Naturalistic Treatment Setting Research Articles

Treatment discontinuation in pharmacological clinical trials for gambling disorder

BackgroundGambling disorder affects 0.5–2% of the population, and of those who receive treatment, dropout tends to be relatively high. Very little is known about participant-specific variables linked to treatment discontinuation/dropout in gambling disorder, especially in pharmacological clinical trial settings. MethodsData were pooled from eight previous randomized, controlled pharmacological clinical trials conducted in people with gambling disorder. Demographic and clinical variables were compared between those who did versus did not subsequently dropout from those treatment trials. ResultsThe sample comprised data from 635 individuals, and the overall rate of treatment dropout was 40%. Subsequent treatment dropout was significantly associated with the following: positive family history of gambling disorder in one or more first degree relatives (relative risk [RR] of dropout in those with positive history vs not = 1.30), preference for mainly strategic vs non-strategic gambling activities (RR = 1.43), lower levels of education (Cohen's D = 0.22), and higher levels of functional disability (Cohen's D = 0.18). These variables did not differ significantly as a function of treatment condition (medication versus placebo). Dropouts and completers did not differ significantly in terms of the other demographic or clinical variables that were considered. ConclusionsThis study identified several candidate participant-specific predictors of pharmacological treatment dropout in gambling disorder. The findings highlight the need for future studies to address a wider range of contextual variables at large scale (including also study-specific variables e.g. trial/intervention duration), including in naturalistic treatment and clinical trial settings, with a view to developing algorithms that might usefully predict dropout risk.

Clinical differences between outpatients with and without internet addiction and emotional disorders: a prospective naturalistic outcome study.

as internet use becomes increasingly ingrained in contemporary society, internet addiction (IA) has emerged as a global public health concern. There is ongoing debate regarding whether IA represents a distinct psychological disorder or a secondary manifestation of other existing disorders. This study aimed to examine the pathological relationship between IA and emotional disorders (ED). this study compared pre-treatment characteristics and treatment process of three groups of patients (N=1292) in a naturalistic treatment setting: IA only, ED only, and comorbidity of IA and ED. the IA only group differed from the other groups by reporting the highest levels of life satisfaction, adaptive emotion regulation, as well as risk behavior urges at intake. In addition, the IA only group displayed the lowest level of depressive and anxiety symptoms throughout the treatment. our findings contribute to a better understanding of the discreteness of IA as a potential psychological disorder and inform more effective treatment strategies for IA and its comorbid conditions.

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients’ unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

The Potential Role of Aripiprazole Augmentation for Major Depressive Disorder with Anxious Distress in Naturalistic Treatment Setting.

: This study tried to observe clinical benefit of aripiprazole augmentation (ARPA) treatment for major depressive disorder with anxious distress (MDDA) in routine practice. : Retrospective chart review (n = 41) was conducted for clinical benefit of ARPA in patients with MDDA in routine practice. The primary endpoint was the mean change of Hamilton Anxiety Rating scale (HAMA) total scores from baseline to the endpoint. Additional secondary endpoints were also retrieved. : The changes of primary endpoint HAMA (t = 5.731, -4.6, p = 0.001), and secondary endpoints including Hamilton Depression Rating scale (HAMD, t = 4.284, -3.4, p ＜ 0.001), Clinical Global Impression-Clinical Benefit (CGI-CB, -0.9, t = 1.821, p = 0.026), and Clinical Global Impression Score-Severity (CGI-S, t = 3.556, -0.4, p ＜ 0.001) scores were also significantly improved during the study. No significant adverse events were observed. : This study has shown additional benefit of ARPA treatment for MDDA patients in routine practice. However, adequately-powered and well-controlled studies are necessary for generalization of the present findings.

