Adjunctive Cognitive Behavioral Therapy Research Articles

Resting state functional connectivity differences following working memory training with massed exposure in individuals with public speaking anxiety

Exposure-based cognitive behavioral therapy (CBT) is a gold standard treatment for Social Anxiety Disorder (SAD), but many patients do not gain complete symptom relief. Since fear extinction is central to the effectiveness of exposure within CBT, adjunctive treatments that target neurocognitive systems underlying fear extinction could increase the effectiveness of CBT. Successful fear extinction and cognitive tasks like working memory share neurocognitive substrates. The present study evaluates the neural impact of working memory training (WMT) as an adjunctive CBT treatment by exploring changes in intrinsic network connectivity associated with combining WMT with exposure exercises. The sample included twenty-four adults (Mean Age = 27.42(9.75), 62.5% female) with elevated social anxiety symptoms. Participants completed either a WMT or sham training (ST) condition, followed by a speech-based massed exposure session (WMT+Exp versus ST+Exp). Compared to ST+Exp, WMT+Exp participants exhibited lower connectivity between the default and visual networks and visual and dorsal networks. Lower connectivity between these networks was associated with lower subjective distress at the end of the massed exposure across the whole sample. WMT+Exp completers exhibited unique functional connectivity between the frontoparietal and dorsal attention networks. WM+Exp was associated with a neural connectivity profile involving networks critical to working memory, fear learning, and emotion regulation, as well as emotional and sensory processing functions. Data provisionally point to combined working memory training and exposure facilitating improvement in neural connections useful for benefitting from CBT for SAD.

Maintenance Treatments of Lithium, Carbamazepine, and Adjunctive CBT in Bipolar Disorder: Review

Bipolar disorder is an acute mental health condition with high relapse rates. At the onset, it can affect the normal functioning of the individual life of patients. Although there are no curative treatments for it, many other treatments are available to reduce relapse rates and stabilise symptoms. This article reviewed previous experiments, meta-analyses, and literature reviews on the topic of pharmacotherapies and integrated therapies in treating bipolar disorder and their effects on recurrent rates. It focused on three treatments, which were lithium, carbamazepine, and adjunctive cognitive behavioural therapy, and aimed to assess their efficacy and tolerability in treating bipolar disorder. Lithium was found to show its anti-manic effect and anti-suicide effect, which remained the gold standard in treating bipolar disorder. Whereas, adverse effects should be carefully noted to avoid worsened long-term health conditions. It was shown that carbamazepine had a comparable effect to lithium and was a potential candidate for lithium. But it requires more research to further assess its effectiveness. Adjunctive CBT showed its efficacy in treating both manic and depressive episodes. While bipolar patients who had relatively more mood episodes may not benefit from it.

Cognitive behavioral therapy for depression in patients with heart failure: a systematic review and metanalysis of randomized control trials.

Major depression (MD) is prevalent in patients with heart failure (HF) and contributes to increased risk of hospitalization and mortality. The implementation of cognitive behavioral therapy (CBT) has become a key strategy for treating HF patients' depression.We performed a comprehensive literature search for studies that evaluated the efficacy of adjunctive CBT compared to the standard of care (SOC) in HF patients with MD. The primary outcome was the depression scale (post-intervention and by the end of follow-up). The secondary outcomes were the quality of life (QoL), self-care scores, and 6-min walk test distance(6-MW). The standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.A total of 6 RCTs with 489 patients (244 in the CBT group and 245 in the SOC group) were included. As compared to the SOC, CBT was associated with a statistically significant improvement in the post-interventional depression scale (SMD: -0.45, 95%CI: -0.69, -0.21; P < 0.01) and by the end of follow-up (SMD: -0.68, 95%CI: -0.87, -0.49; P < 0.01). Furthermore, CBT significantly improved the QoL (SMD: -0.45, 95%CI: -0.65, -0.24; P < 0.01). However, there were no differences in the self-care scores (SMD: 0.17, 95%CI: -0.08, 0.42; P = 0.18) or in 6-MW (SMD: 0.45, 95%CI: -0.39, 1.28; P = 0.29) between the two groups.According to our meta-analysis of published clinical studies, CBT may be more effective than standard therapy at enhancing depression scores and quality of life. To assess the long-term clinical effects of CBT in heart failure patients, larger and more powerful RCTs are required.

Management of anxiety disorders in children with attention-deficit hyperactivity disorder: a narrative review.

