Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders

Anxiety on the internet: Describing person, provider, and organization online posts

Anxiety is a pervasive phenomenon in contemporary society. With increased internet use in recent years, more people in the general population are seeking and providing help and participating in community online. The goal of our study was to evaluate the content of internet narratives among those who post about anxiety and determine what stakeholder groups are saying online. We used the bifurcated method; it is a multi-method (qualitative) approach with inductive, thematic analyses, and with quantification of content-related words via a computer program that crawls websites and counts the occurrences of specified terms (for cross-checking purposes). Themes of posts and webpages about anxiety were: using/reporting treatment strategies (83.3% saturation), providing help (77.8% saturation), telling personal stories (72.2% saturation), seeking help (61.1% saturation), and illustrating interpersonal impact (50% saturation). We argue that anxiety stakeholders may take part in health co-inquiry online (i.e., cooperating with others) in many of the same ways that they might collaborate in person. We recommend that clinicians query their clients about use of the internet in ways related to their anxiety (e.g., seeking information/treatment strategies, offering help to others, telling their personal stories, etc.) so that they might help them process what they experience online.

Values- versus monetary reward-enhanced exposure therapy for the treatment of social anxiety in emerging adulthood

Exposure therapy represents the gold-standard treatment for social anxiety, yet evidence indicates the need for improvement. One promising avenue involves linking exposures to a motivator. The current study examined the impact of intrinsically-rewarding, personal values-enhanced versus extrinsically-rewarding, monetary-enhanced exposure on short-term social anxiety fear and avoidance outcomes, and evaluated impacted initial treatment motivation and exposure generalization.

METHODS

Sixty emerging adults ages 17-26 with significantly elevated social and public speaking anxiety were randomized to receive values-enhanced exposure, monetary reward-enhanced exposure, or exposure alone. They completed a laboratory session with a brief intervention and speech exposure, one-week follow-up with novel exposure, and online follow-up two weeks later. Subjective and behavioral anxiety measures were collected.

RESULTS

Linking exposures to values decreased self-reported anxiety following the speech exposure retest, which generalized to anticipatory anxiety prior to a novel speech task. Linking exposures to money temporarily increased speech length, but this difference did not remain during the novel task. Conditions showed similar improvements on other outcomes.

CONCLUSION

Extrinsic motivators can temporarily motivate exposure engagement, whereas a brief values intervention can enhance exposure learning and decrease subjective anxiety across feared situations compared to monetary enhancement. If replicated, this has pragmatic implications for exposure framing within social anxiety treatment.

Predictors of treatment attrition of cognitive health interventions in first episode psychosis

AIM

Dropping out of psychological interventions is estimated to occur in up to a third of individuals with psychosis. Given the high degree of attrition in this population, identifying predictors of attrition is important to develop strategies to retain individuals in treatment. We observed a particularly high degree of attrition (48%) in a recent randomized controlled study assessing cognitive health interventions for first-episode psychosis participants with comorbid social anxiety. Due to the importance of developing interventions for social anxiety in first episode psychosis, the aim of the present study was to identify putative predictors of attrition through a secondary analysis of data.

METHODS

Participants (n = 96) with first episode psychosis and comorbid social anxiety were randomized to receive cognitive behavioural therapy for social anxiety or cognitive remediation. Differences between completers and non-completers (<50% intervention completed) were compared using t-tests or chi-square analyses; statistically significant variables were entered into a multivariate logistic regression model.

RESULTS

Non-completers tended to be younger, had fewer years of education and had lower levels of social anxiety compared to completers. Lower baseline social anxiety and younger age were statistically significant predictors of non-completion in the logistic regression model.

CONCLUSIONS

Age and social anxiety were predictors of attrition in cognitive health interventions in first episode psychosis populations with comorbid social anxiety. In the ongoing development of social anxiety interventions for this population, future studies should investigate specific engagement strategies, intervention formats and outcome monitoring to improve participant retention in treatment.

Mediators of Ethnic Differences in Dropout Rates From a Randomized Controlled Treatment Trial Among Latinx and Non-Latinx White Primary Care Patients With Anxiety Disorders

ABSTRACT

Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE)

BACKGROUND

Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness.

METHODS

A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment.

DISCUSSION

The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach.

TRIAL REGISTRATION

ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.

A meta-analytic review of randomized clinical trials of online treatments for anxiety: Inclusion/exclusion criteria, uptake, adherence, dropout, and clinical outcomes

Over the last decade there has been rapid growth in the number of clinical trials examining internet-delivered interventions for anxiety. While there have been numerous analyses of treatment efficacy, few studies have examined treatment engagement. The current meta-analysis examined participant eligibility, uptake, adherence, and drop-out in clinical trials of internet-delivered treatments for anxiety. This meta-analysis used random effects models to obtain estimates of participant inclusion, uptake, adherence, drop-out, and within-group treatment effect size. Moderator analyses examined the effects of anxiety disorder type, treatment type, and level of clinician guidance. After screening, 140 trials with 199 treatment arms (N = 11,021) were included. An average of 46% (95% CI 42, 50) of interested people were included in the clinical trials. In the active treatment arms, 98% (95% CI 97, 99) of participants began treatment, 81% (95% CI 78, 85) of the assigned treatments were completed, 21% (95% CI 18, 23) of individuals dropped out at post-treatment based on questionnaire non-completion, and an overall within-group effect size of g = 1.03 (95% CI 0.94, 1.13) was obtained. Several moderators of interest were significant (e.g., clinical guidance, anxiety disorder type), and there was substantial heterogeneity in estimates. In conclusion, a large number of inclusion and exclusion criteria have been used in trials of internet-delivered treatments for anxiety. Once recruited into a trial, however, most people appear to begin, adhere, and complete internet-delivered treatment for anxiety. Further research exploring various eligibility criteria and their impact on engagement and efficacy is warranted.

Predicting non-initiation of care and dropout in a blended care CBT intervention: Impact of early digital engagement, sociodemographic, and clinical factors

Objective

This study examines predictors of non-initiation of care and dropout in a blended care CBT intervention, with a focus on early digital engagement and sociodemographic and clinical factors.

