Routine Cognitive-behavioral Therapy Research Articles

Effectiveness of Usual-Care Cognitive-Behavioral Therapy for Children and Adolescents with Nonorganic Enuresis and Comorbid Mental Disorders

ABSTRACT Highly controlled randomized controlled trials (RCT) have provided considerable evidence for the efficacy of standard urotherapy (SU) consisting of cognitive-behavioral therapy (CBT) in patients with enuresis. However, the effectiveness of CBT under routine care conditions regarding wetting frequency and comorbid mental health problems has not been shown. Changes under routine CBT were analyzed in a sample of n = 220 clinically referred children and adolescents with enuresis (88.2% with at least one comorbid mental disorder) aged 6 to 18 years (M = 9.30; SD = 2.32) treated at a university outpatient clinic (experimental group, EG). At the start and end of treatment, wetting frequency as well as parent- and teacher-rated mental health problems were assessed and compared to a historical control group (CG) receiving a medical placebo. The EG showed a large, statistically significant pre-post reduction in wetting frequency (effect size d = 1.47). When comparing these results to the CG, a net effect size in favor of the EG emerged (d = 1.32). Furthermore, small to large, statistically significant reductions in mental health problems were found in the EG (range: d = 0.26 to d = 1.24). However, a substantial proportion of the EG remained in the clinical range at the end of treatment. The present study indicates that routine CBT for patients with enuresis may be effective, thus supporting the findings of more controlled efficacy trials. Trial registration: DRKS00028094 - Retrospectively registered, May 25, 2022, http://drks.de

Effectiveness of usual-care cognitive-behavioral therapy for adolescents with depressive disorders rated by parents and patients \u2013 an observational study

BackgroundDepressive disorders are common in adolescence and are associated with a wide range of negative long-term outcomes. Highly controlled randomized controlled trials (RCT) provide considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) as a treatment for depression, but studies examining the effectiveness of CBT in clinical settings are very rare .MethodsIn the present observational study, the changes achieved through routine CBT in adolescents with depressive disorders treated in a clinical setting in terms of a university outpatient clinic were analyzed, and compared to a historical control group of adolescents with depressive disorders who had received treatment as usual. At the start and end of treatment (pre- and post-assessment), parent and self-ratings of the German versions of the Youth Self-Report (YSR), the Child Behavior Checklist (CBCL) and rating scales for depressive symptoms (FBB-DES, SBB-DES) were assessed. A total of 331 adolescents aged 11–18 years with complete data were assessed for the main analysis.ResultsThe analysis yielded small to large pre-post effect sizes (Cohen’s d) for the total sample (d = 0.33 to d = 0.82) and large effect sizes for adolescents who were rated in the clinical range on each (sub) scale at the start of treatment (d = 0.85 to d = 1.30). When comparing patients in the clinical range with historical controls, medium to large net effect sizes (d = 0.53 to d = 2.09) emerged for the total scores in self- and parent rating. However, a substantial proportion of the sample remained in the clinical range at the end of treatment.ConclusionsThese findings suggest that CBT is effective for adolescents with depressive disorders when administered under routine care conditions, but the results must be interpreted with caution due to the lack of a direct control condition.Trial registrationDRKS, DRKS00021518. Registered 27 April 2020 - Retrospectively registered, http://drks.de

Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders.

Introduction: Internet- and mobile-based interventions (IMIs) and their integration into routine psychotherapy (i.e., blended therapy) can offer a means of complementing psychotherapy in a flexible and resource optimized way.Objective: The present study will evaluate the non-inferiority, cost-effectiveness, and safety of two versions of integrated blended psychotherapy for depression and anxiety compared to standard cognitive behavioral therapy (CBT).Methods: A three-armed multicenter cluster-randomized controlled non-inferiority trial will be conducted comparing two implementations of blended psychotherapy (PSYCHOnlineTHERAPYfix/flex) compared to CBT. Seventy-five outpatient psychotherapists with a CBT-license will be randomized in a 1:1:1 ratio. Each of them is asked to include 12 patients on average with depressive or anxiety disorders resulting in a total sample size of N = 900. All patients receive up to a maximum of 16 psychotherapy sessions, either as routine CBT or alternating with Online self-help sessions (fix: 8/8; flex: 0–16). Assessments will be conducted at patient study inclusion (pre-treatment) and 6, 12, 18, and 24 weeks and 12 months post-inclusion. The primary outcome is depression and anxiety severity at 18 weeks post-inclusion (post-treatment) using the Patient Health Questionnaire Anxiety and Depression Scale. Secondary outcomes are depression and anxiety remission, treatment response, health-related quality of life, patient satisfaction, working alliance, psychotherapy adherence, and patient safety. Additionally, several potential moderators and mediators including patient characteristics and attitudes toward the interventions will be examined, complemented by ecological day-to-day digital behavior variables via passive smartphone sensing as part of an integrated smart-sensing sub-study. Data-analysis will be performed on an intention-to-treat basis with additional per-protocol analyses. In addition, cost-effectiveness and cost-utility analyses will be conducted from a societal and a public health care perspective. Additionally, qualitative interviews on acceptance, feasibility, and optimization potential will be conducted and analyzed.Discussion: PSYCHOnlineTHERAPY will provide evidence on blended psychotherapy in one of the largest ever conducted psychotherapy trials. If shown to be non-inferior and cost-effective, PSYCHOnlineTHERAPY has the potential to innovate psychotherapy in the near future by extending the ways of conducting psychotherapy. The rigorous health care services approach will facilitate a timely implementation of blended psychotherapy into standard care.Trial Registration: The trial is registered in the German Clinical Trials Register (DRKS00023973; date of registration: December 28th 2020).

