Integrating technology into cognitive behavior therapy for adolescent depression: a pilot study

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

The internet provides a pervasive milieu for healthcare delivery. The purpose of this study was to determine the effectiveness of a novel web-based cognitive behavioral therapy (CBT) course delivered by an automated virtual therapist, when compared with a credible placebo; an approach required because web products may be intrinsically engaging, and vulnerable to placebo response. Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU). Online community of participants in the UK. One hundred sixty-four adults (120 F: [mean age 49y (18-78y)] meeting proposed DSM-5 criteria for Insomnia Disorder, randomly assigned to CBT (n = 55; 40 F), IRT placebo (n = 55; 42 F) or TAU (n = 54; 38 F). CBT and IRT each comprised 6 online sessions delivered by an animated personal therapist, with automated web and email support. Participants also had access to a video library/back catalogue of session content and Wikipedia style articles. Online CBT users had access to a moderated social network/community of users. TAU comprised no restrictions on usual care and access to an online sleep diary. Major assessments at baseline, post-treatment, and at follow-up 8-weeks post-treatment; outcomes appraised by online sleep diaries and clinical status. On the primary endpoint of sleep efficiency (SE; total time asleep expressed as a percentage of the total time spent in bed), online CBT was associated with sustained improvement at post-treatment (+20%) relative to both TAU (+6%; d = 0.95) and IRT (+6%: d = 1.06), and at 8 weeks (+20%) relative to IRT (+7%: d = 1.00) and TAU (+9%: d = 0.69) These findings were mirrored across a range of sleep diary measures. Clinical benefits of CBT were evidenced by modest superiority over placebo on daytime outcomes (d = 0.23-0.37) and by substantial improved sleep-wake functioning on the Sleep Condition Indicator (range of d = 0.77-1.20). Three-quarters of CBT participants (76% [CBT] vs. 29% [IRT] and 18% [TAU]) completed treatment with SE > 80%, more than half (55% [CBT] vs. 17% [IRT] and 8% [TAU]) with SE > 85%, and over one-third (38% [CBT] vs. 6% [IRT] and 0% [TAU]) with SE > 90%; these improvements were largely maintained during follow-up. CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder. ISRCTN - 44615689.

BackgroundChildren prenatally exposed to maternal depression more often show behavioral and emotional problems compared to unexposed children, possibly through epigenetic alterations. Current evidence is largely based on animal and observational human studies. Therefore, evidence from experimental human studies is needed. In this follow-up of a small randomized controlled trial (RCT), DNA-methylation was compared between children of women who had received cognitive behavioral therapy (CBT) for antenatal depression and children of women who had received treatment as usual (TAU). Originally, 54 women were allocated to CBT or TAU. A beneficial treatment effect was found on women’s mood symptoms.FindingsWe describe DNA methylation findings in buccal swab DNA of the 3–7-year-old children (CBT(N) = 12, TAU(N) = 11), at a genome-wide level at 770,668 CpG sites and at 729 CpG sites spanning 16 a priori selected candidate genes, including the glucocorticoid receptor (NR3C1). We additionally explored associations with women’s baseline depression and anxiety symptoms and offspring DNA methylation, regardless of treatment. Children from the CBT group had overall lower DNA methylation compared to children from the TAU group (mean ∆β = − 0.028, 95% CI − 0.035 to − 0.022). Although 68% of the promoter-associated NR3C1 probes were less methylated in the CBT group, with cg26464411 as top most differentially methylated CpG site (p = 0.038), mean DNA methylation of all NR3C1 promoter-associated probes did not differ significantly between the CBT and TAU groups (mean ∆β = 0.002, 95%CI − 0.010 to 0.011). None of the effects survived correction for multiple testing. There were no differences in mean DNA methylation between the children born to women with more severe depression or anxiety compared to children born to women with mild symptoms of depression or anxiety at baseline (mean ∆β (depression) = 0.0008, 95% CI − 0.007 to 0.008; mean ∆β (anxiety) = 0.0002, 95% CI − 0.004 to 0.005).ConclusionWe found preliminary evidence of a possible effect of CBT during pregnancy on widespread methylation in children’s genomes and a trend toward lower methylation of a CpG site previously shown by others to be linked to depression and child maltreatment. However, none of the effects survived correction for multiple testing and larger studies are warranted.Trial registrationTrial registration of the original RCT: ACTRN12607000397415. Registered on 2 August 2007.

