Three ways to change your mind: an epistemic framework for cognitive interventions.

Belief change is an important element of much CBT, yet very little consideration has been given to the theories of knowledge, the epistemology, which underlie this process. This article argues that understanding the epistemic basis of the techniques therapists use can help guide their choice of interventions. The empirical evidence for cognitive restructuring is considered, the importance of distancing and decentring noted, and three epistemic styles are identified: the rational-empiricist, pragmatist and 'constructivist' approaches. Different schools of CBT emphasise one or more of these. The article describes how these epistemes can be used to make decisions about which cognitive interventions to use, particularly when clients may be sceptical about reality testing because of entrenched beliefs or real-life adversity.

Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial.

BACKGROUND: Depression is one of the most common mental disorders in people with advanced cancer. Although cognitive-behavioural therapy (CBT) has been shown to be effective for depression in people with cancer, it is unclear whether this is the case for people with advanced cancer and depression. AIMS: We sought to determine whether CBT is more clinically effective than treatment as usual (TAU) for treating depression in people with advanced cancer (trial registration number ISRCTN07622709). METHOD: A multi-centre, parallel-group single-blind randomised controlled trial comparing TAU with CBT (plus TAU). Participants (n = 230) with advanced cancer and depression were randomly allocated to (a) up to 12 sessions of individual CBT or (b) TAU. The primary outcome measure was the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Patient Health Questionnaire-9, the Eastern Cooperative Oncology Group Performance Status, and Satisfaction with Care. RESULTS: Multilevel modelling, including complier-average intention-to-treat analysis, found no benefit of CBT. CBT delivery was proficient, but there was no treatment effect (-0.84, 95% CI -2.76 to 1.08) or effects for secondary measures. Exploratory subgroup analysis suggested an effect of CBT on the BDI-II in those widowed, divorced or separated (-7.21, 95% CI -11.15 to -3.28). CONCLUSIONS: UK National Institute for Health and Care Excellence (NICE) guidelines recommend CBT for treating depression. Delivery of CBT through the Improving Access to Psychological Therapies (IAPT) programme has been advocated for long-term conditions such as cancer. Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective. CBT for people widowed, divorced or separated needs further exploration. Alternate models of CBT delivery may yield different results.

I've had a good life, what's left is a bonus: factor analysis of the Mental Adjustment to Cancer Scale in a palliative care population.

BACKGROUND: The Mental Adjustment to Cancer Scale is an assessment tool commonly used to measure coping in cancer patients, which characterises adaptive coping under the label of 'fighting spirit'. AIM: This study explores adaptation in patients with advanced cancer, by examining the factor structure of the Mental Adjustment to Cancer Scale. Further aims were to examine associations between types of coping and psychological outcomes measured at the same time (time 1) and 4 weeks after referral to palliative care services (time 2). DESIGN: A cross-sectional study with a follow-up assessment 4 weeks later. Factor analysis examined the structure of the Mental Adjustment to Cancer Scale at time 1. SETTING/PARTICIPANTS: A total of 275 patients with advanced cancer receiving palliative care, of whom 193 took part at follow-up. RESULTS: This study provided evidence for the internal consistency and validity of a new scale of 'acceptance and positivity' for use in advanced cancer patients. Patients with a desire for hastened death had lower acceptance and positivity, and patients with higher global quality of life reported a higher level. Social support was positively associated with acceptance and positivity. Higher scores on the acceptance and positivity scale were associated with reduced odds of a desire for hastened death at time 2. CONCLUSION: Adaptation to advanced cancer differs from adaptation to early stage cancer, comprising a general acceptance of the illness and trying to make the most of the time that is left. Individuals with low social support were less likely to evidence appropriate adaptation to their illness.

'I know they are distressed. What do I do now?'.

Significant advances have been made in our understanding of psychological adjustment to cancer over the last 40 years. Most clinicians now recognise the importance of psychosocial factors and the need for skills in emotional support. In the first phase of psycho-oncology, pioneering work in the 1970s and 1980s mapped the extent of psychological morbidity in cancer. This has been followed by a second phase where clinical trials have demonstrated that psychological treatments are effective. But although clinicians may feel more confident in identifying distress and listening to the patient, they rarely feel confident that they possess the skills to help. This paper will review the progress through the first two phases and argue that we are now in the third phase where we can begin to examine methods for delivering cost-effective psychological care. One of these methods is to equip staff with basic skills to understand and manage psychological distress. This paper will also describe a programme over the last 10 years to evaluate the effectiveness and clinical impact of such training for palliative care professionals.

Outlook and adaptation in advanced cancer: a systematic review.

