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Recent research: half a dozen studies on cognitive therapy

Here are half a dozen recent studies involving cognitive therapy (CBT).  The first by Craigie et al explores the use of mindfulness-based cognitive therapy (MBCT) to treat generalized anxiety disorder (GAD).  Although, as one would expect, MBCT helped GAD sufferers, it was noteworthy that results "fall well short of outcomes achieved by past research".  This adds to my concern that mindfulness training may at times be being over-hyped - see a blog I wrote in September for for more on this.  The next study by Cuijpers et al also suggests limitations to the march of CBT with interpersonal psychotherapy looking a somewhat better candidate for prevention of depression onset.  I guess one could argue that CBT can - and probably more often should - include  behavioural interventions to promote improved relationships.  Click here for tools that can help this approach.   The third piece of research by Grey et al is exciting.  It challenges the Alice in Wonderland dodo bird suggestion that "everyone has won, and all must have prizes" - that all reasonable approaches to psychotherapy end up producing similar results.  I actually think there is some accuracy in this view, but this Grey et al paper strongly suggests that sometimes particular therapy approaches produce better results than others (in this case CBT for panic disorder).  These outcomes agree with a similar point made by Chambless et al last year.  The fourth and fifth articles I have listed are both about a topic of considerable relevance to CBT therapists working with anxiety disorders - how much to allow or discourage "safety behaviours".  In this case it seems Oscar Wilde was right when he said "The truth is rarely pure and never simple".  The last study by Seivewright et al shows useful benefits from using CBT for patients in a genitourinary clinic.  As with GAD, my sense of the field is that a cognitive approach still has a way to go before it can claim to be the obvious candidate to treat health anxiety - see the recent Cochrane review on this.  So overall, here we have six studies demonstrating both one of the major strengths of CBT (its ongoingly active research underpinning) and a caution (at times CBT approaches are not automatically the best way to go).

Craigie, M. A., C. S. Rees, et al. (2008). "Mindfulness-based Cognitive Therapy for Generalized Anxiety Disorder: A Preliminary Evaluation." Behavioural and Cognitive Psychotherapy 36(05): 553-568.  [Abstract/Full Text]
Mindfulness training has been proposed as a potentially important new approach for the treatment of generalized anxiety disorder (GAD). However, to date only a few studies have investigated mindfulness training for GAD. The aim of this study was to further investigate symptom change and recovery in pathological worry after mindfulness-based cognitive therapy (MBCT) using an uncontrolled pre-post design. Twenty-three adults with a primary diagnosis of GAD participated in the study. The MBCT program involved 9 weekly 2-hour group sessions, a post-treatment assessment session, and 6-week and 3-month follow-up sessions. Intent-to-treat analysis revealed significant improvements in pathological worry, stress, quality of life, and a number of other symptoms at post-treatment, which were maintained at follow-up. Attrition was also low, and MBCT was perceived as a credible and acceptable intervention. However, when applying standardized recovery criteria to pathological worry scores, the rate of recovery at post-treatment was very small, although improved at follow-up. Overall, the findings suggest MBCT is definitely worthy of further investigation as a treatment option for GAD, but falls well short of outcomes achieved by past research. Possible reasons for the poor rate of recovery, implications, and limitations are briefly outlined.

Cuijpers, P., A. van Straten, et al. (2008). "Preventing the Onset of Depressive Disorders: A Meta-Analytic Review of Psychological Interventions." Am J Psychiatry 165(10): 1272-1280.  [Abstract/Full Text]
OBJECTIVE: A growing number of studies have tested the efficacy of preventive interventions in reducing the incidence of depressive disorders. Until now, no meta-analysis has integrated the results of these studies. METHOD: The authors conducted a meta-analysis. After a comprehensive literature search, 19 studies were identified that met inclusion criteria. The studies had to be randomized controlled studies in which the incidence of depressive disorders (based on diagnostic criteria) in an experimental group could be compared with that of a control group. RESULTS: The mean incidence rate ratio was 0.78, indicating a reduction of the incidence of depressive disorders by 22% in experimental compared with control groups. Heterogeneity was low to moderate (I2=33%). The number needed to treat to prevent one case of depressive disorder was 22. Moderator analyses revealed no systematic differences between target populations or types of prevention (universal, selective, or indicated). The data included indications that prevention based on interpersonal psychotherapy may be more effective than prevention based on cognitive-behavioral therapy. CONCLUSIONS: Prevention of new cases of depressive disorders does seem to be possible. Prevention may become an important way, in addition to treatment, to reduce the enormous public health burden of depression in the coming years.