BackgroundWhilst evidence suggests cognitive behaviour therapy (CBT) may be effective for depressed older people in a primary care setting, few studies have examined its cost-effectiveness. The aim of this study was to compare the cost-effectiveness of cognitive behaviour therapy (CBT), a talking control (TC) and treatment as usual (TAU), delivered in a primary care setting, for older people with depression.MethodsCost data generated from a single blind randomised controlled trial of 204 people aged 65 years or more were offered only Treatment as Usual, or TAU plus up to twelve sessions of CBT or a talking control is presented. The Beck Depression Inventory II (BDI-II) was the main outcome measure for depression. Direct treatment costs were compared with reductions in depression scores. Cost-effectiveness analysis was conducted using non-parametric bootstrapping. The primary analysis focussed on the cost-effectiveness of CBT compared with TAU at 10 months follow up.ResultsComplete cost data were available for 198 patients at 4 and 10 month follow up. There were no significant differences between groups in baseline costs. The majority of health service contacts at follow up were made with general practitioners. Fewer contacts with mental health services were recorded in patients allocated to CBT, though these differences were not significant. Overall total per patient costs (including intervention costs) were significantly higher in the CBT group compared with the TAU group at 10 month follow up (difference £427, 95% CI: £56 - £787, p < 0.001). Reductions in BDI-II scores were significantly greater in the CBT group (difference 3.6 points, 95% CI: 0.7-6.5 points, p = 0.018). CBT is associated with an incremental cost of £120 per additional point reduction in BDI score and a 90% probability of being considered cost-effective if purchasers are willing to pay up to £270 per point reduction in the BDI-II score.ConclusionsCBT is significantly more costly than TAU alone or TAU plus TC, but more clinically effective. Based on current estimates, CBT is likely to be recommended as a cost-effective treatment option for this patient group if the value placed on a unit reduction in BDI-II is greater than £115.Trial Registrationisrctn.org Identifier: ISRCTN18271323

