Individual Cognitive Behavioral Therapy Research Articles

ES15.03 Managing Sleep Difficulties and Cancer

This paper discusses evidence-based interventions for managing sleep difficulties in people with cancer. Insomnia is a common sleep problem in people with cancer. Insomnia refers to the difficulty of falling asleep, staying asleep and early morning awakenings. It causes distress or impairment in important areas of functioning, such as relationships and employment. It is estimated that between 30-60% of cancer survivors experience significant sleep disturbances that can persist for up to five years post treatment. Aside from greatly impacting on quality of life, poor sleep is associated with anxiety, depression, concentration and memory difficulties, higher rates of pain, increased use of sedatives and poorer work performance [1-3]. People with lung cancer are at an increased risk of experiencing sleep difficulties because of their generally older age, compromised respiratory function, increased disease burden and the impact of treatments [4]. Sleep difficulties also have economic and social impacts on the broader community, due to increased health system costs, productivity losses and wellbeing costs [5]. Cognitive Behaviour Therapy (CBT) is considered to be the first-line treatment for insomnia [6]. CBT targets dysfunctional attitudes, beliefs and habits that interfere with sleep. CBT for insomnia commences with a comprehensive assessment about the nature and duration of sleep complaints, the impact on daytime functioning, compensatory behaviours, the person's beliefs about sleep and any other biopsychosocial factors that might be impacting on sleep. Common screening tools used to assess the impact of sleep difficulties include the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Insomnia Rating Scale (PIRS). These tools are self-reporting and easy to administer. CBT for insomnia is a multi-component intervention and includes psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, cognitive strategies and relapse prevention strategies. It is usually delivered between four to eight session modules. CBT is effective in improving sleep disturbance, fatigue, pain and quality of life. The effects of CBT are durable, with benefits lasting up to three years post-treatment [7, 8]. CBT is suitable for most adults with insomnia, however, it works best with people who are motivated and have the cognitive capacity to learn and adopt CBT strategies. CBT can be effectively provided in group settings, individually, via telephone, video or online methods. Over three quarters of patients achieve remission or significant reduction of sleep disturbance after CBT treatment [9]. CBT has been found to be more effective than mindfulness, massage, exercise and acupuncture intervention. CBT has been found to be as effective as pharmacological intervention in the short-term and more beneficial than medication in the longer term. CBT is also more cost-effective than pharmacological or non-treatment of sleep difficulties [10]. Despite the benefits of CBT, access for people with cancer is limited due to lack specialist availability, cost and awareness of the benefit of CBT. To improve access to evidence-based interventions for people with cancer, stepped-care approaches (where face-to-face CBT is reserved for the most complex cases while less burdensome and less costly self-managed interventions are available for less complex cases) could help translate evidence into clinical practice. Sleep difficulties are highly prevalent in people with cancer, however, access to evidenced-based interventions are limited. Embedding evidence based-screening and CBT into routine care is essential to improving quality of life and care for people with cancer. Savard, J., Simard, S., Blanchet, J., Ivers, H. & Morin, C.M. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep 24, 583-590 (2001). Davidson, J.R., MacLean, A.W., Brundage, M.D. & Schulze, K. Sleep disturbance in cancer patients. Social science & medicine (1982) 54, 1309-1321 (2002). Howell, Doris, et al. "A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer.” Supportive Care in Cancer21.10 (2013): 2695-2706. Halle, Ingrid Helene, et al. "Trajectory of sleep disturbances in patients undergoing lung cancer surgery: a prospective study.” Interactive cardiovascular and thoracic surgery 25.2 (2017): 285-291. Deloitte Access Economics. Re-awakening Australia: the economic cost of sleep disorders in Australia C, Australia: Deloitte Access Economics, 2011.. Re-awakening Australia: the economic cost of sleep disorders in Australia, 2010.Canberra, Australia; 2011. Morin CM, Benca R. Chronic insomnia. Lancet (London, England). 2012;379(9821):1129-41 Arico D, Raggi A, Ferri R. Cognitive Behavioral Therapy for Insomnia in Breast Cancer Survivors: A Review of the Literature. Frontiers in psychology. 2016;7:1162. Blom, K., Jernelöv, S., Rück, C., Lindefors, N., & Kaldo, V. (2016). Three-Year follow-up of insomnia and hypnotics after controlled internet treatment for insomnia. Sleep, 39(6), 1, 1267-1274. https://doi.org/10.5665/sleep.5850 Fiorentino L, McQuaid JR, Liu L, Natarajan L, He F, Cornejo M, et al. Individual cognitive behavioral therapy for insomnia in breast cancer survivors: a randomized controlled crossover pilot study. Nature and science of sleep. 2009;2010:1-8. Reynolds S, R. M. The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment. Sleep Medicine Clinics,. 2017;12(1):39-46.

Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial.

Depression is one of the most common mental disorders in people with advanced cancer. Although cognitive-behavioural therapy (CBT) has been shown to be effective for depression in people with cancer, it is unclear whether this is the case for people with advanced cancer and depression. We sought to determine whether CBT is more clinically effective than treatment as usual (TAU) for treating depression in people with advanced cancer (trial registration number ISRCTN07622709). A multi-centre, parallel-group single-blind randomised controlled trial comparing TAU with CBT (plus TAU). Participants (n = 230) with advanced cancer and depression were randomly allocated to (a) up to 12 sessions of individual CBT or (b) TAU. The primary outcome measure was the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Patient Health Questionnaire-9, the Eastern Cooperative Oncology Group Performance Status, and Satisfaction with Care. Multilevel modelling, including complier-average intention-to-treat analysis, found no benefit of CBT. CBT delivery was proficient, but there was no treatment effect (-0.84, 95% CI -2.76 to 1.08) or effects for secondary measures. Exploratory subgroup analysis suggested an effect of CBT on the BDI-II in those widowed, divorced or separated (-7.21, 95% CI -11.15 to -3.28). UK National Institute for Health and Care Excellence (NICE) guidelines recommend CBT for treating depression. Delivery of CBT through the Improving Access to Psychological Therapies (IAPT) programme has been advocated for long-term conditions such as cancer. Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective. CBT for people widowed, divorced or separated needs further exploration. Alternate models of CBT delivery may yield different results.

Evaluation and comparison of the effects of various cognitive-behavioral therapy methods on climacteric symptoms: A systematic review study

Objective:Climacteric syndrome, which is related to many symptoms, often causes discomfort in women. Non-pharmacologic treatment is one of the treatment options for affected individuals, and this syndrome can be cured with psychological treatments such as cognitive behavioral therapy (CBT). The present study aimed to compare the efficacy of various CBT methods on the improvement of climacteric symptoms.Material and Methods:PubMed, Scopus, Cochrane, Medline, PsycINFO, and Google Scholar were searched for relevant articles published between January 1990 and August 2018. Data extraction and quality assessment were conducted by two authors.Results:A total of 15 articles including 910 women were entered. We divided the CBT methods into two categories, face-to-face (individual and group CBT) and indirect (self-help CBT) methods. Among the three CBT approaches, three articles covered individual CBT, nine articles carried out group CBT, and in five articles, the self-help approach was used. The climacteric symptoms that improved with CBT were categorized into three groups as vasomotor symptoms, psychological symptoms, and organic disorders. Generally, the face-to-face method played a key positive effect on symptom improvement, and the group CBT approach was more effective on psychological symptoms.Conclusion:Although the indirect method is more cost-effective, it has less impact than the face-to-face method; it is better to use face-to-face approaches to achieve better results, if possible. Further studies are required in this regard, particularly in the individual and self-help CBT approaches, to measure the impact of these approaches on more varied symptoms of menopause.

Randomized Clinical Trial Examining Cognitive Behavioral Therapy for Individuals With a First-Time DUI Offense.