Methods

This retrospective cohort analysis included 3566 US-based individuals who presented with clinical levels of anxiety and depression and enrolled in a blended-care CBT (BC-CBT) program. The treatment program consisted of face-to-face therapy sessions via videoconference and provider-assigned digital activities that were personalized to the client's presentation. Multinomial logistic regression and Cox proportional hazard survival analysis were used to identify predictors of an increased likelihood of non-initiation of therapy and dropout.

Results

Individuals were more likely to cancel and/or no-show to their first therapy session if they were female, did not disclose their ethnicity, reported poor financial status, did not have a college degree, endorsed more presenting issues during the onboarding triage assessment, reported taking antidepressants, and had a longer wait time to their first appointment. Of those who started care, clients were significantly more likely to drop out if they did not complete the digital activities assigned by their provider early in treatment, were female, reported more severe depressive symptoms at baseline, reported taking antidepressants, and did not disclose their ethnicity.

Conclusions

Various sociodemographic and clinical predictors emerged for both non-initiation of care and for dropout, suggesting that clients with these characteristics may benefit from additional attention and support (especially those with poor early digital engagement). Future research areas include targeted mitigation efforts to improve initiation rates and curb dropout.

Self-guided virtual reality therapy for social anxiety disorder: a study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is a highly prevalent mental disorder associated with enormous stress and suffering. Cognitive behavior therapy (CBT) is the first-line treatment for SAD, yet its accessibility is often constrained with long waiting times. Digital therapeutic applications, including psychoeducation and self-guided behavioral experiments in virtual reality (VR), could facilitate access and reduce waiting times. The study aims to investigate if ultra-short-time therapy involving self-guided digital therapeutic applications with VR components can reduce the severity of SAD.

METHODS

Forty SAD patients will participate in this randomized controlled trial. Half will get access to a self-guided, digital therapeutic application with exposure-based behavioral experiments in VR, while the other half will receive a control treatment. Both treatments include four therapeutic appointments. Changes in the severity of SAD will be measured after each appointment and on a 6-week follow-up assessment and will be compared between groups, with the change in SAD measured at baseline- and post-assessment as primary outcome.

DISCUSSION

Self-guided digital therapeutic applications including ultra-short-time therapy combined with VR could help reduce the waiting time for patients and relieve the health system. The results of this study may inform psychotherapists regarding the potential of self-guided digital therapeutic applications including exposure-based behavioral experiments in VR for SAD and will provide important insight for future research on VR therapy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18013983 . Registered on 1 February 2022.

Evaluating the efficacy of common humanity-enhanced exposure for socially anxious young adults

Despite some evidence of the benefits of self-compassion training among socially anxious individuals, little is known about whether enhancing self-compassion prior to exposure therapy increases initial exposure engagement. Additionally, manipulations have relied on broad definitions of self-compassion, rendering it difficult to distinguish the impact of individual components. This study employed three experiential exercises designed to enhance one facet of self-compassion-common humanity. Socially anxious undergraduates (N = 63) were randomized in groups to 1) common humanity-enhanced exposure (n = 32) or 2) exposure alone (n = 31). In the common humanity condition, participants wrote self-compassionately, shared fears, and completed a common humanity-focused lovingkindness meditation. All participants then completed a speech exposure in front of live judges followed by an optional second exposure. Within the common humanity condition, positive self-responding to the speech exposure increased (b = 0.30, p = .026). Common humanity participants also remained in the first exposure longer, relative to exposure alone (b = -30.92, p = .002). Participants rated exercises as at least moderately helpful, with sharing fears rated most helpful. In sum, a brief group-based multi-modal common humanity induction represents a promising approach to improving initial engagement with feared contexts among socially anxious individuals.

Treatment of Spider Phobia Using Repeated Exposures and Adjunctive Repetitive Transcranial Magnetic Stimulation: A Proof-of-Concept Study

BACKGROUND

Specific phobias represent the largest category of anxiety disorders. Previous work demonstrated that stimulating the ventromedial prefrontal cortex (vmPFC) with repetitive Transcranial Magnetic Stimulation (rTMS) may improve response to exposure therapy for acrophobia.

OBJECTIVE

To examine feasibility of accelerating extinction learning in subjects with spider phobia using intermittent Theta Burst Stimulation (iTBS) rTMS of vmPFC.

METHODS

In total, 17 subjects with spider phobia determined by spider phobia questionnaires [Spider Phobia Questionnaire (SPQ) and Fear of Spiders questionnaire (FSQ)] underwent ratings of fear of spiders as well as behavioral and skin conductance data during a behavioral avoidance test (BAT). Subjects then received a sequential protocol of in vivo spider exposure followed by iTBS for three sessions administered to either active or control treatment sites (vmPFC [n = 8] or vertex [n = 9], respectively), followed 1 week later by repetition of questionnaires and BAT.

RESULTS

All subjects improved significantly regardless of group across both questionnaires (FSQ η² = 0.43, p = 0.004; SPQ η² = 0.39, p = 0.008) and skin conductance levels during BAT (Wald χ² = 30.9, p < 0.001). Subjects in the vmPFC group tolerated lower treatment intensity than in the control group, and there was a significant correlation between treatment intensity, BAT subjective distress improvement, and physiologic measures (all ρ > 0.5).

CONCLUSION

This proof-of-concept study provides preliminary evidence that a sequential exposure and iTBS over vmPFC is feasible and may have rTMS intensity-dependent effects on treatment outcomes, providing evidence for future areas of study in the use of rTMS for phobias.

The Nature, Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.

Motivational Interviewing Enhances Group Cognitive Behavioral Therapy for Anxiety Disorders

This pilot study tested whether the addition of motivational interviewing (MI) prior to group cognitive behavioral therapy (CBT) for anxiety may improve the effectiveness of the treatment. Prior to group CBT, 40 individuals with a principal diagnosis of an anxiety disorder (40% panic disorder, 25% generalized anxiety disorder, 22.5% social phobia, and 12.5% others) were randomly assigned to receive either three individual sessions of MI or were assigned to a control group that did not receive MI. The pretreatment MI group, compared to the control group, experienced significantly greater reduction in anxiety symptoms post-CBT. These results suggest that brief MI pretreatment enhances the efficacy of CBT on anxiety. A combination of MI and CBT may be particularly promising for the treatment of anxiety, with MI directed at increasing motivation and commitment to change, and CBT directed at helping the client achieve the desired changes.

