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Recent research: 2 on frequency of psychological disorder, and 5 on using books, phones & computers to deliver CBT

Here are seven recent articles that caught my interest (abstracts & links are given further down the page).  The first two revisit the "How common is troublesome psychological distress?" question.  The title of Moffitt et al's paper is self-explanatory - "How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment".  They conclude "The experience of at least one episode of DSM-defined disorder during a lifetime may be far more common in the population than previously thought".  The sheer frequency & size of the problem of psychological suffering is further underlined by Rai et al's study of subsyndromal disorders (which wouldn't count towards Moffitt's lifetime prevalence rates).  They found that " ... subthreshold psychiatric symptoms at baseline were ... independently associated with new-onset functional disability and significant days lost from work at 18-month follow-up"

In this situation of huge need, it's very refreshing to realise that cognitive-behavioural therapy delivered via the internet is a high quality option that can be made much more widely available - see Andrews et al's "Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis".  In a further quoted study, Khanna & Kendall show that this kind of approach also works for children.  We know that, despite the technology attractions of computers, books can be just as helpful.  Nordin et al's study is therefore delightfully low-tech and interesting, showing that simply giving a deadline involving a follow-up review of reading material can make it much more useful.  Still in this area of expanding how we think about therapy delivery, Tutty et al show that CBT by telephone is an effective intervention.  And putting it all together van Straten et al, in their paper "Stepped care for depression in primary care: what should be offered and how?" describe the kind of logical sequence of treatment provision that is now becoming increasingly accepted, with face-to-face psychotherapy of various kinds being saved for those who do not respond adequately to less therapist-intensive interventions.

Moffitt, T. E., A. Caspi, et al. (2010). "How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment." Psychological Medicine 40(06): 899-909.  [Abstract/Full Text]           
Background: Most information about the lifetime prevalence of mental disorders comes from retrospective surveys, but how much these surveys have undercounted due to recall failure is unknown. We compared results from a prospective study with those from retrospective studies.  Method: The representative 1972-1973 Dunedin New Zealand birth cohort (n=1037) was followed to age 32 years with 96% retention, and compared to the national New Zealand Mental Health Survey (NZMHS) and two US National Comorbidity Surveys (NCS and NCS-R). Measures were research diagnoses of anxiety, depression, alcohol dependence and cannabis dependence from ages 18 to 32 years.  Results: The prevalence of lifetime disorder to age 32 was approximately doubled in prospective as compared to retrospective data for all four disorder types. Moreover, across disorders, prospective measurement yielded a mean past-year-to-lifetime ratio of 38% whereas retrospective measurement yielded higher mean past-year-to-lifetime ratios of 57% (NZMHS, NCS-R) and 65% (NCS).  Conclusions: Prospective longitudinal studies complement retrospective surveys by providing unique information about lifetime prevalence. The experience of at least one episode of DSM-defined disorder during a lifetime may be far more common in the population than previously thought. Research should ask what this means for etiological theory, construct validity of the DSM approach, public perception of stigma, estimates of the burden of disease and public health policy.

Rai, D., P. Skapinakis, et al. (2010). "Common mental disorders, subthreshold symptoms and disability: longitudinal study." The British Journal of Psychiatry 197(5): 411-412.  [Abstract/Full Text]          
In a representative sample of the UK population we found that common mental disorders (as a group and in ICD-10 diagnostic categories) and subthreshold psychiatric symptoms at baseline were both independently associated with new-onset functional disability and significant days lost from work at 18-month follow-up. Subthreshold symptoms contributed to almost half the aggregate burden of functional disability and over 32 million days lost from work in the year preceding the study. Leaving these symptoms unaccounted for in surveys may lead to gross underestimation of disability related to psychiatric morbidity.

Andrews, G., P. Cuijpers, et al. (2010). "Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis." PloS one 5(10): e13196.  [Free Full Text]          
BACKGROUND: Depression and anxiety disorders are common and treatable with cognitive behavior therapy (CBT), but access to this therapy is limited. OBJECTIVE: Review evidence that computerized CBT for the anxiety and depressive disorders is acceptable to patients and effective in the short and longer term. METHOD: Systematic reviews and data bases were searched for randomized controlled trials of computerized cognitive behavior therapy versus a treatment or control condition in people who met diagnostic criteria for major depression, panic disorder, social phobia or generalized anxiety disorder. Number randomized, superiority of treatment versus control (Hedges g) on primary outcome measure, risk of bias, length of follow up, patient adherence and satisfaction were extracted. PRINCIPAL FINDINGS: 22 studies of comparisons with a control group were identified. The mean effect size superiority was 0.88 (NNT 2.13), and the benefit was evident across all four disorders. Improvement from computerized CBT was maintained for a median of 26 weeks follow-up. Acceptability, as indicated by adherence and satisfaction, was good. Research probity was good and bias risk low. Effect sizes were non-significantly higher in comparisons with waitlist than with active treatment control conditions. Five studies comparing computerized CBT with traditional face-to-face CBT were identified, and both modes of treatment appeared equally beneficial. CONCLUSIONS: Computerized CBT for anxiety and depressive disorders, especially via the internet, has the capacity to provide effective acceptable and practical health care for those who might otherwise remain untreated.

