Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome

OBJECTIVE: To determine which factors impact on the efficacy of cognitive behavioural therapy (CBT) for depression and anxiety. Factors considered include those related to clinical practice: disorder, treatment type, duration and intensity of treatment, mode of therapy, type and training of therapist and severity of patients. Factors related to the conduct of the trial were also considered, including: year of study, country of study, type of control group, language, number of patients and percentage of dropouts from the trial. METHOD: We used the technique of meta-analysis to determine an overall effect size (standardized mean difference calculated using Hedges' g) and meta-regression to determine the factors that impact on this effect size. We included randomized controlled trials with a wait list, pill placebo or attention/psychological placebo control group. Study participants had to be 18 years or older and all have diagnosed depression, panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD). Outcomes of interest included symptom, functioning and health-related quality of life measures, reported as continuous variables at post-treatment. RESULTS: Cognitive behavioural therapy for depression, panic disorder and GAD had an effect size of 0.68 (95% CI=0.51-0.84, n=33 studies, 52 comparisons). The heterogeneity in the effect sizes was fully explained by treatment, duration of therapy, inclusion of severe patients in the trial, year of study, country of study, control group, language and number of dropouts from the control group. Disorder was not a significant predictor of the effect size. CONCLUSIONS: Cognitive behavioural therapy is significantly less effective for severe patients and trials that compared CBT to a wait-list control group found significantly larger effect sizes than those comparing CBT to an attention placebo, but not to a pill placebo. Further research is needed to determine whether CBT is effective when provided by others than psychologists and whether it is effective for non-English-speaking patient groups.     

Cognitive-behavioral therapy for bipolar disorders in adolescents: a pilot study

Objectives:  To develop a cognitive behavioral intervention for adolescents with bipolar disorders, test its feasibility and preliminary efficacy.
Methods:  Based on existing research, a manualized, individually delivered cognitive behavioral intervention was developed and tested with adolescents with bipolar disorders as an adjunct to pharmacological treatment. Using existing data, baseline characteristics and outcome were compared to a matched group of eight adolescents with bipolar disorders who did not receive any psychosocial intervention.
Results:  Preliminary results support the feasibility and efficacy of this manualized cognitive behavioral intervention.
Conclusions:  Individually delivered cognitive-behavioral therapy (CBT) as an adjunct to pharmacological treatment is feasible and associated with symptom improvement in adolescents with bipolar disorders. Randomized controlled studies are needed.     

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.     

Treatment manuals for long-term psychodynamic psychotherapy and psychoanalysis

An essential component of any clinical trial is the need to deliver treatment in a fashion that is uniform and that can be replicated. The advent of treatment manuals in psychotherapy research has been an important step towards meeting the standard of uniform treatment. Defining long-term psychodynamic treatments as those lasting a year or longer, there are only three published manuals for long-term psychodynamic psychotherapy: supportive-expressive psychotherapy (SE), transference focused psychotherapy (TFP), and mentalization-based treatment (MBT). This article reviews and compares these treatment manuals across six dimensions: 1) frame of reference and conceptualization of disorder(s) treated, 2) mechanisms of change, 3) treatment frame and format, 4) therapist stance and therapeutic relationship, 5) specifics of clinical technique and 6) ratings of adherence and competence. Despite the disparate nature of the three manualized treatments, a number of core features are shared by SE, TFP and MBT. The successful manualization of the three long-term psychodynamic psychotherapies reviewed suggests that psychoanalytic treatments could also be manualized.     

Cognitive-behavior therapy for generalized anxiety in late life: an evaluative overview

Of the pervasive anxiety disorders diagnosed in late life, generalized anxiety disorder (GAD) is the most prevalent. In this paper, the clinical features of GAD among older adults are described, with particular attention to differences in the nature of relevant symptoms among older and younger cohorts. Outcome studies addressing the efficacy of cognitive-behavior therapy (CBT) for younger and middle-aged adults with GAD then are reviewed briefly. Next, early literature investigating the potential usefulness of cognitive-behavioral treatments among older anxious community volunteers is then reviewed and critiqued in some detail. More recent work, some of which is currently in progress, has focused on the efficacy of CBT for older adults with well-diagnosed GAD. This research also is reviewed, and directions for future research in this area are provided.     

Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings.

OBJECTIVE: The authors present data from a pilot research program initiated to develop, refine, and test the outcomes of CBT-GAD/PC, a version of cognitive-behavior therapy (CBT) that targets the needs of older adults with generalized anxiety disorder (GAD) in primary care (PC). METHODS: The study involved a small, randomized clinical trial comparing the impact of CBT-GAD/PC to usual care (UC) in a sample of 12 older medical patients with GAD. RESULTS: Outcome data suggested significant improvements in worry and depression after CBT-GAD/PC, relative to UC. CONCLUSION: Authors discuss results in terms of the "real-world" applicability of this treatment for late-life GAD, and present implications for future research.     

