Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance

Cognitive behavior therapy's (CBT) demonstrated efficacy has prompted calls for its increased dissemination to routine clinical practice settings. For the widespread dissemination of CBT to be successful in achieving effects similar to the original efficacy trials, there must also be effective dissemination of CBT training practices. However, as yet, CBT training is not evidence-based. This review examines what can be learned from existing research into the efficacy and effectiveness of CBT training. Due to the paucity of research specifically investigating CBT training, CBT effectiveness and dissemination studies are also examined to glean information about potentially effective training practices. In order to draw conclusions about effective training practices, comparisons are drawn between studies according to the clinical outcomes that they achieved. Training approaches are compared according to dose and active training elements, and theoretical models of learning are applied to interpret the findings. The limitations of the existing literature are discussed, as well as recommendations for improving training research to meet the standards evident in treatment trials (e.g., random allocation, control conditions, self-report and blind assessment, and adherence monitoring). Finally, the process of developing efficacious CBT treatment protocols is offered as a template for developing evidence-based CBT training protocols.     

Attachment-based family therapy for depressed and suicidal adolescents: theory,clinical model and empirical support

Attachment-Based Family Therapy (ABFT) is a manualized family-based intervention designed for working with depressed adolescents, including those at risk for suicide, and their families. It is an empirically informed and supported treatment. ABFT has its theoretical underpinnings in attachment theory and clinical roots in structural family therapy and emotion focused therapies. ABFT relies on a transactional model that aims to transform the quality of adolescent–parent attachment, as a means of providing the adolescent with a more secure relationship that can support them during challenging times generally, and the crises related to suicidal thinking and behavior, specifically. This article reviews: (1) the theoretical foundations of ABFT (attachment theory, models of emotional development); (2) the ABFT clinical model, including training and supervision factors; and (3) empirical support.     

The empirical status of cognitive-behavioral therapy: a review of meta-analyses

This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.     

Social support, life stress, and psychological distress: an empirical assessment

Previous social support research had demonstrated the presence of either main (network) or buffering (interaction) effects as factors that mitigated the impact of life stress. To date, two studies have assessed both types of social supports in the same subjects at the same time. One study found a main effect, and both studies reported buffering effects. The present study (N = 74) extended this type of inquiry with a more comprehensive assessment of both social support resources that addressed previous methodological limitations. This study found buffering effects, but no main network effect. Possible explanations for these findings are discussed.     

Cell therapy for bone disease: a review of current status

Bone marrow is a reservoir of pluripotent stem/progenitor cells for mesenchymal tissues. Upon in vitro expansion, in vivo bone-forming efficiency of bone marrow stromal cells (BMSCs) is dramatically lower in comparison with fresh bone marrow, and their in vitro multidifferentiation potentials are gradually lost. Nevertheless, when BMSCs are isolated and expanded in the presence of fibroblast growth factor 2, the percentage of cells able to differentiate into the osteogenic, chondrogenic, and adipogenic lineages is greater. Osteogenic progenitors are not exclusive to skeletal tissues. We could also think of cells in different adult tissues as potentially capable of following an osteochondrogenic differentiation pathway, but, under normal physiological conditions, they are inhibited in this process by the environment and/or the adjacent cell populations. When, for some reason such as pathology, the environment changes dramatically and the inhibiting condition is removed, these cells could become osteoblasts. Bone is repaired via local delivery of cells within a scaffold. Bone formation was first assessed in small animal models. Large animal models were successively developed to prove the feasibility of the tissue engineering approach in a model closer to a real clinical situation. Eventually, pilot clinical studies were performed. Extremely appealing is the possibility of using mesenchymal progenitors in the therapy of genetic bone diseases via systemic infusion. There is experimental evidence to suggest that mesenchymal progenitors delivered by this route engraft with a very low efficiency and do not produce relevant and durable clinical effects. Under some conditions, where the local microenvironment is either altered (i.e., injury) or under important remodeling processes (i.e., fetal growth), engraftment of stem and progenitor cells seems to be enhanced. A better understanding of their engraftment mechanisms will, hopefully, extend the field of therapeutic applications of mesenchymal progenitors.     

