Self-help for binge eating disorder in primary care: A randomized controlled trial with ethnically and racially diverse obese patients

Objective

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

Method

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

Results

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

Conclusions

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.     

Participatory work place intervention for stress prevention in primary health care. A randomized controlled trial

The aim of this study is to explore whether a participatory, organizational intervention can reduce work-related risk factors, and thereby prevent stress-related ill health. We build on the job demand-control and effort-reward imbalance models of stress. It is a two-armed randomized trial, with one primary health care unit receiving the intervention and a two-unit control group. Validated questionnaires for the assessment of psychosocial work environment and health were administered, at the baseline and at 6 and 12-month follow up. The primary outcome was job strain. Secondary outcomes were effort–reward imbalance, exhaustion, sleep, and recovery. Group-level objective data on workload and data about relevant processes during the study were continuously collected. The changes in the intervention group with regard to job strain, effort-reward imbalance, exhaustion, sleep and recovery were not statistically different from changes in the control group. For the non-exhausted employees though, reward was significantly higher at follow up compared to baseline, but only in the intervention group. An important piece of information is that the objective workload was statistically significantly higher in the intervention group throughout the study. Not all the components of the intervention were implemented as intended. Context and process information, such as objective data and implementation fidelity are necessary for a valid interpretation of the results.     

A randomized controlled trial of internet-based therapy in depression

Depression is among the most prevalent disorders worldwide. In view of numerous treatment barriers, internet-based interventions are increasingly adopted to “treat the untreated”. The present trial (registered as NCT01401296) was conducted over the internet and aimed to assess the efficacy of an online self-help program for depression (Deprexis). In random order, participants with elevated depression symptoms received program access or were allocated to a wait-list control condition. After eight weeks, participants were invited to take part in an online re-assessment. To compensate for common problems of online studies, such as low completion rates and unclear diagnostic status, reminders and incentives were used, and clinical diagnoses were externally confirmed in a subgroup of 29% of participants. Relative to the wait-list group, program users experienced significant symptom decline on the Beck Depression Inventory (BDI; primary outcome), the Dysfunctional Attitudes Scale (DAS), the Quality of Life scale (WHOQOL-BREF) and the Rosenberg Self-Esteem Scale (RSE). Compared to wait-list participants, symptom decline was especially pronounced among those with moderate symptoms at baseline as well as those not currently consulting a therapist. Completion (82%) and re-test reliability of the instruments (r = .72–.87) were good. The results of this trial suggest that online treatment can be beneficial for people with depression, particularly for those with moderate symptoms.     

Efficacy of guided self-help behavioural activation and physical activity for depression: a randomized controlled trial

Behavioural activation and physical activity have received empirical support that highlight their efficacy in reducing depression. Even though both behavioural activation and physical activity share the common goal of reactivating the individual, limited research has directly compared these interventions, and more research is required to evaluate their efficacy when offered in low-intensity formats. The present study involves a randomized controlled clinical trial comparing the efficacy of two guided self-help interventions for the treatment of depression: behavioural activation and physical activity. Fifty-nine participants presenting mild-to-moderate symptoms of depression were randomized either to a behavioural activation intervention (n = 20), a physical activity intervention (n = 19) or a wait-list control group (n = 20). All participants completed symptom measure pre-, mid- and post-intervention, as well as at a two-month follow-up. Mixed-model analyses of variance revealed that both interventions were significantly more efficacious in reducing depressive symptoms in comparison with the control group. Physical activity involved significantly less time-investment compared to the behavioural activation condition (less than half the amount of time). These results indicate that physical activity and behavioural activation both effectively reduce depressive symptoms and are favourably applicable in low-intensity formats. Implications of these results and avenues for future research are discussed.     

