Treatment Outcome In Cognitive Behavioural Therapy Research Articles

Fear of negative and positive evaluation as mediators and moderators of treatment outcome in social anxiety disorder

IntroductionElevated fear of negative evaluation (FNE) and fear of positive evaluation (FPE) are thought to play key roles in the maintenance of social anxiety disorder (SAD). Although efficacious therapies exist for SAD, the potential mediating and moderating effects of FNE and FPE on social anxiety treatment outcome have not been examined. MethodsThis sample comprised a secondary analysis of 210 individuals who participated in one of three randomized controlled trials for the treatment of SAD. Participants were randomized to: individual cognitive behavioral therapy (CBT), group CBT, community mindfulness-based stress reduction (MBSR), group MBSR, or they were randomized to waitlist and offered treatment after waitlist. Assessments were completed pre- and post-treatment/waitlist and, for the treatment groups, at three-month follow-up. ResultsCBT and MBSR led to greater reductions in FNE and FPE than waitlist, with CBT more efficacious in reducing FPE than MBSR. For both CBT (vs. waitlist) and MBSR (vs. waitlist), there were significant indirect effects on post-treatment social anxiety through both FNE and FPE, and the indirect effect through FPE was greater for CBT than MBSR. However, in the fully longitudinal model testing mediation, CBT and MBSR were not differentially mediated by FPE. Baseline FNE and FPE each moderated CBT treatment outcome compared to waitlist – higher baseline FNE and FPE were associated with higher baseline social anxiety and greater reductions in social anxiety during CBT. DiscussionFNE and FPE contributed in sometimes similar and sometimes distinct ways to the mediation and moderation of psychosocial approaches for treating SAD. This supports the importance of distinguishing between fears of negative and positive evaluation in the assessment and treatment of SAD.

The Impact of Personality Pathology on Treatment Outcome in Late-life Panic Disorder.

Comorbid personality disorders are assumed to negatively interfere with the treatment outcome of affective disorders. Data on late-life panic disorder remain unknown. We examined the association of personality pathology and treatment outcome related to age and treatment modality. An observational study on the effectiveness of cognitive-behavioral therapy (CBT) for panic disorder with agoraphobia among patients 18 to 74 years of age and randomized controlled comparison of paroxetine and CBT in older patients (60 y of age or older) were performed. The diagnosis of panic disorder was confirmed by the Anxiety Disorder Interview Schedule-Revised (ADIS-IV) and personality features were assessed with the Personality Diagnostic Questionnaire. The impact of personality features on either agoraphobic cognitions (Agoraphobic Cognitions Questionnaire) or avoidance behavior (Mobility Inventory Avoidance Scale) was examined by multiple linear regression analyses adjusted for sex, level of education, duration of illness, comorbid psychopathology, and baseline severity. The interaction between personality and age was examined among those treated with CBT (n=90); the interaction between personality and treatment modality was examined among the older subgroup (n=34). Cluster B personality pathology (evaluated on the basis of either Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria depending on the date of assessment) was negatively associated with outcomes of CBT in both younger and older adults with panic disorder and agoraphobia. Older adults with a higher number of features of any personality pathology or cluster A pathology had worse treatment outcomes when treated with paroxetine compared with CBT. Cluster B pathology had a detrimental effect on CBT treatment outcome for panic disorder in both age groups. In late-life panic disorder with comorbid personality pathology, CBT may be preferred over treatment with paroxetine.