Information need,learning need and educational need,definitions and measurements: A systematic review

BackgroundThere are various definitions and tools for Information Need (IN), Learning Need (LN) and Educational Need (EN) which are used interchangeably in the patient education.ObjectiveClarifying the definitions of IN, LN and EN as well as comparing item generation methods and the dimensions of the available tools to be used appropriately.MethodsWe searched PubMed/Scopus/Embase/Science Direct databases from 1960 to 2019. Two reviewers selected studies and extracted data independently.ResultsWe identified 22 tools comprised of 14 IN, 5 LN and 3 EN tools. The Patient Learning Needs Scale (PLNS) was the only general tool. The content of tools includes anatomy, physiology, diagnostic tests, symptoms, treatments, medications, diet, activity and self-care. No difference was found between EN/LN/IN tools in terms of item generation and dimensions according to their concept definitions. Seven tools assessed all 7 domains of patient education components.ConclusionThe EN, LN and IN are different concepts, but using these concepts in the tools is not based on their definitions and they have been used interchangeably. IN and LN tools were more complete and comprehensive.Practical implicationsThe findings of this review can help researchers and clinicians to use EN, LN and IN tools more appropriately.     

Schema therapy for borderline personality disorder: A comprehensive review of its empirical foundations,effectiveness and implementation possibilities

Borderline personality disorder is a serious psychiatric disorder for which the effectiveness of the current pharmacotherapeutical and psychotherapeutic approaches has shown to be limited. In the last decades, schema therapy has increased in popularity as a treatment of borderline personality disorder; however, systematic evaluation of both effectiveness and empirical evidence for the theoretical background of the therapy is limited. This literature review comprehensively evaluates the current empirical status of schema therapy for borderline personality disorder. We first described the theoretical framework and reviewed its empirical foundations. Next, we examined the evidence regarding effectiveness and implementability. We found evidence for a considerable number of elements of Young's schema model; however, the strength of the results varies and there are also mixed results and some empirical blanks in the theory. The number of studies on effectiveness is small, but reviewed findings suggest that schema therapy is a promising treatment. In Western-European societies, the therapy could be readily implemented as a cost-effective strategy with positive economic consequences.     

Added value of elder abuse definitions: A review

Elder abuse has devastating consequences for older persons such as a poor quality of life, psychological distress, and loss of property and security. It is also associated with increased mortality and morbidity. Elder abuse is a problem that manifests itself in both rich and poor countries and at all levels of society. It is timely to discuss one of the basic problems that has hampered the study, detection and intervention of elder abuse as the variety of definitions that exist now produce a definitional chaos for researchers, practitioners, and policy makers.In this article we trace the elements of “how to define elder abuse” and situate them in their socio-historical context. We also analyze the purposes of these different definitions to assess their appropriateness in different settings concerned with elder abuse. Our analysis shows that elder abuse mirrors the societal arrangements which gave rise to them. It also highlights that it is a complex problem that is difficult to define. The central question is whether we need a common definition of elder abuse or different definitions that can be used in different settings. By evidence of our analysis we can see that there is a need for a sufficiently broad and flexible definition in order to cover different behaviors that can constitute abuse and the various settings in which it may occur. On the other hand, the definition needs to be specific and concrete to be useful in professional contexts.To take a further step forward for both research and practice of elder abuse, we propose to consistently adhere to the WHO definition that leads the enquirer towards a better understanding of the problem and helps to distinguish it from other phenomena; and to a simplified definition for professional practice that sets boundaries to the phenomena and is appropriate for effective prevention and intervention measures.     

Delivering patient decision aids on the Internet: definitions,theories, current evidence,and emerging research areas

Background

In 2005, the International Patient Decision Aids Standards Collaboration identified twelve quality dimensions to guide assessment of patient decision aids. One dimension—the delivery of patient decision aids on the Internet—is relevant when the Internet is used to provide some or all components of a patient decision aid. Building on the original background chapter, this paper provides an updated definition for this dimension, outlines a theoretical rationale, describes current evidence, and discusses emerging research areas.

Methods

An international, multidisciplinary panel of authors examined the relevant theoretical literature and empirical evidence through 2012.