Background: Most patients suffering from depression, anxiety and phobias are treated within the primary care setting, although many patients do not seek help or their condition is not recognised by healthcare professionals. Medication is usually the first treatment offered but this is often associated with side-effects. There is substantial evidence to support the use of cognitive behaviour therapy (CBT) in the treatment of these disorders. However, access is limited due to too few therapists, expense, waiting lists, and patients’ reluctance to enter therapy. Computerised cognitive behaviour therapy (CCBT) is a self-help option that offers patients the potential benefits of CBT with less therapist involvement. Objective: The overall aim of the review was to assess the clinical effectiveness of CCBT for treating anxiety, depression and phobias and to compare the cost-effectiveness of CCBT with CBT by conventional methods and with treatment as usual (TAU). Methods: A systematic review of the literature was performed to identify all studies describing trials of CCBT either delivered alone or as part of a package and either via a computer interface or over the telephone with a computer-led response. Databases were searched from 1966 to September 2001. The cost-effectiveness review was divided into two parts: the economic evidence on CCBT was reviewed, and a modelling exercise was undertaken with the aim of estimating the cost per year of providing CCBT and the number of patients that could be treated. An attempt was also made to estimate the effect of CCBT in terms of quality-adjusted life-years (QALYs). Results: Number and quality of studies: Sixteen studies met the inclusion criteria. Of these, 11 were randomised controlled trials (RCTs) and five were pilot studies or cohort studies. The quality of the studies ranged from poor to moderate. An additional three studies were identified that dealt with the use of CCBT as a treatment adjunct for therapist-led CBT (TCBT). Thirteen papers were identified for the cost-effectiveness review although none dealt specifically with CCBT. Four sponsor submissions were used in the cost-effectiveness analysis including Ultrasis (Beating the Blues), Leeds Innovations (Calipso), University of Glasgow (Stresspac) and ST Solutions (FearFighter and Cope). Clinical effectiveness: The results can be summarised as follows. • There is some evidence of poor-to-moderate quality that CCBT is as effective as TCBT in clinically depressed, anxious or phobic outpatient and primary care populations. • There is limited evidence of poor-to-moderate quality that CCBT is more effective than TAU in clinically depressed, anxious or phobic outpatient and primary care populations. • CCBT may be as effective or less effective than bibliotherapy. There is no evidence that CCBT is more effective than bibliotherapy. • In studies reporting accurate estimates of therapist time, CCBT appears to reduce therapist time compared with TCBT and is therefore of use where access to TCBT is limited. • CCBT may form a useful component of a stepped-care programme, being one of the options offered to patients as a first-line treatment approach. • There is evidence to support the effectiveness of Beating the Blues and FearFighter. Cost-effectiveness: No studies performed an economic analysis of CCBT. Therefore the only available economic evidence was provided by the four sponsor submissions. These were critically reviewed and data from them used in a modelling exercise. • CCBT using Stresspac was found to cost more, but was no better in terms of patient outcomes than TAU. • The cost per patient of Cope was less than the corresponding costs for CBT and drug therapy. • CCBT using FearFighter was stated to be less costly than CBT and drug therapy. • There was insufficient data in the Calipso submission to make any judgement regarding the efficiency of Calipso relative to alternative treatment options. • The results of the economic analysis of CCBT using Beating the Blues indicated that compared with TAU, Beating the Blues is a costeffective strategy for treating patients with anxiety and depression. The economic analysis presented in this submission is the most rigorous of all the submissions. Modelling: Under baseline assumptions, the cost in the first year of implementing Beating the Blues with an assistant psychologist is £21,691. If a practice nurse is used, the cost is £25,192. The corresponding costs for Stresspac and FearFighter are £19,902 and £22,574, respectively. Under baseline assumptions, Beating the Blues with an assistant psychologist was estimated to cost £275 million in England and £13 million in Wales. If a practice nurse is used, the corresponding costs were £237 million in England and £11 million in Wales. The costs for Stresspac were estimated to be £206 million in England and £10 million in Wales. In view of the data deficiencies and the large number of assumptions made, all the model estimates should be treated with caution. Cost per QALY: Based on a number of assumptions, one set of data suggest that the incremental cost per QALY gained of Beating the Blues over TAU lies between £1209.68 and £7692.30. If the data from another data set are used, the corresponding range lies between £3000 and £6667 per QALY gained. It should be stated once again, however, that these estimates are crude and should be treated with caution. Conclusions: There is limited evidence of poor-to-moderate quality that CCBT may be effective in the treatment of depression, anxiety and phobias. The evidence for CCBT is uncertain as the studies varied widely in setting, patient populations, comparators and outcome measures. Further research is needed in order to answer the many questions surrounding the design and implementation of CCBT programmes. Recommendations for further research: • Studies are needed to determine the level of therapist involvement needed to produce optimal outcomes for patients using CCBT programmes. • Studies need to be undertaken within the general practice setting. • Efforts should be made to include patients with co-morbidities routinely treated within general practictioner care. • The position of CCBT within a stepped-care programme needs to be identified as well as its relationship to other efforts to increase access to CBT and psychological therapies. • Appropriate comparison groups must be included in studies, such as bibliotherapy and other self-help approaches to treatment that reduce therapist time. Other important research issues include the inclusion of patients from a variety of socioeconomic and ethnic backgrounds, different age groups and both males and females. Co-morbidity and medication need to be taken into account in trial design. Also further research is needed to ensure patients who cannot currently access services because they are housebound may benefit from CCBT. Study design issues include the need for independent researchers, the need for good quality RCTs of adequate power using appropriate comparison groups and well-validated outcome measures. Components of CCBT packages that warrant further research are the type and amount of CBT material to incorporate, length and frequency of sessions, amount of homework and the appropriate software and computer interface necessary for most effective usage. Readability and legibility of CCBT materials must also be taken into account.

Mindfulness training is increasingly being incorporated into traditional cognitive behavioral therapy (CBT) approaches. Although the acquisition and use of both CBT and mindfulness skills have been independently linked with positive therapeutic outcomes, the additional therapeutic benefit provided by mindfulness skills above and beyond traditional CBT skills (e.g., behavioral activation, cognitive reappraisal) is unclear. The present study tested the incremental predictive validity of mindfulness skills above CBT skills in predicting depressive and anxiety symptom improvement within a psychiatric hospital unit incorporating training in both CBT and mindfulness skills. Adult patients (N = 134, mean age = 34.0, 47.8% females, 90.3% White) with depression and anxiety receiving combined psychotherapeutic and pharmacological treatment at a psychiatric hospital completed repeated assessments of CBT skills (Cognitive Behavioral Therapy-Skills Checklist), mindfulness skills (Five Facet Mindfulness Questionnaire), and both depressive (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder Scale-7) symptoms. We tested whether mindfulness skills and/or CBT skills predicted depressive and anxiety symptom improvement. Higher levels of both mindfulness skills (rs = − .15 to − .51) and CBT skills (rs = − .12 to − .21) were cross-sectionally associated with lower depressive and anxiety symptoms. However, while controlling for CBT skills, two mindfulness facets (nonreactivity to inner experience and acting with awareness) predicted subsequent depressive (ts < − 2.49, ps < .014) and anxiety (ts < − 2.31, ps < .022) symptom improvement, thus demonstrating incremental predictive validity. Findings suggest the potential therapeutic benefits of mindfulness skills training for depressed and anxious patients within the context of short-term, intensive psychiatric treatment.

