The Cognitive Therapy Scale: psychometric properties

Enhancing the quality of cognitive behavioral therapy in community mental health through artificial intelligence generated fidelity feedback (Project AFFECT): a study protocol

Background

Each year, millions of Americans receive evidence-based psychotherapies (EBPs) like cognitive behavioral therapy (CBT) for the treatment of mental and behavioral health problems. Yet, at present, there is no scalable method for evaluating the quality of psychotherapy services, leaving EBP quality and effectiveness largely unmeasured and unknown. Project AFFECT will develop and evaluate an AI-based software system to automatically estimate CBT fidelity from a recording of a CBT session. Project AFFECT is an NIMH-funded research partnership between the Penn Collaborative for CBT and Implementation Science and Lyssn.io, Inc. (“Lyssn”) a start-up developing AI-based technologies that are objective, scalable, and cost efficient, to support training, supervision, and quality assurance of EBPs. Lyssn provides HIPAA-compliant, cloud-based software for secure recording, sharing, and reviewing of therapy sessions, which includes AI-generated metrics for CBT. The proposed tool will build from and be integrated into this core platform.

Methods

Phase I will work from an existing software prototype to develop a LyssnCBT user interface geared to the needs of community mental health (CMH) agencies. Core activities include a user-centered design focus group and interviews with community mental health therapists, supervisors, and administrators to inform the design and development of LyssnCBT. LyssnCBT will be evaluated for usability and implementation readiness in a final stage of Phase I. Phase II will conduct a stepped-wedge, hybrid implementation-effectiveness randomized trial (N = 1,875 clients) to evaluate the effectiveness of LyssnCBT to improve therapist CBT skills and client outcomes and reduce client drop-out. Analyses will also examine the hypothesized mechanism of action underlying LyssnCBT.

Discussion

Successful execution will provide automated, scalable CBT fidelity feedback for the first time ever, supporting high-quality training, supervision, and quality assurance, and providing a core technology foundation that could support the quality delivery of a range of EBPs in the future.

Trial registration

ClinicalTrials.gov; NCT05340738; approved 4/21/2022.

Face Your Fears: Virtual reality-based cognitive behavioral therapy (VR-CBT) versus standard CBT for paranoid ideations in patients with schizophrenia spectrum disorders: a randomized clinical trial

BACKGROUND

Schizophrenia spectrum disorders cause suffering for patients, relatives, and the surrounding society. Paranoid ideations, encompassing ideas of social reference and manifest persecutory delusions, are among the most frequent symptoms in this population and a cause of significant distress. Recent meta-analyses of cognitive behavioral therapy (CBT) for psychosis show small to moderate effect sizes in reducing paranoid ideations. Virtual reality-based CBT (VR-CBT) could improve therapy efficacy as exposure and behavioral experiments in VR can be optimized, individualized, and carried out in a safe environment. Few VR-CBT studies exist for paranoid ideations and there is a need for large-scale, methodologically rigorous trials.

METHODS

This study is a randomized, assessor-blinded parallel-groups multi-center superiority clinical trial, fulfilling the CONSORT criteria for non-pharmacological treatment. A total of 256 patients diagnosed with schizophrenia spectrum disorder, including schizotypal disorder (ICD-10 F20-29), will be allocated to either 10 sessions of symptom-specific CBT-VR plus treatment as usual-versus 10 sessions of standard symptom-specific CBT for paranoid ideations (CBT) plus treatment as usual. All participants will be assessed at baseline, treatment end (3 months post baseline), and then 9 months post baseline. A stratified block-randomization with concealed randomization sequence will be conducted. Independent assessors blinded to the treatment will evaluate the outcome. Analysis of outcome will be carried out with the intention to treat principles. The primary outcome is ideas of social reference measured with Green Paranoid Thought Scale Part A (GPTS-A) at the cessation of treatment at 3 months post baseline. Secondary outcomes are ideas of persecution (GPTS-B), Social Interaction Anxiety Scale (SIAS), Personal and Social Performance scale (PSP), Safety Behavior Questionnaire (SBQ), and CANTAB Emotion Recognition Task.

DISCUSSION

The trial will elucidate whether VR-CBT can enhance therapy efficacy for paranoid ideations. Additionally, Trial findings will provide evidence on the effectiveness and cost-effectiveness of VR-CBT for paranoid ideations that can guide the possible dissemination and implementation into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902066 . Initial release April 9th, 2021.

Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol

Background

Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation.

Methods

We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use.

Discussion

Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

Automated quality assessment of cognitive behavioral therapy sessions through highly contextualized language representations

During a psychotherapy session, the counselor typically adopts techniques which are codified along specific dimensions (e.g., 'displays warmth and confidence', or 'attempts to set up collaboration') to facilitate the evaluation of the session. Those constructs, traditionally scored by trained human raters, reflect the complex nature of psychotherapy and highly depend on the context of the interaction. Recent advances in deep contextualized language models offer an avenue for accurate in-domain linguistic representations which can lead to robust recognition and scoring of such psychotherapy-relevant behavioral constructs, and support quality assurance and supervision. In this work, we propose a BERT-based model for automatic behavioral scoring of a specific type of psychotherapy, called Cognitive Behavioral Therapy (CBT), where prior work is limited to frequency-based language features and/or short text excerpts which do not capture the unique elements involved in a spontaneous long conversational interaction. The model focuses on the classification of therapy sessions with respect to the overall score achieved on the widely-used Cognitive Therapy Rating Scale (CTRS), but is trained in a multi-task manner in order to achieve higher interpretability. BERT-based representations are further augmented with available therapy metadata, providing relevant non-linguistic context and leading to consistent performance improvements. We train and evaluate our models on a set of 1,118 real-world therapy sessions, recorded and automatically transcribed. Our best model achieves an F1 score equal to 72.61% on the binary classification task of low vs. high total CTRS.

Psychometric Properties of the Norwegian Version of the Cognitive Therapy Adherence and Competence Scale (CTACS) and Its Associations With Outcomes Following Treatment in IAPT Norway

Background: No studies have examined the underlying structure or predictive validity of the Cognitive Therapy Adherence and Competence Scale (CTACS). Examining the structure of the CTACS is of great relevance because it could provide information on what constitutes competence in CBT, and whether some underlying factors are more important for predicting treatment outcomes than others. This study investigates the psychometric properties of the Norwegian version of CTACS and its associations with treatment outcomes in a sample of primary care clients who received CBT for anxiety and/or depression.