Machine Learning Facial Emotion Classifiers in Psychotherapy Research: A Proof-of-Concept Study

Background: New advances in the field of machine learning make it possible to track facial emotional expression with high resolution, including micro-expressions. These advances have promising applications for psychotherapy research, since manual coding (e.g., the Facial Action Coding System), is time-consuming. Purpose: We tested whether this technology can reliably identify in-session emotional expression in a naturalistic treatment setting, and how these measures relate to the outcome of psychotherapy. Method: We applied a machine learning emotion classifier to video material from 389 psychotherapy sessions of 23 patients with borderline personality pathology. We validated the findings with human ratings according to the Clients Emotional Arousal Scale (CEAS) and explored associations with treatment outcomes. Results: Overall, machine learning ratings showed significant agreement with human ratings. Machine learning emotion classifiers, particularly the display of positive emotions (smiling and happiness), showed medium effect size on median-split treatment outcome (d = 0.3) as well as continuous improvement (r = 0.49, p < 0.05). Patients who dropped out form psychotherapy, showed significantly more neutral expressions, and generally less social smiling, particularly at the beginning of psychotherapeutic sessions. Conclusions: Machine learning classifiers are a highly promising resource for research in psychotherapy. The results highlight differential associations of displayed positive and negative feelings with treatment outcomes. Machine learning emotion recognition may be used for the early identification of drop-out risks and clinically relevant interactions in psychotherapy.

Self-rated personality disorder symptoms do not predict treatment outcome for posttraumatic stress disorder in routine clinical care.

To test the hypothesis that self-rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma-focused treatment using a single-group pretest-posttest design. Treatment-seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM-5 (PCL-5). PD symptoms were measured with the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout. N =1174 patients (59% female, baseline PCL-5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change (p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance (p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions. The findings provide no evidence that self-rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma-focused treatment. Self-report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.

Additional Clinical Benefit of Agomelatine Treatment for Major Depressive Disorder in Naturalistic Treatment Setting.

This study tried to observe additional benefit of agomelatine (AGO) treatment for major depressive disorder (MDD) in routine practice. Retrospective chart review (n = 63) was conducted for additional benefit of combination with or switching to AGO in MDD patients without full remission. The primary endpoint was the mean change of Clinical Global Impression-Clinical Benefit (CGI-CB) total scores from baseline to the endpoint. Additional secondary endpoints were also collected. The changes of CGI-CB (Z = -3.073, p = 0.002) and Montgomery-Åsberg Depression Rating Scale (Z = -3.483, p < 0.001) total scores were significantly decreased from baseline to the endpoint, respectively. At the endpoint, the remission rate was 22.6% (n = 18) and 28.6% of patient had improvement in CGI-CB total scores at the endpoint. No significant adverse events were observed. This study has shown additional benefit of AGO treatment as combination or switching agent for MDD patients without full remission in routine practice. However, adequately-powered and well-controlled studies are necessary for generalization of the present findings.

The effect of a reduction in irrational beliefs on Posttraumatic Stress Disorder (PTSD), depression, and anxiety symptoms in a group treatment for post-9/11 Veterans

ABSTRACT Previous research has indicated that a Rational Emotive Behavior Therapy (REBT)-Informed Group focused on changing irrational beliefs to address comorbid depression and anxiety (as well as anger and guilt) in a combat Veteran population diagnosed with Posttraumatic Stress Disorder (PTSD) demonstrated significant reductions in depression and PTSD symptoms at posttreatment. However, mechanisms of change associated with improvement have not been evaluated. REBT theory suggests that a decline in irrational beliefs predicts a decrease in PTSD, depression, and anxiety symptoms. This study aimed to test this tenet of REBT theory in a naturalistic treatment setting. Participants (N = 86) were post-9/11 combat Veterans, engaged in the REBT-Informed Group between October 2016 and February 2020. Results of hierarchical multiple regression analyses indicated that a reduction in irrational beliefs predicted notable decreases in PTSD, depression, and anxiety symptoms controlling for several covariates. This study extends previous research demonstrating the success of the REBT-Informed Group with combat Veterans and gives support to REBT theory regarding the effect of a decline in irrational beliefs. Future directions include replication of findings with Veterans who experienced military sexual trauma (MST), pre-9/11 Veterans, those at other military or Veterans Affairs (VA) medical centers, and civilians to determine generalizability.