Driving under the influence (DUI) programs are a unique setting to reduce disparities in treatment access to those who may not otherwise access treatment. Providing evidence-based therapy in these programs may help prevent DUI recidivism. We conducted a randomized clinical trial of 312 participants enrolled in 1 of 3 DUI programs in California. Participants were 21 and older with a first-time DUI offense who screened positive for at-risk drinking in the past year. Participants were randomly assigned to a 12-session manualized cognitive behavioral therapy (CBT) or usual care (UC) group and then surveyed 4 and 10months later. We conducted intent-to-treat analyses to test the hypothesis that participants receiving CBT would report reduced impaired driving, alcohol consumption (drinks per week, abstinence, and binge drinking), and alcohol-related negative consequences. We also explored whether race/ethnicity and gender moderated CBT findings. Participants were 72.3% male and 51.7% Hispanic, with an average age of 33.2 (SD=12.4). Relative to UC, participants receiving CBT had lower odds of driving after drinking at the 4- and 10-month follow-ups compared to participants receiving UC (odds ratio [OR]=0.37, p=0.032, and OR=0.29, p=0.065, respectively). This intervention effect was more pronounced for females at 10-month follow-up. The remaining 4 outcomes did not significantly differ between UC versus CBT at 4- and 10-month follow-ups. Participants in both UC and CBT reported significant within-group reductions in 2 of 5 outcomes, binge drinking and alcohol-related consequences, at 10-month follow-up (p<0.001). In the short-term, individuals receiving CBT reported significantly lower rates of repeated DUI than individuals receiving UC, which may suggest that learning cognitive behavioral strategies to prevent impaired driving may be useful in achieving short-term reductions in impaired driving.

Treatment of Social Anxiety Disorder and Avoidant Personality Disorder in Routine Care: A Naturalistic Study of Combined Individual and Group Therapy

Background: Cognitive behavioral therapy (CBT) in a group or individual format has proven effective for treating social anxiety in numerous randomized controlled trials. Studies in routine care are rare and focus exclusively on social anxiety disorder (SAD). Findings for avoidant personality disorder (AVPD) are missing. The current effectiveness study evaluates a combination of group and individual CBT for patients with SAD with or without AVPD. Methods: One hundred and five patients diagnosed with SAD with or without comorbid AVPD completed a combination of group and individual CBT. We administered outcome measures prior to individual therapy, prior to group therapy, after group therapy, and ­after individual therapy. Results: Patients experienced a strong decline in social anxiety symptoms (d = 1.1), depression (d = 1.0), and general mental distress (d = 1.1). They also showed a large increase in self-efficacy (d = 1.1). Descriptively, the largest decreases in social anxiety occurred during the group treatment. Controlling for pretreatment severity and depression, a comorbid diagnosis of AVPD was not associated with symptom improvement during treatment. Discussion: The results of the combined treatment were comparable to those of other effectiveness studies. Group treatment seemed to accelerate change in social fears. Patients with AVPD showed the same average improvements as patients without comorbid AVPD.

Do sudden gains predict treatment outcome in social anxiety disorder? Findings from two randomized controlled trials

ObjectiveSudden gains (SGs) have been found to occur during randomized controlled trials (RCTs) for social anxiety disorder (SAD). Evidence is mixed whether SGs relate to treatment outcome in SAD. We examined SGs in two RCTs for SAD. MethodStudy 1 (N = 68) examined SGs in individual cognitive-behavioral therapy (CBT), and Study 2 (N = 100) compared SGs in group CBT and Mindfulness-Based Stress Reduction (MBSR). Weekly ratings of social anxiety were used to calculate SGs. The Liebowitz Social Anxiety Scale-Self-Report and the Social Interaction Anxiety Scale were completed at pretreatment, posttreatment, and follow-up to assess outcome. ResultsIn Study 1, 17.6% of participants experienced a SG. Participants with SGs started and ended treatment with lower social anxiety. SGs were not associated with greater decreases in social anxiety from pre-to posttreatment or 12-month follow-up. In Study 2, SGs occurred in 27% of participants and at comparable rates in MBSR and group CBT. SGs were not associated with changes in social anxiety during treatment in either condition. ConclusionSGs occurred during treatment for SAD. In both RCTs, participants improved regardless of experiencing a SG, suggesting that SGs are not predictive of greater improvement during treatment for SAD.

Development and Pilot Testing of a Cognitive-Behavioral Therapy Digital Service for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.

