Analysis of therapeutic effect of subliminal cognition combined with hypnotherapy on anxiety disorder via neural network

Hypnotherapy combined with cognitive therapy is an effective way to intervene anxiety problems, which also responds to the call that using hypnotherapy to treat somatic disorders should become a trend in the future. This paper constructs an evaluation index of the intervention effect of cognitive hypnotherapy on anxiety patients, and then uses neural network to evaluate its effect. At last, we have completed the following work: 1) This paper constructs the theoretical basis related to this topic after searching and sorting out the related literature on anxiety disorders and hypnotherapy at home and abroad. 2) This paper constructs the evaluation index system of the intervention effect of cognitive hypnotherapy on anxiety patients, and then introduces the basic principle and structure of DBN model. 3) Experiments are used to determine the best values for the DBN model's parameters. To accomplish this, you will need to input the experimental data into the trained model and compare the evaluation results from experts with the model's predictions. The experimental findings of this study demonstrate the great accuracy of the DBN model presented in this work for assessing the effectiveness of cognitive combination hypnotherapy for anxiety disorders.

Digital phenotyping of generalized anxiety disorder: using artificial intelligence to accurately predict symptom severity using wearable sensors in daily life

BACKGROUND

Generalized anxiety disorder (GAD) is a highly prevalent condition. Monitoring GAD symptoms requires substantial time, effort, and cost. The development of digital phenotypes of GAD may enable new scalable, timely, and inexpensive assessments of GAD symptoms.

METHOD

The current study used passive movement data collected within a large national cohort (N = 264) to assess GAD symptom severity.

RESULTS

Using one week of movement data, machine learning models accurately predicted GAD symptoms across a continuum (r = 0.511) and accurately detected those individuals with elevated GAD symptoms (AUC = 0.892, 70.0% Sensitivity, 95.5% Specificity, Brier Score = 0.092). Those with a risk score at the 90th percentile or above had 21 times the odds of having elevated GAD symptoms compared to those with lower risk scores. The risk score was most strongly associated with irritability, worry controllability, and restlessness (individual rs > 0.5). The risk scores for GAD were also discriminant of major depressive disorder symptom severity (r = 0.190).

LIMITATIONS

The current study examined the detection of GAD symptom severity rather than the prediction of GAD symptom severity across time. Furthermore, the instant sample of data did not include nighttime actigraphy, as participants were not asked to wear the actigraphs at night.

CONCLUSIONS

These results suggest that artificial intelligence can effectively utilize wearable movement data collected in daily life to accurately infer risk of GAD symptoms.

Preventative Care in First Responder Mental Health: Focusing on Access and Utilization via Stepped Telehealth Care

First responders are at high risk for disorders that arise from repeat exposure to stress and trauma (Post Traumatic Stress Disorder, depression, and problematic alcohol use). Although mental health treatments are available, first responders often do not access them, anchored by barriers that include: lack of knowledge, stigma, negative experience with mental health providers, and time-based burdens. In this study, we designed an intervention to address these barriers, extending a Planned-Action framework. Step 1 involved self-report screening for four mental health risks (PTSD, depression, anxiety, and alcohol use risk), delivered to all personnel electronically, who were free to either consent and participate or opt-out. The detection of risk(s) in Step 1 led to scheduling a Step 2 telehealth appointment with a trained clinician. We report descriptive statistics for participation/attrition/utilization in Steps 1 and 2, rates of risk on four mental health variables, and rate of adherence to follow-up treatment recommendations. Step 1: In total, 53.3% of personnel [229 of 429 full-time employees (221 males; eight females; 95% White; 48% paramedic or Emergency Medical Technician; 25% captain; 19% engineer; 7% other)] initially opted-in by consenting and completing the brief remote screening survey. Among those who opted-in and completed (n = 229), 43% screened positive for one or more of the following mental health risks: PTSD (7.9%); depression (9.6%); anxiety (13.5%); alcohol use (36.7%). Step 2: A maximum of three attempts were made to schedule "at risk" individuals into Step 2 (n = 99). Among the 99 who demonstrated a need for mental health treatment (by screening positive for one or more risk), 56 (56.6%) engaged in the telehealth appointment. Of the 56 who participated in Step 2 clinical appointments, 38 were recommended for further intervention (16.6% of full-time personnel who participated). Among the 38 firefighters who were recommended to seek further mental health services, 29 were adherent/followed through (76.3% of those who received recommendations for further services). Taken together, evidence-based, culturally conscious, stepped care models delivered via the virtual/telehealth medium can promote access, utilization, and cost-effective mental health services for first responders. Implications are for informing larger, more rigorous dissemination and implementation efforts.

Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System

IMPORTANCE

With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts.

OBJECTIVE

To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019.

EXPOSURES

The multifaceted implementation intervention included education, external facilitation, and quarterly reports.

MAIN OUTCOMES AND MEASURES

The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame.