Negative symptoms of schizophrenia as primary target of cognitive behavioral therapy: results of the randomized clinical TONES study

Clinical studies on cognitive behavioral therapy (CBT) that include schizophrenia patients primarily on the basis of negative symptoms are uncommon. However, those studies are necessary to assess the efficacy of CBT on negative symptoms. This article first gives an overview of CBT on negative symptoms and discusses the methodological problems of selecting an adequate control group. Furthermore, the article describes a clinical study (the TONES-Study, ISRCTN 25455020), which aims to investigate whether CBT is specifically efficacious for the reduction of negative symptoms. This multicenter randomized clinical trial comparing CBT with cognitive remediation (CR) for control of nonspecific effects is depicted in detail. In our trial, schizophrenia patients (n = 198) participated in manualized individual outpatient treatments. Primary outcome is the negative syndrome assessed with the positive and negative syndrome scale, analyzed with multilevel linear mixed models. Patients in both groups moderately improved regarding the primary endpoint. However, against expectation, there was no difference between the groups after treatment in the intention to treat as well as in the per-protocol analysis. In conclusion, psychotherapeutic intervention may be useful for the reduction of negative symptoms. However, there is no indication for specific effects of CBT compared with CR.     

Does treatment focus on self-efficacy result in better coping? Paradoxical findings from psychodynamic and cognitive–behavioral group treatment of moderately alcohol-dependent patients

In a randomized controlled study, 49 moderately alcohol-dependent patients underwent short-term group psychotherapy (25 in psychodynamic therapy and 24 in cognitive–behavioral therapy [CBT]). Self-efficacy before treatment correlated positively with drinking pattern at follow-up for both the psychodynamic and the CBT groups. However, the measure of self-efficacy did not change as a result of the treatments, and CBT did not result in any change of perceived control in a measure of appraisal despite its typical intense focus on coping and control. The paradox was that psychodynamic therapy patients increased significantly in this measure of control, although coping and control as such were not the primary focus in these groups.     

Cognitive-behavioural therapy reduces unwanted thought intrusions in generalized anxiety disorder

BACKGROUND AND OBJECTIVES: Voluntary attempts to suppress certain thoughts can paradoxically increase their intrusive return. Particular impairments in thought suppression are thought to be key mechanisms in the pathogenesis of mental disorders. To assess the role of this processing bias in the maintenance of generalized anxiety disorder (GAD), we investigated whether it is susceptible to cognitive-behavioural treatment (CBT). METHODS: 22 GAD patients and 22 healthy controls (HC) were tested twice within 15 weeks, with patients receiving CBT in between. A subset of patients was additionally tested while waiting for treatment to control for retest effects. Using a mental control paradigm, we measured intrusion frequency during the voluntary suppression of thoughts related to (a) the individual main worry topic, (b) a negative non-worry topic, and (c) a neutral topic. Self-reported worry was measured before and after treatment, and at 6-months follow-up. RESULTS: Compared to HC, GAD showed specifically more worry-related intrusions. CBT reduced this bias to a healthy level, over and above mere test-retest effects. LIMITATIONS: This study could not clarify whether the demonstrated effect mediates other changes, or how it relates to other cognitive biases in GAD. CONCLUSIONS: The results indicate that thought suppression processes are not only impaired in GAD, but that the impairment is specific to the patients' worries, and that it can be successfully targeted by CBT. This highlights the importance of thought suppression processes in the maintenance of GAD.     

Development of a scale to measure fidelity to manualized group-based cognitive behavioural interventions for people with intellectual disabilities

The context for the present study was a cluster-randomized controlled trial of a group-based anger-management intervention, delivered by day-service staff. We aimed to develop a scale to measure the fidelity of manualized cognitive-behavioural therapy (CBT) delivered to adults with intellectual disabilities in group-based settings. A 30-item monitoring instrument (the MAnualized Group Intervention Check: MAGIC) was adapted from an existing fidelity-monitor instrument for individual CBT. Two sessions for 27 groups were observed by pairs of monitors who had no other contact with the intervention. 16 observers participated, in 15 unique pairings. Observers recorded high levels of inter-rater reliability and the scale had good internal consistency. Fidelity ratings predicted two key outcomes of the intervention, and were themselves predicted by the therapists’ clinical supervisors.     

Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: two pilot investigations.