Method: Independent assessors rated audiotaped therapy sessions (early, mid and late in treatment) in a sample of 132 primary care clients (mean [SD] age = 34.8 [11.8], 63.6% women), participating in the Prompt Mental Health Care trial. Outcomes were symptoms of anxiety and depression assessed by patient self-report questionnaires. Structural validity was examined by means of confirmatory and exploratory factor analyses (CFA/EFA), whereas longitudinal associations with treatment outcome were explored by adopting multilevel modeling.

Results: No evidence was found for the divergent validity of the constructs competence and adherence as indicated by a very high correlation between these two subscales in CTACS (0.97). Regarding reliability, ICCs for the mean score of the full competence scale and its associated subscales were generally good to excellent (0.70–0.80), although the subscale measuring the quality of the therapeutic relationship was relatively low (0.44). Internal consistency was overall acceptable, but our CFA models did not provide an acceptable fit for the pre-specified one-factor and four-factor solutions. EFA results were difficult to interpret, with a sub-optimal three-factor solution providing best model fit and only two meaningful factors [CBT specific skills (α = 0.82) and session structure (α = 0.59)]. Overall, the results indicated no evidence for the scales' predictive validity.

Conclusion: Our findings point to several psychometric problems of the CTACS that may limit both its research and clinical utility. The importance of providing empirical evidence for both reliability and validity aspects of scales are discussed and suggestions for future research are provided.

Use of cognitive techniques is associated with change in positive compensatory skills in the treatment of major depressive disorder in a community mental health setting

To examine the association between adherence and competence in cognitive therapy (CT) techniques and change in positive compensatory skills and depressive symptoms within a community mental health setting.

Adherence ratings were available for 97 individuals receiving CT for major depressive disorder. Assessments of adherence and competence were rated on one early session of CT. Compensatory skills were measured using the Ways of Responding Community Version at baseline and months 1, 2, and 5. Symptom severity was evaluated using the Hamilton Rating Scale for Depression at baseline and months 1, 2, 4, and 5.

In mixed effects models, adherence was significantly associated with linear change in positive compensatory skills from baseline to month 5 (F [1, 76] = 8.05, p=.006, r=.31). Competence was also significantly associated with change in positive compensatory skills from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). High adherence was associated with improvements in HAM-D scores from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25).

Results support the hypothesis that use of CT techniques is associated with change in compensatory skills in a community mental health setting.

A randomized noninferiority trial evaluating remotely-delivered stepped care for depression using internet cognitive behavioral therapy (CBT) and telephone CBT

This trial examined whether a stepped care program for depression, which initiated treatment with internet cognitive behavioral therapy, including telephone and messaging support, and stepped up non-responders to telephone-administered cognitive behavioral therapy (tCBT), was noninferior, less costly to deliver, and as acceptable to patients compared to tCBT alone. Adults with a diagnosis of major depressive episode (MDE) were randomized to receive up to 20 weeks of stepped care or tCBT. Stepped care (n = 134) was noninferior to tCBT (n = 136) with an end-of-treatment effect size of d = 0.03 and a 6-month post-treatment effect size of d = -0.07 [90% CI 0.29 to 0.14]. Therapist time in stepped care was 5.26 (SD = 3.08) hours versus 10.16 (SD 4.01) for tCBT (p < 0.0001), with a delivery cost difference of $-364.32 [95% CI $-423.68 to $-304.96]. There was no significant difference in pre-treatment preferences (p = 0.10) or treatment dropout (39 in stepped care; 27 in tCBT; p = 0.14). tCBT patients were significantly more satisfied than stepped care patients with the treatment they received (p < 0.0001). These findings indicate that stepped care was less costly to deliver, but no less effective than tCBT. There was no significant difference in treatment preference or completion, however satisfaction with treatment was higher in tCBT than stepped care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01906476.

Prognosis Prediction Using Therapeutic Agreement of Video Conference-Delivered Cognitive Behavioral Therapy: Retrospective Secondary Analysis of a Single-Arm Pilot Trial

BACKGROUND

The therapist-patient therapeutic alliance is known to be an important factor in cognitive behavioral therapy (CBT). However, findings by previous studies for obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD) have not been consistent regarding whether this alliance provides symptomatic improvements.

OBJECTIVE

This study investigated predictors of symptom improvement in patients receiving CBT via video conferencing.

METHODS

A total of 29 patients who participated in a previous clinical trial were recruited for the current study. Therapeutic alliance and clinical background in patients with OCD, PD, and SAD were measured at first session or the eighth session, which were calculated by multiple regression analyses to estimate the impact on therapeutic response percentage change.

RESULTS

The multiple regression analyses showed that, among the independent variables, only patients' agreement in the therapeutic alliance remained viable, as other variables were a best fit for the excluded model (P=.002). The results show that patients' agreement on therapeutic goals and tasks explains the prognosis, as the normalization factor beta was 0.54 (SE 32.73; 95% CI 1.23-5.17; P=.002) and the adjusted R2 was .266.

CONCLUSIONS

Patients' agreement on therapeutic goals and tasks predicts improvement after CBT via video conferencing.

TRIAL REGISTRATION

UMIN Clinical Trial Repository UMIN000026609; https://tinyurl.com/ye6dcbwt.

Assessing the Reliability of the CAMS Rating Scale Using a Generalizability Study

Background: An important consideration when conducting randomized controlled trials is treatment differentiation. Direct observation helps ensure that providers in different treatment groups are delivering distinct interventions. One direct observation method is the use of a measure to rate clinician performance when delivering an intervention. Aims: This generalizability study evaluated the reliability of the CAMS Rating Scale (CRS), a measure used to assess delivery of the Collaborative Assessment and Management of Suicidality (CAMS). Method: Digitally recorded tapes of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were coded using the CRS. Sessions (N = 36) were each coded by two raters, and encompassed four clinicians, four time points, and 34 unique patients across two treatment groups. A reliability coefficient (i.e., G coefficient) and the percentages of variance contributed by each component of the measurement model were obtained. Results: The CRS reliably differentiates CAMS from E-CAU, minimizes measurement error relative to expected variance sources, and continues to demonstrate high inter-rater reliability. Limitations: The absence of blind raters, a formal training protocol for the rating team, and ratings from all clinician-patient dyads at all time points was a limitation. Conclusion: The CRS is a reliable treatment differentiation measure that can play an integral role in studies evaluating CAMS.