Clinical features associated with early drop-out among outpatients with unipolar and bipolar depression

Drop-out from follow-up visits carries significant burden for people diagnosed with depression. The present study assesses multiple clinical moderators of drop-out among depressed outpatients. We retrospectively followed-up 131 outpatients over 6 months: 78 major depressive disorder (MDD), and 53 bipolar disorder (BD-I = 24; BD-II = 29) patients diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Participants were assessed with standard rating scales administered by experienced psychiatrists. Upon descriptive and Cox regression analyses, 17/53 BDs (32%) dropped-out; the overall survival time until drop-out was 57.94 ± 17.79 days. BD drop-outs were younger, had an earlier age at onset, shorter illness duration, lower rates of lifetime obsessive-compulsive disorder/suicidal behavior, higher rates of substance use disorder (SUD), anxious and mixed features of depression compared to BDs attending up to six months. Among MDD patients, 10/78 cases (13%) dropped-out by month-6 with an average survival of 42.40 ± 16.45 days. Earlier age of onset, younger age, positive family history for mood disorders, lower rates of lifetime generalized anxiety disorder were significantly more frequent among drop-outs than completers, as opposite to SUD, and lifetime recurrent depression. Older age predicted lower drop-out among BDs and MDDs, although with almost null hazard ratio (HR) = 0.928, p < 0.01 vs. HR = 0.941, p < 0.01, respectively. Higher rates of lifetime SUD predicted higher drop-out rates by month-6 among MDDs (HR = 5.477, p = 0.02). Limitations of the study: retrospective design, small sample size, lack of objective measures of treatment-adherence/mood rating during follow-up. Drop-out is common in the real-world setting, warranting specific interventions since the beginning of the treatment.

The effect of motivational interviewing on ambivalence in social anxiety disorder

BACKGROUND

One reason that motivational interviewing (MI) is thought to translate well to a variety of treatment domains is due to the focus on client ambivalence.

AIMS

Therefore, the current study aimed to explore the construct of ambivalence in the context of MI and cognitive behavioural therapy (CBT) for social anxiety disorder (SAD).

METHOD

Participants were 147 individuals diagnosed with SAD who were randomised to receive either MI or supportive counselling prior to receiving group CBT for SAD.

RESULTS

The results suggested that MI was not related to decreases in general ambivalence or treatment ambivalence, although an indicator of treatment ambivalence was found to predict worse treatment outcome.

CONCLUSIONS

The findings suggest that three sessions of MI prior to CBT may not decrease ambivalence in participants with SAD, which may underscore the potential importance of tackling ambivalence as it arises during CBT.

Enhancing extinction with response prevention via imagery-based counterconditioning: Results on conditioned avoidance and distress

BACKGROUND AND OBJECTIVES

Maladaptive avoidance is a core characteristic of anxiety-related disorders. Its reduction is often promoted using extinction with response prevention (ExRP) procedures, but these effects are often short-lived. Research has shown that pairing a feared stimulus with a stimulus of an incompatible valence (i.e., counterconditioning) may be effective in reducing fear. This laboratory study tested whether positive imagery during ExRP (i.e., imagery counterconditioning protocol) can also reduce avoidance.

METHODS

In the counterconditioning procedure, participants imagined a positive sound. There were four phases. First, participants were presented with squares on a computer screen of which one (CS+) was paired with an aversive sound and another (CS-) was not. Second, they learned to avoid the negative sound in the presence of the CS+, via a key press. Third, they were assigned to either the Counterconditioning (that was asked to imagine a positive sound during ExRP) or No Counterconditioning group (standard ExRP). Finally, they performed a test phase that consisted of two parts: in the first part, avoidance responses were available for each CS and in the second part, these responses were prevented.

RESULTS

The Counterconditioning intervention resulted in a short-lived reduction of distress associated with the CS+. However, groups did not differ in avoidance or distress during the test phases.

LIMITATIONS

US-expectancy ratings were collected only at the end of the experiment.

CONCLUSIONS

The results indicate that positive imagery during ExRP may be effective in reducing distress during the intervention. Explanations for the persistence of avoidance and fear are discussed.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial

BACKGROUND

Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care.

METHODS

In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis.

RESULTS

A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79].

CONCLUSIONS

Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST).

METHODS

Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment.

RESULTS

The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT.

CONCLUSIONS

Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

Historic psychedelic drug trials and the treatment of anxiety disorders

INTRODUCTION

In this paper, we systematically review literature from 1940 to 2000 relating to the combined use of psychological therapies and psychedelic drugs in the treatment of ICD-10 anxiety disorders.

METHODS

The databases Ovid MEDLINE(R), PsycINFO, and Multidisciplinary Association for Psychedelic Studies (MAPS) were searched for case reports and trials involving humans in the treatment of ICD-10 anxiety and related disorders. Twenty-four studies are described; four describe anxiety symptoms in diverse patient groups, 14 studies describe historic diagnoses that usefully correspond with ICD-10 anxiety disorders, six studies pooled results or failed to detail results specific to contemporary ICD-10 anxiety disorders. Two of the 24 studies reported are individual case reports while two of them were inadequate in terms of the reporting of outcome measures. Thus 20 studies were ultimately included in the summary analysis.

RESULTS

Three of the 20 studies reviewed described improvements in anxiety by standardized measures (p < .05) and two studies found that this effect was dose related. Of the 20 studies included in the final analysis, 94 of 145 (65%) cases of "psychoneurotic anxiety reaction" as defined by Diagnostic and Statistical Manual of Mental Disorders-I showed improvement that ranged from moderate improvement to full recovery. Despite methodological inadequacies, the results from previous studies are encouraging and should be used to guide and inform further investigation.

CONCLUSION

The majority of studies indicate that a combination of psychedelic drug administration and psychological therapy was most beneficial. We found no study suggesting that the pharmacological action of psychedelic drugs in isolation is sufficient.

Determinants of treatment non-attendance among those referred to primary mental health care services in Western Sydney, Australia: a retrospective cohort study

OBJECTIVES

Recommendations of the recent mental health reforms provided an opportunity to implement regional approaches to service provision through Primary Health Networks. This study is designed to identify the determinants of sociodemographic, diagnostic and referral-level factors and first treatment session non-attendance among those referred to primary mental health care (PMHC) services in Western Sydney, Australia.

