No Train,No Gain?

[Clin Psychol Sci Prac 17: 36–40, 2010] What kind of training is needed for what type of clinician to deliver what type of therapy? Beidas and Kendall’s (2010) well‐considered recommendations for further research into systematic strategies for training clinicians to utilize evidence‐based treatments highlight the limitations of didactic training alone (without supervision, fidelity monitoring, and feedback) in conferring specific skills to clinicians. To further amplify some of the points made, we summarize findings from our recent series of trials, which involved training community‐based addiction clinicians to perform evidence‐based therapies in a multisite randomized clinical trial. In particular, review of tapes from the “treatment as usual” condition in that study suggests that (a) delivery of interventions associated with evidence‐based treatment was infrequent, (b) clinicians overestimated the time spent on evidence‐based interventions, and (c) ongoing supervision and performance‐based feedback appear to suppress time spent in session on discourse unrelated to the patient’s problems and concerns. We also discuss computer‐assisted treatment and computer‐assisted clinician training as important new tools for disseminating evidence‐based therapies.     

Autism Spectrum Disorder and Evidence‐Based Practice in Psychology

The article discusses current empirical evidence, also identifying gaps and areas for future research, for the three critical elements of evidence‐based practice in psychology (EBPP) (evidence‐based practice; client characteristics, preferences, and culture; and clinical expertise) as applied to autism spectrum disorder (ASD). We contrast EBPP to a pure EBP approach, outline issues in specifying criteria and sources for defining EBP, and identify gaps in the evidence base (e.g., treatments for adults with ASD). We review the impact on treatment of specific client characteristics (client age, ASD severity, intellectual and language ability, diagnostic comorbidity, cultural/family factors) and outline critical issues affecting clinical expertise and decision making when choosing and adapting treatments. Implications for policy, training, and research are discussed.     

Cognitive Behavioral Therapy and Graded Exercise for Chronic Fatigue Syndrome: A Meta‐Analysis

[Clin Psychol Sci Prac 18: 311–324, 2011] Several reviews have concluded that graded exercise therapy (GET) and cognitive behavioral therapy (CBT) may be the most efficacious treatments for chronic fatigue syndrome (CFS). The current review extends the evidence for overall and outcome‐specific effects of CBT and GET by directly comparing the treatments and addressing the methodological limitations of previous reviews. GET (n = 5) and CBT (n = 16) randomized controlled trials were meta‐analyzed. Overall effect sizes suggested that GET (g = 0.28) and CBT (g = 0.33) were equally efficacious. However, CBT effect sizes were lower in primary care settings and for treatments offering fewer hours of contact. The results suggested that both CBT and GET are promising treatments for CFS, although CBT may be a more effective treatment when patients have comorbid anxiety and depressive symptoms.     

Now That We Have a Strong Building,Let’s Add a Few Floors

[Clin Psychol Sci Prac 18: 178–181, 2011] The new review by Chorpita and colleagues (2011) indicates an expanded number of evidence‐based interventions for child and adolescent disorders. Notably, some of the best new treatments combine psychotherapy and medication. The new review wisely includes promising interventions with emerging or lower levels of empirical support. Overall, the evidence base for child and adolescent interventions is broad and strong. Future reviews should provide further differentiation among interventions with higher levels of support. Specifically, the notion of treatment equivalence needs more rigorous justification, effect sizes should be interpreted in the context of trial designs, and reviews should emphasize indices of the quality of supportive evidence.     

The Cognitive and Behavioral Treatment of PTSD,What Is Known and What Is Known to Be Unknown: How Not to Fall Into the Practice Gap

[Clin Psychol Sci Prac 17: 134–143, 2010] Posttraumatic stress disorder is a serious potential consequence of suffering severe trauma. Effective treatments exist, and these include both cognitive and behavioral, mainly exposure‐based treatments. How clinical practice can be guided by the research evidence is a difficult question given the research‐practice gap, and clinicians have a duty of care to provide the optimum treatment for their individual patients. Such duty includes not only taking into account the evidence from clinical trials but also a recognition that there is considerable potential heterogeneity in trauma patients. Factors that influence which treatment is recommended and where future development lies include the following: any potential advantage one treatment has when there is equivalent efficacy; the persistence of physical injury, pain, and disability; presence of medical illness; persistent or long‐term exposure to traumatic stress; comorbidity of psychological disorders; suicide risk and exposure to aversive psychosocial environments. Lastly, the development of positive psychology may offer further treatment options.     