'Fighting spirit' in early-stage cancer comprises optimism about prognosis, a belief that the disease and/or its effects are controllable, and a determination to cope with the situation using various active coping methods. It is associated with better adjustment. In advanced cancer, the usefulness of this coping style is contentious. This systematic review identified eight studies that investigated these qualities in advanced cancer. They provided some evidence that positive attitude and self-efficacy may be associated with better emotional adjustment; active, problem-focused coping appears to be adaptive and avoidant coping maladaptive. However, major methodological flaws make any conclusions highly speculative. Further research in this area using larger samples and longitudinal design is required.

The six cycles maintenance model: Growing a "vicious flower" for depression.

BACKGROUND: Cognitive behavioural models of anxiety disorders often include visual representations of feedback loops that maintain the disorder. Cognitive therapy for depression is the prototype for therapy for many other disorders, and there is now good evidence for factors that maintain depression, yet there is still no accepted diagrammatic form of the maintenance model. AIMS: To develop a simple, clinically acceptable and empirically based version of the "vicious flower" for depression. METHOD: Current theoretical developments in depression (Differential activation and Beck's concept of modes) and empirical findings on maintenance factors were reviewed. A model was developed based on clinical utility and current knowledge of the processes and maintenance factors in depression. This model was tested for its usefulness with a small sample of IAPT trainees. RESULTS: The model contained 6 cycles comprising 2 cognitive cycles (automatic negative thinking and rumination/self-attacking), 2 behavioural cycles (withdrawal/avoidance and unhelpful behaviour), a mood/emotion cycle, and a motivation/physical symptoms cycle. Students found it a very useful tool for understanding maintenance factors. CONCLUSIONS: This diagrammatic maintenance model of depression, like similar "vicious flowers" for anxiety, may be helpful in conceptualization, socialization and treatment planning as well as teaching CBT.

Can we really teach cognitive behavioral therapy with a massive open online course?

A better training in psychotherapy is needed for psychiatry trainees. Online Cognitive Behavioural Therapies (CBT) could be a good solution. Free and wide audience course like Massive Open Online course (MOOCs) increase dissemination and accessibility of the training. However, the engagement needs to be improved. A hybrid approach seems relevant with the MOOC as an incentive. Beyond the promotion of the topic, a MOOC can be a promotion tool for the provider. The economic model of the MOOC needed to be taken into account to allow sustainability. To explore these elements, we take into account a survey taken during the 1st European Psychiatric Association MOOC about CBT.

Manualised cognitive-behavioural therapy in treating depression in advanced cancer: the CanTalk RCT.

BACKGROUND: With a prevalence of up to 16.5%, depression is one of the commonest mental disorders in people with advanced cancer. Depression reduces the quality of life (QoL) of patients and those close to them. The National Institute for Health and Care Excellence (NICE) guidelines recommend treating depression using antidepressants and/or psychological treatments, such as cognitive-behavioural therapy (CBT). Although CBT has been shown to be effective for people with cancer, it is unclear whether or not this is the case for people with advanced cancer and depression. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of treatment as usual (TAU) plus manualised CBT, delivered by high-level Improving Access to Psychological Therapy (IAPT) practitioners, versus TAU for people with advanced cancer and depression, measured at baseline, 6, 12, 18 and 24 weeks. DESIGN: Parallel-group, single-blind, randomised trial, stratified by whether or not an antidepressant was prescribed, comparing TAU with CBT plus TAU. SETTING: Recruitment took place in oncology, hospice and primary care settings. CBT was delivered in IAPT centres or/and over the telephone. PARTICIPANTS: Patients (N = 230; n = 115 in each arm) with advanced cancer and depression. Inclusion criteria were a diagnosis of cancer not amenable to cure, a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnosis of depressive disorder using the Mini-International Neuropsychiatric Interview, a sufficient understanding of English and eligibility for treatment in an IAPT centre. Exclusion criteria were an estimated survival of < 4 months, being at high risk of suicide and receiving, or having received in the last 2 months, a psychological intervention recommended by NICE for treating depression. INTERVENTIONS: (1) Up to 12 sessions of manualised individual CBT plus TAU delivered within 16 weeks and (2) TAU. OUTCOME MEASURES: The primary outcome was the Beck Depression Inventory, version 2 (BDI-II) score at 6, 12, 18 and 24 weeks. Secondary outcomes included scores on the Patient Health Questionnaire-9, the Eastern Cooperative Oncology Group Performance Status, satisfaction with care, EuroQol-5 Dimensions and the Client Services Receipt Inventory, at 12 and 24 weeks. RESULTS: A total of 80% of treatments (185/230) were analysed: CBT (plus TAU) (n = 93) and TAU (n = 92) for the BDI-II score at all time points using multilevel modelling. CBT was not clinically effective [treatment effect -0.84, 95% confidence interval (CI) -2.76 to 1.08; p = 0.39], nor was there any benefit for other measures. A subgroup analysis of those widowed, divorced or separated showed a significant effect of CBT on the BDI-II (treatment effect -7.21, 95% CI -11.15 to -3.28; p < 0.001). Economic analysis revealed that CBT has higher costs but produces more quality-adjusted life-years (QALYs) than TAU. The mean service costs for participants (not including the costs of the interventions) were similar across the two groups. There were no differences in EQ-5D median scores at baseline, nor was there any advantage of CBT over TAU at 12 weeks or 24 weeks. There was no statistically significant improvement in QALYs at 24 weeks. LIMITATIONS: Although all participants satisfied a diagnosis of depression, for some, this was of less than moderate severity at baseline, which could have attenuated treatment effects. Only 64% (74/115) took up CBT, comparable to the general uptake through IAPT. CONCLUSIONS: Cognitive-behavioural therapy (delivered through IAPT) does not achieve any clinical benefit in advanced cancer patients with depression. The benefit of CBT for people widowed, divorced or separated is consistent with other studies. Alternative treatment options for people with advanced cancer warrant evaluation. Screening and referring those widowed, divorced or separated to IAPT for CBT may be beneficial. Whether or not improvements in this subgroup are due to non-specific therapeutic effects needs investigation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07622709. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 19. See the NIHR Journals Library website for further project information.