Prevention of pathological gambling: a randomized controlled trial

Although the gambling industry is expanding rapidly throughout North America and around the world, there are only a few empirically evaluated programs aimed at the prevention of pathological gambling (PG). The purpose of this study was to measure the effectiveness of a new prevention program aimed at PG. The Stop & Think! program was designed to teach at-risk video lottery terminal (VLT) gamblers cognitive restructuring and problem-solving skills that may help to prevent the development of PG. These skills were taught through a variety of methods - including an automated educational presentation, video and text vignettes, audio training tapes, and skill rehearsal. The program was evaluated using a randomized, 2-group experimental design with a wait-list control group and pre-, post-, and follow-up measures. Results indicated that, compared with the control group, the experimental group was less at risk for developing a gambling problem after the program. The experimental group endorsed fewer gambling-related cognitive distortions, engaged in less VLT gambling, and had lower scores on a measure of PG. The results of this study provide the basis for the implementation of the Stop & Think! program in the province of Prince Edward Island, Canada, and perhaps other jurisdictions too.     

Correlates of religious,supernatural and psychosocial causal beliefs about depression among Latino immigrants in primary care

The purpose of this cross-sectional study was to explore causal attributions about depression and to identify psychosocial factors associated with these beliefs among Latino immigrants. We interviewed 177 primary care patients with instruments to assess causal beliefs, depressive and somatic symptoms, ethnic identity and stigma. An exploratory factor analysis of the Causal Beliefs scale yielded three factors, “Balance,” “Psychosocial” and “Malevolent Spirituality/Transgressions” that were used as dependent variables in multivariate analyses. Depressive symptoms, age, country of origin and religiosity were significantly associated with particular factors of causal beliefs. Those with higher education were most likely to endorse psychosocial causal beliefs. Stigma pertained to causal beliefs related to “malevolent forces” and “personal transgressions.” In conclusion, psychosocial and religious explanations of illness were strongly endorsed by these Latino immigrants, indicating a dual system of Western-medicine and traditional beliefs. These results suggest culturally-specific interventions for improving health knowledge and communication with patients about depression.     

The importance of primary care for theoretical medicine: A commentary

Froom and Froom all attention to referral bias as a frequent cause for misinterpreting the medical literature. This is particularly a source of false certainty, and therefore false science, in U.S. practice, where referral centers are often seen as the only legitimate source of medical knowledge and where primary care is discounted as a source of scientific observations. Appreciation of the primary care setting is therefore a critical element in theoretical understanding of medical epistemology.     

Preventing Depression Among Early Adolescents in the Primary Care Setting: A Randomized Controlled Study of the Penn Resiliency Program

This study evaluated the Penn Resiliency Program's effectiveness in preventing depression when delivered by therapists in a primary care setting. Two-hundred and seventy-one 11- and 12-year-olds, with elevated depressive symptoms, were randomized to PRP or usual care. Over the 2-year follow-up, PRP improved explanatory style for positive events. PRP's effects on depressive symptoms and explanatory style for negative events were moderated by sex, with girls benefiting more than boys. Stronger effects were seen in high-fidelity groups than low-fidelity groups. PRP did not significantly prevent depressive disorders but significantly prevented depression, anxiety, and adjustment disorders (when combined) among high-symptom participants. Findings are discussed in relation to previous PRP studies and research on the dissemination of psychological interventions. An erratum to this article is available at .     

Efficacy of brief guided self-help cognitive behavioral treatment for perfectionism in reducing perinatal depression and anxiety: a randomized controlled trial

Perfectionism has been proposed as a transdiagnostic process that maintains depression and anxiety through shared cognitive and behavioral processes. The purpose of this study was to investigate the efficacy of a brief, guided cognitive behavioral treatment (CBT) for perfectionism delivered via a self-help booklet in reducing perfectionism and symptoms of depression and anxiety during the antenatal period. Pregnant women in their third trimester were randomly allocated to self-help (n = 30) or waitlist control (n = 30). There were significant reductions in perfectionism and symptoms for participants who received CBT for perfectionism from pre- to post-treatment, which were maintained at 3-month follow-up, while the waitlist control group demonstrated no significant changes. Path analysis demonstrated a significant indirect effect of treatment condition on post-treatment depression and anxiety scores via perfectionism, controlling for pre-treatment scores, suggesting changes in perfectionism were associated with decreases in symptoms. The findings suggest that it would be useful for future research with larger samples to further investigate the efficacy of CBT for perfectionism for perinatal depression and anxiety.     

