Controlled Trial Of Cognitive Behaviour Therapy Research Articles

Elucidating treatment targets and mediators within a confirmatory efficacy trial: study protocol for a randomized controlled trial of cognitive-behavioral therapy vs. light therapy for winter depression

BackgroundThis study is a confirmatory efficacy trial of two treatments for winter seasonal affective disorder (SAD): SAD-tailored group cognitive-behavioral therapy (CBT-SAD) and light therapy (LT). In our previous efficacy trial, post-treatment outcomes for CBT-SAD and LT were very similar, but CBT-SAD was associated with fewer depression recurrences two winters later than LT (27.3% in CBT-SAD vs. 45.6% in LT). CBT-SAD engaged and altered a specific mechanism of action, seasonal beliefs, which mediated CBT-SAD’s acute antidepressant effects and CBT-SAD’s enduring benefit over LT. Seasonal beliefs are theoretically distinct from LT’s assumed target and mechanism: correction of circadian phase. This study applies the experimental therapeutics approach to determine how each treatment works when it is effective and to identify the best candidates for each. Biomarkers of LT’s target and effect include circadian phase angle difference and the post-illumination pupil response. Biomarkers of CBT-SAD’s target and effect include decreased pupillary and sustained frontal gamma-band EEG responses to seasonal words, which are hypothesized as biomarkers of seasonal beliefs, reflecting less engagement with seasonal stimuli following CBT-SAD. In addition to determining change mechanisms, this study tests the efficacy of a “switch” decision rule upon recurrence to inform clinical decision-making in practice.MethodsAdults with SAD (target N = 160) will be randomzied to 6-weeks of CBT-SAD or LT in winter 1; followed in winter 2; and, if a depression recurrence occurs, offered cross-over into the alternate treatment (i.e., switch from LT➔CBT-SAD or CBT-SAD➔LT). All subjects will be followed in winter 3. Biomarker assessments occur at pre-, mid-, and post-treatment in winter 1, at winter 2 follow-up (and again at mid-/post-treatment for those crossed-over), and at winter 3 follow-up. Primary efficacy analyses will test superiority of CBT-SAD over LT on depression recurrence status (the primary outcome). Mediation analyses will use parallel process latent growth curve modeling.DiscussionConsistent with the National Institute of Mental Health’s priorities for demonstrating target engagement at the level of Research Domain Criteria-relevant biomarkers, this work aims to confirm the targets and mechanisms of LT and CBT-SAD to maximize the impact of future dissemination efforts.Trial registrationClinicalTrials.gov identifier: NCT03691792. Registered on October 2, 2018.

The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

BackgroundPersistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness.MethodsA two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months.ResultsForty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported.ConclusionsThe study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial.Trial registration numberISRCTN10420559.

Bleuler revisited: on persecutory delusions and their resistance to therapy

Bleuler revisited: on persecutory delusions and their resistance to therapy

Brief relaxation training effects on long-term endocrine therapy adherence among women with breast cancer.

12061 Background: Despite life-saving potential, many women struggle to adhere to adjuvant endocrine therapy (AET) for their early-stage, hormone receptor-positive breast cancer. Prior research has demonstrated that emotional distress is a barrier to AET adherence. The current study aimed to test the long-term effects of two 5-week post-surgical group-based stress management interventions, cognitive behavioral therapy (CBT) and relaxation training (RT), versus an attention-matched health education (HE) control on AET adherence at long-term follow-up. Methods: We conducted long-term follow-up (median = 8 years, range = 7-11 years) of a cohort of women who enrolled in a randomized controlled trial of CBT vs. RT vs. HE shortly after surgery for stage 0-3 breast cancer.We measuredadherence with the Endocrine Therapy Medication Usage Questionnaire (ETMUQ) given at long-term follow-up. First, we established adherence factors on the ETMUQ via confirmatory factor analysis. We then used structural equation modeling to regress these factors on study arm, controlling for patient age, stage of disease, and treatments received (chemotherapy/radiation). Results: The sample was predominately middle-aged ( M= 54.81, SD= 10.19), White (41.5%) and Hispanic (42.2%), partnered (62.2%) with stage 1 (57.0%) or stage 2 (25.9%) disease. Of the women who completed long-term follow-up (N = 59, 44.7% of original sample); more than half (n = 30; 50.8%) reported having at least some problems with adherence. There was an effect of intervention group on adherence, such that women receiving RT (n = 15) had significantly better adherence than those receiving CBT (n = 20) on the factor measuring Forgetfulness/Inconsistency ( B(SE) =.57 (.34), p=.001), and marginally better adherence than those receiving CBT on the factor measuring Intentional Nonadherence ( B(SE) =.60 (.33), p =.062). There was no such effect when comparing RT or CBT to HE (n = 24). Conclusions: Women receiving RT were less likely to forget to take their AET and marginally less likely to intentionally miss doses of AET in the long-term compared to women receiving CBT. Future research could investigate the mechanism by which RT may improve adherence. For example, RT may reduce somatic symptoms related to AET or improve a patients’ self-efficacy to cope with these symptoms thereby reducing intentional non-adherence. In addition, RT may improve patients’ attention and awareness leading to less forgetfulness. Clinical trial information: NCT02103387.

