Randomised controlled trial of group cognitive behavioural therapy for comorbid anxiety and depression in older adults

Anxiety and depression are commonly comorbid in older adults and are associated with worse physical and mental health outcomes and poorer response to psychological and pharmacological treatments. However, little research has examined the effectiveness of psychological programs to treat comorbid anxiety and depression in older adults. Sixty-two community dwelling adults aged over 60 years with comorbid anxiety and depression were randomly allocated to group cognitive behavioural therapy or a waitlist condition and were assessed immediately following and three months after treatment. After controlling for cognitive ability at pre-treatment, cognitive behaviour therapy resulted in significantly greater reductions, than waitlist, on symptoms of anxiety and depression based on a semi-structured diagnostic interview rated by clinicians unaware of treatment condition. Significant time by treatment interactions were also found for self-report measures of anxiety and depression and these gains were maintained at the three month follow up period. In contrast no significant differences were found between groups on measures of worry and well-being. In conclusion, group cognitive behavioural therapy is efficacious in reducing comorbid anxiety and depression in geriatric populations and gains maintain for at least three months.     

Group cognitive behavioural therapy for heterogeneous anxiety disorders

Evidence assessing the outcome of cognitive behavioural therapy for anxiety is based on protocols specifically tailored for individual disorders. To date, there is little research that would assess a mode of delivery that is designed for routine service delivery in typical clinical settings, i.e. group cognitive behavioural therapy for unselected, mixed groups of anxiety disorders. The objective of this pilot study is to use program evaluation methods to assess the immediate and enduring improvements following a 12-week Anxiety Management Group. Group participants had any of 5 anxiety disorders and described related avoidance. The weekly 2-hour group sessions and daily homework tasks were guided by a participant handbook. Patients completed questionnaires at baseline and group completion (n = 70); a subset also provided 6-month follow-up data. The results from post-group scores on 2 self-report measures show immediate reductions equivalent to an effect size of eta = 0.73 (p < 0.001). The effect is maintained at 6-month follow-up. This program evaluation suggests that group cognitive behavioural therapy for heterogeneous anxiety disorders may be effective in a routine clinical setting. A more rigorous study of this heterogeneous format appears justified.     

Ambulatory group treatment for cocaine dependent patients combining cognitive behavioral therapy and motivational interviewing

Psychological interventions in cocaine dependent patients have demonstrated efficacy. Remarkable approaches are Contingency Management (CM) and Cognitive Behavioral Therapy (CBT). Lack of treatment adherence is the most important limitation. Motivational Interview (MI) has been shown to be an adherence enhancer. The objective of this study is to evaluate retention and abstinence in a combined CM and CBT group treatment in patients who have reached maintenance stage according to Prochaska and DiClemente's transtheoretical model (1982). Therefore, a longitudinal study was carried out with cocaine dependent patients with or without concomitant mental health disease. A 12-session open group was conducted weekly. Nineteen patients were included (78.9% men, mean age 36.6 years), 95% consumed intranasally and 47% had another psychiatric comorbidity. Treatment retention was 84%. During treatment and the first month of follow-up, all patients remained abstinent whereas at three months, 3 patients relapsed. These data confirm that using combined CM and CBT group therapy in cocaine dependents undergoing maintenance treatment enhances adherence and is effective to achieve abstinence.     

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

ABSTRACT

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

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.     

Adherence as a determinant of effectiveness of internet cognitive behavioural therapy for anxiety and depressive disorders

Since 2009, the Clinical Research Unit for Anxiety and Depression (CRUfAD) has been providing primary care clinicians with internet cognitive behaviour therapy (iCBT) courses to prescribe to patients. Although these courses have demonstrated efficacy in research trials, adherence in primary care is less than half that of the research trials. The present studies pose three questions: first, do course non-completers drop out because of lack of efficacy? Second, can changes in delivery (e.g. adding choice, reminders and financial cost) improve adherence? Last, does clinician contact improve adherence? The results showed that non-completers derive benefit before dropping out; that adding reminders, choice of course and timing, and financial cost can significantly improve adherence; and that clinician contact during the course is associated with increased adherence. It is concluded that improved adherence is an important determinant of effectiveness.     

