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Role of therapist competence in CBT for Depression

The role of therapist competence in cognitive behavioral therapy (CBT) outcomes was the subject of a naturalistic process-outcome study conducted at the Center for Cognitive Therapy, an outpatient clinic at the University of Pennsylvania. Sixty-nine clients presenting with depression, some with comorbid presenting problems, were treated by one of eighteen CBT therapists at the Center. Therapist competence was measured by clients and experts. The findings, published in Psychotherapy and Psychosomatics, were that more competent therapists achieved better outcomes with depression patients, regardless of degree of morbidity. The clinical implication of this finding is that “initial selection of therapists will enhance treatment outcomes,” and this contradicts the idea that more competent therapists should focus on more complex cases.

Study authors: W. Kuyken, D. Tsivrikos

Centers for Disease Control panel recommends CBT for Depression in older adults

A recent review in Preventing Chronic Disease reported that about 5% to 15% of community-dwelling older adults (60+ y.o.) suffer from depression, which results in functional impairment and is possibly associated with increased mortality rates through suicide and complications of cardiac disease. As such, it is increasingly recognized as a significant public health problem in that population.

To address this problem, a panel was convened by the National Center for Chronic Disease Prevention and Health Promotion, one of eight centers within the Centers for Disease Control and Prevention. After systematically reviewing 97 studies, “the researcher-practitioner expert panel strongly recommended interventions based on the depression care management (DCM) model and recommended cognitive behavioral therapy (CBT) as treatment for depression in older adults.”

The report discussed strategies to implement its recommendations. It noted that many CBT practitioners work in specialty mental health settings and are not in contact with primary care or community-based programs for older adults. A further obstacle is that many older adults are reluctant to go to mental health specialists.

The panel concluded that partnerships among researchers, health care providers, and policy makers will be necessary to overcome the obstacles to the treatment of depression in older adults.

Study authors: M. Snowden, L. Steinman, J. Frederick

Adolescents with SSRI-resistant Depression show improved response to treatment that includes CBT

A new study in JAMA reported that approximately 60% of depressed adolescents respond adequately to initial treatments with a selective serotonin reuptake inhibitor (SSRI), but there is a lack of information about subsequent treatment strategies. Four treatment strategies were employed in this study including medication-switching alone (to a different SSRI or to venlafaxine) and medication-switching plus cognitive behavioral therapy (CBT). CBT in this study emphasized cognitive restructuring, behavioral activation, emotion regulation, social skills, and problem solving. Additionally, parent-child sessions emphasized decreasing criticism and improving support, family communication, and problem solving. The authors found that CBT plus a switch to either medication regimen showed a higher response rate than a medication-switch alone (and that there was no difference in response rate between venlafaxine and a second SSRI).

Study authors: D. Brent, G. Emslie, G. Clarke, K. D. Wagner, J. R. Asarnow, M. Keller, et al.

Internet-based CBT helps service members with post-traumatic stress

A recent study in the American Journal of Psychiatry reviews therapist-assisted, Internet-based, self-management cognitive behavior therapy (CBT) for service members with post-traumatic stress disorder (PTSD). This protocol was compared with Internet-based supportive counseling for PTSD. Both groups used websites, homework assignments, and educational information concerning PTSD. The authors found that the CBT protocol led to “sharper declines in daily log-on ratings of PTSD symptoms and global depression” in addition to other symptom reduction; these improvements were also noted at 6 months. The authors state that this protocol “may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care.”

Study authors: B. T. Litz, C. C. Engel, R. A. Bryant, A. Papa  

 

CBT reduces fear and restores function for patients after cardiac defibrillator implantation

A recent article in Current Psychiatry reviews the negative effects on quality of life for people who receive an implantable cardioverter defibrillator (ICD) for irregular heart rhythms. These effects are particularly severe after the first experience of a “shock”—or ICD discharge. Though life-saving, these high-energy electrical discharges (shocks) are typically painful, and many patients experience anxiety, anger, and a sense of helplessness.

After a shock, patients instinctively begin to analyze the events or behaviors leading to the shock—which are often routine and not truly associated with the discharge event—so that they can avoid or even eliminate them from their lives. The fear of another shock and the fear of anything that could precipitate one can result in a “fear of fear” cycle. Patients may then start limiting their lifestyles so dramatically that depression ensues.

