Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive-behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness - Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression. Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods. Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold. Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

The effectiveness of an inpatient group cognitive behavioral therapy program for alcohol dependence

The present study evaluated the effectiveness of attendance at a clinically based, short-term, in-patient group CBT program largely based on Monti, Abrams, Kadden, and Cooney(1) to treat problem drinking. Participants were 37 males and 34 females diagnosed with alcohol dependence. Patients attended 42 CBT sessions over three weeks, with each session being one hour in duration. Measures included the Khavari Alcohol Test (KAT), the Short Alcohol Dependence Data Questionnaire (SADD), the Beck Anxiety Index (BAI), the Symptom Checklist-90-Revised (SCL-90), a General Self-Efficacy scale (GSE), and the Drinking Expectancy Profile (DEP). Group attendance rates were monitored daily. Two structured phone calls were conducted at one month and three months post-discharge. Results showed that attendance rates at CBT group sessions were not associated with improvements found at the end of therapy or in drinking behaviors at three-month follow-up. Full support could not be found for the effectiveness of group CBT and cognitive models of problem drinking.

The feasibility and outcome of clinic plus Internet delivery of cognitive-behavior therapy for childhood anxiety

Seventy-two clinically anxious children, aged 7 to 14 years, were randomly allocated to clinic-based, cognitive-behavior therapy, the same treatment partially delivered Via the Internet. or a wait-list control (WL). Children in the clinic and clinic-plus-Internet conditions showed significantly greater reductions in anxiety from pre- to posttreatment and were more likely to be free of their anxiety diagnoses, compared with the WL group. Improvements were maintained at 12-month follow-up for both therapy conditions', with minimal difference in outcomes between interventions. The Internet treatment content was highly acceptable to families, with minimal dropout and a high level of therapy compliance.

Combined acamprosate and naltrexone, with cognitive behavioural therapy is superior to either medication alone for alcohol abstinence: A single centres' experience with pharmacotherapy

Aims: To compare treatment outcomes amongst patients offered pharmacotherapy with either naltrexone or acamprosate used singly or in combination, in a 12-week outpatient cognitive behavioural therapy (CBT) programme for alcohol dependence. Methods: We matched 236 patients across gender, age group, prior alcohol detoxification, and dependence severity and conducted a cohort comparison study of three medication groups (CBT+acamprosate, CBT+naltrexone, CBT+combined medication) which included 59 patients per group. Outcome measures included programme attendance, programme abstinence and for those who relapsed, cumulative abstinence duration (CAD) and days to first breach (DFB). Secondary analyses compared the remaining matched 59 subjects who declined medication with the pharmacotherapy groups. Results: Across medication groups, CBT+ combined medication produced the greatest improvement across all outcome measures. Although a trend favoured the CBT+ combined group, differences did not reach statistical significance. Programme attendance: CBT + Acamprosate group (66.1%), CBT + Naltrexone group (79.7%), and in the CBT + Combined group (83.1%). Abstinence rates were 50.8, 66.1, and 67.8%, respectively. For those that did not complete the programme abstinent, the average number of days abstinent (CAD) were 45.07, 49.95, and 53.58 days, respectively. The average numbers of days to first breach (DFB) was 26.79, 26.7, and 37.32 days. When the focal group (CBT + combined) was compared with patients who declined medication (CBT-alone), significant differences were observed across all outcome indices. Withdrawal due to adverse medication effects was minimal. Conclusions: The addition of both medications (naltrexone and acamprosate) resulted in measurable benefit and was well tolerated. In this patient population naltrexone with CBT is as effective as combined medication with CBT, but the trend favours combination medication.