Memory rescripting in major depressive disorder

ABSTRACT We applied two sessions of memory rescripting in routine cognitive behavioural therapy (CBT) practice for MDD and measured its effectiveness. We also examined the content of intrusive memories and rescripted memories. Sixteen patients with MDD were asked to identify intrusive memories and rate their vividness, distress, interference with daily life, and uncontrollability before and after memory rescripting. As a result, memory rescripting significantly reduced the intrusive memory index. With one exception, memory rescripting created an image containing compassionate imagery, mastery imagery, or both elements. These results suggest that two sessions of memory rescripting could be incorporated into traditional CBT to improve distress caused by intrusive memories experienced by patients with MDD.

Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

The primary focus of classic cognitive behavioural therapy (CBT) for depression and anxiety is on decreasing symptoms of psychopathology. However, there is increasing recognition that it is also important to enhance wellbeing during therapy. This study investigates the extent to which classic CBT for anxiety and depression leads to symptom relief versus wellbeing enhancement, analysing routine outcomes in patients receiving CBT in high intensity Improving Access to Psychological Therapy (IAPT) Services in the UK. At intake, there were marked symptoms of anxiety and depression (a majority of participants scoring in the severe range) and deficits in wellbeing (a majority of participants classified as languishing, relative to general population normative data). CBT was more effective at reducing symptoms of anxiety and depression than repairing wellbeing. As a result, at the end of treatment, a greater proportion of participants met recovery criteria for anxiety and depression than had moved from languishing into average or flourishing levels of wellbeing. Given the importance of wellbeing to client definitions of recovery, the present results suggest a greater emphasis should be placed on enhancing wellbeing in classic CBT.

Associations between mindfulness and general change mechanisms in individual therapy: Secondary results of a randomised controlled trial

AbstractObjectiveThe aim of this study was to investigate the possible effects of the interactions between mindfulness‐based session introductions and general change mechanisms on outcome in cognitive behavioural therapy (CBT).MethodWe investigated the effects of different session introductions on change mechanisms and their prediction of clinical outcome over the course of 25 sessions of training therapy. We compared session introductions with mindfulness (M) elements with progressive muscle relaxation (PMR) and treatment as usual (TAU) in routine CBT sessions conducted by therapists in training. Participants included 162 patients who were diagnosed primarily with either depression or anxiety disorder and 48 therapists. To address the nested data structure, we used multilevel models.ResultsMultilevel modelling (MLM) indicated that the interaction between an increase in several general change mechanisms and treatment condition (TAU + M vs. TAU + PMR) on therapeutic outcome was significant. From the patient perspective, MLM indicated that only the interaction between an increase in one general change mechanism (clarification of meaning) and treatment condition (TAU + M vs. TAU + PMR) turned out significantly. From both perspectives, correlation analyses revealed that general change mechanism effects on outcome were stronger in TAU + M than in TAU + PMR.ConclusionMindfulness has an impact on general change mechanisms, especially for therapists. These associations lead to a significantly higher effect on outcome compared to introductions with PMR.

Service user involvement in cognitive behavioural therapy training: an interpretive phenomenological analysis

PurposeThe last two decades have seen an increase in service user involvement (SUI) in the training of Mental Health Professionals (MHP). There is developing empirical support for SUI in MHP training, however, there is no published research into SUI in the training of Cognitive Behavioural Therapists. The purpose of this paper is to explore cognitive behavioural therapy (CBT) trainees’ experience of SUI in their training. The study focuses on how an individual service user (SU) led training session is experienced and how this differs to routine CBT training.Design/methodology/approachSemi-structured interviews were conducted with six participants. Transcripts of the interviews were analysed using interpretative phenomenological analysis.FindingsData revealed three superordinate themes: first, predisposing influences on learning; second, factors associated with emotional processing of experience; and third, impact upon learning outcomes. The results suggest that participants’ appraisal of their learning from SUI maybe influenced by how they accommodate the emotional impact of the experience.Originality/valueThe paper makes recommendations for educators on courses involving service users (SUs), acknowledges the study’s methodological limitations and suggests areas for future research.

