Mind the gap: Improving the dissemination of CBT

The role of symptom reduction in improving health-related quality of life through brief cognitive behavioral therapy

Brief cognitive behavior therapy (bCBT) is effective in reducing symptoms of depression and anxiety disorders and improving health-related quality of life (HRQoL). However, the mechanisms through which cognitive behavior therapy impact HRQoL are not well understood. This study evaluated whether anxiety and depression symptom reduction is a mechanism of treatment for HRQoL outcomes.

METHOD

Using secondary data from a multisite, pragmatic, randomized trial, this study evaluated bCBT vs enhanced usual care in 16 VA community-based outpatient clinics. Ordinary least-squares path analysis testing multiple mediators was used to evaluate the role of change in depression and anxiety symptoms in the relationship between treatment condition and HRQoL.

RESULTS

Receiving bCBT (vs. enhanced usual care) was significantly negatively associated with change (reduction) in depression and anxiety scores. The indirect effect of treatment on mental HRQoL was significant with change in depression scores as mediator. A similar pattern was observed for physical HRQoL and change in anxiety scores as mediator.

CONCLUSION

Findings suggest reduction of depression and anxiety symptoms as a mechanism through which bCBT for depression promoted improvements in HRQoL, with important implications for understanding how CBT impacts functioning, as well as the utility of bCBT in nontraditional mental health settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02466126.

Effectiveness of internet-delivered cognitive behavioural therapy for anxiety and obsessive-compulsive disorders within routine clinical care in rural Sweden

Few studies have evaluated the implementation of ICBT in regular child and adolescent mental health services (CAMHS). This study aimed to explore the acceptability, feasibility, and effectiveness of ICBT for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD) within a rural CAMHS. The study also explored outcome predictors and long-term outcomes. Eighty-three participants were consecutively recruited from a non-specialized CAMHS in Region Jämtland Härjedalen in northern Sweden. Therapist-guided ICBT was offered during 12 weeks to children aged 8-17 with an anxiety disorder or OCD. Acceptability and feasibility measures included treatment adherence, treatment satisfaction, and adverse events. The primary outcome measure was the Clinical Global Impression-Severity. Secondary measures of effectiveness included clinician-, self-, and parent-ratings of symptom severity and functional impairment. Assessments were completed at baseline, post-treatment, and three-month follow-up (primary endpoint). A two-year follow up was conducted using medical records. Potential predictors included both patient characteristics and treatment variables. Results indicated that ICBT was both acceptable and feasible according to study measures. Statistically significant improvements were found from baseline to the three-month follow-up on clinician rated severity (B [SE] = -0.92 [0.09]; p < .001), as well as on all secondary measures. Forty-three percent of participants no longer fulfilled criteria for their principal disorder at the three-month follow-up. No serious adverse events were reported. Clinical improvement was highest among children with higher functioning at baseline (B [SE] = -0.05 [0.02]; p < .05). Forty-six percent of participants had been in contact with CAMHS during the two-year follow-up period, mainly for reasons other than their initial diagnosis. Findings suggest that ICBT could be an acceptable and feasible treatment option for young people with anxiety disorders and OCD in rural non-specialized CAMHS settings. Further studies are needed to confirm treatment effectiveness in this setting. Trial registration: NCT02926365.

Application of 'Readiness for Change' concept within implementation of evidence-based mental health interventions globally: protocol for a scoping review

Background

Concerning the growing burden of mental illnesses globally, there has been an increased investment into the implementation of evidence-based mental health interventions (EBmhIs) in routine care settings. However, the uptake and implementation of these EBmhIs has faced challenges in the real-world context. Among the many barriers and facilitators of implementation of EBmhIs identified by implementation science frameworks, evidence on the role of readiness for change (RFC) remains sparse. RFC constitutes the willingness and perceived capacity of stakeholders across an organization to implement a new practice. Theoretically, RFC has been defined at organizational, group, and individual levels, however, its conceptualization and operationalization across all these levels have differed in studies on the implementation of EBmhIs. By conducting a scoping review, we aim to examine the literature on RFC within the implementation of EBmhIs.

Methods

This scoping review will be conducted following the PRISMA-ScR guidelines. Iterative review stages will include a systematic and comprehensive search through four electronic databases (PubMed, Web of Science, Embase, and PsycINFO), selecting studies, charting data, and synthesizing the results. English-language studies meeting the inclusion criteria will be screened independently by two reviewers.

Discussion

This review will synthesize knowledge on the conceptualization of RFC across organizational, group, and individual levels within the implementation of EBmhIs. In addition, it will identify how RFC has been measured in these studies and summarize the reported evidence on its impact on the implementation of EBmhIs.

Conclusions

This review will assist mental health researchers, implementation scientists, and mental health care providers to gain a better understanding of the state of research on RFC within the implementation of EBmhIs.

Registration

The final protocol was registered with the Open Science Framework on October 21, 2022 ( https://osf.io/rs5n7).

State of the art in psychological therapies for psychosis: Family interventions for psychosis

PURPOSE

It is a half-century since the coalescence of social psychiatry and systemic family therapy approaches started to inform condition-specific therapeutic work with families to reduce relapse and hospital readmission for people with schizophrenia. Today, family interventions are a cornerstone of international guidelines for the treatment of psychosis, and of workforce development initiatives. Effect sizes for clinical and economic outcomes are large, and the evidence base is robust and reliable, not only for outcomes but also for the underpinning theoretical models, which are coherent and consistent. Few, if any, psychological therapies, have so powerful a framework to drive widespread implementation. Nevertheless, delivery in clinical services is variable, often lagging behind that of individual cognitive behavioural therapy, notwithstanding its considerably weaker implementation framework. Our aim in this article is to formulate this translation failure and offer potential solutions.

METHOD

We summarise the model/intervention and supporting evidence, then consider why delivery remains problematic.

RESULTS

We highlight the inter-linked issues of conceptual confusion between and conflation of, different approaches to working with families; of addressing diagnostic uncertainty, complex comorbidity and adapting interventions for specific populations; and of translation from gold-standard research trial practice, through educational curricula and training programmes, to routine delivery in frontline services.

CONCLUSION

We present our view of clinical, research and workforce development priorities to address these issues and continue the collective effort, moving into the next half-century, to work more effectively with people with psychosis and their families, to further improve outcomes.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

Improvements in cardiovascular disease risk factors associated with modest weight loss following treatment in patients with binge-eating disorder and obesity

BACKGROUND

Modest weight losses may be associated with improvements in cardiovascular disease risk factors (CVDRF) in patients with obesity. The effects of weight losses on CVDRF in persons with binge-eating disorder (BED) are unknown. This study prospectively examined changes in CVDRF among patients receiving behaviorally-based weight-loss treatment (BBWLT) who attained modest weight losses (≥5 to <10% and ≥10%).

METHOD

Of 191 participants, CVDRF variables were re-assessed in 168 participants at posttreatment and in 151 at 12-month follow-up. Participants who attained ≥5 to <10% weight loss were compared to those who did not on CVDRFs (total cholesterol, HDL, LDL, triglycerides, HbA1C, mean plasma glucose, heart rate, and systolic/diastolic blood pressure); similar comparisons were completed for those who attained ≥10% weight loss.

RESULTS

At posttreatment, ≥5 to <10% weight loss (N = 42; 25.0%) was associated with significant improvements in HbA1c and mean plasma glucose, whereas ≥10% weight loss (N = 40, 23.8%) was associated with significant improvements in total cholesterol, triglycerides, HbA1c, mean plasma glucose, and heart rate. At 12-month follow-up, ≥5 to <10% weight loss (N = 17; 11.1%) was related to significant improvements on HDL, triglycerides, HbA1c, and mean plasma glucose, whereas ≥10% weight loss (N = 40, 26.0%) was associated with significant improvements on all the CVDRF variables (except blood pressure).