Integrating motivational interviewing in career counseling: A case study

Motivational interviewing (MI) is receiving increasing attention in the field of career counseling. However, none of the previous studies have concretely presented how this method could and why it should be integrated in career counseling. Through the use of a single case study design, this paper illustrates how a brief MI (BMI) intervention can be integrated into career counseling interventions to help resolve career dilemmas. An analysis of the interactions between the client and his counselor using the Motivational Interviewing Skills Code 2.1 illustrates why this method can be useful for career counseling. Immediate and long-term effects of the global career counseling intervention on the client's career decision-making difficulties, as well as the specific impacts of the BMI intervention, are assessed. This case study shows that the BMI approach can be integrated in a career counseling intervention to help career counseling clients overcome career dilemmas and increase their readiness to make career choices.     

Cognitive-behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: A preliminary study

Abstract

Lack of motivation may negatively impact cognitive behavioral therapy (CBT) response for pediatric patients with obsessive–compulsive disorder (OCD). Motivational interviewing is a method for interacting with patients in order to decrease their ambivalence and support their self-efficacy in their efforts at behavior change. The authors present a preliminary randomized trial (N = 16) to evaluate the effectiveness of adding motivational interviewing (MI) as an adjunct to CBT. Patients aged 6 to 17 years who were participating in intensive family-based CBT for OCD were randomized to receive either CBT plus MI or CBT plus extra psychoeducation (PE) sessions. After four sessions, the mean Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score for the CBT plus MI group was significantly lower than for the CBT plus psychoeducation group, t(14) = 2.51, p < .03, Cohen's d = 1.34. In addition, the degree of reduction in CY-BOCS scores was significantly greater, t(14) = 2.14, p = .05, Cohen's d = 1.02, for the CBT plus MI group (mean Δ = 16.75, SD = 9.66) than for the CBT plus psychoeducation group (mean Δ = 8.13, SD = 6.01). This effect decreased over time, and scores at posttreatment were not significantly different. However, participants in the MI group completed treatment on average three sessions earlier than those in the psychoeducation group, providing support for the utility of MI in facilitating rapid improvement and minimizing the burden of treatment for families.     

Individually tailored internet-based cognitive behaviour therapy for older adults with anxiety and depression: a randomised controlled trial

Mixed anxiety and depression is common among older adults. The aim of the study was to compare the effects of an eight-week-long tailored internet-supported cognitive behaviour therapy (ICBT) programme and to compare against the provision of weekly general support. A second aim was to investigate if pre-treatment cognitive flexibility and self-reported cognitive problems would predict outcome. We included 66 older adults (aged over 60 years) with mixed anxiety/depression following media recruitment and randomised them into treatment and control groups. We also included a one-year follow-up. As a measure of executive function, we used the Wisconsin Card Sorting Test (perseverative errors) and the Cognitive Failures Questionnaire during the pre-treatment phase. Results showed a moderate between-group effect on the main outcome measure, the Beck Anxiety Inventory (BAI) (d= .50), favouring the treatment group. Nearly half (45.5%) of that group were classified as responders. One person (3%) in the treatment group deteriorated. There were significant correlations between perseverative errors and outcome (on the BAI r = ?.45), but not among self-reported cognitive function. We conclude that guided, tailored ICBT may be effective for some older adults and that the role of cognitive function needs to be investigated further.     

Stress management: a randomized study of cognitive behavioural therapy and yoga

In this study, a stress management program based on cognitive behavioural therapy principles was compared with a Kundaliniyoga program. A study sample of 26 women and 7 men from a large Swedish company were divided randomly into 2 groups for each of the different forms of intervention; a total of 4 groups. The groups were instructed by trained group leaders and 10 sessions were held with each of groups, over a period of 4 months. Psychological (self-rated stress and stress behaviour, anger, exhaustion, quality of life) and physiological (blood pressure, heart rate, urinary catecholamines, salivary cortisol) measurements obtained before and after treatment showed significant improvements on most of the variables in both groups as well as medium-to-high effect sizes. However, no significant difference was found between the 2 programs. The results indicate that both cognitive behaviour therapy and yoga are promising stress management techniques.     