Grey, N., P. Salkovskis, et al. (2008). "Dissemination of Cognitive Therapy for Panic Disorder in Primary Care." Behavioural and Cognitive Psychotherapy 36(05): 509-520.  [Abstract/Full Text]
This study investigated whether brief training in cognitive therapy for panic disorder (Clark et al., 1994) can improve the outcomes that primary care therapists obtain with their patients. Seven primary care therapists treated 36 patients meeting DSM-IV (APA, 1994) criteria for panic disorder with or without agoraphobia in general practice surgeries. Outcomes for the cohort of patients whom the therapists treated with their usual methods (treatment-as-usual) before the training (N = 12) were compared with those obtained with similar patients treated by the same therapists after brief training and ongoing supervision in cognitive therapy (CT) for panic disorder (N = 24). Treatment-as-usual led to significant improvements in panic severity, general anxiety, and depression. However, only a small proportion (17% of the intent-to-treat sample) became panic free and there was no improvement in agoraphobic avoidance. Patients treated with CT achieved significantly better outcomes on all measures of panic attacks, including panic-free rate (54%, intent-to-treat), and showed significantly greater improvements in agoraphobic avoidance and patient-rated general anxiety. In conclusion, cognitive therapy for panic disorder can be successfully disseminated in primary care with a brief therapist training and supervision programme that leads to significant improvements in patient outcomes.

Milosevic, I. and A. S. Radomsky (2008). "Safety behaviour does not necessarily interfere with exposure therapy." Behav Res Ther 46(10): 1111-8.  [PubMed]
There has been much recent controversy regarding whether or not the use of safety and other neutralizing behaviour interferes with exposure-based therapy. The aim of this study was to examine the role of safety behaviour in the treatment of specific phobia. Sixty-two snake-fearful participants were randomized to a 45-min exposure session with or without the use of safety gear, such as gloves and goggles. During the treatment, participants in the safety behaviour group were able to achieve a significantly closer initial distance of approach to the snake compared to controls. When tested post-treatment without any safety gear, both groups demonstrated comparable treatment gains involving significant reductions in fearful cognitions and subjective anxiety, as well as significant improvements in distance of approach. Results suggest that reliance on safety behaviour during exposure therapy for anxiety disorders may not interfere with treatment outcome.

Parrish, C. L., A. S. Radomsky, et al. (2008). "Anxiety-control strategies: Is there room for neutralization in successful exposure treatment?" Clin Psychol Rev.  [PubMed]
Cognitive-behavioral theory suggests that anxiety-control strategies such as neutralization, distraction and various forms of safety behavior have the potential to diminish the effectiveness of and/or interfere with exposure treatment. Yet, it is common practice when treating individuals with anxiety disorders to employ various anxiety-control strategies as a means of assisting clients/patients with difficult exposure situations. Questions surrounding the issue of which anxiety-control strategies help vs. hinder exposure-based treatments (and under which circumstances) have been a topic of much investigation and continue to be a focus of theoretical debate. The present article reviews several key studies which collectively shed some light on this debate. The evidence suggests that clients' anxiety-control strategies may be less likely to become counter-productive when: (i) they promote increases in self-efficacy, (ii) they do not demand excessive attentional resources, (iii) they enable greater approach behavior and integration of corrective information (via 'disconfirmatory experiences'), and (iv) they do not promote misattributions of safety. Theoretical and clinical implications of these findings are discussed, and future directions for research in this area are suggested.

Seivewright, H., J. Green, et al. (2008). "Cognitive-behavioural therapy for health anxiety in a genitourinary medicine clinic: randomised controlled trial." The British Journal of Psychiatry 193(4): 332-337.  [Abstract/Full Text
Background Little is known about the management of health anxiety and hypochondriasis in secondary care settings. Aims To determine whether cognitive-behavioural therapy (CBT) along with a supplementary manual was effective in reducing symptoms and health consultations in patients with high health anxiety in a genitourinary medicine clinic. Method Patients with high health anxiety were randomly assigned to brief CBT and compared with a control group. Results Greater improvement was seen in Health Anxiety Inventory (HAI) scores (primary outcome) in patients treated with CBT (n=23) than in the control group (n=26) (P=0.001). Similar but less marked differences were found for secondary outcomes of generalised anxiety, depression and social function, and there were fewer health service consultations. The CBT intervention resulted in improvements in outcomes alongside higher costs, with an incremental cost of {pound}33 per unit reduction in HAI score. Conclusions Cognitive-behavioural therapy for health anxiety within a genitourinary medicine clinic is effective and suggests wider use of this intervention in medical settings.

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