CONCLUSIONS

Modest weight loss is associated with significant improvements in CVDRFs in patients with BED and obesity following treatment and at 12-month follow-up. Future work should examine whether improvements in CVDRF are attributable to weight loss per se and/or to other related lifestyle changes.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with binge-eating disorder and obesity who attain modest weight loss following treatment exhibit improvements in various measures of cardiovascular disease risk compared to those who do not. While weight loss has been challenging for individuals with binge-eating disorder, clinicians should inform patients of the potential health benefits of modest weight loss. Future research should investigate whether weight loss itself and/or related behavioral lifestyle changes drive improved cardiovascular disease risk factors.

Real-World User Demographics of Three Web-Based Digital Mental Health Interventions Provided by the US Department of Veterans Affairs: Observational Study Using Web Analytics Data

BACKGROUND

Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively.

OBJECTIVE

This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population.

METHODS

Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported.

RESULTS

In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI's age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users.

CONCLUSIONS

Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers.

The Influence of Comorbidity and Perceived Complexity on Outcomes of Referrals to Children and Young Person Mental Health Services (UK): A Mixed Methods Vignette Study

Children and young people (CYP) with long-term physical conditions (LTCs) are four times more likely to develop mental health disorders yet many cannot access Children and Young People's Mental Health Services (CYPMHS) or evidence-based interventions. This study aimed to understand the reasons for this; presence of an LTC neurodevelopmental disorder, or service requirements. 79 CYP mental health practitioners were randomly assigned to read vignettes depicting a hypothetical referral letter for a child with a mental health condition alone (n = 27), mental health condition and LTC (n = 25), or mental health condition and neurodevelopmental disorder (Autism Spectrum Disorder-ASD) (n = 27), answering questions about their likelihood of accepting the referral and proposed treatment plan. There were no significant differences between accessing CYPMHS or being offered first line evidence-based interventions in those with a LTC or ASD compared to those without. However, additional perceived complexity was frequently provided as a reason for rejecting referrals and not offering evidence-based intervention, with clinicians' predicted success of intervention significantly lower for these CYP. Clinicians were significantly more likely to suggest adapting the intervention in the LTC and the ASD groups to account for additional perceived complexity. The research suggests a need for additional services for CYP with LTCs and those with neurodevelopmental disorders, as well as training/awareness for clinicians.

Predictors and Moderators of Treatment Outcomes for Anxious Children Randomized to Computer-Assisted Cognitive Behavioral Therapy or Standard Community Care

Introduction: Computer-assisted cognitive behavioral therapy (CCBT) for childhood anxiety disorders may aid the dissemination of CBT, while maintaining treatment fidelity. Although CCBT is an effective intervention, not everyone benefits equally from treatment. Identifying patient characteristics that predict who will benefit from treatment and to what extent can help with matching patients to suitable interventions, and allow researchers and clinicians to modify, and individualize, their treatment formats more effectively. Such predictors and moderators have not yet been examined for CCBT outcomes in anxious children and studies of more traditional treatment formats have yielded inconsistent results. Methods: Using data from a randomized clinical trial evaluating CCBT for children with anxiety disorders, this study examined predictors and moderators of treatment outcomes in a sample of 100 children (age: mean [M] = 9.82, standard deviation [SD] = 1.82), randomized to either CCBT (n = 49) or standard community care (n = 51). Potential predictors and moderators were identified from the literature and examined in stepwise multiple linear regression models, using posttreatment anxiety severity and global impairment as outcomes. Results: Parent-rated internalizing symptoms predicted posttreatment anxiety severity for both treatment groups. High pretreatment levels of anxiety severity predicted higher global impairment at posttreatment for the group receiving community care, but not for the CCBT group. Conclusion: Further research is needed to clarify which patient characteristics are associated with CCBT outcomes in a consistent way. ClinicalTrials.gov identifier: NCT01416805.

Randomised controlled trial on the effect of video-conference cognitive behavioural therapy for patients with schizophrenia: a study protocol

INTRODUCTION

Cognitive behavioural therapy for psychosis (CBTp) has demonstrated effectiveness in reducing positive symptoms, improving depression, enhancing coping skills and increasing awareness of illness. However, compared with cognitive behavioural therapy for depression and anxiety, the spread of CBTp in clinical practice is minimal. The present study designed a randomised controlled trial (RCT) research protocol to evaluate whether real-time remote video-conference CBTp (vCBTp) could facilitate access to psychosocial interventions and effectively improve symptoms compared with usual care (UC) for patients with schizophrenia.

METHODS AND ANALYSIS

This exploratory RCT will consist of two parallel groups (vCBTp+UC and UC alone) of 12 participants (n=24) diagnosed with schizophrenia, schizoaffective disorder or paranoid disorder, who remain symptomatic following pharmacotherapy. Seven 50-min weekly vCBTp interventions will be administered to test efficacy. The primary outcome will be the positive and negative syndrome scale score at week 8. The secondary outcome will be the Beck Cognitive Insight Scale to assess insight, the Patient Health Questionnaire-9 to assess depression, the Generalised Anxiety Disorder-7 to assess anxiety, the 5-level EuroQol 5-dimensional questionnaire to assess quality of life and the Impact of Event Scale-Revised to assess subjective distress about a specific stressful life event. We will take all measurements at 0 weeks (baseline) and at 8 weeks (post-intervention), and apply intention-to-treat analysis.

ETHICS AND DISSEMINATION

We will conduct this study in the outpatient department of Cognitive Behavioral Therapy Center at Chiba University Hospital. Further, all participants will be informed of the study and will be asked to sign consent forms. We will report according to the Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

UMIN000043396.

Pharmacotherapy compared to placebo for people with Bulimia Nervosa: A systematic review and meta-analysis

Bulimia Nervosa is a disorder with high rates of psychiatric and medical comorbidity and substantial societal costs. Cognitive Behavioural Therapy is considered the preferred treatment, but access can be problematic. Pharmacotherapy is more accessible but remains significantly underutilised. We aimed to assess the efficacy, tolerability, and safety of all available forms of pharmacotherapy for the treatment of bulimia nervosa. We conducted a comprehensive search of PubMed, EMBASE, CENTRAL, ClinicalTrials.gov, and reference lists of relevant articles up until April 2023. The primary outcomes were remission and binge frequency. 52 randomised controlled trials (RCTs) involving 3313 participants were included in the meta-analysis. Overall, no significant difference was observed between drugs and placebo in terms of remission; however, the available data were limited. Notably, drugs, particularly antidepressants, demonstrated a significant reduction in the frequency of binge episodes compared to placebo. Antidepressants were also found to be more effective than placebo in terms of treatment response and other clinically meaningful outcomes. An important limitation is that few RCTs were available for individual drugs. Our findings provide evidence supporting the increased utilisation of pharmacotherapy in clinical practice and underscore the need for further research involving larger populations and a broader range of outcomes.

Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review

BACKGROUND

Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use.

METHODS

We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle-Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance).

RESULTS

Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers.

DISCUSSION

Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes.

REGISTRATION

PROSPERO registration number CRD42021252038.

Introducing Braining-physical exercise as adjunctive therapy in psychiatric care: a retrospective cohort study of a new method

BACKGROUND

Patients with severe mental disorders suffer from higher rates of poor somatic health and have shorter life expectancy than the average population. Physical activity can treat and prevent several diseases, e.g. cardiovascular and metabolic disorders as well as psychiatric symptoms. It is therefore of utmost importance to develop effective methods to integrate physical activity into psychiatric care. To meet this need, the physical activity intervention Braining was developed. This study aims to describe Braining, to assess the number of patients reached during the first years of pilot testing, to analyze clinical data in the group of patients participating in Braining 2017-2020 and to assess the intervention.

METHODS

In this descriptive retrospective study we analyzed data from all patients participating in Braining training sessions ≥ 3 times (n = 239), the Braining Participants. Regular patients at the clinic served as a comparison. Furthermore, medical records were studied for a smaller cohort (n = 51), the Braining Pilot Cohort. Data was analyzed using Chi-square and Fisher's tests.

