Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.     

Treatment-resistant depression in late life

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.     

The Nature,Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.     

Goal-setting protocol in adherence to exercise by Italian adults

A goal-setting protocol, based on research in goal setting and performance and personal construct theory, was tested for its effect on adherence to a new exercise program. The Goal-setting group (n = 50) had significantly less dropout (30%) than the control group (n = 50) (74%). The Goal-setting group also had significantly better attendance (p<.0001). Suggestions for increasing confidence in findings through further research and practical implications of using the protocol to improve exercise maintenance across settings were discussed.     

Positive psychotherapy

Positive psychotherapy (PPT) contrasts with standard interventions for depression by increasing positive emotion, engagement, and meaning rather than directly targeting depressive symptoms. The authors have tested the effects of these interventions in a variety of settings. In informal student and clinical settings, people not uncommonly reported them to be "life-changing." Delivered on the Web, positive psychology exercises relieved depressive symptoms for at least 6 months compared with placebo interventions, the effects of which lasted less than a week. In severe depression, the effects of these Web exercises were particularly striking. This address reports two preliminary studies: In the first, PPT delivered to groups significantly decreased levels of mild-to-moderate depression through 1-year follow-up. In the second, PPT delivered to individuals produced higher remission rates than did treatment as usual and treatment as usual plus medication among outpatients with major depressive disorder. Together, these studies suggest that treatments for depression may usefully be supplemented by exercises that explicitly increase positive emotion, engagement, and meaning. ((c) 2006 APA, all rights reserved).     

The open dialogue approach to acute psychosis: its poetics and micropolitics

In Finland, a network-based, language approach to psychiatric care has emerged, called "Open Dialogue." It draws on Bakhtin's dialogical principles ( Bakhtin, 1984 ) and is rooted in a Batesonian tradition. Two levels of analysis, the poetics and the micropolitics, are presented. The poetics include three principles: "tolerance of uncertainly,""dialogism," and "polyphony in social networks." A treatment meeting shows how these poetics operate to generate a therapeutic a therapeutic dialogue. The micropolitics are the larger institutional practices that support this way of working and are part of Finnish Need-Adapted Treatment, Recent research suggests that Open Dialogue has improved outcomes for young people in a variety of acute, severe psychiatric crises, such as psychosis, as compared to treatment as-usual settings. In a nonrandomized, 2-year follow up of first-episode schizophrenia, hospitalization decreased to approximately 19 days; neuroleptic medication was needed in 35% of cases; 82% had no, or only mild psychotic symptoms remaining; and only 23% were on disability allowance.     

Does sexual offender treatment work? A systematic review of outcome evaluations

The article reports a systematic review of controlled outcome evaluations of psychosocial and organic sexual offender treatment. A comprehensive search of the literature in five languages revealed 80 independent comparisons between treated and untreated groups of sexual offenders ( N = 22,181). The majority of studies confirmed a positive treatment effect. Overall, 11.1% of treated offenders and 17.5% of controls showed sexual recidivism (37% difference). Findings for violent and general recidivism were similar. Studies on surgical castration showed the strongest effect; however, this was confounded with methodological and offender characteristics. Hormonal medication, cognitive-behavioural, and behavioural approaches also revealed a positive effect. Non-behavioural treatments did not show a significant impact. Other moderators such as small sample size, authors' affiliation with the program, program completion versus dropout, or type of outcome measure had a significant impact. Methodological study characteristics explained the largest proportion of effect size variance. Overall, findings are promising but more differentiated evaluations of high quality are needed.     