Outcome trajectories in a county mental health clinic before and after telemental health: a retrospective COVID-19 cohort study.

Telemental health (TMH) care has received increased attention, most recently due to the COVID-19 pandemic. Many treatment settings and clinicians were forced to rapidly shift to TMH modalities, including clinicians with limited exposure to and possibly negative attitudes toward alternative treatment delivery formats. With the shift to new modalities, effectiveness research is necessary to understand if patients are receiving the same quality of care as before the pandemic and their receipt of mostly in person services. This study compared the naturalistic treatment outcome trajectories for a cohort of patients who received in-person services prior to the pandemic and a distinct cohort of patients who received TMH services after the onset of the pandemic, in a community mental health setting with limited exposure to TMH prior to the COVID-19 pandemic. We adopted a retrospective cohort design to examine treatment modality as a between-group moderator of symptom change trajectory on the self-report Patient Health Questionnaire (PHQ-9) in a sample of N = 958 patients in the Northeast United States. Treatment durations differed in the naturalistic treatment setting and we examined patient-reported outcomes up to a maximum of one year. Statistically significant average decreases in symptom severity were found over the course of up to one year of treatment, yet the average outcome trajectory was not significantly different between two modality cohorts (in person delivery before the pandemic versus TMH delivery after pandemic onset). These findings suggest that even in a setting with limited exposure to or training in TMH, the average outcome trajectory for patients who received TMH was statistically similar to the outcome trajectory for patients in an earlier cohort who received in-person services prior to the pandemic onset. Overall, the results appear to support continued use of TMH services in community treatment settings.

Trauma-focused therapies for post-traumatic stress in psychosis: study protocol for the RE.PROCESS randomized controlled trial

IntroductionMany people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE, and EMDR with a waiting list control condition within the same context.Methods and analysisThis is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are as follows: age ≥ 16 years; meeting full DSM-5 diagnostic criteria for PTSD on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), with a total CAPS score ≥ 23; and a psychotic disorder in the schizophrenia spectrum confirmed by the Structured Clinical Interview for DSM-5 (SCID-5). Participants (N=200) will be randomly allocated to 16 sessions of one of the TFTs or WL, in addition to receiving treatment as usual (TAU) for psychosis. The primary objective is to compare the effects of CR, PE, and EMDR to WL on researcher-rated severity of PTSD symptoms over time from baseline to 6-month follow-up. Secondary objectives are to examine these effects at the separate time-points (i.e., mid-treatment, post-treatment, and at 6-month follow-up) and to test the effects for clinician-rated presence of PTSD diagnosis, and self-rated severity of (complex) PTSD symptoms.DiscussionThis is the first RCT to directly compare the effects of CR, PE, and EMDR within the same context to TAU on PTSD symptoms in individuals with psychosis and PTSD. Secondary effects on clinical and functional outcomes will be investigated both directly after therapy and long term.Trial registrationISRCTN ISRCTN56150327. Registered 18 June 2019.

Cognitive control training for urgency: A pilot randomized controlled trial in an acute clinical sample