A meta‐analysis of the effects of internet‐ and computer‐based cognitive‐behavioral treatments for anxiety

Internet‐and computer‐based cognitive‐behavioral treatments have been introduced as novel approaches to deliver standard, quality treatment that may reduce barriers to care. The purpose of this review is to quantitatively summarize the literature examining the treatment effects of Internet‐ or computer‐based treatment (ICT) on anxiety. Nineteen randomized controlled ICT trials were identified and subjected to fixed and random effects meta‐analytic techniques. Weighted mean effect sizes (Cohen's d) showed that ICT was superior to waitlist and placebo assignment across outcome measures (ds=.49–1.14). The effects of ICT also were equal to therapist‐delivered treatment across anxiety disorders. However, conclusions were limited by small sample sizes, the rare use of placebo controls, and other methodological problems. In addition, the number of available studies limited the opportunity to conduct analyses by diagnostic group; there was preliminary support for the use of ICT for panic disorder and phobia. Large, well‐designed, placebo‐controlled trials are needed to confirm and extend the results of this meta‐analysis. © 2008 Wiley Periodicals, Inc. J Clin Psychol 65: 1–21, 2009.     

A Large‐Scale Dissemination and Implementation Model for Evidence‐Based Treatment and Continuing Care

[Clin Psychol Sci Prac 18: 67–83, 2011] Multiple evidence‐based treatments for adolescents with substance use disorders are available; however, the diffusion of these treatments in practice remains minimal. A dissemination and implementation model incorporating research‐based training components for simultaneous implementation across 33 dispersed sites and over 200 clinical staff is described. Key elements for the diffusion of the Adolescent Community Reinforcement Approach and Assertive Continuing Care were as follows: (a) 3 years of funding to support local implementation; (b) comprehensive training, including a 3.5‐day workshop, biweekly coaching calls, and ongoing performance feedback facilitated by a web tool; (c) a clinician certification process; (d) a supervisor certification process to promote long‐term sustainability; and (e) random fidelity reviews after certification. Process data are summarized for 167 clinicians and 64 supervisors.     

Nonpharmacological interventions aimed at modifying health and behavioural outcomes for adults with asthma: a critical review

Evidence suggests that living with asthma is linked with psychological and behavioural factors including self‐management and treatment adherence, and therefore, there is a reasonable hypothesis that nonpharmacological treatments may improve health outcomes in people living with this condition. A systematic review of randomized controlled trials (RCTs) of nonpharmacological interventions for adults with asthma was designed. Databases searched included The Cochrane Airways Group Register of trials, CENTRAL and Psychinfo. The literature search was conducted until May 2014. Twenty‐three studies met the inclusion criteria and were organized into four groups: relaxation‐based therapies (n = 9); mindfulness (n = 1), biofeedback techniques (n = 3); cognitive behavioural therapies (CBT) (n = 5); and multicomponent interventions (n = 5). A variety of outcome measures were used, even when trials belonged to the same grouping, which limited the ability to conduct meaningful meta‐analyses. Deficiencies in the current evidence base, notably trial heterogeneity, means that application to clinical practice is limited and clear guidelines regarding the use of nonpharmacological therapies in asthma is limited. Relaxation and CBT, however, appear to have a consistent positive effect on asthma‐related quality of life and some psychological outcomes, and lung function (relaxation only). Future trials should be informed by previous work to harmonize the interventions under study and outcome measures used to determine their effectiveness; only then will meaningful meta‐analyses inform clinical practice.     

Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression

Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30-year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and reevaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in subclinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and interpersonal psychotherapy are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. Data on predictors, moderators, and mediators are examined and priorities for future research discussed.     