Research round-up

In a network meta-analysis of 155 trials (n=15 191 participants), Pim Cuijpers and colleagues compared five different delivery methods of cognitive behaviour therapy (CBT) for the treatment of depression in adults. Their analysis showed that four of the five CBT delivery methods (individual, group, telephone, and guided self-help CBT) showed comparable effectiveness. However, these four delivery formats were more effective than unguided self-help CBT (standardised mean differences range of 0·34–0·59) and the two control conditions (waiting list, 0·87–1·02, and care as usual, 0·47–0·72). Fewer dropouts occurred in the participants of individual CBT (relative risk 1·44, 95% CI 1·09–1·89) and group CBT (1·38, 1·06–1·80) than in those of guided self-help. International incidence of psychotic disorders, 2002–17: a systematic review and meta-analysisWe found marked variation in incidence of psychotic disorders by personal characteristics and place. Some geographical variation could be partially explained by differences in case ascertainment methods. Full-Text PDF Open Access

Different CBT Formats Shown to Be as Effective as Individual CBT

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessDifferent CBT Formats Shown to Be as Effective as Individual CBTNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:7 Jun 2019https://doi.org/10.1176/appi.pn.2019.5b21AbstractA large meta-analysis finds that group, telephone, and guided self-help versions of CBT can be as good as individual CBT, though guided self-help might have higher dropout rates.Cognitive-behavioral therapy (CBT) is effective for patients with depression, but not everyone has access to individual, face-to-face CBT. Other formats of CBT are available, including group sessions, telephone-based CBT, and self-help modules that people can do at home (either with some guidance from a professional or on their own). A meta-analysis published in JAMA Psychiatry suggests that these different modalities are equally effective. The one exception was unguided self-help CBT, which was slightly less effective at treating depression than the other formats, likely due to a lack of human interaction.Pim Cuijpers, Ph.D., a professor of clinical psychology at Vrije University in Amsterdam, and colleagues used a network meta-analysis to compare 155 clinical trials (which included more than 15,000 participants) involving five common formats of CBT for the treatment of depression. A network meta-analysis uses multiple direct and indirect comparisons to stratify different treatments; for example, if one study compares A and B, a second A and C, and a third B and C, then a network analysis can analyze these to rank A, B, and C in some order.The researchers compared two outcomes of these trials. The first was effectiveness (how well these therapies improve depressive symptoms), and the second was acceptability (how favorably participants view the CBT format). The latter is important since low acceptability increases the risk of patients dropping out of treatment.The analysis showed that individual, group, guided self-help, and telephone-based CBT were similarly effective, and more effective than unguided self-help CBT.Key PointsHow do individual CBT, group CBT, telephone CBT, guided self-help CBT, and unguided self-help CBT stack up in terms of effectiveness and acceptability?Effectiveness: individual, group, telephone, and guided self-help CBT do not significantly differ from each other, and all four are more effective than unguided self-help CBT and usual care.Acceptability: individual, group, and telephone CBT did not significantly differ from each other; guided self-help CBT is rated as less acceptable than both individual and group CBT as well as usual care.Individual, group, telephone, and unguided self-help CBT had similar levels of acceptability, while guided self-help CBT was considered less acceptable than the other formats.“It is not clear why the acceptability of guided self-help CBT was lower compared with that of the other formats,” Cuijpers and colleagues wrote. “Maybe the absence of direct contact with a professional makes it easier to stop the treatment because there is less personal-relationship pressure to continue with the treatment or the study. However, lower acceptability would then also be expected to happen in unguided CBT, which we did not find. More research is needed to examine this issue.”“These findings make sense since other research has shown that you need to provide some level of human guidance to get the most out of these therapies,” said Bruce Rollman, M.D., director of the Center for Behavioral Health and Smart Technology at the University of Pittsburgh Medical Center. Rollman was not involved in this meta-analysis.Human guidance does not have to come strictly from an expert, added Rollman. He believes it’s just important that human interaction be included to keep patients engaged with therapy. He recently completed a study demonstrating that an online CBT program called Beating the Blues was effective at improving depression and anxiety compared with usual primary care. Beating the Blues is a guided, self-help program with guidance from college graduates who have minimal psychotherapy experience. “They just had good empathy and communication skills,” he said.Rollman also was encouraged that telephone-based CBT proved as effective as other formats. While there is a movement to increase video-based, telepsychiatry, the use of video is difficult in poor, rural communities. Finding that CBT can be effectively delivered via a mobile phone or landline will ensure these communities have some means of receiving evidence-based mental health care.The authors reported no funding information for this study. ■“Effectiveness and Acceptability of Cognitive-Behavior Therapy Delivery Formats in Adults With Depression: A Network Meta-Analysis” can be accessed here. ISSUES NewArchived

