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van Santen-Bauer PR, de Beurs E, Deen M, Korrelboom K, van der Heiden C. Goal-Directed Treatment of Patients With Anxiety and Mood Disorders in a Regular Curative Mental Health Care Setting. Clin Psychol Psychother 2024; 31:e2984. [PMID: 38706159 DOI: 10.1002/cpp.2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 05/07/2024]
Abstract
This study examined whether goal-directed treatment leads to improved treatment outcomes for patients with a primary mood or anxiety disorder and whether beneficial outcomes are achieved sooner compared to treatment as usual. In a quasi-experimental controlled study with a nested design, 17 therapists received training in goal-directed treatment and treated 105 patients with anxiety or mood disorders using principles of goal-directed treatment. Treatment results on a generic self-report instrument were compared with two control groups: a historical control group consisting of 16 of the 17 participating therapists, who provided treatment as usual to 97 patients before having received training in goal-directed treatment, and a parallel control group consisting of various therapists, who provided treatment as usual to 105 patients. Symptom reduction on a self-report measure was compared using multilevel analysis. A survival analysis was performed to assess whether a satisfactory end state had been reached sooner after goal-directed treatment. The results of this study show that goal-directed treatment only led to a significantly better overall treatment outcome compared to the parallel treatment as usual group. Furthermore, goal-directed treatment was significantly shorter than both treatment as usual groups. In conclusion, this research suggest that goal-directed treatment led to a similar or better treatment outcome in a shorter amount of time.
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Affiliation(s)
| | - Edwin de Beurs
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- Department of Research and Development, Arkin, Amsterdam, The Netherlands
| | - Mathijs Deen
- Parnassia Psychiatric Institute, The Hague, The Netherlands
- Methodology and Statistics Department, Leiden University, Leiden, The Netherlands
| | - Kees Korrelboom
- Department of Anxiety Disorders, Outpatient Treatment Center PsyQ, The Hague, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Colin van der Heiden
- Department of Anxiety Disorders, Outpatient Treatment Center PsyQ, The Hague, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
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2
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Hannigan B, van Deursen R, Barawi K, Kitchiner N, Bisson JI. Factors associated with the outcomes of a novel virtual reality therapy for military veterans with PTSD: Theory development using a mixed methods analysis. PLoS One 2023; 18:e0285763. [PMID: 37228076 DOI: 10.1371/journal.pone.0285763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Multi-modular motion-assisted memory desensitization and reconsolidation therapy (3MDR) is a new psychological intervention for people with post-traumatic stress disorder (PTSD). 3MDR is immersive, delivered in a virtual reality environment, and emphasises engagement, recollection and reprocessing. OBJECTIVE Through a theory-driven examination of data relating to 10 out of 42 UK military veterans taking part in a trial of 3MDR, the principal objective was to explore the complex interrelationships between people, interventions and context and to investigate how factors within these domains interacted in specific outcome typologies. METHOD Quantitative and qualitative data relating to 10 trial participants were derived from: researcher-assessed and self-report clinical measures; interviews; physiological recordings; words describing thoughts and feelings during therapy; and subjective unit of distress scores. Using a convergent mixed methods approach, data were tabulated using a person, intervention and context model. Participant summaries were grouped into outcome typologies, followed by an analysis of data convergence and divergence within each and an interpretation of identified patterns. RESULTS Three outcome response typologies were identified: dramatic improvement, moderate improvement and minimal improvement. Within the person domain, factors associated with outcomes included walking capacity, commitment and ability to complete therapy, and levels of subjective distress. Within the intervention domain, factors associated with outcomes related to image selection and use, therapeutic alliance and orientations towards the tailoring of sessions. Within the context domain, factors associated with outcomes included reactions to the therapy environment. The patterning of secondary outcomes broadly corresponded with primary outcomes within each typology. Alongside patterned data differentiating aspects of the person, intervention and context domains, within the three response typologies data also existed where no obvious patterning was detected. CONCLUSIONS The model developed here may have novel value in evaluating a range of personalised interventions, but further work is needed before confident assertions can be made of who is likely to benefit from 3MDR specifically.
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Affiliation(s)
- Ben Hannigan
- School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom
| | - Robert van Deursen
- School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kali Barawi
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Neil Kitchiner
- School of Medicine, Cardiff University, Cardiff, United Kingdom
- Veterans' NHS Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
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3
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Polak M, Tanzer NK, Bauernhofer K, Andersson G. Disorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials. Internet Interv 2021; 24:100364. [PMID: 33643852 PMCID: PMC7889983 DOI: 10.1016/j.invent.2021.100364] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 02/08/2023] Open
Abstract
Compared to conventional face-to-face psychological treatments, internet-based cognitive-behavioral therapy (iCBT) presents an innovative alternative that has been found to be effective in the treatment of anxiety disorders. The current study provides a meta-analysis investigating the efficacy of disorder-specific guided self-help (Gsh) iCBT compared to various active and inactive control conditions, with focus on adult panic disorder sufferers with or without agoraphobia (PD/A). Systematic literature search yielded 13 randomized controlled trials (RCTs) (N = 1214) that met the eligibility criteria for this study. We found no statistically significant differences between Gsh iCBT and various active CBT interventions in reducing PD/A symptoms at both post-test (g = 0.015, k = 10) and follow-up (g = 0.113, k = 6) levels. Also, comorbid anxiety and depression were reduced equivalently at post-test (g = 0.004, k = 6) and follow-up (g = 0.004, k = 6). Quality of life was equally improved at post-test (g = -0.100, k = 5) and follow-up (g = 0.074, k = 2). When compared to inactive controls, we found large effect sizes in PD/A (g = -0.892, k = 9) and comorbid anxiety and depression (g = -0.723, k = 9) symptoms, and moderate change in quality of life (g = -0.484, k = 3) at post-test. There was no difference between Guided self-help iCBT and Self-help iCBT in PD/A (g = -0.025, k = 3) and comorbid anxiety and depression (g = -0.025, k = 3) at post-test. Baseline severity, country of original research and adherence to the treatment in form of initial uptake were identified as statistically significant moderators of the iCBT treatment.
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Affiliation(s)
- Martin Polak
- Department of Psychology, University of Graz, Austria
| | | | | | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Sweden
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Higgins C, Chambers JA, Major K, Durham RC. Healthcare costs and quality of life associated with the long-term outcome of anxiety disorders. ANXIETY STRESS AND COPING 2020; 34:228-241. [PMID: 33108887 DOI: 10.1080/10615806.2020.1839731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Anxiety disorders are costly; however, the relationship with treatment outcome has been neglected. This study examined healthcare costs and quality of life by diagnostic status (treatment outcome and the presence of comorbidity) at long-term follow-up. DESIGN AND METHODS This cohort study comprized 317 patients entering treatment for at least one Axis I anxiety disorder. Four groups were identified based on diagnostic status at follow-up (recovered or disordered) and self-reported degree of interim treatment (high or low). A further grouping was established based on co-morbid diagnostic status at follow-up. Healthcare costs were calculated for the two years prior to treatment entry and the two years prior to follow-up using a repeated measures analysis of variance (ANOVA). Group differences in quality of life were assessed using a univariate ANOVA. RESULTS Over two thirds of the sustained recovery group was treatment-free at follow-up whilst the remainder required adjuvant drug therapy. Over half of those remaining disordered at follow-up incurred substantial healthcare costs and presented with treatment-resistant symptoms and severely impaired quality of life. CONCLUSIONS Despite substantial investment some patients were associated with a clinical anxiety diagnosis at follow-up, and multimorbidity was associated with considerably higher costs.
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Affiliation(s)
- Cassie Higgins
- Division of Neuroscience, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Julie A Chambers
- Psychology, School of Natural Sciences, University of Stirling, Stirling, UK
| | - Kirsten Major
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Robert C Durham
- Division of Neuroscience, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
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Melton H, Meader N, Dale H, Wright K, Jones-Diette J, Temple M, Shah I, Lovell K, McMillan D, Churchill R, Barbui C, Gilbody S, Coventry P. Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. Health Technol Assess 2020; 24:1-312. [PMID: 32924926 DOI: 10.3310/hta24430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. OBJECTIVE To identify candidate psychological and non-pharmacological treatments for future research. DESIGN Mixed-methods systematic review. PARTICIPANTS Adults aged ≥ 18 years with a history of complex traumatic events. INTERVENTIONS Psychological interventions versus control or active control; pharmacological interventions versus placebo. MAIN OUTCOME MEASURES Post-traumatic stress disorder symptoms, common mental health problems and attrition. DATA SOURCES Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. REVIEW METHODS Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. RESULTS One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. LIMITATIONS Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. CONCLUSIONS Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. FUTURE WORK Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. STUDY REGISTRATION This study is registered as PROSPERO CRD42017055523. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hollie Melton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Holly Dale
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Peter Coventry
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Health Sciences, University of York, York, UK
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Flückiger C, Wampold BE, Delgadillo J, Rubel J, Vîslă A, Lutz W. Is There an Evidence-Based Number of Sessions in Outpatient Psychotherapy? - A Comparison of Naturalistic Conditions across Countries. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:333-335. [PMID: 32403101 PMCID: PMC7490483 DOI: 10.1159/000507793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/04/2020] [Indexed: 11/19/2022]
Affiliation(s)
| | - Bruce E. Wampold
- Modum Bad Psychiatric Center, Modum Bad, Vikersund, Norway,School of Education, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Jaime Delgadillo
- Department of Psychology, The University of Sheffield, Sheffield, United Kingdom
| | - Julian Rubel
- Department of Psychology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Andreea Vîslă
- Department of Psychology, University of Zürich, Zürich, Switzerland
| | - Wolfgang Lutz
- Department of Psychology, University of Trier, Trier, Germany
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The Combined Effect of Exercise and Behavioral Therapy for Depression and Anxiety: Systematic Review and Meta-Analysis. Behav Sci (Basel) 2020; 10:bs10070116. [PMID: 32674359 PMCID: PMC7407099 DOI: 10.3390/bs10070116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023] Open
Abstract
Behavioral therapy (BT) and exercise are efficacious treatments for depression and anxiety when employed separately. The combination of BT and exercise (BT+Ex) may augment improvements but the combined effect of these therapies is not fully elucidated. The purpose of this meta-analysis was to determine if BT+Ex yielded a significant reduction in depression and anxiety symptoms compared to BT alone (BT). Randomized controlled studies published prior to September 2019 were searched among several databases (PUBMED, MEDLINE, PsychArticle, and Cochrane Central Register of Clinical Trials). Studies that measured depression and anxiety symptoms following BT+Ex vs. BT were extracted and analyzed. The effect of these therapies on depression and anxiety were analyzed. Subgroup analyses were performed to evaluate the effect of exercise intensity (moderate and high), exercise type (aerobic and combined exercise), and baseline levels of depression. The moderating effects of gender, age, and treatment duration were performed. Data were extracted from 18 studies (1686 participants, mean age = 47 years, 65% female). There was a significant effect of BT+Ex on symptoms of depression. The effect of BT+Ex was significant for moderate intensity exercise and elevated baseline levels of depression. Age moderated the effect for depression. There was a significant effect of BT+Ex on depressive symptoms in humans. Exercise intensity and elevated depressive symptoms may play a role in the effect of exercise.