Lowering the cost of assessing clinicians' competence could promote the scalability of evidence-based treatments such as cognitive behavioral therapy (CBT). This study examined the concordance between clinicians', supervisors' and independent observers' session-specific ratings of clinician competence in school-based CBT and treatment as usual (TAU). It also investigated the association between clinician competence and supervisory session observation and rater agreement. Fifty-nine school-based clinicians (90% female, 73% Caucasian) were randomly assigned to implement TAU or modular CBT for youth anxiety. Clinicians rated their confidence after each therapy session (n = 1898), and supervisors rated clinicians' competence after each supervision session (n = 613). Independent observers rated clinicians' competence from audio recordings (n = 395). Patterns of rater discrepancies differed between the TAU and CBT groups. Correlations with independent raters were low across groups. Clinician competence and session observation were associated with higher agreement among TAU, but not CBT, supervisors and clinicians. These results support the gold standard practice of obtaining independent ratings of adherence and competence in implementation contexts. Further development of measures and/or rater training methods for clinicians and supervisors is needed.

Assessing treatment efficacy by examining relationships between age groups of children with autism spectrum disorder and clinical anxiety symptoms: Prediction by correspondence analysis

Purpose – The efficacy of cognitive-behavioural therapy (CBT) for schizophrenia in community and general psychiatric settings has been widely investigated and its practice recommended in primary and secondary care. In secure forensic mental health services the evidence is less established. The purpose of this paper is to evaluate the effectiveness of group CBT for schizophrenia in a high secure hospital. Design/methodology/approach – In all, 27 male forensic patients completed a manualised CBT group and were compared on primary and secondary outcomes to patients receiving treatment as usual (TAU). Primary outcomes were positive and negative symptoms as measured by the Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS) and the Psychotic Symptom Rating Scales (PSYRATS). A secondary outcome was interpersonal functioning as measured by the Inventory of Interpersonal Problems (IIP-64). Findings – CBT participants showed improvement on negative symptoms; affective flattening, alogia, anhedonia and avolition; in comparison to participants in TAU. CBT participants also showed reductions in delusions and hallucinations on the SAPS but not the PSYRATS. TAU participants improved on positive symptoms as measured by the PSYRATS. CBT participants showed reductions in overall interpersonal problems, and most notably in being socially inhibited and self-sacrificing. No iatrogenic effects of treatment were found; improvements in depression anxiety and stress were reported by group completers, which contrasted to experiences of the TAU group. Research limitations/implications – Absence of random allocation to CBP or TAU groups retains the risk of recruitment bias. Findings are preliminary given the sample size. Multiple outcome assessments increase risk of a type I error. Practical implications – CBT for schizophrenia can be effective with clients in secure forensic mental health settings. Improvements in negative symptoms and interpersonal functioning appear to be particular gains. Self-report measures might be subject to specific demand characteristics in such settings. Originality/value – The evaluation includes a comparator group in a high secure setting, which is typically absent in reported evidence for this population (Blackburn, 2004). The study also investigated changes in interpersonal functioning, which has previously been noted as an important but absent outcome in CBT for psychosis (Haddock et al., 2009). Iatrogenic outcomes were also considered in the evaluation to ensure no adverse effects were experienced from treatment.

A prognostic index (PI) as a moderator of outcomes in the treatment of depression: A proof of concept combining multiple variables to inform risk-stratified stepped care models

A Randomized Effectiveness Trial of Brief Cognitive-Behavioral Therapy for Depressed Adolescents Receiving Antidepressant Medication