Urgency – rash action in the context of strong emotion – is a facet of impulsivity closely related to many psychological disorders. Deficits in working memory and response inhibition are potential mechanisms underlying urgency, and a previous study showed that cognitive training targeting these domains is efficacious in reducing urgency. However, the feasibility and efficacy of this intervention has not yet been tested in a clinical sample or naturalistic treatment setting. To fill this gap, we conducted a pilot study of cognitive training for individuals reporting high levels of urgency in a partial hospitalization program. We evaluated this intervention in an open trial (n = 20), followed by a randomized controlled trial (n = 46) comparing cognitive training plus treatment as usual to treatment as usual. Results supported the feasibility and acceptability of cognitive training. Participants in the training group showed significant improvement on cognitive tasks, but groups did not differ in urgency. In pooled analyses combining the open trial and RCT, there was a significant reduction in distress intolerance in the training group only. Results indicate the potential benefit of cognitive training for distress intolerance, but do not support the use of cognitive training for urgency in acute clinical settings.The study conducted in the RCT phase of this manuscript is registered on ClinicalTrials.gov (NCT: NCT03527550). The full trial protocol is available on ClinicalTrials.gov.

Competence and Adherence Scale for Cognitive Behavioural Therapy (CAS-CBT) for anxiety disorders in youth: reliability and factor structure.

There has been increased research interest into the concept of treatment integrity within psychotherapy research. The Competence and Adherence Scale for Cognitive Behavioural Therapy (CAS-CBT) was developed to measure therapists' competence and adherence in cognitive behavioural therapy (CBT), when delivered to children and youth with anxiety disorders. The aim of this study was to evaluate the psychometric properties of the CAS-CBT in a naturalistic treatment setting. Ratings of 212 randomly selected sessions from a clinical effectiveness trial for children with anxiety disorders (n = 165, mean age = 10.46 years, SD = 1.49) were analysed to assess the psychometric properties of CAS-CBT. Therapy format included both individual sessions and group sessions. Internal consistency for the CAS-CBT was excellent (Cronbach's alpha = .88). Factor analysis suggested a two-factor solution for the total sample, where the first factor was related to CBT structure and session goals, and the second factor was associated with process and relational skills. The individual CBT treatment condition (ICBT) and group CBT treatment condition (GCBT) showed the same factor solution. The CAS-CBT is a feasible and reliable measure for assessing competence and adherence to CBT in the treatment of anxious children. Future research is needed to further assess the generalizability of this scale, its psychometric properties in different treatment populations and with other treatment approaches, and ideally with larger sample sizes.

Serotonin Transporter Gene Promoter Hypomethylation as a Predictor of Antidepressant Treatment Response in Major Depression: A Replication Study.

BackgroundThe serotonin transporter gene (SLC6A4; 5-HTT; SERT) is considered a prime candidate in pharmacogenetic research in major depressive disorder (MDD). Besides genetic variation, recent advances have spotlighted the involvement of epigenetic mechanisms such as DNA methylation in predicting antidepressant treatment response in “pharmaco-epigenetic” approaches. In MDD, lower SLC6A4 promoter methylation has been suggested to predict impaired response to serotonergic antidepressants. The present study sought to replicate and extend this finding in a large, independent sample of MDD patients.MethodsThe sample comprised n = 236 Caucasian patients with MDD receiving antidepressant medication in a naturalistic treatment setting. Functional DNA methylation of 9 CpG sites located in the SLC6A4 promoter region was analyzed via direct sequencing of sodium bisulfite– treated DNA extracted from blood cells. Patients were assessed over the course of a 6-week in-patient treatment using the Hamilton Depression Scale (HAM-D).ResultsResults confirm relative SLC6A4 hypomethylation to predict impaired antidepressant response both dimensionally and categorically (HAM-D reductions < 50%) and to furthermore be indicative of nonremission (HAM-D > 7). This also held true in a homogenous subgroup of patients continuously treated with selective serotonin reuptake inhibitors or serotonin/noradrenaline reuptake inhibitors (n = 110).ConclusionsImpaired response to serotonergic antidepressants via SLC6A4 hypomethylation may be conveyed by increased gene expression and consequently decreased serotonin availability, which may counteract the effects of serotonergic antidepressants. The present results could in the future inform clinical decision-making towards a more personalized treatment of MDD.

Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: outcomes from a specialist clinic in the UK.