RESULTS

During the introduction period of Braining, 580 patients attended an information meeting about Braining, or at least one training session. 239 patients participated in ≥ 3 training sessions, considered to be participants of Braining. These Braining Participants (n = 239), ages 19 to 82, males 23.4%, attended between 3 and 308 training sessions (median 9). The main diagnoses were affective and anxiety disorders. Number of diagnoses ranged from 0 to 10 (median = 2). For the subsample, the Braining Pilot Cohort (n = 51), participants attended between 3 and 208 training sessions (median = 20). Twelve percent were working full-time, and symptom severity of depression and general anxiety was moderate. Two thirds had ≥ 3 different classes of medication. Regarding metabolic morbidity, 28 had been diagnosed with hypertension, though blood lipids, blood glucose as well as blood pressure were within the normal range. Thirty-seven percent were prescribed Physical Activity on Prescription during 2017-2020. One severe adverse event was reported.

CONCLUSIONS

The Braining intervention reached all age-groups and patients with a wide and representative diagnostic panorama, suggesting that Braining could be a promising and safe method for implementing physical activity in a psychiatric patient population.

Cognitive-behavioral therapy for binge-eating disorder for non-responders to initial acute treatments: Randomized controlled trial

OBJECTIVE

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but many patients who receive "evidence-based" interventions do not derive sufficient benefit. Given the dearth of controlled research examining treatments for patients who fail to respond to initial interventions, this study tested the efficacy of cognitive-behavioral therapy (CBT) for patients with BED who do not respond to initial acute treatments.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested 16-weeks of therapist-led CBT for non-responders to initial treatment (naltrexone/bupropion and/or behavioral therapy) for BED with obesity. Thirty-one patients (mean age 46.3 years, 77.4% women, 80.6% White, mean BMI 38.99 kg/m2 ) who were non-responders to initial acute treatments were randomized to CBT (N = 18) or no-CBT (N = 13), in addition to continuing double-blinded pharmacotherapy. Independent assessments were performed at baseline, throughout treatment, and posttreatment; 83.9% completed posttreatment assessments.

RESULTS

Intention-to-treat remission rates were significantly higher for CBT (61.1%; N = 11/18) than no-CBT (7.7%; N = 1/13). Mixed models of binge-eating frequency (assessed using complementary methods) converged revealing a significant interaction between CBT and time and a significant main effect of CBT. Binge-eating frequency decreased significantly with CBT but did not change significantly with no-CBT. Since only four patients received behavioral treatment during the acute treatments, we performed "sensitivity-type" analyses restricted to the 27 patients who received pharmacotherapy during the acute treatment and found the same pattern of findings for CBT versus no-CBT.

CONCLUSIONS

Adult patients with BED who fail to respond to initial pharmacological treatments should be offered CBT.

PUBLIC SIGNIFICANCE

Even with leading evidence-based treatments for binge-eating disorder, many patients do not derive sufficient benefit. Almost no controlled research has examined treatments for patients who fail to respond to initial interventions. This study found that that cognitive-behavioral therapy was effective for patients with binge-eating disorder who did not respond to initial interventions, with 61% achieving abstinence.

A Mobile Application Adjunct to Augment Cognitive-Behavioral Group Therapy for Adolescents with Social Anxiety: Feasibility and Acceptability Results from the Wiring Adolescents with Social Anxiety via Behavioral Interventions Pilot Trial

Objective: Cognitive-Behavioral Group Therapy (CBGT) is an established treatment for Social Anxiety (SA). However, diagnostic recovery rate is only 20.5% in CBGT, and up to 50% of patients remain symptomatic posttreatment. Using videocalls to deliver digital CBGT (dCBGT) is feasible, cost-effective, and efficacious. Yet, the impact of dCBGT on social functioning remains limited, as dCBGT does not offer opportunities for monitoring cognition and behavior in social situations. Wiring Adolescents with Social Anxiety via Behavioral Interventions (WASABI), a clinician-assisted application that uses ecological momentary assessments (EMAs), cognitive bias tests, and clinical self-reports, was investigated as an adjunct to dCBGT. Methods: A prospective, parallel arm, double-blind randomized controlled trial was employed in 24 SA adolescents randomly assigned to dCBGT versus dCBGT plus WASABI. Results: Study completion rates (83%) and exit survey data indicated that WASABI is feasible and acceptable. Engagement with EMAs varied from four to 244 EMAs completed per person. Cognitive bias tests and clinical self-reports were completed at least weekly by 53% and 69% of participants, respectively. While standard tests did not reveal statistically significant differences between dCBGT plus WASABI and dCBGT alone, effect sizes were greater for dCBGT plus WASABI on symptom severity, social skills, and functioning. Conclusions: Despite the small sample, preliminary results suggest that WASABI is feasible, acceptable, and may be an effective augmentation tool for treating SA in teenagers.

Implementing a revised online screening tool in a routine care online clinic treating anxiety and depression

Introduction

The ItFits implementation toolkit was developed as part of the ImpleMentAll EU Project, to help guide implementation processes. The ItFits toolkit was tested in the online clinic, Internetpsykiatrien, in the Region of Southern Denmark, where it was employed to optimize screening and intake procedures. We hypothesized that a larger proportion of assessed patients would be referred to treatment. Further, we hypothesized the completion rate and effectiveness would increase, as a result of including a more relevant sample.

Method

Using the ItFits-toolkit, Internetpsykiatrien developed a revised online screening tool. Data on patient flow and symptom questionnaires was extracted from Internetpsykiatrien six months prior to- and six months after implementation of the revised online screening tool.

Results

A total of 1,830 applicants self-referred for treatment during the study period. A significantly lower proportion of patients were referred to treatment after implementation of the revised screening tool (pre-implementation, n = 1,009; post-implementation, n = 821; odds ratio 0.67, 95% CI: 0.51; 0.87). The number of patients that completed treatment increased significantly (pre-implementation: 136/275 [49.45%], post-implementation, n = 102/162 [62.96%]; odds ratio 1.79, 95% CI 1.20; 2.70). The treatment effect was unchanged (B = 0.01, p = .996). Worth noting, the number of patients that canceled their appointment for the video assessment interview decreased drastically.

Conclusion

By using the ItFits toolkit for a focused and structured implementation effort, the clinic was able to improve the completion rate, which is an important effect in iCBT. However, contrary to our hypotheses, we did not find an increase in clinical effect, nor a larger ratio being referred to treatment after assessment. The decreased number of referrals for treatment could be a result of increased awareness of inclusion criteria among the clinicians.

Applying the Project ECHO Model to Support Implementation and Sustainment of Cognitive Behavioral Therapy for Psychosis

INTRODUCTION

Project Extension for Community Healthcare Outcomes (ECHO) is a teleconsultation model that leverages technology to sustain specialized interventions in underresourced settings. We present the application of the ECHO model to longitudinal training and consultation for community behavioral health providers learning to deliver cognitive behavioral therapy for psychosis, an evidence-based psychotherapy for individuals with psychotic disorders that has poorly penetrated the US mental health system.

METHODS

We analyzed within-group change over practitioners' 6-month ECHO participation cycle using the Expanded Outcomes Framework. We evaluated outcomes associated with participation, satisfaction, knowledge acquisition, performance, patient symptom severity, and functional impairment.

RESULTS

In the first 3 years, the cognitive behavioral therapy for psychosis ECHO Clinics supported 150 providers from 12 community agencies. Forty percent did not complete the 6-month ECHO calendar, most commonly due to separation from their agency. Participants reported high degrees of satisfaction. Declarative and procedural knowledge increased over the 6-month period. Of the 24 providers who received a fidelity review, 87.5% met or exceeded the competency benchmark within the 6-month period. Clinical outcomes reflected reductions in hallucinations, negative symptoms, depression, mania, and functional impairment, but no reductions were detected in delusions, disorganized speech, or abnormal psychomotor behavior.