Cannabis abuse in psychotic patients is associated with rehospitalizations, reduced adherence and increased symptom severity. Previous psychosocial interventions have been ineffective in cannabis use, possibly because of low sample sizes and short interventions. We investigated whether adding CapOpus to treatment as usual (TAU) reduces cannabis use in patients with cannabis use disorder and psychosis. Method A total of 103 patients with psychosis and cannabis use disorder were centrally randomized to 6 months of CapOpus plus TAU (n=52) or TAU (n=51). CapOpus consisted mainly of motivational interviewing and cognitive behaviour therapy (CBT). TAU was targeted primarily at the psychotic disorder. The primary outcome was self-reported days with cannabis use in the preceding month. Pre-randomization cannabis use frequency was 14.9 [95% confidence interval (CI) 12.7-17.1] days/month. Post-treatment, the ratio of days/month with cannabis use in CapOpus versus TAU was 0.76 (95% CI 0.38-1.50) (p=0.42), and 0.80 (95% CI 0.21-3.10) (p=0.75) at the 4-month follow-up. From 46.4 (95% CI 36.4-56.3) monthly joints pre-randomization, consumption fell to 27.3 (95% CI 12.6-41.9) joints in CapOpus and 48.2 (95% CI 31.8-64.6) in TAU (p=0.06). Follow-up amounts were 28.4 (95% CI 13.5-43.2) and 41.6 (95% CI 25.2-58.0) joints (p=0.23). Several subgroup analyses suggested benefits of CapOpus. CapOpus did not reduce the frequency, but possibly the amount, of cannabis use. This is similar to the findings of previous trials in this population. Implementation of CapOpus-type interventions is thus not warranted at present but subgroup analyses call for further trials.

Major depressive disorder has a prevalence between 2% and 8% in children and adolescents and approximately 5-10% of people under 18 years old have subclinical depressive symptoms. Suicidal thoughts are common among youngsters, depression being an important risk factor. The treatment of depression has three stages: acute, continuation and maintenance. In the case of a mild depressive episode, sometimes, an initial period of “watchful waiting”, supportive management or psychosocial treatment can be recommended. Cognitive behavioral therapy, interpersonal therapy or medication can also be recommended. Psychoeducation is necessary in each phase of the treatment, as it is necessary to discuss the causes, symptoms, evolution and various methods of treatment, as well as the side effects with the patient and the family. In the case of a moderate or severe depressive episode, guidelines recommend psychotherapy, monotherapy (a selective serotonin reuptake inhibitor) or combined therapy (fluoxetine and psychotherapy). Fluoxetine is the only substance that proved to have a better efficacy than placebo and it is one of the only substances approved by FDA (Food and Drug Administration) for the treatment of depression in children over 8 years. The TADS study (Treatment for Adolescents with Depression Study) showed that combined treatment (fluoxetine and cognitive behavioral therapy) is superior to monotherapy in the treatment of depression in adolescents. Prevention and a proper evaluation are also necessary in primary care services, being known that children and adolescents easily mask their symptoms.

A Randomized Controlled Pilot Study of a Cognitive-Behavioral Therapy Approach for Painful Diabetic Peripheral Neuropathy

Previous studies in nonclinical samples have shown psychosocial treatments to be efficacious in the treatment of adolescent depression, but few psychotherapy treatment studies have been conducted in clinically referred, depressed adolescents. One hundred seven adolescent patients with DSM-III-R major depressive disorder (MDD) were randomly assigned to 1 of 3 treatments: individual cognitive behavior therapy, systemic behavior family therapy (SBFT), or individual nondirective supportive therapy (NST). Treatments were 12 to 16 sessions provided in as many weeks. Intent-to-treat analyses were conducted using all follow-up data. Of the 107 patients enrolled in the study, 78 (72.9%) completed the study, 4 (3.7%) never initiated treatment, 10 (9.3%) had exclusionary criteria that were undetected at entry, 8 (7.5%) dropped out, and 7 (6.5%) were removed for clinical reasons. Cognitive behavior therapy showed a lower rate of MDD at the end of treatment compared with NST (17.1% vs 42.4%; P = .02), and resulted in a higher rate of remission (64.7%, defined as absence of MDD and at least 3 consecutive Beck Depression Inventory scores < 9) than SBFT (37.9%; P = .03) or NST (39.4%; p = .04). Cognitive behavior therapy resulted in more rapid relief in interviewer-rated (vs both treatments, P = .03) and self-reported depression (vs SBFT, P = .02). All 3 treatments showed significant and similar reductions in suicidality and functional impairment. Parents' views of the credibility of cognitive behavior therapy improved compared with parents' views of both SBFT (P = .01) and NST (P = .05). Cognitive behavior therapy is more efficacious than SBFT or NST for adolescent MDD in clinical settings, resulting in more rapid and complete treatment response.