Providing manualized individual trauma-focused CBT to unaccompanied refugee minors with uncertain residence status: a pilot study

BackgroundUnaccompanied refugee minors (URMs) seeking asylum show high rates of posttraumatic stress disorder (PTSD), depression and anxiety. In addition, they experience post-migration stressors like an uncertain residence status. Therefore, psychotherapeutic interventions for URMs are urgently needed but have scarcely been investigated up to now. This study aimed to examine manualized individual trauma-focused cognitive behavioural therapy (TF-CBT) for URMs with PTSD involving their professional caregivers (i.e. social workers in child and adolescent welfare facilities).MethodsWe conducted an uncontrolled pilot study with three follow-up assessments (post-intervention, 6 weeks, and 6 months). Participants who met the PTSD diagnostic criteria were treated in a university psychotherapeutic outpatient clinic in Germany with a mean of 15 sessions of TF-CBT. All participants (n = 26) were male UM (Mage = 17.1, SD = 1.0), predominately from Afghanistan (n = 19, 73.1%) and did not have a residence permit. The sample was severely traumatized according to the number of traumatic event types reported (M = 11.3, SD = 2.8). The primary outcome was PTSD measured with the Child and Adolescent Trauma Screen (CATS) and the Diagnostic Interview for Mental Disorders in Childhood and Adolescence (Kinder-DIPS). Secondary outcomes were depression, behavioural and somatic symptoms. All but the somatic symptoms were assessed in both self-report and proxy report.ResultsAt post-intervention the completer sample (n = 19) showed significantly decreased PTSD symptoms, F(1, 18) = 11.41, p = .003, with a large effect size (d = 1.08). Improvements remained stable after 6 weeks and 6 months. In addition to PTSD symptoms, their caregivers reported significantly decreased depressive and behavioural symptoms in participants. According to the clinical interview, 84% of PTSD cases recovered after TF-CBT treatment. After 6 months, youths whose asylum request had been rejected showed increased PTSD symptoms according to individual trajectories in the Kinder-DIPS. The effect was, however, non-significant.ConclusionsIntervention studies are feasible with URMs. This pilot study presents preliminary evidence for the efficacy of an evidence-based intervention like TF-CBT in reducing PTSD symptoms in URMs. Stressors related to asylum proceedings after the end of therapy have the potential to negatively influence psychotherapy outcomes.

Group Cohesion and Climate in Cognitive Behavioral Therapy for Individuals with a First-Time DUI

ABSTRACTFew studies have examined group cohesion and climate in the substance use disorder treatment literature. We examined whether group cohesion and climate are associated with increased self-efficacy outcomes and reduced drinks per week, binge drinking and DUI behaviors, in a sample of individuals with a first-time DUI receiving either cognitive behavioral therapy (CBT) or usual care. Additionally, we examined whether CBT moderates these relationships. Group measures and drinking outcomes were not significantly associated. This study is the first to provide an in-depth analysis on group processes in DUI settings, and as such, provides important insights into how group processes may differ in a mandated DUI context.

Can Cognitive-Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico.

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive-behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n=121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre- to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT+TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1-year follow-up. Regarding family outcomes, adolescents in CBT+TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT-alone showed an increase. The implication of these findings is discussed.

GAD-Specific Cognitive Behavioral Treatment for Children and Adolescents: A Pilot Randomized Controlled Trial

Cognitive behavioral therapy (CBT) designed to target generalized anxiety disorder (GAD) in youth was examined in a pilot feasibility trial. Participants (aged 10–18 years) were randomized to either 10 weeks of individual CBT (n = 20) or supported wait-list (n = 20). Diagnostic status (primary outcome) was assessed blindly at post-treatment for both groups, and at a 3-month follow-up for treated participants. Two participants failed to complete CBT and retained their GAD during the trial. Intention-to-treat analyses revealed large between-group differences in favor of CBT at post-treatment for remission from GAD (80% vs 0%) and comorbid disorders (83% vs 0%), and for all secondary outcomes (child and parent-reported). All gains were maintained at 3-month follow-up in the CBT group. Consistent with the treatment model, significant pre- to post-treatment reductions in several cognitive processes were found for CBT but not wait-listed participants, with these gains maintained at follow-up. Further investigations are warranted. Trial registry: ISRCTN.com Identifier ISRCTN50951795

Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression

Cognitive behavior therapy (CBT) has been shown to be effective in the treatment of acute depression. However, whether CBT can be effectively delivered in individual, group, telephone-administered, guided self-help, and unguided self-help formats remains unclear. To examine the most effective delivery format for CBT via a network meta-analysis. A database updated yearly from PubMed, PsycINFO, Embase, and the Cochrane Library. Literature search dates encompassed January 1, 1966, to January 1, 2018. Randomized clinical trials of CBT for adult depression. The 5 treatment formats were compared with each other and the control conditions (waiting list, care as usual, and pill placebo). PRISMA guidelines were used when extracting data and assessing data quality. Data were pooled using a random-effects model. Pairwise and network meta-analyses were conducted. Severity of depression and acceptability of the treatment formats. A total of 155 trials with 15 191 participants compared 5 CBT delivery formats with 2 control conditions. In half of the studies (78 [50.3%]), patients met the criteria for a depressive disorder; in the other half (77 [49.7%]), participants scored above the cutoff point on a self-report measure. The effectiveness of individual, group, telephone, and guided self-help CBT did not differ statistically significantly from each other. These formats were statistically significantly more effective than the waiting list (standardized mean differences [SMDs], 0.87-1.02) and care as usual (SMDs, 0.47-0.72) control conditions as well as the unguided self-help CBT (SMDs, 0.34-0.59). In terms of acceptability (dropout for any reason), individual (relative risk [RR] = 1.44; 95% CI, 1.09-1.89) and group (RR = 1.38; 95% CI, 1.06-1.80) CBT were significantly better than guided self-help. Guided self-help was also less acceptable than being on a waiting list (RR = 0.63; 95% CI, 0.52-0.75) and care as usual (RR = 0.72; 95% CI, 0.57-0.90). Sensitivity analyses supported the overall findings. For acute symptoms of depression, group, telephone, and guided self-help treatment formats appeared to be effective interventions, which may be considered as alternatives to individual CBT; although there were few indications of significant differences in efficacy between treatments with human support, guided self-help CBT may be less acceptable for patients than individual, group, or telephone formats.

Clinical effectiveness and cost minimisation model of Alpha-Stim cranial electrotherapy stimulation in treatment seeking patients with moderate to severe generalised anxiety disorder

BackgroundCranial electrotherapy stimulation (CES) is a well-tolerated neuromodulation treatment with demonstrated trial efficacy in anxiety disorders. The aim of the current study was to demonstrate its clinical and cost effectiveness during and after CES in people with generalised anxiety disorder (GAD) who had not responded to low intensity psychological treatment in a routine health service. MethodsConsecutive sample of eligible patients with GAD waiting for individual cognitive behaviour therapy (CBT) selected from two publicly funded services in England. They received 60 min per day Alpha-Stim CES for 6–12 weeks. Primary outcome was remission on the GAD-7 scale at 12 and 24 weeks. Cost effectiveness was examined using a cost minimisation model of direct health costs. ResultsOf 161 patients recruited, 72 (44.7%) and 77 (47.8%) achieved remission on the GAD-7 at 12 and 24 weeks respectively with 122 (75.8%) receiving at least 6 weeks CES. Mean (sd) GAD-7 score at baseline significantly improved from 15.77 (3.21) to 8.92 (5.42) and 8.99 (6.18) at 12 and 24 weeks respectively (p < 0.001). 80 (49.7%) participants required further individual CBT. CES provided a saving of £540.88 per patient (95% CI −£327.12, £648.69). LimitationsParticipants were not randomised and there was no control group. Only 48 (29.9%) participants completed every assessment. ConclusionIn patients with generalised anxiety disorder not responding to low intensity psychological treatment, 6–12 weeks daily Alpha Stim CES may be effective after treatment and 3 months later, thereby reducing the need for individual CBT and saving health costs.