RESULTS

Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77).

CONCLUSIONS AND RELEVANCE

A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial

STUDY OBJECTIVES

Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I).

METHODS

A total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step.

RESULTS

Results indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores.

CONCLUSION(S)

The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).

Development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP): Facilitating the early detection of patients in need of highly specialized care

BACKGROUND

Early identification of patients with an anxiety disorder, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD) in need of highly specialized care could facilitate the selection of the optimal initial treatment in these patients. This paper describes the development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP), which aims to aid clinicians in the early identification of patients with an anxiety disorder, OCD, or PTSD in need of highly specialized mental healthcare.

METHODS

A systematic literature review and a concept mapping procedure were carried out to inform the development of the DTAOP. To evaluate the psychometric properties of the DTAOP, a cross-sectional study in 454 patients with a DSM-IV-TR anxiety disorder was carried out. Feasibility was evaluated by the completion time and the content clarity of the DTAOP. Inter-rater reliability was assessed in a subsample of 87 patients. Spearman's rank correlation coefficients between the DTAOP and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were computed to examine the convergent validity. Criterion validity was assessed against independent clinical judgments made by clinicians.

RESULTS

The average time required to complete the eight-item DTAOP was 4.6 min and the total DTAOP was evaluated as clear in the majority (93%) of the evaluations. Krippendorff's alpha estimates ranged from 0.427 to 0.839. Based on the qualitative feedback, item wording and instructions were improved. As hypothesized, the DTAOP correlated negatively with EQ-5D-5L scores. The area under the curve was 0.826 and the cut-off score of ≥4 optimized sensitivity (70%) and specificity (71%).

CONCLUSIONS

The DTAOP demonstrated excellent feasibility and good validity, but weak inter-rater reliability. Based on the qualitative feedback and reliability estimates, revisions and refinements of the wording and instructions were made, resulting in the final version of the DTAOP.

A Qualitative Examination of a School-Based Implementation of Computer-Assisted Cognitive-Behavioral Therapy for Child Anxiety

Mental health treatment in schools has the potential to improve youth treatment access. However, school-specific barriers can make implementing evidence-based interventions difficult. Task-shifting (i.e., training lay staff to implement interventions) and computer-assisted interventions may mitigate these barriers. This paper reports on a qualitative examination of facilitators and barriers of a school-based implementation of a computer-assisted intervention for anxious youth (Camp Cope-A-Lot; CCAL). Participants (N = 45) included school staff in first through fourth grades. Providers attended a training in CCAL and received weekly, hour-long group consultation calls for three months. In the second year, the sustainability of CCAL use was assessed. Qualitative interviews were conducted after the first year (initial implementation) and second year (sustainability). Interviews were analyzed using the Consolidated Framework for Implementation Research domains to classify themes. Although participants reported that CCAL included useful skills, they expressed concerns about recommended session length (45 minutes) and frequency (weekly). Time burden of consultation calls was also a barrier. School staff facilitated implementation by enabling flexible scheduling for youth to be able to participate in the CCAL program. However, the sustainability of the program was limited due to competing school/time demands. Results suggest that even with computer assisted programs, there is a need to tailor interventions and implementation efforts to account for the time restrictions experienced by school-based service providers. Optimal fit between the intervention and specific school is important to maintain the potential benefits of computer-assisted treatments delivered by lay service providers in schools.

Stepped-care versus treatment as usual in panic disorder: A randomized controlled trial

Stepped-care (SC) models for anxiety disorders are implemented on a large scale and are assumed to be as effective for the greater majority of patients as more intensive treatment schemes. To compare the outcomes of SC and international guideline-based treatment (Treatment as Usual: TAU) for panic disorder, a total of 128 patients were randomized to either SC or TAU (ratio 2: 1, respectively) using a computer generated algorithm. They were treated in four mental health care centres in the Netherlands after therapists had been trained in SC by a senior expert therapist. SC comprised 10-week guided self-help (pen-and-paper version) followed, if indicated, by 13-week manualized face-to-face cognitive behavioural therapy (CBT), with medication- if prescribed- kept constant. TAU consisted of 23-week regular face-to-face CBT (RCBT) with medication -when prescribed- also kept constant. The means of the attended sessions in the SC condition was 5.9 (SD = 4.8) for ITT and 9.6 (SD = 9.6) for the RCBT condition. The difference in the number of attended sessions between the conditions was significant (t(126) = -3.87, p < .001). Remission rates between treatment conditions did not differ significantly (SC: 44.5%; RCBT: 53.3%) and symptom reduction was similar. Stepping up SC treatment to face-to-face CBT showed a minimal additional effect. Importantly, drop-out rates differed significantly for the two conditions (SC: 48.2%; RCBT: 26.7%). SC was effective in the treatment of panic disorder in terms of symptom reduction and remission rate, but dropout rates were twice as high as those seen in RCBT, with the second phase of SC not substantially improving treatment response. However, SC required significantly less therapist contact time compared to RCBT, and more research is needed to explore predictors of success for guided self-help interventions to allow treatment intensity to be tailored to patients' needs and preferences.

