Exploring the Effectiveness of a Mixed-Diagnosis Group Cognitive Behavioral Therapy Intervention Across Diverse Populations

Depression and anxiety are the most common mental health disorders seen in clinical practice and they are highly comorbid. Cognitive behavioral therapy (CBT) has been demonstrated as an effective treatment for both depression and anxiety but is often not available to all individuals who could benefit from it. This paper investigates the effectiveness of a mixed-diagnosis group CBT intervention that incorporates mindfulness meditation for individuals presenting with depression and/or anxiety: CBT Basics II. This intervention was evaluated across two distinct mental health programs to determine both if it can demonstrate positive results and if it is feasible to implement in these types of programs. Sample 1 (n = 42 completers) consisted of higher-functioning individuals in a general mental health program. Sample 2 (n = 53 completers) consisted of individuals with more chronic and severe mental health diagnoses. Overall, intent-to-treat analyses revealed improvements in psychiatric symptoms, and increases in CBT knowledge and mindfulness skill across both programs. This indicates that CBT Basics II is effective across diverse mental health populations and shows promise for improving access to CBT.     

Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial

The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n = 85) or direct FtF CBT (n = 88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients’ access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.     

Axis I anxiety and mental health disorders among stuttering adolescents

PurposeThe purpose of this study was to evaluate anxiety and psychological functioning among adolescents seeking speech therapy for stuttering using a structured, diagnostic interview and psychological questionnaires. This study also sought to determine whether any differences in psychological status were evident between younger and older adolescents.MethodParticipants were 37 stuttering adolescents seeking stuttering treatment. We administered the Computerized Voice Version of the Diagnostic Interview Schedule for Children, and five psychometric tests. Participants were classified into younger (12–14 years; n = 20) and older adolescents (15–17 years; n = 17).ResultsThirty-eight percent of participants attained at least one diagnosis of a mental disorder, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involving anxiety. This figure is double current estimates for general adolescent populations, and is consistent with our finding of moderate and moderate–severe quality of life impairment. Although many of the scores on psychological measures fell within the normal range, older adolescents (15–17 years) reported significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioral problems, than younger adolescents (12–14 years). There was scant evidence that self-reported stuttering severity is correlated with mental health issues. There are good reasons to believe these results are conservative because many participants gave socially desirable responses about their mental health status.DiscussionThese results reveal a need for large-scale, statistically powerful assessments of anxiety and other mental disorders among stuttering adolescents with reference to control populations.Educational Objectives: The reader will be able to: (a) explain the clinical importance of assessing for mental health with stuttering adolescents, (b) state the superior method for adolescent mental health assessment and (c) state a major issue with determining the genuineness of stuttering adolescent responses to psychological assessment.     

Cognitive Behavioral Therapy for Bariatric Surgery Patients: Preliminary Evidence for Feasibility,Acceptability, and Effectiveness

Bariatric surgery is the most effective treatment for extreme obesity; however, 20% to 50% of patients begin to regain their weight within the first 1.5 to 2 years following surgery. Despite some psychosocial factors predicting postoperative weight loss and weight regain, psychosocial interventions are not routinely offered in bariatric surgery programs. In this paper, we describe a 6-session cognitive behavioral therapy (CBT) intervention for preoperative and postoperative bariatric surgery patients with maladaptive eating behaviors or thought patterns, which can be delivered either in person or by telephone. In addition, we describe a small pilot study (n = 8) designed to examine the feasibility and acceptability of the CBT intervention, as well as its effectiveness in improving eating pathology and psychosocial functioning. Most pilot study participants reported improvements in binge eating severity, emotional eating, and depression from pre- to posttreatment, and all participants provided positive qualitative feedback regarding the intervention.     

Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People With HIV: A Clinical Case Study

Despite high rates of co-occurring tobacco use and anxiety symptoms and disorders among persons with HIV, evidence-based interventions for these individuals are not yet available. The present study sought to evaluate an integrated treatment model addressing smoking cessation and anxiety sypmtoms among HIV-positive smokers. Treatment was an 8-week intervention integrating a standard smoking cessation protocol (i.e., cognitive-behavioral therapy [CBT], nicotine replacement therapy) with CBT for anxiety. Inclusion criteria were 18–65 years of age, ≥ 10 cigarettes/day, State–Trait Anxiety Inventory [STAI-T] score of > 39, and moderate motivation (i.e., ≥ 5 out of 10 on a 10-point Likert scale) to quit smoking. Primary outcomes included scores on the Anxiety Sensitivity Index (ASI) and cigarettes smoked per day. Self-reported abstinence was biochemically verified by carbon monoxide breath analysis. Three male participants (mean age 49.3, SD = 9.1) completed through 2-month follow-up. At baseline all participants reported smoking an average of 20 cigarettes per day. Two participants quit smoking and maintained abstinence by the 2-month follow-up, and demonstrated a reduction in ASI scores. Participant 3 continued to smoke but at a reduced rate. Participants’ response to cognitive and behavioral strategies (e.g., creating balanced thoughts, interoceptive exposures) will be discussed. Clinical lessons learned include use of a flexible approach to cognitive restructuring, use of imaginal and in vivo exposures in session to better prepare patients for homework practice, and flexibility in delivering the treatment in an individual or group format. This clinical presentation provides preliminary support for the feasibility and initial effectiveness of an integrated treatment to reduce anxiety symptoms and aid in smoking cessation in anxious, HIV-positive smokers.     

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.     

Evaluating the Effectiveness of ACT for Anxiety Disorders in a Self-Help Context: Outcomes From a Randomized Wait-List Controlled Trial

Rigorous evaluations of cognitive behavioral self-help books for anxiety in pure self-help contexts are lacking. The present study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT) self-help workbook for anxiety-related concerns, with no therapist contact, in an international sample. Participants (N = 503; 94% mental health diagnosis) were randomized to an immediate workbook (n = 256) or wait-list condition (n = 247). Assessments at pretreatment, 12 weeks, 6 months, and 9 months evaluated anxiety and related symptoms, quality of life, and ACT treatment processes (e.g., psychological flexibility). Participants in the wait-list arm crossed over to the workbook following the 12-week assessment. The workbook condition yielded significant improvements on all assessments from pre- to posttreatment relative to wait-list, and these gains were maintained at follow-ups. The pattern observed in the wait-list condition was virtually identical to the active treatment arm after receiving the workbook, but not before. Attrition was notable, but supplemental analyses suggested dropout did not influence treatment effects for all but one measure. Overall, findings provide preliminary support for the effectiveness of this self-help workbook and suggest ACT-based self-help bibliotherapy might be a promising low-cost intervention for people experiencing significant anxiety-related concerns.     

Exposure-Based Family Therapy (FBT-E): An Open Case Series of a New Treatment for Anorexia Nervosa

The overlap between anorexia nervosa (AN) and anxiety disorders has led to the development of anxiety-based etiological models of AN and anxiety-based interventions for AN, including exposure treatment. Family-based treatment (FBT) is an efficacious intervention for adolescents with AN; however, it has recently been proposed that FBT accomplishes parent-facilitated exposure and habituation to food and related triggers in the individual's natural environment. FBT was recently altered to include an explicit exposure component that targets the broad construct of anxiety, including fear, worry, and disgust. This case series examines the application of FBT with an exposure component (FBT-E) to a group of adolescents meeting diagnostic criteria for AN (n = 4) and eating disorder not otherwise specified–restricting type (SAN, n = 6). Ten outpatients (ages 12–17, mean age: 15.28) participated in a course of FBT-E. Session-by-session weight was examined, along with BMI at pre- and posttreatment and responses to self-report measures of eating disorder symptoms (Eating Disorder Examination Questionnaire; EDE-Q), depression and anxiety. Parent reports of their adolescents' anxiety were also collected. The results of this study provide preliminary evidence that FBT-E may effectively target disordered eating and anxiety symptoms and may be a viable alternative to traditional FBT. Implications and future directions are discussed.     