Improvement in measures of psychological distress amongst amphetamine misusers treated with brief cognitive-behavioural therapy (CBT)

This trial of cognitive-behavioural therapy (CBT) based amphetamine abstinence program (n = 507) focused on refusal self-efficacy, improved coping, improved problem solving and planning for relapse prevention. Measures included the Severity of Dependence Scale (SDS), the General Health Questionnaire-28 (GHQ-28) and Amphetamine Refusal Self-Efficacy. Psychiatric case identification (caseness) across the four GHQ-28 sub-scales was compared with Australian normative data. Almost 90% were amphetamine-dependent (SDS 8.15 +/- 3.17). Pretreatment, all GHQ-28 sub-scale measures were below reported Australian population values. Caseness was substantially higher than Australian normative values {Somatic Symptoms (52.3%), Anxiety (68%), Social Dysfunction (46.5%) and Depression (33.7%). One hundred and sixty-eight subjects (33%) completed and reported program abstinence. Program completers reported improvement across all GHQ-28 sub-scales Somatic Symptoms (p < 0.001), Anxiety (p < 0.001), Social Dysfunction (p < 0.001) and Depression (p < 0.001)}. They also reported improvement in amphetamine refusal self-efficacy (p < 0.001). Improvement remained significant following intention-to-treat analyses, imputing baseline data for subjects that withdrew from the program. The GHQ-28 sub-scales, Amphetamine Refusal Self-Efficacy Questionnaire and the SDS successfully predicted treatment compliance through a discriminant analysis function (p

Psychotherapy and social change:utilizing principles of cognitive-behavioral therapy to help develop new prejudice-reduction interventions

We propose that key concepts from clinical psychotherapy can inform science-based initiatives aimed at building tolerance and community cohesion. Commonalities in social and clinical psychology are identified regarding (1) distorted thinking (intergroup bias and cognitive bias), (2) stress and coping (at intergroup level and intrapersonal level), and (3) anxiety (intergroup anxiety and pathological anxiety). On this basis we introduce a new cognitive-behavioral model of social change. Mental imagery is the conceptual point of synthesis, and anxiety is at the core, through which new treatment-based approaches to reducing prejudice can be developed. More generally, we argue that this integration is illustrative of broader potential for cross-disciplinary integration in the social and clinical sciences, and has the potential to open up new possibilities and opportunities for both disciplines.

Family and group cognitive behavior therapy: Evaluation of treatment outcome and treatment specificity

This dissertation examined the efficacy of family cognitive behavior treatment (FCBT) and group cognitive behavior treatment (GBCT) for reducing anxiety disorders in children and adolescents using several approaches: clinical significant change, equivalence testing, and analyses of variance. It also examined treatment specificity in terms of targeting family/parents (in FCBT) and peers/group (in GCBT) contextual variables using two main approaches: analyses of variance and structural equation modeling (SEM). The sample consisted of 143 children and their parents who presented to the Child Anxiety and Phobia Program housed within the Child and Family Psychosocial Research Center at Florida International University. Diagnostic interviews and questionnaires were administered to assess youth anxiety. Questionnaires were administered to assess child and parent views of family/parents and peers/group contextual variables. In terms of clinical significant change, results indicated that 84.6% of youth in FCBT and 71.2% of youth in GBCT no longer met diagnostic criteria for their primary/targeted anxiety disorder. In addition, results from analyses of variance indicated that FCBT and GCBT were both efficacious in reducing anxiety disorders in youth across both child and parent ratings. Results using both analyses of variance and structural equation modeling also indicated that there was no meaningful treatment specificity between FCBT and GCBT in terms of either family/parents or peers/group contextual variables. That is, child social skills improved in GCBT in which these skills were targeted and in FCBT in which these skills were not targeted; parenting skills improved in FCBT in which these skills were targeted and in GCBT in which these skills were not targeted. Clinical implications and future research recommendations are discussed.