DISCUSSION

ECHO Clinics offer a mode of providing continuous access to expert instruction, peer-to-peer consultation, and case-based learning that other workforce training models lack. Our evaluation suggests that the ECHO model supports continuous professional development for practitioners, most of whom had indicated inadequate preparation for their role. We observed improved learner and select patient outcomes.

The role of implementation organizations in scaling evidence-based psychosocial interventions

BACKGROUND

To bring evidence-based interventions (EBIs) to individuals with behavioral health needs, psychosocial interventions must be delivered at scale. Despite an increasing effort to implement effective treatments in communities, most individuals with mental health and behavioral problems do not receive EBIs. We posit that organizations that commercialize EBIs play an important role in disseminating EBIs, particularly in the USA. The behavioral health and implementation industry is growing, bringing the implementation field to an important inflection point: how to scale interventions to improve access while maintaining EBI effectiveness and minimizing inequities in access to psychosocial intervention.

MAIN BODY

We offer a first-hand examination of five illustrative organizations specializing in EBI implementation: Beck Institute for Cognitive Behavioral Therapy; Incredible Years, Inc.; the PAXIS Institute; PracticeWise, LLC; and Triple P International. We use the Five Stages of Small Business Growth framework to organize themes. We discuss practical structures (e.g., corporate structures, intellectual property agreements, and business models) and considerations that arise when trying to scale EBIs including balancing fidelity and reach of the intervention. Business models consider who will pay for EBI implementation and allow organizations to scale EBIs.

CONCLUSION

We propose research questions to guide scaling: understanding the level of fidelity needed to maintain efficacy, optimizing training outcomes, and researching business models to enable organizations to scale EBIs.

Resting-state EEG delta and alpha power predict response to cognitive behavioral therapy in depression: a Canadian biomarker integration network for depression study

Cognitive behavioral therapy (CBT) is often recommended as a first-line treatment in depression. However, access to CBT remains limited, and up to 50% of patients do not benefit from this therapy. Identifying biomarkers that can predict which patients will respond to CBT may assist in designing optimal treatment allocation strategies. In a Canadian Biomarker Integration Network for Depression (CAN-BIND) study, forty-one adults with depression were recruited to undergo a 16-week course of CBT with thirty having resting-state electroencephalography (EEG) recorded at baseline and week 2 of therapy. Successful clinical response to CBT was defined as a 50% or greater reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to post-treatment completion. EEG relative power spectral measures were analyzed at baseline, week 2, and as early changes from baseline to week 2. At baseline, lower relative delta (0.5-4 Hz) power was observed in responders. This difference was predictive of successful clinical response to CBT. Furthermore, responders exhibited an early increase in relative delta power and a decrease in relative alpha (8-12 Hz) power compared to non-responders. These changes were also found to be good predictors of response to the therapy. These findings showed the potential utility of resting-state EEG in predicting CBT outcomes. They also further reinforce the promise of an EEG-based clinical decision-making tool to support treatment decisions for each patient.

Preliminary Evaluation of Translated and Culturally Adapted Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: Multicenter, Single-Arm Trial in Japan

BACKGROUND

Internet-delivered cognitive therapy for social anxiety disorder (iCT-SAD), which is a therapist-guided modular web-based treatment, has shown strong efficacy and acceptability in English-language randomized controlled trials in the United Kingdom and Hong Kong. However, it is not yet known whether iCT-SAD can retain its efficacy following linguistic translation and cultural adaptation of treatment contents and implementation in other countries such as Japan.

OBJECTIVE

This study aimed to examine the preliminary efficacy and acceptability of the translated and culturally adapted iCT-SAD in Japanese clinical settings.

METHODS

This multicenter, single-arm trial recruited 15 participants with social anxiety disorder. At the time of recruitment, participants were receiving usual psychiatric care but had not shown improvement in their social anxiety and required additional treatment. iCT-SAD was provided in combination with usual psychiatric care for 14 weeks (treatment phase) and for a subsequent 3-month follow-up phase that included up to 3 booster sessions. The primary outcome measure was the self-report version of the Liebowitz Social Anxiety Scale. The secondary outcome measures examined social anxiety-related psychological processes, taijin kyofusho (the fear of offending others), depression, generalized anxiety, and general functioning. The assessment points for the outcome measures were baseline (week 0), midtreatment (week 8), posttreatment (week 15; primary assessment point), and follow-up (week 26). Acceptability was measured using the dropout rate from the treatment, the level of engagement with the program (the rate of module completion), and participants' feedback about their experience with the iCT-SAD.

RESULTS

Evaluation of the outcome measures data showed that iCT-SAD led to significant improvements in social anxiety symptoms during the treatment phase (P<.001; Cohen d=3.66), and these improvements were maintained during the follow-up phase. Similar results were observed for the secondary outcome measures. At the end of the treatment phase, 80% (12/15) of participants demonstrated reliable improvement, and 60% (9/15) of participants demonstrated remission from social anxiety. Moreover, 7% (1/15) of participants dropped out during treatment, and 7% (1/15) of participants declined to undergo the follow-up phase after completing the treatment. No serious adverse events occurred. On average, participants completed 94% of the modules released to them. Participant feedback was positive and highlighted areas of strength in treatment, and it included further suggestions to improve suitability for Japanese settings.

CONCLUSIONS

Translated and culturally adapted iCT-SAD demonstrated promising initial efficacy and acceptability for Japanese clients with social anxiety disorder. A randomized controlled trial is required to examine this more robustly.

The Bergen 4-day treatment for panic disorder: implementation in a rural clinical setting

INTRODUCTION

The Bergen 4-Day Treatment (B4DT) is a concentrated treatment with individually tailored exposure exercises. The format has shown promising results in the treatment of panic disorder.

AIM

The aim of the current study was to investigate the effectiveness of the B4DT in a large sample in a rural clinical setting.

METHOD

Fifty-eight patients with panic disorder were consecutively included using an open trial design. The primary outcome measure was the Panic Disorder Severity Scale. The Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9 were used as secondary outcome measures. Assessments were conducted at pretreatment, posttreatment, and 3-month follow-up. Treatment satisfaction was measured at posttreatment using the Client Satisfaction Questionnaire-8.

RESULTS

There was a significant reduction in symptoms of panic disorder from pre- to posttreatment (d = 3.36) and from pretreatment to follow-up (d = 3.63). At posttreatment and follow-up, 72.4% and 81.0% of patients, respectively, were classified as in remission. Patients reported high treatment satisfaction, and there were significant reductions in symptoms of generalized anxiety and depression.

CONCLUSION

The results from the current study replicated the findings from previous studies using a larger sample size. The findings indicate that the B4DT is a promising treatment format for panic disorder. The study also demonstrated that the treatment format can be successfully implemented in new rural clinics.

Translating Research Evidence Into Marketplace Application: Cohort Study of Internet-Based Intervention Platforms for Perinatal Depression

BACKGROUND

Internet-based intervention platforms may improve access to mental health care for women with perinatal depression (PND). Though the majority of platforms in the market lack an evidence base, a small number of them are supported by research evidence.

OBJECTIVE

This study aims to assess the current status of internet-based PND intervention platforms supported by published evidence, understand the reasons behind the disappearance of any of these previously accessible platforms, examine adjustments made by those active platforms between research trials and market implementation, and evaluate their current quality.

METHODS

A cohort of internet-based PND intervention platforms was first identified by systematic searches in multiple academic databases from database inception until March 26, 2021. We searched on the World Wide Web and the iOS and Android app stores to assess which of these were available in the marketplace between April and May 2021. The basic characteristics of all platforms were collected. For inaccessible platforms, inquiries were made via email to the authors of publications to determine the reasons for their unavailability. We compared the intervention-related information of accessible platforms in the marketplace with that reported in original publications and conducted quality assessments using the App Evaluation Model of the American Psychiatric Association. Fisher exact tests were used to compare the functional characteristics in publications of available and unavailable platforms and to investigate potential associations between functional adjustments or quality indices and platform survival time.

