Effects of medical comorbidity on anxiety treatment outcomes in primary care.

OBJECTIVE: To evaluate the effects of medical comorbidity on anxiety treatment outcomes. METHODS: Data were analyzed from 1004 primary care patients enrolled in a trial of a collaborative care intervention for anxiety. Linear-mixed models accounting for baseline characteristics were used to evaluate the effects of overall medical comorbidity (two or more chronic medical conditions [CMCs] versus fewer than two CMCs) and specific CMCs (migraine, asthma, and gastrointestinal disease) on anxiety treatment outcomes at 6, 12, and 18 months. RESULTS: At baseline, patients with two or more CMCs (n = 582; 58.0%) reported more severe anxiety symptoms (10.5 [95% confidence interval {CI} = 10.1-10.9] versus 9.5 [95% CI = 9.0-10.0], p = .003) and anxiety-related disability (17.6 [95% CI = 17.0-18.2] versus 16.0 [95% CI = 15.3-16.7], p = .001). However, their clinical improvement was comparable to that of patients with one or zero CMCs (predicted change in anxiety symptoms = -3.9 versus -4.1 at 6 months, -4.6 versus -4.4 at 12 months, -4.9 versus -5.0 at 18 months; predicted change in anxiety-related disability = -6.4 versus -6.9 at 6 months, -6.9 versus -7.3 at 12 months, -7.3 versus -7.5 at 18 months). The only specific CMC with a detrimental effect was migraine, which was associated with less improvement in anxiety symptoms at 18 months (predicted change = -4.1 versus -5.3). CONCLUSIONS: Effectiveness of the anxiety intervention was not significantly affected by the presence of multiple CMCs; however, patients with migraine displayed less improvement at long-term follow-up. Trial Registration ClinicalTrials.com Identifier: NCT00347269.

DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results.

BACKGROUND: Maintenance of gains with cognitive-behavioral treatment for trichotillomania (TTM) has historically been problematic. METHODS: We conducted follow-up assessments 3 and 6 months after completion of a 3-month maintenance phase on 10 individuals with DSM-IV-TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT). RESULTS: Significant improvement from baseline was reported at 3-and 6-month follow-up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6-month follow-up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity. CONCLUSIONS: DBT-enhanced HRT offers promise for improved long-term treatment results in TTM. Changes in TTM severity from baseline to 3-and 6-month follow-up is correlated with changes in emotion regulation capacity.

Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania.

BACKGROUND: Not all hair pullers improve acutely with cognitive-behavioral treatment (CBT) and few maintain their gains over time. METHODS: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM-IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)-enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self-report measures of hair pulling severity and emotion regulation. RESULTS: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. CONCLUSIONS: This study offers preliminary evidence for the efficacy of DBT-enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment.

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT: Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE: To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS: A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION: CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES: Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS: A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION: For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00347269.

Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings.

OBJECTIVES: This article describes a computer-assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced-based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary-care settings. The purpose of the current report is to (1) present the structure and format of the computer-assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. METHODS: Thirteen clinicians using the computer-assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert-scale ratings and open-ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected. RESULTS: Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. CONCLUSIONS: Computer-assisted CBT programs provide a practice-based system for disseminating evidence-based mental health treatment in primary-care settings while maintaining treatment fidelity, even in the hands of novice clinicians.

Emotional responses to self-injury imagery among adults with borderline personality disorder.

Nonsuicidal self-injury (NSSI) and suicide attempts (SAs) are especially prevalent in borderline personality disorder. One proposed mechanism for the maintenance of NSSI and SAs is escape conditioning, whereby immediate reductions in aversive emotional states negatively reinforce the behaviors. Psychophysiological and subjective indicators of negative emotion associated with NSSI and SA imagery were examined in 42 individuals who met criteria for border personality disorder. Personally relevant imagery scripts that involved an NSSI and/or an SA incident were created, as were control scenes involving imagery of an accidental injury, an accidental death, or an emotionally neutral event. Results did not support the hypothesis that decreases in negative emotion would occur during NSSI imagery; however, decreases were found during imagery of the moments after NSSI, which suggests some support for escape conditioning. Support for the model was not found for SAs. Possible implications of patterns that demonstrate decreases in negative emotion during accidental death imagery are discussed.

A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women.

OBJECTIVE: Depression among pregnant women is a prevalent public health problem associated with poor maternal and offspring development. Behavioral activation (BA) is a scalable intervention aligned with pregnant women's preference for nonpharmacological depression care. This is the first test of the effectiveness of BA for depression among pregnant women, which aimed to evaluate the effectiveness of BA as compared with treatment as usual (TAU). METHOD: Pregnant women (mean age = 28.75 years; SD = 5.67) with depression symptoms were randomly assigned to BA (n = 86) or TAU (n = 77). Exclusion criteria included known bipolar or psychotic disorder or immediate self-harm risk. Follow-up assessment occurred 5 and 10 weeks postrandomization and 3 months postpartum using self-report measures of primary and secondary outcomes and putative targets. RESULTS: Compared with TAU, BA was associated with significantly lower depressive symptoms (d = 0.34, p = .04) and higher remission (56.3% vs. 30.3%, p = .003). BA also demonstrated significant advantage on anxiety and perceived stress. Participants attended most BA sessions and reported high satisfaction. Participants in BA reported significantly higher levels of activation (d = 0.69, p < .0002) and environmental reward (d = 0.54, p < .003) than those who received TAU, and early change in both of these putative targets significantly mediated subsequent depression outcomes. CONCLUSIONS: BA is effective for pregnant women, offering significant depression, anxiety, and stress benefits, with mediation analyses supporting the importance of putative targets of activation and environmental reward. (PsycINFO Database Record

Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder.