The global therapist competence scale for youth psychosocial treatment: Development and initial validation

OBJECTIVE

We describe the development and initial psychometric properties of the observer-rated Global Therapist Competence Scale for Youth Psychosocial Treatment (G-COMP) in the context of cognitive-behavioral treatment (CBT) for youth anxiety disorders.

METHOD

Independent coders rated 744 sessions from a sample of 68 youth (mean age = 10.56 years) using the G-COMP and the instruments of alliance, involvement, CBT adherence, CBT competence.

RESULTS

Inter-rater reliability coefficients, ICC(2,2), were greater than .60 for the 5 G-COMP domain scores. G-COMP scores yielded small to medium correlations with instruments of alliance (rs = .17-.44) and youth involvement in treatment (rs = .08-.53), and medium to large correlations with instruments of CBT competence and adherence (rs = .26-.63). Therapists in the research setting were rated higher compared to newly trained therapists in community clinics.

CONCLUSION

Preliminary reliability and validity of the G-COMP are promising, but future research is needed with non-CBT samples.

Mechanisms of change in cognitive therapy for major depressive disorder in the community mental health setting

OBJECTIVE

This study examined the relation of change in theory-relevant cognitive variables to depressive symptom change over the course of cognitive therapy, as well as the specificity of change mechanisms to cognitive therapy as compared with dynamic therapy.

METHOD

There were 237 adult outpatients who were randomized to either cognitive (n = 119) or dynamic (n = 118) therapy for major depressive disorder in a community mental health setting. Assessments of compensatory skills (Ways of Responding Community Version and Self-Report Version), dysfunctional attitudes (Dysfunctional Attitudes Scale), and depressogenic schemas (Psychological Distance Scaling Task) were obtained at baseline and months 1, 2, and 5 following baseline. Primary outcome was measured using the Hamilton Rating Scale for Depression.

RESULTS

Across both therapy conditions, change in all 3 cognitive domains was associated with concurrent change in depressive symptoms. After controlling for other cognitive variables, increased interconnectedness of the positive achievement-related schema was significantly associated with concurrent symptom change in cognitive (rp = .26, p < .001) but not dynamic therapy (rp = .08, p = .29). Increases in positive compensatory skills were associated with subsequent change in depressive symptoms in cognitive therapy (rp = -.36, p = .003), but not in dynamic therapy (rp = .11, p = .386).

CONCLUSIONS

Results provide support for the compensatory skills model of cognitive therapy (CT) within a community mental health setting. Additional research is necessary to understand other possible mechanisms of change in CT in the community setting. (PsycINFO Database Record

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

BACKGROUND

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.

METHODS

To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.

DISCUSSION

It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.

TRIAL REGISTRATION

NCT02449421 . Registered 02/09/2015.

Implementation of transdiagnostic cognitive therapy in community behavioral health: The Beck Community Initiative

OBJECTIVE

Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP.

METHOD

Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity.

RESULTS

Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other).

CONCLUSIONS

Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

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

Background

The prevalence of depressive disorder in adults with advanced cancer is around 20 %. Although cognitive behavioural therapy (CBT) is recommended for depression and may be beneficial in depressed people with cancer, its use for depression in those with advanced disease for whom cure is not likely has not been explored.

Methods

People aged 18 years and above with advanced cancer attending General Practitioner (GP), oncology or hospice outpatients from centres across England will be screened to establish a DSM-IV diagnosis of depression. Self-referral is also accepted. Eligible consenters will be randomised to a single blind, multicentre, randomised controlled trial of the addition to treatment as usual (TAU) of up to 12 one-hour weekly sessions of manualised CBT versus TAU alone. Sessions are delivered in primary care through Increasing Access to Psychological Care (IAPT) service, and the manual includes a focus on issues for people approaching the end of life. The main outcome is the Beck Depression Inventory-II (BDI-II). Subsidiary measures include the Patient Health Questionnaire, quality of life measure EQ-5D, Satisfaction with care, Eastern Cooperative Oncology Group-Performance Status and a modified Client Service Receipt Inventory. At 90 % power, we require 240 participants to enter the trial. Data will be analysed using multi-level (hierarchical) models for data collected at baseline, 6, 12, 18 and 24 weeks. Cost effectiveness analysis will incorporate costs related to the intervention to compare overall healthcare costs and QALYs between the treatment arms. We will conduct qualitative interviews after final follow-up on patient and therapist perspectives of the therapy.

Discussion

This trial will provide data on the clinical and cost effectiveness of CBT for people with advanced cancer and depression. We shall gain an understanding of the feasibility of delivering care to this group through IAPT. Our findings will provide evidence for policy-makers, commissioners and clinicians in cancer and palliative care, and in the community.

Trial registration

Controlled Trials ISRCTN07622709, registered 15 July 2011.

Effect of virtual reality exposure therapy on social participation in people with a psychotic disorder (VRETp): study protocol for a randomized controlled trial

BACKGROUND

Many patients with a psychotic disorder participate poorly in society. When psychotic disorders are in partial remission, feelings of paranoia, delusions of reference, social anxiety and self-stigmatization often remain at diminished severity and may lead to avoidance of places and people. Virtual reality exposure therapy (VRET) is an evidence-based treatment for several anxiety disorders. For patients with a psychotic disorder, the VRETp was developed to help them experience exposure to feared social situations. The present study aims to investigate the effects of VRETp on social participation in real life among patients with a psychotic disorder.

METHODS/DESIGN

The study is a single-blind randomized controlled trial with two conditions: the active condition, in which participants receive the virtual reality treatment together with treatment as usual (TAU), and the waiting list condition, in which participants receive TAU only. The two groups are compared at baseline, at 3 months posttreatment and at 6 months follow-up. All participants on the waiting list are also offered the virtual reality treatment after the follow-up measurements are completed. The primary outcome is social participation. Secondary outcomes are quality of life, interaction anxiety, depression and social functioning in general. Moderator and mediator analyses are conducted with stigma, cognitive schemata, cognitive biases, medication adherence, simulator sickness and presence in virtual reality. If effective, a cost-effectiveness analysis will be conducted.

DISCUSSION

Results from the posttreatment measurement can be considered strong empirical indicators of the effectiveness of VRETp. The 6-month follow-up data may provide reliable documentation of the long-term effects of the treatment on the outcome variables. Data from pre-treatment and mid-treatment can be used to reveal possible pathways of change.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN12929657 . Date of registration: 8 September 2015.