The Role of Executive Functioning in Treatment Outcome for Child Anxiety

ABSTRACTOne possible predictor of treatment outcome in cognitive-behavioral therapy (CBT) is executive functioning (EF; i.e., planning, initiating, and maintaining goal-directed behavior), but the role of EF in treatment outcome has not been studied in pediatric anxiety disorders. The current study examines the predictive role of pre-treatment EF and change in EF over treatment (EF change) in the Resilience Builder Program® (RBP), a manualized, 12-week CBT group intervention implemented in a private practice. The RBP targets social competence and resilience skills.The current study examines 73 children ages 7–13 years (mean age = 9.95 ± 1.53 years, 69.86% male, 79.45% White) diagnosed with an anxiety disorder who completed the RBP. The studied outcome variables included anxiety symptomatology, social competence, and resilience. Hierarchical linear modeling and hierarchical linear regressions were used to examine if pre-treatment EF and EF change predicted post-treatment symptomatology, controlling for pre-treatment functioning and ADHD diagnosis. Pre-treatment EF was not significantly related to any of the outcome variables. EF change was significantly related to improved anxiety and resilience, but not social competence. Adding EF change to the model significantly improved model fit when predicting resilience. Change in EF predicted parent-reported reductions in anxiety symptomatology and increases in resilience over and above pre-treatment EF levels. EF change was particularly important for predicting resilience outcomes. Results indicate that, for children with anxiety, pre-treatment EF is not an important predictor of outcome, but improvement in EF during treatment may improve treatment response as measured by anxiety symptomatology and resilience.

T14. Predicting Cognitive Behavioral Therapy Treatment Outcome Using Neural Markers of Maladaptive Self-Focused Attention

Maladaptive self-focused attention (SFA) is a bias toward internal thoughts that may predict poor cognitive-behavioral therapy (CBT) response. In this study, we used resting state functional connectivity MRI to test whether maladaptive SFA maps onto hyperconnectivity within the default mode network (DMN), an intrinsic brain network mediating internally-directed mentation, and whether DMN hyperconnectivity predicts worse CBT response.

S157. Neurocognitive Performance Predicts Treatment Outcome With Cognitive Behavioral Therapy for Major Depressive Disorder

Cognitive behavioral therapy (CBT) is an effective, widely-used treatment for depression, but predictors of its antidepressant benefit are lacking. While pretreatment neurocognitive functioning has been shown to predict pharmacological antidepressant treatment outcome (e.g., Bruder et al. 2014), research on neurocognitive functioning as a predictor of CBT treatment outcome is less extensive. The current study examined the contribution of baseline neuropsychological functioning to the prediction of antidepressant outcome with CBT for Major Depressive Disorder (MDD). We hypothesized that depressed participants who were more neurocognitively intact would respond better to the structured approach of CBT.

Anxiety Sensitivity, Obsessive Beliefs, and the Prediction of CBT Treatment Outcome for OCD

Cognitive behavioral therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) although a significant proportion of clients remain symptomatic following treatment. Knowledge regarding individual differences that influence treatment response could help guide future augmentations to CBT. The current study examined two potential predictors of treatment response to CBT for OCD: anxiety sensitivity and obsessive beliefs. Participants (n = 93) with a primary diagnosis of OCD completed measures of anxiety sensitivity (Anxiety Sensitivity Index (ASI); Reiss et al. in Behaviour Research and Therapy, 24(1), 1–8, 1986) and obsessive beliefs (Obsessive Belief Questionnaire (OBQ): OCCWG in Behaviour Research and Therapy, 35(7), 667–681, 1997, 39(8), 987–1006, 2001) before engaging in a course of group CBT for OCD. Obsessive-compulsive symptom severity was measured (Yale-Brown Obsessive-Compulsive Scale; Goodman et al. in Archives of General Psychiatry, 46(11), 1012–1016, 1989a, 1006–1011, 1989b) before and upon treatment completion. Results indicated a significant two-way interaction, whereby elevated ASI-Physical scores by elevated OBQ-Importance/Control significantly predicted higher post-treatment symptom severity. These results have implications for the cognitive modeling of OCD and its treatment with CBT.