Empirically defining treatment response and remission in body dysmorphic disorder.

The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD. We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment. A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale. Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

Are claims of non-inferiority of Internet and computer-based cognitive-behavioural therapy compared with in-person cognitive-behavioural therapy for adults with anxiety disorders supported by the evidence from head-to-head randomised controlled trials? A systematic review.

This review examines the evidence from head-to-head randomised controlled trials addressing whether the efficacy of cognitive-behavioural therapy for anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorders in adults delivered by computer or online (computer- and Internet-delivered cognitive-behavioural therapy) is not inferior to in-person cognitive-behavioural therapy for reducing levels of symptoms and producing clinically significant gains at post-treatment and at follow-up. A supplementary aim is to examine the evidence for severity as a moderator of the relative efficacy of computer- and Internet-delivered cognitive-behavioural therapy and in-person cognitive-behavioural therapy. PubMed, PsycINFO, Embase and Cochrane database of randomised trials were searched for randomised controlled trials of cognitive-behavioural therapy for these disorders with at least an in-person cognitive-behavioural therapy and Internet or computer cognitive-behavioural therapy arm. A total of 14 randomised controlled trials (9 Internet, 5 computer) of cognitive-behavioural therapy for social anxiety disorder, panic disorder and specific phobia and 3 reports of effect moderators were included. One study showed a low risk of bias when assessed against risk of bias criteria for non-inferiority trials. The remaining studies were assessed as high or unclear risk of bias. One study found that Internet-delivered cognitive-behavioural therapy was superior and non-inferior at post-treatment and follow-up to group in-person cognitive-behavioural therapy for social anxiety disorder. One study of Internet-delivered cognitive-behavioural therapy for panic disorder showed non-inferiority to individual in-person cognitive-behavioural therapy for responder status at post-treatment and one of Internet cognitive-behavioural therapy for panic disorder for symptom severity at follow-up. Other comparisons (22 Internet, 13 computer) and for estimates pooled for Internet cognitive-behavioural therapy for social anxiety disorder, Internet cognitive-behavioural therapy for panic disorder and computer-delivered cognitive-behavioural therapy studies did not support non-inferiority. Evidence of effect moderation by severity and co-morbidity was mixed. There is limited evidence from randomised controlled trials which supports claims that computer- or Internet-delivered cognitive-behavioural therapy for anxiety disorders is not inferior to in-person delivery. Randomised controlled trials properly designed to test non-inferiority are needed before conclusions about the relative benefits of in-person and Internet- and computer-delivered cognitive-behavioural therapy can be made. CRD420180961655-6.

Study protocol for a randomised controlled trial of CBT vs antipsychotics vs both in 14\u201318-year-olds: Managing Adolescent first episode Psychosis: a feasibility study (MAPS)