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8
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Barawi KS, Lewis C, Simon N, Bisson JI. A systematic review of factors associated with outcome of psychological treatments for post-traumatic stress disorder. Eur J Psychotraumatol 2020; 11:1774240. [PMID: 33029317 PMCID: PMC7473314 DOI: 10.1080/20008198.2020.1774240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap. METHOD We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission. RESULTS Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome. CONCLUSION Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials.
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Affiliation(s)
- Kali S Barawi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Wales, UK
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Wales, UK
| | - Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Wales, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Wales, UK
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9
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Bilet T, Olsen T, Andersen JR, Martinsen EW. Cognitive behavioral group therapy for panic disorder in a general clinical setting: a prospective cohort study with 12 to 31-years follow-up. BMC Psychiatry 2020; 20:259. [PMID: 32448206 PMCID: PMC7247216 DOI: 10.1186/s12888-020-02679-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The long-term prognosis after cognitive behavioral therapy (CBT) in outpatient groups for panic disorder and agoraphobia is not well known. The purpose of this study was to assess long-term outcomes in terms of psychological health, health-related quality of life (HRQoL), quality of life (QoL) and treatment satisfaction after CBT for panic disorder and agoraphobia. METHODS The sample consisted of 68 patients (61% response rate), who were assessed at pretreatment; at the start and end of treatment; and after 3 months, after 1 year, and over the long term (M = 24 years; SD = 5.3; range: 12 to 31 years). The main outcome was the total score on the Phobic Avoidance Rating Scale (PARS-total). At long-term follow-up, HRQoL was measured with the RAND-12 questionnaire, and QoL was measured with two questions from the "Study on European Union Statistics on Income and Living Conditions". Patient experiences and treatment satisfaction were assessed by the Generic Short Patient Experiences Questionnaire. A marginal longitudinal model was applied to study the main outcome. RESULTS The effect size of the long-term change (mean change/ pooled SD) in the PARS-total score was (- 1.6, p < 0.001) and was stable over time. A PARS-total score reduction of 50% was found in 98% of patients at the long-term follow-up. The patients' HRQoL and QoL were similar to the expected scores for the general Norwegian population. Of the patients, 95% reported high to very high satisfaction with the CBT, and 93% reported large treatment benefits. CONCLUSIONS To the best of our knowledge, this study has the longest follow-up after group CBT for panic disorder and agoraphobia, showing a good prognosis in ≥93% of the participating patients.
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Affiliation(s)
- Truls Bilet
- Division of Psychiatry, District General Hospital of Førde, Førde, Norway
| | - Torbjørn Olsen
- Division of Psychiatry, District General Hospital of Førde, Førde, Norway
| | - John Roger Andersen
- Centre of Health Research, Førde Hospital Trust, Førde, Norway. .,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Førde, Norway.
| | - Egil W. Martinsen
- grid.55325.340000 0004 0389 8485Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Bosnjak Kuharic D, Kekin I, Hew J, Rojnic Kuzman M, Puljak L. Interventions for prodromal stage of psychosis. Cochrane Database Syst Rev 2019; 2019:CD012236. [PMID: 31689359 PMCID: PMC6823626 DOI: 10.1002/14651858.cd012236.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Psychosis is a serious mental condition characterised by a loss of contact with reality. There may be a prodromal period or stage of psychosis, where early signs of symptoms indicating onset of first episode psychosis (FEP) occur. A number of services, incorporating multimodal treatment approaches (pharmacotherapy, psychotherapy and psychosocial interventions), developed worldwide, now focus on this prodromal period with the aim of preventing psychosis in people at risk of developing FEP. OBJECTIVES The primary objective is to assess the safety and efficacy of early interventions for people in the prodromal stage of psychosis. The secondary objective is, if possible, to compare the effectiveness of the various different interventions. SEARCH METHODS We searched Cochrane Schizophrenia's study-based Register of studies (including trials registers) on 8 June 2016 and 4 August 2017. SELECTION CRITERIA All randomised controlled trials (RCTs) evaluating interventions for participants older than 12 years, who had developed a prodromal stage of psychosis. DATA COLLECTION AND ANALYSIS Review authors independently inspected citations, selected studies, extracted data, and assessed study quality. MAIN RESULTS We included 20 studies with 2151 participants. The studies analysed 13 different comparisons. Group A comparisons explored the absolute effects of the experimental intervention. Group B were comparisons within which we could not be clear whether differential interactive effects were also ongoing. Group C comparisons explored differential effects between clearly distinct treatments. A key outcome for this review was 'transition to psychosis'. For details of other main outcomes please see 'Summary of findings' tables. In Group A (comparisons of absolute effects) we found no clear difference between amino acids and placebo (risk ratio (RR) 0.48 95% confidence interval (CI) 0.08 to 2.98; 2 RCTs, 52 participants; very low-quality evidence). When omega-3 fatty acids were compared to placebo, fewer participants given the omega-3 (10%) transitioned to psychosis compared to the placebo group (33%) during long-term follow-up of seven years (RR 0.24 95% CI 0.09 to 0.67; 1 RCT, 81 participants; low-quality evidence). In Group B (comparisons where complex interactions are probable) and in the subgroup focusing on antipsychotic drugs added to specific care packages, the amisulpiride + needs-focused intervention (NFI) compared to NFI comparison (no reporting of transition to psychosis; 1 RCT, 102 participants; very low-quality evidence) and the olanzapine + supportive intervention compared to supportive intervention alone comparison (RR 0.58 95% CI 0.28 to 1.18; 1 RCT, 60 participants; very low-quality evidence) showed no clear differences between groups. In the second Group B subgroup (cognitive behavioural therapies (CBT)), when CBT + supportive therapy was compared with supportive therapy alone around 8% of participants allocated to the combination of CBT and supportive therapy group transitioned to psychosis during follow-up by 18 months, compared with double that percentage in the supportive therapy alone group (RR 0.45 95% CI 0.23 to 0.89; 2 RCTs, 252 participants; very low-quality evidence). The CBT + risperidone versus CBT + placebo comparison identified no clear difference between treatments (RR 1.02 95% CI 0.39 to 2.67; 1 RCT, 87 participants; very low-quality evidence) and this also applies to the CBT + needs-based intervention (NBI) + risperidone versus NBI comparison (RR 0.75 95% CI 0.39 to 1.46; 1 RCT, 59 participants; very low-quality evidence). Group C (differential effects) also involved six comparisons. The first compared CBT with supportive therapy. No clear difference was found for the 'transition to psychosis' outcome (RR 0.74 95% CI 0.28 to 1.98; 1 RCT, 72 participants; very low-quality evidence). The second subgroup compared CBT + supportive intervention was compared with a NBI + supportive intervention, again, data were equivocal, few and of very low quality (RR 6.32 95% CI 0.34 to 117.09; 1 RCT, 57 participants). In the CBT + risperidone versus supportive therapy comparison, again there was no clear difference between groups (RR 0.76 95% CI 0.28 to 2.03; 1 RCT, 71 participants; very low-quality evidence). The three other comparisons in Group C demonstrated no clear differences between treatment groups. When cognitive training was compared to active control (tablet games) (no reporting of transition to psychosis; 1 RCT, 62 participants; very low quality data), family treatment compared with enhanced care comparison (RR 0.54 95% CI 0.18 to 1.59; 2 RCTs, 229 participants; very low-quality evidence) and integrated treatment compared to standard treatment comparison (RR 0.57 95% CI 0.28 to 1.15; 1 RCT, 79 participants; very low-quality evidence) no effects of any of these approaches was evident. AUTHORS' CONCLUSIONS There has been considerable research effort in this area and several interventions have been trialled. The evidence available suggests that omega-3 fatty acids may prevent transition to psychosis but this evidence is low quality and more research is needed to confirm this finding. Other comparisons did not show any clear differences in effect for preventing transition to psychosis but again, the quality of this evidence is very low or low and not strong enough to make firm conclusions.