Cognitive Behavioral Therapy Is Associated With Enhanced Cognitive Control Network Activity in Major Depression and Posttraumatic Stress Disorder

BackgroundBoth major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are characterized by depressive symptoms, abnormalities in brain regions important for cognitive control, and response to cognitive behavioral therapy (CBT). However, whether a common neural mechanism underlies CBT response across diagnoses is unknown. MethodsBrain activity during a cognitive control task was measured using functional magnetic resonance imaging in 104 participants: 28 patients with MDD, 53 patients with PTSD, and 23 healthy control subjects; depression and anxiety symptoms were determined on the same day. A patient subset (n = 31) entered manualized CBT and, along with controls (n = 19), was rescanned at 12 weeks. Linear mixed effects models assessed the relationship between depression and anxiety symptoms and brain activity before and after CBT. ResultsAt baseline, activation of the left dorsolateral prefrontal cortex was negatively correlated with Montgomery–Åsberg Depression Rating Scale scores across all participants; this brain–symptom association did not differ between MDD and PTSD. Following CBT treatment of patients, regions within the cognitive control network, including ventrolateral prefrontal cortex and dorsolateral prefrontal cortex, showed a significant increase in activity. ConclusionsOur results suggest that dimensional abnormalities in the activation of cognitive control regions were associated primarily with symptoms of depression (with or without controlling for anxious arousal). Furthermore, following treatment with CBT, activation of cognitive control regions was similarly increased in both MDD and PTSD. These results accord with the Research Domain Criteria conceptualization of mental disorders and implicate improved cognitive control activation as a transdiagnostic mechanism for CBT treatment outcome.

Systematic Review of In-Session Affect Experience in Cognitive Behavioral Therapy for Depression

One way of attempting to improve the efficacy and effectiveness of Cognitive Behavioral Therapy (CBT) for depression is to identify the processes of change that contribute towards its positive outcome. In addition to well-researched cognitive processes, another possible change process is affect experiencing (AE); i.e., a patient’s affective experience in-session. Theorists, clinicians and researchers have emphasized the role of affective traits, tendencies and symptoms in the development, maintenance, and treatment of depression. We make the case that it may be important to also consider patients’ full range of affect experiencing (AE), as a changeable in-session process that may relate to CBT treatment outcome. This systematic review aimed to clarify what is already empirically known regarding in-session AE in CBT for depression and which gaps in empirical research need to be filled by future studies. The reviewed studies on AE in CBT for depression suggest that it is possible to identify and measure AE. In-session experiencing of positive and negative affect (when it includes cognitive processes) relates to and may predict a reduction of symptoms. We encourage researchers to develop and refine multifaceted process measures and analyses to explore when, how and how much AE can be effectively experienced by patients, and how optimal levels of AE may be facilitated by the therapist.

Does prior traumatization affect the treatment outcome of CBT for panic disorder? The potential role of the MAOA gene and depression symptoms.

Although cognitive behavioral therapy (CBT) is highly effective in the treatment of anxiety disorders, many patients still do not benefit. This study investigates whether a history of traumatic event experience is negatively associated with outcomes of CBT for panic disorder. The moderating role of the monoamine oxidase A (MAOA) gene and depression symptoms as well as the association between trauma history and fear reactivity as a potential mechanism are further analyzed. We conducted a post-hoc analysis of 172 male and 60 female patients with panic disorder treated with CBT in a multi-center study. Treatment outcome was assessed at post-treatment using self-report and clinician rating scales. Fear reactivity before treatment was assessed via heart rate and self-reported anxiety during a behavioral avoidance test. Among females, we did not find any differences in treatment response between traumatized and non-traumatized individuals or any two-way interaction trauma history×MAOA genotype. There was a significant three-way interaction trauma history×MAOA genotype×depression symptoms on all treatment outcomes indicating that in traumatized female patients carrying the low-activity allele, treatment effect sizes decreased with increasing depression symptoms at baseline. No such effects were observed for males. In conclusion, we found no evidence for a differential treatment response in traumatized and non-traumatized individuals. There is preliminary evidence for poorer treatment outcomes in a subgroup of female traumatized individuals carrying the low-active variant of the MAOA gene. These patients also report more symptoms of depression symptomatology and exhibit a dampened fear response before treatment which warrants further investigation.