RESULTS

Out of 35 platforms supported by research evidence, only 19 (54%) were still accessible in the marketplace. The main reason for platforms disappearing was the termination of research projects. No statistically significant differences were found in functional characteristics between available and unavailable platforms. A total of 18 (95%) platforms adapted their core functions from what was reported in related publications. The adjustments included changes to intervention methods (11/19, 58%), target population (10/19, 53%), human resources for intervention support (9/19, 47%), mood assessment and monitoring (8/19, 42%), communication modality (4/19, 21%), and platform type (2/19, 11%). Quality issues across platforms included low frequency of update, lack of crisis management mechanism, poor user interactivity, and weak evidence base or absence of citation of supporting evidence. Platforms that survived longer than 10 years had a higher tendency to use external resources from third parties compared to those that survived less than 10 years (P=.04). No significant differences were found for functional adjustments or other quality indices.

CONCLUSIONS

Internet-based platforms supported by evidence were not effectively translated into real-world practice. It is unclear if adjustments to accessible platforms made during actual operation may undermine the proven validity of the original research. Future research to explore the reasons behind the success of the implementation of evidence-based platforms in the marketplace is warranted.

Psychological therapists' perceptions of adolescent depression and its treatment: A mixed methods online survey

BACKGROUND

Challenges to implementating interventions for adolescent depression exist. Exploring the perceptions of key stakeholders in the treatment of adolescent depression is essential for improving implementation . This study aimed to explore psychological therapists' perceptions of, and experiences treating, adolescent depression to identify future avenues for exploration.

METHOD

Data were collected opportunistically via a survey integrated within an e-learning package about adolescent depression.

RESULTS

Participants believed that adolescent depression was characterised by adolescents' lack of understanding, isolation, and a lack of hope and knowledge. Participants overcame engagement barriers by building trust. Following the e-learning, participants expressed increased understanding of the risk factors associated with adolescent depression and of assessment using different measures. Several key areas for future research to explore were identified and discussed, including (1) whether clinicians of different modalities or at different career stages have difference perceptions, (2) how to meaningfully engage adolescents in treatment and (3) how to train clinicians on different modalities so patients have a choice over their treatment.

CONCLUSION

This study demonstrates the value of knowledge gained from understanding psychological therapists' perceptions and illustrates how this can contribute to the improved treatment of adolescent depression.

Efficacy of a digital mental health intervention embedded in routine care compared with treatment as usual in adolescents and young adults with moderate depressive symptoms: protocol for randomised controlled trial

INTRODUCTION

There are unmet mental health needs of depressed adolescents and young adults (AYAs) across the USA. Behavioural technology adequately integrated into clinical care delivery has potential to improve care access and efficiency. This multisite randomised controlled trial evaluates how a coach-enhanced digital cognitive behavioural intervention (dCBI) enhances usual care for depressed AYAs in paediatric practices with minority enriched samples.

METHODS AND ANALYSIS

Participants (n=750) ages 16-22 who meet threshold criteria for depressive severity (Patient Health Questionnaire-9; PHQ-9 score 10-24) will be recruited through paediatric practices across three academic institutions (Boston, Pittsburgh and San Diego). Participants will be randomised to 12 weeks of dCBI+treatment as usual (TAU) (n=450) or TAU alone (n=300) in outpatient paediatric practices. Assessments will be completed at baseline, 6 weeks and 12 weeks with the primary outcome being improvement in clinician-rated and self-reported depressive severity (Children's Depression Rating Scale-Revised and PHQ-9) and secondary outcomes being self-reported suicidal ideation (item 9 on PHQ-9), anxiety severity (Generalised Anxiety Disorder), general quality of life (Satisfaction with Life Scale) and general functioning (Children's Global Assessment Scale). The study design is an intent-to-treat mixed effects regression with group, and covariates nested within the sites.

ETHICS AND DISSEMINATION

All participants or their parent/guardian (under 18 years or unemancipated) will give informed consent to a study team member. All data are expected to be collected over 18 months. The Institutional Review Board (IRB) is a board at each institution in the United States that reviews and monitors research involving human subjects. IRB approval from the University of Pittsburgh was obtained on 30 November 2021 (STUDY21080150), from the University of California San Diego's Human Research Protection Program IRB on 14 July 2022 (802047), and from the Boston Children's Hospital IRB on 25 October 2022 (P00040987). Full study results are planned to be published within 2 years of initial study recruitment (October 2024). Dissemination of findings will occur in peer-reviewed journals, professional conferences and through reports to participating entities and stakeholders.

TRIAL REGISTRATION NUMBER

NCT05159713; ClinicalTrials.gov.

A Feasibility Study Investigating Mechanisms of Change in Public Mental Health Dialectical Behaviour Therapy Programmes

Few studies have investigated the feasibility of researching brief forms of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in public mental health settings. This study aimed to provide preliminary evidence for the feasibility of implementing DBT over a 6-month period for BPD symptoms within Australian public mental health services. Of the 79 participants with BPD recruited, 62 commenced and 24 participants completed the therapy. The participants attended one of three outpatient DBT programmes and completed measures of BPD symptoms, DBT skills-use, and difficulties with emotion regulation at baseline and after 6 months of treatment. A major challenge with feasibility identified was the high attrition rate (61%). However, for completers there were significant improvements in BPD symptoms, DBT skills-use, and difficulties with emotion regulation. These effect sizes were used to estimate the sample sizes needed by future larger trials of brief DBT for BPD in public health settings. The implementation of brief DBT for BPD patients within a public mental health outpatient setting, appears to result in significant reductions in BPD symptoms. However, further exploration of strategies to reduce drop-out rates are required.

Anxiety sensitivity as a predictor, and non-specific therapeutic factors as predictors and mediators of CBT outcome for obsessive-compulsive disorder in a naturalistic mental health setting

OBJECTIVE

We examined the unique predictive strength of anxiety sensitivity (AS) and the role of expectancy, credibility, and therapeutic alliance (TA) as predictors and mediators of cognitive-behavioral treatment (CBT) outcomes in obsessive-compulsive disorder (OCD).

METHOD

The current study is a prospective cohort study. Participants (N = 116) were treatment-seeking individuals with a primary diagnosis of OCD. Independent raters assessed patients on Yale-Brown Obsessive-Compulsive Scale (YBOCS) and Anxiety Sensitivity Index-3 at baseline, post-intervention, and three-month follow-up. Participants responded to the Credibility and Expectancy questionnaire and Working Alliance Inventory-Short revised at baseline, first-session, and mid-session.

RESULTS

The individual addition of AS, end-of-first-session credibility and expectancy, mid-session credibility and expectancy, and therapeutic alliance predicted significant CBT outcomes. There was a moderate positive correlation between baseline OCD severity and the global score of AS, but a weak one with AS dimensions. Both expectancy and credibility significantly improved from baseline to end-of-first-session treatment. End-of-first and third-session outcome expectancies, not credibility, have significant, indirect effects on OCD CBT outcomes.

CONCLUSIONS

AS, within-session credibility and expectancies and TA independently predict CBT outcomes. Within-sessions outcome expectancies mediate CBT outcomes in OCD, not credibility. Expectancy and credibility both include state-like elements that can be influenced to enhance the outcomes of CBT. Proposals for reducing treatment barriers in CBT for OCD are offered.

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Predictors and significance of rapid response to behaviorally based treatment of binge eating disorder

OBJECTIVE

This study examined baseline predictors of rapid response and its prognostic significance in a clinical trial of behaviorally based weight loss treatment (BBWLT) for binge eating disorder in patients with obesity.

METHODS

One hundred ninety-one participants receiving BBWLT were assessed at baseline, throughout treatment, and at posttreatment (6 months) by independent assessors. Rapid response was defined as ≥ 65% reduction in binge eating by the fourth treatment week. Patients with versus without rapid response were compared on demographic features, a broad range of current/past clinical and psychiatric variables, and treatment attitudes. Rapid response was used to prospectively predict posttreatment outcomes.

