Cognitive Behavioral Therapy Protocol Research Articles

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

In this review, we begin by considering why post-stroke depression (PSD) is so prevalent. We then examine the current evidence base to support cognitive behavioural therapy (CBT) as a treatment approach for the condition. While there is limited evidence currently, we demonstrate that much remains to be established with regard to PSD and the efficacy of CBT. We argue there is every reason to believe CBT should be an effective treatment, but that clinicians must augment and individually tailor this approach to ensure effectiveness. We set out our rationale for a novel augmented, individually tailored CBT protocol, and describe five key components that we believe once incorporated, and tested using randomized controlled methods, should enhance treatment outcome of PSD.

Treatment of Depression and Suicide in Older Adults

This article describes a cognitive behavior therapy (CBT) intervention for suicide prevention in older adults. Although many studies have found that CBT interventions are efficacious for reducing depressive symptoms in the elderly, researchers have yet to evaluate the efficacy of such interventions for preventing suicide or reducing suicide risk in older adults. In this article we describe a 12-session CBT protocol for reducing depression, suicide ideation, and other risk factors of late-life suicide. The following aspects of the treatment are described: assessing suicide risk, conceptualizing the problem through a cognitive behavioral framework, developing a safety plan, increasing hope and reasons for living, improving social resources, improving problem-solving skills and efficacy, improving adherence to medical regimen, and relapse prevention. In addition, we review other behavioral and cognitive strategies such as activity scheduling and cognitive restructuring that are commonly associated with CBT interventions for depression. We illustrate the application of these strategies through the use of case examples.

Book Review: Cognitive-Behavioural Therapy: The Case Formulation Approach to Cognitive-Behavior Therapy

The Case Formulation Approach to Cognitive-Behavior Therapy Jacqueline B Persons. New York (NY): The Guilford Press; 2008. 273 p. US$35.00 Reviewer rating: Excellent Cognitive-Behavioural Therapy Trainees new to cognitive-behavioural therapy (CBT) often worry about their capacity to do the technical interventions for which CBT is best known. How does one use a thought record to change key assumptions? What is an exposure hierarchy, and how is it made? What is the best way to carry out behavioural activation? When they begin treating patients with CBT, they soon discover that the tough part of CBT is not really technique, but rather the choices the therapist makes during the therapy: choosing what to target, choosing when to do so, choosing which interventions would be the most fruitful. This book focuses on the decision-making tasks1' l(1 the therapist must make in the course of therapy. The case formulation approach to CBT is in contrast to the manual ized CBT protocols featured in research trials (those same trials, it must be said, that have established the evidence of CBT's efficacy in emotional disorders). Research trials typically treat highly selected groups with a single diagnosis, while the average therapist in practice is faced with patients with comorbidity, not otherwise specified diagnoses, or diagnoses for which there are no protocols. Further, the burgeoning number of treatment approaches to common disorders makes it hard for any therapist to know how best to treat their patient. The case formulation approach involves making a comprehensive list of the patient's problems, and developing hypotheses about how these problems relate to each other and to putative underlying mechanisms. These hypotheses are derived from the principles of the cognitive, learning, and emotion theories which currently underpin most empirically supported treatments for emotional disorders. The case formulation chosen will then guide the treatment targets and interventions, and guide the therapist in the management of the minute-to-minute interactions in therapy. An example: the case of lateness for a session can be understood in many different ways, depending on the person's case formulation. The patient with underlying beliefs relating to worthlessness (my needs don't matter) may have found it difficult to break away from a telephone conversation that will make her late for her appointment (cognitive theory). …

Significant Other Enhanced Cognitive-Behavioral Therapy for PTSD and Alcohol Misuse in OEF/OIF Veterans.

This manuscript describes early work to develop a cognitive-behavioral therapy protocol for returning OEF/OIF Veterans with co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD). Based on the unique characteristics of this population, and on the literature supporting cognitive behavioral coping skills and significant other involvement for both PTSD and for AUD, the new therapy involves both of those components. The paper includes brief descriptions of two patients who were successfully treated with this approach. Although preliminary, these case studies suggest that cognitive-behavioral therapy enhanced by significant other involvement may be a promising approach for OEF/OIF Veterans with PTSD-AUD.

