Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial

Cognitive–behavioural therapy (CBT) is an effective treatment for clinical and subclinical symptoms of depression and general anxiety, and increases life satisfaction. Patients’ usage of CBT skills is a core aspect of treatment but there is insufficient empirical evidence suggesting that skills usage behaviours are a mechanism of clinical change. This study investigated if an internet-delivered CBT (iCBT) intervention increased the frequency of CBT skills usage behaviours and if this statistically mediated reductions in symptoms and increased life satisfaction. A two-group randomised controlled trial was conducted comparing internet-delivered CBT (n = 65) with a waitlist control group (n = 75). Participants were individuals experiencing clinically significant symptoms of depression or general anxiety. Mixed-linear models analyses revealed that the treatment group reported a significantly higher frequency of skills usage, lower symptoms, and higher life satisfaction by the end of treatment compared with the control group. Results from bootstrapping mediation analyses revealed that the increased skills usage behaviours statistically mediated symptom reductions and increased life satisfaction. Although skills usage and symptom outcomes were assessed concurrently, these findings support the notion that iCBT increases the frequency of skills usage behaviours and suggest that this may be an important mechanism of change.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

Dysfunctional beliefs in panic disorder: The Panic Belief Inventory

The Panic Belief Inventory (PBI) was developed to assess beliefs that increase the likelihood of catastrophic reactions to physical and emotional experiences in panic disorder. In the first stage of scale development, 197 panic disorder patients completed the PBI and standard self-report inventories of psychiatric symptomatology. An exploratory factor analysis yielded a 4-factor solution from which a 35-item instrument with 4 scales was constructed. The shortened measure and its scales had good internal consistency and convergent validity and moderate discriminant validity. Subsequently, 22 panic disorder patients who received cognitive therapy completed the PBI and other self-report inventories of dysfunctional cognitions at intake, 4 weeks, 8 weeks, termination, and several follow-up intervals. Results indicated that the PBI decreased significantly across treatment, with the largest decline occurring between intake and 4 weeks into treatment. The PBI correlated more strongly with dysfunctional cognitions associated with anxiety than dysfunctional cognitions associated with depression. These results provide preliminary evidence that the PBI has adequate psychometric characteristics, is useful to assess change in dysfunctional beliefs during treatment, and has the potential to advance cognitive theories of panic.     

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

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

Effects of cognitive-behavioural therapy on anxiety,depression and condom use in people with HIV in Mexico City: a pilot study

Anxiety and depression in people living with HIV (PLWH) are negatively associated with healthy sexual behaviours. We pilot-tested a Cognitive-Behavioural Therapy (CBT)-based intervention to reduce anxiety and depression, aimed to increase serostatus disclosure to sexual partners, quality of sexual life (QoSL) and condom use. The study had a single-case experimental design (AB) with follow-up measures. Eleven PLWH with moderate/severe anxiety/depression received six-module CBT intervention delivered in ten one-hour individual weekly sessions. Anxiety, depression, consistent/correct condom use and QoSL were measured. Depression and anxiety decreased after the intervention (depression baseline [BL] Mdn = 21, final [F] Mdn = 3, z = -2.934, p = .003; anxiety BL Mdn = 30, F Mdn = 4, z = -2.941, p = .003). QoSL improved (BL Mdn = 28, F Mdn = 13, z = -2.625, p = .009), along with participants’ ability to use condoms (57.14 vs.100, z = -2.937, p = .003). Effect size was large, changes were maintained at follow-up measurements. The CBT intervention had positive effects in reducing anxiety and depression, which could facilitate the acquisition of healthy sexual behaviours. Further studies are important to clarify the benefits of targeting emotional variables to improve wellbeing and prevention behaviours in PLWH.     

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.     