BackgroundAdolescent-onset psychosis is associated with more severe symptoms and poorer outcomes than adult-onset psychosis. The National Institute for Clinical Excellence (NICE) recommend that adolescents with first episode psychosis (FEP) should be offered a combination of antipsychotic medication (APs), cognitive behavioural therapy (CBT) and family intervention (FI). The evidence for APs in treating psychosis is limited in adolescents compared to adults. Nevertheless, it indicates that APs can reduce overall symptoms in adolescents but may cause more severe side effects, including cardiovascular and metabolic effects, than in adults. CBT and FI can improve outcomes in adults, but there are no studies of psychological interventions (PI) in patients under 18 years old. Given this limited evidence base, NICE made a specific research recommendation for determining the clinical and cost effectiveness of APs versus PI versus both treatments for adolescent FEP.Methods/designThe current study aimed to establish the feasibility and acceptability of conducting such a trial by recruiting 14–18-year-olds with a first episode of psychosis into a feasibility prospective randomised open blinded evaluation (PROBE) design, three-arm, randomised controlled trial of APs alone versus PI alone versus a combination of both treatments. We aimed to recruit 90 participants from Early Intervention and Child and Adolescent Mental Health Teams in seven UK sites. APs were prescribed by participants’ usual psychiatrists. PI comprised standardised cognitive behavioural therapy and family intervention sessions.DiscussionThis is the first study to compare APs to PI in an adolescent population with FEP. Recruitment finished on 31 October 2018. The study faced difficulties with recruitment across most sites due to factors including clinician and service-user treatment preferences.Trial registrationCurrent controlled trial with ISRCTN, ISRCTN80567433. Registered on 27 February 2017.

Assessing Clinical Improvement in School-Based Treatment for Social Anxiety Disorder: Agreement Between Adolescents, Parents, and Independent Evaluators.

The Clinical Global Impressions of Improvement (CGI-I) scale is widely used in clinical trials to monitor clinically meaningful change during treatment. Although it is standard practice in research to have independent evaluators (IEs) complete the CGI-I, this approach is not practical in school and community settings. Few studies have explored the potential utility of other informants, such as youth and parents. Therefore, this study aimed to investigate agreement between IEs and both adolescents and parents in CGI-I improvement ratings in the context of a randomized controlled trial of cognitive-behavioral therapy for social anxiety disorder, as delivered by psychologists and school counselors. Multilevel growth models indicated that IEs were generally more conservative in their ratings of positive treatment response across time and treatment conditions, though greater agreement was observed between parents and IEs by post-intervention and 5-month follow-up. Possible explanations for these findings and suggestions for alternative approaches are discussed.

Evaluating the Psychometric Properties of 3 Depression Measures in a Sample of Persons With Traumatic Brain Injury and Major Depressive Disorder.

To explore the psychometric properties of 3 widely used measures of depression in a sample of individuals with traumatic brain injury (TBI) and major depressive disorder and refine them to maximize efficiency. Secondary analysis of data from a randomized controlled trial of cognitive-behavioral therapy for depression after TBI. Nationwide recruitment from community and clinical settings. One hundred adults within 10 years of complicated mild to severe TBI. Telephone and in-person cognitive-behavioral therapy. Patient Health Questionnaire-9 (PHQ-9), Symptom Checklist-20, and Hamilton Depression Rating Scale. We used Rasch rating scale analysis and multilevel modeling to investigate the 3 measures. Measurement properties of each of the depression measures were strong. We explored modifications to the rating scales to improve efficiency while retaining strong psychometric characteristics. Correlations among these revised measures were high. Treatment effects of each revised depression measure were compared using a multilevel model, and effect size estimates were comparable among the revised PHQ-9, Symptom Checklist-20, and Hamilton Depression Rating Scale. Although each of the 3 measures demonstrated adequate reliability, the efficiency of all 3 instruments was improved with rating scale analysis. The PHQ-9 required the fewest modifications and functions well as a measure of depression among those with TBI.

Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy

Cognitive-behavioural therapy (CBT) is the recommended treatment for binge eating, yet many individuals do not recover, and innovative new treatments have been called for. The current study compares traditional CBT with two augmented versions of CBT; schema therapy, which focuses on early life experiences as pivotal in the history of the eating disorder; and appetite-focused CBT, which emphasises the role of recognising and responding to appetite in binge eating. 112 women with transdiagnostic DSM-IV binge eating were randomized to the three therapies. Therapy consisted of weekly sessions for six months, followed by monthly sessions for six months. Primary outcome was the frequency of binge eating. Secondary and tertiary outcomes were other behavioural and psychological aspects of the eating disorder, and other areas of functioning. No differences among the three therapy groups were found on primary or other outcomes. Across groups, large effect sizes were found for improvement in binge eating, other eating disorder symptoms and overall functioning. Schema therapy and appetite-focused CBT are likely to be suitable alternative treatments to traditional CBT for binge eating.