The Long Way to Refugee Status Acquisition and Mental Health in Post-Migration: Based on Asylum Seekers and Refugees in South Korea

Apart from North Korean defectors, South Korea is becoming a destination for Asylum seekers from all over the world. However, 1 out of 220 asylum applicants receives recognition through long and arduous administration and litigation process while being underrepresented in any kind of support services.This particular study comparatively tested the mental health status of recognized refugees(n = 45) and Asylum applicants (n = 55) to determine if the acquisition of refugee status could make a difference in their overall quality of life. We first employed the Depression, Anxiety and Stress Test and then applied an independent t-test using SPSS 22 software.As a result, there is a statistically significant difference in the mean scores of depression and anxiety. However, the stress scale did not show a statistical significance--indicating there are still lingering stressing factors even after the acquisition of refugee status. Ways and preconditions to improve the mental health service for asylum seekers and refugees are suggested at the end of the paper.

Evaluation of a brief intervention within a stepped care whole of service model for personality disorder

BACKGROUND

Although there is growing evidence that stepped models of care are useful for providing appropriate, person centered care, there are very few studies applied to personality disorders. A brief, four session, psychological treatment intervention for personality disorder within a whole of service stepped care model was evaluated. The intervention stepped between acute emergency crisis mental health services and longer-term outpatient treatments.

METHODS

Study 1 used service utilization data from 191 individuals referred to the brief intervention at a single community health site in a metropolitan health service. Proportions of individuals retained across the intervention and the referral pathways accessed following the intervention were examined. Study 2 examined 67 individuals referred to the brief intervention across 4 different sites in metropolitan health services. A range of measures of symptoms and quality of life were administered at the first and last session of the intervention. Effect sizes were calculated to examine mean changes across the course of the intervention.

RESULTS

Study 1 found that 84.29% of individuals referred to the intervention attended at least 1 session, 60.21% attended 2 sessions or more and 41.89% attended 3 or more sessions. 13.61% of the sample required their care to be "stepped up" within the service, whereas 29.31% were referred to other treatment providers following referral to the intervention. Study 2 found a significant reduction in borderline personality disorder symptom severity and distress following the intervention, and an increase in quality of life. The largest reduction was found for suicidal ideation (d = 1.01).

CONCLUSIONS

Brief psychological intervention was a useful step between acute services and longer-term treatments in this stepped model of care for personality disorder. Suicide risk and symptom severity reduced and quality of life improved, with only a small proportion of individuals requiring ongoing support from the health service following the intervention.

A Pilot Study of Smartphone-Based Memory Bias Modification and Its Effect on Memory Bias and Depressive symptoms in an Unselected Population

Memory bias modification (MBM) is a relatively new approach at targeting biased processing—a central cognitive factor causing and maintaining depression. In this pilot study we aimed to develop a smartphone-based autobiographical memory training, a novel form of MBM. A total of 153 unselected participants were randomly allocated to one of three experimental training conditions (positive, negative or sham memory training) conducted over a period of three days. Autobiographical memory bias and depressive scores were assessed pre- and post-training, whilst recent event recall and explicit self-referent memory bias were assessed post-training. Positive memory bias significantly increased in the positive training condition, however memory bias did not significantly differ post-training between the three conditions. Participants who received positive training recalled a positive autobiographical event more frequently compared to the other conditions. No significant difference between conditions was found in the other outcomes, including symptoms. The novel smartphone-based MBM intervention seems apt to affect autobiographical memory of emotional material. Future research should explore its possible (therapeutic) application.

Stepped Care as an Implementation and Service Delivery Model for Cognitive Behavioral Therapy for Psychosis

Cognitive behavioral therapy for schizophrenia spectrum disorders is an evidence-based treatment that is recommended by United States schizophrenia treatment guidelines. Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States. Stepped care interventions have shown promise as an applied treatment delivery model in other settings and for other psychotherapeutic interventions. The current paper describes how the stepped care model can be applied to CBT for psychosis in the US to increase access to the intervention in community mental health settings by leveraging the multidisciplinary team.

Economic Evaluations of Stepped Models of Care for Depression and Anxiety and Associated Implementation Strategies: A Review of Empiric Studies

Since the mid-2000s stepped care, a model of integrated healthcare delivery, has been promoted for offering accessible, effective and efficient services for individuals with mental health conditions. However, adoption of the model has not been widespread warranting additional investment by way of implementation strategies to encourage uptake. These strategies also require funding and their value for money should be assessed to inform decision making and practice. We conducted a review to better understand the extent to which the cost-effectiveness of stepped care has been evaluated (review i) and also to investigate whether economic evaluation has been applied to implementation strategies of stepped care services for anxiety and depression in developed (high income) countries and to chart their methods and outcomes (review ii). The searches were conducted in six electronic databases, grey literature and relevant journals. The search strategies returned two papers for reviews (i) and a single paper for review (ii). Despite stepped care models of integrated mental health service provision being promoted as optimal, there is limited knowledge surrounding the real-world cost-effectiveness of their application and clearly a need for good quality economic evaluations of integrated care that comply with international guidelines of good practice. There is even less information pertaining to the cost-effectiveness and budget impact of strategies designed to increase the uptake of these models.