SAT-095 The Impact of CPAP on Intensive Calorie Restriction Weight Loss

Obesity has been recognized as a worldwide pandemic, and the first-line treatment is weight loss via a calorie restricted diet (1). Obstructive sleep apnea (OSA) is recognized as one of the key obesity-related comorbidities and has complex interactions with obesity and weight loss treatments. Treating OSA with continuous positive airway pressure (CPAP) is recommended widely in clinical practice as an adjunct therapy with weight loss despite a lack of evidence to support the strategy. Therefore, we conducted a retrospective study with the patients seen in UAMS weight loss clinic from 1/1/2014 to 8/31/2017. Patients were eligible if they were 18-65 years old, body mass index >= 30 and < 50, and underwent a 16-week intensive calorie restriction weight loss program obtained by strict calorie restriction (800 Kcal per day), exercise programs, weekly individual counseling and cognitive behavioral therapy. Patients who suffered from thyroid dysfunction, uncontrolled diabetes, active infection, active malignancy, or end-organ damage were excluded. Participants underwent a standardized medical examination before and every week in the program. Of the 300 patients included in the analysis, the average ages was 55 ± 10 years old, and 236 (78.7%) were female. They were divided into three groups based on self- reported OSA symptoms and CPAP treatment status: asymptomatic OSA group (OSA-A, n = 89), symptomatic group (OSA-S, n = 164), and OSA on CPAP treatment group (OSA-T, n = 47). In 16 weeks, the absolute weight loss of the OSA-T group was significantly higher than that of the OSA-S and OSA-A groups (-12.1 ± 5.9 vs. -9.5 ± 5.5 vs. -8.7 ± 5.3 kg, P < 0.01), whereas, the percentage weight loss of the OSA-T group was not significantly higher than that of the OSA-A and OSA-S groups (-10.46 ± 5.63% vs. -9.14 ± 4.89% vs. -8.47 ± 4.97%, P = 0.065). There had no difference of the absolute weight loss between OSA-A group and OSA-S group. Further analysis established a correlation of CPAP treatment to the absolute weight loss (Spearman’s correlation coefficient -0.181, P = 0.013) after adjustment of baseline body mass index, age and gender. Our results showed that the patients who had CPAP treatment achieved a larger weight reduction than non-CPAP treatment patients in a 16-week intensive calorie restriction weight loss program. Sleep quality may impact success in weight loss programs and several mechanisms may underpin this. Reference: (1) Varady KA. Intermittent versus daily calorie restriction: Which diet regimen is more effective for weight loss? Obes Rev. 2011;12:e593-e601.

Cognitive-Behavioral Therapy for Anxiety in Parkinson's Disease.

Parkinson's disease (PD) is characterized by motor symptoms, but nonmotor symptoms also significantly impair daily functioning and reduce quality of life. Anxiety is prevalent and debilitating in PD, but remains understudied and undertreated. Much affective research in PD focuses on depression rather than anxiety, and as such, there are no evidence-based treatments for anxiety in this population. Cognitive-behavioral therapy (CBT) has shown promise for treating depression in PD and may be efficacious for anxiety. This exploratory study implemented a multiple-baseline single-case experimental design to evaluate the utility and feasibility of CBT for individuals with PD who also met criteria for a DSM-5 anxiety disorder (n = 9). Participants were randomized to a 2-, 4-, or 6-week baseline phase, followed by 12 CBT sessions, and two post treatment assessments (immediately post treatment and 6-week follow-up). Multiple outcome measures of anxiety and depression were administered weekly during baseline and intervention. Weekly CBT sessions were conducted in-person (n = 5) or via secure videoconferencing (n = 4). At post treatment, seven of the nine participants showed significant reductions in anxiety and/or depression, with changes functionally related to treatment and most improvements maintained at 6-week follow-up. Effects of CBT on secondary outcomes varied across participants, with preliminary evidence for reduction in fear of falling. Adherence and retention were high, as were treatment satisfaction and acceptability. The findings of this pilot study provide preliminary evidence for the utility of CBT as a feasible treatment for anxiety and comorbid depressive symptoms in PD and highlight the potential of telehealth interventions for mood in this population.

Group Metacognitive Therapy for Generalized Anxiety Disorder: A Pilot Feasibility Trial.