Long‐term periodic anthelmintic treatments are associated with increased allergen skin reactivity

Background The low prevalence of allergic disease in the rural tropics has been attributed to the protective effects of chronic helminth infections. There is concern that treatment‐based control programmes for these parasites may lead to an increase in the prevalence of allergic diseases. Objective We measured the impact of 15–17 years of anthelmintic treatment with ivermectin on the prevalence of allergen skin test reactivity and allergic symptoms in school‐age children. Methods The prevalence of allergen skin test reactivity, exercise‐induced bronchospasm and allergic symptoms was compared between school‐age children living in communities that had received community‐based treatments with ivermectin (for onchocerciasis control) for a period of 15–17 years with those living in geographically adjacent communities that had received no ivermectin. Results The prevalence of allergen skin test reactivity was double in children living in treated communities compared with those in untreated communities (16.7% vs. 8.7%, adjusted OR 2.10, 95% CI 1.50–2.94, P<0.0001), and the effect was mediated partly by a reduced prevalence of Trichuris trichiura among treated children. Ivermectin treatments were associated with an increased prevalence of recent eczema symptoms (adjusted OR 2.24, 95% CI 1.05–4.78, P=0.04) but not symptoms of asthma or rhino‐conjunctivitis. The effect on eczema symptoms was not associated with reductions in geohelminth infections. Conclusion Long‐term periodic treatments with ivermectin were associated with an increased prevalence of allergen skin test reactivity. There was some evidence that treatment was associated with an increased prevalence of recent eczema symptoms but not those of asthma or rhino‐conjunctivitis. Cite this as: P. Endara, M. Vaca, M. E. Chico, S. Erazo, G. Oviedo, I. Quinzo, A. Rodriguez R. Lovato, A.‐L. Moncayo, M. L. Barreto, L. C. Rodrigues and P. J. Cooper, Clinical & Experimental Allergy, 2010 (40) 1669–1677.     

The impact of client treatment preferences on outcome: a meta‐analysis

An important part of evidence‐based practice is to include client preferences in the treatment decision‐making process. However, based on previous reviews of the literature there is some question as to whether including client preferences actually has an effect on treatment outcome. This meta‐analytic review summarized data from over 2,300 clients across 26 studies comparing the treatment outcome differences between clients matched to a preferred treatment and clients not matched to a preferred treatment. The findings indicate a small significant effect (r=.15, CI_.95: .09 to .21) in favor of clients who received a preferred treatment. The binomial effect size indicated that matched clients have a 58% chance of showing greater improvement, and further analysis indicate that they are about half as likely to drop‐out of treatment when compared with clients not receiving a preferred treatment. Study design was seen to be a moderating variable in that partially randomized preference trials may underestimate the treatment preference effect. Implications for best practice standards are discussed. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–14, 2009.     

EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy

Food allergy can have significant effects on morbidity and quality of life and can be costly in terms of medical visits and treatments. There is therefore considerable interest in generating efficient approaches that may reduce the risk of developing food allergy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Prevention and is part of the EAACI Guidelines for Food Allergy and Anaphylaxis. It aims to provide evidence‐based recommendations for primary prevention of food allergy. A wide range of antenatal, perinatal, neonatal, and childhood strategies were identified and their effectiveness assessed and synthesized in a systematic review. Based on this evidence, families can be provided with evidence‐based advice about preventing food allergy, particularly for infants at high risk for development of allergic disease. The advice for all mothers includes a normal diet without restrictions during pregnancy and lactation. For all infants, exclusive breastfeeding is recommended for at least first 4–6 months of life. If breastfeeding is insufficient or not possible, infants at high‐risk can be recommended a hypoallergenic formula with a documented preventive effect for the first 4 months. There is no need to avoid introducing complementary foods beyond 4 months, and currently, the evidence does not justify recommendations about either withholding or encouraging exposure to potentially allergenic foods after 4 months once weaning has commenced, irrespective of atopic heredity. There is no evidence to support the use of prebiotics or probiotics for food allergy prevention.     

Anorexia Nervosa as a Disorder of Emotion Dysregulation: Theory,Evidence, and Treatment Implications

[Clin Psychol Sci Prac 18: 203–207, 2011] At present, no evidence‐based treatments are available showing benefit for adults with anorexia nervosa (AN). Reasons for the absence of large‐scale controlled trials include AN’s relative rarity and challenges regarding participant retention. A promising investigative field is neuropsychology. Findings that AN patients demonstrate specific deficits in executive functioning are currently being translated into clinical interventions (e.g., cognitive remediation therapy). Emerging in parallel is literature emphasizing the role of emotion regulation deficits in disordered behavior. Originally developed for borderline personality disorder, emotion regulation–based treatments have been adapted for bulimia and binge eating. Haynos and Fruzzetti (2011) propose the utility of extending emotion dysregulation theories and treatments to AN, presenting evidence to support the need for further exploration in this area.     

