A Randomized Pilot Study of CBT Anger Treatment for Iraq and Afghanistan Veterans

OBJECTIVE: Anger and aggression are serious problems for a significant proportion of veterans who have served in combat. While prior research has suggested that cognitive behavioral treatments may be effective for anger problems, there are few controlled studies of anger treatment in veterans and no studies of anger treatment focusing exclusively on veterans from the Iraq and Afghanistan wars. This randomized pilot study compared an adapted cognitive behavioral intervention (CBI) to a supportive intervention (SI) control condition for the treatment of anger problems in veterans returning from deployment in Iraq or Afghanistan.

METHODS: 25 veterans with warzone trauma, problems with anger, and one or more additional hyperarousal symptoms were randomized and 23 started treatment (CBI, n = 12; SI, n = 11). Outcome measures were administered at pre- and post- treatment and at 3 months post-treatment.

RESULTS: CBI was associated with significantly more improvement than SI on measures of anger and interpersonal functioning. Gains were maintained at follow-up.

CONCLUSIONS: Findings suggest that CBI may be more effective than an active control providing psychoeducation, relaxation, and supportive therapy for treating anger problems in returning veterans. The findings need to be replicated in an adequately powered and more diverse sample.

Shea, M. T., Lambert, J., & Reddy, M. K. (2013). A randomized pilot study of anger treatment for Iraq and Afghanistan veterans. Behaviour Research and Therapy, 51, 10, 607-13.

The Beck Scale for Suicide Ideation (BSS) is a useful tool designed to help clinicians detect and measure the severity of suicidal ideation. For more information on the BSS, visit www.beckscales.com.

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CBT improves Memory of Veterans Suffering from PTSD

Posttraumatic stress disorder (PTSD) is characterized by hyperarousal, flashbacks, avoidance, and memory dysfunctions. Although psychotherapy improves the clinical symptoms, its effect on memory has not been explored. In addition, there is no information about gene expression changes related to hippocampal functions. We assessed PTSD patients (n = 20) using the Wechsler Memory Scale-Revised (WAIS-R) and a paired associates learning (PAL) test, as well as changes in blood FK506 binding protein (FKBP5) mRNA expression before and after cognitive behavioral therapy (CBT). Results revealed that before CBT PTSD patients were impaired on WAIS-R delayed recall, attention/concentration, and PAL compared with trauma-exposed control subjects (n = 20). These memory dysfunctions showed a significant improvement after CBT. Better performance on the PAL test correlated with enhanced blood FKBP5 mRNA expression. These results suggest that elevated FKBP5 expression during CBT is related to improved associative memory linked to the hippocampal formation.

Szabó, C., Kelemen, O., & Kéri, S. (2014). Changes in FKBP5 expression and memory functions during cognitive–behavioral therapy in posttraumatic stress disorder: A preliminary study. Neuroscience Letters, 569, 116-120.

The Beck Scale for Suicide Ideation (BSS) is a useful tool designed to help clinicians detect and measure the severity of suicidal ideation. For more information on the BSS, visit www.beckscales.com.

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CBT Helps Patients with Rheumatoid Arthritis Cope with Pain

OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.

METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.

RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.

CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Lumley, M. A., Keefe, F. J., Mosley-Williams, A., Rice, J. R., McKee, D., Waters, S. J., Partridge, R. T., … Kalaj, A. (2014). The Effects of Written Emotional Disclosure and Coping Skills Training in Rheumatoid Arthritis: A Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, 82, 4, 644-658.

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CBT is shown to be Effective for Body Dysmorphic Disorder

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking).

Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n = 17) or to a 12-week waitlist (n = 19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory–II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ? 30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p = 0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d = 2.1, p < 0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD = 12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., Keshaviah, A., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45, 3, 314-327.

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Telephone-based CBT Improves PTSD Symptoms among Returning Veterans

Objectives: Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).

Methods: Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.

Results: Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.

Conclusions: A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.

Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (2014). RCT of a Brief Phone-Based CBT Intervention to Improve PTSD Treatment Utilization by Returning Service Members. Psychiatric Services (washington, D.c), 65, 10, 1232-7.

