Background
To compare the effectiveness and cost of stepped care trauma‐focused cognitive behavioral therapy (SC‐TF‐CBT), a new service delivery method designed to address treatment barriers, to ...standard TF‐CBT among young children who were experiencing posttraumatic stress symptoms (PTSS).
Methods
A total of 53 children (ages 3–7 years) who were experiencing PTSS were randomly assigned (2:1) to receive SC‐TF‐CBT or TF‐CBT. Assessments by a blinded evaluator occurred at screening/baseline, after Step One for SC‐TF‐CBT, posttreatment, and 3‐month follow‐up. Trial registration: ClinicalTrials.gov: https://www.clinicaltrials.gov/ct2/show/NCT01603563.
Results
There were comparable improvements over time in PTSS and secondary outcomes in both conditions. Noninferiority of SC‐TF‐CBT compared to TF‐CBT was supported for the primary outcome of PTSS, and the secondary outcomes of severity and internalizing symptoms, but not for externalizing symptoms. There were no statistical differences in comparisons of changes over time from pre‐ to posttreatment and pre‐ to 3‐month follow‐up for posttraumatic stress disorder diagnostic status, treatment response, or remission. Parent satisfaction was high for both conditions. Costs were 51.3% lower for children in SC‐TF‐CBT compared to TF‐CBT.
Conclusions
Although future research is needed, preliminary evidence suggests that SC‐TF‐CBT is comparable to TF‐CBT, and delivery costs are significantly less than standard care. SC‐TF‐CBT may be a viable service delivery system to address treatment barriers.
Read the Commentary on this article at doi: 10.1111/jcpp.12533
Objective
The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many ...clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence‐based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework.
Method
Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive‐behavioral therapy for eating disorders (CBT‐ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians.
Results
A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT‐ED methods.
Discussion
Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence‐based practice. These are shared to assist clinicians over the period of changed practice.
ABSTRACT
Obsessive–compulsive disorder (OCD) is a common mental health condition characterized by distressing, intrusive thoughts (obsessions) and repetitive behaviours (compulsions) aimed at ...reducing anxiety. Internet‐based cognitive behavioural therapy (ICBT) has emerged as an effective treatment modality for various mental health disorders. This meta‐analysis evaluates the efficacy of guided self‐help ICBT (GSH ICBT) and unguided self‐help ICBT (SH ICBT) against active and passive control conditions in adults with OCD. A comprehensive systematic literature search yielded 12 randomized controlled trials (RCTs) comprising 15 comparison arms (N = 1416) that met the inclusion criteria. Results indicate that GSH ICBT significantly reduced OCD symptomatology posttreatment compared to active controls (g = 0.378, k = 9), with no significant effects maintained at follow‐up (g = 0.153, k = 4). GSH ICBT was also found to be as effective as active CBT interventions in reducing comorbid anxiety and depression symptoms posttreatment (g = 0.278, k = 6) and at follow‐up (g = 0.124, k = 4). However, improvements in quality of life were not significant posttreatment (g = 0.115, k = 4) nor at follow‐up (g = 0.179, k = 3). Combined GSH and SH ICBT demonstrated large effects on reducing OCD symptoms (g = 0.754, k = 6), medium effects on comorbid symptoms (g = 0.547, k = 6) and small effects on quality of life (g = 0.227, k = 2) when compared to inactive controls. No significant differences were found between GSH and SH ICBT in all measured outcomes posttreatment (OCD: g = 0.098, k = 3; AD: g = 0.070, k = 3; QoL: g = −0.030, k = 1) and at follow‐up (OCD: g = 0.265, k = 2; AD: g = 0.084, k = 2; QoL: g = 0.00, k = 1). Sample size was identified as a significant moderator of treatment effects. This paper further explores clinical significance, treatment adherence, therapist time investment and moderator influences of the ICBT. The limitations of the study and recommendations for future research are thoroughly discussed.