An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury.

Systematic review. To examine the evidence supporting the effectiveness of cognitive behavioral therapy (CBT) for improving psychosocial outcomes in individuals with spinal cord injury (SCI). Electronic databases (MEDLINE, CINAHL, EMBASE, and PsycINFO) were searched for studies published between 1990 and October 2010. Randomized control trials (RCTs) and nonrandomized control trials (non-RCTs) utilizing a CBT intervention to improve psychosocial outcomes (depressive symptomatology, anxiety, coping, and adjustment to disability) in outpatient persons with SCI were included for review. Levels of evidence were assigned to each study using a modified Sackett scale. Effect size calculations for the interventions were provided where possible. Nine studies met the inclusion criteria. The studies reviewed included two RCTs, six prospective controlled trials (PCTs) and one cohort study. All studies examined at least two groups. There is Level 1 and Level 2 evidence supporting the use of specialized CBT protocols in persons with SCI for improving outcomes related to depression, anxiety, adjustment, and coping. CBT holds promise as an effective approach for persons with SCI experiencing depression, anxiety, adjustment, and coping problems. As CBT may involve many different components, it is important in the future to determine which of these elements alone or in combination is most effective in treating the emotional consequences of SCI.

The Clinical Assessment and Treatment of Nicotine Dependence

In the United States and around the world, nicotine dependence is a leading cause of preventable death. Smoking cessation results in immediate and enduring health benefits. A wide range of clinical interventions have been shown to facilitate smoking cessation and to have a favorable cost-benefit profile. Practice guidelines and national reports have issued calls to action and have made smoking cessation resources readily available. Yet utilization of smoking cessation interventions and resources is lagging. Health care systems and providers have a shared responsibility to ensure that all smokers are offered appropriate interventions. This article summarizes the epidemiology and pathophysiology of nicotine dependence as a background for reviewing the central components of clinical evidence-based smoking cessation interventions: screening, assessment, advice, assistance, and follow-up. Specific patient populations are discussed, as well as emerging strategies to address nicotine dependence.

Cognitive Behavioral Therapy in Adults with Obsessive–Compulsive Disorder and Borderline Intellectual Functioning: A Case Series of Three Patients

Cognitive-behavior therapy (CBT) is widely accepted as the most effective psychological treatment for obsessive–compulsive disorder (OCD). Although this modality flexibly treats a variety of OCD symptom subtypes, it is unclear how CBT should be adapted to meet the needs of individuals with OCD and limitations in their cognitive functioning. In this paper, we report on three adults with borderline intellectual functioning who received CBT following a protocol that was adapted to meet their unique developmental and intellectual needs. For the purposes of this case study, the following modifications were made to a standard treatment CBT protocol: 1) increased parental involvement, 2) simplified language, 3) decreased reliance on cognitive techniques, and 4) the addition of contingency management strategies and role modeling by caregivers. All three adult patients benefited from treatment as evidenced by significant reductions in their OCD symptoms at post-treatment. Conclusions from these cases are drawn, as well as directions for future research.

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

The onset of appearance-related concerns associated with body dysmorphic disorder (BDD) typically occurs in adolescence, and these concerns are often severe enough to interfere with normal development and psychosocial functioning. Cognitive behavioral therapy (CBT) is an effective treatment for adults with BDD. However, no treatment studies focusing on adolescents with BDD have been conducted. The need for an effective treatment in this population led to the development of a brief CBT protocol with family involvement. The treatment focuses on enhancing an adolescent's quality of life through the reduction of maladaptive thoughts and behaviors, and incorporates skills training and parent training. Similar treatment packages have already been shown to be efficacious for children and adolescents with similar disorders, such as obsessive-compulsive disorder and social phobia. The following case illustrates the application of this brief CBT protocol for BDD in an adolescent, and highlights clinical considerations needed when adapting CBT for a pediatric population. Treatment was associated with clinically significant improvement in symptoms of BDD, self-esteem, depression, and quality of life. This report extends extant literature by suggesting that CBT may be a helpful treatment for adolescents with BDD.

Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: A randomized clinical trial.

To examine the efficacy of a developmentally appropriate parent-child cognitive behavioral therapy (CBT) protocol for anxiety disorders in children ages 4-7 years. Randomized wait-list controlled trial. Conduct: Sixty-four children (53% female, mean age 5.4 years, 80% European American) with anxiety disorders were randomized to a parent-child CBT intervention (n = 34) or a 6-month wait-list condition (n = 30). Children were assessed by interviewers blind to treatment assignment, using structured diagnostic interviews with parents, laboratory assessments of behavioral inhibition, and parent questionnaires. Chi-square analyses of outcome rates and linear and ordinal regression of repeated measures, examining time by intervention interactions. The response rate (much or very much improved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32% (CBT vs. controls), p < .01; intent-to-treat: 59% vs. 30%, p = .016. Treated children showed a significantly greater decrease in anxiety disorders (effect size [ES] = .55) and increase in parent-rated coping (ES = .69) than controls, as well as significantly better CGI improvement on social phobia/avoidant disorder (ES = .95), separation anxiety disorder (ES = .82), and specific phobia (ES = .78), but not on generalized anxiety disorder. Results on the Child Behavior Checklist Internalizing scale were not significant and were limited by low return rates. Treatment response was unrelated to age or parental anxiety but was negatively predicted by behavioral inhibition. Gains were maintained at 1-year follow-up. Results suggest that developmentally modified parent-child CBT may show promise in 4- to 7-year-old children.

Negative Life Events and Avoidant Coping are Associated with Poorer Long-Term Outcome in Older Adults Treated for Generalized Anxiety Disorder

The objective of this investigation was to explore predictors of long-term outcome following treatment of generalized anxiety disorder (GAD) in older adults. A small sample of older adults (N = 27) were randomized into a modular cognitive behavioral therapy protocol or enhanced community treatment for 12 weeks and followed for one year. Results from random effects regression models indicated that baseline levels of anxiety symptoms, avoidant coping, and negative life events are significantly associated with anxiety across follow-up. These preliminary data suggest that negative life events and avoidant coping may merit further investigation as predictors of long-term treatment outcome in geriatric GAD.

A penny for your thoughts: Patterns of sleep-related beliefs, insomnia symptoms and treatment outcome

The aim of this study was to determine how distinctive patterns of unhelpful beliefs about sleep endorsed by insomnia patients relate to their presenting symptoms and treatment responses. A sample of 281 primary insomnia sufferers completed items comprising the Dysfunctional Beliefs About Sleep scale (DBAS-16). Their resultant scores on the four DBAS-16 subscales were then subjected to a cluster analysis, which resulted in the identification of four distinctive age-matched subgroups. Two subgroups were characterized by pathologically elevated scores on at least two of the DBAS-16 subscales, whereas the other two subgroups had subscale scores that closely resembled those of a normative sample. Subsequent comparisons showed the insomnia subgroups differed in regard to their insomnia severity, use of prescribed medication for sleep, depression and anxiety symptoms, and daytime sleepiness. Furthermore, comparisons of treatment outcomes (i.e. analysis of change scores and normative comparisons) across clusters showed that the subgroups did not benefit equally from a standardized form of Cognitive-Behavioral Therapy (CBT) for insomnia. Findings demonstrate the contribution of specific sleep-related beliefs on presenting insomnia symptoms and suggest the potential usefulness of tailoring CBT protocols to match the needs of distinctive insomnia subtypes.

Children with High‐Functioning Autism Spectrum Disorders and Co‐occurring Anxiety Symptoms: Implications for Assessment and Treatment

The purpose of this article is to provide guidance and recommendations for children with high-functioning Autism Spectrum Disorders (ASD) and anxiety, including suggestions for assessment and intervention. Children with ASD are at increased risk for developing clinical anxiety symptoms. Anxiety symptoms can impact school performance, peer relationships, and family functioning. Emerging clinical research has demonstrated the potential positive impact of modified cognitive behavioral therapy to reduce anxiety symptoms in children with ASD. Modifications necessary to make cognitive behavioral therapy (CBT) protocols accessible to children with ASD are presented, along with specific suggestions for evaluating and treating anxiety symptoms.

Changes in Emotion Regulation Following Cognitive-Behavioral Therapy for Anxious Youth

This study examined emotion-related functioning following cognitive-behavioral therapy (CBT) with 37 youth with anxiety disorders (22 boys, 15 girls) ranging in age from 7 to 15 with a principal diagnosis of generalized anxiety disorder (n = 27), separation anxiety disorder (n = 12), and/or social phobia (n = 13). Treated youth exhibited a reduction in anxiety and increased anxiety self-efficacy and emotional awareness at posttreatment. Treated youth also demonstrated improved coping and less emotional dysregulation with worry but not with anger or sadness. The results suggest that the gains made in worry regulation do not generalize to other emotions that are not specifically targeted within the CBT protocol.

Innovative child and adolescent treatment research for anxiety and depressive disorders

‘‘Taking it to the Streets: Advancing the Dissemination of CBT’’ was the theme of the annual meeting of the Association for Behavioral and Cognitive Therapies (ABCT) held in Orlando, Florida in November 2008. ABCT is an interdisciplinary organization comprising researchers, clinicians, and trainees who are committed to development, implementation, and dissemination of behavioral, cognitive, and other evidence-based interventions. Historically, the ABCT annual meetings have had a preponderance of presentations focused on the treatment of anxiety and depressive disorders, and the 2008 meeting was no exception. Below are some of the highlights of this year’s convention. Treatments for childhood anxiety were evaluated in the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS), a multisite National Institute of Mental Health (NIMH)-supported trial comparing the efficacy of cognitive-behavior therapy (CBT), sertraline, pill placebo, and a combination of CBT and sertraline for treating children and adolescents with Generalized Anxiety Disorder, Social Phobia, and/or Separation Anxiety Disorder. Study investigators presented a symposium focused on the primary outcomes of CAMS, the largest (n5 488) and first ever randomized clinical trial for childhood anxiety. Results indicated that the combined intervention led to significantly better response rates than CBT alone or sertraline alone (81% versus 60% and 55%, Po.001), whereas the monotherapies were not significantly different from each other. All three active conditions were superior to pill placebo (23.7% response rate, Po.001). John Walkup, M.D. and colleagues emphasized that clinicians can recommend three options for treating child and adolescent anxiety based on treatment availability and family preferences. Paul Rohde, Ph.D. from the Oregon Research Institute presented the findings of the continuation and maintenance treatments provided in the multisite Treatments of Adolescents with Depression Study (TADS). TADS examined the impact of psychosocial and psychopharmacological interventions on the achievement and maintenance of sustained treatment response for depression, comparing the effectiveness of fluoxetine (FLX), CBT, combination therapy (COMB), and pill placebo with clinical management (PBO). Following 12 weeks of acute treatment, patients in the FLX, CBT, and COMB conditions received 6 weeks of continuation treatment (intensity based on degree of response to acute treatment) followed by three maintenance treatment sessions scheduled over 18 weeks. Patients continued in the same treatment conditions assigned during acute treatment. Among the 39% (n5 95) of patients who had not achieved a sustained response (two consecutive ratings of a full response in assessments conducted 6 weeks apart) at the end of the acute treatment, sustained response rates during continuation and maintenance treatments were as follows: 80% COMB, 62% FLX, and 77% CBT (difference not significant). These results indicate that for most depressed adolescents who do not achieve a sustained response during acute treatment, extra time and treatment will result in the desired treatment effect. Although CAMS and TADS studied treatments for either anxiety or depression, respectively, Robin Weersing, Ph.D. from San Diego State University and University of California, San Diego presented the results of a pilot effectiveness study of a brief, integrated cognitive-behavioral approach to treat children with anxiety and/or depressive disorders in a primary-care setting. The eight-session treatment adapted and combined two CBT protocols, one for anxiety and one for depression, with a focus on ‘‘graded engagement’’ (a combination of exposure and behavioral activation). Children aged 8–17 (n5 60) with diagnoses of depression and/or anxiety were randomized to receive either the brief behavioral treatment or outside referral. Results at 12 weeks indicated that children in the brief CBT condition demonstrated significantly greater clinical global improvement and symptom reduction than children in the control group. Children with comorbid diagnoses demonstrated significant reductions in both anxious and depressive symptoms, suggesting the feasibility of a