DESIGN

This study used routinely collected retrospective PMHC data between July 2016 and December 2018.

SETTING

The study was based on a geographical catchment that covers four local government areas of Blacktown, Parramatta, Cumberland and Hills Shire in Western Sydney, Australia.

PARTICIPANTS

All individuals 5 years of age or older referred to PMHC services.

PRIMARY OUTCOME MEASURE

First treatment session non-attendance, following a referral to receive psychological treatments.

RESULTS

There were 9158 referrals received for 8031 clients, with 1769 (19.32%) referrals resulting in non-attendance to the first treatment session. Those with younger age (ORs ranging from 1.63 to 1.92), substance use (OR=1.55, 95% CI 1.17 to 2.06), poor English proficiency (OR=1.64, 95% CI 1.23 to 2.20), lower socioeconomic status (OR=1.57, 95% CI 1.34 to 1.83), psychotropic medication use (OR=1.20, 95% CI 1.06 to 1.36), and a referral by a social worker (OR=2.04, 95% CI 1.36 to 3.05), allied health (OR=1.49, 95% CI 1.03 to 2.16) or other professional (OR=1.72, 95% CI 1.30 to 2.29) were associated with a higher likelihood of first treatment session non-attendance. Those with a risk of suicide, who mainly speak a language other than English, and a previous use of PMHC services were more likely to attend their first treatment session.

CONCLUSION

Youth-specific treatment approaches, behavioural engagement strategies, facilitation of transport services for those live in deprived regions and improvements in capacity for mental health training among allied health professionals are areas of focus for primary care service and policy responses.

Patterns of change in physical functioning and posttraumatic stress disorder with cognitive processing therapy in a randomized controlled implementation trial

Background: Physical health concerns (e.g. chronic pain, fatigue) are common among clients with posttraumatic stress disorder (PTSD). Prior research has indicated that clients report improved physical functioning and fewer physical health symptoms after receiving Cognitive Processing Therapy (CPT) for PTSD. However, less is known about the impact of physical functioning on the clients' PTSD symptom improvement in CPT. Objective: The current study examined the patterns of change of and between physical functioning and PTSD symptoms over the course of CPT among a diverse military, veteran, and community sample. Method: We collected clients' (N = 188) physical functioning and PTSD symptom severity prior to and during CPT using the 12-Item Short Form Health Survey and the PTSD Checklist. We used multilevel modelling to 1) evaluate the impact of baseline physical functioning on the PTSD symptom trajectory, 2) examine the trajectory of physical functioning, and 3) assess the dynamics between physical functioning and PTSD symptoms over the course of CPT. Results: Our multilevel analyses indicated that 1) physical functioning significantly improved for those with low levels of functioning prior to treatment, 2) poorer baseline physical functioning predicted slower improvements in PTSD symptoms, and 3) poorer physical functioning in one session predicted less PTSD symptom improvement by the next session. Conclusions: Our findings demonstrate that while physical functioning can interfere with PTSD symptom improvement, physical functioning can also improve over the course of CPT. In light of the interconnected nature of physical health and PTSD symptoms, clinicians may need to attend to lower levels of physical functioning when providing CPT or other trauma-focused therapies. Future research to determine whether specific treatment adaptations may benefit such clients is needed.

Treatment for anxiety: Mindfulness meditation versus escitalopram (TAME): Design of a randomized, controlled non-inferiority trial

Anxiety disorders (generalized anxiety disorder, social anxiety disorder, panic disorder, and agoraphobia) are common, distressing, and impairing. While pharmacotherapy and psychotherapy are first-line treatment strategies for anxiety disorders, many patients are reluctant to take psychiatric medication, and many prefer to avoid any kind of mental health treatment due to stigma or distrust of traditional medical care. We present the trial protocol for the first study comparing first-line medication treatment with Mindfulness-Based Stress Reduction (MBSR), a popular mindfulness meditation training program, for the treatment of anxiety disorders. We will use a non-inferiority, comparative effectiveness trial design, in which individuals with diagnosed anxiety disorders will be randomized to either pharmacotherapy with escitalopram or MBSR for 8 weeks of treatment. Treatment outcome will be based on gold standard symptom severity measures assessed by trained independent evaluators blind to treatment allocation. Secondary outcomes will include key symptom and function measures, as well as tolerability and satisfaction with treatment. Findings will provide crucial information to inform decision making about the relative benefits of MBSR versus a first line medication for anxiety disorders by patients, medical care providers, healthcare insurers and other stakeholders.

Motivational interviewing prior to cognitive behavioural treatment for social anxiety disorder: A randomised controlled trial

BACKGROUND

We examined whether providing three sessions of treatment based on motivational interviewing (MI) prior to Cognitive Behavioral Therapy (CBT) for Social Anxiety Disorder (SAD) improved outcomes.

METHODS

Participants diagnosed with SAD (N = 186) were randomly allocated to receive three sessions of MI (MI+CBT; n = 85) or supportive counselling (SC+CBT; n = 101) prior to a 12-week group CBT program. Assessments occurred at baseline, after preparatory treatment, after CBT, and at 6-months follow-up. Outcomes were expectations for change, number of CBT sessions attended, self- and clinician-rated CBT homework completion, and self- and clinician-rated social anxiety severity.

RESULTS

Conditions did not differ significantly on expectations for change, number of CBT sessions attended, or clinician-rated homework completion. Self-rated homework completion was greater in MI+CBT than in SC+CBT. Change over time in social anxiety severity did not differ between conditions overall, however, this outcome was significantly moderated by two variables; those in MI+CBT, as compared to SC+CBT, showed significantly poorer outcomes on self-reported social anxiety severity if they were higher in change readiness and significantly better outcomes on clinician-rated social anxiety severity if they were higher in functional impairment.

LIMITATIONS

Although therapists in MI sessions were rated as behaving more consistently with MI than therapists in SC sessions, some MI consistent behaviors occurred in the SC sessions.

CONCLUSIONS

Addition of a MI-based discussion prior to evidence-based CBT appears to benefit people with SAD who have high functional impairment but may interfere with outcomes for those higher in readiness for change.