ObjectivesCognitive behavioural therapy is commonly used to treat chronic fatigue syndrome and has been shown to be effective for reducing fatigue and improving physical functioning. Most of the evidence on the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome is from randomised control trials, but there are only a few studies in naturalistic treatment settings. Our aim was to examine the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic setting and examine what factors, if any, predicted outcome.DesignUsing linear mixed effects analysis, we analysed patients' self-reported symptomology over the course of treatment and at three-month follow-up. Furthermore, we explored what baseline factors were associated with improvement at follow-up.SettingData were available for 995 patients receiving cognitive behavioural therapy for chronic fatigue syndrome at an outpatient clinic in the UK.ParticipantsParticipants were referred consecutively to a specialist unit for chronic fatigue or chronic fatigue syndrome.Main outcome measuresPatients were assessed throughout their treatment using self-report measures including the Chalder Fatigue Scale, 36-item Short Form Health Survey, Hospital Anxiety and Depression Scale and Global Improvement and Satisfaction.ResultsPatients’ fatigue, physical functioning and social adjustment scores significantly improved over the duration of treatment with medium to large effect sizes (|d| = 0.45–0.91). Furthermore, 85% of patients self-reported that they felt an improvement in their fatigue at follow-up and 90% were satisfied with their treatment. None of the regression models convincingly predicted improvement in outcomes with the best model being (R2 = 0.137).ConclusionsPatients’ fatigue, physical functioning and social adjustment all significantly improved following cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic outpatient setting. These findings support the growing evidence from previous randomised control trials and suggest that cognitive behavioural therapy could be an effective treatment in routine treatment settings.

Exploratory Study of Common Changes in Client Behaviors Following Routine Psychotherapy: Does Psychological Flexibility Typically Change and Predict Outcomes?

Psychological flexibility refers to a modifiable pattern of interacting with one’s experiences with openness and awareness (acceptance-and-mindfulness) and active engagement guided by personal values (commitment-and-behavioral activation). Psychological flexibility has a base of research literature that supports its utility as a model of human behavioral health and pathology. Although the model is central in organizing the therapeutic processes of Acceptance and Commitment Therapy, researchers have argued that psychological flexibility processes might be activated in other effective therapy models included in routine psychotherapy, even if those models do not purport to target those processes. This study explored the degree to which aspects of clients’ psychological flexibility, specifically acceptance-and-mindfulness and commitment-and-behavioral activation, changed after episodes of routine psychotherapy and were predictors of outcome changes for a clinically heterogeneous sample (n = 197) in a naturalistic treatment setting. Results showed statistically significant and small improvements in acceptance-and-mindfulness (d = 0.22) and commitment-and-behavioral activation (d = 0.24) and that changes in psychological flexibility were significant predictors of changes in both flourishing and distress, explaining 42% and 23% of those respective therapy outcomes. Whereas a mix of therapy approaches may slightly improve psychological flexibility, more explicit attention to strengthening it might benefit the work of diverse psychotherapists given its potential relevance to achieving common overarching therapy outcomes.

Safety and effectiveness of long-acting injectable Aripiprazole in daily practice: A naturalistic retrospective study

Background and objectivesIt was postulated that Aripiprazole may cause impulse-control problems. Therefore, real-world data on the effects and side effects of Aripiprazole 400 mg depot are needed to review the utility, safety and the clinical effectiveness of Aripriprazole 400 mg depot and highlight the occurrence of adverse effects including impulsivity in a naturalistic treatment settings. MethodsA non-interventional, retrospective study was conducted to examine the electronic records of all patients who were receiving or had received Aripiprazole Lauroxil in South West London before May 2017. Disorder symptoms and side effects were compared between pre- and post-Aripiprazole PO and Aripiprazole Depot treatments. ResultsData were considered for 57 patients who switched to Aripiprazole depot due to non-compliance and/or side effects. Most were suffering from chronic schizophrenia (75.4 %) and half (50.9 %) had comorbid alcohol and/or illicit drug use. Oral Aripiprazole was effective in improving hallucinations, delusions and depressive symptoms (P < 0.022); these benefits were maintained or enhanced further with Aripiprazole Depot. Proportions of patients experiencing sexual disinhibition, aggression and deliberate self-ham decreased significantly (P < 0.003) after starting oral Aripiprazole with no further change after Aripiprazole Depot. By study end, a quarter of patients had stopped taking Aripiprazole Depot due to ineffectiveness, side effects or patient request. ConclusionAripriprazole Lauroxil 400 mg depot was safe, effective and well tolerated. Side effects manifestations should prompt full evaluations and dose reduction should be considered.