Use of ratings of perceived exertion to anticipate treadmill test termination in patients taking beta-blockers

This investigation identified a perceptually-based "warning zone" that can be used to anticipate termination of treadmill tests administered to individuals taking beta-blockers. The use of ratings of perceived exertion to anticipate test termination may be valuable given the attenuation of heart rate associated with the use of this class of medication. Sixteen men with coronary artery disease participated in this investigation. Ratings of perceived exertion (Borg 6-20 Scale) were estimated during the last 15 sec. of each minute of a progressively incremented treadmill test. Tests were terminated when participants indicated they were too fatigued to continue. The time-to-test termination was determined from the point that participants estimated a rating of 10, 11, 12, 13, 14, 15, 16, and 17 in order to determine the rating that was less than or equal to the time associated with a single exercise stage. A rating of 14 was associated with impending termination, which can be used as a "warning zone." The time to termination corresponding to a rating of 14 was 153.1 sec. (SD = 27.0). Participants exercised for 153.1 sec. (SE = 27.0) after estimating a rating of 14. Once a rating of 14 is reached, volitional test termination will occur before the next exercise stage is completed.     

Tobacco Use Predicts Treatment Dropout and Outcome in an Acute,Transdiagnostic Psychiatric Treatment Setting

Tobacco use is consistently associated with greater levels of depression and anxiety, broadly, and preliminary evidence suggests that current tobacco use is a significant predictor of dropout from psychiatric treatment. The current study extends past work to examine the impact of tobacco use on treatment dropout and outcomes in an acute psychiatric treatment setting. Upon intake to a partial hospitalization program (PHP), patients completed a battery of measures assessing sociodemographic characteristics, current tobacco use, depression and generalized anxiety, and substance use. Patients at the PHP also completed measures assessing levels of depression and generalized anxiety again upon discharge from the program. In line with hypotheses, current tobacco use was a significant predictor of dropout from treatment at the PHP. Importantly, this relationship remained significant when statistically controlling for demographic variables and psychiatric and substance use severity (such as number of previous inpatient psychiatric hospitalizations and degree of alcohol or drug problems). Results from the current study indicate that tobacco use is a significant risk factor for treatment dropout. Further research is needed to replicate these findings and to determine the mechanism underlying this link between tobacco use and treatment dropout for people receiving intensive psychiatric care.     

Is amenorrhea a clinically useful criterion for the diagnosis of anorexia nervosa?

Aim of the study was to evaluate the clinical characteristics and the treatment outcome of underweight patients with eating disorder (ED) not otherwise specified without amenorrhea (EDNOS-WA), compared with classical anorexia nervosa (AN) cases. Seventy-three consecutive female patients (57 AN, and 16 EDNOS-WA) were evaluated before and after a 20-week cognitive behaviour inpatient treatment (CBT-I). Assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Temperament and Character Inventory (TCI). At logistic regression analysis, amenorrhea was only predicted by baseline BMI and intense exercise, not by psychopathological variables. Response to CBT-I was good and similar between groups, without differences in the dropout rate or time-to-dropout. Our data lend support to the hypothesis that the criterion “amenorrhea” is of no clinical utility in the diagnosis and treatment of AN and could be removed in the forthcoming DSM-V proposal.     

Subjective theories of exercise course instructors: causal attributions for dropout in health and leisure exercise programmes

Objectives: Dropout is a major problem in exercise programmes. Investigations have usually focused on exercise participants. The present study examines dropout from the perspective of exercise course instructors.Design: Course instructors' cognitions about why participants quit their course were examined. Instructors evaluated a number of possible reasons for dropout and assessed the dropout rate in their courses.Sample: Instructors of exercise classes (N=343).Method: Self-reported cross-sectional mailed survey.Results: Cluster analysis supported three different types of exercise course instructors. Type 1 attribute the participants' quitting to external reasons (‘self-protecting type’). Type 2 evaluate all potential causes as irrelevant (‘disregarding type’). Type 3 assign equal weight to internal and external reasons, seemingly reflecting an adaptation to situational requirements (‘adaptive type’). Type 3 exercise course instructors report the highest increase in number of participants. They were therefore identified as successful in motivating and attracting participants to their programmes.Conclusion: Exercise course instructors' subjective theories about reasons for dropout may influence their ability to motivate individuals to remain in their programmes or attract them to programmes.     

Predicting the completion of an integrative and intensive outpatient chronic pain treatment with the personality assessment inventory

The effects of intensive, integrative treatments for chronic pain are affected by patient compliance, and in many cases, selecting noncompliant individuals adversely impacts the cost-effectiveness of such programs. The pretreatment identification of individuals who are at risk for dropout could assist clinicians in augmenting treatments with motivational enhancement strategies for high-risk patients or using such information to select individuals who are most likely to complete a given intervention program. In this study, we tested the ability of indicators from the Personality Assessment Inventory (PAI; Morey, 1991), administered prior to treatment, to identify individuals who dropped out of a 20-day chronic pain program. Results replicate findings from outpatient psychotherapy research in finding that PAI Mean Clinical Elevation and Treatment Process Index significantly differentiated dropouts from graduates, particularly when the Treatment Rejection scale suggested patients were motivated for treatment. We discuss these results and offer recommendations for the prediction of treatment dropout in pain settings.     

Symptoms of emotional disorders and sociodemographic factors as moderators of dropout in psychological treatment: A meta-review

ObjectiveDropout from psychological treatment is an important problem that substantially limits treatment effectiveness. A better understanding of this phenomenon, could help to minimize it. Therefore, we performed a systematic review of meta-analyses (MA) on dropout from psychological treatments to (1) determine the estimated overall dropout rate (DR) and (2) to examine potential predictors of dropout, including clinical symptoms (anxiety and depression) and sociodemographic factors.MethodA literature search of the PubMed PsycINFO, Embase, Scopus and Google Scholar databases was conducted. We identified 196 MAs on dropout from psychological treatment carried out primarily in adult patients or mixed samples (adults and children) between 1990 and 2022. Of these, 12 met all inclusion criteria. Two forest plots were created to visualize the DR and the relationship between DR and the disorder.ResultsThe DR ranged from 15.9% to 46.8% and was significantly moderated by symptoms of emotional disorders. The highest DR were observed in younger, unmarried patients, and those with lower educational and income levels.ConclusionsDR in patients undergoing psychological treatment is highly heterogeneous, but higher in individuals presenting symptoms of anxiety and/or depression, especially the latter. Given that high DR undermine the effectiveness of psychological interventions, it is clear that greater efforts are needed to reduce dropout, particularly among individuals with symptoms of emotional disorders.     

Effects of the COACH APPROACH intervention on drop-out rates among adults initiating exercise programs at nine YMCAs over three years

Physical inactivity is a health problem that has not been largely affected by mass communications. An interpersonal counseling intervention, THE COACH APPROACH, was tested with 2380 adults (overall M age = 40.9 yr., SD = 10.8) initiating exercise programs in 2003, 2004, and 2005, January through March, at nine YMCA facilities in the Atlanta, GA area. Contrasts of comparison (2002) and treatment condition cohorts suggested that the protocol, based on tenets of social cognitive and self-efficacy theories, resulted in significant reductions in exercise program drop out over 6 months. Changes in dropout were not significantly correlated to participants' income, percentage of full-time exercise counselors administering the intervention, or proportion of female counselors. Although the field design did not permit randomization of participants, results of conservative statistical testing suggested that THE COACH APPROACH may be effective for settings which allow for large scale dissemination of the intervention.     

Terminal illness and suicide

Case vignette: Henry, age 19, has been under medical care struggling for 5 months with a non-Hodgkin's lymphoma that has been resistant to treatment. Proven chemotherapy protocols have failed to sustain a remission, and it is evident that his condition is terminal, although not immediately so. When not in temporary remissions he is in extreme pain. The quantity of analgesic medication needed to control the pain also leaves him feeling, in his own words, "too snowed out to do anything." During his last hospital admission, a week ago, he had talked obliquely about ending his life when signs of another painful relapse become evident. Today he appeared in the outpatient clinic, although he had no appointment scheduled. He sought out several of the people who had cared for him over the past few months to thank them and to "say good-bye." He gave some prized personal possessions to one or two of the staff with whom he felt especially close. As this was happening, some of the staff members realized that Henry had a sufficient stock of narcotics at home to end his life. Our commentators are Sanford Leikin, MD, and Richard A. McCormick, SJ.     