Parent- and Teacher-Rated Effectiveness of Cognitive-Behavioral Therapy for Children and Adolescents Under Usual Care Conditions in a University Outpatient Clinic.

Compared to randomized controlled trials, studies examining the effectiveness of cognitive behavioral therapy (CBT) in children and adolescents with mental disorders are rare, and a teacher perspective is scarce. The present study investigated the effectiveness of routine CBT in 519 patients aged 6-18years with mental disorders. Changes in mental health problems were assessed in teacher (Teacher Report Form, TRF) and parent rating (Child Behavior Checklist, CBCL) and were analyzed within the total sample, yielding statistically significant, small to medium effect sizes (teacher rating: d = .74-2.39; parent rating: d = .65-1.18). Changes in a subgroup of patients with elevated symptom scores at treatment start were compared to a historical control group receiving weekly academic tutoring. Net total score effect sizes lay between d = 0.98 and d = 1.29 for teacher rating (parent rating: d = 0.84 to d = 1.01). Nevertheless, a substantial number of patients remained in the clinical range. Symptom changes during family- and patient-based CBT interventions did not differ from treatments including additional school-based interventions, as was also the case for the comparison of treatments with and without additional pharmacotherapy.

Effectiveness of cognitive-behavioral therapy in children and adolescents with obsessive-compulsive disorders treated in an outpatient clinic

Cognitive-behavioral therapy (CBT) is considered as treatment of first choice for children and adolescents with obsessive-compulsive disorders (OCD). However, its effectiveness has so far mostly been examined in randomized controlled trials with strictly manualized interventions. Only few studies have examined whether the effectiveness of CBT for juvenile OCD generalizes to clinical practice. To test the effectiveness of CBT under routine care conditions, data of n = 53 patients with parent-ratings and n = 53 patients with self-ratings that were treated in a university-based outpatient clinic for child and adolescent psychotherapy was analyzed. Pre-post-mean-comparisons, effect sizes and the clinical significance of changes of the symptoms were examined. OCD and comorbid symptoms were significantly reduced during treatment. Strong effect sizes (Cohen’s d) were found for parent rated (d = 0.91) and patient rated (d = 0.88) OCD symptoms. Moderate to strong pre-post-effect sizes were found for the reduction of parent rated (d = 0.55 to d = 0.87) and patient rated (d = 0.46 to d = 0.74) comorbid symptoms. The percentage of children and adolescents who achieved clinically significant improvements and no longer showed dysfunctional OCD symptoms post-treatment was 46.3 % according to the parent-ratings and 59.4 % according to the self-ratings. Concerning comorbid symptoms the same was reached for between 22.5 % and 45.5 % of the patients (parent-ratings) and between 32.0 % and 81.8 % (self-ratings) respectively. Significant reductions in both OCD and comorbid symptoms were demonstrated over the course of cognitive-behavioral therapy of juvenile OCD disorders in a university outpatient clinic for child and adolescent psychotherapy. These results indicate that routine CBT treatment is an effective way to treat juvenile OCD disorders in clinical practice.

The predictive value of early response in patients with depressive disorders

Objective: Several randomized controlled trials have identified early response to psychotherapy as a predictor for later treatment outcome among patients with depressive disorders. However, supporting evidence under routine conditions is rare. This study evaluated the predictive value of early improvement for final outcomes in psychotherapy among depressive patients in the naturalistic setting of a German university outpatient clinic. Method: We used the method of percent symptom reduction to classify 639 patients with major depression or dysthymic disorder who underwent an average of 40.0 sessions (SD = 16.3) of naturalistic cognitive–behavioral therapy (CBT) as having either an early response or an early nonresponse. Results: Early response was a good predictor for final response and remission regarding depressive symptoms (OR = 8.75 and OR = 5.32, respectively), as well as overall psychological distress (OR = 3.95 and OR = 3.16, respectively). Early nonresponse was distinctly associated with later deterioration of both depressive (OR = 9.56) and general psychological symptomatology (OR = 4.92). Conclusions: Early response to psychotherapy has high predictive qualities for positive later treatment outcome in depressive patients under routine CBT. Therefore, early treatment effects should be considered in clinical decision-making and treatment planning in everyday clinical practice.

Effects of Affective and Anxiety Disorders on Outcome in Problem Gamblers Attending Routine Cognitive-Behavioural Treatment in South Australia.