Diagnosis and Management of Anxiety Disorders

PURPOSE OF REVIEW

This article provides a synopsis of the current understanding of the pathophysiology of anxiety disorders, the biological and environmental risk factors that contribute to their development and maintenance, a review of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria, and a practical approach to the treatment of anxiety disorders in adults.

RECENT FINDINGS

Despite the ubiquity of anxiety, the evidence is that most individuals with an anxiety disorder are not identified and do not receive guideline-level care. In part, this may be because of the manifold clinical presentations of anxiety disorders and clinicians' lack of confidence in accurately diagnosing and treating these conditions, especially in nonpsychiatric settings. Anxiety disorders represent the complex interplay between biological, psychological, temperamental, and environmental factors. Converging lines of evidence point to dysfunction in regulating activity in the "threat circuit" in the brain as a putative common pathophysiology underlying anxiety disorders. Evidence-based treatments for anxiety disorders, such as cognitive-behavioral therapy and antidepressant medications, have been shown to regulate activity in this circuit, which consists of reciprocal connections between the dorsomedial prefrontal cortex, insula, and amygdala.

SUMMARY

Anxiety disorders are the most common class of emotional disorders and a leading cause of disability worldwide. A variety of effective treatment strategies are available, which may exert their therapeutic benefits from top-down or bottom-up modulation of the dysfunctional brain activity associated with anxiety disorders.

Predictors of Attrition in Longitudinal Neuroimaging Research: Inhibitory Control, Head Movement, and Resting-State Functional Connectivity

Attrition is a major problem in longitudinal neuroimaging studies, as it may lead to unreliable estimates of the stability of trait-like processes over time, of the identification of risk factors for clinical outcomes, and of the effects of treatment. Identification of characteristics associated with attrition has implications for participant recruitment and participant retention to achieve representative longitudinal samples. We investigated inhibitory control deficits, head motion, and resting-state functional connectivity within the cognitive control network (CCN) as predictors of attrition. Ninety-seven individuals with remitted major depressive disorder or healthy controls completed a functional magnetic resonance imaging scan, which included a go/no-go task and resting-state functional connectivity. Approximately 2 months later, participants were contacted and invited to return for a second scan. Seventeen individuals were lost to follow-up or declined to participate in the follow-up scan. Worse inhibitory control was correlated with greater movement within the scanner, and each predicted a greater likelihood of attrition, with movement mediating the effects of inhibitory control on attrition. Individuals who dropped out of the study exhibited greater movement than nondropouts across 9 of the 14 runs of the scan, with medium-to-large effect sizes. Finally, exploratory analyses suggested that attenuated resting-state connectivity with the CCN (particularly in bilateral dorsolateral prefrontal cortex) was associated with greater likelihood of attrition after accounting for head motion at several levels of analysis. Inhibitory control and movement within the scanner are associated with attrition, and should be considered for strategic oversampling and participant retention strategies to ensure generalizability of results in longitudinal studies.

Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial

IMPORTANCE

Globally, access to evidence-based psychological treatment is limited. Innovative self-help methods using smartphone applications and low-cost virtual reality have the potential to significantly improve the accessibility and scalability of psychological treatments.

OBJECTIVE

To examine the effectiveness of ZeroPhobia, a fully self-guided app-based virtual reality cognitive behavior therapy (VR CBT) using low-cost (cardboard) virtual reality goggles compared with a wait-list control group and to determine its user friendliness.

DESIGN, SETTING, AND PARTICIPANTS

In a single-blind randomized clinical trial, participants were enrolled between March 24 and September 28, 2017, and randomly assigned (1:1) by an independent researcher to either VR CBT app or a wait-list control group. A total of 193 individuals aged 18 to 65 years from the Dutch general population with acrophobia symptoms and access to an Android smartphone participated. The 6 animated modules of the VR-CBT app and gamified virtual reality environments were delivered over a 3-week period in participants' natural environment. Assessments were completed at baseline, immediately after treatment, and at 3-month follow-up. Analysis began April 6, 2018, and was intention to treat.

INTERVENTION

Self-guided app-based VR CBT.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the Acrophobia Questionnaire. The hypothesis was formulated prior to data collection.

RESULTS

In total, 193 participants (129 women [66.84%]; mean [SD] age, 41.33 [13.64] years) were randomly assigned to intervention (n = 96) or a wait-list control group (n = 97). An intent-to-treat analysis showed a significant reduction of acrophobia symptoms at posttest at 3 months for the VR-CBT app compared with the controls (b = -26.73 [95% CI, -32.12 to -21.34]; P < .001; d = 1.14 [95% CI, 0.84 to 1.44]). The number needed to treat was 1.7. Sensitivity and robustness analysis confirmed these findings. Pretreatment attrition was 22 of 96 (23%) because of smartphone incompatibility. Of the 74 participants who started using the VR-CBT app, 57 (77%) completed the intervention fully.

CONCLUSIONS AND RELEVANCE

A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions. To our knowledge, this study is the first to show that virtual reality acrophobia treatment can be done at home without the intervention of a therapist.

TRIAL REGISTRATION

Trialregister.nl identifier: NTR6442.

Antenatal Anxiety: Prevalence and Patterns in a Routine Obstetric Population

Introduction: Expectant mothers may appear anxious even during healthy pregnancies. Unfortunately, little is known about antenatal anxiety, and affected women may remain undetected and untreated. This study aimed to examine the prevalence, incidence, course and associations of high state anxiety in routine obstetric care. Materials and Methods: This was an observational prospective cohort study at a large maternity unit. Obstetric outpatients with low-risk singleton pregnancies were recruited during first trimester consultations. Participants provided sociodemographic data and completed the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale. The STAI was re-administered at each subsequent trimester. Results: Prevalence and incidence of  high state anxiety among 634 completers were 29.5% (95% CI 25.6%-33.6%) and 13.9% (95% CI 9.9%-18.0%), respectively. Anxiety was persistent in 17.0% (95% CI 14.3%-20.2%) and transient in 26.3% (95% CI 23.1%-29.9%). Only persistently anxious participants had high mean second trimester state anxiety scores. Odds for anxiety of greater persistence increased by 29% (95% CI 24%-35%) per 1-point increase in first trimester depression scores, and decreased by 36% (95% CI 7%-56%) with tertiary education. Conclusion: Antenatal anxiety symptoms are common even in normal pregnancies, especially among women with depression and lower education. Our study indicates value in exploring diagnostic criteria and quantitative measures for antenatal anxiety. Key words: Depression, Pregnancy, State-Trait Anxiety Inventory