Electrocortical Evidence of Enhanced Performance Monitoring in Social Anxiety

Self-focused attention is thought to be a key feature of social anxiety disorder. Yet few studies have used event-related potentials (ERPs) to examine whether socially anxious individuals display greater monitoring of their performance and attention to their errors. Similarly, only a few studies have used ERPs to examine how social anxiety is related to processing of performance feedback. Individuals with high (n = 26) and low (n = 28) levels of social anxiety completed a trial-and-error learning task. Self-focus was manipulated using false heart-rate feedback during a random subset of trials. Performance feedback was given using emotional and neutral faces in a positive context (correct = happy face; incorrect = neutral face) and negative context (correct = neutral face; incorrect = disgust face) in order to investigate biased interpretation and attention to feedback. Socially anxious subjects displayed enhanced amplitude of the ERN and CRN, suggesting greater response monitoring, and enhanced Pe amplitude, suggesting greater processing of errors relative to the low social anxiety group. No group differences were observed with respect to feedback processing. Before learning stimulus–response mappings in the negative context, the FRN was larger for self-focus compared to standard trials and marginally larger for socially anxious subjects compared to controls. These findings support cognitive models and suggest avenues for future research.     

Depression screening and treatment among uninsured populations in Primary Care

Uninsured populations have poor treatment engagement and are less likely to receive evidence-based interventions for depression. The objective of the current study was to retrospectively examine depression screening, diagnosis, and treatment patterns among uninsured patients in primary care. Study sample included all patients (N = 11,803) seen in nine community-based clinics. Key variables included depression screener and/or a depression diagnosis, anti-depressant initiation, behavioral health visits, and patient follow up measures. Treatment patterns from the subsample of patients diagnosed with depression were analyzed by collecting the number of behavioral health visits and antidepressant use six months (180 days) following the diagnosis. Utilization of the depression screening tool was high (67%, n = 7,935) and 24% (n = 2,789) of the patients had a diagnosis of depression, however, more than half of the patients with a depression diagnosis did not have a recorded treatment plan (n = 1,474). The odds of anti-depressant use and behavioral visits for Hispanic patients were significantly greater than for Non-Hispanic patients. Universal screening with brief measures in primary care is improving, however, guideline-concordant depression treatment remains elusive for uninsured populations.     

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.     

Cognitive flexibility and response inhibition in patients with Obsessive-Compulsive Disorder and Generalized Anxiety Disorder

Background/ObjectiveThe main aim of this study was to analyze differences in inhibition and cognitive flexibility, taking into account some variables that may influence results (non verbal reasoning, depression, anxiety, intolerance of uncertainty, comorbidity, medication consumption).MethodThe participants were 95 adults aged 17-61 years old (M = 33.48, SD = 11.13), primary (most severe) Generalized Anxiety Disorder or Obsessive-Compulsive Disorder and a healthy control group. Neuropsychological neasures were completed using computerized Wisconsin Card Sorting Test, Stroop Color Word Test and Go/NoGo Task.ResultsClinical groups presented worse results in cognitive flexibility to the control group. The obsessive-compulsive group showed worse scores in flexibility than the generalized anxiety group, once non-verbal reasoning and tolerance to uncertainty were controlled. Comorbidity and medication use did not affect results in the obsessive compulsive group but did however influence the generalized anxiety group.ConclusionsCognitive flexibility could be included treatment in the treatment of obsessive-compulsive disorder and generalized anxiety disorder.     

“To g or not to g?” — Analysis of the dimensional structure of a cognitive abilities’ battery

Over the past century there has been an extensive debate in Psychology over whether intelligence structure is best represented through a single general ability, multiple specific abilities, or a hierarchical structure of abilities. This study aims at contributing to this debate through an analysis of the dimensional structure of a cognitive abilities’ battery aiming to evaluate, in combination, differentiated cognitive processes of increasing complexity (comprehension, reasoning, and problem solving) through items of different contents (verbal, numerical, and spatial). A Portuguese representative sample of 2546 adolescents enrolled in secondary education participated in the study. Confirmatory factor analyses were carried out and the results showed that: (1) the hierarchical model is the only presenting an acceptable fit to the data (RMSEA = .07; CFI = .96; TLI = .92), (2) the existence of specific factors cannot be neglected, and (3) contents of the subtests assume relevance to explain the levels of adolescents’ cognitive performance. These results are discussed taking into account the contribution of school experience for the development and differentiation of adolescents’ cognitive abilities.     

