Cognitive-Behavioral Therapy: Innovations for Cardiopulmonary Patients With Depression and Anxiety

Medically ill patients face unique physical and emotional challenges that place them at increased risk for symptoms of depression and anxiety. Despite high prevalence and significant impact, depression and anxiety are infrequently treated in the medically ill because of a variety of patient, provider, and system factors. The current article describes the development of an innovative, modular-based cognitive-behavioral intervention (Adjusting to Chronic Conditions Using Education Support and Skills [ACCESS]) that integrates treatment for symptoms of anxiety and depression with medical disease self-management in patients with heart failure and chronic obstructive pulmonary disease. Data from 3 patients who participated in an ongoing open clinical trial are reviewed to illustrate the feasibility, acceptability, and potential strengths and limitations of this intervention.     

Culturally Competent Family Therapy with Latino/Anglo-American Adolescents: Facilitating Identity Formation

On two occasions separated by one year, Chinese adolescents (N = 2,758) responded to instruments measuring their perceived parent-adolescent trust (i.e., paternal trust of the child and the child's trust of the parent) and other dimensions of parent-child relational qualities (satisfaction with parental control, readiness to communicate with the parent, and global satisfaction with the parent-child relationship). Results showed that perceived parent-adolescent trust was concurrently and longitudinally related to other dimensions of parent-child relational qualities. Multiple regression analyses suggest that the relations between perceived parent-adolescent trust and different dimensions of parent-child relational qualities over time were bidirectional in nature. Relative to perceived paternal trust of the adolescent child, adolescent child's trust of their parents exerted a stronger influence on different dimensions of parent-adolescent relational qualities, particularly in the father-adolescent dyad. While the influence of the child's readiness to communicate with the parents on parent-adolescent trust was weak in the father-adolescent dyad, the influence of global satisfaction with the parent-adolescent relationship on parent-adolescent trust was weak in the mother-adolescent dyad. The implications of the present findings on parent education and family therapy are discussed.     

Filial Therapy and Hispanic Values: Common Ground for Culturally Sensitive Helping

Hispanics are the largest and fastest growing minority group in the United States, and numerous and varied interested constituencies stress that preventive intervention with Hispanic families is imperative. Filial therapy as an intervention and prevention counseling approach shows promise as an effective way to help these families. This article explores some of the constructs of filial therapy, specifically regarding ways they interface with important social and cultural values of Hispanic families.     

A Pilot Study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression

The purpose of this study was to evaluate a culturally adapted cognitive-behavioral treatment (CBT) for major depression among Hispanics in primary care. Cultural adaptations were applied based on a range of cultural considerations described in the literature. Fifteen Hispanic primary care patients with major depression were enrolled. All participants received the 12-session intervention and completed baseline, posttreatment, and 6-month follow-up assessments. Four participants (27%) dropped out of the treatment. Analyses focused on changes from baseline functioning using a Wilcoxon Signed Rank Test. Results showed significant reductions in depressive, anxious, and somatic symptoms at posttreatment and 6-month follow-up. Mean reduction of depressive symptoms at posttreatment was 57%. Findings of acceptable treatment retention rates and clinically meaningful reductions in depressive symptoms showed promise for this intervention to treat Hispanics with major depression. Future studies should conduct a more rigorously controlled evaluation of this intervention.     

Change in Seasonal Beliefs Mediates the Durability Advantage of Cognitive-Behavioral Therapy Over Light Therapy for Winter Depression

In treating an acute episode of winter depression, cognitive-behavioral therapy for seasonal affective disorder (CBT-SAD) and light therapy are comparably efficacious, with improvement in depression symptoms during CBT-SAD mediated by reduced seasonal beliefs (i.e., maladaptive thoughts about the seasons, light availability, and weather). Here, we tested whether the enduring benefit of CBT-SAD over light therapy following treatment is associated with offsetting seasonal beliefs during CBT-SAD. Currently depressed adults with Major Depression, Recurrent with Seasonal Pattern (N = 177) were randomized to 6 weeks of light therapy or group CBT-SAD and followedup one and two winters after treatment. Outcomes measured during treatment and at each follow-up included depression symptoms on the Structured Clinical Interview for the Hamilton Rating Scale for Depression—SAD Version and Beck Depression Inventory—Second Edition. Candidate mediators measured at pre-, mid-, and posttreatment were SAD-specific negative cognitions (Seasonal Beliefs Questionnaire; SBQ); general depressogenic cognitions (Dysfunctional Attitudes Scale; DAS); brooding rumination (Ruminative Response Scale-Brooding subscale; RRS-B); and chronotype (Morningness-Eveningness Questionnaire; MEQ). Latent growth curve mediation models found a significant positive path from treatment group to the slope of SBQ during treatment, with CBT-SAD showing larger improvements in seasonal beliefs with overall change in seasonal beliefs in the medium-effect range, and significant positive paths from SBQ slope to depression scores at the first and second winter follow-ups, indicating greater change towards more flexible seasonal beliefs during active treatment was associated with less severe depression symptoms following treatment. Estimated indirect effects (treatment group → SBQ change * SBQ change → outcome) were also significant at each follow-up for each outcome with β_indirect ranging from .091 to .162. Models also found significant positive paths from treatment group to the slope of MEQ and RRS-B during treatment, with light therapy showing a greater increase in “morningness” and CBT-SAD showing a greater decrease in brooding during active treatment; however, neither construct emerged as a mediator of follow-up depression scores. Change in seasonal beliefs during treatment mediates both the acute antidepressant and long-term effects of CBT-SAD and explains lower depression severity following CBT-SAD relative to light therapy.     