Objective: Depression is a highly common mental disorder and a major cause of disability worldwide. Several psychological interventions are available, but there is a lack of evidence to decide which ...treatment works best for whom. This study aimed to identify subgroups of patients who respond differentially to cognitive-behavioral therapy (CBT) or person-centered counseling for depression (CfD). Method: This was a retrospective analysis of archival routine practice data for 1,435 patients who received either CBT (N = 1,104) or CfD (N = 331) in primary care. The main outcome was posttreatment reliable and clinically significant improvement (RCSI) in the PHQ-9 depression measure. A targeted prescription algorithm was developed in a training sample (N = 1,085) using a supervised machine learning approach (elastic net with optimal scaling). The clinical utility of the algorithm was examined in a statistically independent test sample (N = 350) using chi-square analysis and odds ratios. Results: Cases in the test sample that received their model-indicated "optimal" treatment had a significantly higher RCSI rate (62.5%) compared to those who received the "suboptimal" treatment (41.7%); χ2(df = 1) = 4.79, p = .03, OR = 2.33 (95% CI 1.09, 5.02). Conclusion: Targeted prescription has the potential to make best use of currently available evidence-based treatments, improving outcomes for patients at no additional cost to psychological services.
What is the public health significance of this article?
Reviews of clinical trials often conclude that different types of psychological interventions for depression are equally efficacious, and differential effects are rarely statistically or clinically significant. Recent studies suggest that subgroups of patients with specific characteristics respond more favorably to specific psychotherapies, and therefore targeted prescription could potentially improve their treatment outcomes. Using data from a large (N = 1,435) naturalistic cohort of patients who accessed either cognitive-behavioral therapy or person-centered counseling for depression, the present study found evidence of differential response to treatments in a subsample of ∼30%. These results were cross-validated in an adequately powered external test sample, which considerably strengthens the reliability of findings. Targeted prescription of these widely available and well-established psychological treatments could potentially improve clinical outcomes at no additional cost to services, representing a major advance in precision mental healthcare.
Abstract
Background
fear of falling is prevalent among older people and associated with various health outcomes. A growing number of studies have examined the effects of interventions designed to ...reduce the fear of falling and improve balance among older people, yet our current understanding is restricted to physiological interventions. Psychological interventions such as cognitive behavioural therapy (CBT) have not been reviewed and meta-analysed.
Objective
to perform a systematic review and meta-analysis evaluating the effects of CBT on reducing fear of falling and enhancing balance in community-dwelling older people.
Method
randomised controlled trials (RCTs) addressing fear of falling and balance were identified through searches of six electronic databases, concurrent registered clinical trials, forward citation and reference lists of three previous systematic reviews.
Results
a total of six trials involving 1,626 participants were identified. Four studies used group-based interventions and two adopted individual intervention. Intervention period ranged from 4 to 20 weeks, and the number and duration of face-to-face contact varied. Core components of the CBT intervention included cognitive restructuring, personal goal setting and promotion of physical activities. The risk of bias was low across the included studies. Our analysis suggests that CBT interventions have significant immediate and retention effects up to 12 months on reducing fear of falling, and 6 months post-intervention effect on enhancing balance.
Conclusions
CBT appears to be effective in reducing fear of falling and improving balance among older people. Future researches to investigate the use of CBT on reducing fear of falling and improving balance are warranted.
People with social anxiety disorder (SAD) fear social interactions and may be reluctant to seek treatments involving exposure to social situations. Social exposure conducted in virtual reality (VR), ...embedded in individual cognitive-behavioural therapy (CBT), could be an answer.
To show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure
Participants were randomly assigned to either VR exposure (
= 17),
exposure (
= 22) or waiting list (
= 20). Participants in the active arms received individual CBT for 14 weekly sessions and outcome was assessed with questionnaires and a behaviour avoidance test. (Trial registration number ISRCTN99747069)
Improvements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list. Conducting exposure in VR was more effective at post-treatment than
on the primary outcome measure and on one secondary measure. Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than
exposure.
Using VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.
Major depressive disorder is one of the most commonly diagnosed psychiatric illnesses, and it has a profound negative impact on an individual's ability to function. Up to 90% of individuals suffering ...from depression also report sleep and circadian disruptions. If these disruptions are not effectively resolved over the course of treatment, the likelihood of relapse into depression is greatly increased. Cognitive Behavioural Therapy for Insomnia (CBT-I) has shown promise in treating these sleep and circadian disturbances associated with depression, and may be effective as a stand-alone treatment for depression. This may be particularly relevant in cases where antidepressant medications are not ideal (e.g. due to contraindications, cost, or treatment resistance).
A systematic literature review was conducted of trials investigating the use of CBT-I to treat depression in adults. Therapy included in-person CBT-I, as well as telehealth and group CBT-I.
