ABSTRACT Cognitive behavioural therapy (CBT) can effectively treat common mental disorders (CMDs), but access to treatment is insufficient. Guided self-help (GSH) CBT has shown effects comparable to face-to-face CBT and may be a resource-efficient treatment alternative. However, not all patients respond to GSH. Learning more about predictors of outcome may increase knowledge regarding which patients respond to GSH. The aim of this study was to investigate predictors of outcome for GSH CBT for patients with CMDs in primary care. Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia or stress-related disorders were included. All patients received GSH CBT. Outcomes were remission status, reliable change and post-treatment depression ratings. Predictors investigated were clinical, demographic and therapy-related variables. Analyses were conducted using logistic and linear regression. Higher educational level predicted remission, higher quality of life ratings predicted remission and decreased depression, and higher age at onset predicted reliable change. Therapy-related variables, i.e. patient adherence to treatment and patients’ and clinicians’ estimation of treatment response, were all related to outcome. More large-scale studies are needed, but the present study points at the importance of therapy-related variables such as monitoring and supporting treatment adherence for an increased chance of remission.

ABSTRACTExercise is an efficacious intervention for mental and physical health, but few studies have identified the additive benefits of exercise prescriptions for those undergoing empirically supported psychosocial treatment. Behavioral activation (BA) involves completing activities to improve mood, an ideal format for exercise augmentation. The purpose of this study was to examine the credibility and exploratory effect size estimates of augmenting BA with exercise. Thirty-one sedentary, depressed patients were randomized to receive nine sessions of BA+exercise or BA+stretching over 12 weeks. Monthly assessments of depression, quality of life, distress intolerance (DI), perceived stress, and exercise were conducted. Results demonstrated strong credibility and completion rates of BA+exercise, comparable to other PA interventions. Randomization did not contribute to differential exercise between conditions; all participants engaged in more exercise over time. Similarly, all participants significantly improved on all outcomes over time. Condition differences emerged for DI and perceived stress; the exercise condition evidenced greater improvements over time. Participants who engaged in more exercise also evidenced greater and faster declines in depression. BA may be a useful strategy for improving depression and increasing exercise. Additional explicit exercise prescriptions may not be necessary to improve depression but may be helpful for DI and stress. Clinical Trials Registry (clinicaltrials.gov): NCT02176408, “Efficacy of Adjunctive Exercise for the Behavioral Treatment of Major Depression”.

ABSTRACT The current systematic review and meta-analysis examined the efficacy and effectiveness of internet-delivered cognitive behavioral therapy (iCBT) on panic disorder and agoraphobia symptom severity. Twenty-seven studies were identified. Results from nine randomised controlled trials (RCTs) showed that iCBT outperformed waiting list and information controls for panic (g = 1.22) and agoraphobia (g = .91) symptoms, but the quality of RCTs varied and heterogeneity was high. Results from three RCTs suggested iCBT may have similar outcomes to face-to-face CBT in reducing panic and agoraphobia symptoms. Within-group effect sizes between baseline and post-treatment were large for panic (n = 29, g = 1.16) and medium for agoraphobia symptom severity (n = 18, g = .73). Subgroup analyses of within-group pre/post treatment effect sizes showed larger within-group effect sizes for efficacy studies (n = 15) compared to effectiveness studies (n = 14) for panic severity (g = 1.38 vs. g = .98) but not agoraphobia severity. There was no impact of program length, inclusion or arousal reduction techniques, or degree of clinician support. Within-group effects of iCBT suggest the reduction in panic and agoraphobia symptom severity is maintained at 3–6 month follow-up (n = 12).

ABSTRACTPatient behaviors that may interfere with the process and outcome of therapy have been examined in the context of dialectical behavior therapy, but no measures exist to systematically characterize patient (or caregiver) treatment interfering behaviors (TIBs) in cognitive behavioral therapy (CBT) for anxiety disorders and obsessive-compulsive disorder (OCD). Accordingly, the primary aims of this study were to develop preliminary measures of TIBs, asking clinicians who provide CBT for anxiety disorders and/or OCD to adults and/or children to retrospectively reflect on the presence of TIBs in a recent patient (or caregiver of a child patient). These measures assessed the presence of 27 adult patient and 34 caregiver behaviors that may have interfered with treatment. Clinicians were also asked to rate their perception of treatment outcome (i.e. patient symptom improvement). Clinicians’ ratings of overall interference with treatment were correlated with their perception of improvement, such that more treatment interference was associated with less symptom reduction. Interference with exposure completion, the process of therapy sessions, and attendance to therapy sessions emerged as potentially important behaviors to assess for in anxiety disorder/OCD treatment. Implications and directions for future research are discussed.