Results

The updated definition distinguishes Internet-delivery of patient decision aids from online health information and clinical practice guidelines. Theories in cognitive psychology, decision psychology, communication, and education support the value of Internet features for providing interactive information and deliberative support. Dissemination and implementation theories support Internet-delivery for providing the right information (rapidly updated), to the right person (tailored), at the right time (the appropriate point in the decision making process). Additional efforts are needed to integrate the theoretical rationale and empirical evidence from health technology perspectives, such as consumer health informatics, user experience design, and human-computer interaction.Despite Internet usage ranging from 74% to 85% in developed countries and 80% of users searching for health information, it is unknown how many individuals specifically seek patient decision aids on the Internet. Among the 86 randomized controlled trials in the 2011 Cochrane Collaboration’s review of patient decision aids, only four studies focused on Internet-delivery. Given the limited number of published studies, this paper particularly focused on identifying gaps in the empirical evidence base and identifying emerging areas of research.

Conclusions

As of 2012, the updated theoretical rationale and emerging evidence suggest potential benefits to delivering patient decision aids on the Internet. However, additional research is needed to identify best practices and quality metrics for Internet-based development, evaluation, and dissemination, particularly in the areas of interactivity, multimedia components, socially-generated information, and implementation strategies.

     

A comparison of client preferences for intervention empirical support versus common therapy variables

Client preferences have been identified as an essential part of evidence‐based practice in psychology. Further, client preferences have been found to play an important role in determining premature termination and therapy outcomes. However, our current understanding of this client variable is limited because of the methodologies that have previously been used to assess these preferences. In this study, 57 adult clients from a university‐based psychology department clinic completed an instrument weighing preferences for intervention specific empirical support against preferences for 4 other common factor variables. These clients were found to discount a significant amount of intervention empirical support to ensure the following: (a) a satisfactory therapeutic relationship could be developed, (b) their therapist would be empathetic and accepting, (c) their therapist would have a greater level of experience, and (d) they, as clients, would do more of the talking during sessions. These findings suggest that clients prefer treatment decisions to be based on variables other than intervention empirical support alone. Recommendations are made for assessing and including client preferences to provide more individually tailored interventions. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1–15, 2010.     

Biased attentional behavior in childhood anxiety. A review of theory and current empirical investigation

This review examines the state of current theory and research regarding a relatively new area of study in childhood anxiety: the examination of attentional biases associated with the processing of threatening environmental stimuli. In particular, this paper focuses upon current attempts to extend an information processing framework traditionally associated with childhood psychopathology (i.e., Crick & Dodge [Psychol Bull 115 (1994) 74]) and anxiety-related attentional bias research previously conducted only with adults, to populations of anxious children. First, a thorough discussion of Crick and Dodge's model and its applicability to current theories of anxiety is presented. Although each stage of Crick and Dodge's model is shown to possess correlates with current conceptualizations of anxiety, the research investigations reviewed here focus upon the multiple approaches that have been undertaken to better comprehend anxious children's attentional biases in encoding and subsequent task performance decrements. Specifically, recent investigations of anxious children's attentional performance utilizing Stroop tasks, probe detection tasks, and the relatively new probe localization task are reviewed. A discussion of the disparate findings associated with recent studies of each of these tasks is given, with an eye toward the need to specify the developmental, theoretical, demographic, and clinically relevant characteristics associated with the biased attentional behavior observed among highly anxious children.     

Night terrors: A clinical and empirical review

Night terrors are intense and striking clinical phenonema. Because of the dramatic nature of this disorder and its widespread confusion with nightmares, a comprehensive overview of the empirical literature reflecting the characteristics, etiology, and treatment of night terrors is presented. Data gathered from recent sleep laboratory investigations and clinical findings are integrated to highlight the unique clinical presentation and course of this disorder. It appears that night terrors are a nighttime disorder of arousal in persons that are predisposed genetically. Treatment should be based on comprehensive assessment of the disorder and most likely be related to the reduction of stress.     