Honoring the Past, Envisioning the Future: ABCT's 50th Anniversary Presidential Address

The theme of the Association for Behavioral and Cognitive Therapies (ABCT) 50^th Anniversary was to honor the past and envision the future. From the wisdom, foresight, and determination of the pioneers of our organization, and the continuous upholding of the scientific method over the last 50 years, cognitive behavioral therapy (CBT) has become the most empirically supported psychological treatment for a wide array of mental health problems. Yet, we still have a long way to go. This address outlines a vision for the future of CBT, which involves greater collaborative science, with all minds working together on the same problem, and greater attention to the risk factors and critical processes that underlie psychopathology and explain treatment change. Such knowledge generation can inform the development of new, more efficient and more effective therapies that are tailored with more precision to the needs of each person. Latest technologies provide tools for a precision focus while at the same time increasing the reach of our treatments to the many for whom traditional therapies are unavailable. Our impact will be greatly enhanced by large samples with common methods and measures that inform a precision approach. We have come a long way since ABCT was founded in 1966, and we are poised to make even larger strides in our mission to enhance health and well-being by harnessing science, our major guiding principle.

Why don't patients attend their appointments? Maintaining engagement with psychiatric services

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

Development and Preliminary Psychometric Evaluation of Decisional Balance and Self-Efficacy Measures for Managing Anxiety in a National Sample of Clinically Anxious Adults

PURPOSE

Anxiety is the most common and costly mental illness in the United States. Reducing avoidance is a core element of evidence-based treatments. Past research shows readiness to address avoidance affects outcomes. Investigating avoidance from a transtheoretical model (TTM) perspective could facilitate tailored approaches for individuals with low readiness. This study developed and examined psychometric properties of TTM measures for addressing anxiety-based avoidance.

DESIGN

Cross-sectional survey.

SETTING

Community centers, online survey.

PARTICIPANTS

Five hundred ninety-four individuals aged 18 to 70 with clinically significant anxiety.

MEASURES

Overall Anxiety Severity Questionnaire, stages of change, decisional balance, and self-efficacy.

ANALYSIS

The sample was randomly split into halves for principal component analyses (PCAs) and confirmatory factor analyses (CFAs) to test measurement models. Further analyses examined relationships between constructs.

RESULTS

For decisional balance, PCA indicated two 5-item factors (pros and cons). Confirmatory factor analysis supported a 2-factor correlated model, Satorra-Bentler scaled chi-square [Formula: see text], comparative fit index (CFI = 0.94), root mean square error of approximation (RMSEA = 0.07), pros: α = 0.87, ρ = 0.87, cons: α = 0.75, and ρ = 0.75. For self-efficacy, PCA indicated one 6-item factor supported by CFA, [Formula: see text], P < .01, CFI = 0.98, RMSEA = 0.09, α = 0.90, ρ = 0.87. As hypothesized, significant cross-stage differences were observed for pros and self-efficacy, and significant relationships between anxiety severity and pros, cons, and self-efficacy were found.

CONCLUSION

Findings show strong psychometric properties and support the application of a readiness-based model to anxiety. In contrast to findings of other behaviors, cons remain high in action and maintenance. These measures provide a solid empirical foundation to develop TTM-tailored interventions to enhance engagement in treatment.

The Therapy Attitudes and Process Questionnaire: A Brief Measure of Factors Related to Psychotherapy Appointment Attendance

BACKGROUND

Patient non-attendance and dropout remains problematic in mental health settings. The theory of planned behavior (TPB) has proven useful in understanding such challenges in a variety of healthcare settings, but the absence of an adequate measure in mental health has hampered research in this area.

OBJECTIVE

The aim of the current study was to develop and conduct an initial psychometric investigation of a brief measure, the Therapy Attitudes and Process Questionnaire (TAP), utilizing the TPB to understand factors associated with attendance in mental health settings.

METHODS

We used a quantitative survey-based design and administered the TAP to 178 adult participants who were engaged in individual or group psychotherapy. A subsample also provided data to assess validity and reliability.

RESULTS

A four-factor solution was revealed through exploratory factor analysis and accounted for approximately 75 % of the variance in scores. Factors corresponded to those predicted by the TPB. Analyses supported the reliability, validity, and internal consistency of the measure.

CONCLUSIONS

Results suggest that the TAP may be a useful tool for examining patients' attitudes and beliefs about attending psychotherapy appointments. The TAP can be used to better understand patients' intentions, attitudes, perceptions of behavioral control, and subjective norms relating to psychotherapy attendance. This understanding may facilitate improved outcomes for patients and clinicians.

Adherence to a web-based pre-treatment for phobias in outpatient clinics

BACKGROUND

Non-adherence in Internet interventions is a persistent and multifaceted issue and potentially limits the applicability and effectiveness of these interventions. Factors that influence non-adherence are poorly understood, especially in outpatient samples with more complex symptoms.

OBJECTIVE

The current study is a secondary analysis of data from a randomised controlled trial that examined the cost-effectiveness of offering an Internet-based exposure treatment to phobic outpatients on a wait-list to receive face-to-face psychotherapy.

METHODS

We collected baseline demographic and clinical information, and adherence data of the Internet-based intervention and conducted regression analyses to predict non-adherence to the intervention.

RESULTS

The adherence to the intervention was low, with only 13.3% of 105 patients completing all five lessons of the intervention. The median number of exercises completed (out of a possible 8) was 3. In a multi-predictor model, a higher baseline score of anxiety (OR = 0.94, 95% CI 0.90-0.99) was a risk factor for low adherence. Higher age (OR = 1.05, 95% CI 1.00-1.09) was a protective factor against non-adherence. Participants who adhered to the intervention were more likely to complete post-test assessments, further biasing results. However, overall participant attrition was high. The results are based on a small subset of participants and should be interpreted with caution.