Change in body image and psychological well-being during behavioral obesity treatment: Associations with weight loss and maintenance

This study reports on outcomes from a behavioral obesity treatment program, evaluating if treatment-related changes in body image and psychological well-being are predictors of weight change during treatment and after follow-up. Participants were 142 overweight/obese women (BMI = 30.2 ± 3.7 kg/m²; age = 38.3 ± 5.8 years) participants in a behavioral treatment program consisting of a 4-month treatment period and a 12-month follow-up. Psychosocial variables improved during treatment and these changes were correlated with 4-month weight reduction. Short-term changes in body size dissatisfaction (p = .002) and mood (p = .003) predicted long-term weight loss. Additional results suggest that there might be a predictive role of short-term changes in body size dissatisfaction and self-esteem on long-term weight loss after accounting for initial weight change (p < .028). We conclude that, along with weight changes, cognitive and affect-related processes influenced during obesity treatment may be related long-term success, in some cases independently of initial weight loss.     

A speech and psychological profile of treatment-seeking adolescents who stutter

PurposeThe purpose of this study was to evaluate the relationship between stuttering severity, psychological functioning, and overall impact of stuttering, in a large sample of adolescents who stutter.MethodParticipants were 102 adolescents (11–17 years) seeking speech treatment for stuttering, including 86 boys and 16 girls, classified into younger (11–14 years, n = 57) and older (15–17 years, n = 45) adolescents. Linear regression models were used to evaluate the relationship between speech and psychological variables and overall impact of stuttering.ResultsThe impact of stuttering during adolescence is influenced by a complex interplay of speech and psychological variables. Anxiety and depression scores fell within normal limits. However, higher self-reported stuttering severity predicted higher anxiety and internalizing problems. Boys reported externalizing problems—aggression, rule-breaking—in the clinical range, and girls reported total problems in the borderline-clinical range. Overall, higher scores on measures of anxiety, stuttering severity, and speech dissatisfaction predicted a more negative overall impact of stuttering.ConclusionTo our knowledge, this is the largest cohort study of adolescents who stutter. Higher stuttering severity, speech dissatisfaction, and anxiety predicted a more negative overall impact of stuttering, indicating the importance of carefully managing the speech and psychological needs of adolescents who stutter. Further research is needed to understand the relationship between stuttering and externalizing problems for adolescent boys who stutter.     

A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology

To date, most early intervention programs have been based on emotion regulation strategies that address dysfunctional cognitive appraisals, problem-solving skills, and rumination. Another emotion regulation strategy, ‘acceptance’ training, has largely been overlooked. To examine the efficacy of this strategy, a school-based mental health program combining positive psychology with acceptance and commitment therapy (Strong Minds) was evaluated in a randomized controlled trial with a sample of 267 Year 10 and 11 high-school students in Sydney, Australia. Mixed models for repeated measures examined whether the program led to reductions in symptoms amongst students who commenced the program with high depression, anxiety, and stress scores, and increased wellbeing scores amongst all students. Results demonstrated that compared to controls, participants in the Strong Minds condition with elevated symptom scores (n = 63) reported significant reductions in depression (p = .047), stress (p = .01), and composite depression/anxiety symptoms (p = .02) with medium to strong effect sizes (Cohen's d = 0.53, 0.74, and 0.57, respectively). Increased wellbeing (p = .03) in the total sample and decreased anxiety scores (p = .048) for students with elevated symptoms were significant for Year 10 students with medium effect sizes (Cohen's d = 0.43 and 0.54, respectively). This study tentatively suggests that including the emotion regulation strategy of acceptance in early intervention programs may be effective in reducing symptoms and improving wellbeing in high school students. Further research to investigate the generalizability of these findings is warranted.