There are high rates of depression in people with advanced (cannot-be-cured) cancer. Depression worsens a person's quality of life (QoL), may become a burden for carers and may prolong a patient's hospital stay. Cognitive­behavioural therapy (CBT) challenges unhelpful thinking and ways of doing things to help improve mood. CBT is effective for treating depression, but it is unclear if it works for depression in advanced cancer patients. Advanced cancer patients with depression were entered into a research trial to see if the addition of CBT to usual care was better at improving depressive symptoms than usual care alone. We also wished to evaluate whether or not CBT helped to save costs. We enrolled 230 participants from hospital clinics, general practitioner (GP) surgeries and the Marie Curie Hospice, Hampstead. A computer program randomly allocated people to one of two groups: (1) CBT plus usual care or (2) usual care alone. Everyone received usual care from their GPs and oncology teams. Patients who were offered the addition of CBT received up to 12 1-hour sessions delivered through a community service called Improving Access to Psychological Therapies. We measured depression using a questionnaire called the Beck Depression Inventory, version 2 collected at the start of, and at 6, 12, 18 and 24 weeks into, the trial. We also collected other measures, including those relating to health, QoL and resource costs at various times. Overall, there was no improvement in symptoms of low mood or cost savings with the addition of CBT to usual care compared with usual care alone. This means that CBT does not benefit people with depression and advanced cancer, and should not be routinely offered. However, those widowed, divorced or separated appeared to benefit from CBT over and above their usual care. CBT targeted to these people may be helpful and may ensure that resources are allocated in the best way.

The cognitive therapy of depression rests on substantial theoretical, empirical and clinical foundations: a reply to Dr Gipps.

Dr Gipps claims that the cognitive therapy for depression rests on a mistake. But his anachronistic analysis of Beck's early research from the perspective of current psychoanalytic theory misses the point. The value of the research was not that it disproved psychoanalytic theory, but that it generated a model of depression that has revolutionised psychotherapy research. Psychoanalysts are belatedly adopting research methods that Beck pioneered half a century ago. The cognitive model of depression has explanatory power for both maintenance and vulnerability and has substantial research underpinning it. Cognitive therapy for depression has a larger body of evidence for its efficacy and relapse prevention effect than any other psychotherapy. Transference-focused approaches to depression have yet to establish themselves in the same way.

Preliminary study of reminiscence therapy on depression and self-esteem in cancer patients.

The present study investigated use of life review, a form of reminiscence, on the depression and self-esteem in cancer patients. 15 cancer patients in the experimental group participated in individual reminiscence therapy. 21 patients in the comparison group received no therapy. All patients were measured on both depression and self-esteem scales during two testing periods. Analysis showed mean depression scores of the cancer patients decreased and mean self-esteem increased significandy after the life-review therapy sessions, while the scores of the comparison group did not change. Furthermore, patients' psychological states were improved, and they thought their problems had been addressed. These results suggest reminiscence therapy can be useful for cancer patients.

The clinical and cost effectiveness of cognitive behavioural therapy plus treatment as usual for the treatment of depression in advanced cancer (CanTalk): study protocol for a randomised controlled trial.