The development and validation of the Memory Support Rating Scale

Patient memory for treatment information is poor, and worse memory for treatment information is associated with poorer clinical outcomes. Memory support techniques have been harnessed to improve patient memory for treatment. However, a measure of memory support used by treatment providers during sessions has yet to be established. The present study reports on the development and psychometric properties of the Memory Support Rating Scale (MSRS)-an observer-rated scale designed to measure memory support. Adults with major depressive disorder (MDD; N = 42) were randomized to either cognitive therapy plus memory support (CT + MS; n = 22) or cognitive therapy as-usual (CT-as-usual; n = 20). At posttreatment, patients freely recalled treatment points via the patient recall task. Sessions (n = 171) were coded for memory support using the MSRS, 65% of which were also assessed for the quality of cognitive therapy via the Cognitive Therapy Rating Scale (CTRS). A unidimensional scale composed of 8 items was developed using exploratory factor analysis, though a larger sample is needed to further assess the factor structure of MSRS scores. High interrater and test-retest reliabilities of MSRS scores were observed across 7 MSRS coders. MSRS scores were higher in the CT + MS condition compared with CT-as-usual, demonstrating group differentiation ability. MSRS scores were positively associated with patient recall task scores but not associated with CTRS scores, demonstrating convergent and discriminant validity, respectively. Results indicate that the MSRS yields reliable and valid scores for measuring treatment providers' use of memory support while delivering cognitive therapy. (PsycINFO Database Record

Assessing cognitive therapy skills comprehension, acquisition, and use by means of an independent observer version of the Skills of Cognitive Therapy (SoCT-IO)

The purposes of this study were (a) to describe the adaptation and psychometric properties of the Skills for Cognitive Therapy (SoCT) measure for use by an independent observer (SoCT-IO) who rates the cognitive therapy (CT) skill acquisition, comprehension, and use by depressed adults and (b) to compare ratings of CT skill comprehension, acquisition, and use by independent observers to those by patients and therapists. Like the other SoCT versions, the SoCT-IO consists of 8 items that assess patients' comprehension, acquisition, and use of cognitive and behavioral skills for managing depressive symptoms, using a 5-point Likert-type scale. Four experienced raters (2 doctoral-level CT therapists and 2 bachelor-level nontherapists) used the SoCT-IO to rate 80 CT videotapes from both mid and later sessions in acute-phase CT from a randomized controlled trial for outpatients with recurrent major depression. The SoCT-IO ratings showed excellent internal consistency reliability and moderately high interrater reliability. Concurrent validity was demonstrated by convergence of the SoCT-IO with 2 other versions of the SoCT, 1 completed by therapists (SoCT-O) and the other by patients (SoCT-P). SoCT-IO ratings evidenced good predictive validity: Independent observers' ratings of patient CT skills midphase in therapy predicted treatment response even when the predictive effects of SoCT ratings by therapists and patients were controlled. The SoCT-IO is a psychometrically sound measure of CT skill comprehension, acquisition and use for rating outpatients with recurrent depression. The clinical utility and implications for using the SoCT-IO as a measure of CT skills acquisition are discussed. (PsycINFO Database Record

Comparative effectiveness of cognitive and dynamic therapies for major depressive disorder in a community mental health setting: study protocol for a randomized non-inferiority trial

BACKGROUND

There is substantial evidence that cognitive therapy is an effective intervention for the treatment of major depressive disorder. Although dynamic psychotherapies have been widely studied and are commonly practiced worldwide, there are few randomized comparisons of cognitive therapy and dynamic therapy for major depressive disorder.

METHODS

We are completing data collection on a randomized non-inferiority trial comparing the effectiveness of cognitive therapy and short-term dynamic psychotherapy in the treatment of major depressive disorder in the community mental health setting. Therapists employed in the community setting have been recruited for training in either short-term dynamic psychotherapy or cognitive therapy. Patients seeking services at the community site who meet criteria for major depressive disorder based on a blind independent diagnostic interview are randomized to 16 sessions of treatment. All patients are assessed at baseline and months 1, 2, 4, and 5 utilizing a comprehensive battery.

DISCUSSION

This study adds to the growing literature evaluating the effectiveness of short-term dynamic psychotherapy for specific diagnostic groups. These results will have implications for the dissemination of effective interventions for major depressive disorder in community mental health settings.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, a service of the United States National Institute of Health. NIH Identifier: NCT01207271. Registered 21 September 2010.

Therapeutic alliance in face-to-face and telephone-administered cognitive behavioral therapy

OBJECTIVE

Telephone-administered therapies have emerged as an alternative method of delivery for the treatment of depression, yet concerns persist that the use of the telephone may have a deleterious effect on therapeutic alliance. The purpose of this study was to compare therapeutic alliance in clients receiving cognitive behavioral therapy (CBT) for depression by telephone (T-CBT) or face-to-face (FtF-CBT).

METHOD

We randomized 325 participants to receive 18 sessions of T-CBT or FtF-CBT. The Working Alliance Inventory (WAI) was administered at Weeks 4 and 14. Depression was measured during treatment and over 1 year posttreatment follow-up using the Hamilton Rating Scale for Depression and Patient Health Questionnaire-9.

RESULTS

There were no significant differences in client or therapist WAI between T-CBT or FtF-CBT (Cohen's f² ranged from 0 to .013, all ps > .05). All WAI scores predicted depression end of treatment outcomes (Cohen's f² ranged from .009 to .06, all ps < .02). The relationship between the WAI and depression outcomes did not vary by treatment group (Cohen's f² ranged from 0 to .004, ps > .07). The WAI did not significantly predict depression during posttreatment follow-up (all ps > .12).

CONCLUSIONS

Results from this analysis do not support the hypothesis that the use of the telephone to provide CBT reduces therapeutic alliance relative to FtF-CBT.

Teaching psychological knowledge and skills to family physicians

Psychological problems (e.g., anxiety, depression, substance abuse) are prevalent in primary care medical settings. Family physicians (FPs) treat more patients than any other primary care medical specialists. Thus, FPs can play an extremely important role in providing psychological services to their patients. In contrast to other specialists (e.g., internists, obstetricians), FPs are required to complete behavioral science training in their residencies. In this paper, we describe standard undergraduate, graduate, and postgraduate training of FPs. We present our unique program for teaching psychological principles and skills to family practice residents at the University of Kansas Medical Center. And finally, we introduce an instrument, the Interview Rating Scale (IRS), for evaluating the interviewing skills of physicians and residents.