Is self-guided internet-based cognitive behavioural therapy (iCBT) harmful? An individual participant data meta-analysis

BACKGROUND

Little is known about potential harmful effects as a consequence of self-guided internet-based cognitive behaviour therapy (iCBT), such as symptom deterioration rates. Thus, safety concerns remain and hamper the implementation of self-guided iCBT into clinical practice. We aimed to conduct an individual participant data (IPD) meta-analysis to determine the prevalence of clinically significant deterioration (symptom worsening) in adults with depressive symptoms who received self-guided iCBT compared with control conditions. Several socio-demographic, clinical and study-level variables were tested as potential moderators of deterioration.

METHODS

Randomised controlled trials that reported results of self-guided iCBT compared with control conditions in adults with symptoms of depression were selected. Mixed effects models with participants nested within studies were used to examine possible clinically significant deterioration rates.

RESULTS

Thirteen out of 16 eligible trials were included in the present IPD meta-analysis. Of the 3805 participants analysed, 7.2% showed clinically significant deterioration (5.8% and 9.1% of participants in the intervention and control groups, respectively). Participants in self-guided iCBT were less likely to deteriorate (OR 0.62, p < 0.001) compared with control conditions. None of the examined participant- and study-level moderators were significantly associated with deterioration rates.

CONCLUSIONS

Self-guided iCBT has a lower rate of negative outcomes on symptoms than control conditions and could be a first step treatment approach for adult depression as well as an alternative to watchful waiting in general practice.

Navigating the ethics of Internet-guided self-help interventions

Internet-guided self-help (IGSH) programs have proliferated recently to treat common mental health problems such as anxiety and depression. However, technology has outpaced the development of ethical guidelines for this mode of delivery. We examine ethical challenges in this new space, including defining the role "guides" play in treatment, crisis management, and user selection and screening. IGSH programs can provide safe and ethical care when they (a) coordinate care effectively with other systems; (b) provide competent and well-defined guidance; and (c) reach users that are appropriate for and well-educated about the services they are going to receive. We argue that jurisdictional practice constraints and outdated regulatory and ethical guidelines may impede the ability of IGSH programs to maintain or even improve performance when faced with greater demand, larger populations, heterogeneous settings, and the desire for large-scale dissemination.

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness

BACKGROUND

Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need.

INTRODUCTION

This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern.

MATERIALS AND METHODS

Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change.

RESULTS

Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (β = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques.

DISCUSSION

Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT).

CONCLUSIONS

This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

Large Group Exposure Treatment: A Feasibility Study of Exposure Combined with Diaphragmatic Breathing in Highly Dental Fearful Individuals

A large-group one session treatment (LG-OST) combining exposure and diaphragmatic breathing as a bodily coping element was carried out to investigate its feasibility and effectiveness in a sample of 43 highly dental fearful individuals treated simultaneously. We assessed subjective dental fear, dysfunctional dental-related beliefs, and perceived control pre- and post-intervention and at four-month follow-up. Participants additionally performed a behavioural approach test (BAT) pre- and post-intervention. During the applied exposure exercises, four participants (9.3%) discontinued the program all reporting too high levels of distress. Regarding subjective dental fear and dysfunctional dental related beliefs post treatment effects, LG-OST showed medium to large effect sizes, ranging from Cohen's d = 0.51 to d = 0.84 in the Intention-to-Treat analysis. Subjective dental fear improved clinically significantly in about one fourth (25.6%) of therapy completers. All post-treatment effects remained stable over time. Concerning the behavioral fear dimension, we observed a strong ceiling effect. Already at pre-assessment, participants accomplished more than six out of seven BAT-steps. Thus, behavioral approach did not increase significantly following treatment. Overall, the LG-OST protocol proved feasible and efficient. Compared to other one-session individual and multi-session group treatments the observed LG-OST effects were smaller. However, if LG-OST could match the efficacy of highly intensive short treatments delivered in an individual setting in the future, for example, by applying a wider array of exposure exercises, it could be a very useful treatment option as an intermediate step within a stepped care approach.