RESULTS

Rapid response, which characterized 63% (N = 120) of participants, was not associated significantly with any demographic features or with any current/past clinical and psychiatric variables. Higher ratings (at week one) regarding the logic of BBWLT and greater confidence that treatment would help with binge eating and weight loss were associated significantly with rapid response (at week four). Rapid response was prospectively associated with significantly better binge eating and weight loss outcomes.

CONCLUSIONS

These findings indicate that rapid response to BBWLT for binge eating disorder prospectively predicts superior clinical outcomes in both binge eating and weight loss. Treatment attitudes, rather than patient demographic or clinical severity variables, are prospectively associated with rapid response.

Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students

BACKGROUND

There is a paucity of research on therapist competence development following extensive training in cognitive behavioural therapy (CBT). In addition, metacognitive ability (the knowledge and regulation of one's cognitive processes) has been associated with learning in various domains but its role in learning CBT is unknown.

AIMS

To investigate to what extent psychology and psychotherapy students acquired competence in CBT following extensive training, and the role of metacognition.

METHOD

CBT competence and metacognitive activity were assessed in 73 psychology and psychotherapy students before and after 1.5 years of CBT training, using role-plays with a standardised patient.

RESULTS

Using linear mixed modelling, we found large improvements of CBT competence from pre- to post-assessment. At post-assessment, 72% performed above the competence threshold (36 points on the Cognitive Therapy Scale-Revised). Higher competence was correlated with lower accuracy in self-assessment, a measure of metacognitive ability. The more competent therapists tended to under-estimate their performance, while less competent therapists made more accurate self-assessments. Metacognitive activity did not predict CBT competence development. Participant characteristics (e.g. age, clinical experience) did not moderate competence development.

CONCLUSIONS

Competence improved over time and most students performed over the threshold post-assessment. The more competent therapists tended to under-rate their competence. In contrast to what has been found in other learning domains, metacognitive ability was not associated with competence development in our study. Hence, metacognition and competence may be unrelated in CBT or perhaps other methods are required to measure metacognition.

Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial

Importance

Anxiety disorders are common, highly distressing, and impairing conditions. Effective treatments exist, but many patients do not access or respond to them. Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR) are popular and can decrease anxiety, but it is unknown how they compare to standard first-line treatments.

Objective

To determine whether MBSR is noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders.

Design, Setting, and Participants

This randomized clinical trial (Treatments for Anxiety: Meditation and Escitalopram [TAME]) included a noninferiority design with a prespecified noninferiority margin. Patients were recruited between June 2018 and February 2020. The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks. Of 430 individuals assessed for inclusion, 276 adults with a diagnosed anxiety disorder from 3 urban academic medical centers in the US were recruited for the trial, and 208 completed the trial.

Interventions

Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg.

Main Outcomes and Measures

The primary outcome measure was anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S), with a predetermined noninferiority margin of -0.495 points.

Results

The primary noninferiority sample consisted of 208 patients (102 in MBSR and 106 in escitalopram), with a mean (SD) age of 33 (13) years; 156 participants (75%) were female; 32 participants (15%) were African American, 41 (20%) were Asian, 18 (9%) were Hispanic/Latino, 122 (59%) were White, and 13 (6%) were of another race or ethnicity (including Native American or Alaska Native, more than one race, or other, consolidated owing to low numbers). Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample. At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram. The difference between groups was -0.07 (0.16; 95% CI, -0.38 to 0.23; P = .65), where the lower bound of the interval fell within the predefined noninferiority margin of -0.495, indicating noninferiority of MBSR compared with escitalopram. Secondary intent-to-treat analyses using imputed data also showed the noninferiority of MBSR compared with escitalopram based on the improvement in CGI-S score. Of patients who started treatment, 10 (8%) dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%).

Conclusions and Relevance

The results from this randomized clinical trial comparing a standardized evidence-based mindfulness-based intervention with pharmacotherapy for the treatment of anxiety disorders found that MBSR was noninferior to escitalopram.

Trial Registration

ClinicalTrials.gov Identifier: NCT03522844.

Therapist perceptions of the implementation of a new screening procedure using the ItFits-toolkit in an iCBT routine care clinic: A mixed-methods study using the consolidated framework for implementation research

Introduction

This study investigates the implementation of a new, more automated screening procedure using the ItFits-toolkit in the online clinic, Internet Psychiatry (iPsych) (www.internetpsykiatrien.dk), delivering guided iCBT for mild to moderate anxiety and depressive disorders. The study focuses on how the therapists experienced the process.

Methods

Qualitative data were collected from semi-structured individual interviews with seven therapists from iPsych. The interviews were conducted using an interview guide with questions based on the Consolidated Framework for Implementation Research (CFIR). Quantitative data on the perceived level of normalization were collected from iPsych therapists, administrative staff, and off-site professionals in contact with the target demographic at 10-time points throughout the implementation.

Results

The therapists experienced an improvement in the intake procedure. They reported having more relevant information about the patients to be used during the assessment and the treatment; they liked the new design better; there was a better alignment of expectations between patients and therapists; the patient group was generally a better fit for treatment after implementation; and more of the assessed patients were included in the program. The quantitative data support the interview data and describe a process of normalization that increases over time.

Discussion

The ItFits-toolkit appears to have been an effective mediator of the implementation process. The therapists were aided in the process of change, resulting in an enhanced ability to target the patients who can benefit from the treatment program, less expenditure of time on the wrong population, and more satisfied therapists.

Adaptation, personalization and capacity in mental health treatments: a balancing act?

PURPOSE OF REVIEW

There are increasing calls for mental health treatments to be adapted for different groups to maximize their acceptability and benefit to patients. However, adaptations can be costly to develop and evaluate, difficult to implement in routine clinical practice and may reduce service capacity at a time when there is unprecedented unmet need. An alternative method is personalization on an individual level. This review provides an overview of the issues related to personalization and adaptation of mental health interventions.

RECENT FINDINGS

Several terms have been used to describe changes to existing therapies, these reflect different extents to which existing treatments have been changed. Evidence-based practice and modular therapies allow a level of flexibility within intervention delivery without formal changes and not all changes to therapy should be considered as a new/adapted treatment but instead regarded as 'metacompetence'. Implementing existing interventions in new contexts is preferable to developing new interventions in many instances. New guidance outlines how researchers can adapt and transfer interventions to varied contexts.

SUMMARY

The review provides proposed definitions of different changes to therapy. Modified and personalized treatments may improve acceptability to patients whilst maximizing implementation of evidence-based practice within clinical services.

Doctoral clinical psychology student commentary on common myths about CBT: lessons learned for competency-based training

Effective methods for training and education in the dissemination of evidence-based treatments is a priority. This commentary provides doctoral clinical psychology graduate student authors perspectives on common myths about cognitive behavioural therapy (CBT). Three myths were identified and considered: (1) CBT does not value the therapeutic relationship; (2) CBT is overly rigid; and (3) exposure techniques are cruel. Graduate students were engaged in a competency-based course in Cognitive Behavioural Approaches to Psychotherapy at an American Psychological Association (APA)-accredited doctoral clinical psychology program. The origins of common myths identified by graduate students included a lack of in-depth coverage of CBT and brief video segments provided during introductory courses, lived experience with CBT, and pre-determined views of manualized treatment and exposure techniques. Myth-addressing factors discussed by graduate students included holding space at the start of training for a discussion of attitudes about CBT, specific learning activities, and course content described in this commentary. Finally, self-reported changes in graduate students’ attitudes and behaviour following the course included a more favourable view of CBT as valuing the therapeutic relationship, as well as implementation of resources provided, and techniques learned and practised at practicum settings. Limitations and lessons learned are discussed through the lens of a model of adult learning that may be applied to future graduate training in evidence-based therapies like CBT.