Primary care counsellors’ experiences of working with treatment resistant depression: A qualitative pilot study

Treatment resistant depression (TRD) is a severe and enduring form of depression that does not respond fully to medication. Although the evidence base for effective psychological treatments is not yet established, it is inevitable that counsellors working in primary care will encounter patients with this presentation. This pilot study explores the experience of four primary care counsellors with this patient group using Interpretative Phenomenological Analysis (IPA) and considers the implications for training and practice.     

Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help

Internet-delivered self-help for depression with therapist guidance has shown efficacy in several trials. Results from meta-analyses suggest that guidance is important and that self-help programs without support are less effective. However, there are no direct experimental comparisons between guided and unguided internet-based treatments for depression. The present study compared the benefits of a 10-week web-based unguided self-help treatment with the same intervention complemented with weekly therapist support via e-mail. A waiting-list control group was also included. Seventy-six individuals meeting the diagnostic criteria of major depression or dysthymia were randomly assigned to one of the three conditions. The Beck Depression Inventory (BDI-II) was used as the primary outcome measure. Secondary outcomes included general psychopathology, interpersonal problems, and quality of life. Sixty-nine participants (91%) completed the assessment at posttreatment and 59 (78%) at 6-month follow-up. Results showed significant symptom reductions in both treatment groups compared to the waiting-list control group. At posttreatment, between-group effect sizes on the BDI-II were d = .66 for unguided self-help versus waiting-list and d = 1.14 for guided self-help versus waiting-list controls. In the comparison of the two active treatments, small-to-moderate, but not statistically significant effects in favor of the guided condition were found on all measured dimensions. In both groups, treatment gains were maintained at 6-month follow-up. The findings provide evidence that internet-delivered treatments for depression can be effective whether support is added or not. However, all participants were interviewed in a structured diagnostic telephone interview before inclusion, which prohibits conclusions regarding unguided treatments that are without any human contact.     

Religion and anxiety treatments in primary care patients

Earlier data suggested that religious physicians are less likely to refer to a psychiatrist or psychologist. This follow-up study measures how religious beliefs affect anxiety treatments in primary care. We surveyed US primary care physicians and psychiatrists using a vignette of a patient with anxiety symptoms. Physicians were asked how likely they were to recommend antianxiety medication, see the patient for counseling, refer to a psychiatrist, refer to a psychologist or licensed counselor, encourage meaningful relationships and activities, and encourage involvement in religious community. We experimentally varied symptom severity, whether the patient was Christian or Jewish, and whether she attended religious services. Physician attendance at religious services was assessed in the survey. The response rate was 896 out of 1427 primary care physicians and 312 out of 487 psychiatrists. Religious physicians were more likely to promote religious resources. There was no statistically significant difference between physicians' recommendations for religious and nonreligious patients. There was no statistically significant difference in religious and nonreligious physicians' referrals to a psychologist, licensed counselor, or psychiatrist. Ultimately, we did not find a difference in religious and nonreligious physicians' support for mental health referrals, however, religious physicians were more likely to encourage using religious resources.     

Domestic violence in primary care: The psychologist's role

This paper highlights the difficulties facing medical and mental health professionals in helping families in which there is violence. Emphasis is placed on how domestic violence presents in primary care medical settings. Physician and patient characteristics that interfere with domestic violence detection are reviewed. A role is outlined for psychologists in primary care settings to facilitate detection and treatment. Facilitative efforts include educating physicians through collaboration and serving as an on-site resource for information and consultation.     