Khanna, M. S. and P. C. Kendall (2010). "Computer-assisted cognitive behavioral therapy for child anxiety: results of a randomized clinical trial." Journal of Consulting and Clinical Psychology 78(5): 737-745.  [PubMed]          
OBJECTIVE: This study examined the feasibility, acceptability, and effects of Camp Cope-A-Lot (CCAL), a computer-assisted cognitive behavioral therapy (CBT) for anxiety in youth. METHOD: Children (49; 33 males) ages 7-13 (M = 10.1 +/- 1.6; 83.7% Caucasian, 14.2% African American, 2% Hispanic) with a principal anxiety disorder were randomly assigned to (a) CCAL, (b) individual CBT (ICBT), or (c) a computer-assisted education, support, and attention (CESA) condition. All therapists were from the community (school or counseling psychologists, clinical psychologist) or were PsyD or PhD trainees with no experience or training in CBT for child anxiety. Independent diagnostic interviews and self-report measures were completed at pre- and posttreatment and 3-month follow-up. RESULTS: At posttreatment, ICBT or CCAL children showed significantly better gains than CESA children; 70%, 81%, and 19%, respectively, no longer met criteria for their principal anxiety diagnosis. Gains were maintained at follow-up, with no significant differences between ICBT and CCAL. Parents and children rated all treatments acceptable, with CCAL and ICBT children rating higher satisfaction than CESA children. CONCLUSIONS: Findings support the feasibility, acceptability and beneficial effects of CCAL for anxious youth. Discussion considers the potential of computer-assisted treatments in the dissemination of empirically supported treatments.

Nordin, S., P. Carlbring, et al. (2010). "Expanding the Limits of Bibliotherapy for Panic Disorder: Randomized Trial of Self-Help Without Support but With a Clear Deadline." Behavior Therapy 41(3): 267-276.  [Abstract/Full Text]          
Cognitive behavioral bibliotherapy for panic disorder has been found to be less effective without therapist support. In this study, participants were randomized to either unassisted bibliotherapy (n = 20) with a scheduled follow-up telephone interview or to a waiting list control group (n = 19). Following a structured psychiatric interview, participants in the treatment group were sent a self-help book consisting of 10 chapters based on cognitive behavioral strategies for the treatment of panic disorder. No therapist contact of any kind was provided during the treatment phase, which lasted for 10 weeks. Results showed that the treatment group had, in comparison to the control group, improved on all outcome measures at posttreatment and at 3-month follow-up. The tentative conclusion drawn from these results is that pure bibliotherapy with a clear deadline can be effective for people suffering from panic disorder with or without agoraphobia.

Tutty, S., D. L. Spangler, et al. (2010). "Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults." Behavior Therapy 41(2): 229-236.   [Abstract/Full Text] 
Telephone psychotherapy is an emerging form of delivery of care that has recently demonstrated utility and efficacy for adult depression when provided as an adjunct to antidepressant treatment in primary care trials. This study constitutes one of the initial evaluations of cognitive behavioral therapy-telephone treatment (CBT-TT) as a stand-alone treatment for adult depression in specialty care. Thirty adults initiating psychotherapy for depression at a mental health clinic participated in the trial. The majority of participants (69%) were very satisfied with the 8-session CBT-TT, reduction in depression severity was significant over 3 and 6 months, and 42% of participants were considered recovered at termination. These outcomes closely parallel the findings from an earlier primary care trial, despite specialty care participants beginning treatment with more severe depression and without adjunctive antidepressant medication. These findings suggest that CBT-TT for adult depression is feasible and has potential as a stand-alone treatment. Implementation of this telephone-based delivery approach in primary and specialty care settings is discussed.

van Straten, A., W. Seekles, et al. (2010). "Stepped care for depression in primary care: what should be offered and how?" Medical Journal of Australia 192(11 Suppl): S36-39.  [PubMed]          
Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of "watchful waiting", as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.


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