Brachial plexus anesthesia: A review of the relevant anatomy,complications, and anatomical variations

The trend towards regional anesthesia began in the late 1800s when William Halsted and Richard Hall experimented with cocaine as a local anesthetic for upper and lower limb procedures. Regional anesthesia of the upper limb can be achieved by blocking the brachial plexus at varying stages along the course of the trunks, divisions, cords and terminal branches. The four most common techniques used in the clinical setting are the interscalene block, the supraclavicular block, the infraclavicular block, and the axillary block. Each approach has its own unique set of advantages and indications for use. The supraclavicular block is most effective for anesthesia of the mid‐humerus and below. Infraclavicular blocks are useful for procedures requiring continuous anesthesia. Axillary blocks provide effective anesthesia distal to the elbow, and interscalene blocks are best suited for the shoulder and proximal upper limb. The two most common methods for localizing the appropriate nerves for brachial plexus blocks are nerve stimulation and ultrasound guidance. Recent literature on brachial plexus blocks has largely focused on these two techniques to determine which method has greater efficacy. Ultrasound guidance has allowed the operator to visualize the needle position within the musculature and has proven especially useful in patients with anatomical variations. The aim of this study is to provide a review of the literature on the different approaches to brachial plexus blocks, including the indications, techniques, and relevant anatomical variations associated with the nerves involved. Clin. Anat. 27:210–221, 2014. © 2013 Wiley Periodicals, Inc.     

Machine learning for clinical decision support in infectious diseases: a narrative review of current applications

BackgroundMachine learning (ML) is a growing field in medicine. This narrative review describes the current body of literature on ML for clinical decision support in infectious diseases (ID).ObjectivesWe aim to inform clinicians about the use of ML for diagnosis, classification, outcome prediction and antimicrobial management in ID.SourcesReferences for this review were identified through searches of MEDLINE/PubMed, EMBASE, Google Scholar, biorXiv, ACM Digital Library, arXiV and IEEE Xplore Digital Library up to July 2019.ContentWe found 60 unique ML-clinical decision support systems (ML-CDSS) aiming to assist ID clinicians. Overall, 37 (62%) focused on bacterial infections, 10 (17%) on viral infections, nine (15%) on tuberculosis and four (7%) on any kind of infection. Among them, 20 (33%) addressed the diagnosis of infection, 18 (30%) the prediction, early detection or stratification of sepsis, 13 (22%) the prediction of treatment response, four (7%) the prediction of antibiotic resistance, three (5%) the choice of antibiotic regimen and two (3%) the choice of a combination antiretroviral therapy. The ML-CDSS were developed for intensive care units (n = 24, 40%), ID consultation (n = 15, 25%), medical or surgical wards (n = 13, 20%), emergency department (n = 4, 7%), primary care (n = 3, 5%) and antimicrobial stewardship (n = 1, 2%). Fifty-three ML-CDSS (88%) were developed using data from high-income countries and seven (12%) with data from low- and middle-income countries (LMIC). The evaluation of ML-CDSS was limited to measures of performance (e.g. sensitivity, specificity) for 57 ML-CDSS (95%) and included data in clinical practice for three (5%).ImplicationsConsidering comprehensive patient data from socioeconomically diverse healthcare settings, including primary care and LMICs, may improve the ability of ML-CDSS to suggest decisions adapted to various clinical contexts. Currents gaps identified in the evaluation of ML-CDSS must also be addressed in order to know the potential impact of such tools for clinicians and patients.     

Pre-hospital treatment of ophidian accidents: review, update, and current problems

Mythic, out-dated, ambiguous and sometimes iatrogenic procedures, still remain in pre-hospital and hospital ophidian accident treatment. Errors, omissions and ignorance make ophidian accidents appear more dangerous than they truly are, resulting in a general public contempt toward snakes. Here we present an updated review of current knowledge on pre-hospital and hospital treatment of ophidian bite incidents, including indications, recommendations and logic errors. We describe an appropriate treatment for native Mexican poisonous snakebites using fabotherapics, based on our experience. Adequate initial pre-hospital and hospital management is crucial for a successful outcome of this medical emergency. We describe the state of the art in snake bite research discussing those procedures where research is needed to implement them either by the patient, first responders, paramedics and doctors. We suggest proposals to achieve even more efficient management of fabotherapics based on support networks. Finally, we emphasize prevention as the main subject of venom bite treatment, as it is always more adequate and economic to invest in prevention than to spend on mitigation during emergency and recovery.