BACKGROUND: The prevalence of depressive disorder in adults with advanced cancer is around 20 %. Although cognitive behavioural therapy (CBT) is recommended for depression and may be beneficial in depressed people with cancer, its use for depression in those with advanced disease for whom cure is not likely has not been explored. METHODS: People aged 18 years and above with advanced cancer attending General Practitioner (GP), oncology or hospice outpatients from centres across England will be screened to establish a DSM-IV diagnosis of depression. Self-referral is also accepted. Eligible consenters will be randomised to a single blind, multicentre, randomised controlled trial of the addition to treatment as usual (TAU) of up to 12 one-hour weekly sessions of manualised CBT versus TAU alone. Sessions are delivered in primary care through Increasing Access to Psychological Care (IAPT) service, and the manual includes a focus on issues for people approaching the end of life. The main outcome is the Beck Depression Inventory-II (BDI-II). Subsidiary measures include the Patient Health Questionnaire, quality of life measure EQ-5D, Satisfaction with care, Eastern Cooperative Oncology Group-Performance Status and a modified Client Service Receipt Inventory. At 90 % power, we require 240 participants to enter the trial. Data will be analysed using multi-level (hierarchical) models for data collected at baseline, 6, 12, 18 and 24 weeks. Cost effectiveness analysis will incorporate costs related to the intervention to compare overall healthcare costs and QALYs between the treatment arms. We will conduct qualitative interviews after final follow-up on patient and therapist perspectives of the therapy. DISCUSSION: This trial will provide data on the clinical and cost effectiveness of CBT for people with advanced cancer and depression. We shall gain an understanding of the feasibility of delivering care to this group through IAPT. Our findings will provide evidence for policy-makers, commissioners and clinicians in cancer and palliative care, and in the community. TRIAL REGISTRATION: Controlled Trials ISRCTN07622709 , registered 15 July 2011.

Sexual violence against adult women primary care attenders in east London.

BACKGROUND: Sexual violence against women is common. The prevalence appears to be higher in north America than Europe. However, not all surveys have differentiated the experience of forced sex by a current or former partner. Few women are thought to report these experiences to their general practitioner (GP). AIM: To measure the prevalence of rape, sexual assault, and forced sexual intercourse by a partner among women attending general practices, to test the association between these experiences of sexual violence and demographic factors, and to assess the acceptability to women of screening for sexual violence by GPs. DESIGN OF STUDY: Cross-sectional survey. METHOD: A self-administered questionnaire survey of 1207 women aged over 15 years was carried out in 13 general practices in Hackney, east London. RESULTS: Eight per cent (95% confidence interval [CI] = 6.2 to 9.6) of women have experienced rape, 9% (95% CI = 7.0 to 10.6) another type of sexual assault, and 16% (95% CI = 13.6 to 18.1) forced sex by a partner in adulthood: 24% (95% CI = 21.2 to 26.5) have experienced one or more of these types of sexual violence. Experiences of sexual violence demonstrated high levels of lifetime co-occurrence. Women forced to have sex by partners experienced the most severe forms of domestic violence. One in five women would object to routine questioning about being raped and/or sexually assaulted, and one in nine about being forced to have sex by a partner. CONCLUSION: Experiences of sexual violence are common in the lives of adult women in east London, and they represent a significant public health problem. Those women who have one experience appear to be at risk of being victims again. A substantial minority object to routine questions about sexual violence.

How Disorder-Specific are Depressive Attributions? A Comparison of Individuals with Depression, Post-Traumatic Stress Disorder and Healthy Controls.

Depressed individuals tend to assign internal, stable, and global causes to negative events. The present study investigated the specificity of this effect to depression and compared depressive attributional styles of individuals with major depression (MD), post-traumatic stress disorder (PTSD), and healthy controls. We indexed attributional style using the depressive attributions questionnaire in 164 participants. Additionally, we assessed appraisals characteristic of PTSD using the post-traumatic cognitions inventory (PTCI), depressive rumination, trauma history, and depression and PTSD symptom severity. Individuals with MD endorsed a depressive attributional style to a greater extent than both individuals with PTSD, who were not depressed, and healthy controls. Depressive attributional style was associated with the severity of depressive and PTSD symptoms, number and distress of traumatic experiences, frequency of rumination, and post-traumatic cognitions. Depressive attributions and PTCI appraisals independently predicted MD and PTSD symptom severity. They may thus be useful in predicting MD and PTSD, and should be targeted in psychological treatments of these conditions.

Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners.