Anxiety disorders are common comorbidities of attention deficit/hyperactivity disorder (ADHD) and conversely, ADHD is prevalent among anxious youths. A variety of treatments, both psychopharmacological and nonpsychopharmacological, are used to manage combined ADHD/anxiety disorder. This article aims to review the literature on the treatment of ADHD with comorbid anxiety disorders, and make evidence-based recommendations for clinical practice. In most cases, when ADHD is the primary condition, stimulants are the first-line of treatment, frequently resulting not only in improvement in ADHD symptoms but also alleviating the symptoms of the comorbid anxiety disorder. Stimulant treatment is relatively safe and well-tolerated in ADHD with comorbid anxiety disorder. When the stimulant administration does not attenuate the severity of the comorbid anxiety disorder, a treatment that targets specifically the anxiety disorder should be added. This recommendation, however, might be challenged by the impressive efficacy of atomoxetine for both the ADHD and anxiety disorder symptoms. Adjunctive cognitive-behavior therapy for anxiety disorder symptoms is strongly recommended and is considered superior to medication alone. Other options include adding pharmacological treatment for the anxiety symptoms. In moderate and severe cases of comorbid Ads, selective serotonin reuptake inhibitors can be added to the stimulants, with the required caution.

Development, Feasibility, and Acceptability of a Brief, Adjunctive Cognitive-Behavioral Intervention Aimed at Encouraging Rapid Response to Intensive Eating Disorder Treatment

This study reports on feasibility and acceptability outcomes of a brief, adjunctive cognitive-behavior therapy (CBT) intervention focused on encouraging rapid behavior change in intensive eating disorder treatment (CBT-RR). Effectiveness outcomes of this study have been previously reported (MacDonald et al., 2017). CBT-RR was found to be feasible to implement and acceptable to patients, relative to the comparison condition (motivational interviewing [MI]). Rates of treatment retention were good in both conditions. CBT-RR participants reported higher goal-related alliance with the therapist compared to MI, whereas task-related and bond-related alliances with the therapist were similar between interventions. Both groups reported high levels of homework completion, and strong satisfaction with treatment. Following demonstration of feasibility and acceptability, the second part of this paper provides a detailed description of how we conceptualized and developed the CBT-RR intervention. A detailed description of the protocol components and session content is provided, with a fictional case vignette to illustrate use of the intervention. This section provides a clinical resource that may be helpful to clinicians interested in actively encouraging rapid behavior change with clients with eating disorders.

Is adjunctive CBT really effective for schizophrenia?

SUMMARYAlthough antipsychotic medication remains the mainstay of treatment for schizophrenia, medications alone are not always successful. Cognitive–behavioural therapy (CBT) is recommended as an adjunct to pharmacological treatment. The Cochrane review under consideration evaluates the effects of offering CBT as an add-on to standard care compared with standard care alone, and this commentary puts those findings into their clinical context.DECLARATION OF INTERESTNone.

The Role of Cognitive Behavioral Therapy in Opioid Use Reduction in Pediatric Sickle Cell Disease: Protocol for a Systematic Review.

BackgroundSickle cell disease (SCD) is a genetic disorder of red blood cells that results in acute and chronic health problems, including painful syndromes. Opioid analgesia is the mainstay of moderate to severe pain management in SCD, although adjunctive psychosocial approaches such as cognitive behavioral therapy (CBT) are increasingly incorporated. CBT has been used in populations of various ages to address a wide range of issues, such as mood disorders and chronic pain. It is unclear if effective CBT reduces the use of opioids to manage pain in pediatric SCD.ObjectiveThe aim of this study is to evaluate the association between CBT and decreased opioid use in children with SCD.MethodsIn this systematic review protocol, we describe our approach to applying predetermined eligibility criteria to searches of PubMed (including Medline), Embase, Cochrane, Web of Science, and PsycINFO databases, as well as Google Scholar and grey literature. In particular, we will use keywords to search for English-language studies of individuals with SCD aged 21 years old and younger published before November 2018. Keywords will allow us to assess for the primary outcome—total use of opioid medications—and the secondary outcomes—pain intensity and emotional functioning—during pain management using a combined opioid and CBT approach, opioids alone, or CBT alone. The review team will use standardized abstraction forms to review articles at the title, abstract, and full-text levels. Finally, reviewers will assess the risk for bias, quality of evidence, and adequacy of data for quantitative versus qualitative synthesis. If meta-analysis is deemed inappropriate, a narrative review will be conducted.ResultsWe will report a summary of findings across studies that meet eligibility criteria to compare the extent to which adjunctive CBT is associated with decreased opioid use among children with SCD.ConclusionsThis systematic review will present the current state of the evidence on CBT and opioid use in pediatric SCD, which may inform clinical practice and health policy to support optimized pain management.International Registered Report Identifier (IRRID)PRR1-10.2196/13211

F141. Effects of Subcallosal Cingulate Deep Brain Stimulation on Emotion Regulation in Patients With Treatment Resistant Depression

The subcallosal cingulate (SCC) is involved in emotional regulation (ER) through connections with limbic and frontal regions. Maladaptive ER strategies (decrease in reappraisal and increase in suppression) contribute to negative emotion and negative bias in depression. Here we examined the respective effects of SCC-deep brain stimulation (DBS), adjunctive cognitive behavioral therapy (CBT) and depression recovery on ER strategies in patients with treatment resistant depression (TRD).