'One man's medicine is another man's poison': a qualitative study of user perspectives on low intensity interventions for Obsessive-Compulsive Disorder (OCD)

BACKGROUND

Low intensity interventions based on cognitive-behavioral therapy (CBT) such as computerized therapy or guided self-help can offer effective and accessible care for mild to moderate mental health problems. However, critics argue that by reducing therapist input and the level of experience of the professionals delivering therapy, low intensity interventions deprive users of critical 'active ingredients'. Thus, while demand management arguments support the use of low intensity interventions for OCD, their integration into existing mental health services remains incomplete. Studies of user views of low intensity interventions can offer valuable insights to define their role and optimize their implementation in practice.

METHODS

Qualitative interviews (n = 36) in adults with OCD explored user perspectives on the initiation, continuation and acceptability of two low intensity CBT interventions: guided self-help (6 h of professional support) and computerized CBT (1 h of professional support), delivered within the context of a large pragmatic effectiveness trial (ISRCTN73535163).

RESULTS

While uptake was relatively high, continued engagement with the low intensity interventions was complex, with the perceived limitations of self-help materials impacting on users' willingness to continue therapy. The addition of professional support provided an acceptable compromise between the relative benefits of self-help and the need for professional input. However, individual differences were evident in the extent to which this compromise was considered necessary and acceptable. The need for some professional contact to manage expectations and personalize therapy materials was amplified in users with OCD, given the unique features of the disorder. However, individual differences were again evident regarding the perceived value of face-to-face support.

CONCLUSIONS

Overall the findings demonstrate the need for flexibility in the provision of low intensity interventions for OCD, responsive to user preferences, as these preferences impact directly on engagement with therapy and perceptions of effectiveness.

Long-Term Effects of Two Formats of Cognitive Behavioral Therapy for Insomnia Comorbid with Breast Cancer

STUDY OBJECTIVES

The goal of this randomized controlled trial, conducted in breast cancer patients, was to assess the long-term efficacy of a video-based cognitive behavioral therapy for insomnia (VCBT-I), as compared to a professionally administered intervention (PCBT-I) and to a no-treatment group (CTL). An earlier report revealed that, at posttreatment, VCBT-I patients showed significantly greater sleep improvements than CTL, but that PCBT-I produced superior effects than VCBT-I on some sleep and secondary outcomes. In this report, long-term effects are compared.

METHODS

Two hundred forty-two women with breast cancer and with insomnia symptoms or using hypnotic medications participated to this three-arm randomized controlled trial: (1) PCBT-I (n = 81); (2) VCBT-I (n = 80); or (3) no treatment (CTL; n = 81) group. PCBT-I was composed of six weekly, individual sessions of approximately 50 min, whereas VCBT-I comprised a 60-min animated video and six booklets.

RESULTS

Study measures (sleep and secondary variables) were administered at pretreatment and posttreatment, and at a 3-, 6-, and 12-mo follow-up. Treatment gains were well sustained at follow-up in both PCBT-I and VCBT-I. As at posttreatment, the remission rate of insomnia at follow-up was greater in PCBT-I than in VCBT-I, which was greater than in CTL.

CONCLUSIONS

Although face-to-face therapy remains the optimal format to efficaciously administer CBT for insomnia in cancer patients, a minimal intervention, such as the video-based intervention tested in this study, produces significant and sustainable treatment effects.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00674830.

Pilot CBT trial for anxiety in alcohol use disorders treatment

Purpose

– The purpose of this paper is to test the effectiveness of a self-directed cognitive behavioural therapy (CBT) booklet allowing immediate access to treatment for anxiety during alcohol use disorder (AUD) interventions.

Design/methodology/approach

– Parallel pilot randomised controlled trial: 69 individuals in AUD treatment, continued to receive treatment alone (control: n=29) or in addition, a self-directed, four week CBT booklet to manage anxiety (intervention: n=40). Primary outcome measures were changes in state (SAnx) and trait anxiety (TAnx) at four weeks. Secondary outcome measures were changes in adaptive (ACop), maladaptive (MCop) coping and quality of life (QoL, physical (PHQoL), psychological (PSQoL), social (SQoL), environment (EQoL)) at four weeks.

Findings

– Participants had significantly higher SAnx (p < 0.01) and TAnx (p < 0.01) baseline scores compared to the general population. There were no statistically significant group changes in SAnx or TAnx (p > 0.05). Control group allocation predicted improvement in ACop (p < 0.01), MCop (p < 0.05), PHQoL (p < 0.01), PSQoL (p < 0.05) and SQoL (p < 0.01); CBT group allocation predicted improvement in EQoL (p=0.05). All effect sizes were small to moderate (Cohen’s d < 0.50). Percentage of book completion did not determine changes in anxiety, coping or quality of life.

Originality/value

– A four week self-directed CBT booklet did not significantly reduce anxiety during AUD treatment. Larger sample sizes will determine the most suitable treatment delivery mode for this type of CBT.