The authors suggest that this scenario can be avoided by routine cognitive-behavioral assessments during follow-up visits after the ICD implantation. Ideally, treatment consists of a combination of medication, psychotherapy, and support. With CBT, patients are guided to see how their thoughts about the device might be erroneous. Daily logs of ICD-related thoughts and cognitive re-structuring are useful CBT strategies.

In an example referenced in this article, eight sessions of CBT, which included exposure therapy and relaxation training, allowed a patient to resume most of his activities, and had a beneficial effect on his personal relationships and quality of life.

Study authors: D. P. Gibson, K. K. Kuntz  

 

Adolescent Depression & Suicide Prevention: National Review of Cognitive Behavioral Therapy

A national review of treatments for depressed adolescents (ages 13-17), with special focus on preventing teen suicide, finds Cognitive Behavioral Therapy (CBT) to be highly effective. Age-appropriate adaptations of CBT yielded these key results: “CBT achieved a higher remission rate among youth (60%) than either systemic behavior family therapy (37.9%) or nondirective support therapy (39.4%).” Additionally, CBT yielded no adverse effects.

(The reporting agency is a program of the US Department of Health and Human Services Substance Abuse & Mental Health Services Administration.)

There’s nothing either good or bad, but thinking makes it so…

Does Shakespeare’s famous maxim apply to head injury?

According to a new study, the answer is yes.

Researchers recently looked at patients with mild head injuries (90% of head injuries in Western countries are classified as “mild”) to see whether perceptions of illness contributed to the development and severity of post-concusional syndrome (PCS). 73 patients with mild head injuries participated in the study. They were monitored for PCS symptoms, post-traumatic stress symptoms, perceptions of illness, depression and anxiety. Scales were completed at the time of injury, and at 3-month follow-up.

The results: patients who believed their injuries would have a serious effect on their quality of life were at greater risk for post-concusional symptoms.

What are the implications for treatment? As the article states: “Recognition of the maladaptive cognitions that contribute to poor outcome of the sort suggested by this study will be helpful in the development of effective cognitive-behavioral interventions.”

Maximizing daily satisfaction to help alleviate Depression

At a recent case conference, Dr. Aaron Beck met with a patient suffering from depression while graduate students watched the session via live video feed in another room. The patient expressed strong dissatisfaction with his job and career direction (even though he held an objectively desirable position). At the same time, the patient was depressed, and did not presently have enough initiative or belief in himself to alter his trajectory.

During the session, after hearing about the patient’s typical week and what was bothering him most, Dr. Beck began to focus on alleviating the most pressing current problem – depression. He asked, “if your job isn’t giving you satisfaction, what else could give you satisfaction?” Read more

Cognitive Restructuring Group

We recently received the following update from Kevin Benbow about the positive effects of teaching Cognitive Restructuring in a group format:

About six months ago I came up with the idea to create a group based on the premises of Greenberger and Padesky’s “Mind Over Mood.”  This was a pilot program, and the intention of the group was to solely teach the basics of cognitive restructuring to the participants.   This was done via handouts, movie clips, and a power point presentation. The group ran for 12 sessions and we systematically taught all participants to make the connection between situations, moods and automatic thoughts.  The BDI* and BAI* were administered prior to beginning group and were also administered at the last session.

It should be noted that in addition to the teaching of CR techniques these clients would also receive individual therapy as well as psychotropic medication if needed.

While I have seen the power and utility of CR before, I was pleasantly surprised to see how group dynamics can be used to reinforce the completion of homework and normalize symptoms of depression and anxiety.  Once the basic concepts were taught, we would complete thought records on the white board using actual stressors from the clients’ lives.  Read more

CBT for Smoking Cessation among Cancer Patients

Smoking, alcohol use and depression often co-exist at high rates among patients with head and neck cancer. Researchers recently designed a randomized, controlled study to see whether patients with head and neck cancer and at least one of the above traits improved with integrated Cognitive Behavior Therapy (CBT) that addressed all of the above factors.

184 patients were randomly assigned to either usual care or 9-11 CBT phone sessions plus optional medications over a period of six months. At the end of the trial, those in the CBT group had significantly improved their smoking cessation rate as compare to those in the usual care group (47% compared to 31%).

The study suggests that an integrated CBT approach, which treats smoking cessation, alcohol and depression simultaneously, may improve smoking cessation rates and provide a more practical means of addressing these co-morbid factors.