Key learning aims

(1)

Near-infrared spectroscopy in child and adolescent neurodevelopmental disorders

Near-infrared spectroscopy (NIRS) is a noninvasive optical technique that uses the near-infrared spectrum for functional neuroimaging by measuring oxygenation and hemodynamic changes in the cerebral cortex. The advantages of NIRS include its portability and ease of application, which allows for testing with the subject in natural positions, such as sitting or standing. Since 1994, NIRS has been increasingly used to conduct functional activation studies on different psychiatric disorders, most prominently schizophrenia, depression, bipolar disorder, and neurodevelopmental disorders. However, limited information on its use among child and adolescent patients is available. We herein review recent findings obtained using NIRS measurements of the brain during cognitive tasks in neurodevelopmental disorders, such as autism spectrum disorder, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and Tourette's disorder. This will facilitate evaluations of the causation and treatment of prefrontal cortex dysfunctions.

Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study

BACKGROUND

Symptoms of depression and anxiety, suicidal ideation, and self-harm have escalated among adolescents to crisis levels during the COVID-19 pandemic. As a result, primary care providers (PCPs) are often called on to provide first-line care for these youth. Digital health interventions can extend mental health specialty care, but few are evidence based. We evaluated the feasibility of delivering an evidence-based mobile health (mHealth) app with an embedded conversational agent to deliver cognitive behavioral therapy (CBT) to symptomatic adolescents presenting in primary care settings during the pandemic.

OBJECTIVE

In this 12-week pilot study, we evaluated the feasibility of delivering the app-based intervention to adolescents aged 13 to 17 years with moderate depressive symptoms who were treated in a practice-based research network (PBRN) of academically affiliated primary care clinics. We also obtained preliminary estimates of app acceptability, effectiveness, and usability.

METHODS

This small, pilot randomized controlled trial (RCT) evaluated depressive symptom severity in adolescents randomized to the app or to a wait list control condition. The primary end point was depression severity at 4-weeks, measured by the 9-item Patient Health Questionnaire (PHQ-9). Data on acceptability, feasibility, and usability were collected from adolescents and their parent or legal guardian. Qualitative interviews were conducted with 13 PCPs from 11 PBRN clinics to identify facilitators and barriers to incorporating mental health apps in treatment planning for adolescents with depression and anxiety.

RESULTS

The pilot randomized 18 participants to the app (n=10, 56%) or to a wait list control condition (n=8, 44%); 17 participants were included in the analysis, and 1 became ineligible upon chart review due to lack of eligibility based on documented diagnosis. The overall sample was predominantly female (15/17, 88%), White (15/17, 88%), and privately insured (15/17, 88%). Mean PHQ-9 scores at 4 weeks decreased by 3.3 points in the active treatment group (representing a shift in mean depression score from moderate to mild symptom severity categories) and 2 points in the wait list control group (no shift in symptom severity category). Teen- and parent-reported usability, feasibility, and acceptability of the app was high. PCPs reported preference for introducing mHealth interventions like the one in this study early in the course of care for individuals presenting with mild or moderate symptoms.

CONCLUSIONS

In this small study, we demonstrated the feasibility, acceptability, usability, and safety of using a CBT-based chatbot for adolescents presenting with moderate depressive symptoms in a network of PBRN-based primary care clinics. This pilot study could not establish effectiveness, but our results suggest that further study in a larger pediatric population is warranted. Future study inclusive of rural, socioeconomically disadvantaged, and underrepresented communities is needed to establish generalizability of effectiveness and identify implementation-related adaptations needed to promote broader uptake in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04603053; https://clinicaltrials.gov/ct2/show/NCT04603053.

Naturalistic outcome of nurse-led psychological therapy for mental disorders in routine outpatient care: A retrospective chart review

This study aimed to investigate the clinical effectiveness of nurse-led cognitive/behavioral therapy (CBT) in Japanese routine outpatient care. We retrospectively collected data from 100 cases with mental disorders who had received nurse-led CBT. Results demonstrated that CBT provided by nurses led to significant improvements in quality of life and other clinical outcomes during the intervention period (all p < 0.001). Among participants who received optional follow-up, these improvements were well-maintained. This real-world evidence of nurse-led CBT bridges the research-practice gap, and will encourage frontline nurses and motivate institutional/organizational leaders, academic/professional societies, and policymakers to employ empirically-supported psychotherapeutic techniques in routine nursing care.

Study protocol for a randomized controlled trial evaluating the effectiveness of an internet-based self-help intervention to cope with psychological distress due to COVID-19 in the Italian general population: the RinasciMENTE project

BACKGROUND

This study aims to evaluate the feasibility and effectiveness of the RinasciMENTE program, an Internet-based self-help intervention based on cognitive behavioral therapy (CBT) principles and techniques in supporting individuals experiencing psychological impairments during the COVID-19 pandemic. A randomized controlled trial (RCT) design with random allocation at the level of individual will be conducted to compare the impact of the RinasciMENTE program with a waiting list control in improving the psychological functioning of the general population during the COVID-19 pandemic.

METHODS

A minimum sample of 128 participants experiencing mild/subthreshold levels of psychological symptoms during the COVID-19 pandemic will be recruited. After the initial screening, participants will be randomly assigned to either the experimental group or the control condition. The program will last 2 months, during which participants will receive 8 weekly CBT treatment modules. The impact of the RinasciMENTE program on selected primary and secondary psychological outcomes will be tested at the end of the intervention (2 months) and 6- and 12-month follow-ups.

DISCUSSION

We expect people to show an increased level of psychological functioning and to acquire the skills and self-confidence necessary to deal with the psychological consequences of the COVID-19 outbreak and its related social isolation during and following the pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT0497903 Registered on 28 May 2021.

Clinical feasibility of cognitive behavioural therapy for insomnia in a real-world mixed sample at a specialized psychiatric outpatient clinic

BACKGROUND

A majority of psychiatric patients suffer from insomnia or insomnia-like problems. In addition to impairing quality of life, sleep problems can worsen psychiatric conditions, such as depression and anxiety, and can make treatment of various psychiatric conditions less successful. Several international guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first line treatment. However, patients in psychiatric care are rarely offered this treatment, and there is a lack of studies evaluating the treatment in regular psychiatric settings. In this pilot study, we aimed to determine the clinical feasibility of a group-based CBT-I intervention in an outpatient clinical setting for patients with depression, bipolar disorder, anxiety disorders and PTSD. We also aimed to investigate if symptoms of insomnia, depression and anxiety changed after CBT-I.

METHODS

Seventeen patients at an out-patient psychiatric clinic for mixed psychiatric problems of anxiety, affective disorders and PTSD, were enrolled in a six-week long group-based CBT-I intervention. Primary outcomes were pre-defined aspects of treatment feasibility. Secondary outcomes were changes in self-reported symptoms of insomnia severity, depression, and anxiety between pre - and post intervention. Assessment of insomnia severity was also performed 3 months after treatment. Feasibility data is reported descriptively, changes in continuous data from pre- to post-treatment were analysed with dependent t-tests.

RESULTS

All feasibility criteria were met; there were enough patients to sustain at least one group per semester (e.g., minimum 8), 88% of included patients attended the first session, mean of attended sessions was 4.9 of 6, and drop-out rate was 5.9%. Therapists, recruited from clinical staff, found the treatment manual credible, and possible to use at the clinic. Symptoms of insomnia decreased after treatment, as well as symptoms of depression and anxiety.

CONCLUSION

CBT-I could prove as a clinically feasible treatment option for insomnia in a psychiatric outpatient setting.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05379244. Retrospectively registered 18/05/2022.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS)

Background

Urologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response.

Methods

UCPPS patients (240) ages 18–70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief.

Discussion

Empirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine.

Trial Registration

Clinicaltrials.gov NCT05127616. Registered on 9/19/21.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06554-9.

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey

BACKGROUND

Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE).

OBJECTIVE

To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE.

METHODS

An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo^†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers.

RESULTS

In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia.