Cariprazine

Abstract Objective Cariprazine is a new antipsychotic drug approved for the treatment of schizophrenia in Europe in 2017. Clinical studies suggest advantages of cariprazine in comparison to other antipsychotic agents regarding therapeutic effects on “negative symptoms”, antipsychotic-induced weight gain and increased serum prolactin levels. Akathisia was reported to be one of the most common side effects. Currently, however, data from naturalistic treatment settings regarding the efficacy, safety and tolerability of cariprazine are missing. Thus, we report and discuss our clinical experiences with cariprazine regarding efficacy, safety and tolerability in order to provide first treatment data from a naturalistic treatment setting. Material and methods The course of treatment of a series of 3 patients with schizophrenia spectrum disorders and treatment with cariprazine (mono- or combined therapy) is presented and discussed. Results Cariprazine demonstrated sufficient antipsychotic effects in 2 out of 3 cases; however, in 2 out of 3 cases treatment had to be discontinued due to akathisia/agitation; in 1 case, cariprazine monotherapy facilitated successful normalization of elevated prolactin serum levels (due to combined treatment with risperidone and olanzapine). Conclusion(s): In general, experience with cariprazine within a naturalistic treatment setting is in accordance with data from clinical studies, particularly concerning effects on “negative symptoms”, antipsychotic-associated elevation of prolactin serum levels and risk of akathisia. The comparatively high incidence of discontinuation of cariprazine due to akathisia/agitation in our case series may be an effect of polypharmacy which was very common among our three cases. Clinical relevance This case series provides some evidence that safety, tolerability and antipsychotic efficacy of cariprazine in naturalistic treatment settings may be similar to findings from the available clinical studies.

Anxiety sensitivity and emotion regulation as mechanisms of successful CBT outcome for anxiety-related disorders in a naturalistic treatment setting

BackgroundNumerous randomized controlled trials (RCTs) have examined the efficacy of cognitive behavioral therapy (CBT) in reducing anxiety symptoms. However, relatively fewer studies have examined the effectiveness of CBT in naturalistic treatment settings. There is even less known about the mechanisms underlying successful outcomes in naturalistic samples receiving CBT. This study aimed to examine the absolute and relative mediation of emotion regulation (ER) difficulties and anxiety sensitivity (AS) on anxiety symptom reduction. MethodsParticipants were treatment-seeking patients (N = 247) at an outpatient anxiety clinic. Measures of difficulties in ER, AS, and disorder specific symptoms were administered at baseline, mid, and post-treatment. A composite anxiety score was calculated to measure anxiety disorder symptom severity across anxiety-related diagnoses. ResultsIndividual mediation models revealed that both AS and ER significantly mediated the reduction in anxiety-related symptoms over the course of treatment. A multiple mediation model found that ER was the strongest mediator (indirect effect = −1.030, 95% CI = −2.172 to −0.153). Further analyses revealed that the ER subscale of impulse control difficulties (e.g., the tendency to avoid when confronted with a feared stimulus) was the strongest mediator (indirect effect = −0.849, 95% CI = −1.913 to −0.081). LimitationsThis study relied solely on self-report measures of ER, AS, and anxiety pathology, and did not have a control group. ConclusionsThese results suggest that improvement in the ability to control impulses may act as a mechanism of anxiety symptom reduction and may be important to target in CBT with naturalistic samples.