The Nature of the Association between Anxiety Sensitivity and Pain-Related Anxiety: Evidence from Correlational and Intervention Studies

High anxiety sensitivity (AS) has been associated with elevated pain-related anxiety in anxiety and pain samples. The present study investigated (a) the associations among the lower order dimensions of AS and pain-related anxiety, using a robust measure of AS, and (b) the pain-related anxiety outcomes of a telephone-delivered cognitive behavioural treatment (CBT) designed to reduce high AS. Participants were 80 anxiety treatment-seeking participants with high AS (M age = 36 years; 79% women). After providing baseline data on AS and pain-related anxiety, participants were randomly assigned to an eight-week telephone CBT or a waiting list control. At baseline, bivariate correlations showed AS physical and cognitive, but not social, concerns were significantly associated with pain-related fear and arousal but not escape/avoidance behaviours. Multiple regression revealed that after accounting for emotional distress symptoms, AS physical, but not cognitive or social, concerns uniquely predicted pain-related anxiety. Multilevel modelling showed that the AS-targeted CBT reduced pain-related anxiety and treatment-related changes in global AS and AS physical concerns mediated changes in pain-related anxiety. Results suggest that an AS-targeted intervention may have implications for reducing pain-related anxiety. Further research is needed in a chronic pain sample.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Daytime functioning in older patients suffering from chronic insomnia: treatment outcome in a randomized controlled trial comparing CBT with Zopiclone

The paper presents data from a randomized controlled trial comparing treatment effects of cognitive behavioural therapy (CBT), hypnotic treatment (Zopiclone), and placebo in a sample of insomnia patients. Data from the same trial have already demonstrated that CBT was more efficient in improving sleep than Zopiclone. The novel outcomes that are reported here concern daytime functioning.

Forty-six older patients (age55) qualifying for a diagnosis of primary insomnia were recruited to participate. Assessments were completed at baseline, post-treatment, and at a 6-months follow-up, and measures of worry, anxiety, depression, interpersonal relationships, subjective alertness, vigilance, and quality of life were used.

The participants in both treatment conditions scored within the normal range on the outcome measures at baseline with the exception of reporting less alertness, relative to a group of good sleepers. One interaction effect indicated that subjective alertness improved more in the Zopiclone group than the CBT group from baseline to post-treatment, and another that CBT was more effective than Zopiclone in reducing trait anxiety from baseline to follow-up.

It was concluded that the treatments yielded only minor effects on the measures of daytime functioning, and that none of them was clearly superior to the other.     

Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.     

Exposure-based cognitive behavior therapy for atopic dermatitis: an open trial

Atopic dermatitis (AD) is a common and debilitating inflammatory dermatological disorder and is marked by itch and inflamed skin. Scratching, sleep loss, and avoidance of situations associated with more AD symptoms are central hypothesized mechanisms that perpetuate the disorder and cause reduced quality of life. We developed an exposure-based cognitive behavioral treatment (CBT) that entailed mindfulness practice as a means to increase tolerance for aversive experiences during exposure. The aim of the present study was to test the treatment’s acceptability and preliminary efficacy in adults with AD. We used an uncontrolled pretest-posttest design and recruited participants (N = 9) from a university hospital dermatological clinic. The treatment comprised 10 weekly sessions over 10 weeks and assessments of AD symptoms as well as psychiatric symptoms and quality of life were conducted at baseline, posttreatment and 6-month follow-up. The results showed significant and large baseline to posttreatment improvements on self-reported measures of AD symptoms (p = .020) and general anxiety (p = .005), but there was no significant improvement in depression or quality of life. Treatment satisfaction was high and a majority of participants (67%) completed the treatment. We conclude that exposure-based CBT for adult AD can be feasible, acceptable, and potentially efficacious.     

Effects of cancer rehabilitation on problem-solving, anxiety and depression: a RCT comparing physical and cognitive-behavioural training versus physical training

We tested the effects on problem-solving, anxiety and depression of 12-week group-based self-management cancer rehabilitation, combining comprehensive physical training (PT) and cognitive-behavioural problem-solving training (CBT), compared with PT. We expected that PT + CBT would outperform PT in improvements in problem-solving (Social Problem-Solving Inventory-Revised (SPSI-R)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), and that more anxious and/or depressed participants would benefit most from adding CBT to PT. Cancer survivors (aged 48.8 ± 10.9 years, all cancer types, medical treatment completed) were randomly assigned to PT + CBT (n = 76) or PT (n = 71). Measurement occasions were: before and post-rehabilitation (12 weeks), 3- and 9-month follow-up. A non-randomised usual care comparison group (UCC) (n = 62) was measured at baseline and after 12 weeks. Longitudinal intention-to-treat analyses showed no differential pattern in change between PT + CBT and PT. Post-rehabilitation, participants in PT and PT + CBT reported within-group improvements in problem-solving (negative problem orientation; p < 0.01), anxiety (p < 0.001) and depression (p < 0.001), which were maintained at 3- and 9-month follow-up (p < 0.05). Compared with UCC post-rehabilitation, PT and PT + CBT only improved in anxiety (p < 0.05). CBT did not add to the effects of PT and had no extra benefits for higher distressed participants. PT was feasible and sufficient for durably reducing cancer survivors' anxiety.     