Group cognitive -behavioral therapy for heterogeneous anxiety disorders in children and adolescents: A multiple baseline study

This study investigated the efficacy of Group Cognitive-Behavioral Therapy (GCBT) in the treatment of heterogeneous anxiety disorders in children. A partially nonconcurrent multiple baseline across groups design was used to assess the effects of the treatment on 12 clinically referred children and adolescents between 6 and 16 years of age who met DSM-IV criteria for an anxiety disorder. Targeted diagnoses included Obsessive Compulsive Disorder, Simple Phobia, Separation Anxiety Disorder, Social Phobia, and Generalized Anxiety Disorder, with three of the children also presenting with school refusal behavior. Duration of baseline for each of the three groups varied and ran for one, two, or three weeks. Dependent measures included diagnostic status, child and parent-completed reports, and daily child and parent ratings of child anxiety severity. Results indicated that GCBT was efficacious in reducing anxious symptoms in children and adolescents treated in diagnostically heterogeneous groups, and that gains were generally maintained at 6 and 12 month follow-ups. Findings are discussed in terms of their theoretical and practical implications for the efficient treatment of children and adolescents with anxiety disorders. ^

Cognitive behavior therapy for anxiety disorders in youth: Treatment specificity and mediation effects

The present study investigated the efficacies of Individual CBT (ICBT), Parent Relationship Skill Training (RLST, which targets increasing parental acceptance of youth and increasing autonomy granting) and Parent Reinforcement Skills Training (RLST, which targets increasing parental positive reinforcement and decreasing negative reinforcement). The specific aims were to examine treatment specificity and mediation effects of parenting variables. ICBT was used as a baseline comparison condition. The sample consisted of 253 youth (ages 5-16 years; M = 9.38; SD = 2.42) and their parents. To examine treatment outcome and specificity, the data were analyzed using analysis of variance within a structural equation modeling framework. Mediation was analyzed via structural equation modeling using MPlus. Results indicated that ICBT, RLST, and RFST produced positive treatment outcomes across all indices of change (i.e., clinically significant improvement, anxiety symptom reduction) and across all informants (i.e., youths and parents). RLST was associated with incremental reduction in youth anxiety symptoms beyond ICBT, as per youth report. Treatment specificity effects were found for participants in RFST in terms of parental reinforcement, as per parent report only. Treatment mediation was not found for any of the hypothesized parenting variables (i.e., parental acceptance, parental autonomy granting, parental reinforcement). The results support the use of CBT involving only the youth and the parent and youth together for treating youth anxiety. The findings’ implications are further discussed in terms of the need to conduct further meditational treatment outcome designs in order to continue to advance theory and research in youth anxiety treatment.

A Cognitive Behavioural Therapy approach to Suicide Assessment and Intervention

An evaluation of training delivered to undergraduate nursing students on the therapeutic benefits and efficacy of the application of a basic CBT model and the use of simple CBT techniques for the assessment and intervention of service users with suicidal intent.

Multicomponent cognitive-behavioral therapy for intermittent explosive disorder by videoconferencing: a case study

Cognitive-behavioral Therapy (CBT) for the treatment of Intermittent Explosive Disorder (IED) has proved to be effective, with moderate to large effect sizes both in individual and group interventions. Videoconferencing has been used effectively to treat different mental disorders but its use for IED patients is as yet unknown. The aim of this study is to provide preliminary evidence of the possibility of treating IED by videoconference. We present a case-study experiment of a Spanish male, aged 33 years, living and working in China. After the intervention, the patient's aggressive episodes decreased dramatically, as well as his negative affect. In contrast, he showed an important increment in positive emotions and self-esteem. There were also positive changes in some personality dimensions and facets measured by NEO-PI-R, specifically in neuroticism, extraversion, and agreeableness. The benefits were maintained at 3-, 8- and 18-month follow-ups. These preliminary results reveal that CBT by videoconference oriented to increasing emotion regulation skills was effective when implemented in a case study of a person suffering from IED.