Cognitive-Behavioral Therapy for Depression in an Older Gay Man: A Clinical Case Study

Although strong evidence supports cognitive-behavioral therapy for late-life depression and depression in racial and ethnic minorities, there are no empirical studies on the treatment of depression in older sexual minorities. Three distinct literatures were tapped to create a depression treatment protocol for an older gay male. Interventions were deduced from the late-life depression literature, culturally adapted CBT protocols for racial minorities, and the emerging social and developmental psychological theories for lesbian, gay, and bisexual populations. Specific treatment interventions, processes, and outcomes are described to illustrate how these literatures may be used to provide more culturally appropriate and effective health care for the growing, older sexual minority population.     

Role of Comorbid Depression and Co-occurring Depressive Symptoms in Outcomes for Anxiety-Disordered Youth Treated with Cognitive-Behavioral Therapy

This study examined the role of comorbid depressive disorders (major depressive disorder or dysthymic disorder) and co-occurring depressive symptoms in treatment outcome and maintenance for youth (N = 72, aged 7–14) treated with cognitive-behavioral therapy for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Hierarchical linear modeling examined treatment outcome and maintenance in terms of severity of the principal anxiety disorder. Results indicated that higher levels of child-reported depressive symptoms predicted less favorable treatment outcome. Higher levels of mother-reported depressive symptoms predicted less favorable treatment maintenance at a 1-year follow-up. Results suggest that co-occurring depressive symptoms play a role in effective treatment for anxiety-disordered youth and support the merits of treatment adaptations for these youth.     

Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment

The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies (N = 69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.     

Brief Cognitive-Behavioral Therapy for Suicidal Inpatients

Suicide risk is elevated in psychiatric patients following discharge from inpatient care. Despite this vulnerability, there has been limited research investigating suicide prevention protocols that take into account the unique system characteristics of this setting (e.g., short lengths of stay, crisis stabilization treatment model, multidisciplinary team coordination). Cognitive-behavioral therapy (CBT) has demonstrated efficacy for improving suicide risk in outpatients, but has not been validated with inpatients. The current study was a treatment development and pilot feasibility open trial that modified brief cognitive-behavioral therapy (BCBT) for an inpatient setting (BCBT-I). Key treatment modifications included administering up to 10 sessions (depending on patient length of stay), daily, and in a standardized order, with core crisis management skills introduced during the first three sessions. In addition, coordination with the inpatient treatment team was included in BCBT-I implementation. Six adult inpatients with a recent suicide attempt enrolled and completed an average of 4.67 BCBT-I sessions (SD = 1.36). The treatment was highly acceptable (Client Satisfaction Questionnaire total score M = 3.49, SD = 0.73). Pre- to posttreatment effect sizes demonstrated improvements in suicidal ideation (d = 0.97), depression (d = 1.33), and suicidal implicit associations (d = 1.28). All but one of the participants (83%) completed follow-up assessments 1-, 2-, and 3-months postdischarge. Over follow-up, two participants reported suicidal ideation (both without intent), and none reported suicide attempts, preparatory acts or behaviors, or nonsuicidal self-injury. This study provided preliminary evidence supporting the feasibility of CBT to treat suicidal inpatients. Future research is needed to validate BCBT-I in a larger, randomized controlled trial to determine whether BCBT-I reduces suicide risk beyond that afforded by inpatient treatment alone.     

Feminist Cognitive-Behavioral Therapy for Negative Body Image

Negative body image in women is evidence of internalized cultural messages about obtaining an unrealistic and changing body image ideal. Feminist therapy for negative body image balances an emphasis on socio-cultural and intrapsychic issues, while cognitive-behavioral therapy addresses specific thought patterns and dysfunctional behaviors. This paper reviews the literature on these approaches and gives specific suggestions for developing an integrated model. Ideas for setting the stage for therapy and using psychoeducational material are presented. Discussion also includes feminist cognitive restructuring, including normalizing and relabelling beliefs and developing counterarguments and adaptive restatements. Behavioral interventions include confronting avoidance behaviors and body image distortion, and including kinesthetic experiences and nurturing behaviors.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