A randomized trial comparing two models of web-based training in cognitive–behavioral therapy for substance abuse counselors

This study compared training outcomes obtained by 147 substance abuse counselors who completed eight self-paced online modules on cognitive–behavioral therapy (CBT) and attended a series of four weekly group supervision sessions using Web conferencing software. Participants were randomly assigned to two conditions that systematically varied the degree to which they explicitly promoted adherence to the CBT protocol and the degree of control that they afforded participants over the sequence and relative emphasis of the training curriculum. Outcomes were assessed at baseline and immediately following training. Counselors in both conditions demonstrated similar improvements in CBT knowledge and self-efficacy. Counselors in the low-fidelity condition demonstrated greater improvement on one of three measures of job-related burnout when compared to the high-fidelity condition. The study concludes that it is feasible to implement a technology-based training intervention with a geographically diverse sample of practitioners, that two training conditions applied to these samples of real-world counselors do not produce statistically or clinically significant differences in knowledge or self-efficacy, and that further research is needed to evaluate how a flexible training model may influence clinician behavior and patient outcomes.

The Transdiagnostic Perspective on Cognitive-Behavioral Therapy for Anxiety and Depression: New Wine for Old Wineskins?

Transdiagnostic cognitive-behavioral therapy (CBT) for anxiety and depression has been of growing interest in psychotherapy research. In this article we discuss several fundamental issues raised by contributors to this special issue on transdiagnostic CBT for emotional disorders. Although researchers have tended to assume that interventions are transdiagnostic because they are labeled as such, the actual boundary between transdiagnostic and disorderspecific treatments may be far less clear than previously acknowledged. Nevertheless, there are many reasons to advocate for greater attention to a transdiagnostic perspective, not the least being the large shared variance in the emotional disorders, which is often overlooked in contemporary disorder-specific CBT protocols. Evidence of the efficacy of transdiagnostic CBT for anxiety and depression is limited, and issues facing comparative outcome and process studies are discussed. The article concludes by suggesting a programmatic framework for advancing a theory-driven, empirically based psychotherapy research agenda that could lead to the development of a truly integrated, transdiagnostic CBT for anxiety and depression.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods.

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7–17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.NCT00074815

CBT does not improve relapse rates in people with recently relapsed psychosis

### Question: What is the effect of cognitive behavioural therapy (CBT) and family intervention on relapse rates and symptoms in people with recently relapsed non-affective psychosis? ### Patients: 301 people...

School-Based Cognitive-Behavioral Therapy for Adolescent Depression

The current study evaluated cognitive-behavioral therapy (CBT) for adolescent depression delivered in health clinics and counseling centers in four high schools. Outcomes were benchmarked to results from prior efficacy trials. Fifty adolescents diagnosed with depressive disorders were treated by eight doctoral-level psychologists who followed a manual-guided, 12-session, individual CBT protocol. Referred adolescents presented with high rates of comorbidity, traumatic experiences, and prior suicide attempts. Posttreatment response to school-based CBT (64%) was comparable to results obtained in efficacy trials. On average, symptom reduction in this school-based study was similar to prior efficacy trials, exceeded results from an efficacy trial using the original manual, and exceeded results from a prior school-based CBT trial. Examination of predictors of symptom change and treatment response showed that life stress, trauma history, and depressive symptom severity were negatively associated with outcomes. Results suggest that school-based CBT is a relatively robust treatment for adolescent depression across gender, age, and ethnic groups as well as for adolescents with varied patterns of comorbidity.

Poster 26: Examination of Maintenance of Gains From a New Cognitive Behavioral Therapy Protocol for People With Brain Injury

Poster 26: Examination of Maintenance of Gains From a New Cognitive Behavioral Therapy Protocol for People With Brain Injury