This study evaluated the influence of 12-month affective and anxiety disorders on treatment outcomes for adult problem gamblers in routine cognitive-behavioural therapy. A cohort study at a state-wide gambling therapy service in South Australia. Primary outcome measure was rated by participants using victorian gambling screen (VGS) 'harm to self' sub-scale with validated cut score 21+ (score range 0-60) indicative of problem gambling behaviour. Secondary outcome measure was Work and Social Adjustment Scale (WSAS). Independent variable was severity of affective and anxiety disorders based on Kessler 10 scale. We used propensity score adjusted random-effects models to estimate treatment outcomes for sub-populations of individuals from baseline to 12 month follow-up. Between July, 2010 and December, 2012, 380 participants were eligible for inclusion in the final analysis. Mean age was 44.1 (SD = 13.6) years and 211 (56%) were males. At baseline, 353 (92.9%) were diagnosed with a gambling disorder using VGS. For exposure, 175 (46%) had a very high probability of a 12-month affective or anxiety disorder, 103 (27%) in the high range and 102 (27%) in the low to moderate range. For the main analysis, individuals experienced similar clinically significant reductions (improvement) in gambling related outcomes across time (p < 0.001). Individuals with co-varying patterns of problem gambling and 12 month affective and anxiety disorders who present to a gambling help service for treatment in metropolitan South Australia gain similar significant reductions in gambling behaviours from routine cognitive-behavioural therapy in the mid-term.

Emotion Regulation Skills Training Enhances the Efficacy of Inpatient Cognitive Behavioral Therapy for Major Depressive Disorder: A Randomized Controlled Trial

Background: Deficits in emotion regulation skills are possible factors maintaining major depressive disorder (MDD). Therefore, the aim of the study was to test whether integrating a systematic emotion regulation training (ERT) enhances the efficacy of routine inpatient cognitive behavioral therapy (CBT) for MDD. Methods: In a prospective randomized controlled trial, 432 inpatients meeting criteria for MDD were assigned to receive either routine CBT or CBT enriched with an intense emotion regulation skills training (CBT-ERT). Results: Participants in the CBT-ERT condition demonstrated a significantly greater reduction in depression (response rates - CBT: 75.5%, CBT-ERT: 84.9%; remission rates - CBT: 51.1%, CBT-ERT: 65.1%). Moreover, CBT-ERT participants demonstrated a significantly greater reduction of negative affect, as well as a greater increase of well-being and emotion regulation skills particularly relevant for mental health. Conclusions: Integrating strategies that target emotion regulation skills improves the efficacy of CBT for MDD.

Mindfulness in the management of eating disorders

K. Halmi provides an excellent summary of recent advances in the treatment of eating disorders. There are no doubts concerning the usefulness of structured units for people with anorexia nervosa and cognitive behavioral therapy (CBT) for bulimia nervosa. Structured clinical units require a multi-disciplinary (multi-dimensional) team including nurses, dietitians and psychologists, as well as social and family therapists. However, these experienced staff can be recruited only in environments where the standing of our specialty is high. Even in university hospitals, it happens frequently that nursing staff are moved periodically to other departments, so that it may be difficult to retain well trained nurses. Further, most psychiatric units are general, and to set up a specialized unit or sub-unit may not be easy. On the other hand, an intensive outpatient program or residential treatment cannot be replaced by a structured unit: all of them should be part of a comprehensive service. CBT for patients who show bingeing/purging behavior within a normal weight range has become the standard. However, there are many non-responders and premature drop-outs. Most chronic eating disorder patients have already experienced the failure of CBT throughout their long history of illness, and do not improve through short-term motivational interviewing. Transdiagnostic therapy and enhanced CBT have shown promise 1, but it remains to be documented that they are more effective than routine CBT in ordinary clinical conditions. Eating disorders arise as a way of patients trying to escape from difficulties they may have. On facing these life-threatening disorders, we must be mindful 2,3, honest, and be aware of our limitations. Structured units and enhanced CBT aim to rapidly change behaviors or patterns of thought, but chronic patients are usually extremely inflexible, and change is slow. Psychological “Judo” in motivational interviewing focuses on the patients’ “moment of inertia” to change rather than confronting their relentless pursuit of thinness. In Asia, the relationship between mother and daughter is closer than in Western countries. Even though similar percentages of eating disorder patients are impulsive 4, most patients have family support. Family support is a double-edged sword (risks of over-involvement and being manipulated), but there is the possibility that the family be truly of help. Treating eating disorders is always challenging. However, using a heavy-handed approach will make the patients more rigid. We, psychiatrists dealing with eating disorder patients, should not treat aggressively, but rather share our understanding of patients’ painful experiences and hope of recovery. It is important to develop a small-scale system that just one psychiatrist is able to run, even though it may be difficult in several contexts.