Using Treatment Integrity Methods to Study the Implementation Process

[Clin Psychol Sci Prac 18: 36–40, 2011] The last decade has witnessed increased interest in the implementation and dissemination of evidence‐based treatments (EBTs) for youth. Nakamura et al. (2011) detail lessons learned over the past decade from the large‐scale implementation of EBTs for children in Hawaii. This commentary discusses how lessons from Hawaii’s initiative can help inform the next generation of implementation research. Specifically, we focus on how treatment integrity models and methods designed to characterize core aspects of treatment delivery can be used to study the implementation process. Using the new interactive online reporting systems developed by Nakamura et al. to collect treatment integrity data offers researchers a way to determine how best to implement EBTs in community‐based service settings with integrity and skill.     

DNA methylation of FKBP5 and response to exposure‐based psychological therapy

Differential DNA methylation of the hypothalamic‐pituitary‐adrenal axis related gene FKBP5 has recently been shown to be associated with varying response to environmental influences and may play a role in how well people respond to psychological treatments. Participants (n = 111) received exposure‐based cognitive behavioural therapy (CBT) for agoraphobia with or without panic disorder, or specific phobias. Percentage DNA methylation levels were measured for the promoter region and intron 7 of FKBP5. The association between percentage reduction in clinical severity and change in DNA methylation was tested using linear mixed models. The effect of genotype (rs1360780) was tested by the inclusion of an interaction term. The association between change in DNA methylation and FKBP5 expression was examined. Change in percentage DNA methylation at one CpG site of intron 7 was associated with percentage reduction in severity (β = ?4.26, p = 3.90 × 10^?4), where a decrease in DNA methylation was associated with greater response to therapy. An interaction was detected between rs1360780 and changes in DNA methylation in the promoter region of FKBP5 on treatment outcome (p = .045) but did not survive correction for multiple testing. Changes in DNA methylation were not associated with FKBP5 expression. Decreasing DNA methylation at one CpG site of intron 7 of FKBP5 was strongly associated with decreasing anxiety severity following exposure‐based CBT. In addition, there was suggestive evidence that allele‐specific methylation at the promoter region may also be associated with treatment response. The results of this study add to the growing literature demonstrating the role of biological processes such as DNA methylation in response to environmental influences.     

Cognitive behavioural therapy and the psychopathology of schizophrenia: Systematic review and meta‐analysis

Purpose. To examine whether cognitive behaviour therapy (CBT) reduces psychopathology in patients with schizophrenia more effectively than the use of non‐cognitive psychotherapies. Method. Systematic review and meta‐analysis of the literature was performed. All Randomized Controlled Trials meeting the inclusion criteria were analysed using RevMan software. This design was used to maximize power and study efficacy. Medline, PsycINFO, and Embase were searched using free‐text keywords to identify potential papers. Nine were included in the final meta‐analysis. Change in psychopathology at the end of therapy was the end point investigated. A random effects model was used to assess the standard mean difference between the CBT and supportive control groups. Results. Meta‐analysis of CBT versus supportive therapy did not find significant differences between the therapy groups at the end of treatment in respect of psychopathology. There was no evidence of publication bias. Post hoc power analysis using the Z test ruled out type one error. Conclusions. Theoretically based CBT therapies, although proving effective, may not out perform more accessible and simpler forms of therapy for patients with schizophrenia in reducing psychopathology. Consideration of supportive therapy should be made for patients with psychotic mental disorder.

Practitioner Points

• ? CBT may not be the psychotherapeutic treatment of choice to alleviate the phenomenology of Schizophrenia.
• ? It may be valuable trialling simple supportive therapies prior to implementing more costly and complex cognitive therapies.
• ? This review, like the Cochrane review and others, does not suggest CBT in psychosis is not effective, simply that it dose not outperform supportive therapy in effecting change in phenomenology.