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Affiliation(s)
- Dina Bosnjak Kuharic
- University Psychiatric Hospital VrapčeBolnicka cesta 32ZagrebGrad ZagrebCroatia10000
| | - Ivana Kekin
- Clinical Hospital Centre ZagrebDepartment of PsychiatryKispaticeva 1210 000ZagrebCroatia
| | - Joanne Hew
- South London and Maudsley NHS Foundation TrustDepartment of Acute Care PsychiatryLadywell Unit, University Hospital LewishamLondonUK
| | - Martina Rojnic Kuzman
- Clinical Hospital Centre ZagrebDepartment of PsychiatryKispaticeva 1210 000ZagrebCroatia
| | - Livia Puljak
- Catholic University of CroatiaCenter for Evidence‐Based Medicine and Health CareIlica 242ZagrebCroatia10000
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Zala D, Brabban A, Stirzaker A, Kartha MR, McCrone P. The Cost-Effectiveness of the Improving Access to Psychological Therapies (IAPT) Programme in Severe Mental Illness: A Decision Analytical Model Using Routine Data. Community Ment Health J 2019; 55:873-883. [PMID: 30848414 DOI: 10.1007/s10597-019-00390-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
This is the first site level economic evaluation of the Improving Access to Psychological Therapies programme for severe mental illness (IAPT-SMI) that is funded by NHS England. It also aims to illustrate the challenges involved in evaluations based on routine data with low internal validity. Six IAPT-SMI pilot sites treated 1 of 2 clinical groups: (i) psychosis or bipolar disorder; (ii) personality disorder. A decision analytical model nested in a before-after framework- the same patients 12 months after treatment versus 12 months before treatment-was used to compare the cost-effectiveness of IAPT-SMI with treatment as usual (TAU). IAPT-SMI appears to be more costly overall but save non-psychological treatment costs. There is evidence it may improve function and lower incidence of harmful behaviour. However, there is a need for evaluations with a more conventional study design that measure a more comprehensive array of resource use and clinical outcomes.
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Affiliation(s)
- Darshan Zala
- Department of Health Service and Population Research, King's Health Economics (KHE) Institute of Psychiatry, Psychology & Neuroscience, David Goldberg Centre, King's College London, De Crespigny Park, Denmark Hill, Box 24, London, SE5 8AF, UK.
| | - Alison Brabban
- Avon and Wiltshire Mental Health Partnership NHS Trust, Jenner House, Langley Park, Chippenham, SN15 1GG, UK
| | - Alex Stirzaker
- Avon and Wiltshire Mental Health Partnership NHS Trust, Jenner House, Langley Park, Chippenham, SN15 1GG, UK
| | - Muralikrishnan Radhakrishnan Kartha
- Department of Health Service and Population Research, King's Health Economics (KHE) Institute of Psychiatry, Psychology & Neuroscience, David Goldberg Centre, King's College London, De Crespigny Park, Denmark Hill, Box 24, London, SE5 8AF, UK
| | - Paul McCrone
- Department of Health Service and Population Research, King's Health Economics (KHE) Institute of Psychiatry, Psychology & Neuroscience, David Goldberg Centre, King's College London, De Crespigny Park, Denmark Hill, Box 24, London, SE5 8AF, UK
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12
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Koekkoek B, van Meijel B, Perquin A, Hutschemaekers G. Decision making on (dis)continuation of long-term treatment in mental health services is an interpersonal negotiation rather than an objective process: qualitative study. BMC Psychiatry 2019; 19:92. [PMID: 30885155 PMCID: PMC6421659 DOI: 10.1186/s12888-019-2072-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/04/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Research into termination of long-term psychosocial treatment of mental disorders is scarce. Yearly 25% of people in Dutch mental health services receive long-term treatment. They account for many people, contacts, and costs. Although relevant in different health care systems, (dis)continuation is particularly problematic under universal health care coverage when secondary services lack a fixed (financially determined) endpoint. Substantial, unaccounted, differences in treatment duration exist between services. Understanding of underlying decisional processes may result in improved decision making, efficient allocation of scarce resources, and more personalized treatment. METHODS A qualitative study design, according to Grounded Theory principles, was used to understand the decision making process. In four teams in three large Dutch mental health services, 29 multidisciplinary case conferences were observed, and 12 semi-structured interviews were conducted. RESULTS We describe two constituent elements of decision making: the process through which decision making is prepared and executed, and the substantial factors guiding its outcomes. The first consists of: (1) steps towards a team discussion on treatment termination, (2) team-related factors that influence decisions, and (3) the actual team decision making process. The second consists of factors related to patients, professionals, organization, and wider environment. Our main finding was that discussions of treatment (dis)continuation are highly unstructured. Professionals find it difficult to discuss with patients and teams, team discussion are ad-hoc, and clear decisions are scarce. We offer four explanations: first, long-term treatment lacks golden rules on outcome and process to base decisions on. Second, in the absence of such rules professionals rely on experience but underappreciate their own biases. Third, consequently, professionals aim for decisional consensus, which however is scarce among professionals. Fourth, treatment environments are hardly in favour of changing default (continuation) settings. CONCLUSION Clear decision making, and terminating treatment when appropriate, is systematically hampered within secondary mental health services. Since continuation is the 'easy' default option, discontinuation requires skillful and determined navigation of interpersonal negotiations. Given services' scarce means, people's large demands for help, and patients' unused potential autonomy, it is desirable to invest in decision making skills and procedures - both human and economic benefits may be substantial.
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Affiliation(s)
- B. Koekkoek
- 0000 0000 8809 2093grid.450078.eHAN University of Applied Sciences, Research Group Social Psychiatry & Mental Health Nursing, Kapittelweg 33, 6525 EJ Nijmegen, The Netherlands ,0000 0004 0466 1666grid.491369.0Pro Persona Mental Health Services, Wolfheze, The Netherlands
| | - B. van Meijel
- grid.448984.dInholland University of Applied Sciences, Amsterdam, The Netherlands ,0000 0004 0435 165Xgrid.16872.3aDepartment of Psychiatry, Amsterdam Public Health research institute, Amsterdam UMC, VU Amsterdam, Amsterdam, The Netherlands ,Parnassia Psychiatric Institute, The Hague, The Netherlands ,GGZ-VS, Academy for Masters in Advanced Nursing Practice, Utrecht, The Netherlands
| | - A. Perquin
- 0000 0000 8809 2093grid.450078.eHAN University of Applied Sciences, Research Group Social Psychiatry & Mental Health Nursing, Kapittelweg 33, 6525 EJ Nijmegen, The Netherlands
| | - G. Hutschemaekers
- 0000000122931605grid.5590.9Research Group Clinical Psychology, Radboud University, Nijmegen, The Netherlands ,0000 0004 0466 1666grid.491369.0Pro Persona Mental Health Services, Wolfheze, The Netherlands
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Johnson SU, Hoffart A. Moderators and predictors of outcome in metacognitive and cognitive behavioural therapy for co‐morbid anxiety disorders. Clin Psychol Psychother 2019; 26:399-408. [DOI: 10.1002/cpp.2361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/18/2019] [Accepted: 02/21/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Asle Hoffart
- Research InstituteModum Bad Psychiatric Center Vikersund Norway
- Department of PsychologyUniversity of Oslo Oslo Norway
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Lingawi NW, Laurent V, Westbrook RF, Holmes NM. The role of the basolateral amygdala and infralimbic cortex in (re)learning extinction. Psychopharmacology (Berl) 2019; 236:303-312. [PMID: 29959461 DOI: 10.1007/s00213-018-4957-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/19/2018] [Indexed: 11/25/2022]
Abstract
The basolateral amygdala complex (BLA) and infralimbic region of the prefrontal cortex (IL) play distinct roles in the extinction of Pavlovian conditioned fear in laboratory rodents. In the past decade, research in our laboratory has examined the roles of these brain regions in the re-extinction of conditioned fear: i.e., extinction of fear that is restored through re-conditioning of the conditioned stimulus (CS) or changes in the physical and temporal context of extinction training (i.e., extinction of renewed or spontaneously recovered fear). This paper reviews this research. It has revealed two major findings. First, in contrast to the acquisition of fear extinction, which usually requires neuronal activity in the BLA but not IL, the acquisition of fear re-extinction requires neuronal activity in the IL but can occur independently of neuronal activity in the BLA. Second, the role of the IL in fear extinction is determined by the training history of the CS: i.e., if the CS was novel prior to its fear conditioning (i.e., it had not been trained), the acquisition of fear extinction does not require the IL; if, however, the prior training of the CS included a series of CS-alone exposures (e.g., if the CS had been pre-exposed), the acquisition of fear extinction was facilitated by pharmacological stimulation of the IL. Together, these results were taken to imply that a memory of CS-alone exposures is stored in the IL, survives fear conditioning of the CS, and can be retrieved and strengthened during extinction or re-extinction of that CS (regardless of whether the extinction is first- or second-learned). Hence, under these circumstances, the initial extinction of fear to the CS can be facilitated by pharmacological stimulation of the IL, and re-extinction of fear to the CS can occur in the absence of a functioning BLA.
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Affiliation(s)
- Nura W Lingawi
- School of Psychology, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - Vincent Laurent
- School of Psychology, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - R Fredrick Westbrook
- School of Psychology, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - Nathan M Holmes
- School of Psychology, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia.