Improving the efficiency of cognitive-behavioural therapy by using formal client feedback

Objective: Feedback from clients on their view of progress and the therapeutic relationship can improve effectiveness and efficiency of psychological treatments in general. However, what the added value is of client feedback specifically within cognitive-behavioural therapy (CBT), is not known. Therefore, the extent to which the outcome of CBT can be improved is investigated by providing feedback from clients to therapists using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Method: Outpatients (n = 1006) of a Dutch mental health organization either participated in the “treatment as usual” (TAU) condition, or in Feedback condition of the study. Clients were invited to fill in the ORS and SRS and in the Feedback condition therapists were asked to frequently discuss client feedback. Results: Outcome on the SCL-90 was only improved specifically with mood disorders in the Feedback condition. Also, in the Feedback condition, in terms of process, the total number of required treatment sessions was on average two sessions fewer. Conclusion: Frequently asking feedback from clients using the ORS/SRS does not necessarily result in a better treatment outcome in CBT. However, for an equal treatment outcome significantly fewer sessions are needed within the Feedback condition, thus improving efficiency of CBT.

Cognitive-Behavioral Therapy for Body Dysmorphic Disorder by Proxy

Body dysmorphic disorder (BDD) is a distressing or impairing preoccupation with a perceived defect in physical appearance. BDD by proxy (BDDBP) is a significant but understudied variant of BDD in which the primary preoccupation involves perceived imperfections of another person. Like BDD, individuals with BDDBP engage in time-consuming rituals to “fix” the other person’s appearance or alleviate distress. Avoidance is common and the impact of BDDBP on social functioning is profound. Cognitive-behavioral therapy (CBT) is the best-studied and most promising psychological treatment for BDD, but no studies have examined its generalizability to the BDDBP variant. We tested feasibility, acceptability, and treatment outcome of CBT modified for BDDBP in a sample of 6 adults with primary BDDBP. Treatment was delivered in weekly individual sessions over 12–20weeks. Mean symptom severity (BDDBP-YBOCS) dropped from the moderately severe range at pretreatment to the subclinical range at posttreatment, t(6)=10.7, p<.001, d=3.3. One hundred percent of treatment completers were responders (≥30% reduction in BDDBP-YBOCS). Insight also improved. Treatment gains were maintained at 3-month follow-up. To our knowledge, this represents the first treatment study for BDDBP.

The impact of early symptom change and therapeutic alliance on treatment outcome in cognitive-behavioural therapy for eating disorders

The present study explored the impact of early symptom change (cognitive and behavioural) and the early therapeutic alliance on treatment outcome in cognitive-behavioural therapy (CBT) for the eating disorders. Participants were 94 adults with diagnosed eating disorders who completed a course of CBT in an out-patient community eating disorders service in the UK. Patients completed a measure of eating disorder psychopathology at the start of treatment, following the 6th session and at the end of treatment. They also completed a measure of therapeutic alliance following the 6th session. Greater early reduction in dietary restraint and eating concerns, and smaller levels of change in shape concern, significantly predicted later reduction in global eating pathology. The early therapeutic alliance was strong across the three domains of tasks, goals and bond. Early symptom reduction was a stronger predictor of later reduction in eating pathology than early therapeutic alliance. The early therapeutic alliance did not mediate the relationship between early symptom reduction and later reduction in global eating pathology. Instead, greater early symptom reduction predicted a strong early therapeutic alliance. Early clinical change was the strongest predictor of treatment outcome and this also facilitated the development of a strong early alliance. Clinicians should be encouraged to deliver all aspects of evidence-based CBT, including behavioural change. The findings suggest that this will have a positive impact on both the early therapeutic alliance and later change in eating pathology.

Cognitive Behavioral Therapy for PTSD: The Role of Complex PTSD on Treatment Outcome

Posttraumatic stress disorder (PTSD) represents an often chronic and debilitating mental illness resulting from exposure to trauma. Although the most compelling evidence for the treatment of PTSD is cognitive behavioral therapy (CBT), many patients experience residual functional impairment, or relapse, suggesting that this approach does not work for all cases of PTSD. Repeated severe trauma, particularly during development, might increase the risk for a more intricate clinical profile, called complex PTSD (CPTSD), which might contribute to poorer treatment response. The following provides a comprehensive summary of the evidence examining whether CPTSD symptomatology is related to poorer treatment outcome of CBT, reviews the literature on the treatment of CPTSD, and offers insights into current issues and future directions of the construct.

