Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review

Abstract

Background: Major depressive disorder (MDD) causes a massive disease burden worldwide. Cognitive behavioural therapy (CBT) is an important treatment approach for depression. Cost-utility analysis (CUA) is a method to support decisions on efficient allocation of resources in health policy. The objective of our study was to systematically review CUA of CBT in the treatment of patients suffering from MDD.research blog (6)

Methods: We conducted a systematic literature search in Medline, Embase, PsycINFO and National Health Service Economic Evaluation Database (NHS EED) to identify CUA of CBT for MDD. Cost data were inflated to the year 2011 and converted into USD using purchasing power parities (USD PPP) to ensure comparability of the data. Quality assessment of CUA was performed.

Results: Twenty-two studies were included in this systematic review. No study employed a time horizon of more than 5 years. In most studies, individual and group CBT as well as CBT for maintenance showed acceptable incremental cost-utility ratios (<50,000 USD PPP/quality-adjusted life year). The CUA results of CBT for children and adolescents and of computerized CBT were inconsistent.

Discussion: We found consistent evidence that individualized CBT is cost-effective from the perspective of a third-party payer for short-term treatment and for relapse prevention of MDD in the adult population.

 

Brettschneider C., Djadran H. Härter M., Löwe B.Riedel-Heller S., & König H.H. (January 2015). Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review.  Psychotherapy and Psychosomatics (84), 1, 6-21.

Why Anxiety Persists

Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.

 

At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?

Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.

Rob Web

Robert Hindman, PhD

Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.

Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.”  Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”

Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking.  For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers.  For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.

Judith S. Beck, PhD

Judith S. Beck, PhD

Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).

Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.”  The problem with perfectionism is that it’s impossible to be perfect.  When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.

Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.

Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.

 

Learn more about the upcoming CBT for Anxiety workshop in Chicago. 

 

Perspectives of suicidal veterans on safety planning: Findings from a pilot study

Abstract

Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning.

Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement.research blog (5)

Results: The veterans’ experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed.

Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.

 

Kayman, J. D., Goldstein, F. G., Dixon, L., & Goodman, M. (October 27, 2015). Perspectives of suicidal verterans on safety planning: Findings from a pilot study. The Journal of Crisis Intervention and Suicide Prevention, 36, 371-383.

Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents A Randomized Clinical Trial

Importance

Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.

 

research blog (3)

Objective

To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.

 

Design, Setting, and Participants

A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.

 

Interventions

The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.

 

Main Outcomes and Measures

The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.

 

Results

Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.

 

Conclusions and Relevance

The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.

 

Brent, D. A., Brunwasser, S. M., Hollon, S. D., Weersing, V. R., Clarke, G. N., Dickerson, J. F., Beardslee, W. R., … Garber, J. (January 01, 2015). Effect of a cognitive-cehavioral prevention program on depression 6 years after implementation among at-risk adolescents: A randomized clinical trial. Jama Psychiatry, 72, 11, 1110-8.

Amy Buckley – Workshop Participant Spotlight

Traveling from Burlington, Vermont, Amy is a clinical social worker in a private practice where she treats anxiety and depression in college students and young professionals. A BuckleyThe transition into college and navigating the independence and responsibility of adulthood can be daunting, and she uses CBT and mindfulness to improve the lives of her clients.

She attended our recent CBT for Anxiety: Core 2 workshop in Philadelphia and learned practical strategies for treating clients with anxiety. All the knowledge from this workshop hasn’t sunken in yet, so she is looking forward to “go home and study” the enormous amount of information Dr. Amy Wenzel presented during the workshop. Learning about the worry script and using exposures are the main take-aways for Amy. Her favorite part? Meeting with Dr. Judith Beck and having the opportunity to Skype with Dr. Aaron Beck were her favorite parts of the experience.

CBT and Mindfulness for Depression

Rob Webby Robert Hindman, PhD

Clinical Psychologist at Beck Institute

 

Mindfulness-based interventions have been becoming more popular in psychotherapy. One such treatment, Mindfulness-Based Cognitive Therapy (MBCT), has specifically been developed to prevent relapse in clients who have experienced recurrent major depressive episodes (Segal, Williams, & Teasdale, 2001).  We have incorporated mindfulness strategies into our work at the Beck Institute. Instead of thinking about mindfulness-based interventions as separate treatments, however, we think about mindfulness as a potential strategy to use in a larger CBT framework.  I’ll review one common mindfulness technique we use with our non-suicidal depressed clients.

A body of research has demonstrated rumination to be an important factor in maintaining depression (e.g., Nolen-Hoeksema, 2000).  We view rumination as a strategy clients use to cope with depression.  For example, Mark, a client I recently treated, felt depressed, then ruminated to try to figure out why he felt depressed. His ruminative thoughts included, “Why do I feel so depressed? What’s wrong with me?  I just can’t do anything right, like I got a bad review at work.  My friends don’t try to call me either. . .”  I worked with this client to help him identify his beliefs about the rumination process instead of solely evaluating the content of each thought.

First I help clients identify, and then evaluate, beliefs about rumination. I start this way (instead of going straight into mindfulness) because clients tend to continue to use strategies that they view as helpful. I want them to recognize that rumination is doing them more harm than good.  One way to identify beliefs about rumination is to complete a cost-benefit analysis, eliciting from clients the advantages and disadvantages of rumination.  Instead of using the term “rumination,” I asked them what they call the strategy (e.g., “asking myself why,” “listing all of my problems,” “trying to think my way out of depression”).