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15
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Jones C, Hacker D, Xia J, Meaden A, Irving CB, Zhao S, Chen J, Shi C. Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia. Cochrane Database Syst Rev 2018; 12:CD007964. [PMID: 30572373 PMCID: PMC6517137 DOI: 10.1002/14651858.cd007964.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to re-mediate distressing emotional experiences or dysfunctional behaviour by changing the way in which a person interprets and evaluates the experience or cognates on its consequence and meaning. This approach helps to link the person's feelings and patterns of thinking which underpin distress. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. This review is also part of a family of Cochrane CBT reviews for people with schizophrenia. OBJECTIVES To assess the effects of cognitive behavioural therapy added to standard care compared with standard care alone for people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (up to March 6, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. SELECTION CRITERIA We selected all randomised controlled clinical trials (RCTs) involving people diagnosed with schizophrenia or related disorders, which compared adding CBT to standard care with standard care given alone. Outcomes of interest included relapse, rehospitalisation, mental state, adverse events, social functioning, quality of life, and satisfaction with treatment.We included studies fulfilling the predefined inclusion criteria and reporting useable data. DATA COLLECTION AND ANALYSIS We complied with the Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated relative risk (RR) and its 95% confidence interval (CI) for binary data and mean difference (MD) and its 95% confidence interval for continuous data. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS This review now includes 60 trials with 5,992 participants, all comparing CBT added to standard care with standard care alone. Results for the main outcomes of interest (all long term) showed no clear difference between CBT and standard care for relapse (RR 0.78, 95% CI 0.61 to 1.00; participants = 1538; studies = 13, low-quality evidence). Two trials reported global state improvement. More participants in the CBT groups showed clinically important improvement in global state (RR 0.57, 95% CI 0.39 to 0.84; participants = 82; studies = 2 , very low-quality evidence). Five trials reported mental state improvement. No differences in mental state improvement were observed (RR 0.81, 95% CI 0.65 to 1.02; participants = 501; studies = 5, very low-quality evidence). In terms of safety, adding CBT to standard care may reduce the risk of having an adverse event (RR 0.44, 95% CI 0.27 to 0.72; participants = 146; studies = 2, very low-quality evidence) but appears to have no effect on long-term social functioning (MD 0.56, 95% CI -2.64 to 3.76; participants = 295; studies = 2, very low-quality evidence, nor on long-term quality of life (MD -3.60, 95% CI -11.32 to 4.12; participants = 71; study = 1, very low-quality evidence). It also has no effect on long-term satisfaction with treatment (measured as 'leaving the study early') (RR 0.93, 95% CI 0.77 to 1.12; participants = 1945; studies = 19, moderate-quality evidence). AUTHORS' CONCLUSIONS Relative to standard care alone, adding CBT to standard care appears to have no effect on long-term risk of relapse. A very small proportion of the available evidence indicated CBT plus standard care may improve long term global state and may reduce the risk of adverse events. Whether adding CBT to standard care leads to clinically important improvement in patients' long-term mental state, quality of life, and social function remains unclear. Satisfaction with care (measured as number of people leaving the study early) was no higher for participants receiving CBT compared to participants receiving standard care. It should be noted that although much research has been carried out in this area, the quality of evidence available is poor - mostly low or very low quality and we still cannot make firm conclusions until more high quality data are available.
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Affiliation(s)
- Christopher Jones
- University of BirminghamSchool of PsychologyEdgbastonBirminghamUKB15 2TT
| | - David Hacker
- Birmingham and Solihull Mental Health Foundation NHS TrustBirminghamUK
| | - Jun Xia
- The University of NottinghamCochrane Schizophrenia GroupTriumph RoadNottinghamUKNG7 2TU
| | - Alan Meaden
- Birmingham and Solihull Mental Health Foundation NHS TrustBirminghamUK
| | - Claire B Irving
- The University of NottinghamCochrane Schizophrenia GroupTriumph RoadNottinghamUKNG7 2TU
| | - Sai Zhao
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
| | - Jue Chen
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of MedicineDepartment of Clinical Psychology600 Wan Ping Nan RoadShanghaiChina200030
| | - Chunhu Shi
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthManchesterGreater ManchesterUKM13 9PL
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16
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Fordham B, Sugavanam T, Hopewell S, Hemming K, Howick J, Kirtley S, das Nair R, Hamer-Hunt J, Lamb SE. Effectiveness of cognitive-behavioural therapy: a protocol for an overview of systematic reviews and meta-analyses. BMJ Open 2018; 8:e025761. [PMID: 30552285 PMCID: PMC6303684 DOI: 10.1136/bmjopen-2018-025761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/08/2018] [Accepted: 10/19/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Cognitive-behavioural therapy (CBT) is a psychological therapy that has been used to improve patient well-being across multiple mental and physical health problems. Its effectiveness has been examined in thousands of randomised control trials that have been synthesised into hundreds of systematic reviews. The aim of this overview is to map, synthesise and assess the reliability of evidence generated from these systematic reviews of the effectiveness of CBT across all health conditions, patient groups and settings. METHODS AND ANALYSIS We will run our search strategy, to identify systematic reviews of CBT, within the Database of Abstracts of Reviews of Effects, the Cochrane Library of Systematic Reviews, MEDLINE, Embase, PsycInfo, CINAHL, Child Development and Adolescent Studies, and OpenGrey between January 1992 and 25 April 2018. Independent reviewers will sift, perform data extraction in duplicate and assess the quality of the reviews using the Assessing the Methodological Quality of Systematic Reviews (V.2) tool. The outcomes of interest include: health-related quality of life, depression, anxiety, psychosis and physical/physiological outcomes prioritised in the individual reviews. The evidence will be mapped and synthesised where appropriate by health problem, patient subgroups, intervention type, context and outcome. ETHICS AND DISSEMINATION Ethical approval is not required as this is an overview of published systematic reviews. We plan to publish results in peer-reviewed journals and present at international and national academic, clinical and patient conferences. TRIAL REGISTRATION NUMBER CRD42017078690.
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Affiliation(s)
- Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karla Hemming
- Department of Public Health, University of Birmingham, Birmingham, UK
| | - Jeremy Howick
- Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roshan das Nair
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | | | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Paintain E, Cassidy S. First-line therapy for post-traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches. COUNSELLING & PSYCHOTHERAPY RESEARCH 2018; 18:237-250. [PMID: 30147450 PMCID: PMC6099301 DOI: 10.1002/capr.12174] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite evidence supporting cognitive behavioural therapy (CBT)-based interventions as the most effective approach for treating post-traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)-based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD. AIMS Existing research exploring effective therapeutic interventions for PTSD includes trauma-focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT-based techniques over CBT-based techniques for the treatment of PTSD. RESULTS The evidence reviewed provided examples supporting PDT-based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD. CONCLUSION/IMPLICATIONS The need to routinely observe evidence-based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT-based interventions for the treatment of PTSD are identified.
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18
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Rodd H, Kirby J, Duffy E, Porritt J, Morgan A, Prasad S, Baker S, Marshman Z. Children's experiences following a CBT intervention to reduce dental anxiety: one year on. Br Dent J 2018; 225:247-251. [DOI: 10.1038/sj.bdj.2018.540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2018] [Indexed: 12/28/2022]
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19
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Abstract
England’s flagship ‘Improving Access to Psychological Therapies’ (IAPT) service has cost around £1 billion yet Scott’s (2018a) study suggests that only 9.2% of IAPT patients recover. This leaves an enormous gap of 40.8% between the observed recovery rate and IAPT’s claimed recovery rate of 50.0%. The spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term conditions’ (LTCs) such as ‘diabetes, COPD and ME/CFS, yet there is no way of knowing whether IAPT is capable of yielding the promised rewards or English patients are being sold an expensive pup. An urgent independent expert review of IAPT recovery rates is necessary to answer this question.
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20
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Tyrer P, Salkovskis P, Tyrer H, Wang D, Crawford MJ, Dupont S, Cooper S, Green J, Murphy D, Smith G, Bhogal S, Nourmand S, Lazarevic V, Loebenberg G, Evered R, Kings S, McNulty A, Lisseman-Stones Y, McAllister S, Kramo K, Nagar J, Reid S, Sanatinia R, Whittamore K, Walker G, Philip A, Warwick H, Byford S, Barrett B. Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years. Health Technol Assess 2018; 21:1-58. [PMID: 28877841 DOI: 10.3310/hta21500] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive-behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients. DESIGN Randomised controlled trial. SETTING Five general hospitals in London, Middlesex and Nottinghamshire. PARTICIPANTS A total of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not. INTERVENTIONS Cognitive-behaviour therapy for health anxiety - between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care. MAIN OUTCOME MEASURES Primary - researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes - costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years. RESULTS Of the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overall p < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment. LIMITATIONS Many eligible patients were not randomised and the population treated may not be representative. CONCLUSIONS CBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings. TRIAL REGISTRATION Current Controlled Trials ISRCTN14565822. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 50. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Tyrer
- Centre for Psychiatry, Imperial College London, London, UK
| | | | - Helen Tyrer
- Centre for Psychiatry, Imperial College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Simon Dupont
- Central and North West London NHS Foundation Trust, London, UK
| | - Sylvia Cooper
- Centre for Psychiatry, Imperial College London, London, UK
| | - John Green
- Central and North West London NHS Foundation Trust, London, UK
| | - David Murphy
- Imperial College Healthcare NHS Trust, London, UK
| | - Georgina Smith
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | - Valentina Lazarevic
- East Midlands & South Yorkshire Mental Health Research Network, Nottingham, UK
| | | | - Rachel Evered
- North London Hub, Mental Health Research Network, London, UK
| | - Stephanie Kings
- East Midlands & South Yorkshire Mental Health Research Network, Nottingham, UK
| | | | | | | | - Kofi Kramo
- Centre for Psychiatry, Imperial College London, London, UK
| | - Jessica Nagar
- North London Hub, Mental Health Research Network, London, UK
| | - Steven Reid
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | - Gemma Walker
- Centre for Psychiatry, Imperial College London, London, UK
| | - Aaron Philip
- Centre for Psychiatry, Imperial College London, London, UK
| | - Hilary Warwick
- Centre for Psychiatry, Imperial College London, London, UK
| | - Sarah Byford
- King's Health Economics, King's College London, London, UK
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Buhmann CB, Nordentoft M, Ekstroem M, Carlsson J, Mortensen EL. Long-term treatment effect of trauma-affected refugees with flexible cognitive behavioural therapy and antidepressants. Psychiatry Res 2018; 264:217-223. [PMID: 29655114 DOI: 10.1016/j.psychres.2018.03.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 02/06/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
Few studies exist on the long-term effect of treatment of trauma-affected refugees. The purpose of this study was to estimate the long-term treatment effects of cognitive behavioural therapy and antidepressants (sertraline and mianserin) in trauma-affected refugees. Follow-ups were conducted 6 and 18 months after a randomised controlled clinical trial. The included patients were refugees with war-related traumatic experiences, PTSD and without psychotic disorders. We found a small improvement over time in PTSD, depression and anxiety symptoms and level of functioning, but the improvement was not associated with any specific treatment. Personality change after catastrophic experiences and life events influenced the symptom level at all follow-ups while depression at completion of treatment was associated with a steeper decline in symptom load at the follow-ups. In spite of the limited decline in symptom scores and treatment effects immediately after treatment, the condition of the treated trauma-affected refugees was significantly improved 6 and 18 months after treatment although the improvement was small.