Bipolar disorder with comorbid anxiety disorders: impact of comorbidity on treatment outcome in cognitive-behavioral therapy and psychoeducation.

BackgroundComorbid anxiety disorders are extremely prevalent in bipolar disorder (BD) and have substantial impact on the course of illness. Limited evidence regarding treatment factors has led to a renewal of research efforts examining both the impact of treatments on comorbid anxiety and the impact of comorbid anxiety on treatments. The current study examines the impact of comorbid anxiety disorders on response to two psychosocial interventions for BD.MethodsA sample of 204 patients with BD took part in the study. Of them, 41.7% had a comorbid anxiety disorder. All participants received either individual cognitive-behavioral therapy or group psychoeducation for BD. Evaluations included complete pretreatment and 18-month follow-up assessments of mood and anxiety symptoms, functioning, medication compliance, dysfunctional attitudes, and coping style. Outcome was compared based on the presence or absence of a comorbid anxiety disorder.Results and discussionThe participants with comorbid anxiety disorders ranked more severe than those without on several measures. Despite more severe illness characteristics, the magnitude of their treatment gains was equivalent or superior to that of the participants without anxiety disorders on a variety of outcome measures. Although the treatments did not specifically target the anxiety disorder, the participants made significant improvements in anxiety symptoms. Despite greater illness severity, patients with comorbid anxiety disorders can make substantial gains from psychosocial interventions targeting BD. Even in the presence of an anxiety disorder, they are able to attend to the content of the psychosocial treatments and apply it to better manage their condition. The presence of a comorbid anxiety disorder should not be considered a deterrent to offering BD-focused psychosocial treatments.

SLEEP QUALITY PREDICTS TREATMENT OUTCOME IN CBT FOR SOCIAL ANXIETY DISORDER

Sleep quality may be an important, yet relatively neglected, predictor of treatment outcome in cognitive-behavioral therapy (CBT) for anxiety disorders. Specifically, poor sleep quality may impair memory consolidation of in-session extinction learning. We therefore examined sleep quality as a predictor of treatment outcome in CBT for social anxiety disorder and the impact of d-cycloserine (DCS) on this relationship. One hundred sixty-nine participants with a primary diagnosis of DSM-IV generalized social anxiety disorder were recruited across three sites. Participants were enrolled in 12 weeks of group CBT. Participants randomly received 50 mg of DCS (n = 87) or pill placebo (n = 82) 1 hr prior to sessions 3-7. Participants completed a baseline measure of self-reported sleep quality and daily diaries recording subjective feelings of being rested upon wakening. Outcome measures including social anxiety symptoms and global severity scores were assessed at each session. Poorer baseline sleep quality was associated with slower improvement and higher posttreatment social anxiety symptom and severity scores. Moreover, patients who felt more "rested" after sleeping the night following a treatment session had lower levels of symptoms and global severity at the next session, controlling for their symptoms and severity scores the previous session. Neither of these effects were moderated by DCS condition. Our findings suggest that poor sleep quality diminishes the effects of CBT for social anxiety disorder and this relation is not attenuated by DCS administration. Therapeutic attention to sleep quality prior to initiation of CBT and during the acute treatment phase may be clinically indicated.

Specificity of Homework Compliance Effects on Treatment Outcome in CBT: Evidence from a Controlled Trial on Panic Disorder and Agoraphobia

Although homework assignments are an integral component of cognitive-behavioral therapy (CBT) and relate to positive therapy outcomes, it is unclear whether specific homework types and their completion have specific effects on outcome. Data from N = 292 patients (75% female, mean age 36 years) with panic disorder and agoraphobia and treated with standardized CBT were analyzed with homework compliance quality and quantity for different types of homework serving as predictors for different outcome variables. Quality ratings of homework completion were stronger outcome predictors than quantitative compliance ratings. Exposure homework was a better outcome predictor than homework relating to psychoeducation and self-monitoring. Different aspects of homework compliance and specific homework types might differentially relate to CBT outcome.