Beyond intent to treat (ITT): A complier average causal effect (CACE) estimation primer

Randomized control trials (RCTs) have long been the gold standard for allowing causal inferences to be made regarding the efficacy of a treatment under investigation, but traditional RCT data analysis perspectives do not take into account a common reality: imperfect participant compliance to treatment. Recent advances in both maximum likelihood parameter estimation and mixture modeling methodology have enabled treatment effects to be estimated, in the presence of less than ideal levels of participant compliance, via a Complier Average Causal Effect (CACE) structural equation mixture model. CACE is described in contrast to “intent to treat” (ITT), “per protocol”, and “as treated” RCT data analysis perspectives. CACE model assumptions, specification, estimation, and interpretation will all be demonstrated with simulated data generated from a randomized controlled trial of cognitive-behavioral therapy for Juvenile Fibromyalgia. CACE analysis model figures, linear model equations, and Mplus estimation syntax examples are all provided.Data needed to reproduce analyses in this article are available as supplemental materials (online only) in the Appendix of this article.

Parkinson's Impulse-Control Scale for the Severity Rating of Impulse-Control Behaviors in Parkinson's Disease: A Semistructured Clinical Assessment Tool.

BackgroundImpulse‐control behaviors (ICBs) are increasingly recognized in Parkinson's disease (PD) as drug‐related effects of dopaminergic mediation that occur in 15% to 35% of patients with PD. The authors describe the design and evaluation of a new, clinician‐rated severity scale for the assessment of syndromal and subsyndromal forms of impulse‐control disorders (ICDs), simple (punding) and complex (hobbyism) repetitive behaviors, and compulsive overuse of medication (dopamine dysregulation syndrome).MethodsThe Parkinson's Impulse‐Control Scale (PICS), the first PD‐specific, semistructured interview to cover the full range of PD‐related ICBs, is described along with initial evidence on its clinimetric properties including interrater reliability, discriminant validity and sensitivity to change. A convenience sample of PD patients with ICBs and those without were administered a semistructured interview (n = 92).ResultsThe scale distinguished between those with and without clinically detected ICBs and between patients with syndromal ICD and subsyndromal ICB (receiver operating characteristic areas under the curve, 92%–95%). Cutoff values were suggested, and substantial agreement was reported on weighted kappa (Κ) values for clinician‐clinician rating of severity (Κ = 0.92). Significant improvements were detected on the scale after a randomized controlled trial of cognitive‐behavioral therapy and medication adjustment (t[22] = 5.47; P < 0.001).ConclusionsThe PICS appears to be a reliable measure of the full range of PD ICBs with good levels of interrater reliability. It may provide a useful measure to assess the severity of ICBs and monitor change in clinical and research settings; although, given the specialized centers used for recruitment of this sample, further psychometric evaluation is required.

Neural Mechanisms of Cognitive-Behavioral Therapy for Aggression in Children and Adolescents: Design of a Randomized Controlled Trial Within the National Institute for Mental Health Research Domain Criteria Construct of Frustrative Non-Reward

We present the rationale and design of a randomized controlled trial of cognitive-behavioral therapy (CBT) for aggression in children and adolescents, which is conducted in response to the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) approach initiative. Specifically, the study is focused on the brain-behavior associations within the RDoC construct of frustrative non-reward. On the behavioral level, this construct is defined by reactions elicited in response to withdrawal or prevention of reward, most notably reactive aggression. This study is designed to test the functional magnetic resonance (fMRI) and electrophysiological (EEG) correlates of aggression and its reduction after CBT. Eighty children and adolescents with high levels of aggression across multiple traditional diagnostic categories, ages 8-16, will be randomly assigned to receive 12 sessions of CBT or 12 sessions of supportive psychotherapy. Clinical outcomes will be measured by the ratings of aggressive behavior collected at baseline, midpoint, and endpoint evaluations, and by the Improvement Score of the Clinical Global Impressions Scale assigned by an independent evaluator (blinded rater). Subjects will also perform a frustration-induction Go-NoGo task and a task of emotional face perception during fMRI scanning and EEG recording at baseline and endpoint. Consistent with the NIMH strategic research priorities, if functional neuroimaging and EEG variables can identify subjects who respond to CBT for aggression, this can provide a neuroscience-based classification scheme that will improve treatment outcomes for children and adolescents with aggressive behavior. Demonstrating that a change in the key nodes of the emotion regulation circuitry is associated with a reduction of reactive aggression will provide evidence to support the validity of the frustrative non-reward construct.

The effect of rumination and reappraisal on social anxiety symptoms during cognitive-behavioral therapy for social anxiety disorder.