Psychological therapies for treatment-resistant depression in adults.

Psychological therapies for treatment-resistant depression in adults.

Rapid response to intensive treatment for bulimia nervosa and purging disorder: A randomized controlled trial of a CBT intervention to facilitate early behavior change.

Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record

Pilot Randomized Controlled Trial of Internet-Delivered Cognitive-Behavioral Treatment for Pediatric Headache.

To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention for adolescents with chronic headache. Headache is among the most common pain complaints of childhood. Cognitive-behavioral interventions are efficacious for improving pain among youth with headache. However, many youth do not receive psychological treatment for headache due to poor access, which has led to consideration of alternative delivery modalities such as the Internet. We used a parallel arm randomized controlled trial design to evaluate the feasibility and preliminary effectiveness of an Internet-delivered family-based CBT intervention, Web-based management of adolescent pain. Adolescents were eligible for the trial if they were a new patient being evaluated in a specialized headache clinic, between 11 and 17 years of age, and had recurrent headache for 3 months or more as diagnosed by a pediatric neurologist. Eighty-three youths were enrolled in the trial. An online random number generator was used to randomly assign participants to receive Internet CBT adjunctive to specialized headache treatment (n = 44) or specialized headache treatment alone (n = 39). The primary treatment outcome was headache days. Youth and parents in the Internet CBT group demonstrated high levels of engagement with the web program and reported satisfaction with the intervention. Multilevel modelling (MLM) was used to conduct hypothesis testing for continuous outcomes. For our primary treatment outcome of headache days, adolescents reported a statistically significant reduction in headache days from baseline to post-treatment and baseline to 3-month follow-up in both treatment conditions (main effect for time F(2, 136) = 19.70, P < .001). However, there was no statistically significant difference between the Internet CBT group and the specialized headache treatment group at post-treatment or follow-up (group × time interaction F(2, 134) = 0.94, P = .395). For our secondary treatment outcomes, findings from MLM showed that adolescents in both groups demonstrated statistically significant improvement headache pain intensity, activity limitations, depressive symptoms, and parent protective behaviors from baseline to post-treatment and these gains were maintained at 3-month follow-up. Adolescent anxiety symptoms and sleep did not change during the study period for either group. There were no statistically significant group differences on any secondary outcomes at post-treatment or follow-up (P > .05 for all outcomes). No adverse events were reported. Although adjunctive Internet CBT did not lead to additional benefit in this population, future research should evaluate whether it is an effective intervention for adolescents with headache who are unable to access specialized headache treatment.

Is immediate adjunctive CBT more beneficial than delayed CBT in treating depression?: A Pilot Study.

Cognitive-behavioral therapy (CBT) is an efficacious first-line therapy for patients with major depressive disorder (MDD). Due to the limited accessibility of CBT, long wait lists result in delayed treatment, which may affect treatment outcomes. The goal of this pilot study was to obtain preliminary data from a randomized controlled trial to determine whether delayed CBT reduces the effectiveness of the therapy compared to immediate CBT in patients with MDD receiving pharmacotherapy. Patients were randomized to receive immediate CBT (n=18) or to begin CBT after 6 months (n=20) and received 14 weekly sessions, followed by two additional booster sessions. During the active treatment months, patients in the immediate group demonstrated reductions in scores on the Beck Depression Inventory II (BDI-II) that were similar to those in the delayed CBT group. However, when the analysis was performed using only data from patients in the delayed group who were still in a depressive episode, there was an overall greater decrease in BDI-II scores in the immediate group vs. the delayed group over the active treatment months, but not specifically at the 6-month endpoint. These findings suggest delays in depression treatment, similar to what occurs with real-world wait list times, may not have a significant impact on the effectiveness of CBT in patients who are already receiving treatment as usual. However, such delays may affect the effectiveness of CBT in those patients who remain depressed during the time delay. A larger trial is necessary to confirm these findings. (Journal of Psychiatric Practice 2015;21:107-113).