A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic Stress Disorder

Background

Posttraumatic Stress Disorder (PTSD) is a serious mental health condition with substantial costs to individuals and society. Among military veterans, the lifetime prevalence of PTSD has been estimated to be as high as 20%. Numerous research studies have demonstrated that short-term cognitive-behavioral psychotherapies, such as Cognitive Processing Therapy (CPT), lead to substantial and sustained improvements in PTSD symptoms. Despite known benefits, only a minority of clinicians provide these therapies. Transferring this research knowledge into clinical settings remains one of the largest hurdles to improving the health of veterans with PTSD. Attending a workshop alone is insufficient to promote adequate knowledge transfer and sustained skill; however, relatively little research has been conducted to identify effective post-training support strategies.

Methods

The current study investigates whether clinicians receiving post-workshop support (six-month duration) will deliver CPT with greater fidelity (i.e., psychotherapy adherence and competence) and have improved patient outcomes compared with clinicians receiving no formal post-workshop support. The study conditions are: technology-enhanced group tele-consultation; standard group tele-consultation; and fidelity assessment with no consultation. The primary outcome is independent assessment (via audio-recordings) of the clinicians’ adherence and competence in delivering CPT. The secondary outcome is observed changes in patient symptoms during and following treatment as a function of clinician fidelity. Post-consultation interviews with clinicians will help identify facilitators and barriers to psychotherapy skill acquisition. The study results will inform how best to implement and transfer evidence-based psychotherapy (e.g., CPT) to clinical settings to attain comparable outcomes to those observed in research settings.

Discussion

Findings will deepen our understanding of how much and what type of support is needed following a workshop to help clinicians become proficient in delivering a new protocol. Several influences on clinician learning and patient outcomes will be discussed. An evidence-based model of clinical consultation will be developed, with the ultimate goal of informing policy and influencing best practice in clinical consultation.

Trial registration

ClinicalTrials.gov: NCT01861769

Two-group randomised, parallel trial of cognitive and exposure therapies for problem gambling: a research protocol

BACKGROUND

Problem gambling is a serious public health concern at an international level where population prevalence rates average 2% or more and occurs more frequently in younger populations. The most empirically established treatments until now are combinations of cognitive and behavioural techniques labelled cognitive behaviour therapy (CBT). However, there is a paucity of high quality evidence for the comparative efficacy of core CBT interventions in treating problem gamblers. This study aims to isolate and compare cognitive and behavioural (exposure-based) techniques to determine their relative efficacy.

METHODS

A sample of 130 treatment-seeking problem gamblers will be allocated to either cognitive or exposure therapy in a two-group randomised, parallel design. Repeated measures will be conducted at baseline, mid and end of treatment (12 sessions intervention period), and at 3, 6 and 12 months (maintenance effects). The primary outcome measure is improvement in problem gambling severity symptoms using the Victorian Gambling Screen (VGS) harm to self-subscale. VGS measures gambling severity on an extensive continuum, thereby enhancing sensitivity to change within and between individuals over time.

DISCUSSION

This article describes the research methods, treatments and outcome measures used to evaluate gambling behaviours, problems caused by gambling and mechanisms of change. This study will be the first randomised, parallel trial to compare cognitive and exposure therapies in this population.

ETHICS AND DISSEMINATION

The study was approved by the Southern Adelaide Health Service/Flinders University Human Research Ethics Committee. Study findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN 12610000828022.

Impact of reproductive status and age on response of depressed women to cognitive therapy

OBJECTIVE

Previous research suggests that reproductive hormones are potential affective modulators in mood disorders and may influence response to antidepressant medications. To our knowledge, there are no data on relationships between hormonal status and response to psychotherapy for recurrent major depressive disorder (MDD).

METHODS

At two sites, female outpatients (n=353), aged 18-70, with recurrent MDD received 12-14 weeks of cognitive therapy (CT). Menopausal status and age were based on self-report. In the parent study, nonresponse to therapy was defined as persistence of a major depressive episode (MDE) as defined by the DSM-IV or a final Hamilton Rating Scale for Depression-17-Item (HRSD(17)) score of ≥ 12 or both. More traditional definitions of response (at least a 50% reduction in pretreatment HRSD(17)) and remission (a final HRSD(17) ≤ 6) were also examined.

RESULTS

Controlling for pretreatment HRSD(17) scores, there were no significant differences found in the rates of response to CT or symptom status among premenopausal, perimenopausal, and postmenopausal women.

CONCLUSIONS

We found no support for the hypotheses that response to CT or the rates of change in depressive symptoms are moderated by reproductive status. The findings, however, are limited by the absence of early follicular phase serum sampling/analysis to estimate hormone levels and the reliance on self-report to establish menopausal status. These data motivate a full investigation of the effects of reproductive status on response to psychosocial interventions.

Advances in fidelity measurement for mental health services research: four measures

Mental health intervention research requires clear and accurate specification of treatment conditions in intervention studies. Measures are increasingly available for community-based interventions for persons with serious mental illnesses. Measures must go beyond structural features to assess critical processes in interventions. They must also balance effectiveness, or adequate coverage of active treatment elements, with efficiency, or the degree to which measures may be used cost-effectively. The context of their use is changing with the emergence of new frameworks for implementation research and quality improvement. To illustrate a range of approaches, this article describes four recently developed fidelity measures: Cognitive Therapy for Psychosis Adherence Scale, Strengths Model Fidelity Scale, Illness Management and Recovery Program Fidelity Scale, and Tool for Measurement of ACT. The fidelity measures assess interventions in a range of treatment contexts from dyads to teams. Each measure focuses assessment resources on critical elements. Each has demonstrated coverage of its target intervention and satisfactory psychometric properties and is related to outcomes. Measures have been used for training, quality improvement, or certification. They assess domains and have uses beyond their nominal position in implementation and quality frameworks. This review of recent fidelity measures indicates that process components in community-based interventions can be effectively assessed. Omission of elements assessing potentially critical active treatment components poses risk to both research and practice until there is evidence to demonstrate that they are nonessential. Further development of fidelity measurement theory and approaches should proceed in conjunction with development of theory and methods in implementation science.

A randomized trial of stress management for the prevention of new brain lesions in MS

OBJECTIVES

This trial examined the efficacy of a stress management program in reducing neuroimaging markers of multiple sclerosis (MS) disease activity.