There is growing interest in the role of transdiagnostic processes in the onset, maintenance, and treatment of mental disorders (Nolen-Hoeksema & Watkins, 2011). Two such transdiagnostic processes-rumination and reappraisal-are the focus of the present study. The main objective was to examine the roles of rumination (thought to be harmful) and reappraisal (thought to be helpful) in adults with social anxiety disorder (SAD). We conducted a randomized controlled trial of cognitive-behavioral therapy (CBT) with 75 adults with SAD and examined pre- to post-CBT changes as well as weekly fluctuations in rumination, reappraisal, and social anxiety symptoms. Socially anxious individuals' baseline rumination (brooding) scores predicted weekly levels of social anxiety, rumination, and reappraisal, whereas baseline reappraisal scores did not. Greater weekly rumination was associated with greater weekly social anxiety, but reappraisal was not related to social anxiety. These findings suggest that rumination may have a more significant role than reappraisal in understanding fluctuations in social anxiety during CBT for SAD.

Cannabis abstinence during treatment and one-year follow-up: relationship to neural activity in men.

Cannabis is among the most frequently abused substances in the United States. Cognitive control is a contributory factor in the maintenance of substance-use disorders and may relate to treatment response. Therefore, we assessed whether cognitive-control-related neural activity before treatment differs between treatment-seeking cannabis-dependent and healthy individuals and relates to cannabis-abstinence measures during treatment and 1-year follow-up. Cannabis-dependent males (N=20) completed a functional magnetic resonance imaging (fMRI) cognitive-control (Stroop) task before a 12-week randomized controlled trial of cognitive-behavioral therapy and/or contingency management. A healthy-comparison group (N=20) also completed the fMRI task. Cannabis use was assessed by urine toxicology and self-report during treatment, and by self-report across a 1-year follow-up period (N=18). The cannabis-dependent group displayed diminished Stroop-related neural activity relative to the healthy-comparison group in multiple regions, including those strongly implicated in cognitive-control and addiction-related processes (eg, dorsolateral prefrontal cortex and ventral striatum). The groups did not differ significantly in response times (cannabis-dependent, N=12; healthy-comparison, N=14). Within the cannabis-dependent group, greater Stroop-related activity in regions including the dorsal anterior cingulate cortex was associated with less cannabis use during treatment. Greater activity in regions including the ventral striatum was associated with less cannabis use during 1-year posttreatment follow-up. These data suggest that lower cognitive-control-related neural activity in classic 'control' regions (eg, dorsolateral prefrontal cortex and dorsal anterior cingulate) and classic 'salience/reward/learning' regions (eg, ventral striatum) differentiates cannabis-dependent individuals from healthy individuals and relates to less abstinence within-treatment and during long-term follow-up. Clinically, results suggest that treatment development efforts that focus on enhancing cognitive control in addition to abstinence may improve treatment outcomes in cannabis dependence.

Does pattern recognition software using the Bahr monitor improve the sensitivity, specificity, and concordance of ambulatory skin conductance monitoring of hot flushes?

The aim of this study was to validate the performance of a new pattern recognition method for quantifying physiological hot flushes against conventional fixed criterion methods and to explore its suitability for use in ambulatory clinical trials. This study performed a secondary analysis of baseline and outcome sternal skin conductance monitoring data from two recent randomized controlled trials of cognitive-behavioral therapy (CBT) for hot flushes in breast cancer patients (MENOS1) and healthy peri- and postmenopausal women (MENOS2) using a revised pattern recognition method (Bahr monitor; software version 1.1.6). Sensitivity and specificity were recalculated and compared with previous findings, based on conventional criteria, using monitor-defined flushes as "gold standard" and combined baseline data. Outcome data for physiologically measured flushes between the CBT group and the treatment-as-usual group were separately reexamined using the revised method for each trial. Pattern recognition showed higher concordance (36%), sensitivity (0.64), and specificity (0.99) than the standard method. Hot flushes recorded during the day showed slightly higher concordance (39%) and fewer false-negatives than 24-hour recordings. Based on the revised method, well women randomized to CBT (MENOS2) had significantly fewer flushes than those randomized to treatment as usual at posttreatment (P < 0.04), but CBT did not impact on physiologically measured hot flushes for breast cancer patients (MENOS1). Pattern recognition can identify flushes more reliably by detecting the shape of physiological signals rather than by relying solely on the amplitude of their signals (as used in conventional criteria). With application of the revised method, ambulatory sternal skin conductance monitoring detects changes after a CBT intervention in well women but not in breast cancer survivors.