Off label CBT: a promising therapy or an adjunctive pluralistic therapeutic ingredient?

Off label CBT: a promising therapy or an adjunctive pluralistic therapeutic ingredient?

CBT for psychotic disorders: beyond meta-analyses and guidelines - it is time to implement!

The treatment of psychotic disorders has considerably improved since the introduction of antipsychotic medication more than half a century ago, and there is no doubt that this medication can reduce psychotic symptoms and the risk of relapse 1. However, even though pharmacological treatment is significantly better than placebo, there are a number of patients who experience side effects which in some cases can be harmful, and a proportion of people who still experience psychotic symptoms in spite of antipsychotic treatment 2. There are also patients who refuse antipsychotics because of the risk of side effects, the belief that they are able to handle their difficulties without medication, or a fundamental disagreement with the clinician about the nature of their symptoms. In other words: there is room for improvement, and the use of approaches other than medication alone should be explored. There is clear evidence that cognitive behavior therapy (CBT) can reduce psychotic symptoms in schizophrenia when added to pharmacotherapy 1. Several meta-analyses have supported this conclusion, although many studies did not meet optimal standards for randomized controlled trials with regard to blinded measurement of outcome. The effect size in the most rigorously conducted trials is small 3, and evidence is lacking about the effectiveness of short versus long duration CBT 5. Few trials have directly compared CBT with other talking therapies 4, and it is possible, but not yet proven, that other therapies may also be effective. However, based on current evidence, it has not been established that psychodynamic therapy is better than treatment as usual 1. On this background, the American Schizophrenia Patient Outcomes Research Team (PORT) recommendations state that persons with schizophrenia who have persistent psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive CBT to reduce the severity of symptoms 6, and the National Institute for Clinical Excellence (NICE) guidelines recommend to offer CBT to all people with psychosis or schizophrenia 7. In a recent paper, Morrison et al 8 presented data indicating that CBT can be effective even among patients who do not want to take antipsychotic medication. Whilst the sample size was small, this result is promising and warrants replication. Many CBT trials have focused on treatment resistant delusions, where the therapist and the patient will examine the basis and the likelihood of the delusional belief, exploring alternative explanations and identifying behavior that can reduce the stress related to the symptoms. Hallucinations can also be a target for CBT interventions. In a recently published multicenter trial, Birchwood et al 9 reported that CBT focusing on modifying conviction of beliefs linked to the construct of voice power, thereby challenging the omniscience and omnipotence of the voices, can successfully decrease compliance with command hallucinations. This finding is very important from a clinical point of view, as the patients were otherwise treatment resistant, and in many cases posed a significant danger to themselves or others. Hallucinations and delusions, however, are not the only symptoms in schizophrenia. For many patients, negative symptoms, depression, anxiety and low self-esteem are experienced as much more debilitating. CBT has been shown to be a promising intervention in reducing these phenomena. A more holistic approach to treatment, focusing not only on primary symptoms but also on the functional and psychological consequences of having a severe mental illness, is congruent with the current emphasis on factors that can facilitate recovery. In order to ensure that guidelines in different countries are actually rolled out, a carefully designed and closely monitored plan for implementation is required, including financial resources for educational material, training and supervision. Politicians and administrators should understand the need for a strong educational fundament. A continuing focus on intervention quality through skilled supervision is necessary to avoid “puppet on a string” therapists, who can only mechanically implement the intervention as taught in training courses without a clear understanding of what is needed in a specific clinical situation 10. The systematic evaluation of the implementation of CBT interventions in clinical settings can help build on the current evidence base and provide valuable information such as which subgroups may benefit from CBT, the acceptability of the intervention, the durability of treatment effects, and the meaningful outcomes which can be achieved.

The evolution of psychoeducation for bipolar disorder: from lithium clinics to integrative psychoeducation

Coping and living with bipolar disorder is complex and sometimes counterintuitive. It demands a number of attitudes and aptitudes that include a huge emotional insight, healthy and regular lifestyle, skills to identify subtle changes and motivation to reach full treatment adherence. Patients' engagement and proactive attitude are a must for a successful therapeutic outcome. This may partly explain the therapeutic impact of psychoeducational programs in this disorder. However, the history of group psychoeducation in bipolar disorder is full of ups and downs. Interestingly enough, worldwide-respected opinion leaders in group therapy were initially not very enthusiastic with the use of such strategy with bipolar patients. I. Yalom, for instance, defined a bipolar patient as “one of the worst calamities that could befall group therapy” 1. Since then, the practice of psychoeducation has been evolving together with the conceptualization of bipolar disorder.

Schizophrenia with Obsessive-Compulsive Symptoms: Clinical and Conceptual Issues

CME Educational Objectives 1. Develop familiarity with the diverse pathogeneses and subtyping strategies in obsessive-compulsive schizophrenia and examine their corresponding treatment options. 2. Consider the use of adjunctive cognitive behavioral therapy for obsessive-compulsive disorder in clinically stable patients with schizophrenia or schizoaffective disorder. 3. Incorporate knowledge of the patient’s clinical history, pathogenesis and pharmaco-behavioral therapy in the development of individualized treatment strategies. Since its debut in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision ( DSM-IV-TR ), the recognition of obsessive-compulsive disorder (OCD) as a comorbidity in schizophrenia has steadily increased to an estimated rate of 12% to 23% from less than 5% in the early 20th century. 1–3 Evidence also suggests that the rates of OCD or obsessive-compulsive symptoms (OCS) vary according to the stage of psychotic illness and are perhaps more prevalent in those at high risk of developing schizophrenia. 2

Adjunctive CBT increases response in pharmacotherapy-resistant depression in primary care

QUESTION Question: How effective is adding cognitive behavioural therapy (CBT) to pharmacotherapy-based usual care for primary care patients with treatment resistant depression? Patients: A total of 469 adults (average age...

The Efficacy of Cognitive-Behavioral Therapy in Bipolar Disorder

The goal of the current study was to conduct a quantitative meta-analysis investigating the role of cognitive-behavioral therapy (CBT) as adjunctive treatment to medication for patients diagnosed with bipolar disorder. Studies included in the sample were identified through a computer search of articles in English in the MEDLINE database from January 1980 to March 2008. Key terms entered were cognitive and bipolar disorder, cognitive therapy and bipolar disorder, cognitive behavioral therapy and bipolar disorder, psychotherapy and bipolar disorder, and psychosocial and bipolar disorder. Inclusion criteria were (1) randomized clinical trial investigating the role of adjunctive CBT in patients diagnosed with bipolar disorder, (2) clearly defined CBT intervention, (3) the inclusion of a control group, and (4) sufficient data reported to allow calculation of effect sizes. Twelve randomized clinical trials were selected for analysis on the basis of these criteria. Effect sizes (Cohen d) were calculated according to published procedures. We found a low to medium overall effect size of CBT at posttreatment (d = -0.42, P < .05) and follow-up (d = -0.27, P < .05), and we found a positive impact of CBT on clinical symptoms (posttreatment d = -0.44, P < .05), cognitive-behavioral etiopathogenetic mechanisms (posttreatment d = -0.49, P < .05), treatment adherence (posttreatment d = -0.53, P < .05), and quality of life (posttreatment d = -0.36, P < .05). The impact was less evident in the case of relapse and/or recurrence (posttreatment d = -0.28). These effects on outcome categories were more evident at posttreatment compared to follow-up. Cognitive-behavioral therapy can be used as an adjunctive treatment to medication for patients with bipolar disorder, but new CBT strategies are needed to increase and enrich the impact of CBT at posttreatment and to maintain its benefits during follow-up.

Effective components of TORDIA cognitive–behavioral therapy for adolescent depression: Preliminary findings.

In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.

Is Cognitive-Behavioural Therapy More Effective Than Psychoeducation in Bipolar Disorder?

Psychosocial research in bipolar disorder (BD) has not yet assessed the relative benefits of a short course of psychoeducation (PE), compared with a longer course of cognitive-behavioural therapy (CBT) containing psychoeducational principles. This pilot study evaluated the efficacy and added benefit of adding a course of CBT to a standard course of brief PE, as maintenance therapy for BD. Seventy-nine consenting adult men and women with BD on stable medication regimens, who were in full or partial remission from an index episode (BD I = 52; BD II = 27), were randomized to receive either 7 sessions of individual PE, or 7 sessions of PE followed by 13 additional individual sessions of CBT. Weekly mood and medication adherence was rated using the National Institute of Mental Health's Life Chart Method, while psychosocial functioning and mental health use were assessed monthly. Forty-six participants completed the entire study. Participants who received CBT in addition to PE experienced 50% fewer days of depressed mood over the course of one year. Participants who received PE alone had more antidepressant increases compared with those who received CBT. There were no group differences in hospitalization rates, medication adherence, psychosocial functioning, or mental health use. Pilot data from this real-world study suggest that even after medication treatment has been optimized, a longer course of adjunctive CBT may offer some additional benefits over a shorter course of PE alone for the maintenance treatment of BD. Larger randomized controlled trials with equal treatment lengths are indicated.