One year follow-up and mediation in cognitive behavioral therapy and acceptance and commitment therapy for adult depression.

BACKGROUND: Existing therapies for depression are effective, but many patients fail to recover or relapse. To improve care for patients, more research into the effectiveness and working mechanisms of treatments is needed. We examined the long-term efficacy of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for Major Depressive Disorder (MDD), testing the hypothesis that CBT outperforms ACT and that both therapies work through their designated mechanisms of change. METHODS: We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before, during and after treatment, and at 12-month follow-up, assessing symptoms of depression, quality of life, dysfunctional attitudes, decentering, and experiential avoidance. RESULTS: Patients in both conditions reported significant and large reductions of depressive symptoms (d = - 1.26 to - 1.60) and improvement in quality of life (d = 0.91 to - 1.28) 12 months following treatment. Our findings indicated no significant differences between the two interventions. Dysfunctional attitudes and decentering mediated treatment effects of depressive symptoms in both CBT and ACT, whereas experiential avoidance mediated treatment effects in ACT only. CONCLUSIONS: Our results indicate that CBT is not more effective in treating depression than ACT. Both treatments seem to work through changes in dysfunctional attitudes and decentering, even though the treatments differ substantially. Change in experiential avoidance as an underlying mechanism seems to be an ACT-specific process. Further research is needed to investigate whether ACT and CBT may work differently for different groups of patients with depression. TRIAL REGISTRATION: clinicaltrials.gov; NCT01517503 . Registered 25 January 2012 - Retrospectively registered.

Virtual Reality Therapy in Mental Health.

Initially designed for the treatment of phobias, the use of virtual reality in phobic disorders has expanded to other mental health disorders such as posttraumatic stress disorder, substance-related disorders, eating disorders, psychosis, and autism spectrum disorder. The goal of this review is to provide an accessible understanding of why this approach is important for future practice, given its potential to provide clinically relevant information associated with the assessment and treatment of people suffering from mental illness. Most of the evidence is available for the use of virtual reality exposure therapy in anxiety disorders and posttraumatic stress disorder. There is hardly any evidence that virtual reality therapy is effective in generalized anxiety disorder and obsessive-compulsive disorder. There is increasing evidence that cue exposure therapy is effective in addiction and eating disorders. Studies into the use of virtual reality therapy in psychosis, autism spectrum disorder, and attention deficit hyperactivity disorder (ADHD) are promising.

Virtual Reality Therapy in Social Anxiety Disorder.

PURPOSE OF REVIEW: This review provides an overview of current methods and important aspects to consider when applying virtual worlds in the treatment of social anxiety disorder (SAD). RECENT FINDINGS: Different aspects such as dialogs between avatars and patients have been investigated as well as virtual audiences, emotional facial expression, and verbal interaction with avatars. Results of these studies are promising. Few randomized controlled trials (RCTs) have investigated the efficacy of virtual reality exposure therapy (VRET) in SAD. Unfortunately, most RCTs into the efficacy of VRET in comparison with exposure in vivo in SAD have been conducted with a combination of cognitive interventions and VRET. No differences between these conditions were found, but the pure effect of VRET as a stand-alone treatment has only been investigated in one RCT, wherein VRET was not superior to exposure in vivo. Current research into different facets of SAD and VRET has produced promising results with respect to technological aspects. No differences in efficacy between cognitive behavior therapy and VRET were found, but there is a clear need for studies investigating the efficacy of VRET as a stand-alone treatment and the therapeutic processes involved before this therapy can be disseminated in routine clinical practice.

Explicit and implicit attachment and the outcomes of acceptance and commitment therapy and cognitive behavioral therapy for depression.

BACKGROUND: Attachment theory predicts that patients who are not securely attached may benefit less from psychological treatment. However, evidence on the predictive role of attachment in the effectiveness of treatment for depression is limited. METHODS: Explicit attachment styles, levels of attachment anxiety and attachment avoidance, as well as implicit relational self-esteem and implicit relational anxiety were assessed in 67 patients with major depressive disorder (MDD) receiving Acceptance and Commitment Therapy (ACT) or Cognitive Behavioral Therapy (CBT). ANOVA and hierarchical regression analyses were performed to investigate the predictive power of explicit and implicit attachment measures on treatment outcome. RESULTS: Explicit attachment avoidance at pre-treatment significantly predicted reduction of depressive symptoms following treatment. Reductions in attachment anxiety and avoidance from pre- to post-treatment predicted better treatment outcomes. Neither one of the implicit measures, nor change in these measures from pre- tot post-treatment significantly predicted treatment outcome. CONCLUSIONS: Our findings show that attachment avoidance as well as reductions in avoidant and anxious attachment predict symptom reduction after psychological treatment for depression. Future research should use larger sample sizes to further examine the role of attachment orientation as moderator and mediator of treatment outcome. TRIAL REGISTRATION: clinicaltrials.gov; NCT01517503.

Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial.

The objective is to investigate the effectiveness of home-based behavioral parent training for school-aged children with attention-deficit/hyperactivity disorder (ADHD) and behavior problems with remaining impairing disruptive behaviors after routinely offered treatments in clinical practice. In a randomized controlled study including 73 referred children with ADHD and impairing disruptive symptoms after routine clinical pharmacotherapy and/or clinic-based parent training had been tried or, at least, offered, home-based behavioral parent training (n = 26) was compared to a waiting list (n = 23) and a care-as-usual home-based treatment (n = 24). It was unknown to families which of the home-based treatments that they received. Using mixed models for repeated measures, we examined the effectiveness on the primary outcome measure of children's severity of disruptive behaviors and on a number of secondary outcome measures [the degree to which parents experienced the disruptive behaviors as troublesome, ADHD symptoms, oppositional-defiant disorder (ODD) symptoms, and internalizing problems]. Compared to the waiting list, children receiving home-based parent training improved significantly more regarding severity of disruptive behaviors (ES = 0.75), ADHD symptoms (ES = 0.89), ODD symptoms (ES = 0.65), and internalizing problems (ES = 0.60). Compared to care-as-usual, home-based parent training was more effective in reducing disruptive behaviors (ES = 0.57), ADHD symptoms (ES = 0.89), and ODD symptoms (ES = 0.88). Significantly more reduction of children's internalizing problems was not found. In conclusion, children with ADHD and residual behavioral problems after routine treatment may benefit from home-based behavioral parent training.

Cognitive predictors of treatment outcome for exposure therapy: do changes in self-efficacy, self-focused attention, and estimated social costs predict symptom improvement in social anxiety disorder?

BACKGROUND: Cognitions play an important role in the development and maintenance of social anxiety disorder (SAD). METHODS: To investigate whether changes in cognitions during the first six sessions of exposure therapy are associated with treatment outcome, we assessed reported self-focused attention, self-efficacy in social situations, and estimated social costs in 60 participants (Mage = 36.9 years) diagnosed with SAD who received in vivo or virtual reality exposure therapy. RESULTS: Patients demonstrating a greater decrease in estimated social costs during treatment reported greater improvement of their social anxiety symptoms following both forms of exposure therapy. While changes in self-focused attention and social self-efficacy during treatment were significantly associated with treatment outcome when examined individually, these changes did not significantly predict symptom improvement beyond social costs. CONCLUSIONS: Changes in estimated social costs during treatment are associated with improvement of social anxiety symptoms after exposure therapy. Future research needs to further investigate estimated social costs as a predictor in relation to other cognitive variables. TRIAL REGISTRATION: NCT01746667 ; www.clinicaltrials.gov, November 2012, retrospectively registered.

Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement.

Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence-outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness-based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory-II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in-session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.

A Randomized Controlled Trial in Routine Clinical Practice Comparing Acceptance and Commitment Therapy with Cognitive Behavioral Therapy for the Treatment of Major Depressive Disorder.

BACKGROUND: Since current therapies for depression are effective but not for all patients alike, we need to further improve available treatments. Existing research suggests that acceptance and commitment therapy (ACT) may effectively treat major depressive disorder (MDD). We compared ACT with cognitive behavioral therapy (CBT) for depression, testing the hypothesis that CBT would outperform ACT. METHODS: We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before and after treatment and at the 6-month follow-up, assessing diagnosis, symptom levels of depression, and quality of life. RESULTS: After treatment, the rates of remission from depression were 75 and 80% for the ACT and CBT conditions, respectively. Patients in both conditions further reported significant and large reductions in depressive symptoms and improvement in quality of life from before to after treatment as well as at the follow-up. Our findings indicated no significant differences between the two intervention groups. CONCLUSION: Our results indicate that CBT is not more effective in treating depression than ACT. Further research is needed to investigate whether ACT and CBT work differently for different groups of patients with depression.

Standardization of health outcomes assessment for depression and anxiety: recommendations from the ICHOM Depression and Anxiety Working Group.