Rationale and Considerations for the Internet-Based Delivery of Parent-Child Interaction Therapy

Given the enormous individual, familial, and societal costs associated with early disruptive behavior disorders, transformative efforts are needed to develop innovative options for overcoming traditional barriers to effective care and for broadening the availability of supported interventions. This paper presents the rationale and key considerations for a promising innovation in the treatment of early-onset disruptive behavior disorders-that is, the development of an Internet-based format for the delivery of Parent-Child Interaction Therapy (PCIT) directly to families in their own homes. Specifically, we consider traditional barriers to effective care, and discuss how technological innovations can overcome problems of treatment availability, accessibility, and acceptability. We then detail our current Internet-delivered PCIT treatment program (I-PCIT), which is currently being evaluated across multiple randomized clinical trials relative to waitlist comparison, and to traditional in-office PCIT. Embedded video clips of children treated with I-PCIT are used to illustrate novel aspects of the treatment.

Classification models for subthreshold generalized anxiety disorder in a college population: Implications for prevention

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders on college campuses and often goes unidentified and untreated. We propose a combined prevention and treatment model composed of evidence-based self-help (SH) and guided self-help (GSH) interventions to address this issue. To inform the development of this stepped-care model of intervention delivery, we evaluated results from a population-based anxiety screening of college students. A primary model was developed to illustrate how increasing levels of symptomatology could be linked to prevention/treatment interventions. We used screening data to propose four models of classification for populations at risk for GAD. We then explored the cost considerations of implementing this prevention/treatment stepped-care model. Among 2489 college students (mean age 19.1 years; 67% female), 8.0% (198/2489) met DSM-5 clinical criteria for GAD, in line with expected clinical rates for this population. At-risk Model 1 (subthreshold, but considerable symptoms of anxiety) identified 13.7% of students as potentially at risk for developing GAD. Model 2 (subthreshold, but high GAD symptom severity) identified 13.7%. Model 3 (subthreshold, but symptoms were distressing) identified 12.3%. Model 4 (subthreshold, but considerable worry) identified 17.4%. There was little overlap among these models, with a combined at-risk population of 39.4%. The efficiency of these models in identifying those truly at risk and the cost and efficacy of preventive interventions will determine if prevention is viable. Using Model 1 data and conservative cost estimates, we found that a preventive intervention effect size of even 0.2 could make a prevention/treatment model more cost-effective than existing models of "wait-and-treat."

Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service

OBJECTIVE

To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up.

METHODS

A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures.

RESULTS

1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was $12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of $708 per patient. Significant differences were seen between groups for follow-up hospital costs.

CONCLUSIONS

ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS.

GOV IDENTIFIER NUMBER

NCT01924715.

Outcome predictors of Internet-based brief sex therapy for sexual dysfunctions in heterosexual men

The authors investigated whether baseline and therapy process characteristics of 82 heterosexual men participating in an Internet-based sex therapy study predict posttreatment sexual functioning. Problem severity, baseline sexual desire and baseline sexual satisfaction, but also partner problems and quality of the therapeutic relationship are predictive for sexual functioning and sexual satisfaction after finishing Internet-based sex therapy. The obtained outcome predictors could benefit men with sexual dysfunctions by tailoring online therapy programs to their individual characteristics. In addition, therapists should realize that clients suffering from erectile dysfunction or premature ejaculation in online sex therapy attach great importance to the therapeutic relationship.

Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial

STUDY OBJECTIVE

To assess the short-term efficacy of a video-based cognitive behavioral therapy for insomnia (CBT-I) as compared to a professionally administered CBT-I and to a no-treatment group.

DESIGN

Randomized controlled trial.

SETTING

Radio-oncology department of a public hospital affiliated with Université Laval (CHU de Québec).

PARTICIPANTS

Two hundred forty-two women with breast cancer who had received radiation therapy in the past 18 mo and who had insomnia symptoms or were using hypnotic medications were randomized to: (1) professionally administered CBT-I (PCBT-I; n = 81); (2) video-based CBT-I (VCBT-I; n = 80); and (3) no treatment (CTL; n = 81).

INTERVENTIONS

PCBT-I composed of six weekly, individual sessions of approximately 50 min; VCBT-I composed of a 60-min animated video + six booklets.

MEASUREMENT AND RESULTS

Insomnia Severity Index (ISI) total score and sleep parameters derived from a daily sleep diary and actigraphy, collected at pretreatment and posttreatment. PCBT-I and VCBT-I were associated with significantly greater sleep improvements, assessed subjectively, as compared to CTL. However, relative to VCBT-I, PCBT-I was associated with significantly greater improvements of insomnia severity, early morning awakenings, depression, fatigue, and dysfunctional beliefs about sleep. The remission rates of insomnia (ISI < 8) were significantly greater in PCBT-I as compared to VCBT-I (71.3% versus 44.3%, P < 0.005).

CONCLUSIONS

A self-administered cognitive behavioral therapy for insomnia (CBT-I) using a video format appears to be a valuable treatment option, but face-to-face sessions remain the optimal format for administering CBT-I efficaciously in patients with breast cancer. Self-help interventions for insomnia may constitute an appropriate entry level as part of a stepped care model.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00674830.