METHODS

A total of 121 patients with relapsing forms of MS were randomized to receive stress management therapy for MS (SMT-MS) or a wait-list control condition. SMT-MS provided 16 individual treatment sessions over 24 weeks, followed by a 24-week post-treatment follow-up. The primary outcome was the cumulative number of new gadolinium-enhancing (Gd+) brain lesions on MRI at weeks 8, 16, and 24. Secondary outcomes included new or enlarging T2 MRI lesions, brain volume change, clinical exacerbation, and stress.

RESULTS

SMT-MS resulted in a reduction in cumulative Gd+ lesions (p = 0.04) and greater numbers of participants remained free of Gd+ lesions during the treatment (76.8% vs 54.7%, p = 0.02), compared to participants receiving the control treatment. SMT-MS also resulted in significantly reduced numbers of cumulative new T2 lesions (p = 0.005) and a greater number of participants remaining free of new T2 lesions (69.5% vs 42.7%, p = 0.006). These effects were no longer detectable during the 24-week post-treatment follow-up period.

CONCLUSIONS

This trial indicates that SMT-MS may be useful in reducing the development of new MRI brain lesions while patients are in treatment.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that SMT-MS, a manualized stress management therapy program, reduced the number of Gd+ lesions in patients with MS during a 24-week treatment period. This benefit was not sustained beyond 24 weeks, and there were no clinical benefits.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT00147446.

Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: a randomized trial

CONTEXT

Primary care is the most common site for the treatment of depression. Most depressed patients prefer psychotherapy over antidepressant medications, but access barriers are believed to prevent engagement in and completion of treatment. The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery.

OBJECTIVE

To examine whether telephone-administered cognitive behavioral therapy (T-CBT) reduces attrition and is not inferior to face-to-face CBT in treating depression among primary care patients.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial of 325 Chicago-area primary care patients with major depressive disorder, recruited from November 2007 to December 2010.

INTERVENTIONS

Eighteen sessions of T-CBT or face-to-face CBT.

MAIN OUTCOME MEASURES

The primary outcome was attrition (completion vs noncompletion) at posttreatment (week 18). Secondary outcomes included masked interviewer-rated depression with the Hamilton Depression Rating Scale (Ham-D) and self-reported depression with the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Significantly fewer participants discontinued T-CBT (n = 34; 20.9%) compared with face-to-face CBT (n = 53; 32.7%; P = .02). Patients showed significant improvement in depression across both treatments (P < .001). There were no significant treatment differences at posttreatment between T-CBT and face-to-face CBT on the Ham-D (P = .22) or the PHQ-9 (P = .89). The intention-to-treat posttreatment effect size on the Ham-D was d = 0.14 (90% CI, -0.05 to 0.33), and for the PHQ-9 it was d = -0.02 (90% CI, -0.20 to 0.17). Both results were within the inferiority margin of d = 0.41, indicating that T-CBT was not inferior to face-to-face CBT. Although participants remained significantly less depressed at 6-month follow-up relative to baseline (P < .001), participants receiving face-to-face CBT were significantly less depressed than those receiving T-CBT on the Ham-D (difference, 2.91; 95% CI, 1.20-4.63; P < .001) and the PHQ-9 (difference, 2.12; 95% CI, 0.68-3.56; P = .004).

CONCLUSIONS

Among primary care patients with depression, providing CBT over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression at posttreatment. At 6-month follow-up, patients remained less depressed relative to baseline; however, those receiving face-to-face CBT were less depressed than those receiving T-CBT. These results indicate that T-CBT improves adherence compared with face-to-face delivery, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00498706.

Therapist Competence in Cognitive-behavioural Therapies: Review of the Contemporary Empirical Evidence

Therapist competence refers to the extent that a given treatment is conducted in accordance with the instructions or intentions of the respective treatment manual. Despite this relatively straightforward notion, existing research on cognitive-behavioural therapy (CBT) processes have been unsuccessful in defining and measuring this construct. This article reviews the contemporary empirical research on therapist competence in CBT, outlines the development and psychometric evaluation of the commonly used measures of therapist adherence, and discusses how competence has been linked to treatment outcomes. The psychometric evidence for existing measures is mixed, and in particular, there has been difficulty in the demonstration of adequate interrater reliability, even among identified experts in the field. New measures of therapist competence hold promise — most notably, in the separation of therapist adherence and competence constructs. The assessment of therapist adherence, therapist competence, and the role of supervisor ratings in the clinical context are also discussed.

The effect of telephone-administered cognitive-behavioral therapy on quality of life among patients with multiple sclerosis

BACKGROUND

Past research has found that a variety of physical, psychological, and social factors can affect quality of life (QOL). These previous findings suggest that interventions that address these factors could potentially improve QOL.

PURPOSE

The purpose of this study was to examine whether cognitive behavioral therapy (CBT) can improve QOL, and if so, explore which factors might mediate this effect.

METHODS

This is a secondary analysis of a randomized controlled trial. One hundred twenty-seven participants with multiple sclerosis and depression were randomly assigned to either a telephone-administered CBT (T-CBT) or telephone-administered supportive emotion-focused therapy (T-SEFT) intervention.

RESULTS

Patients assigned to T-CBT showed significantly greater improvements in QOL compared with those assigned to T-SEFT. The greater improvement in QOL among T-CBT recipients was mediated by improvements in depression and positive affect. There was also inconsistent support for the superior effect of CBT on QOL being mediated by improvement in fatigue.

CONCLUSIONS

T-CBT provided greater QOL benefits compared with T-SEFT, which controlled for non-specific treatment components. This study further suggests that T-CBT procedures specific to the management of depression and positive affect were uniquely useful in improving QOL.

Feasibility of dissemination of cognitive behavioral therapy to Texas community mental health centers

State mental health systems are actively seeking to disseminate empirically supported treatment approaches to improve the outcomes of adults with serious mental illnesses. However, many of these interventions have not been studied within public mental health settings. Cognitive behavioral therapy (CBT) has been shown to be effective for major depression in well-controlled trials, but its effectiveness in public mental health settings is less known. The present study examines the feasibility of dissemination of CBT in the Texas public mental health system. Seven clinicians were trained by a CBT expert and supervised for 5 months, during which time their skills approached competency levels of therapists in randomized controlled trials. Forty clients were treated during the therapists' training phase, attending an average of ten sessions and experiencing a significant reduction in depressive symptoms. Study results are compared with previously published studies of CBT.