PURPOSE: National initiatives, such as the UK Improving Access to Psychological Therapies program (IAPT), demonstrate the feasibility of conducting empirical mental health assessments on a large scale, and similar initiatives exist in other countries. However, there is a lack of international consensus on which outcome domains are most salient to monitor treatment progress and how they should be measured. The aim of this project was to propose (1) an essential set of outcome domains relevant across countries and cultures, (2) a set of easily accessible patient-reported instruments, and (3) a psychometric approach to make scores from different instruments comparable. METHODS: Twenty-four experts, including ten health outcomes researchers, ten clinical experts from all continents, two patient advocates, and two ICHOM coordinators worked for seven months in a consensus building exercise to develop recommendations based on existing evidence using a structured consensus-driven modified Delphi technique. RESULTS: The group proposes to combine an assessment of potential outcome predictors at baseline (47 items: demographics, functional, clinical status, etc.), with repeated assessments of disease-specific symptoms during the treatment process (19 items: symptoms, side effects, etc.), and a comprehensive annual assessment of broader treatment outcomes (45 items: remission, absenteeism, etc.). Further, it is suggested reporting disease-specific symptoms for depression and anxiety on a standardized metric to increase comparability with other legacy instruments. All recommended instruments are provided online ( www.ichom.org ). CONCLUSION: An international standard of health outcomes assessment has the potential to improve clinical decision making, enhance health care for the benefit of patients, and facilitate scientific knowledge.

The Classification of Anxiety and Fear-Related Disorders in the ICD-11.

Anxiety disorders are highly prevalent worldwide and engender substantial economic costs and disability. The World Health Organization is currently developing the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), which represents the first opportunity to improve the validity, clinical utility, and global applicability of the classification in more than 25 years. This article describes changes in the organization and diagnostic guidelines for anxiety and fear-related disorders proposed by the ICD-11 Working Group on the Classification of Mood and Anxiety Disorders and the rationale and evidence base for the proposals. In ICD-11, anxiety and fear-related disorders that manifest across the lifespan are brought together under a new grouping, and are partly distinguished by their focus of apprehension. The focus of apprehension is the stimulus or situation that triggers the fear or anxiety and may be highly specific as in specific phobia or relate to a broader class of situations as in social anxiety disorder. The guidelines also clarify the relationship between panic disorder and agoraphobia and a qualifier is provided for panic attacks in the context of other disorders. A standardized format emphasizing essential features of anxiety disorders is intended to improve clinical utility. Guidelines will be further refined based on findings from two types of field studies: those using a case-controlled vignette methodology disseminated via the Internet to practitioners worldwide (http://gcp.network) and clinic-based field trials implemented globally at participating field study centers.

A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems.

BACKGROUND: The current study presents the results of a meta-analysis of 39 randomized controlled trials on the efficacy of acceptance and commitment therapy (ACT), including 1,821 patients with mental disorders or somatic health problems. METHODS: We searched PsycINFO, MEDLINE and the Cochrane Central Register of Controlled Trials. Information provided by the ACBS (Association of Contextual Behavioral Science) community was also included. Statistical calculations were conducted using Comprehensive Meta-Analysis software. Study quality was rated using a methodology rating form. RESULTS: ACT outperformed control conditions (Hedges' g = 0.57) at posttreatment and follow-up assessments in completer and intent-to-treat analyses for primary outcomes. ACT was superior to waitlist (Hedges' g = 0.82), to psychological placebo (Hedges' g = 0.51) and to treatment as usual (TAU) (we defined TAU as the standard treatment as usual; Hedges' g = 0.64). ACT was also superior on secondary outcomes (Hedges' g = 0.30), life satisfaction/quality measures (Hedges' g = 0.37) and process measures (Hedges' g = 0. 56) compared to control conditions. The comparison between ACT and established treatments (cognitive behavioral therapy) did not reveal any significant differences between these treatments (p = 0.140). CONCLUSIONS: Our findings indicate that ACT is more effective than treatment as usual or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions. More research that focuses on quality of life and processes of change is needed to understand the added value of ACT and its transdiagnostic nature.

Recovery of Work-Related Stress: Complaint Reduction and Work-Resumption are Relatively Independent Processes.