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Affiliation(s)
- Caecilie Böck Buhmann
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Ballerup, Denmark.
| | | | - Morten Ekstroem
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Ballerup, Denmark
| | - Jessica Carlsson
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Ballerup, Denmark
| | - Erik Lykke Mortensen
- University of Copenhagen, Department of Public Health and Center for Healthy Aging, Copenhagen, Denmark
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Bandelow B, Sagebiel A, Belz M, Görlich Y, Michaelis S, Wedekind D. Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies. Br J Psychiatry 2018; 212:333-338. [PMID: 29706139 DOI: 10.1192/bjp.2018.49] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is a widespread opinion that after treatment with psychotherapy, patients with anxiety disorders maintain their gains beyond the active treatment period, whereas patients treated with medication soon experience a relapse after treatment termination.AimsWe aimed to provide evidence on whether enduring effects of psychotherapy differ from control groups. METHOD We searched 93 randomised controlled studies with 152 study arms of psychological treatment (cognitive-behavioural therapy or other psychotherapies) for panic disorder, generalised anxiety disorder and social anxiety disorder that included follow-up assessments. In a meta-analysis, pre-post effect sizes for end-point and all follow-up periods were calculated and compared with control groups (medication: n = 16 study arms; pill and psychological placebo groups: n = 17 study arms). RESULTS Gains with psychotherapy were maintained for up to 24 months. For cognitive-behavioural therapy, we observed a significant improvement over time. However, patients in the medication group remained stable during the treatment-free period, with no significant difference when compared with psychotherapy. Patients in the placebo group did not deteriorate during follow-up, but showed significantly worse outcomes than patients in cognitive-behavioural therapy. CONCLUSIONS Not only psychotherapy, but also medications and, to a lesser extent, placebo conditions have enduring effects. Long-lasting treatment effects observed in the follow-up period may be superimposed by effects of spontaneous remission or regression to the mean.Declaration of interestIn the past 12 months and in the near future, Dr Bandelow has been/will be on the speakers/advisory board for Hexal, Mundipharma, Lilly, Lundbeck, Pfizer and Servier. Dr Wedekind was on the speakers' board of AstraZeneca, Essex Pharma, Lundbeck and Servier. All other authors have nothing to declare.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
| | - Anne Sagebiel
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
| | - Michael Belz
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
| | - Yvonne Görlich
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
| | - Sophie Michaelis
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
| | - Dirk Wedekind
- Department of Psychiatry and Psychotherapy,University Medical Centre Göttingen,Germany
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Abstract
Anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, social anxiety disorder, and others) are the most prevalent psychiatric disorders, and are associated with a high burden of illness. Anxiety disorders are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the disorder. The treatment recommendations given in this article are based on guidelines, meta-analyses, and systematic reviews of randomized controlled studies. Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for routine use. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. After remission, medications should be continued for 6 to 12 months. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University Medical Center, Gottingen, Germany
| | - Sophie Michaelis
- Department of Psychiatry and Psychotherapy, University Medical Center, Gottingen, Germany
| | - Dirk Wedekind
- Department of Psychiatry and Psychotherapy, University Medical Center, Gottingen, Germany
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Abstract
SummaryAs many as 10% of the population experience post-traumatic stress disorder (PTSD) at some time in their lives. It often runs a severe, chronic and treatment-resistant course. This article reviews the evidence base for typically recommended treatments such as cognitive-behavioural therapy (CBT), eye movement desensitisation and reprocessing and selective serotonin reuptake inhibitors (SSRIs). It tabulates the major randomised controlled trials of SSRIs and trauma-focused CBT and reviews research on novel treatments such as ketamine, MDMA, quetiapine, propranolol and prazosin.
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Ekroll VB, Rønnestad MH. Exploring Associations Between Therapy Factors and Post-therapy Development After Naturalistic Psychotherapies. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2017. [DOI: 10.1007/s10879-017-9366-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Johnson SU, Hoffart A, Nordahl HM, Wampold BE. Metacognitive therapy versus disorder-specific CBT for comorbid anxiety disorders: A randomized controlled trial. J Anxiety Disord 2017. [PMID: 28651207 DOI: 10.1016/j.janxdis.2017.06.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Few studies have compared the effects of Metacognitive therapy (MCT) and Cognitive behavioral therapy (CBT) for comorbid anxiety disorders. In the current study we compared CBT and MCT for heterogeneous anxiety disorders in a residential setting. Ninety patients with a primary diagnosis of Post Traumatic Stress Disorder, Social Phobia or Panic disorder, with and without Agoraphobia, were randomized to either CBT or MCT. Patients were assessed at pre-treatment, post-treatment and one-year follow-up. Primary outcome measures were Beck Anxiety Inventory and ADIS IV and secondary outcome measures were SCID II, Beck Depression Inventory, Penn State Worry Questionnaire, The Symptom Checklist-90 and the Inventory of Interpersonal Problems-64. Treatment fidelity was satisfactory and therapist credibility was equal in both treatments. There was a significant difference in the level of anxiety favouring MCT at post-treatment (d=0.7), but there were no differences at one-year follow-up, mainly due to a further improvement in the CBT group during the follow-up period. Both treatments were efficacious. No differences in effect on comorbid diagnoses and symptoms were found, but MCT produced larger change in personality problems. MCT seems to have a more rapid effect on anxiety symptoms, but there were no significant differences in the long term for patients with comorbid anxiety disorders.
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Affiliation(s)
- Sverre Urnes Johnson
- Modum Bad Psychiatric Center, Vikersund, Norway; University of Oslo, Department of Psychology, Norway.
| | - Asle Hoffart
- Modum Bad Psychiatric Center, Vikersund, Norway; University of Oslo, Department of Psychology, Norway.
| | - Hans M Nordahl
- Norwegian University of Science and Technology, Institute of Mental Health, Norway; St. Olavs Hospital, Div of Psychiatry, Nidaros DPS, 7006 Trondheim.
| | - Bruce E Wampold
- Modum Bad Psychiatric Center, Vikersund, Norway; University of Wisconsin-Madison, USA.
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Kennis PhD M, van Rooij PhD SJH, Reijnen MSc A, Geuze PhD E. The predictive value of dorsal cingulate activity and fractional anisotropy on long-term PTSD symptom severity. Depress Anxiety 2017; 34:410-418. [PMID: 28294478 DOI: 10.1002/da.22605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/17/2016] [Accepted: 12/26/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) can be treated with trauma-focused therapy, although only about 50% of the patients recover on the short-term. In order to improve response rates it is important to identify who will and will not recover from trauma-focused therapy. Although previous studies reported dorsal anterior cingulate cortex (ACC) activity, as well as dorsal cingulum bundle white matter microstructure integrity as markers for the persistence of PTSD symptoms on the short-term, it remains unclear whether these markers also predict long-term PTSD symptom severity. METHODS PTSD patients (n = 57) were investigated with clinical interviews and an MRI protocol before the start of treatment. Clinical interviews were repeated after 6-8 months of treatment (short-term follow-up), and on average 4 years later (long-term follow-up). Twenty-eight PTSD patients returned for the long-term follow-up. Dorsal ACC activity in response to negative images, and fractional anisotropy (FA) of the dorsal cingulum were the neural markers investigated. RESULTS In this long-term follow-up sample (n = 28), dorsal ACC activity and dorsal cingulum FA values significantly predicted CAPS scores on short- and long-term follow-up. The results remained significant after controlling for baseline CAPS score, early trauma, and comorbidity. CONCLUSION This study confirms the importance of the cingulate cortex activation and white matter integrity not only for short-term treatment outcome, but also for PTSD long-term symptom severity. Future treatments should target ACC function in particular during treatment in order to improve response rates.
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Affiliation(s)
- Mitzy Kennis PhD
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Sanne J H van Rooij PhD
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Alieke Reijnen MSc
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Elbert Geuze PhD
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
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Levar N, van Leeuwen JMC, Puts NAJ, Denys D, van Wingen GA. GABA Concentrations in the Anterior Cingulate Cortex Are Associated with Fear Network Function and Fear Recovery in Humans. Front Hum Neurosci 2017; 11:202. [PMID: 28496404 PMCID: PMC5406467 DOI: 10.3389/fnhum.2017.00202] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/07/2017] [Indexed: 12/03/2022] Open
Abstract
Relapse of fear after successful treatment is a common phenomenon in patients with anxiety disorders. Animal research suggests that the inhibitory neurotransmitter γ-aminobutyric acid (GABA) plays a key role in the maintenance of extinguished fear. Here, we combined magnetic resonance spectroscopy and functional magnetic resonance imaging to investigate the role of GABA in fear recovery in 70 healthy male participants. We associated baseline GABA levels in the dorsal anterior cingulate cortex (dACC) to indices of fear recovery as defined by changes in skin conductance responses (SCRs), blood oxygen level dependent responses, and functional connectivity from fear extinction to fear retrieval. The results showed that high GABA levels were associated with increased SCRs, enhanced activation of the right amygdala, and reduced amygdala-ventromedial prefrontal cortex connectivity during fear recovery. Follow-up analyses exclusively for the extinction phase showed that high GABA levels were associated with reduced amygdala activation and enhanced amygdala-ventromedial prefrontal cortex connectivity, despite the absence of correlations between GABA and physiological responses. Follow-up analyses for the retrieval phase did not show any significant associations with GABA. Together, the association between GABA and increases in SCRs from extinction to retrieval, without associations during both phases separately, suggests that dACC GABA primarily inhibits the consolidation of fear extinction. In addition, the opposite effects of GABA on amygdala activity and connectivity during fear extinction compared to fear recovery suggest that dACC GABA may initially facilitate extinction learning.