We describe training in CBT techniques for 20 palliative care practitioners delivered as 12 days' equivalent teaching plus skills-building supervision over a six month period. Audiotapes of trainees' interactions with patients during their usual work were rated using a specially devised 'Cognitive First Aid' rating scale (CFARS). The CFARS was highly internally consistent (Cronbach's Alpha 0.93) and inter-rater reliability was high. Trainees showed significant gain in CBT skills competency over six months (p=0.001). After initial training, half the trainees were randomised to discontinue supervision; their measured CBT skill dropped as did their self-reported confidence when reassessed six months later, whereas those who continued in supervision gained further skill and maintained confidence (p=0.007). Palliative care practitioners can be trained in CBT skills by a simple and brief training course and supportive, skills-building supervision. These skills are compatible with national guidelines on delivery of psychological support to patients at all stages of cancer. Supervision is necessary to ensure maintenance of skills and confidence to use them.

The Cancer Coping Questionnaire: a self-rating scale for measuring the impact of adjuvant psychological therapy on coping behaviour.

The Cancer Coping Questionnaire is a brief, self-rating scale designed to measure coping strategies taught in Adjuvant Psychological Therapy. This paper describes the development of the 21 item Cancer Coping Questionnaire (CCQ) in a sample of 201 patients with mixed cancers. The construct validity and reliability of the instrument are reported from work on 3 samples (a mixed cancer group, n=42; women with breast cancer, n=50; and a group of patients referred for psychological help, n=48). The CCQ showed very good internal reliability and test-retest reliability. As hypothesised cancer patients with more psychological morbidity demonstrated lower CCQ scores, and the CCQ correlated with measures of adjustment to cancer. Compared with an established coping inventory (the Coping Responses Indices; CRI) the CCQs overall individual scale (items 1-14) assessed similar coping areas, particularly in relation to the CRIs foci of coping. The CCQ correlated with Active Behavioural Coping methods on the CRI. The study did not demonstrate sufficiently consistent results concerning the Interpersonal Scale of the CCQ to confirm its validity. Further psychometric work is needed, but the study demonstrated the reliability and validity of the CCQ, supporting the view that change in CCQ scores with cognitive therapy indicates improvement in coping.

Abusive experiences and psychiatric morbidity in women primary care attenders.

BACKGROUND: Abusive experiences in childhood and adulthood increase risks of psychiatric morbidity in women and independently increase risks of further abuse over the lifetime. It is unclear which experiences are most damaging. AIMS: To measure lifetime prevalence of abusive experiences and psychiatric morbidity, and to analyse associations in women primary care attenders. METHOD: A cross-sectional, self-report survey of 1207 women attending 13 surgeries in the London borough of Hackney, UK. Independent associations between demographic measures, abusive experiences and psychiatric outcome were established using logistic regression. RESULTS: Childhood sexual abuse had few associations with adult mental health measures, in contrast to physical abuse. Sexual assault in adulthood was associated with substance misuse; rape with anxiety, depression and post-traumatic stress disorder but not substance misuse. Domestic violence showed strongest associations with most mental health measures, increased for experiences in the past year. CONCLUSIONS: Abuse in childhood and adulthood have differential effects on mental health; effects are increased by recency and severity. Women should be routinely questioned about ongoing and recent experiences as well as childhood.

Identifying domestic violence: cross sectional study in primary care.

OBJECTIVES: To measure the prevalence of domestic violence among women attending general practice; test the association between experience of domestic violence and demographic factors; evaluate the extent of recording of domestic violence in records held by general practices; and assess acceptability to women of screening for domestic violence by general practitioners or practice nurses. DESIGN: Self administered questionnaire survey. Review of medical records. SETTING: General practices in Hackney, London. PARTICIPANTS: 1207 women (>15 years) attending selected practices. MAIN OUTCOME MEASURES: Prevalence of domestic violence against women. Association between demographic factors and domestic violence reported in questionnaire. Comparison of recording of domestic violence in medical records with that reported in questionnaire. Attitudes of women towards being questioned about domestic violence by general practitioners or practice nurses. RESULTS: 425/1035 women (41%, 95% confidence interval 38% to 44%) had ever experienced physical violence from a partner or former partner and 160/949 (17%, 14% to 19%) had experienced it within the past year. Pregnancy in the past year was associated with an increased risk of current violence (adjusted odds ratio 2.11, 1.39 to 3.19). Physical violence was recorded in the medical records of 15/90 (17%) women who reported it on the questionnaire. At least 202/1010 (20%) women objected to screening for domestic violence. CONCLUSIONS: With the high prevalence of domestic violence, health professionals should maintain a high level of awareness of the possibility of domestic violence, especially affecting pregnant women, but the case for screening is not yet convincing.