Dissociating effects of subclinical anxiety and depression on cognitive control

Even at subclinical levels, anxiety and depression are associated with impaired cognitive control. It is unclear, though, to what extent these deficits reflect a common underlying dysfunction. Using a non-affective hybrid masked prime-Simon task, we obtained several measures of within- and between- trial inhibitory behavioral control in 80 young, healthy volunteers, together with measures of their anxiety and depression levels. Neither depression nor anxiety affected low-level within-trial control, or any of the between-trial control measures. However, increased levels of depression, but not of anxiety, were associated with impaired high-level within-trial control (increased Simon effect). Results indicate that depression, but not anxiety, impairs voluntary online response-control mechanisms independent of affective content.     

An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: a modified Delphi study

ABSTRACT

Designing new approaches to delivering cognitive behavioural therapy (CBT) requires an understanding of the key components. This study aimed to establish an expert consensus on the effective components of CBT for depressed adults. An international panel of 120 CBT experts was invited to participate in a modified Delphi study. Thirty-two experts participated in round 1; 21 also provided data in round 2. In round 1, experts rated the effectiveness of 35 content and process components. A priori rules identified components carried forward to round 2, in which experts re-rated items and final consensus items were identified. Consensus was achieved for nine content components (ensuring understanding; developing and maintaining a good therapeutic alliance; explaining the rationale for CBT; eliciting feedback; identifying and challenging avoidant behaviour; activity monitoring; undertaking an initial assessment; relapse prevention methods; homework assignments); and three process components (ensuring therapist competence; scheduling sessions flexibly; scheduling sessions for 45–60 mins). Five of the twelve components identified were generic therapeutic competences rather than specific CBT items. There was less agreement about the effectiveness of cognitive components of CBT. This is an important first step in the development of novel approaches to delivering CBT that may increase access to treatment for patients.     

Attention control: Relationships between self-report and behavioural measures,and symptoms of anxiety and depression

Previous research has demonstrated differences in processing between fear-relevant stimuli, such as snakes and spiders, and non-fear-relevant stimuli. The current research examined whether non-fear-relevant animal stimuli, such as dogs, birds and fish, were processed like fear-relevant stimuli following aversive learning. Pictures of a priori fear-relevant animals, snakes and spiders, were evaluated as negative in affective priming and ratings and were preferentially attended to in a visual search task. Pictures of dogs, birds and fish that had been trained as CS+ in an aversive conditioning design were evaluated more negatively and facilitated dot probe detection relative to CS? pictures. The current studies demonstrated that stimuli viewed as positive prior to aversive learning were negative and were preferentially attended to after a brief learning episode. We propose that aversive learning may provide a mechanism for the acquisition of stimulus fear relevance.     

Ethnicity and the therapeutic relationship: views of young people accessing cognitive behavioural therapy

Few studies have explored the views of black and minority ethnic (BME) adolescents engaging in cognitive behavioural therapy. This study aimed to examine BME adolescent service users' perceptions of how ethnicity featured in the therapeutic relationship and its relevance to their presenting difficulties. Interpretative phenomenological analysis was used to explore the experiences of five young people using an adolescent mental health service. Four interrelated themes emerged from the analysis and are considered in detail. The complexities of participants' views are discussed and recommendations are made for therapists as to how to enquire about, acknowledge and remain attuned to the client's ethnicity.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges’ g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58–1.05, depression: g = .79, 95% CI: .59–1.00) and medium on quality of life (g = .56, 95% CI: .37–.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.     

Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition

There is a need to understand the mechanism through which homework contributes to clinically meaningful change in therapy. Theoretically meaningful factors such as willingness to complete therapeutic assignments and cognitive skill acquisition have not been carefully studied in prior research. Depressed outpatients (N = 46) received cognitive behavioural group therapy for a 10-week period and were assigned relevant homework activities. Patient self-report and independent ratings of homework compliance were obtained on a session-by-session basis. Using path analysis, the authors found evidence that willingness to complete homework assignments and mastery of skill in cognitive restructuring helped account for the relationship between homework compliance and reduced symptom severity (R2 = .40). However, paths were only significant when patient self-report of homework compliance was used in the model. The present study highlights the problems in assessing homework compliance and in assuming that independent assessment of compliance is more accurate than patient self-report.