Effectiveness of modular CBT for child anxiety in elementary schools.

Most randomized controlled trials of cognitive-behavioral therapy (CBT) for children with anxiety disorders have evaluated treatment efficacy using recruited samples treated in research settings. Clinical trials in school settings are needed to determine if CBT can be effective when delivered in real world settings. This study evaluated a modular CBT program for childhood anxiety disorders in two elementary schools. Forty children (5-12 years old) with anxiety disorders, referred by teachers and school staff, were randomly assigned to modular CBT or a 3-month waitlist. Clinicians worked with individual families as well as teachers and school staff. Evaluators blind to treatment condition conducted structured diagnostic interviews and caregivers and children completed symptom checklists at pre- and posttreatment. The primary study outcome, the Clinical Global Impressions-Improvement scale, yielded a positive treatment response at posttreatment for 95.0% of CBT participants, as compared with only 16.7% of the waitlist participants. CBT also outperformed the waitlist on diagnostic outcomes and caregiver-report measures of anxiety. Treatment effects did not extend beyond anxiety diagnoses and symptoms. Results suggest that modular CBT delivered within the elementary school setting may be effective for the treatment of child anxiety disorders. A replication of the study results with a larger sample is indicated.

Patient characteristics and variability in adherence and competence in cognitive-behavioral therapy for panic disorder.

Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. (a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.

Treating Chemobrain: Rehabilitation Therapies Emerge

Cancer patients had been reporting problems with cognitive function for years. And for years, clinicians had been stumped about how to handle a problem that has come to be known as chemobrain. But now, more cancer centers have begun testing interventions for chemobrain, including, most notably, cognitive behavioral therapy (CBT). Major cancer centers in the U.S. and Australia, among others, are now recruiting patients for randomized controlled trials of CBT; five of the trials have 2012 launch dates (see sidebar). The growing number of trials reflects accumulating data and changing attitudes. Patricia Ganz, M.D., at UCLA’s Jonsson Comprehensive Cancer Center, traces several stages in the evolution of thinking about cancer and cognition. At first, everyone believed that the blood–brain barrier protected patients from chemotherapy, so patient reports were not taken seriously. As chemotherapy became more common and rigorous, complaints multiplied and researchers began paying attention. Now, more sophisticated imaging methods and animal models have begun to show evidence of brain changes associated with cancer and to suggest mechanisms that could make chemotherapy one of the culprits. “We are chipping away at getting a scientific database to persuade people,” Ganz said. One addition to that database came in March, with the publication of a small controlled study showing that impaired cognitive function after chemotherapy associated with longitudinal changes in the brain’s white matter. Sabine Deprez, M.D., of Belgium’s University Hospital Gasthuisberg, and colleagues showed that changes in the white matter associated with neuropsychological test results and with the patients’ own reports of specific problems, such as word retrieval. The study appeared in the Journal of Clinical Oncology. Subjective Versus Objective Cognition Many chemobrain studies have found no association between patient reports of cognitive problems—“subjective cognition” in psychologists’ terms—and the findings of test results, or “objective cogni tion. ” But Deprez’s study found that structural changes in the brain associated with both

A Quality-Based Review of Randomized Controlled Trials of Cognitive-Behavioral Therapy for Depression: An Assessment and Metaregression

The authors assessed the methodological quality of randomized controlled trials of cognitive-behavioral therapy (CBT) for depression using the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). They then compared the quality of CBT trials with that of psychodynamic therapy trials, predicting that CBT trials would have higher quality. The authors also sought to examine the relationship between quality and outcome in the CBT trials. An independent-samples t test was used to compare CBT and psychodynamic therapy trials for average total quality score. Metaregression was used to examine the relationship between quality score and effect size in the CBT trials. A total of 120 trials of CBT for depression met inclusion criteria. Their mean total quality score on the RCT-PQRS was 25.7 (SD=8.90), which falls into the lower range of adequate quality. In contrast to our prediction, no significant difference was observed in overall quality between CBT and psychodynamic therapy trials. Lower quality was related to both larger effect sizes and greater variability of effect sizes when analyzed across all available comparisons to CBT. On average, randomized controlled trials of CBT and of psychodynamic therapy did not differ significantly in quality. In CBT trials, low quality appeared to reduce the reliability and validity of trial results. These findings highlight the importance of discerning quality in individual psychotherapy trials and also point toward specific methodological standards for the future.