The onset of appearance-related concerns associated with body dysmorphic disorder (BDD) typically occurs in adolescence, and these concerns are often severe enough to interfere with normal development and psychosocial functioning. Cognitive behavioral therapy (CBT) is an effective treatment for adults with BDD. However, no treatment studies focusing on adolescents with BDD have been conducted. The need for an effective treatment in this population led to the development of a brief CBT protocol with family involvement. The treatment focuses on enhancing an adolescent's quality of life through the reduction of maladaptive thoughts and behaviors, and incorporates skills training and parent training. Similar treatment packages have already been shown to be efficacious for children and adolescents with similar disorders, such as obsessive-compulsive disorder and social phobia. The following case illustrates the application of this brief CBT protocol for BDD in an adolescent, and highlights clinical considerations needed when adapting CBT for a pediatric population. Treatment was associated with clinically significant improvement in symptoms of BDD, self-esteem, depression, and quality of life. This report extends extant literature by suggesting that CBT may be a helpful treatment for adolescents with BDD.     

Cognitive-Behavioral Therapy for Insomnia in Older Adults

Sleep is disturbed by a range of factors across the lifespan. However, older adults experiencing disruptions in their sleep are often simultaneously contending with a range of comorbid medical and psychiatric conditions that compound the biological changes in sleep that commonly occur with age. Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard, nonpharmacological intervention for sleep disturbances, and is a cost-effective treatment approach that can occur in either individual or group format. It has also been shown effective in older adults with medical, psychiatric, and cognitive comorbid disorders. This review highlights the success of CBT-I with older adults, as well as studies that illustrate the use of alternative delivery methods and treatment modifications for complex clinical presentations.     

Ethical Considerations for Cognitive-Behavioral Therapists in Psychotherapy Research Trials

Psychotherapy research studies, which balance the pursuit of knowledge with the provision of treatment, can place unique demands on clinicians, patients, and research staff. However, the literature on ethical considerations in psychotherapy trials is minimal. The current paper depicts CBT community standards of practice in the context of two NIMH-funded treatment trials of major depression, both involving CBT and medication. We describe issues that arose; discuss the ethical considerations involved; and describe our course of action, along with our rationale.     

Cognitive-Behavioral Treatment of Depression with Comorbid Borderline Personality Traits

Personality dysfunction can influence the onset and maintenance of depressive symptoms. When both depression and personality dysfunction are present, it is important to develop an integrated treatment plan that addresses both conditions. A case example is used to illustrate how features of borderline personality disorder can influence the assessment and treatment of major depression. Specific challenges encountered by the therapist include: 1) differentiating borderline personality from depressive symptoms, 2) maintaining the therapeutic alliance, 3) managing impulsivity and self-destructive tendencies, 4) staying focused on long-term therapeutic goals, and 5) coping with noncompliance. Over the course of 27 sessions, the client was able to make positive changes in mood, self-image, and impulsive tendencies. Although the client's borderline personality traits complicated the course of treatment for depression, neglecting these personality problems would have left the client vulnerable to depressive relapse.     

Perceptions of Cognitive-Behavioral Therapy and Antidepressant Medication for Depression After Brief Psychoeducation: Examining Shifts in Attitudes

The majority of people with depression in the United States either never seek treatment or gravitate exclusively to antidepressant medication (ADM), despite the existence of other effective treatments, such as cognitive-behavioral therapy (CBT). Reluctance to use psychotherapy is partly due to lack of appropriate mental health literacy and perceptions of low treatment acceptability (appropriateness for a given problem) and credibility (treatment logicalness, and whether the patient expects improvement). In the current investigation, we examined whether providing psychoeducation about CBT for depression would change participant perceptions of the treatment’s acceptability and credibility. We recruited 554 (female n = 314; 57%) participants across two online studies, and assessed their baseline perceptions of CBT and ADM using modified Treatment Acceptability (TAAS) and Treatment Credibility and Expectancy (CEQ) scales. Participants were subsequently presented with evidence-based, expert-vetted psychoeducational materials describing CBT and ADM, and were asked to recomplete the TAAS and CEQ. In Study 1, participants endorsed significantly higher CBT-CEQ (credibility/expectancy) scores postpsychoeducation. In Study 2, participants endorsed significantly lower CBT-TAAS (acceptability), and among those with no exposure to depression treatments, endorsed significantly higher CBT-CEQ scores postpsychoeducation. In both studies, there were no perceptual changes of ADM after the psychoeducation. Finally, in Study 2, endorsement of a biological model of depression and depressive symptoms were negatively predictive of CBT’s acceptability and credibility and expectancy postpsychoeducation. Perceptions of credibility and expectancy of CBT for depression appear malleable even after exposure to brief psychoeducation, whereas shifting perceptions of CBT’s acceptability may require more extensive intervention.     

Cognitive-Behavioral Therapy for Body Dysmorphic Disorder by Proxy

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

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.