The Partners for Life Program: A Couples Approach to Cardiac Risk Reduction

Morbidity and mortality are reliably lower for the married compared with the unmarried across a variety of illnesses. What is less well understood is how a couple uses their relationship for recommended lifestyle changes associated with decreased risk for illness. Partners for Life compared a patient and partner approach to behavior change with a patient only approach on such factors as exercise, nutrition, and medication adherence. Ninety‐three patients and their spouses/partners consented to participate (26% of those eligible) and were randomized into either the individual or couples condition. However, only 80 couples, distributed across conditions, contributed data to the analyses, due to missing data and missing data points. For exercise, there was a significant effect of couples treatment on the increase in activity and a significant effect of couples treatment on the acceleration of treatment over time. In addition, there was an interaction between marital satisfaction and treatment condition such that patients who reported higher levels of marital distress in the individuals condition did not maintain their physical activity gains by the end of treatment, while both distressed and nondistressed patients in the couples treatment exhibited accelerating gains throughout treatment. In terms of medication adherence, patients in the couples treatment exhibited virtually no change in medication adherence over time, while patients in the individuals treatment showed a 9% relative decrease across time. There were no condition or time effects for nutritional outcomes. Finally, there was an interaction between baseline marital satisfaction and treatment condition such that patients in the individuals condition who reported lower levels of initial marital satisfaction showed deterioration in marital satisfaction, while non satisfied patients in the couples treatment showed improvement over time.     

Understanding Intentions to Exercise Following a Structured Exercise Program: An Attributional Perspective1

The present study examined the relationships among perceived outcome, causal attributions, affect, expected success, and intentions to exercise following a structured exercise program. Participants were 105 volunteers who had just completed a 12-week exercise program. Results indicated that perceived outcome over objective outcome (% attendance) was significantly more important for understanding the attribution process. Interesting interactions indicated that (a) individuals who made personally controllable attributions reported higher positive affect following perceived success, but lower positive affect following perceived failure than those who made personally uncontrollable attributions, and (b) individuals who made external attributions following perceived failure reported higher expected success than those who made internal attributions. Finally, both positive affect and expected success showed positive relationships with intention to exercise following the program. It was suggested that attribution theory may be beneficial to understanding continued exercise following structured exercise programs.     

Generalized anxiety disorder: acute and chronic treatment

Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.     

Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients

Cancer-related fatigue (CRF) is a significant clinical problem for more than 10 million adults diagnosed with cancer each year worldwide. No "gold standard" treatment presently exists for CRF. To provide a guide for future research to improve the treatment of CRF, the authors conducted the most comprehensive combined systematic and meta-analytic review of the literature to date on non-pharmacological (psychosocial and exercise) interventions to ameliorate CRF and associated symptoms (vigor/vitality) in adults with cancer, based on 119 randomized controlled trials (RCTs) and non-RCT studies. Meta-analyses conducted on 57 RCTs indicated that exercise and psychological interventions provided reductions in CRF, with no significant differences between these 2 major types of interventions considered as a whole. Specifically, multimodal exercise and walking programs, restorative approaches, supportive-expressive, and cognitive-behavioral psychosocial interventions show promising potential for ameliorating CRF. The results also suggest that vigor and vitality are distinct phenomena from CRF with regard to responsiveness to intervention. With improved methodological approaches, further research in this area may soon provide clinicians with effective strategies for reducing CRF and enhancing the lives of millions of cancer patients and survivors.     

Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy

Premature termination from group psychotherapy continues to be a serious problem in the treatment of patients with borderline personality disorder (BPD). Qualitative research is regarded as an important means to shed light upon the complex dynamics leading to dropout. We conducted an interview study with patients having a diagnosis of BPD (n = 8) who dropped out from long-term group psychotherapy as a continuation therapy following intensive day treatment. The group therapists for these patients were interviewed as well (n = 12). The findings suggest the operation of many processes that contribute to dropout. Most significant appeared to be experiences of separation and loss of the day hospital that were not worked through and a failure of the group to regulate and contain the patients' affects. To integrate patients at risk of premature termination it seems necessary to pay attention to the strong negative emotions that they experience in the group. A higher treatment intensity than weekly group sessions may help to promote more beneficial group processes.