Short‐term cognitive‐behavioral treatment in multicultural primary care of patients with longstanding backache

The efficacy of cognitive‐behavioral therapy in multi‐cultural primary care patients with longstanding backache is not evaluated. The purpose of this study was to investigate the outcome of a four weekly‐treatment given by primary care physicians regarding pain‐related worry, depression and severe pain and to determine which social, clinical or gender factors were associated with outcome.The study group consisted of 245 patients in consecutive order from 19 countries, 18 to 45 years, entering rehabilitation program because of longstanding backache. Prevalences of pain‐related worry and depression and severe pain was counted and compared before and after. Logistic regression was used to calculate the odds (OR; 95% CI) for persistent pain‐related worry and/or persistent depression and severe pain (VAS ≥ 50). The prevalences of pain‐related worry and depression were both significantly lower after treatment (pain‐related worry 83% before vs. 38% after; depression 43% before vs. 31% after). Also the number of patients scoring ≥ 50 VAS was a little, but significantly, fewer (68% vs. 61%). Use of interpreter doubled the risk of having persistent pain‐related worry (OR 2.1; 95% CI 1.1–4.1) but the risk was not significant regarding persistent depression (OR 1.8; 0.6‐5.4). The rating of VAS rating ≥ 50 after treatment was twice as high, OR 2.3 (95% CI 1.1–4.6) in the 38–45 year old age group. To conclude, a focus on pain ideas reduced pain‐related worry and depression in these patients with various sociocultural backgrounds and longstanding backache.     

The potential mediating role of anxiety sensitivity in the impact of mindfulness training on anxiety and depression severity and impairment: A randomized controlled trial

The benefits of mindfulness-based interventions to alleviate anxiety and depression have been supported by many studies. Given the effectiveness of mindfulness-based interventions on anxiety and depression, the underlying mechanisms need to be explored. Using a randomized waitlist-controlled design, this study investigated whether anxiety sensitivity was a potential mechanism for the impact of mindfulness training on anxiety and depression. Participants with high psychological distress were randomly assigned to an eight-week mindfulness intervention (N = 35) or a wait-list control group (N = 34). Before and after the intervention or corresponding waitlist period, participants completed measures of anxiety and depression severity and impairment and anxiety sensitivity. Separate mixed ANOVA demonstrated significant group (intervention vs. control group) × time (pre- vs. post-test) interactions for anxiety sensitivity and overall anxiety severity and impairment and marginally significant interaction for overall depression severity and impairment. Moreover, simple mediation models showed that reductions of anxiety sensitivity from pre- to post-test mediated the impact of mindfulness training on changes in anxiety and depression severity and impairment. The findings suggest that anxiety sensitivity is a potential mechanism underlying the effect of mindfulness training on anxiety and depression, which provides a new perspective for the study of processes of change of mindfulness-based interventions.     

Counselling in primary care: a systematic review of the evidence

Primary objective: To undertake a systematic review which aimed to locate, appraise and synthesise evidence to obtain a reliable overview of the clinical effectiveness, cost‐effectiveness and user perspectives regarding counselling in primary care. Main results: Evidence from 26 studies was presented as a narrative synthesis and demonstrated that counselling is effective in the short term, is as effective as CBT with typical heterogeneous primary care populations and more effective than routine primary care for the treatment of non‐specific generic psychological problems, anxiety and depression. Counselling may reduce levels of referrals to psychiatric services, but does not appear to reduce medication, the number of GP consultations or overall costs. Patients are highly satisfied with the counselling they have received in primary care and prefer counselling to medication for depression. Conclusions and implications for future research: This review demonstrates the value of counselling as a valid choice for primary care patients and as a broadly effective therapeutic intervention for a wide range of generic psychological conditions presenting in the primary care setting. More rigorous clinical and cost‐effectiveness trials are needed together with surveys of more typical users of primary care services.     

Treatment of obsessions: A randomized controlled trial

This study tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment.