Cognitive-Behavioral Therapy in the Treatment of Internalizing Disorders in High-Functioning Youth with Autism Spectrum Disorder

Anxiety and depression are often comorbid with Autism Spectrum Disorder (ASD). There is empirical support to suggest that cognitive-behavioral therapy (CBT) is an efficacious treatment for comorbid anxiety disorders in youth with ASD. Modifications to CBT for youths with ASD have been made with emphasis on exposure being a critical component. Few studies have evaluated the efficacy of CBT on symptoms of depression in youths with ASD. Modifications to CBT will be outlined in this review, as will implementation suggestions for the clinician practicing CBT with ASD youth. Limitations of the studies investigating this intervention include small sample sizes, clinician- and parent-report of symptom change but not consistent self-identified change, limited validated tools for assessing change, and lack of long-term follow-up.     

Effectiveness of an Individualized Case Formulation-Based CBT for Non-responding Youths with Anxiety Disorders

The study examined the effectiveness of an individualized case formulation-based cognitive behavior therapy (CBT) for youths (9–17 years) with anxiety disorders and their parents after unsuccessful treatment with a manualized group CBT program (the Cool Kids). Out of 106 participant youths assessed at a 3-month follow-up after manualized CBT, 24 were classified as non-responders on the Clinical Global Impression-Improvement scale (CGI-I), and 14 of 16 non-responders with anxiety as their primary complaint accepted an offer for additional individual family CBT. The treatment was short-term (M sessions = 11.14) and based on a revised case formulation that was presented to and agreed upon by the families. At post-treatment, nine youths (64.3 %) were classified as responders on the CGI-I and six (42.9 %) were free of all anxiety diagnoses, while at the 3-month follow-up 11 (78.6 %) had responded to treatment and nine (64.3 %) had remitted from all anxiety diagnoses. Large effect sizes from pre- to post-individualized treatment were found on youths’ anxiety symptoms, self-reported (d = 1.05) as well as mother-reported (d = .81). There was further progress at the 3-month follow-up, while treatment gains remained stable from post-treatment to the 1-year follow-up. Results indicate that non-responders to manualized group CBT for youth anxiety disorders can be helped by additional CBT targeting each family’s specific needs.     

Cognitive behaviour therapy for common mental disorders in people with Multiple Sclerosis: A bench marking study

Background

Mental health problems such as depression and anxiety are common in Multiple Sclerosis (MS) and are often under treated.

Aims

This paper reports on the clinical effectiveness of a cognitive behaviour therapy service for common mental disorders in people with MS and compares it to previous randomised controlled trials (RCTs) of cognitive behaviour therapy (CBT) in this population.

Methods

49 patients were deemed appropriate for CBT and 29 accepted treatment. Assessments were completed at baseline and end of treatment and included the Hospital Anxiety & Depression Scale. Results in the form of a standardized effect of treatment were compared with five previous RCTs.

Results

The results from this clinical service indicated statistically significant outcomes with reductions in depression and anxiety. The uncontrolled effect size was large but inferior to those found in published RCTs.

Conclusions

Cognitive behaviour therapy is effective for people with MS in routine clinical practice. Possible limits on effectiveness include more liberal patient selection, lack of specificity in rating scales and heterogeneity of target problems. Given the high rates of distress in this population, routine psychological interventions within neurology services are justifiable. Future research should aim to maximise CBT in such settings.     

A Nonrandomized Effectiveness Comparison of Broad-Spectrum Group CBT to Individual CBT for Depressed Outpatients in a Community Mental Health Setting

Controlled trials have established the efficacy of cognitive-behavior therapy (CBT) for depression. However, the relative effectiveness of individual versus group treatment formats in real-world settings is less well established. The current study evaluated the effectiveness of group CBT (n = 157) compared to individual CBT (n = 77) for depressed outpatients in a naturalistic setting. Symptom improvements for depression, anxiety, and quality of life were compared between treatment formats in intent-to-treat and completer analyses. Effect sizes and rates of recovery were examined. Results showed that both individual and group CBT were effective, even in the presence of high levels of comorbidity. Whereas individual CBT was associated with larger effect sizes and significantly higher rates of recovery, group CBT compared favorably to outcomes established by past research. A broad-spectrum group CBT program may be a viable treatment option when depression symptoms are less severe and when this format of treatment delivery is desirable.     

Cognitive behavioral therapy in practice: treatment delivered by trainees at an outpatient clinic is clinically effective

Cognitive–behavioral therapy (CBT) is known to be effective for a number of disorders, and can be delivered effectively by trainees in controlled settings. However, the effectiveness of trainee therapists in general practice compared to that of more experienced therapists is unknown. In this study, the authors used a benchmarking strategy to compare the outcomes of naturalistic CBT delivered by trainee therapists to those of efficacy and effectiveness studies using primarily professional therapists. Patients (N = 249) with mood and anxiety disorders were treated by trainees (primarily by interns and postdocs) using nonstandardized nonmanualized CBT at an outpatient clinic in an urban academic medical center. Changes in anxiety and depression were assessed using effect sizes, reliable and clinically significant change, and benchmarked to efficacy and effectiveness studies. Symptoms of anxiety and depression significantly improved from start to end of treatment. Rates of improvement and recovery compared favorably to those achieved in other studies, with the exception of recovery rates in severe depression. Effect sizes were in the medium to large range, but generally lower than those achieved in other studies. Results suggest that CBT can be delivered effectively by trainees in an outpatient setting.     

Investigating trajectories of change in psychological distress amongst patients with depression and generalised anxiety disorder treated with internet cognitive behavioural therapy

Internet based cognitive behavioural therapy (CBT) is efficacious for the treatment of anxiety and depression. The current study aimed to examine the effectiveness of internet based CBT prescribed by primary care clinicians for the treatment of depression and generalised anxiety disorder. Psychological distress data from 302 patients who completed an online CBT course for depression and 361 patients who completed an online CBT course for generalised anxiety disorder were subjected to growth mixture analysis. For both disorders psychological distress decreased across each lesson in a quadratic trend. Two classes of individuals were identified with different trajectories of change: a large group of individuals who responded well to the courses and a smaller group of individuals with a lower response. Both groups were similar with respect to socio-demographic characteristics however the Low Responders tended to have higher levels of symptom severity and psychological distress at baseline in comparison to the responders. For the majority of patients (75-80%) the internet CBT courses for depression and generalised anxiety disorder were effective. Further research is required to identify and effectively treat the smaller proportion of patients who did not improve during internet CBT.     

Effectiveness of Cognitive Behavior Therapy for Severe Mood Disorders in an Acute Psychiatric Naturalistic Setting: A Benchmarking Study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, “real world” settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.     

Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients

This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.     

Cognitive-behavioral treatment of childhood obsessive-compulsive disorder in community-based clinical practice: clinical significance and benchmarking against efficacy

Objective

To evaluate the feasibility and outcomes of evidence-based (EB) manualized, cognitive-behavioral treatment (CBT) for childhood obsessive-compulsive disorder (OCD), when delivered in an outpatient community-based specialist clinic.

Method

This study, conducted in an outpatient private clinic in South-East Queensland Australia, involved thirty-three children and adolescents with OCD. Children were assessed at pre- and post-treatment, by means of diagnostic interviews, symptom severity interviews, and self-report. Treatment involved 12 sessions CBT delivered either individually or in small groups and included parental involvement.

Results

Manualized CBT could be transported to the community setting effectively, with 63% of the current sample responding positively, based on post-treatment diagnosis. Significant change was evident across a wide-range of outcomes; including, diagnostic severity, symptom severity, child reported depression and anxiety, and both child and parent reported OCD functional impairment.

Conclusions

This study provides evidence for the transportability of manualized CBT in clinical community practice for pediatric OCD. The next important step is larger community based dissemination and effectiveness studies to advance both research and clinical practice outcomes.     

Trauma‐focused CBT with maltreated children: A clinic‐based evaluation of a new treatment manual

The effectiveness of a locally developed trauma‐focused cognitive behavioural therapy (TF‐CBT) program for maltreated children with post‐traumatic stress disorder (PTSD) was examined across different therapists in a child protection clinic setting. An earlier phase of the research piloting the program had provided promising results. This second phase involved two studies evaluating the completed TF‐CBT manual delivered by (a) the developer and (b) other therapists. A single‐case multiple‐baseline design was used to demonstrate the controlling effects of the treatment on PTSD symptoms and child coping. Eight 9–13‐year‐old abused children with PTSD were treated. Positive outcomes support the effectiveness of the TF‐CBT program delivered by both the developer and other therapists. The study design and methodology were robust enough to confirm empirically the clinically beneficial effects and potential for this new program. It was also apparent, however, from study limitations, including missing data for some patients, that there are a number of challenges in carrying out such research in a busy child protection service setting with multiply‐abused patients. This paper considers implications and ways forward for engaging in empirically supported practice as well as future development and research.     

The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice

Chronic insomnia is a very common clinical condition which may respond well to non-pharmacological treatment. Indeed, the literature supports the efficacy of cognitive behaviour therapy (CBT). However, there has been no substantial study of clinical effectiveness. Since insomniacs typically present in general medical practice this is a crucial gap in the outcome research. This study, therefore, specifically investigated the clinical effectiveness of CBT delivered by Health Visitors (primary care nurses) trained as therapists. One hundred and thirty-nine insomniacs (mean age 51 yr) were randomised to CBT or Self-Monitoring Control (SMC) in a controlled trial. CBT comprised six group sessions (n=4 to 6 patients). After the controlled phase, SMC patients entered deferred treatment (CBT-DEF), allowing both treatment replication and long-term outcome to be investigated for a sizeable, treated sample. Repeated measures ANOVAs demonstrated superiority of CBT over SMC in substantially reducing sleep latency and wakefulness during the night. CBT-DEF replicated similar effects and maintained improvement was observed in both groups one year later. Furthermore, total sleep increased significantly during follow-up and 84% of patients initially using hypnotics remained drug-free. Results suggest that CBT administered by Health Visitors offers a clinically effective treatment for insomnia.     

Development and Implementation of Health and Wellness CBT for Individuals With Depression and HIV

Rates of depression are reported to be between 22% to 33% in adults with HIV, which is double that of the general population. Depression negatively affects treatment adherence and health outcomes of those with medical illnesses. Further, it has been shown in adults that reducing depression may improve both adherence and health outcomes. To address the issues of depression and nonadherence, Health and Wellness (H&W) cognitive behavioral therapy (CBT) and medication management (MM) treatment strategies have been developed specifically for youth living with both HIV and depression. H&W CBT is based on other studies with uninfected youth and upon research on adults with HIV. H&W CBT uses problem solving, motivational interviewing, and cognitive-behavioral strategies to decrease adherence obstacles and increase wellness. The intervention is delivered in 14 planned sessions over a 6-month period, with three different stages of CBT. This paper summarizes the feasibility and acceptability data from an open depression trial with 8 participants, 16 to 24 years of age, diagnosed with HIV and with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis of depression, conducted at two treatment sites in the Adolescent Trials Network (ATN). Both therapists and subjects completed a Session Evaluation Form (SEF) after each session, and results were strongly favorable. Results from The Quick Inventory of Depressive Symptomatology–Clinician (QIDS-C) also showed noteworthy improvement in depression severity. A clinical case vignette illustrates treatment response. Further research will examine the use of H&W CBT in a larger trial of youth diagnosed with both HIV and depression.     

Disorder-specific Effects of CBT for Anxious and Depressed Youth: A Meta-analysis of Candidate Mediators of Change

The commonalities between anxiety and depression have been discussed before, but few have delineated the potentially different mechanisms through which treatments work for these populations. The current study conducted a comprehensive review of child and adolescent randomized clinical trials that tested cognitive-behavioral therapy (CBT) for anxiety or depression. All studies were required to have assessed both treatment outcomes and at least one theory-specific process target, including behavioral, physiological, cognitive, and coping variables. Using a meta-analytic approach, CBT demonstrated positive treatment gains across anxiety, depression, and general functioning outcomes. CBT for anxiety also produced moderate to large effects across behavioral, physiological, cognitive, and coping processes, with behavioral targets demonstrating potentially the greatest change. CBT for depression produced small effects for cognitive processes but nonsignificant effects for behavioral and coping variables. Findings were generally consistent with CB theory but suggest potentially different mediators in the treatment of anxiety and depression. Results are discussed in terms of implications for mechanisms research, theories of change, and treatment development.     

Improving the Transportability of CBT for Internalizing Disorders in Children

Research provides strong support for the efficacy and effectiveness of cognitive behavioral therapy (CBT) for the treatment of childhood internalizing disorders. Given evidence for limited dissemination and implementation of CBT outside of academic settings, efforts are underway to improve its transportability so that more children with mental health needs may benefit from treatment. Creative modifications to existing treatments aim to deliver CBT for anxiety disorders and depression in a more transportable format. Notable progress has been made within the areas of computerized CBT, camp-based CBT, school-based CBT, and CBT delivered through primary care settings. These approaches are discussed within the context of key elements of transportability that are particularly germane to the dissemination and implementation of child treatments.     

Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example

Low self-esteem is a common, disabling, and distressing problem that has been shown to be involved in the etiology and maintenance of a range of Axis I disorders. Hence, it is a priority to develop effective treatments for low self-esteem. A cognitive-behavioral conceptualization of low self-esteem has been proposed and a cognitive-behavioral treatment (CBT) program described (Fennell, 1997, 1999). As yet there has been no systematic evaluation of this treatment with routine clinical populations. The current case report describes the assessment, formulation, and treatment of a patient with low self-esteem, depression, and anxiety symptoms. At the end of treatment (12 sessions over 6 months), and at 1-year follow-up, the treatment showed large effect sizes on measures of depression, anxiety, and self-esteem. The patient no longer met diagnostic criteria for any psychiatric disorder, and showed reliable and clinically significant change on all measures. As far as we are aware, there are no other published case studies of CBT for low self-esteem that report pre- and posttreatment evaluations, or follow-up data. Hence, this case provides an initial contribution to the evidence base for the efficacy of CBT for low self-esteem. However, further research is needed to confirm the efficacy of CBT for low self-esteem and to compare its efficacy and effectiveness to alternative treatments, including diagnosis-specific CBT protocols.     

Strategies included in cognitive behavioral therapy programs to treat internalized disorders: a systematic review

This review aimed to identify the strategies used in programs based on cognitive behavioral therapy (CBT) to prevent and treat symptoms of anxiety, depression, and internalized behaviors of children and adolescents. Based on an online search (ERIC, PsycInfo, Virtuose UQAM, and Google Scholar), 61 studies describing different cognitive behavioral programs were selected. Results showed that 40 strategies were implemented in at least one program. However, none of the strategies were systematically present in all programs, and only few were reported in more than 50% of the studies. Cognitive restructuring and problem-solving were the most popular strategies to treat depressive symptoms, whereas anxiety programs also generally included relaxation and exposure. Furthermore, six strategies were identified in a single anxiety program, whereas nine strategies were implemented in only one depression program. These results suggest that in anxiety and depression programs designed for children and adolescents, the label “CBT” encompasses a wide variety of programs with only few similar strategies. Such findings highlight the need to define a common basis for CBT programs, in order to better reflect CBT theory and to identify the effectiveness of the strategies included in these programs.     

Differential Effectiveness of Behavioral Parent-Training and Cognitive-Behavioral Therapy for Antisocial Youth: A Meta-Analysis

Extended the findings from previous meta-analytic work by comparing the effectiveness of behavioral parent-training (BPT) and cognitive-behavioral therapy (CBT) for youth with antisocial behavior problems. Youth demographic variables were also examined as potential moderators of the effectiveness of these 2 types of interventions. Thirty BPT studies and 41 CBT studies met inclusion criteria for this meta-analysis. The weighted mean effect size (ES) for all interventions was 0.40. Youth age was found to moderate the outcome of the 2 interventions, with BPT having a stronger effect for preschool and school-aged youth and CBT having a stronger effect for adolescents. The results also indicate that there may be systematic differences in the outcomes associated with BPT and CBT when the setting of the intervention is considered, suggesting the need to carefully consider the effect of setting in future research. This study also highlights the need for outcome research dealing with more diverse populations and the better classification of research participants on different developmental trajectories of antisocial behavior.