OBJECTIVE: Although cognitive-behavior therapy (CBT) is an efficacious treatment for generalized anxiety disorder (GAD) in younger adults, little is known about its efficacy in older patients. Investigations to date have tested group-format or otherwise nonstandard versions of CBT. The studies described here are, to our knowledge, the first to test the efficacy of individual-format CBT administered in a mental health clinic for treatment of late-life GAD. METHODS: Study 1 tested a standard version, and Study 2 tested an enhanced version (ECBT) that included learning and memory aids designed to make the therapy more effective with elderly patients (e.g., homework reminder and troubleshooting calls, weekly review of all concepts and techniques). RESULTS: Study 1 CBT participants showed significant improvement on GAD severity ratings. Study 2 ECBT participants showed significant improvement on two self-report measures, rates of posttreatment GAD, and GAD severity ratings. ECBT resulted in improvement on more measures and yielded larger effect sizes than standard CBT, when each was compared against a wait-list control group. CONCLUSION: Results of these pilot studies suggest that standard individual-format CBT may not be optimally effective for treating late-life GAD; thus, ECBT should be tested further in randomized trials.     

Nonpharmacological treatments for anxiety disorders

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.     

Comorbidity in generalized anxiety disorder: prevalence and course after cognitive-behavioural therapy]

OBJECTIVE: To evaluate the prevalence and course of Axis I concurrent disorders in a population of patients who underwent cognitive-behavioural therapy (CBT) to treat their generalized anxiety disorder (GAD). METHOD: This study is a secondary analysis combining patients from 3 treatment studies done at Université Laval. A total of 90 patients with a DSM-IV consistent GAD diagnosis received from 12 to 16 CBT sessions to treat GAD. Symptomatology was assessed at pretest, posttest, and 6 months after treatment, with the Anxiety Disorders Interview Schedule, a structured diagnostic interview. RESULTS: Seventy-three per cent of patients had both GAD and a concurrent diagnosis. The most common diagnoses were simple phobia, social phobia, panic disorder, and major depression. CBT applied to GAD decreases the number of concurrent diagnoses. A panic disorder or a greater number of concurrent diagnoses at pretest is associated with a less efficient treatment at follow-up 6 months later. CONCLUSION: Patients with GAD have a high comorbidity rate with other Axis I disorders, but these significantly decrease after a short CBT aimed at GAD. Implications for GAD treatment and mechanisms that might explain these findings are discussed.     

Therapeutic orientation preferences in trainee clinical psychologists: Personality or training?

Abstract

This study investigated the relative influence of person and training factors on preference for three common therapeutic orientations—cognitive–behavioural therapy (CBT), psychodynamic therapy, and systemic therapy—in 142 U.K. trainee clinical psychologists. Consistent with previous research, preferences for therapeutic orientation were related to personality, philosophical worldview, the theoretical emphasis of training courses, and the orientation of supervisors. Preference for psychodynamic therapy was influenced more by training factors and preference for CBT more by person factors, with the influence of both sets of factors being approximately equal for systemic therapy. Supervision was more influential than the theoretical emphasis of training courses in predicting preferences for psychodynamic and systemic therapies, with the converse pattern found for CBT.     

Predictors of CBT outcome in older adults with GAD

The current study is a secondary analysis of data from a randomized controlled trial of CBT for late-life GAD (Stanley et al., 2014) which provided an opportunity to examine predictors of outcome among those who received CBT. Participants were 150 older adults who were randomized to receive 10 sessions of CBT. Completer analyses found that homework completion, number of sessions attended, lower worry severity, lower depression severity, and recruitment site predicted 6-month worry outcome on the PSWQ-A, whereas homework completion, credibility of the therapy, lower anxiety severity, and site predicted 6-month anxiety outcome on the STAI-T. In intent-to-treat multivariate analyses, however, only initial worry and anxiety severity, site, and number of sessions completed predicted treatment outcome. These results are largely consistent with predictors of outcome in younger adults and suggest that lower initial symptom severity and variables consistent with greater engagement in treatment predict outcome.     

Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial

Seventy-six individuals with a principal diagnosis of generalized anxiety disorder (GAD) were randomly assigned to receive either an MI pretreatment or no pretreatment (NPT), prior to receiving CBT. Significant group differences favoring the MI-CBT group were observed on the hallmark GAD symptom of worry and on therapist-rated homework compliance, which mediated the impact of treatment group on worry reduction. Adding MI pretreatment to CBT was specifically and substantively beneficial for individuals with high worry severity at baseline. There was evidence of relapse at 6-month follow-up for high severity individuals who received MI-CBT, but significant moderator effects favoring the high severity MI-CBT group were again apparent at 12-months post-treatment. Pending replication in a more controlled test, these findings suggest that MI may be a promising adjunct to CBT for GAD for those of high severity, a group which has been less responsive to CBT in past research.     