Short-term cognitive-behavioural group treatment for hoarding disorder: a naturalistic treatment outcome study

The study aim was to test whether a 12-week publically rebated group programme, based upon Steketee and Frost's Cognitive Behavioural Therapy-based hoarding treatment, would be efficacious in a community-based setting. Over a 3-year period, 77 participants with clinically significant hoarding were recruited into 12 group programmes. All completed treatment; however, as this was a community-based naturalistic study, only 41 completed the post-treatment assessment. Treatment included psychoeducation about hoarding, skills training for organization and decision making, direct in-session exposure to sorting and discarding, and cognitive and behavioural techniques to support out-of-session sorting and discarding, and nonacquiring. Self-report measures used to assess treatment effect were the Savings Inventory-Revised (SI-R), Savings Cognition Inventory, and the Depression, Anxiety and Stress Scales. Pre-post analyses indicated that after 12 weeks of treatment, hoarding symptoms as measured on the SI-R had reduced significantly, with large effect sizes reported in total and across all subscales. Moderate effect sizes were also reported for hoarding-related beliefs (emotional attachment and responsibility) and depressive symptoms. Of the 41 participants who completed post-treatment questionnaires, 14 (34%) were conservatively calculated to have clinically significant change, which is considerable given the brevity of the programme judged against the typical length of the disorder. The main limitation of the study was the moderate assessment completion rate, given its naturalistic setting. This study demonstrated that a 12-week group treatment for hoarding disorders was effective in reducing hoarding and depressive symptoms in an Australian clinical cohort and provides evidence for use of this treatment approach in a community setting. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: A 12-week group programme delivered in a community setting was effective for helping with hoarding symptoms with a large effect size. Hoarding beliefs (emotional attachment and responsibility) and depression were reduced, with moderate effect sizes. A third of all participants who completed post-treatment questionnaires experienced clinically significant change. Suggests that hoarding CBT treatment can be effectively translated into real-world settings and into a brief 12-session format, albeit the study had a moderate assessment completion rate.

A preliminary, qualitative exploration of the influences associated with drop-out from cognitive-behavioural therapy for problem gambling : an Australian perspective

It has been estimated that 80% of Australians engage in some form of gambling, with approximately 115,000 Australians experiencing severe problems (Productivity Commission 2010). Very few people with problem gambling seek help and, of those who do, large numbers drop-out of therapy before completing their program. To gain insights into these problems, participants who had either completed or withdrawn prematurely from an individual CBT-based problem gambling treatment program were interviewed to examine factors predictive of premature withdrawal from therapy as well as people's 'readiness' for change. The results indicated that there might be some early indicators of risk for early withdrawal. These included: gambling for pleasure or social interaction; non-compliance with homework tasks; gambling as a strategy to avoid personal issues or dysphoric mood; high levels of guilt and shame; and a lack of readiness for change. The study further showed that application of the term 'drop-out' to some clients may be an unnecessarily negative label in that a number appear to have been able to reduce their gambling urges even after a short exposure to therapy.

Two-group randomised, parallel trial of cognitive and exposure therapies for problem gambling: a research protocol

BACKGROUND: Problem gambling is a serious public health concern at an international level where population prevalence rates average 2% or more and occurs more frequently in younger populations. The most empirically established treatments until now are combinations of cognitive and behavioural techniques labelled cognitive behaviour therapy (CBT). However, there is a paucity of high quality evidence for the comparative efficacy of core CBT interventions in treating problem gamblers. This study aims to isolate and compare cognitive and behavioural (exposure-based) techniques to determine their relative efficacy.

METHODS: A sample of 130 treatment-seeking problem gamblers will be allocated to either cognitive or exposure therapy in a two-group randomised, parallel design. Repeated measures will be conducted at baseline, mid and end of treatment (12 sessions intervention period), and at 3, 6 and 12 months (maintenance effects). The primary outcome measure is improvement in problem gambling severity symptoms using the Victorian Gambling Screen (VGS) harm to self-subscale. VGS measures gambling severity on an extensive continuum, thereby enhancing sensitivity to change within and between individuals over time.

DISCUSSION: This article describes the research methods, treatments and outcome measures used to evaluate gambling behaviours, problems caused by gambling and mechanisms of change. This study will be the first randomised, parallel trial to compare cognitive and exposure therapies in this population.

ETHICS AND DISSEMINATION: The study was approved by the Southern Adelaide Health Service/Flinders University Human Research Ethics Committee. Study findings will be disseminated through peer-reviewed publications and conference presentations.