The Association between Insomnia and Anxiety Symptoms in a Naturalistic Anxiety Treatment Setting

ABSTRACT Objective/Background: Few studies have examined the relationship between insomnia and anxiety treatment outcomes in naturalistic settings. Furthermore, prior studies typically examine insomnia within a single anxiety diagnosis without accounting for the high overlap between disorders. Here we investigate the association between insomnia and multiple anxiety disorders over a course of cognitive behavioral treatment (CBT) in a naturalistic treatment setting. Participants: Insomnia was assessed in 326 patients seeking treatment at a clinic specializing in CBT for anxiety. Methods: Multilevel modeling was used to investigate whether insomnia moderated reductions in anxiety symptoms. A cross-lagged analysis tested for bidirectional effects between insomnia and anxiety. Multiple regression was used to investigate the relationship between insomnia and anxiety while controlling for the other anxiety disorders and depression. Results: While there was a significant reduction in insomnia during treatment in all anxiety disorders, the majority of the most severe patients remained in the clinical range at post-treatment. Baseline insomnia did not significantly moderate anxiety outcomes, suggesting that patients with high or low levels of insomnia will do equally well in CBT for anxiety. The bidirectional effect between insomnia and anxiety did not reach significance. Additionally, posttraumatic stress disorder, generalized anxiety disorder, and panic disorder were associated with the greatest endorsement of insomnia, after controlling for the overlap between disorders. Conclusions: Sleep problems may persist after anxiety treatment, suggesting that CBT for insomnia may be warranted during or after a course of CBT for anxiety. Importantly, baseline insomnia does not impede anxiety reduction during CBT.

B-36 Effects of Electroconvulsive Therapy on Cognitive Performance and Depressive Symptoms: A Naturalistic Study

Abstract Objective 1) Examine the short- and long-term effects of electroconvulsive therapy (ECT)—conducted in a naturalistic treatment setting—on objective and subjective cognitive functioning. 2) Examine the long-term effects of naturalistic ECT on depressive symptoms. Method Participants (N = 108) were outpatients (aged 18-65) diagnosed with a Major Depressive Episode who received ECT at St. Joseph’s Healthcare Hamilton, Ontario. Parameters of ECT varied clinically. Participants completed a cognitive and psychological test battery at baseline (n = 108), mid-treatment (n = 82), 2–6-weeks post-ECT (n = 52), 6-months post-ECT (n = 24), and 12-months post-ECT (n = 14) that included Repeatable Battery for Assessment of Neuropsychological Status (RBANS), Squire Subjective Memory Questionnaire (SSMQ), Beck Depression Inventory-II (BDI-II), and WHO Disability Assessment Schedule (WHODAS-2). Results Overall cognitive performance (total RBANS scaled scores) did not improve from baseline to 2-6 weeks post-ECT (p = 0.156), significantly improved from baseline to 6-months post-ECT (t(22) = -2.34, p = .026, CI: = -8.93– -0.63), but were not maintained at 12-months post-ECT (p = 0.20). SSMQ scores significantly worsened from baseline to mid-ECT (t(75) = -5.04, p &lt; .001, CI: -17.53– -7.60), but returned to baseline levels by 2–6-weeks post-ECT. Depressive symptoms (BDI-II) significantly improved by the 4th ECT session and gains were maintained across all timepoints (p &lt; 0.004). WHODAS-2 scores significantly improved from baseline and were maintained across follow-up (t &lt; 0.05). Conclusion ECT was effective at improving depressive symptoms in a naturalistic setting with diverse patient presentations. Preliminary findings show minimal, if any, gains in cognitive performance–although, functioning did not appear to worsen following ECT. RBANS may not be sufficiently sensitive. Developing recommendations for conducting and evaluating ECT in naturalistic settings marks an essential next step.