Specific and common processes as mediators of the long-term effects of cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder

Objective: A trial of psychotherapy for generalized anxiety disorder (GAD) demonstrated that motivational interviewing (MI) integrated with cognitive-behavioral therapy (CBT) outperformed CBT alone on clients’ worry reduction across a 12-month follow-up. In the present study, we hypothesized and tested that less client resistance and greater client-perceived therapist empathy (specific foci of MI) would account for MI’s additive effect. Exploratory analyses assessed whether the common processes of homework completion and therapeutic alliance quality mediated the treatment effect. Method: Clients with GAD were randomized to 15 sessions of MI-CBT (n?=?42) or CBT alone (n?=?43). Worry was assessed throughout treatment and follow-up. Observers rated resistance at midtreatment, and clients reported on perceived therapist empathy, alliance, and homework completion throughout treatment. Mediation was tested with bootstrapping methods. Results: Expectedly, MI-CBT clients evidenced less resistance and perceived greater therapist empathy, each of which related to lower 12-month worry. However, when both variables were tested simultaneously, only resistance remained a significant mediator of treatment. No indirect effects through homework completion or alliance emerged. Conclusions: Reducing client resistance may be a theory-consistent mechanism through which integrative MI-CBT promotes superior long-term improvement than traditional CBT when treating GAD.

Clinical or methodological significance of this article: This study further supports the long-term clinical benefit of integrating MI into CBT when treating the highly prevalent and historically difficult-to-treat condition of GAD. In particular, it points to the theory-specific mechanism of MI (helping to reduce/resolve patients’ in-treatment resistance) as accounting for the integrative treatment’s additive effect on worry reduction across a follow-up period. Therapists using CBT to treat patients with GAD should be trained to incorporate MI principles (e.g., empathy, collaboration, autonomy support) in general and in response to explicit markers of resistance.     

Growing Evidence for Psychodynamic Therapy for Depression

Psychodynamic therapy (PT) for depression is the least examined treatment method for depression, compared to cognitive-behavioral therapy (CBT) and interpersonal therapy. This article, consisting of five randomized clinical trials of short psychodynamic supportive psychotherapy (SPSP) conducted over the last 25 years in Amsterdam, will review the trial results to provide answers to the question about which role SPSP can play in the treatment of depression. The researchers conclude that it is justified to qualify SPSP an empirically supported therapy form of PT for depression. In particular, adding SPSP to pharmacotherapy yields better results than pharmacotherapy by itself. Adding medication to SPSP may have a significant added value, but it is not as large as in the first comparison. The results also confirm no difference in efficacy between CBT and SPSP.     

Cognitive errors, symptom severity, and response to cognitive behavior therapy in older adults with generalized anxiety disorder.

OBJECTIVE: Recent research by Wetherell et al. investigating the differential response to group-administered cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults found that GAD severity, homework adherence, and psychiatric comorbidity predicted statistically significant improvement. The current study investigated whether the presence/absence of cognitive errors on separate domains of the Mini-Mental State Exam (MMSE) predicted baseline differences in symptom severity and improvement following CBT, above and beyond already established predictors. METHODS: Baseline characteristics were investigated in a sample of 208 older patients diagnosed with GAD. Predictors of treatment response were examined in a subsample of 65 patients who completed CBT and were included in a prior study by Wetherell et al. of response predictors. RESULTS: Results from the baseline sample indicated that only subjects who committed an error on the MMSE Working Memory domain exhibited increased severity in anxiety and depressive symptoms. Results from the treatment sample indicated that an error on the MMSE Orientation domain was a significant predictor of outcome at 6-month follow-up, while controlling for previously established predictors. Patients who committed at least one error in this domain showed decreased response relative to patients who committed no errors. CONCLUSION: In this sample of older adults diagnosed with GAD, poor performance on the MMSE Working Memory domain was associated with increased baseline anxiety and depression, while baseline performance differences on the MMSE Orientation domain predicted outcome six months after CBT intervention.     

Integrated cognitive-behavioral and psychodynamic psychotherapy for intimate partner violent men

Intimate partner violence (IPV) continue to have widespread negative effects on victims, children who witness IPV, and perpetrators. Current treatments have proven to be only marginally effective in stopping or reducing IPV by men. The two most prominent treatment approaches are feminist sociocultural and cognitive-behavioral therapy (CBT). The feminist sociocultural approach has been criticized for failing to adequately consider the therapeutic alliance, personality factors, and sole focus on patriarchy as the cause for IPV, whereas CBT has been criticized for failing to attend to motivation issues in treatment protocols. This article reviews the effectiveness of current treatments for partner-violent men, examines relationship and personality variables related to IPV and its treatment, and presents an emerging IPV treatment model that combines CBT and psychodynamic therapy. The article addresses how psychodynamic therapy is integrated into the more content-based elements of CBT.