CONCLUSION

Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Efficacy and Acceptability of Remote Cognitive Behavioral Therapy for Patients With Major Depressive Disorder in Japanese Clinical Settings: A Case Series

Remote cognitive and behavioral therapy (CBT) via videoconference has been garnering attention as a means of improving access to CBT for depression, in particular during the coronavirus disease 2019 pandemic. However, there is a lack of evidence supporting its implementation in Japanese clinical settings. This case series aimed to establish preliminary evidence of whether remote CBT can be an effective therapy for major depression in Japanese clinical settings. Five patients who met the diagnostic criteria for major depressive disorder were enrolled and underwent remote CBT via videoconference and face-to-face assessment interviews. The results showed that remote CBT via videoconference improved depressive symptoms, enabling a relatively high level of patient satisfaction and working alliance. Moreover, detailed feedback from our patients showed that continuous monitoring was preferable for increasing treatment engagement. Further research is warranted to test the efficacy and acceptability of remote CBT via videoconference for treating major depression.

Treating sleep and circadian problems to promote mental health: perspectives on comorbidity, implementation science and behavior change

Insufficient sleep and mistimed sleep are prominent, yet under-appreciated and understudied, contributors to poor mental health and to mental disorders. The evidence that improving sleep and circadian functioning is an important pathway to mental health continues to mount. The goal of this paper is to highlight three major challenges ahead. Challenge 1 points to the possibility that comorbidity is the norm not the exception for the sleep and circadian disorders that are associated with mental disorders. Hence, the sleep and circadian problems experienced by people diagnosed with a mental disorder may not fit into the neat diagnostic categories of existing nosologies nor be adequately treated with single disorder approaches. The Sleep Health Framework and the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) are discussed as alternative approaches. Challenge 2 points to the large time lag between the development of a treatment and the availability of that treatment in routine clinical practice. This is a key reason for the emergence of implementation science, which is a flourishing, well-developed, and quickly moving field. There is an urgent need for more applications of implementation science within sleep and circadian science. Challenge 3 describes one of the greatest puzzles of our time-the need to unlock the fundamental elements of behavior change. There is potential to harness the science of behavior change to encourage widespread engagement in sleep health behavior and thereby reduce the staggering burden of sleep and circadian problems and the associated mental health problems.

Paraprofessional Youth Mentoring: A Framework for Integrating Youth Mentoring with Helping Institutions and Professions

The demand for child mental health services, including those provided by psychologists, counselors, and social workers, exceeds the supply. This trend is expected to continue or worsen unless there are substantial structural changes in how mental health services are provided. We propose a framework for paraprofessional youth mentors, defined as a subgroup of professionally supervised, non-expert volunteer or paid mentors to whom aspects of professional helping tasks are delegated. Our proposal is aligned with historical and modern solutions to scaling mental health services, and this framework could simultaneously increase the number of youth receiving evidence-based mental health services and reduce the burden on existing systems of care. The framework defines three plausible tasks for paraprofessional mentors: (1) reducing barriers to mental health service, (2) increasing engagement in services, and (3) providing direct services. The safety and effectiveness of these task-shifting efforts will hinge on competency-based training and evaluation, supervision by professionals, and documentation of services rendered, all of which the field of youth mentoring currently lacks. We describe several requisite scientific, institutional, and regulatory advances that will be necessary to realize this variant of youth mentoring for a subgroup of youth who are presenting for assistance with mental health problems.

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial

Background

Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps.

Methods

With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II).

Discussion

Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system.

Trial registration

ClinicalTrials.govNCT05037344. Registered May 2019, last release August 13th, 2021.

Economic evaluation alongside a randomized controlled trial of blended cognitive-behavioral therapy for patients suffering from major depressive disorder

OBJECTIVE

This study aimed to investigate the cost-effectiveness of blended cognitive-behavioral therapy (CBT) compared to standard CBT for adult patients suffering from major depressive disorder (MDD).

DESIGN

A cost-utility analysis alongside the randomized controlled ENTER trial.

SETTING

Center for Telepsychiatry, Mental Health Services in the Region of Southern Denmark, Denmark.

PARTICIPANTS

The study included 76 patients suffering from MDD.

INTERVENTIONS

The patients in the intervention group received blended CBT treatment comprising a combination of online modules and face-to-face consultations with a psychologist. The patients in the control group received standard CBT treatment, that is, solely face-to-face consultations with a psychologist. The treatment period was 12 weeks.

OUTCOME MEASURES

Cost-effectiveness was reported as incremental cost-effectiveness ratio. A micro-costing approach was applied to evaluate the savings derived. Changes in quality-adjusted life-years (QALYs) were estimated using the EuroQol 5-Dimensions 5-Levels questionnaire at the baseline and the six-month follow-up.

RESULTS

Data for 74 patients were included in the primary analysis. The adjusted QALY difference between blended CBT and standard CBT was -0.0291 (95% CI: -0.0535 to -0.0047), and the adjusted difference in costs was -£226.32 (95% CI: -300.86 to -151.77). Blended CBT was estimated to have a 6.6% and 3.1% probability of being cost-effective based on thresholds of £20,000 and £30,000.

CONCLUSION

Compared to standard CBT, blended CBT represents a cost-saving but also a loss in QALYs for patients suffering from MDD. However, results should be carefully interpreted, given the small sample size. Future research involving larger replication studies focusing on other aspects of blended CBT with more patient involvement is advised.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov: S-20150150.

A pilot randomized controlled trial of the shogi-assisted cognitive behavioral therapy (S-CBT) preventive stress management program

Background

Shogi is a traditional board game in Japan. A preventive stress management program based on Shogi-assisted cognitive behavioral therapy (S-CBT) was applied in the Japanese municipality of Kakogawa City. The study aimed to develop an S-CBT preventive stress management program for the elderly and determine its efficacy.

Methods

The participants were 67 elderly men with amateur-level Shogi skills. They were randomly assigned to either the S-CBT group (n = 33) or the waiting-list control group (n = 34). The S-CBT program was conducted over six 90-min sessions. The outcome measures were recorded using K6 instrument, the Japanese version of the abbreviated Lubben Social Network Scale, five items on cognitive behavioral functioning, and subjective well-being scale.

Results and conclusions

The dropout rates of the S-CBT group and waiting-list control groups were 36.4 and 44.1%, respectively. Effect sizes (Cohen’s d) and 95% confidence intervals (CIs) were calculated for each group. Domains that changed immediately after the S-CBT intervention were problem-solving skills, self-reinforcement, and negative automatic thoughts. Future research should promote mental and physical health through the design of intervention programs using familiar materials.

Trial registration

University Hospital Medical Information Network (UMIN CTR) UMIN000036003.

Digitized thought records: a practitioner-focused review of cognitive restructuring apps

Mental health (MH) apps can be used as adjunctive tools in traditional face-to-face therapy to help implement components of evidence-based treatments. However, practitioners interested in using MH apps face a variety of challenges, including knowing which apps would be appropriate to use. Although some resources are available to help practitioners identify apps, granular analyses of how faithfully specific clinical skills are represented in apps are lacking. This study aimed to conduct a review and analysis of MH apps containing a core component of cognitive behaviour therapy (CBT) – cognitive restructuring (CR). A keyword search for apps providing CR functionality on the Apple App and Android Google Play stores yielded 246 apps after removal of duplicates, which was further reduced to 15 apps following verification of a CR component and application of other inclusionary/exclusionary criteria. Apps were coded based on their inclusion of core elements of CR, and general app features including app content, interoperability/data sharing, professional involvement, ethics, and data safeguards. They were also rated on user experience as assessed by the Mobile App Rating Scale (MARS). Whereas a majority of the CR apps include most core CR elements, they vary considerably with respect to more granular sub-elements of CR (e.g. rating the intensity of emotions), other general app features, and user experience (average MARS = 3.53, range from 2.30 to 4.58). Specific apps that fared best with respect to CR fidelity and user experience dimensions are highlighted, and implications of findings for clinicians, researchers and app developers are discussed.

Key learning aims

(1)