evaluates how the literature has improved since the last update in 2014. A secondary goal is to propose an additional framework for the categorization of studies based on central research questions rather than treatment format. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the Journal of Clinical Child and Adolescent Psychology evidence-based treatment evaluation criteria. Findings again converge in support of cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with obsessive-compulsive disorder. Family-focused CBT is now well-established. A number of other treatments including CBT+ D-Cycloserine, CBT+ Sertraline, CBT+ positive family interaction therapy, and technology-based CBT are now probably efficacious. Demographic, clinical, and family factors are consistent predictors of CBT outcome with conflicting findings for neurocognitive predictors. The field has advanced significantly since the last review, but there is still room for improvement. Some of the conclusions that can be drawn may be limited by our evaluation criteria. Future directions are proposed to advance treatment outcome research beyond a focus on which treatments work to exploring factors that account for how and why they work.     

Predicting time to recovery among depressed adolescents treated in two psychosocial group interventions

Aims were to identify the demographic, psychopathology, and psychosocial factors predicting time to major depressive disorder (MDD) recovery and moderators of treatment among 114 depressed adolescents recruited from a juvenile justice center and randomized to a cognitive behavioral treatment (CBT) condition or a life skills-tutoring control condition. Nine variables predicted time to recovery over 1-year follow-up (e.g., earlier MDD onset, attention-deficit/hyperactivity disorder, functional impairment, hopelessness, negative thoughts, low family cohesion, coping skills); suicidal ideation and parental report of problem behaviors were the best predictors. CBT resulted in faster recovery time relative to control treatment, specifically among adolescents of White ethnicity, with recurrent MDD, and with good coping skills. Results suggest that psychopathology plays a more prominent role in maintaining adolescent depression than demographic or psychosocial factors.     

Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment

The clinical efficacy of cognitive behavior therapy (CBT) for chronic insomnia has been established, yet clinical effectiveness is less clear. This study presents data on 109 patients from general practice during a formal evaluation of clinical effectiveness. Two thirds achieved normative values of < or =30 min for sleep latency and wakefulness during the night after CBT. Furthermore, almost half of the sample reduced sleeplessness by > or =50%. Logistic regression revealed that initial severity did not contraindicate good outcome. Rather, greater sleep disturbance was positively associated with large symptom reduction, although lower endpoint scores were less likely. Similarly, symptoms of anxiety, depression, and thinking errors positively predicted good outcome. Hypnotic using patients responded equally well to CBT, and demographic factors were of no significant predictive value. It is concluded that CBT is clinically and durably effective for persistent insomnia in routine practice.     

Rapid Early Response, Cognitive Modification, and Nonspecific Factors in Cognitive Behavior Therapy for Depression: A Reply to Tang and DeRubeis

Tang and DeRubeis (this issue) challenge the Ilardi and Craighead (1994) hypothesis that nonspecific factors mediate a large proportion of clinical improvement In cognitive behavior therapy (CUT) for depression, and argue that Beck's cognitive hypothesis is not contradicted by the phenomenon of rapid early treatment response. They propose (a) that cognitive modification techniques are introduced in CBT as early as Session 2, (b) that dose-response analyses are inconsistent with the rapid early response pattern, and (c) that observed heterogeneity of patient temporal response curves is problematic for the nonspecific factors hypothesis. In response, we note that (a) there is no compelling evidence that cognitive modification techniques are routinely implemented prior to Week 3 of CBT, (b) disproportionately rapid improvement In depressive symptoms typically occurs over the first six sessions (3 weeks) of CBT, and (c) the two newly reported heterogeneous temporal response patterns are each consistent with the hypothesis of nonspecific mediation of clinical improvement.     

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

In a controlled clinical trial, 57 Ss meeting DSM-III-R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4-12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.     

One-year follow-up results of a randomized controlled clinical trial on internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years

BACKGROUND: Internet-based cognitive behaviour therapy (CBT) is a promising new approach for the treatment of depressive symptoms. The current study had two aims: (1) to determine whether, after 1 year, an internet-based CBT intervention was more effective than a waiting-list control group; and (2) to determine whether the effect of the internet-based CBT differed from the group CBT intervention, 1 year after the start of treatment. METHOD: A total of 191 women and 110 men (mean age=55 years, s.d.=4.6) with subthreshold depression were randomized into internet-based treatment, group CBT (Lewinsohn's Coping with Depression Course), or a waiting-list control condition. The main outcome measure was treatment response after 1 year, defined as the difference in pretreatment and follow-up scores on the Beck Depression Inventory (BDI). Missing data were imputed using the multiple imputation procedure of data augmentation. Analyses were performed using multiple imputation inference. RESULTS: In the waiting-list control group, we found a pretreatment to follow-up improvement effect size of 0.69, which was 0.62 in the group CBT condition and 1.22 with the internet-based treatment condition. Simple contrasts showed a significant difference between the waiting-list condition and internet-based treatment (p=0.03) and no difference between both treatment conditions (p=0.08). CONCLUSIONS: People aged over 50 years with subthreshold depression can still benefit from internet-based CBT 1 year after the start of treatment.