Typical advantages include “It helps me figure out my problems;” “I can come up with solutions.” “I’ll be able to know what to do next time I feel depressed.”  Next we list the disadvantages, such as: “It makes me feel worse.” “Once I start, it’s hard to stop.”  Then we evaluate each advantage.  For instance, I asked Mark, “How often do you come up with a specific solution?” and “If ruminating helped you solve your problems, do you think they would be solved by now?”  Next we evaluate whether the advantages or disadvantages are stronger. Clients have effectively assessed their positive beliefs about rumination when they conclude that the disadvantages outweigh the advantages. A list of the advantages and disadvantages shows clients the consequences of rumination and acts a motivator to stop the unhelpful strategy.  (If the advantages are still stronger, you’ll need to either spend more time evaluating the advantages or add to the disadvantages.)

The next step is to teach clients how to use mindfulness as a strategy to disengage from rumination.  I record the mindfulness exercises (usually using clients’ cell phones) to make it easier for them to practice. Before I start, I guide clients through a rumination induction by having them close their eyes and actively think about a topic involved in their typical ruminations. I get them to simulate the process of ruminating in session so they can experience being able to disengage from the rumination process.  As I noted before, this strategy should not be used with actively suicidal clients because it can increase their depressed mood and sense of hopelessness.

Once clients have been ruminating for about 30 seconds, I ask for a rating of their depressed mood from 0-10, turn on the recording app on their phone (“voice memos” on iPhones or “voice recorder” on Androids), and begin guiding them through a mindfulness of the breath exercise that lasts for 5 minutes.  At 5 minutes, I get another mood rating, end the exercise, and ask them about the experience (e.g., “What did you notice?” “Were you able to let go of ruminative thoughts and refocus on breathing?” “What happened to your mood over time?”)  The vast majority of clients learn that it’s possible to disengage from rumination, and that by not actively ruminating, their mood gradually improves.  I make sure to emphasize that mindfulness is not for the purpose of making them feel better or suppressing thoughts but is a strategy to help them relate to their thoughts in a different manner.  Their action plan then consists of listening to the recording every day (preferably at the beginning of the day to serve as a reminder to use mindfulness throughout the day) and to use mindfulness by letting go of thoughts and refocusing on the breath with their eyes open whenever they notice themselves ruminating during the day.

 

Dr. Hindman will be teaching mindfulness exercises as part of the CBT for Depression – Core 1 workshop at Beck Institute in March and the CBT for Anxiety workshop in Chicago in April.

 

References

Nolen-Hoeksema, S. (2000).  The role of rumination in depressive disorders and mixed anxiety/depressive symptoms.  Journal of Abnormal Psychology, 109, 504-511.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001).  Mindfulness-Based Cognitive Therapy for depression.  New York: Guilford Press.

School-based cognitive behavioral therapy: Current status and alternative approaches

Congratulations to Torrey (and team) on her recent publication in Current Psychiatry Reviews!

Abstract

Cognitive Behavioral Therapy (CBT) is among the most studied EBPs with support for its efficacy across a range of presenting problems in youth, but broad uptake of traditional CBT in school-based settings has been slow. A review of CBT in schools is presented, which suggests that most school-based studies have examined the use of a protocol for a single research blog (4)disorder or presenting problem, delivered by an individual provider (e.g., teacher, counselor). Evidence supports the effectiveness of these interventions for targeted problems, but limitations of these practices may present barriers to broader implementation of CBT. A review of alternative strategies is then presented, which suggests an approach that may flexibly meet the needs of a broader range of students, capitalize on the unique characteristics of a school setting, and emphasize principles of resilience. Finally, the University of Pennsylvania Beck Community Initiative is presented to illustrate an integrated approach to CBT within schools that is case conceptualization-driven, milieu-focused, and resilience-oriented to apply these strategies in a school setting.

 

Learn more about the upcoming workshop CBT for Children and Adolescents, taught by Dr. Torrey Creed. 

 

Creed, A. T., Waltman, H. S., Frankel A. S. & Williston, A. M. School-based cognitive behavioral therapy: Current status and alternative approachesCurrent Psychiatry Reviews, 11. 

CBT for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial

Abstract

Numerous studies have demonstrated comorbidity between migraine and tension-type headache on the one hand, and depression on the other. Presence of depression is a negative prognostic indicator for behavioral treatment of headaches. Despite the recognised comorbidity, there is a limited research literature evaluating interventions designed for comorbid headaches and depression. research blog (2)Sixty six participants (49 female, 17 male) suffering from migraine and/or tension-type headache and major depressive disorder were randomly allocated to a Routine Primary Care control group or a Cognitive Behavior Therapy group that also received routine primary care. The treatment program involved 12 weekly 50-min sessions administered by clinical psychologists. Participants in the treatment group improved significantly more than participants in the control group from pre-to post-treatment on measures of headaches, depression, anxiety, and quality of life. Improvements achieved with treatment were maintained at four month follow-up. Comorbid anxiety disorders were not a predictor of response to treatment, and the only significant predictor was gender (men improved more than women). The new integrated treatment program appears promising and worthy of further investigation.

 

Martin, P. R., Aiello, R., Gilson, K., Meadows, G., Milgrom, J., & Reece, J. (January 01, 2015). Cognitive behavior therapy for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial. Behaviour Research and Therapy, 73, 8-18.