Background: Individual metacognitive therapy (MCT) for generalized anxiety disorder (GAD) is well established, but only one study has investigated the effectiveness of Group MCT (g-MCT) for GAD. The aim of the current study was therefore to evaluate the feasibility and effectiveness of g-MCT for GAD within a community mental health setting whilst addressing limitations evident in the previous study.Methods: The study used an open trial design, and 23 consecutively referred adults with GAD completed 10 sessions (90 min) of g-MCT, delivered by two therapists trained in MCT. Diagnoses were assessed by trained raters using the Anxiety Disorder Interview Schedule-IV. All patients but one had previous psychosocial treatment, and 17 (73.9%) had at least one comorbid axis-I disorder. Self-reported symptoms were assessed using the Penn State Worry Questionnaire, the Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9 at pre- and post-treatment as well as 3-month follow-up. Feasibility was assessed using rates of patients who declined group treatment in favor of individual treatment, patients not able to attend due to pre-scheduled dates for sessions, and drop-out rate.Results: Of 32 eligible participants, six patients (19%) declined g-MCT in favor of individual MCT, and three (9%) were unable to attend due to scheduling conflicts. No patients dropped out during treatment, but two patients did not complete the self-report questionnaires at 3-month follow-up. g-MCT was associated with significant reductions in worry, anxiety, depression, metacognitive beliefs, and maladaptive coping. According to the standardized Jacobson criteria for recovery, 65.3% were recovered at post-treatment, whereas 30.4% were improved and 4.3% showed no change. At 3-month follow-up, the recovery rate increased to 78.3%. Moreover, recovery rates were comparable for patients with- and without comorbidity. Number of therapist hours per patient was 6.5 and the treatment has now been implemented as a standard treatment option at the clinic.Conclusion: g-MCT for GAD is an acceptable treatment which may offer a cost-effective alternative approach to individual MCT. Recovery rates and effect sizes suggested that g-MCT could be just as efficient as individual MCT and cognitive behavioral therapy.

Cost-effectiveness of individual versus group female-specific cognitive behavioral therapy for alcohol use disorder

ObjectiveTo determine the relative cost-effectiveness of individual female-specific cognitive behavioral therapy (I-FS-CBT) versus group female-specific cognitive behavioral therapy (G-FS-CBT). MethodsThis cost-effectiveness study is based on a randomized controlled trial in which 155 women seeking treatment for alcohol use disorder at an academic outpatient clinic were randomized to 12 manual-guided sessions of I-FS-CBT (n = 75) or G-FS-CBT (n = 80). The primary patient outcomes were the number of drinking days and the number of heavy drinking days during the 12-week treatment and 1-year follow-up periods. All cost data (including resource utilizations) were collected prospectively alongside the trial. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were used to determine the cost-effectiveness of I-FS-CBT relative to G-FS-CBT. Results are presented from the provider perspective. ResultsDuring the 12-week treatment period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $141 (or $258), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $141 (or $258). During the 1-year follow-up period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $54 (or $169), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $54 (or $169). The results are robust to sensitivity analyses on several key cost parameters. ConclusionsCompared to I-FS-CBT, G-FS-CBT holds promise as a cost-effective approach, in both the short run and the long run, for improving drinking outcomes of women with alcohol use disorder.

Telephone-Based Cognitive Behavioral Intervention Improves Dementia Caregivers' Quality of Life.

The present study examined the effects of a telephone-based cognitive behavioral intervention on dementia caregivers' quality of life (QoL). A total of 273 caregivers were randomly assigned to an intervention or control group. The intervention comprised 12 telephone sessions of individual cognitive behavioral therapy (CBT) over 6 months. At baseline, postintervention, and 6-month follow-up, QoL was assessed with the World Health Organization QoL-BREF, which measures perceived QoL for the domains physical health, psychological health, social relationships, and environment as well as overall QoL and satisfaction with general health. Intention-to-treat analyses using latent change models were performed. At postintervention, intervention group participants reported better overall QoL and satisfaction with general health as well as better physical and psychological health compared to control group participants. Together with existing evidence, the results suggest that the telephone CBT intervention does not only reduce impairments but also fosters improvements in health-related QoL.