CONCLUSIONS

Poor baseline clinical status and age are factors to consider when deciding whether to offer an Internet-based intervention to outpatients. Low adherence among those patients might be related to intrinsic motivation and might even be lower in outpatient settings where participants expect to receive face-to-face treatment. It might be worthwhile to develop a concise instrument to assess intrinsic motivation and treatment expectations for using Internet-based interventions, and for the therapist to review the range of possible (Internet-based) intervention options to suit personal preferences and expectations.

TRIAL REGISTRATION

Netherlands Trial Register, NTR2233.

A randomized controlled trial reporting functional outcomes of cognitive-behavioural therapy in medication-treated adults with ADHD and comorbid psychopathology

Studies assessing psychological treatment of attention deficit hyperactivity disorder (ADHD) in adults are increasingly reported. However, functional outcomes are often neglected in favour of symptom outcomes. We investigated functional outcomes in 95 adults with ADHD who were already treated with medication and randomized to receive treatment as usual (TAU/MED) or psychological treatment (CBT/MED) using a cognitive-behavioural programme, R&R2ADHD, which employs both group and individual modalities. RATE-S functional outcomes associated with ADHD symptoms, social functioning, emotional control and antisocial behaviour were given at baseline, end of treatment and three-month follow-up. The Total composite score of these scales is associated with life satisfaction. In addition, independent evaluator ratings of clinicians who were blind to treatment arm were obtained on the Clinical Global Impression scale at each time point. CBT/MED showed overall (combined outcome at end of treatment and 3-month follow-up) significantly greater functional improvement on all scales. Post-group treatment effects were maintained at follow-up with the exception of emotional control and the Total composite scales, which continued to improve. The largest treatment effect was for the RATE-S Total composite scale, associated with life satisfaction. CGI significantly correlated with all outcomes except for social functioning scale at follow-up. The study provides further evidence for the effectiveness of R&R2ADHD and demonstrates the importance of measuring functional outcomes. The key mechanism associated with improved functional outcomes is likely to be behavioural control.

Low pre-treatment end-tidal CO2 predicts dropout from cognitive-behavioral therapy for anxiety and related disorders

Recent clinical trial research suggests that baseline low end-tidal CO₂ (ETCO₂, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO₂ among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO₂, and respiration rate (the first minute was analyzed). Lower ETCO₂ was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO₂ significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO₂ significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO₂ patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO₂ is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO₂ might benefit from additional intervention that targets respiratory abnormality.

Predictors of Dropout From Cognitive-Behavioral Group Treatment for Panic Disorder With Agoraphobia

Panic disorder and agoraphobia are both characterized by avoidance behaviors, which are known correlates of treatment discontinuation. The aim of this exploratory study is to distinguish the profile of participants suffering from panic disorder with agoraphobia that complete treatment from those who discontinue therapy by assessing four categories of predictor variables: the severity of the disorder, sociodemographic variables, participants’ expectations, and dyadic adjustment. The sample included 77 individuals diagnosed with panic disorder with agoraphobia who completed a series of questionnaires and participated in a cognitive-behavioral group therapy consisting of 14 weekly sessions. Hierarchical linear regression analyses revealed the importance of anxiety, prognosis, and role expectations as well as some individual variables as predictors of therapeutic dropout, either before or during treatment. Among the most common reasons given by the 29 participants who discontinued therapy were scheduling conflicts, dissatisfaction with treatment, and conflicts with their marital partner. These results suggest that expectations and dyadic relationships have an impact on therapeutic discontinuation. The clinical implications of these findings are discussed.

Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say?

The purposes of this review were to: 1) determine the attrition rates for exposure with response prevention (ERP) for obsessive-compulsive disorder (OCD), 2) compare them to those in other treatments for OCD, and 3) identify predictors of ERP attrition. A systematic literature search of randomized controlled trials for ERP for OCD yielded 21 studies, representing 1400 participants. Attrition data were extracted for individual treatment conditions. The weighted mean dropout rate for ERP was 14.7% (95% CI [11.4%, 18.4%]). This figure was not statistically different from that of comparison conditions (e.g., cognitive therapy; OR=0.67-2.22, all ps>0.15). Only two studies reported refusal rates for ERP (weighted mean=4.0%; 95% CI [0.7%, 9.2%]), which precluded calculation of a reliable refusal rate for ERP. Based on these figures, we estimated an overall attrition rate of 18.7% for ERP. Treatment experience, therapist qualification, and number of treatment sessions did not significantly predict dropout rate. Our review indicates that ERP may have treatment dropout rates similar to other treatments for OCD.

Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial

BACKGROUND

Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist.

METHODS/DESIGN

Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment.

DISCUSSION

VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02533310. Registered on 25 August 2015.

Cognitive-behavioural therapy in medication-treated adults with attention-deficit/hyperactivity disorder and co-morbid psychopathology: a randomized controlled trial using multi-level analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by high rates of co-morbid psychopathology. Randomized controlled trials of multimodal interventions, combining pharmacological and psychological treatments, have shown a robust treatment effect for ADHD symptoms but outcomes for co-morbid symptoms have been mixed. This may be accounted for by the type of intervention selected and/or by methodological problems including lack of follow-up and low power. The current study addressed these limitations in a parallel-group randomized controlled trial conducted in Iceland.

METHOD

A total of 95 adult ADHD patients who were already being treated with medication (MED) were randomly assigned to receive treatment as usual (TAU/MED) or 15 sessions of cognitive-behavioural therapy (CBT/MED) using the R&R2ADHD intervention which employs both group and individual modalities. Primary measures of ADHD symptoms and severity of illness, and secondary measures of anxiety, depression and quality of life were given at baseline, end of treatment and 3-month follow-up. Primary outcomes were rated by clinicians blind to treatment condition assignment.

RESULTS

CBT/MED showed overall (combined outcome at end of treatment and 3-month follow-up) significantly greater reduction in primary outcomes for clinician-rated and self-rated ADHD symptoms. Treatment effect of primary outcomes was maintained at follow-up, which suggests robust and lasting findings. In contrast to the primary outcomes, the secondary outcomes showed significant improvement over time.

CONCLUSIONS

The study provides evidence for the effectiveness of R&R2ADHD and demonstrates that there are differential effects over time for ADHD symptoms versus co-morbid problems, the latter taking longer to show positive effects.