CITATION

Savard J, Ivers H, Savard MH, Morin CM. Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial.

Combined medication and CBT for generalized anxiety disorder with African American participants: reliability and validity of assessments and preliminary outcomes

Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared with European American patients. Internal consistency and short-term stability coefficients for African Americans (n=42) were adequate and similar or higher compared with those found for European Americans (n=164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared with European Americans. A subset of patients with DSM-IV-diagnosed GAD (n=24 African Americans; n=52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n=8) of the African Americans and 32.6% (n=17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

Development of a guided self-help (GSH) program for the treatment of mild-to-moderate posttraumatic stress disorder (PTSD)

BACKGROUND

There is a shortage of suitably qualified therapists able to deliver evidence-based treatment for posttraumatic stress disorder (PTSD), precluding timely access to intervention. This work aimed to develop an optimally effective, feasible, and acceptable guided self-help (GSH) program for treatment of the disorder.

METHODS

The study followed Medical Research Council (MRC) guidance for the development of a complex intervention. A prototype GSH program was developed through an initial modeling phase. Systematic reviews of the literature informed a portfolio of up-to-date information for key stakeholders to consider and discuss in a series of focus groups and semistructured interviews, which included 10 mental health professionals with expertise in the fields of GSH and/or PTSD, and seven former PTSD sufferers. Data were analyzed through a process of Inductive Thematic Analysis and used to inform the content, delivery, and guidance of a GSH program for PTSD. The prototype was piloted with 19 PTSD sufferers in two pilot studies, and refined on the basis of their quantitative results and qualitative feedback.

RESULTS

The final version was available online and in hardcopy. It included 11 modules, some being mandatory and others optional, allowing tailoring of the intervention to meet an individual's specific needs. Qualitative and quantitative results of the pilot studies supported its efficacy in terms of reducing traumatic stress symptoms and its acceptability to PTSD sufferers.

CONCLUSIONS

Delivering psychological treatment in a GSH format shows promise as an effective and acceptable way of treating mild-to-moderate PTSD.

Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that often persists into adulthood. Barrett, Farrell, Pina, Peris, and Piacentini (2008), in this journal, provided a detailed review of evidence-based psychosocial treatments for youth with OCD. The current review provides an evidence base update of the pediatric OCD psychosocial treatment literature with particular attention to advances in the field as well as to the methodological challenges inherent in evaluating such findings. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the JCCAP evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, this issue). Findings from this review clearly converge in support of cognitive-behavioral therapy as an effective and appropriate first line treatment for youth with OCD (either alone or in combination with medication). Although no treatment for pediatric OCD has yet to be designated as "well-established," both individual and individual family-based treatments have been shown to be "probably efficacious." Moderators and predictors of treatment outcome are discussed as are the areas where we have advanced the field and the areas where we have room to grow. The methodological and clinical challenges inherent in a review of the evidence base are reviewed. Finally, future research directions are outlined.

Technological advances in psychotherapy: implications for the assessment and treatment of obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is a prevalent and costly condition that causes significant functional impairment and reduced quality of life. Although treatments with demonstrated efficacy for OCD, such as cognitive behavior therapy and antidepressants, have existed for over three decades, many patients remain inadequately treated or untreated. Challenges encountered in the treatment of OCD include problems with homework compliance, frequent relapse, difficulties in simulating the spontaneous nature of intrusive thoughts, and infrequent treatment sessions. Accumulated research now indicates that computerized assessment and therapy tools can significantly improve the cost/time-effectiveness of conventional psychotherapeutic interventions for anxiety disorders such as OCD without impairing therapeutic progress and outcome. In this paper we examine the potential of such technology, address current challenges in the assessment and treatment of OCD, and provide a rationale for future research in the field. We outline the general utility of computer technology in psychotherapeutic interventions, critically evaluate the existing literature on computer-assisted assessment and treatment specific to OCD, as well as discuss potential implications of portable technology for OCD treatment delivery and outcomes.

Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy

Generalized anxiety disorder (GAD) is a common and disabling condition associated with significant personal and societal costs. Although efficacious treatments exist for GAD, the majority of these individuals fail to access our most effective treatments. In the current paper, we report the results of an open trial that examined the efficacy of a computer-delivered home-based treatment program for GAD. Twenty-one individuals seeking treatment for GAD received a self-administered program over 6 weeks that comprised two components: (1) an Attention Modification Program (AMP) designed to facilitate attentional disengagement from threat-relevant stimuli and (2) brief computer-delivered cognitive and behavioral treatment modules (CCBT). Fourteen of the 21 enrolled participants (67%) completed the treatment program. Intent-to-treat and completer analyses revealed that AMP+CCBT resulted in significant reductions in clinician- and self-rated symptoms of anxiety, worry, depression, and functional impairment. Moreover, treatment completers displayed significant reductions in attentional bias for threat from pre- to postassessment. Change in attentional bias for threat from pre- to postassessment was associated with change in worry symptoms. Finally, 79% of participants no longer met DSM-IV criteria for GAD at postassessment and 36% were classified as remitted (Hamilton Rating Scale for Anxiety ≤7; Rickels et al., 2006). These results suggest that computer-delivered AMP+CCBT may serve as an effective and easily accessible treatment option for individuals with GAD.

Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review

BACKGROUND

Self-help interventions for psychiatric disorders represent an increasingly popular alternative to therapist-administered psychological therapies, offering the potential of increased access to cost-effective treatment.

AIMS

To determine the efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders.

METHOD

Randomised controlled trials (RCTs) of self-help interventions for anxiety disorders were identified by searching nine online databases. Studies were grouped according to disorder and meta-analyses were conducted where sufficient data were available. Overall meta-analyses of self-help v. waiting list and therapist-administered treatment were also undertaken. Methodological quality was assessed independently by two researchers according to criteria set out by the Cochrane Collaboration.

RESULTS

Thirty-one RCTs met inclusion criteria for the review. Results of the overall meta-analysis comparing self-help with waiting list gave a significant effect size of 0.84 in favour of self-help. Comparison of self-help with therapist-administered treatments revealed a significant difference in favour of the latter with an effect size of 0.34. The addition of guidance and the presentation of multimedia or web-based self-help materials improved treatment outcome.

CONCLUSIONS

Self-help interventions appear to be an effective way of treating individuals diagnosed with social phobia and panic disorder. Further research is required to evaluate the cost-effectiveness and acceptability of these interventions.

Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder

This study reports a waitlist controlled randomized trial of family-based cognitive-behavioral therapy delivered via web-camera (W-CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty-one primarily Caucasian youth with OCD (range=7-16years; 19 male) were randomly assigned to W-CBT or a Waitlist control. Assessments were conducted immediately before and after treatment, and at 3-month follow-up (for W-CBT arm only). Primary outcomes included the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), clinical global improvement rates, and remission status. When controlling for baseline group differences, W-CBT was superior to the Waitlist control on all primary outcome measures with large effect sizes (Cohen's d≥1.36). Thirteen of 16 youth (81%) in the W-CBT arm were treatment responders, versus only 2/15 (13%) youth in the Waitlist arm. Similarly, 9/16 (56%) individuals in the W-CBT group met remission criteria, versus 2/15 (13%) individuals in the Waitlist control. Gains were generally maintained in a naturalistic 3-month follow-up for those randomized to W-CBT. This preliminary study suggests that W-CBT may be helpful in reducing obsessive-compulsive symptoms in youth with OCD. Given considerable access issues, such findings hold considerable promise for treatment dissemination.

Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness

Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress often neglects a central goal—namely, to reduce the burden of mental illness and related conditions. The need for psychological services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media. Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment, and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations are discussed as key considerations for reducing the burden of mental illness.

Computers and psychosocial treatment for child anxiety: recent advances and ongoing efforts

Building on the empirical data supporting the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, researchers are working on the development and evaluation of cost-effective and transportable CBT approaches. Related to this, a widely endorsed goal is to disseminate evidence-based treatments from research settings to community settings. Computer-assisted treatments have emerged as a means to provide cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. We offer a rationale for the development and evaluation of computer-assisted psychosocial treatments for anxiety in youth, offer illustrative advances made in this area, and describe our efforts in using computers to enhance dissemination of CBT for child anxiety. Specifically, our illustrations include a description of (a) Camp-Cope-A-Lot (CCAL), a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7-12, and (b) CBT4CBT: Computer-based training in CBT for anxious youth. Findings from evaluations of these programs are summarized, and further advances are proposed and discussed.

Expectancy/Credibility Change as a Mediator of Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Mechanism of Action or Proxy for Symptom Change?

Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-session cognitive and behavioral therapy for generalized anxiety disorder (GAD). In 76 adults with primary GAD, we predicted that expectancy/credibility would change significantly from sessions 4-7, that degree of change in expectancy/credibility would predict degree of reliable change at posttreatment, and that changes in expectancy/credibility would mediate the relationship between pretreatment severity and change at posttreatment. In support of the hypotheses, a latent growth model revealed significant increases in expectancy/credibility over the critical period. In addition, baseline GAD severity, expectancy/credibility intercept, and rate of change in expectancy/credibility all positively predicted degree of reliable change at posttreatment. Rate of change in expectancy/credibility during the critical period partially mediated the effect of baseline GAD severity, accounting for 38% of the variance in this relationship. This effect was not accounted for by preceding or concurrently changing anxiety levels.

Stepped care for depression in primary care: what should be offered and how?

Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of "watchful waiting", as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.

Diagnostic comorbidity in adults with generalized anxiety disorder: impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n=46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.