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Affiliation(s)
- Nina Levar
- Department of Psychiatry, Academic Medical CenterAmsterdam, Netherlands.,Brain Imaging Center, Academic Medical CenterAmsterdam, Netherlands.,Amsterdam Brain and Cognition, University of AmsterdamAmsterdam, Netherlands.,Spinoza Center for NeuroimagingAmsterdam, Netherlands
| | - Judith M C van Leeuwen
- Department of Psychiatry, Academic Medical CenterAmsterdam, Netherlands.,Department of Psychiatry, University Medical Center UtrechtUtrecht, Netherlands
| | - Nicolaas A J Puts
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins UniversityBaltimore, MD, USA.,FM Kirby Center for Functional Brain Imaging, Kennedy Krieger InstituteBaltimore, MD, USA
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical CenterAmsterdam, Netherlands.,Brain Imaging Center, Academic Medical CenterAmsterdam, Netherlands.,Amsterdam Brain and Cognition, University of AmsterdamAmsterdam, Netherlands.,Spinoza Center for NeuroimagingAmsterdam, Netherlands
| | - Guido A van Wingen
- Department of Psychiatry, Academic Medical CenterAmsterdam, Netherlands.,Brain Imaging Center, Academic Medical CenterAmsterdam, Netherlands.,Amsterdam Brain and Cognition, University of AmsterdamAmsterdam, Netherlands.,Spinoza Center for NeuroimagingAmsterdam, Netherlands
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Arnfred SM, Aharoni R, Hvenegaard M, Poulsen S, Bach B, Arendt M, Rosenberg NK, Reinholt N. Transdiagnostic group CBT vs. standard group CBT for depression, social anxiety disorder and agoraphobia/panic disorder: Study protocol for a pragmatic, multicenter non-inferiority randomized controlled trial. BMC Psychiatry 2017; 17:37. [PMID: 28114915 PMCID: PMC5260024 DOI: 10.1186/s12888-016-1175-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/23/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Transdiagnostic Cognitive Behavior Therapy (TCBT) manuals delivered in individual format have been reported to be just as effective as traditional diagnosis specific CBT manuals. We have translated and modified the "The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders" (UP-CBT) for group delivery in Mental Health Service (MHS), and shown effects comparable to traditional CBT in a naturalistic study. As the use of one manual instead of several diagnosis-specific manuals could simplify logistics, reduce waiting time, and increase therapist expertise compared to diagnosis specific CBT, we aim to test the relative efficacy of group UP-CBT and diagnosis specific group CBT. METHODS/DESIGN The study is a partially blinded, pragmatic, non-inferiority, parallel, multi-center randomized controlled trial (RCT) of UP-CBT vs diagnosis specific CBT for Unipolar Depression, Social Anxiety Disorder and Agoraphobia/Panic Disorder. In total, 248 patients are recruited from three regional MHS centers across Denmark and included in two intervention arms. The primary outcome is patient-ratings of well-being (WHO Well-being Index, WHO-5), secondary outcomes include level of depressive and anxious symptoms, personality variables, emotion regulation, reflective functioning, and social adjustment. Assessments are conducted before and after therapy and at 6 months follow-up. Weekly patient-rated outcomes and group evaluations are collected for every session. Outcome assessors, blind to treatment allocation, will perform the observer-based symptom ratings, and fidelity assessors will monitor manual adherence. DISCUSSION The current study will be the first RCT investigating the dissemination of the UP in a MHS setting, the UP delivered in groups, and with depressive patients included. Hence the results are expected to add substantially to the evidence base for rational group psychotherapy in MHS. The planned moderator and mediator analyses could spur new hypotheses about mechanisms of change in psychotherapy and the association between patient characteristics and treatment effect. TRIAL REGISTRATION Clinicaltrials.gov NCT02954731 . Registered 25 October 2016.
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Affiliation(s)
- Sidse M. Arnfred
- Psychiatric Hospital Slagelse & Psychiatric Research Unit, Region Zealand Psychiatry, Faelledvej 6, Building 3, Level 4., DK-4200 Slagelse, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ruth Aharoni
- Psychotherapeutic Clinic Nannasgade, Mental Health Centre Copenhagen, Capital Region Mental Health Services, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Hvenegaard
- Psychiatric Hospital Slagelse & Psychiatric Research Unit, Region Zealand Psychiatry, Faelledvej 6, Building 3, Level 4., DK-4200 Slagelse, Denmark
| | - Stig Poulsen
- Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Bach
- Psychiatric Hospital Slagelse & Psychiatric Research Unit, Region Zealand Psychiatry, Faelledvej 6, Building 3, Level 4., DK-4200 Slagelse, Denmark
| | - Mikkel Arendt
- Unit for Anxiety and Compulsive Disorders, Psychiatric Hospital Risskov, Aarhus University Hospital, Aarhus, Denmark
| | - Nicole K. Rosenberg
- Psychotherapeutic Clinic Nannasgade, Mental Health Centre Copenhagen, Capital Region Mental Health Services, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nina Reinholt
- Psychotherapeutic Clinic Nannasgade, Mental Health Centre Copenhagen, Capital Region Mental Health Services, Copenhagen University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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30
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Meng H, Friedberg F. Cost-Utility of Home-Based Fatigue Self-Management versus Usual Care for the Treatment of Chronic Fatigue Syndrome. FATIGUE-BIOMEDICINE HEALTH AND BEHAVIOR 2017; 5:202-214. [PMID: 30931176 DOI: 10.1080/21641846.2017.1343171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Chronic fatigue syndrome is a complex chronic condition with large negative impact on patients' function and quality of life. Efficacy and cost-effectiveness of cognitive behavioral intervention remain inconclusive. Objective To evaluate the cost-utility of a home-based fatigue self-management (FSM) intervention as compared to usual care among primary care patients with severe chronic fatigue syndrome (CFS). Methods An economic evaluation alongside of a randomized controlled study design was used. Cost and utility data were collected from 137 patients with severe CFS at baseline and 1-year follow-up. The FSM group (n=89) received self-delivered cognitive behavioral self-management intervention and the usual care group (n=48) received regular medical care. Cost was measured by total costs (direct, indirect, and intervention costs) during the follow-up period. Quality-adjusted life years (QALY), as the utility measure, were derived from the Medical Outcomes Survey Short Form-36. A societal perspective was adopted. Bootstrapped incremental cost-utility ratios (ICURs) and net monetary benefit were calculated as measures of cost-effectiveness. Results Baseline individual characteristics were similar between the two groups. The intervention was well-received by the participants with only minimum attrition. At the end of one year post-intervention, FSM dominated usual care in terms of ICUR in both the intention-to-treat analysis and the complete-cases-only analysis. Net monetary benefit analysis showed that FSM has higher probability of achieving positive net monetary across the entire range of possible societal willingness-to-pay for fatigue symptom management. CONCLUSIONS In primary care patients with severe CFS, the low-cost FSM appears to be a cost-effective treatment.
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Affiliation(s)
- Hongdao Meng
- School of Aging Studies, University of South Florida
| | - Fred Friedberg
- Department of Psychiatry, Stony Brook University Medical Center
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31
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Affiliation(s)
- Dina Bošnjak
- University Psychiatric Hospital Vrapče; Bolnicka cesta 32 Zagreb Grad Zagreb Croatia 10000
| | - Ivana Kekin
- Clinical Hospital Centre Zagreb; Department of Psychiatry; Kispaticeva 12 10 000 Zagreb Croatia
| | - Joanne Hew
- St Mary's Hospital; Department of Medicine; Praed Street London UK W2 1NY
| | - Martina Rojnic Kuzman
- Clinical Hospital Centre Zagreb; Department of Psychiatry; Kispaticeva 12 10 000 Zagreb Croatia
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Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, Kessler D, Kuyken W, Lewis G, Morrison J, Williams C, Peters TJ, Hollinghurst S. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. Lancet Psychiatry 2016; 3:137-44. [PMID: 26777773 DOI: 10.1016/s2215-0366(15)00495-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/22/2015] [Accepted: 10/27/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3-5 years in primary care patients with treatment-resistant depression. METHODS CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18-75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3-5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0-63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs). This study is registered with isrctn.com, number ISRCTN38231611. FINDINGS Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5-51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means -4·7 [95% CI -6·4 to -3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000. INTERPRETATION CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective. FUNDING National Institute for Health Research Health Technology Assessment.
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Affiliation(s)
- Nicola J Wiles
- Centre for Academic Mental Health, University of Bristol, Bristol, UK.
| | - Laura Thomas
- Centre for Academic Mental Health, University of Bristol, Bristol, UK
| | - Nicholas Turner
- Centre for Academic Mental Health, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Daphne Kounali
- Centre for Academic Mental Health, University of Bristol, Bristol, UK
| | - John Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - David Kessler
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Willem Kuyken
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Jill Morrison
- Institute of Health and Wellbeing, General Practice and Primary Care Group, University of Glasgow, Glasgow, Scotland, UK
| | - Chris Williams
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, Scotland, UK
| | - Tim J Peters
- School of Social and Community Medicine and School of Clinical Sciences, University of Bristol, Bristol, UK
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Haaker J, Lonsdorf TB, Kalisch R. Effects of post-extinction l-DOPA administration on the spontaneous recovery and reinstatement of fear in a human fMRI study. Eur Neuropsychopharmacol 2015; 25:1544-55. [PMID: 26238968 DOI: 10.1016/j.euroneuro.2015.07.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/29/2015] [Accepted: 07/14/2015] [Indexed: 12/29/2022]
Abstract
Relapse is a pertinent problem in the treatment of anxiety disorders. In the laboratory, relapse is modeled as return of conditioned fear responses after successful fear extinction and is explained by insufficient retrieval and/or expression of the fear-inhibitory extinction memory that is generated during extinction learning. We have shown in mice and humans that return of fear can be prevented by administration of a single dose of the dopamine precursor l-3,4-dihydroxyphenylalanine (l-DOPA) immediately after extinction. In mice, this effect could be attributed to an enhancement of extinction memory consolidation. In our human study, we could not exclude that l-DOPA might have acted by interfering with the consolidation of the original fear memory. In the present study, we therefore used a combined differential cue and context conditioning paradigm where initial fear conditioning and extinction were conducted one day apart, in analogy to previous mouse studies. l-DOPA (N=21) or placebo (N=19) were administered after extinction, precluding any action on fear memory consolidation. In the return-of-fear test conducted one week later, drug effects on conditioned skin conductance responses were absent. However, we found evidence indicative of reduced neural activity, measured with functional magnetic resonance imaging (fMRI), in the l-DOPA group in areas related to conditioned fear and return of fear (amygdala, posterior hippocampus) and enhanced activity in a key area of extinction retrieval/expression (ventromedial prefrontal cortex), relative to placebo controls. These findings require further corroboration in additional experiments. Implications for further investigations on the role of the dopamine system in extinction and on the neuropharmacological augmentation of extinction-based therapies are discussed.