Symptom and Cognitive Predictors of Treatment Response in CBT for Social Anxiety Disorder

The present study examined the impact of baseline depression symptom severity and the anxiety sensitivity dimensions (i.e., fears of physical sensations, cognitive dyscontrol, and publicly observable anxiety reactions) on cognitive-behavioral therapy (CBT) response in individuals with social anxiety disorder (SAD). Participants consisted of a treatment-seeking sample (n = 110; 52% women) of individuals with a primary DSM-IV (American Psychiatric Association, 2000) diagnosis of SAD who received 12 sessions of weekly CBT for SAD. Participants completed measures of depression, anxiety sensitivity, and SAD symptom severity. Regression analyses demonstrated differential relationships between baseline depression symptom severity and anxiety sensitivity and CBT treatment outcome for SAD. Specifically, baseline depression severity, but not anxiety sensitivity, negatively impacted posttreatment SAD symptoms and clinically significant change of SAD symptoms. Additionally, the anxiety sensitivity (AS) fear of cognit...

Depression Does Not Affect the Treatment Outcome of CBT for Panic and Agoraphobia: Results from a Multicenter Randomized Trial

Background: Controversy surrounds the questions whether co-occurring depression has negative effects on cognitivebehavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology. Methods: Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional). Results: Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression. Conclusions: Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology.

Pre-treatment patient variables as predictors of drop-out and treatment outcome in cognitive behavioural therapy for social phobia: A systematic review

Background: Although cognitive behavioural therapy (CBT) has been shown to be an efficacious treatment for social phobia (SP), many patients drop out or achieve little or no benefit from treatment. This fact is generally considered an argument for the importance of studies of predictor variables. Aims: This paper systematically reviews pre-treatment patient variables as predictors of drop-out from and outcome of CBT for SP. Method: A structured literature search was conducted in PsycINFO, Embase and PubMed. Results: 28 published studies with n≥60 were located. No pre-treatment patient variables were found to predict drop-out. Consistently across studies, higher levels of pre-treatment symptomatic severity predicted higher levels of end-state symptomatic severity, but not degree of improvement. There was some evidence that comorbid depression and avoidant personality disorder before treatment negatively influenced post-treatment end-state functioning, but not consistently improvement. No other patient variables consistently predicted outcome across studies. Conclusions: Generally, the results are in line with the conclusion that more disturbed patients with SP both begin and end treatment at a higher symptomatic level but with a similar degree of improvement. There is, however, little clinically or theoretically relevant knowledge to be gained from existing studies of pre-treatment patient variables as predictors of drop-out and treatment outcome in CBT for patients with SP. The field is in need of conceptual and methodological improvements if more solid findings should be hoped for.

Cognitive deficits in marijuana users: Effects on motivational enhancement therapy plus cognitive behavioral therapy treatment outcome

Clinical variables that affect treatment outcome for marijuana-dependent individuals are not yet well understood, including the effects of cognitive functioning. To address this, level of cognitive functioning and treatment outcome were investigated. Twenty marijuana-dependent outpatients were administered a neuropsychological battery at treatment entry. All patients received 12 weekly individual sessions of combined motivational enhancement therapy and cognitive behavioral therapy. The Wilcoxon Exact Test was used to compare cognitive functioning test scores between completers and dropouts, and the Fisher Exact Test was used to compare proportion of negative urines between those with higher and lower scores on the cognitive tests. Marijuana abstinence was unrelated to cognitive functioning. However, dropouts scored significantly lower than completers on measures of abstract reasoning and processing accuracy, providing initial evidence that cognitive functioning plays a role in treatment retention of adult marijuana-dependent patients. If supported by further studies, the findings may help inform the development of interventions tailored for cognitively impaired marijuana-dependent patients.