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CBT Treatment for Insomnia Improves Patient Outcomes while Reducing Healthcare Costs and Utilization

Study Objectives: To examine health care utilization (HCU) and costs following brief cognitive behavioral treatment for insomnia (bCBTi).

Methods: Reviewed medical records of 84 outpatients [mean age = 54.25 years (19.08); 58% women] treated in a behavioral sleep medicine clinic (2005-2010) based in an accredited sleep disorders center. Six indicators of HCU and costs were obtained: estimated total and outpatient costs, estimated primary care visits, CPT costs, number of office visits, and number of medications. All patients completed ? 1 session of bCBTi. Those who attended ? 3 sessions were considered completers (n = 37), and completers with significant sleep improvements were considered responders (n = 32).

Results: For completers and responders, all HCU and cost variables, except number of medications, significantly decreased (ps < 0.05) or trended towards decrease at post-treatment. Completers had average decreases in CPT costs of $200 and estimated total costs of $75. Responders had average decreases in CPT costs of $210. No significant decreases occurred for non-completers.

Conclusions: bCBTi can reduce HCU and costs. Response to bCBTi resulted in greater reduction of HCU and costs. While limited by small sample size and non-normal data distribution, the findings highlight the need for greater dissemination of bCBTi for several reasons: a high percentage of completers responded to treatment, as few as 3 sessions can result in significant improvements in insomnia severity, bCBTi can be delivered by novice clinicians, and health care costs can reduce following treatment. Insomnia remains an undertreated disorder, and brief behavioral treatments can help to increase access to care and reduce the burden of insomnia.

McCrae, C. S., Bramoweth, A. D., Williams, J., Roth, A., & Mosti, C. (2014). Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs. Journal of Clinical Sleep Medicine, 10, 2, 127-35.

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Dr. Aaron Beck Receives Changing Minds Award

Congratulations to Dr. Aaron Beck who received the Changing Minds Award at the Minding Your Mind Annual Blue Gene Gala, in Wyndmoor, Pennsylvania on October 19, 2014. Dr. Beck received this award for his lifetime achievement in psychiatry. During his acceptance speech, Dr. Beck discussed the influence of catastrophizing across all of the psychological disorders. He described how catastrophizing was adaptive in the wild, and that individuals with the “catastrophizing gene” were at the top of the evolutionary ladder. His message was to de-stigmatize mental illness and to show the positive aspects of some symptoms in an evolutionary sense.

Dr. Judith Beck, a featured speaker for this event, provided the Keynote address. Dr. Beck talked about ways to reduce stigma, first, by providing a rationale for labeling both mental illness and physical illness as just “illness. ” Second, she discussed how people with mental illness need help to de-stigmatize themselves by evaluating their self-critical thoughts, especially those that interfere with seeking treatment. Dr. Beck also talked about Cognitive Behavior Therapy and noted the overwhelming amount of research that demonstrates its effectiveness for a large number of problems. Dr. Beck described what a typical therapy session is like and how it leads to improvement. She concluded with why we should all have hope for people with mental illness—because good therapy can help them get better and stay better. Dr. Judith Beck was also presented with a plaque in recognition of her advances in the field.

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Internet-based, CBT Stress Management Workbook for Breast Cancer Patients

Cognitive behavioral stress management groups have been shown to be decrease psychological symptoms and increase adaptive coping in breast cancer patients, but dissemination of this effective intervention has been challenging. The goal of the present project was to develop an online cognitive behavioral stress management intervention for early stage breast cancer survivors and evaluate its effectiveness using a 2 group × 3 time randomized, waitlist-controlled design. Intervention and waitlist control group participants were assessed at three time points: at baseline; at 10 weeks, after which only intervention participants had used the workbook; and at 20 weeks, after which both groups had used the workbook. Results indicate that at 10 weeks intervention participants showed improved self-efficacy for coping with their cancer and for regulating negative mood and lower levels of cancer-related post-traumatic symptoms as compared to the control group, suggesting that an internet stress management intervention could be effective for helping breast cancer patients increase their confidence in their ability to cope with stress.