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Affiliation(s)
- Jan Haaker
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Karolinska Institutet, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Tina B Lonsdorf
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raffael Kalisch
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neuroimaging Center (NIC), Focus Program Translational Neuroscience, Johannes Gutenberg University Medical Center Mainz, Germany
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Hoffart A, Øktedalen T, Svanøe K, Hedley LM, Sexton H. Predictors of short- and long-term avoidance in completers of inpatient group interventions for agoraphobia. J Affect Disord 2015; 181:33-40. [PMID: 25917291 DOI: 10.1016/j.jad.2015.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/14/2015] [Accepted: 04/06/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Little is currently known about predictors of follow-up outcome of psychological treatment of agoraphobia. In this study, we wished to examine predictors of short- and long-term avoidance after inpatient group interventions for agoraphobia. METHODS Ninety-six (68%) of 141 agoraphobic patients (74% women) who had completed treatment in two open and one randomized controlled trial (RCT) were followed up 13 to 21 years after start of treatment. RESULTS Major depression at pre-treatment predicted less short-term (up to one year after end of treatment) improvement in agoraphobic avoidance. Working and being married/cohabiting at pre-treatment predicted greater long-term (across one-year, two-year, and 13-21 years follow-up) improvement. In contrast, the duration of agoraphobia, amount of Axis I and II co-morbidity, being diagnosed with avoidant, dependent, and obsessive-compulsive personality disorder, and the use of antidepressants and benzodiazepines the month before intake to treatment, were unrelated to short-term as well as long-term outcome. LIMITATIONS As many as 31.9% of the included patients did not attend long-term follow-up and the power of the study was limited. The long time period between the two and 13-21 year follow-ups is a limitation, in which it is difficult to assess what actually happened. Although all the patients received some form of CBT, there was variability among the treatments. CONCLUSIONS The only short-term predictor identified represented a clinical feature, whereas the long-term predictors represented features of the patients' life situation. The limited power of the study precludes the inference that non-significant predictors are unrelated to follow-up outcome.
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Affiliation(s)
- Asle Hoffart
- Research Institute, Modum Bad, N-3370 Vikersund, Norway; Department of Psychology, University of Oslo, PB 1094, Blindern, N-0317 Oslo, Norway.
| | - Tuva Øktedalen
- Research Institute, Modum Bad, N-3370 Vikersund, Norway; Department of Psychology, University of Oslo, PB 1094, Blindern, N-0317 Oslo, Norway
| | - Karol Svanøe
- Buskerud and Vestfold University College, PB 2243, N-3103 Tønsberg, Norway
| | - Liv M Hedley
- Research Institute, Modum Bad, N-3370 Vikersund, Norway
| | - Harold Sexton
- Research Institute, Modum Bad, N-3370 Vikersund, Norway
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Needham M, Gummerum M, Mandeville-Norden R, Rakestrow-Dickens J, Mewse A, Barnes A, Hanoch Y. Association between three different cognitive behavioral alcohol treatment programs and recidivism rates among male offenders: findings from the United Kingdom. Alcohol Clin Exp Res 2015; 39:1100-7. [PMID: 25939685 DOI: 10.1111/acer.12738] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cognitive behavioral therapy-based alcohol treatment programs have been widely used to break the link between alcohol and crime. While evidence exists on the connection between alcohol and crime, there is little data that demonstrate the effectiveness of different alcohol treatment programs in reducing criminal behavior. We tested whether male offenders who participate in alcohol treatment programs show lower rates of recidivism than a matched offender group who did not participate in an alcohol prevention program. METHODS This is an observational matched case-control study. Participants were 564 male offenders with an alcohol problem related to offending. Participants were assigned by the courts to 1 of 3 alcohol treatment programs (141 offenders per treatment): Low Intensity Alcohol Program (LIAP), Alcohol Specified Activity Requirement, and Addressing Substance-Related Offending. A fourth matched group (n = 141) was not assigned to a program and served as a control group. Survival analysis was used to calculate participants' charged and reconviction rates over 4 time periods (0 to 3, 4 to 6, 7 to 9, and 10 to 12 months after completion of program or order). RESULTS Offenders who did not participate in a program were more than twice as likely to be charged compared to offenders who participated in a program. Furthermore, offenders who did not participate in a program were over 2.5 times more likely to be reconvicted. Among the 3 alcohol treatment programs evaluated, the LIAP was the most cost-effective. CONCLUSIONS Offenders enrolled in an alcohol treatment program showed a significant reduction in being charged with or reconvicted of a crime. With costs of keeping offenders in prison per year reaching close to £40,000 per offender per year (Mulheirn et al., 2010, www.smf.co.uk), assigning offenders to alcohol preventive programs-such as LIAP-are a promising way to reduce recidivism and reduce cost.
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Affiliation(s)
- Marie Needham
- School of Psychology, Cognition Institute, Faculty of Health & Human Sciences, Plymouth University, Plymouth, United Kingdom
| | - Michaela Gummerum
- School of Psychology, Cognition Institute, Faculty of Health & Human Sciences, Plymouth University, Plymouth, United Kingdom
| | | | | | - Avril Mewse
- Department of Psychology, College of Life & Environmental Sciences, University of Exeter, Exeter, United Kingdom
| | - Andrew Barnes
- Department of Healthcare Policy and Research, Virginia Commonwealth University, Richmond, Virginia
| | - Yaniv Hanoch
- School of Psychology, Cognition Institute, Faculty of Health & Human Sciences, Plymouth University, Plymouth, United Kingdom
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Ridyard CH, Hughes DA. Taxonomy for methods of resource use measurement. HEALTH ECONOMICS 2015; 24:372-8. [PMID: 24442966 DOI: 10.1002/hec.3029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 09/12/2013] [Accepted: 12/04/2013] [Indexed: 05/21/2023]
Abstract
Resource use measures, including forms, diaries and questionnaires, are ubiquitous in trial-based economic evaluations in the UK. However, there are concerns about the accuracy of how they are described, which limits the transparency of reporting. We developed a simple and structured taxonomy for methods of resource use measurement by examining 94 resource use measures (RUMs) employed within clinical trials, conducting a descriptive synthesis of the extracted data and soliciting wider opinion during a period of consultation. The reporting of RUMs was found to be varied and inconsistent. Our new taxonomy, which considered the views of 20 consultees, requires that RUMs are reported with a description of the following: (i) the source of data (patient; patient proxy, e.g. carer, parent or guardian; observation of contemporary events; medical records; or other databases); (ii) who completes the RUM (patient or their proxy, and researcher or health care professional); (iii) how it is administered (to self [the patient], face to face or telephone); (iv) how it is recorded (form, questionnaire, log or diary); and (v) medium of recording (e.g. paper or electronically). Based on the present analysis, we have developed a taxonomy for RUMs that should result in data collection methods being described more accurately.
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Affiliation(s)
- Colin H Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
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Bullis JR, Fortune MR, Farchione TJ, Barlow DH. A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Compr Psychiatry 2014; 55:1920-7. [PMID: 25113056 PMCID: PMC4252968 DOI: 10.1016/j.comppsych.2014.07.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/15/2014] [Accepted: 07/17/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). METHOD Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N=15, mean age=32.27; 60% female) who completed a clinical trial of the UP. RESULTS Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12months later (at an average of 18months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range. CONCLUSIONS These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment.
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Affiliation(s)
| | - Meghan R Fortune
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
| | - Todd J Farchione
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
| | - David H Barlow
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
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Brown KM, Tracy DK. Psychoanalytic Psychotherapy in Contemporary Mental Health Services: Current Evidence, Future Role and Challenges. BRITISH JOURNAL OF PSYCHOTHERAPY 2014. [DOI: 10.1111/bjp.12074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Ebert D, Tarnowski T, Gollwitzer M, Sieland B, Berking M. A transdiagnostic internet-based maintenance treatment enhances the stability of outcome after inpatient cognitive behavioral therapy: a randomized controlled trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2014; 82:246-56. [PMID: 23736751 DOI: 10.1159/000345967] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 11/15/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND High relapse rates following acute treatment for common mental health disorders support the importance of developing maintenance phase interventions. Internet-based interventions have been effective for a broad range of mental disorders, but less is known about their potential to enhance long-term outcomes of traditional face-to-face therapy. Therefore, the goal of the present study was to evaluate a transdiagnostic Internet-based maintenance treatment (TIMT) with the purpose of fostering long-term effects of inpatient psychotherapy. METHOD In this pragmatic randomized controlled trial, a sample of 400 inpatients with affective, neurotic, and/or behavioral disorders was assigned to either 12 weeks of TIMT + treatment as usual (TAU) or to TAU-only following hospital discharge. TIMT consists of a self-management module, asynchronous patient-coach communication, online patient support group, and online-based monitoring of psychopathological symptoms. Self-ratings of psychopathological symptoms were conducted at the beginning of inpatient treatment (t1), at discharge from inpatient treatment/start of TIMT (t2), and at 3-month (t3) and 12-month follow-ups (t4). RESULTS The TIMT + TAU group was superior to the TAU-only group with regard to differences in change of general psychopathological symptom severity from discharge to 3- and 12-month follow-up. Moreover, participants of the TIMT + TAU group showed less frequent symptom deteriorations and were more often in remission/recovery than controls. CONCLUSION TIMT effectively enhances long-term outcome of inpatient psychotherapy.
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Affiliation(s)
- David Ebert
- Philipps University Marburg, Marburg, Germany.