An evaluation of the effect of an educational intervention for Australian social workers on competence in delivering brief cognitive behavioural strategies: a randomised controlled trial

Background

Broad community access to high quality evidence-based primary mental health care is an ongoing challenge around the world. In Australia one approach has been to broaden access to care by funding psychologists and other allied health care professionals to deliver brief psychological treatments to general practitioners' patients. To date, there has been a scarcity of studies assessing the efficacy of social worker delivered psychological strategies. This study aims to build the evidence base by evaluating the impact of a brief educational intervention on social workers' competence in delivering cognitive behavioural strategies (strategies derived from cognitive behavioural therapy).

Methods

A randomised controlled trial design was undertaken with baseline and one-week follow-up measurement of both objective and self-perceived competence. Simulated consultations with standardised depressed patients were recorded on videotape and objective competence was assessed by blinded reviewers using the Cognitive Therapy Scale. Questionnaires completed by participants were used to measure self-perceived competence. The training intervention was a 15 hour face-to-face course involving presentations, video example consultations, written materials and rehearsal of skills in pairs.

Results

40 Melbourne-based (Australia) social workers enrolled and were randomised and 9 of these withdrew from the study before the pre training simulated consultation. 30 of the remaining 31 social workers (97%) completed all phases of the intervention and evaluation protocol (16 from intervention and 14 from control group). The intervention group showed significantly greater improvements than the control group in objective competence (mean improvement of 14.2 (7.38-21.02) on the 66 point Cognitive Therapy Scale) and in subjective confidence (mean improvement of 1.28 (0.84-1.72) on a 5 point Likert scale). On average, the intervention group improved from below to above the base competency threshold on the Cognitive Therapy Scale whilst the control group remained below.

Conclusions

Social workers can attain significant improvements in competency in delivering cognitive behavioural strategies from undertaking brief face to face training. This is relevant in the context of health reforms that involve social worker delivery of evidence based psychological care. Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.

Therapist competence in cognitive therapy for depression: predicting subsequent symptom change

OBJECTIVE

The efficacy of cognitive therapy (CT) for depression has been well established. Measures of the adequacy of therapists' delivery of treatment are critical to facilitating therapist training and treatment dissemination. While some studies have shown an association between CT competence and outcome, researchers have yet to address whether competence ratings predict subsequent outcomes.

METHOD

In a sample of 60 moderately to severely depressed outpatients from a clinical trial, we examined competence ratings (using the Cognitive Therapy Scale) as a predictor of subsequent symptom change.

RESULTS

Competence ratings predicted session-to-session symptom change early in treatment. In analyses focused on prediction of symptom change following 4 early sessions through the end of 16 weeks of treatment, competence was shown to be a significant predictor of evaluator-rated end-of-treatment depressive symptom severity and was predictive of self-reported symptom severity at the level of a nonsignificant trend. To investigate whether competence is more important to clients with specific complicating features, we examined 4 patient characteristics as potential moderators of the competence-outcome relation. Competence was more highly related to subsequent outcome for patients with higher anxiety, an earlier age of onset, and (at a trend level) patients with a chronic form of depression (chronic depression or dysthymia) than for those patients without these characteristics. Competence ratings were not more predictive of subsequent outcomes among patients who met (vs. those who did not meet) criteria for a personality disorder (i.e., among personality disorders represented in the clinical trial).

CONCLUSIONS

These findings provide support for the potential utility of CT competence ratings in applied settings.

Comparative efficacy and durability of continuation phase cognitive therapy for preventing recurrent depression: design of a double-blinded, fluoxetine- and pill placebo-controlled, randomized trial with 2-year follow-up

BACKGROUND

Major Depressive Disorder (MDD) is highly prevalent and associated with disability and chronicity. Although cognitive therapy (CT) is an effective short-term treatment for MDD, a significant proportion of responders subsequently suffer relapses or recurrences.

PURPOSE

This design prospectively evaluates: 1) a method to discriminate CT-treated responders at lower vs. higher risk for relapse; and 2) the subsequent durability of 8-month continuation phase therapies in randomized higher risk responders followed for an additional 24 months. The primary prediction is: after protocol treatments are stopped, higher risk patients randomly assigned to continuation phase CT (C-CT) will have a lower risk of relapse/recurrence than those randomized to fluoxetine (FLX).

METHODS

Outpatients, aged 18 to 70 years, with recurrent MDD received 12-14 weeks of CT provided by 15 experienced therapists from two sites. Responders (i.e., no MDD and 17-item Hamilton Rating Scale for Depression

RESULTS

The trial began in 2000. Enrollment is complete (n=523). The follow-up continues.

CONCLUSIONS

The trial evaluates the preventive effects and durability of acute and continuation phase treatments in the largest known sample of CT responders collected worldwide.

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Key Words

• relapse prevention
• recurrent depression
• cognitive therapy
• fluoxetine
• longitudinal follow-up

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MESH Headings

• Adolescent
• Adult
• Aged
• Antidepressive Agents, Second-Generation/therapeutic use
• Cognitive Behavioral Therapy
• Depressive Disorder, Major/prevention & control
• Depressive Disorder, Major/therapy
• Double-Blind Method
• Female
• Fluoxetine/therapeutic use
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Research Design
• Secondary Prevention
• Young Adult

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Grants

• K24 MH001571 NIMH NIH HHS
• K24-MH001571 NIMH NIH HHS
• R01 MH-58356 NIMH NIH HHS
• R01 MH058397 NIMH NIH HHS
• R01 MH069618 NIMH NIH HHS
• R01 MH058397-11 NIMH NIH HHS
• R01 MH-69219 NIMH NIH HHS
• R01 MH-58397 NIMH NIH HHS
• R01 MH069619-05 NIMH NIH HHS
• R01 MH-69618 NIMH NIH HHS
• L40 MH069219 NIMH NIH HHS
• R01 MH069619 NIMH NIH HHS
• R01 MH058356 NIMH NIH HHS
• K24 MH001571-10 NIMH NIH HHS

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Affiliation(s)

Robin B. Jarrett Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9149, United States of America; 214-648-5345; fax 214-648-5340
Michael E. Thase The University of Pennsylvania School of Medicine, 3535 Market Street, Suite 670, Philadelphia, PA, 19104, United States of America. Philadelphia, Veterans Affairs Medical Center and University of Pittsburgh Medical Center

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Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings

In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.