CBT-I presents a promising treatment for depression comorbid with insomnia. In-person therapy has the most supporting evidence for its efficacy, though treatment effects may not be additive with those of antidepressant medications. Insomnia improvement due to CBT-I may mediate the improvement in depressive symptoms. There is less evidence for the use of telehealth, though a stepped-care approach is indicated based on baseline depressive severity. More research on group therapy and telehealth modalities of delivering CBT-I are required before making recommendations.
•Cognitive Behavioural Therapy for Insomnia (CBT-I) is a promising treatment for depression comorbid with insomnia, both independently of and as a compliment to antidepressant medications.•Effects of CBT-I and antidepressant medications may not be additive.•Insomnia improvement as a result of CBT-I may mediate improvement in depressive symptoms.•More research is required before recommending group CBT-I or telehealth CBT-I to treat depression comorbid with insomnia, though a stepped-care approach may be appropriate.
Background
Post‐traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta‐analyses, have found ...these to be effective, with trauma‐focused treatments being more effective than non‐trauma‐focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007.
Objectives
To assess the effects of psychological therapies for the treatment of adults with chronic post‐traumatic stress disorder (PTSD).
Search methods
For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR‐Studies and CCDANCTR‐References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles.
Selection criteria
Randomised controlled trials of individual trauma‐focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non‐trauma‐focused CBT (non‐TFCBT), other therapies (supportive therapy, non‐directive counselling, psychodynamic therapy and present‐centred therapy), group TFCBT, or group non‐TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician‐rated traumatic‐stress symptoms.
Data collection and analysis
We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects.
Main results
We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) ‐1.62; 95% CI ‐2.03 to ‐1.21; 28 studies; n = 1256 and SMD ‐1.17; 95% CI ‐2.04 to ‐0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post‐treatment although there was some evidence that individual TFCBT and EMDR were superior to non‐TFCBT at follow‐up, and that individual TFCBT, EMDR and non‐TFCBT were more effective than other therapies. Non‐TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop‐out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution.
Authors' conclusions
The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician‐assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non‐TFCBT are equally effective immediately post‐treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non‐TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non‐TFCBT are more effective than other therapies. There was evidence of greater drop‐out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow‐up data, which compromises conclusions regarding the long‐term effects of psychological treatment.
Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were ...included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential.
What is the public health significance of this article?
This meta-analysis demonstrates that CBT is an efficacious psychological treatment for individuals with eating disorders. CBT produces large and long lasting improvements in core behavioral and cognitive symptoms of eating disorders.
Background
To evaluate whether the symptoms of children and adolescents with clinically significant posttraumatic stress symptoms (PTSS) form classes consistent with the diagnostic criteria of ...complex PTSD (CPTSD) as proposed for the ICD‐11, and to relate the emerging classes with treatment outcome of Trauma‐Focused Cognitive Behavioral Therapy (TF‐CBT).
Methods
Latent classes analysis (LCA) was used to explore the symptom profiles of the clinical baseline assessment of N = 155 children and adolescents participating in a randomized controlled trial of TF‐CBT. The treatment outcomes of patients with posttraumatic stress disorder (PTSD) and of patients with CPTSD were compared by a t‐test for depended samples and a repeated‐measures ANOVA.
Results
The LCA revealed two distinct classes: a PTSD class characterized by elevated core symptoms of PTSD (n = 62) and low symptoms of disturbances in self‐organization versus a complex PTSD class with elevated PTSD core symptoms and elevated symptoms of disturbances in self‐organization (n = 93). The Group × Time interaction regarding posttraumatic stress symptoms was not significant. Pre–post effect sizes regarding posttraumatic stress symptoms were large for both groups (PTSD: d = 2.81; CPTSD: d = 1.37). For disturbances in self‐organization in the CPTSD class, we found medium to large effect sizes (d = 0.40–1.16) after treatment with TF‐CBT.
Conclusions
The results provide empirical evidence of the ICD‐11 CPTSD and PTSD distinction in a clinical sample of children and adolescents. In terms of relative improvement from their respective baseline posttraumatic stress symptoms, patients with PTSD and CPTSD responded equally to TF‐CBT; however, those with CPTSD ended treatment with clinically and statistically greater symptoms than those with PTSD.
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