PURPOSE: The process of recovery from work-related stress, consisting of complaint reduction and work-resumption, is not yet fully understood. The aim of this study was to investigate predictors of complaint reduction and work-resumption, as well as testing complaint reduction as a mediator in the association between predictors and work-resumption. METHODS: Seventy-one patients on sickness-leave because of work-related stress complaints were followed over a period of 13 months. Predictors comprised personal (demographics, coping, cognitions), work-related (job-characteristics, social support), and illness-related (complaint duration, absence duration) variables. Dependent variables were distress complaints, burnout complaints, and work-resumption. RESULTS: Complaints reduced considerably over time to borderline clinical levels and work-resumption increased to 68% at 13 months. Predictors of stronger reduction of distress complaints were male gender, less working hours, less decision authority, more co-worker support, and shorter absence duration. Predictors of stronger reduction of burnout complaints were male gender, lower age, high education, less avoidant coping, less decision authority, more job security, and more co-worker support. Predictors of work-resumption were lower age and stronger reduction of burnout complaints. No indication for a mediating role of burnout complaints between the predictor age and work-resumption was found. CONCLUSIONS: Complaint reduction and work-resumption are relatively independent processes. Symptom reduction is influenced by individual and work-related characteristics, which holds promise for a multidisciplinary treatment approach for work-related stress.

Effectiveness of Psychotherapy in Personality Disorders Not Otherwise Specified: A Comparison of Different Treatment Modalities.

OBJECTIVE: Although personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy. METHOD: A total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups. RESULTS: All treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished. CONCLUSION: Patients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness. KEY PRACTITIONER MESSAGES: The effectiveness of different modalities of psychotherapy in patients with PDNOS (i.e., short-term vs long-term; outpatient versus day hospital versus inpatient psychotherapy) has not yet been compared. Different modalities of psychotherapy are effective for patients with PDNOS, and positive effects remain after 5 years. In patients with PDNOS short-term (less than 6 months) outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the four other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Development and assessment of brief versions of the Penn State Worry Questionnaire and the Ruminative Response Scale.

OBJECTIVES: Worry and depressive rumination have been found to be involved in the onset and maintenance of a range of psychological disorders. The development of brief screening measures for excessive worry and depressive rumination is therefore desirable to facilitate the assessment of worry and rumination in prevention and treatment settings where routine administration of full questionnaires is not practical due to time-related constraints. DESIGN AND METHODS: Using the Penn State Worry Questionnaire (PSWQ) and the Ruminative Response Scale (RRS) as gold standard starting points, brief versions of these measures were developed in a large sample of adolescents (N = 1,952) and results were cross-validated in two independent samples (N = 1,954; N = 457). RESULTS: The brief versions demonstrated acceptable to high internal consistency (brief PSWQ: α = .84-.91; brief RRS: α = .78-.81) and correlated highly with the full questionnaires (brief PSWQ: r = .91-.94; brief RRS: r = .88-.91). In addition, they showed high sensitivity (brief PSWQ: .90-.92; brief RRS: .90-.93), and high specificity (brief PSWQ: .88-.90; brief RRS: .80-.87) to detect excessive worry and rumination. The validity of the brief measures was further supported by demonstrating that the brief measures showed similar differences in scores between males and females as the full measures as well as substantial relationships to other measures of repetitive negative thinking and symptom measures of anxiety and depression. Finally, the brief measures predicted future symptoms of anxiety and depression. CONCLUSIONS: The brief versions of the PSWQ and RRS are time-efficient and valid instruments for the screening of worry and depressive rumination. Their use in clinical practice is recommended to inform treatment and/or to select individuals at risk for development of psychological disorders who may benefit from preventive interventions.

Paternal influences on treatment outcome of behavioral parent training in children with attention-deficit/hyperactivity disorder.

This study aims to explore the influence of paternal variables on outcome of behavioral parent training (BPT) in children with attention-deficit/hyperactivity disorder (ADHD). 83 referred, school-aged children with ADHD were randomly assigned to BPT plus ongoing routine clinical care (RCC) or RCC alone. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Moderator variables included paternal ADHD symptoms, depressive symptoms, and parenting self-efficacy. We conducted repeated measures analyses of variance (ANOVA) for all variables, and then analyzed the direction of interaction effects by repeated measures ANOVA in high and low scoring subgroups. Paternal ADHD symptoms and parenting self-efficacy played a moderating role in decreasing behavioral problems, but not in decreasing ADHD symptoms. Paternal depressive symptoms did not moderate either treatment outcome. BPT is most beneficial in reducing children's behavioral problems when their fathers have high levels of ADHD symptoms or high-parenting self-efficacy.