We conducted a randomized controlled trial to evaluate whether dialectical behavior therapy (DBT), a treatment that synthesizes behavioral change with radical acceptance strategies, would be more effective for heroin-dependent women with borderline personality disorder (N = 23) than Comprehensive Validation Therapy with 12-Step (CVT + 12S), a manualized approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. In addition to psychosocial treatment, subjects also received concurrent opiate agonist therapy with adequate doses of LAAM (thrice weekly; modal dose 90/90/130 mg). Treatment lasted for 12 months. Drug use outcomes were measured via thrice-weekly urinalyses and self-report. Three major findings emerged. First, results of urinalyses indicated that both treatment conditions were effective in reducing opiate use relative to baseline. At 16 months post-randomization (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in CVT + 12S). With regard to between-condition differences, participants assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment while those assigned to CVT + 12S significantly increased opiate use during the last 4 months of treatment. Second, CVT + 12S retained all 12 participants for the entire year of treatment, compared to a 64% retention rate in DBT. Third, at both post-treatment and at the 16-month follow-up assessment, subjects in both treatment conditions showed significant overall reductions in level of psychopathology relative to baseline. A noteworthy secondary finding was that DBT participants were significantly more accurate in their self-report of opiate use than were those assigned to CVT + 12S.

High-risk situations associated with parasuicide and drug use in borderline personality disorder.

Both parasuicide and drug use continue to be difficult problems to treat in borderline personality disorder (BPD). One useful approach that has not yet been applied to BPD is to develop a taxonomy of triggering situations for these problems. Once these high-risk precipitants are identified, then the behaviors can be targeted with skills training. This model has been applied by Marlatt (1996) with very influential results. To examine high-risk situations for parasuicide and drug use in BPD, the current study examined women with BPD who came to treatment for two different primary problems: parasuicide (N = 75) and drug dependence (N = 47). Participants identified the situation associated with highest risk for relapse in either the parasuicide or drug category. A taxonomy is presented, which divides results into six main categories. Differences between high-risk situations for drugs and parasuicide were also explored. Parasuicide was significantly more likely to be linked to interpersonal problems, whereas drug use was more likely to be preceded by addiction cues (i.e., being near drugs or people who use drugs).

Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders.

OBJECTIVES: This paper describes the training approach used with primary care staff to deliver an evidence-based computer-assisted cognitive-behavioral therapy (CBT) program for anxiety disorders within a collaborative care treatment delivery model. METHODS: We describe the training and proficiency evaluation procedures utilized in the Coordinated Anxiety Learning and Management (CALM) study, a large multisite study of collaborative care for anxiety disorders in primary care. Training incorporated readings, didactic presentations, video demonstrations of CBT skills, role-plays, computer-assisted practice, CBT training cases and ongoing group supervision provided by study psychologists. RESULTS: Proficiency training case data from 15 clinicians are presented. The anxiety clinical specialists (ACSs) were highly proficient at delivering the CBT component of the CALM intervention. The ACSs also provided Likert-scale ratings and open-ended responses about their experiences with the training. Overall, the training was rated very positively and was described as very thorough, indicating a high level of acceptability to clinicians. Recommendations for future training are described. CONCLUSIONS: Primary care staff with none or minimal prior CBT experience can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders. The implications for dissemination and transportability of evidenced-based interventions are discussed.

Brief intervention for anxiety in primary care patients.

To address the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, this article provides a simple, easy-to-learn, unified approach to the diagnosis, care management, and pharmacotherapy of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders; a validated method for monitoring treatment outcome; and an algorithmic approach for the selection of initial medication treatment, the selection of alternative or adjunctive treatments when the initial approach has not produced optimal results, and indications for mental health referral.

A valence-dependent group-specific recall bias of retrospective self-reports: a study of borderline personality disorder in everyday life.

Recall is an active reconstruction process likely to distort past experiences. This distortion, known as recall bias, seems to manifest itself differently in sick and healthy people. A recall bias has been documented in several disorders, but never investigated in borderline personality disorder (BPD). To determine recall bias in BPD, we assessed momentary and retrospective ratings of specific emotions in 50 patients with BPD and 50 healthy controls (HCs), using the methodology of 24-hour ambulatory monitoring. Our data reveal a group-specific valence-dependent recall bias of retrospective self-report, indicated by a different overall recall pattern in HCs and BPD. BPD patients show an overall negative recall pattern, whereas HCs show a positive recall pattern. A traditional questionnaire approach does not distinguish between symptoms of the disorder and recall bias, although the pathological mechanisms underlying them as well as the appropriate treatment strategies may be different.