Telephone-administered psychotherapy for depression in MS patients: moderating role of social support

Depression is common in individuals with multiple sclerosis (MS). While psychotherapy is an effective treatment for depression, not all individuals benefit. We examined whether baseline social support might differentially affect treatment outcome in 127 participants with MS and depression randomized to either Telephone-administered Cognitive-Behavioral Therapy (T-CBT) or Telephone-administered Emotion-Focused Therapy (T-EFT). We predicted that those with low social support would improve more in T-EFT, since this approach emphasizes the therapeutic relationship, while participants with strong social networks and presumably more emotional resources might fare better in the more structured and demanding T-CBT. We found that both level of received support and satisfaction with that support at baseline did moderate treatment outcome. Individuals with high social support showed a greater reduction in depressive symptoms in the T-CBT as predicted, but participants with low social support showed a similar reduction in both treatments. This suggests that for participants with high social support, CBT may be a more beneficial treatment for depression compared with EFT.

Sources of site differences in the efficacy of a multisite clinical trial: the Treatment of SSRI-Resistant Depression in Adolescents

Site differences in treatment outcomes are not often highlighted when the results of multisite randomized clinical trials (MRCTs) are reported. The primary analyses of a 6-site MRCT, the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study, showed substantial variation by site in the performance of a medication-only condition and a combined medication plus cognitive-behavioral therapy (CBT) condition. Two potential primary causes of site differences in MRCT outcomes were examined in this article: sampling factors, particularly clinical characteristics of participants, and treatment protocol factors, particularly fidelity. The authors found that differences in the clinical characteristics of participants at baseline across site and within site/across conditions were the most salient explanations for site differences and differences within sites across conditions in outcome. Study findings are discussed with respect to the overall study outcomes in TORDIA as well as MRCTs in general.

Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS): Conceptual Development and Content Validity

The Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS) is introduced as a scale to measure a therapist's fidelity to the EFT model. The rationale and conceptual development of the scale are presented. Members of an EFT electronic mailing list who participated in a survey (n=130) rated all of the items as highly important for the practice providing support for the content validity of the scale. Finally, the 13 items of the EFT-TFS are presented. Future research directions for the EFT-TFS are presented.

Treatment of depression after coronary artery bypass surgery: a randomized controlled trial

CONTEXT

There has been little research on the treatment of depression after coronary artery bypass surgery.

OBJECTIVE

To test the efficacy of 2 nonpharmacological interventions for depression after coronary artery bypass surgery compared with usual care.

DESIGN

A 12-week, randomized, single-blind clinical trial with outcome evaluations at 3, 6, and 9 months.

SETTING

Outpatient research clinic at Washington University School of Medicine, St Louis, Missouri.

PATIENTS

One hundred twenty-three patients who met the DSM-IV criteria for major or minor depression within 1 year after surgery.

INTERVENTION

Twelve weeks of cognitive behavior therapy or supportive stress management. Approximately half of the participants were taking nonstudy antidepressant medications.

MAIN OUTCOME MEASURE

Remission of depression, defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression.

RESULTS

Remission of depression occurred by 3 months in a higher proportion of patients in the cognitive behavior therapy (71%) and supportive stress-management (57%) arms than in the usual care group (33%) (chi(2)(2) = 12.22, P = .002). Covariate-adjusted Hamilton scores were lower in the cognitive behavior therapy (mean [standard error], 5.5 [1.0]) and the supportive stress-management (7.8 [1.0]) arms than in the usual care arm (10.7 [1.0]) at 3 months. The differences narrowed at 6 months, but the remission rates differed again at 9 months (73%, 57%, and 35%, respectively; chi(2)(2) = 12.02, P = .003). Cognitive behavior therapy was superior to usual care at most points on secondary measures of depression, anxiety, hopelessness, stress, and quality of life. Supportive stress management was superior to usual care only on some of the measures.

CONCLUSIONS

Both cognitive behavior therapy and supportive stress management are efficacious for treating depression after coronary artery bypass surgery, relative to usual care. Cognitive behavior therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00042198.

Treatment Integrity Concerns in Cognitive Therapy for Depression

With the emergence of manualized treatments in the 1980s, research protocols have focused increasing attention on documenting the integrity of treatment delivery. Two constructs have guided the conceptualization of assessing treatment integrity. The first, adherence, concerns the extent to which therapists adhere to the interventions of a therapy being tested, and measuring which particular interventions are performed. The second, competence, concerns the quality or skill in therapists’ execution of the therapy being tested. This article reviews the development of treatment integrity research for cognitive therapy in depression, and discusses salient issues that have arisen in its assessment. Recommendations for further refining the considerations of adherence and competence in the delivery of cognitive therapy are provided.

Treatment of atypical depression with cognitive therapy or phenelzine: a double-blind, placebo-controlled trial

BACKGROUND

Patients with atypical depression are more likely to respond to monoamine oxidase inhibitors than to tricyclic antidepressants. They are frequently offered psychotherapy in the absence of controlled tests. There are no prospective, randomized, controlled trials, to our knowledge, of psychotherapy for atypical depression or of cognitive therapy compared with a monoamine oxidase inhibitor. Since there is only 1 placebo-controlled trial of cognitive therapy, this trial fills a gap in the literature on psychotherapy for depression.

METHODS

Outpatients with DSM-III-R major depressive disorder and atypical features (N = 108) were treated in a 10-week, double-blind, randomized, controlled trial comparing acute-phase cognitive therapy or clinical management plus either phenelzine sulfate or placebo. Atypical features were defined as reactive mood plus at least 2 additional symptoms: hypersomnia, hyperphagia, leaden paralysis, or lifetime sensitivity to rejection.

RESULTS

With the use of an intention-to-treat strategy, the response rates (21-item Hamilton Rating Scale for Depression score, < or =9) were significantly greater after cognitive therapy (58%) and phenelzine (58%) than after pill placebo (28%). Phenelzine and cognitive therapy also reduced symptoms significantly more than placebo according to contrasts after a repeated-measures analysis of covariance and random regression with the use of the blind evaluator's final Hamilton Rating Scale for Depression score. The scores between cognitive therapy and phenelzine did not differ significantly. Supplemental analyses of other symptom severity measures confirm the finding.

CONCLUSIONS

Cognitive therapy may offer an effective alternative to standard acute-phase treatment with a monoamine oxidase inhibitor for outpatients with major depressive disorder and atypical features.