The POSE study - panic control treatment versus panic-focused psychodynamic psychotherapy under randomized and self-selection conditions: study protocol for a randomized controlled trial

BACKGROUND

Panic disorder with or without agoraphobia is a commonly occurring disorder affecting 2 to 3% of the population in Sweden. Untreated, panic disorder is a chronic condition that significantly increases the risk for psychiatric comorbidity, morbidity and mortality, employment difficulties, and healthcare utilization. Cognitive behavioral approaches are the recommended first-line treatment for panic disorder; however, many patients in routine care receive another evidence-based psychotherapy, including psychodynamic therapy. Allowing patients to choose among evidence-based approaches to panic disorder may improve outcomes and reduce overall health costs. Trials comparing the 'gold standard' treatment for panic disorder to other evidence-based psychotherapies are needed, and also trials that can separate patient preferences for treatment from randomization effects on outcome, disability and healthcare utilization in the longer term.

METHODS/DESIGN

A phase 2/3 doubly-randomized controlled trial carried out in routine care with 216 adults (aged 18 to 70 years) with a primary diagnosis of DSM-IV Panic Disorder (with or without Agoraphobia). Within each clinic, patients are randomized to self-selection, random assignment of treatment, or wait-list. Patients choose or are randomly assigned to either Panic Control Treatment or Panic-Focused Psychodynamic Psychotherapy. Primary outcomes are changes in panic symptom severity, occupational status, and sickness-related absences from work at post-treatment and 6, 12 and 24 months post-treatment. Secondary outcomes include changes in agoraphobic avoidance, psychiatric comorbidity, disability, and healthcare utilization. The study also employs elements of an effectiveness trial as therapist and service-related effects on outcome will be estimated. Putative change mechanisms for the two treatments are also assessed.

DISCUSSION

Cognitive behavioral and psychodynamic therapies are both evidence-based approaches that are routinely offered to panic disordered patients in Sweden. However, little is known about the relative effectiveness of these two approaches for panic/agoraphobia, work-related disability and healthcare utilization over the longer term. The current trial (POSE) also addresses the important but understudied issue of whether patient preference for a particular psychotherapeutic approach moderates outcome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01606592 (registered 19 March 2012).

Predictors of patient non-attendance at Improving Access to Psychological Therapy services demonstration sites

BACKGROUND

Improving Access to Psychological Therapy (IAPT) services have increased the number of people with common mental health disorders receiving psychological therapy in England, but concerns remain about how equitably these services are accessed.

METHOD

Using cohort patient data (N=363) collected as part of the independent evaluation of the two demonstration sites, logistic regression was utilised to identify socio-demographic, clinical and service factors predictive of IAPT non-attendance.

RESULTS

Significant predictors of IAPT first session non-attendance by patients were: lower non-risk score on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); more frequent thoughts of "being better off dead" (derived from the CORE-OM); either a very recent onset of common mental health disorder (1 month or less) or a long term condition (more than 2 years); and site.

LIMITATIONS

The small sample and low response rate are limitations, as the sample may not be representative of all those referred to IAPT services. The predictive power of the logistic regression model is limited and suggests other variables not available in the dataset may also be important predictors.

CONCLUSIONS

The clinical characteristics of risk to self, severity of emotional distress, and illness duration, along with site, were more predictive of IAPT non-attendance than socio-demographic characteristics. Further testing of the relationship between these variables and IAPT non-attendance is recommended. Clinicians should monitor IAPT uptake in those they refer and implement strategies to increase their engagement with services, particularly when referring people presenting with suicidal ideation or more chronic illness.

Short-term effectiveness of web-based guided self-help for phobic outpatients: randomized controlled trial

Background

Internet-based guided self-help has been successfully used in the general population, but it is unknown whether this method can be effectively used in outpatient clinics for patients waiting for face-to-face psychotherapy for phobias.

Objective

The aim was to assess the clinical effectiveness of Phobias Under Control, an Internet-based intervention based on exposure therapy with weekly guidance.

Methods

We conducted a randomized controlled trial, recruiting 212 outpatients scheduled to receive face-to-face psychotherapy for any type of phobia at an outpatient clinic. Participants suffering from at least 1 DSM-IV or ICD-10 classified phobia (social phobia, agoraphobia with or without panic disorder, and/or specific phobia as ascertained by a telephone interview at baseline) were randomly allocated to either a 5-week Internet-based guided self-help program based on exposure therapy with weekly student support followed by face-to-face psychotherapy (n=105) or a wait-list control group followed by face-to-face psychotherapy (n=107). Primary outcome was the Fear Questionnaire (FQ). Secondary outcomes were the Beck Anxiety Inventory (BAI) and Center of Epidemiological Studies-Depression scale (CES-D). Assessments took place by telephone at baseline (T0) and on the Internet at posttest (T1, self-assessment at 5 weeks after baseline). Missing data at T1 were imputed.

Results

At posttest, analysis of covariance on the intention-to-treat sample showed significant but small effect sizes between intervention and control groups on the FQ (d=0.35, P=.02), CES-D (d=0.34, P=.03), and a nonsignificant effect size on the BAI (d=0.28. P=.05). Although initial acceptance was good, high nonresponse was observed, with 86 of 212 participants (40.5%) lost to follow-up at T1 and only 14 of 105 (13.3%) intervention participants finishing all 5 weeks.

Conclusions

Phobias Under Control is modestly effective in lowering phobic and depressive symptoms in a relatively short period and may be clinically beneficial when implemented in routine outpatient practice.

Trial Registration

Netherlands Trial Register NTR2233; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2233 (Archived by WebCite at http://www.webcitation.org/6O2ioOQSs).

The influence of diagnosis on psychotherapy missed opportunities in a veteran population

OBJECTIVE

Canceled or unattended psychotherapy sessions are a source of concern for patients, providers, and health-care systems. Veterans are particularly likely to experience mental health problems, and yet they are also especially susceptible to variables leading to premature termination of services.

METHOD

This study examined a large (n = 2285) sample of veterans receiving psychotherapy services to determine if mental health diagnosis had an impact upon missed psychotherapy opportunities.

RESULTS

There were differential cancelation rates for individuals with different classes of disorder, and the total number of appointments a person scheduled changed the nature of the effect.

CONCLUSIONS

Health-care administrators and treatment providers should consider the specific effects of individuals with differing diagnoses when planning courses of treatment and coordinating care.