Irrational Beliefs and Self-Management as Separable Predictors of Anxiety and Depression

Irrational beliefs and self-management are both cognitive-behavioral constructs that are integral in modern Rational-Emotive Behavior Therapy and Self-Management Therapy, respectively. Both irrational beliefs and self-management have been linked to anxiety and depression, and there is evidence for their usefulness for these types of distress. This is the first study to consider irrational beliefs and self-management as simultaneous predictors of anxiety and depression. An outpatient clinical sample (n = 51) completed measures of irrational beliefs, self-management, and emotional symptoms. Results indicated that as simultaneous predictors of fear and worry, self-management did not account for any additional variance accounted for by irrational beliefs. However, both irrational beliefs and self-management predicted unique variance in depression, negative affect, and positive affect. Exploratory analyses with single diagnosis (n = 26) and multiple diagnoses (n = 25) subsamples provided some divergent results. These results are discussed in terms of case conceptualization and potential future applications in the treatment of affective disorders, in particular depression.     

Emotion Regulation Strategies in Cognitive Behavioral Therapy for Panic Disorder

Emotion regulation (ER) has been incorporated into many models of psychopathology, but it has not been examined directly in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/A). In this study, a preliminary model of ER in CBT for PD/A is proposed based on existing theories, and several propositions of the model are tested. We hypothesized that increases in cognitive reappraisal would precede decreases in biased cognitions, decreases in expressive suppression would follow decreases in biased cognitions, and a reduction in symptom severity would follow decreases in expressive suppression. Twenty-nine patients who received CBT for PD/A completed weekly self-report measures of symptom severity, anxiety sensitivity, reappraisal and expressive suppression. In addition, patients were compared to a matched normal sample. Cross-lagged analyses partially supported the hypotheses. Reappraisal did not change until late stages of therapy and was generally not associated with treatment outcome. Suppression decreased significantly and exhibited a reciprocal relationship with biased cognitions. Symptom reduction followed decreases in suppression as hypothesized. However, patients did not differ in ER from matched controls at either pre- or posttreatment. Results suggest the important distinction between reappraisal and appraisal, and stress the role of session-by-session decreases in suppression as a predictor of symptom reduction.     

Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: a pilot study

Exposure therapy and cognitive behaviour therapy (CBT) are both effective in the treatment of panic disorder with agoraphobia. Cognitive theories suggest that the way in which exposure to avoided situations is implemented in either treatment may be crucial. In particular, it is suggested that clinical improvement will be greatest if opportunities for disconfirmation of feared catastrophes are maximized. In a small pilot study, 16 patients with panic disorder and (moderate or severe) agoraphobia were randomly allocated to either habituation based exposure therapy (HBET) or exposure planned as a belief disconfirmation strategy and accompanied by dropping of safety-seeking behaviours. Both treatments were brief (total of 3.25 h of exposure) and were similar in terms of expectancy of change. Patients in the CBT condition showed significantly greater improvements in self-report measures of anxiety, panic and situational avoidance. They also completed significantly more steps in a standardized behavioural walk, during which they experienced significantly less anxiety. The controlled effect sizes for CBT were substantial (range 1.7-2.7), which suggests it may be a particularly efficient way of managing therapeutic exposure to feared situations in panic disorder with agoraphobia. Further research is needed to clarify the mechanism of change involved.     

Religious versus Conventional Internet-based Cognitive Behavioral Therapy for Depression

The accessibility and efficacy of two Internet-supported interventions for depression: conventional cognitive behavioral therapy (C-CBT) and religious CBT (R-CBT) were investigated. Depressed participants (N = 79) were randomly assigned to either active treatment or wait-listed control group. Self-report measures of depression, anxiety, and life quality were collected before, immediately after, and 6 months after the intervention. Significant differences among the three conditions emerged at post-intervention with medium to large effect sizes (Cohen’s d between 0.45 and 1.89), but no differences between the R-CBT and C-CBT were found. However, the addition of religious components to CBT contributed to the initial treatment appeal for religious participants, thus increasing the treatment accessibility.     