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Travers MF, Benton SA. The Acceptability of Therapist-Assisted, Internet-Delivered Treatment for College Students. JOURNAL OF COLLEGE STUDENT PSYCHOTHERAPY 2014. [DOI: 10.1080/87568225.2014.854676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Yoo DH, Hong DG, Lee JS. The Standardization of the Clock Drawing Test (CDT) for People with Stroke Using Rasch Analysis. J Phys Ther Sci 2014; 25:1587-90. [PMID: 24409026 PMCID: PMC3885845 DOI: 10.1589/jpts.25.1587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/03/2013] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The aim of this study was to standardize the clock drawing test (CDT) for
people with stroke using Rasch analysis. [Subjects and Methods] Seventeen items of the CDT
identified through a literature review were performed by 159 stroke patients. The data was
analyzed with Winstep version 3.57 using the Rasch model to examine the unidimensionality
of the items’ fit, the distribution of the items’ difficulty, and the reliability and
appropriateness of the rating scale. [Result] Ten out of the 159 participations (6.2%)
were considered misfit subjects, and one item of the CDT was determined to be a misfit
item based on Rasch analysis. The rating scales were judged as suitable because the
observed average showed an array of vertical orders and MNSQ values < 2. The separate
index and reliability of the subject (1.98, 0.80) and item (6.45, 0.97) showed relatively
high values. [Conclusion] This study is the first to examine the CDT scale in stroke
patients by Rasch analysis. The CDT is expected to be useful for screening stroke patients
with cognitive problems.
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Affiliation(s)
- Doo Han Yoo
- Department of Occupational Therapy, Chonbuk National University Hospital, Republic of Korea
| | - Deok Gi Hong
- Department of Occupational Therapy, Wonkwang University Oriental Medical Hospital, Republic of Korea
| | - Jae Shin Lee
- Department of Occupational Therapy, Graduate School of Konyang University: 158 Kwanjeo, Seo, Daejeon 302-718, Republic of Korea
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Gloster AT, Hauke C, Höfler M, Einsle F, Fydrich T, Hamm A, Sthröhle A, Wittchen HU. Long-term stability of cognitive behavioral therapy effects for panic disorder with agoraphobia: A two-year follow-up study. Behav Res Ther 2013; 51:830-9. [DOI: 10.1016/j.brat.2013.09.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 08/22/2013] [Accepted: 09/30/2013] [Indexed: 12/18/2022]
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Ebert DD, Gollwitzer M, Riper H, Cuijpers P, Baumeister H, Berking M. For whom does it work? moderators of outcome on the effect of a transdiagnostic internet-based maintenance treatment after inpatient psychotherapy: randomized controlled trial. J Med Internet Res 2013; 15:e191. [PMID: 24113764 PMCID: PMC3849694 DOI: 10.2196/jmir.2511] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 07/15/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022] Open
Abstract
Background Recent studies provide evidence for the effectiveness of Internet-based maintenance treatments for mental disorders. However, it is still unclear which participants might or might not profit from this particular kind of treatment delivery. Objective The study aimed to identify moderators of treatment outcome in a transdiagnostic Internet-based maintenance treatment (TIMT) offered to patients after inpatient psychotherapy for mental disorders in routine care. Methods Using data from a randomized controlled trial (N=400) designed to test the effectiveness of TIMT, we performed secondary analyses to identify factors moderating the effects of TIMT (intervention) when compared with those of a treatment-as-usual control condition. TIMT involved an online self-management module, asynchronous patient–therapist communication, a peer support group, and online-based progress monitoring. Participants in the control condition had unstructured access to outpatient psychotherapy, standardized outpatient face-to-face continuation treatment, and psychotropic management. Self-reports of psychopathological symptoms and potential moderators were assessed at the start of inpatient treatment (T1), at discharge from inpatient treatment/start of TIMT (T2), and at 3-month (T3) and 12-month follow-up (T4). Results Education level, positive outcome expectations, and diagnoses significantly moderated intervention versus control differences regarding changes in outcomes between T2 and T3. Only education level moderated change differences between T2 and T4. The effectiveness of the intervention (vs control) was more pronounced among participants with a low (vs high) education level (T2-T3: B=–0.32, SE 0.16, P=.049; T2-T4: B=–0.42, SE 0.21, P=.049), participants with high (vs low) positive outcome expectations (T2-T3: B=–0.12, SE 0.05, P=.02) and participants with anxiety disorder (vs mood disorder) (T2-T3: B=–0.43, SE 0.21, P=.04). Simple slope analyses revealed that despite some subgroups benefiting less from the intervention than others, all subgroups still benefited significantly. Conclusions This transdiagnostic Internet-based maintenance treatment might be suitable for a wide range of participants differing in various clinical, motivational, and demographic characteristics. The treatment is especially effective for participants with low education levels. These findings may generalize to other Internet-based maintenance treatments. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 28632626; http://www.controlled-trials.com/isrctn/pf/28632626 (Archived by WebCite at http://www.webcitation.org/6IqZjTLrx).
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Affiliation(s)
- David Daniel Ebert
- Innovation Incubator, Division Health-Training.Online, Leuphana University Lueneburg, Lüneburg, Germany.
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Fullana MA, Fernández de la Cruz L, Bulbena A, Toro J. Eficacia de la terapia cognitivo-conductual para los trastornos mentales. Med Clin (Barc) 2012; 138:215-9. [DOI: 10.1016/j.medcli.2011.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 02/15/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Durham RC, Higgins C, Chambers JA, Swan JS, Dow MGT. Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups. J Affect Disord 2012; 136:875-81. [PMID: 22014916 DOI: 10.1016/j.jad.2011.09.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND Few clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders have conducted follow-up beyond one year post-treatment. This paper summarises the long-term outcome of eight clinical trials of CBT for anxiety disorders in terms of diagnostic status, healthcare usage and symptom severity and compares the symptom profile of participants with the best and worst outcomes relative to chronic depression and the normal population. METHODS Follow-up at 2-14years with 396 patients (51% of those available to contact) employed structured diagnostic interview, assessment of healthcare usage and self-report measures of symptom severity. This paper concerns 336 participants who had either no disorder or at least one anxiety disorder and information on healthcare usage over the follow-up period. RESULTS Only 38% recovered with little or no treatment over the follow-up period while 30% had a very poor outcome despite extensive treatment for anxiety over many years. The symptom profile of this 'treatment-resistant' group was comparable to 76 patients with chronic depression and significantly worse than normative data for psychiatric outpatients. Chronic anxiety disorder with co-morbid depression has a more severe symptom profile than chronic anxiety disorder alone. LIMITATIONS The follow-up sample, although broadly representative, may have a bias towards a more favourable picture of overall outcome. CONCLUSIONS The long-term outcome of anxiety disorders, irrespective of diagnosis or active treatment, is diverse but with a tendency towards chronicity. Distinctions between acute and chronic presentations of common mental disorders are more important than distinctions between chronic anxiety and chronic depression.
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Affiliation(s)
- Robert C Durham
- Centre for Neuroscience, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland, United Kingdom.
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Gudkovs J. Intentional teams in rural health care: a preliminary report. Australas Psychiatry 2011; 19 Suppl 1:S98-101. [PMID: 21878032 DOI: 10.3109/10398562.2011.583063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This paper reports on how private practitioners were engaged in a rural community in an intentional team to provide a comprehensive lifestyle program for "hard to treat" patients with physical and mental health problems. METHODS A field trial of a 12-week program for patients with depression or anxiety plus other chronic disease was delivered by a team of allied health practitioners. RESULTS Significant improvements in mental health as measured by DASS and SF36 were achieved. CONCLUSIONS Utilizing community resources effectively can lessen the burden on other aspects of the health care system.
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Affiliation(s)
- Jan Gudkovs
- Total Health and Education Foundation, Warwick, QLD, Australia.
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Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat 2011; 7:167-81. [PMID: 21552319 PMCID: PMC3083990 DOI: 10.2147/ndt.s10389] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD. METHODS Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites. RESULTS The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT. CONCLUSION There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.
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Affiliation(s)
- Nilamadhab Kar
- Department of Psychiatry, Wolverhampton City Primary Care Trust, Wolverhampton, UK
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Cognitive behavioural therapy for auditory hallucinations: effectiveness and predictors of outcome in a specialist clinic. Behav Cogn Psychother 2010; 39:129-38. [PMID: 21062528 DOI: 10.1017/s1352465810000548] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cognitive behavioural therapy has been established as an effective treatment for residual psychotic symptoms but a substantial proportion of people do not benefit from this treatment. There has been little direct study of predictors of outcome, particularly in treatment targeting auditory hallucinations. METHOD The Psychotic Symptom Rating Scales (PSYRATS) and Positive and Negative Syndrome Scale (PANSS) were administered pre- and post-therapy to 33 people with schizophrenia-related disorders receiving CBT for auditory hallucinations in a specialist clinic. Outcome was compared with pre-therapy measures of insight, beliefs about the origin of hallucinations, negative symptoms and cognitive disorganization. RESULTS There were significant improvements post-treatment on the PSYRATS and PANSS Positive and General Scales. Improvement on the PSYRATS was associated with lower levels of negative symptoms, but was unrelated to overall insight, delusional conviction regarding the origins of hallucinations, or levels of cognitive disorganization. CONCLUSIONS Lack of insight and presence of formal thought disorder do not preclude effective cognitive-behavioural treatment of auditory hallucinations. There is a need to further understand why negative symptoms may present a barrier to therapy.
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Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future. Schizophr Res 2010; 122:1-23. [PMID: 20655178 DOI: 10.1016/j.schres.2010.05.025] [Citation(s) in RCA: 231] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 05/22/2010] [Accepted: 05/25/2010] [Indexed: 12/20/2022]
Abstract
The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.
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Durham RC, Chambers JA, Macdonald RR, Fisher PL. Predictive Validity of Two Prognostic Indices for Generalized Anxiety Disorder. Int J Cogn Ther 2009. [DOI: 10.1521/ijct.2009.2.4.383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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