ABSTRACTInitial evidence suggests that experiential avoidance (EA) mediates the relation between anxiety sensitivity (AS) and depression. We examined the AS-EA-depression pathway, examining both concurrent, and prospective (cross-lag), mediation models. Utilizing data from a study that examined the effects of exercise on AS (N = 60), we modeled depressive symptoms, EA, and AS over four time points. Time-varying predictors were disaggregated into between-subjects (each person’s mean level of the predictor) and within-subjects change (each person’s deviations, at each time point, from their mean level on the predictor) components. Tests of the concurrent relations were partially consistent with predictions, with mean EA levels, but not within-subjects changes in EA, partially mediating the relation between AS and depression symptom severity. However, the prospective, cross-lag mediation model, in which AS predicted future EA controlling for previous EA, and EA predicted future depression, controlling for previous depression, yielded no significant effects. These results suggest that observed between-subjects mediation findings, found here and in previous studies, may not replicate using more stringent, quasi-causal, cross-lag mediation analyses. These results highlight the importance of estimating causal pathways in mediation analyses. Clinical implications and directions for future research are discussed.

ABSTRACTThis study provides a preliminary exploration of factors which differentially predict treatment response to telephone-delivered cognitive behavioural therapy (TCBT) compared to face-to-face CBT (CBT) in a randomised non-inferiority controlled trial of 72 children (aged 11–18 years) with obsessive–compulsive disorder (OCD). Potential moderator variables, their interaction with treatment group (CBT, TCBT) and baseline levels of OCD severity were entered into separate regression models where the primary outcome measure was the post-intervention Children’s Yale–Brown Obsessive–Compulsive Scale total score (CYBOCS). Separate regressions were also used to test associations between predictors and outcome controlling for pretreatment CYBOCS. Only pretreatment level of parent-rated child peer problems moderated the effects of the two interventions on CYBOCS severity at post-treatment. After controlling for baseline CYBOCS, only family accommodation rated by mothers predicted poorer outcomes in both groups. While CBT and TCBT may be equally effective for adolescents with OCD, the current results tentatively suggest that higher baseline level of peer problems strengthened the response to therapy for youth receiving TCBT and the predictor analyses reinforce the importance of directly addressing family accommodation during CBT for paediatric OCD regardless of delivery mode. Limitations of the current findings and directions for future work are discussed.

ABSTRACTMobile apps are promising for teaching how to practice psychological skills in high-risk and in vivo momentary situations, but there has been minimal research on the immediate effects of app-based skill coaching on mental health in-the-moment. This study analyzed the mobile app data in a non-clinical sample of 39 adults participating in a larger randomized controlled trial, with participants randomized to an acceptance and commitment therapy (ACT) mobile app that tailors skill coaching based on in-the-moment variables (n = 17) or an app that provides randomly selected skill coaching (n = 22). Data were collected before and after each ACT skill coaching session on proximal outcome (depression, anxiety, and engagement in meaningful activity) and ACT process variables. Multilevel models indicated significant immediate improvements on average following ACT skill coaching sessions on all proximal outcome and ACT process variables, although with relatively small effects ranging between 0.17 and 0.27 SD units change. Larger immediate pre-to-post effects from ACT coaching sessions were found for anxiety, experiential avoidance, and cognitive fusion in the tailored app versus random app condition. Overall, results suggest that an ACT app can have immediate, in-the-moment effects on psychological functioning, which may be enhanced by tailoring skills to current context.

ABSTRACTMeta-analyses suggest that exposure with response prevention (ERP) is the most efficacious treatment for obsessive–compulsive disorder (OCD) and treatment guidelines for the disorder accordingly recommend ERP. Despite this, many therapists, including those with a cognitive-behavioral therapeutic background, do not perform ERP in patients with OCD. The present study aimed to elucidate the reasons why. German therapists (N = 216) completed an anonymous online survey, the newly developed Reasons for Not Performing Exposure in OCD Scale (REPEX), that inquired whether, to what extent, and how they perform ERP in the treatment of OCD. We also asked their reasons for not applying ERP in the past. Most therapists considered ERP an efficient treatment for OCD. Marked differences emerged between physicians and psychologists, however. The former used exposure less often and for a shorter period, preferred in sensu to in vivo exposure, and conducted exposure less often in the personal environment of the patient than did psychologists. Both groups were familiar with clinical guidelines to a similar extent. A factor analysis of the REPEX scale revealed five factors. Patient lack of motivation, preference for exposure to be self-help as well as alleged organizational difficulties were endorsed most often. The latter was correlated with the age of the therapist and was far more often affirmed by physicians. Fear of side effects was named by a subgroup of clinicians; in the context of patient ambivalence, this may foster “phobie à deux”. Unlike prior research, lack of expertise was rarely identified as a reason not to use ERP. Recommendations for improving adherence to guidelines are discussed.

The present study examined sudden gains (SGs; large symptom improvements between adjacent treatment sessions) and its association with treatment outcome in a randomized-controlled trial comparing cognitive-behavioral group therapy (CBGT) versus group psychotherapy (GPT; designed to incorporate only non-specific factors) for social anxiety disorder (SAD). SAD symptoms were assessed after each treatment session in a sample of 45 college students. Independent assessors evaluated symptom severity at baseline, post-treatment and follow-up. A total of 10 (22.2%) participants experienced SGs during treatment. No differences were found in symptom improvement at post-treatment or follow-up between individuals with and without SGs. SGs appeared at similar rates across both treatments but were associated with greater improvements at post-treatment and follow-up in GPT compared to CBGT. Majority of SGs in CBGT occurred early in treatment before the provision of specific treatment techniques. These results suggest that non-specific treatment factors may be important in promoting SGs.

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, Mage = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.