Treating Youth Depression and Anxiety: A Randomised Controlled Trial Examining the Efficacy of Computerised versus Face‐to‐face Cognitive Behaviour Therapy

Barriers to accessing psychologists for the treatment of depression and anxiety include a shortage of specialised therapists, long waiting lists, and the affordability of therapy. This study examined the efficacy of a computerised‐based self‐help program (MoodGYM) delivered in‐conjunction with face‐to‐face cognitive behavioural therapy (CBT) to expand the delivery avenues of psychological treatment for young adults (aged 18–25 years). Eighty‐nine participants suffering from depression and/or generalised anxiety were randomly allocated to a control intervention or to one of three experimental groups: receiving face‐to‐face CBT, receiving computerised CBT (cCBT), or receiving treatment in‐conjunction (face‐to‐face CBT and cCBT). While MoodGYM did not significantly decrease depression in comparison to the control group, significant decreases were found for anxiety. MoodGYM delivered in‐conjunction with face‐to‐face CBT is more effective in treating symptoms of depression and anxiety compared with standalone face‐to‐face or cCBT. This study suggests that for youth who are unable to access face‐to‐face therapy—such as those in rural or remote regions, or for communities in which there is stigma attached to seeking help—computerised therapy may be a viable option. This is an important finding, especially in light of the current capacity‐to‐treat and accessibility problems faced by youth when seeking treatment for depression and/or anxiety.     

Challenging the omnipotence of voices: group cognitive behavior therapy for voices

The present study examines the impact of group based cognitive behavior therapy (CBT) for drug resistant auditory hallucinations, or voices. In particular it assesses treatment effect on beliefs in a voice's omnipotence and control. Twenty-two participants entered one of five 8-session CBT groups. Measures of omnipotence, control, process measures, and symptoms of anxiety and depression were completed at assessment, and first and last group sessions. The groups achieved a significant reduction in conviction in beliefs about omnipotence (df 2, P = 0.002) and control (df 2, P = 0.001). There were no affective changes. Certain participants showed important spontaneous changes in behavior. Process measures suggested that participants valued the groups and benefited from them. These results are promising and the treatment may prove a useful addition to existing psychological interventions.     

Reward-related brain function as a predictor of treatment response in adolescents with major depressive disorder

The present study provides preliminary evidence that pretreatment reward-related brain function in the striatum and medial prefrontal cortex (PFC) could have relevance for predicting both final level and rate of change of clinical characteristics in adolescents with major depressive disorder. Adolescents with depression underwent a functional MRI scan during a monetary reward task, participated in an 8-week open trial of cognitive behavioral therapy (CBT) or CBT plus selective serotonin reuptake inhibitor, and completed reports of anxiety and depressive symptoms before, during, and after treatment. Clinicians rated adolescents’ improvement and severity at the same time points. Growth models were used to examine change in clinical characteristics and its association with brain function. Severity, anxiety symptoms, and depressive symptoms decreased over treatment. Final levels of severity and anxiety symptoms were associated with pretreatment striatal reactivity, and rate of anxiety symptom reduction was associated with greater striatal reactivity and lower medial PFC reactivity.     

The Children's Automatic Thoughts Scale in a clinical sample: psychometric properties and clinical utility

The aim of this study was to examine the psychometric properties and clinical utility of the Children's Automatic Thoughts Scale (CATS; Schniering, C. A., & Rapee, R. M. (2002). Development and validation of a measure of children's automatic thoughts: The Children's Automatic Thoughts Scale. Behaviour Research and Therapy, 40, 1091-1109) in a large sample of anxious youth. The participants were 891 referred children and adolescents. Participants completed the CATS and a wide range of symptom measures, and were assessed via a structured diagnostic interview. Previous community-based psychometric properties were confirmed. The scale was highly sensitive to treatment change, and showed evidence of cognitive specificity with reductions in threat and failure beliefs, but not in hostility beliefs following treatment. The CATS demonstrated good convergent validity with related anxiety and depression scales, and moderate discriminant validity was found across anxious, anxious-depressed and anxious-oppositional groups. Implications for the assessment of child anxiety, and difficulties around children "faking good" on anxiety measures are discussed.