Carpenter, K. M., Stoner, S. A., Schmitz, K., McGregor, B. A., & Doorenbos, A. Z. (2014). An online stress management workbook for breast cancer. Journal of Behavioral Medicine, 37, 3, 458-468.

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Internet-Based Cognitive Behavior Therapy is Effective for Severe Health Anxiety

OBJECTIVE: A sudden gain is defined as a large and stable individual improvement occurring between two consecutive treatment sessions. Sudden gains have been shown to predict better long-term improvement in several treatment studies, including cognitive behavioural therapy for depression and anxiety disorders, but have not been studied in the treatment of health anxiety or any form of internet-based cognitive behavioural therapy. The aim of this study was to investigate the role of sudden gains in internet-based cognitive behavioural therapy for severe health anxiety.

METHOD: We examined the occurrence and significance of sudden gains in measures of health anxiety in 81 participants receiving internet-based cognitive behavioural therapy. We compared patients with sudden gains, patients without sudden gains, and patients with gradual gains.

RESULTS: Thirteen participants (16%) experienced one sudden gain in health anxiety with individual sudden gains distributed across the treatment. As expected, patients with a sudden gain showed larger improvements than patients without a sudden gain at post-treatment (d = 1.04) and at one-year follow-up (d = 0.91) on measures of health anxiety.

CONCLUSIONS: Consistent with previous studies, sudden gains in internet-based cognitive behavioural therapy are associated with significantly larger and stable treatment effects up to one-year follow-up.

Hedman, E., Lekander, M., Ljotsson, B., Lindefors, N., Ru?ck, C., Hofmann, S. G., Andersson, E., … Schulz, S. M. (January 01, 2014). Sudden gains in internet-based cognitive behaviour therapy for severe health anxiety. Behaviour Research and Therapy, 54, 22-9.

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Cognitive Therapy plus Medication is More Effective than Medication Alone in the Treatment of Depression

OBJECTIVE: To determine the effects of combining cognitive therapy (CT) with ADM vs ADM alone on remission and recovery in major depressive disorder (MDD).

METHOD: A total of 452 adult outpatients with chronic or recurrent MDD participated in a trial conducted in research clinics at 3 university medical centers in the United States. The patients were randomly assigned to ADM treatment alone or CT combined with ADM treatment. Treatment was continued for up to 42 months until recovery was achieved.

RESULTS: Combined treatment enhanced the rate of recovery vs treatment with ADM alone (72.6% vs 62.5%; t451?=?2.45; P?=?.01; hazard ratio [HR], 1.33; 95% CI, 1.06-1.68; number needed to treat [NNT], 10; 95% CI, 5-72). This effect was conditioned on interactions with severity (t451?=?1.97; P?=?.05; NNT,?5) and chronicity (?2?=?7.46; P?=?.02; NNT,?6) such that the advantage for combined treatment was limited to patients with severe, nonchronic MDD (81.3% vs 51.7%; n?=?146; t145 = 3.96; P?=?.001; HR, 2.34; 95% CI, 1.54-3.57; NNT, 3; 95% CI, 2-5). Fewer patients dropped out of combined treatment vs ADM treatment alone (18.9% vs 26.8%; t451?=?-2.04; P?=?.04; HR, 0.66; 95% CI, 0.45-0.98). Remission rates did not differ significantly either as a main effect of treatment or as an interaction with severity or chronicity. Patients with comorbid Axis II disorders took longer to recover than did patients without comorbid Axis II disorders regardless of the condition (P?=?.01). Patients who received combined treatment reported fewer serious adverse events than did patients who received ADMs alone (49 vs 71; P?=?.02), largely because they experienced less time in an MDD episode.

CONCLUSIONS: Cognitive therapy combined with ADM treatment enhances the rates of recovery from MDD relative to ADMs alone, with the effect limited to patients with severe, nonchronic depression.

Hollon S.D., DeRubeis R.J., Fawcett J., et al. Effect of Cognitive Therapy With Antidepressant Medications vs Antidepressants Alone on the Rate of Recovery in Major Depressive Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online August 20, 2014. doi:10.1001/jamapsychiatry.2014.1054.

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