Cognitive remediation therapy: Does it generalize to significant outcome areas?

Objective: Cognitive remediation therapy (CRT) approaches have demonstrated to be effective in improving cognitive functions in schizophrenia. However, there is a lack of integrated CR approaches that target multiple neuro- and social-cognitive domains with a special focus on the generalization of therapy effects to functional outcome and negative symptoms. Method: This 8-site randomized controlled trial evaluated the efficacy of a novel cognitive-behavioral group therapy approach called integrated neurocognitive therapy (INT). INT includes manual-based exercises to improve all neuro- and social-cognitive domains as defined by the Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative by compensation and restitution. One hundred and fifty-six outpatients with a diagnosis of schizophrenia or schizoaffective disorder accord- ing to DSM-IV-TR were randomly assigned to receive 15 weeks of INT or treatment as usual (TAU). INT patients received 30 bi-weekly therapy sessions. Each session lasted 90min. Mixed models were applied to assess changes in neurocognition, social cognition, symptoms, and functional outcome at post-treatment and at 9-month follow-up. Results: Compared to TAU, INT patients showed significant improvements on multiple neuro- and social-cognitive domains, negative symptoms, and functional outcome after therapy and at 9-month follow-up. Number-needed-to-treat analyses indicate that only five INT patients are necessary to produce durable and meaningful improvements in functional outcome. Conclusions: Integrated interventions on neurocognition and social cognition have the potential to improve not only cognitive performance but also functional outcome and negative symptoms. These findings are important as treatment guidelines for schizophrenia have criticized CRT for their poor generalization effects.

Differential effectiveness of integrated cognitive remediation therapy for schizophrenbia outpatients: The impact oft he duration of illness

Background Nowadays there is extensive evidence available showing the efficacy of cognitive remediation (CR). To date, only limited evidence is available about the impact of the duration of illness on CR effects. The Integrated Neurocognitive Therapy (INT) represents a new developed CR approach. It is a manualized group therapy targeting all 11 NIMH-MATRICS domains. Methods In an international multicenter study, 166 schizophrenia outpatients (DSM-IV-TR) were randomly assigned either to INT or to Treatment-As-Usual (TAU). 60 patients were defined as Early Course group (EC) characterized by less than 5 years of illness, 40 patients were in the Long-Term group (LT) characterized by more than 15 years of illness, and 76 patients were in the Medium-Long-Term group (MLT) characterized by an illness of 5-15 years. Treatment comprised of 15 biweekly sessions. Assessments were conducted before and after treatment and at follow up (1 year). Multivariate General Linear Models (GLM) examined our hypothesis, whether EC, LT, and MLT groups differ under INT and TAU from each other in outcome. Results First of all, the attendance rate of 65% was significantly lower and the drop out rate of 18.5% during therapy was higher in the EC group compared to the other groups. Interaction effects regarding proximal outcome showed that the duration of illness has a strong impact on neurocognitive functioning in speed of processing (F>2.4) and attention (F>2.8). But INT intervention compared to TAU only had a significant effect in more chronically ill patients of MLT and LT, but not in younger patients in EC. In social cognitive domains, only the EC group showed a significant change in attribution (hostility; F>2.5), LT and MLT groups did not. However, no differences between the 3 groups were evident in memory, problem solving, and emotion perception. Regarding more distal outcome, LT patients had more symptoms compared to EC (F>4.4). Finally, EC patients showed higher improvements in psychosocial functioning compared to LT and MLT (F=1.8). Conclusions Against common expectations, long-term, more chronically ill patients showed higher effects in basal cognitive functions compared to younger patients and patients without any active therapy (TAU). On the other hand, early-course patients had a greater potential to change in attribution, symptoms and psychosocial functioning. Consequently, more integrated therapy offers are also recommended for long-term course schizophrenia patients.

Descriptive/Inferential Cognitive Processes and Evaluative Cognitive Processes: Relationships Among Each Other and with Emotional Distress

We aimed to delineate key constructs from two forms of cognitive-behavioral therapy: cognitive therapy and rational-emotive behavior therapy. Furthermore, we aimed to investigate the interrelations among each other and with emotional distress. The key constructs of the underlying theories of these therapies (i.e., descriptive/inferential beliefs, evaluative beliefs) are often treated together as distorted cognitions and included as such in various scales. We used a cross-sectional design. Seventy-four undergraduate students (mean age = 24.68) completed measures of automatic thoughts and emotional distress. Three therapists trained in cognitive-behavioral therapy divided automatic thoughts into descriptive/inferential beliefs and evaluative beliefs by consensus. Correlation and mediation analyses were performed. These constructs showed medium to high associations to each other and to distress. The relationship between descriptive/inferential beliefs and distress was mediated by evaluative beliefs. Descriptive and inferential cognitions may not produce emotions without first being appraised in terms of personal relevance.

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice

Background: The efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs. Method: N=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates. Results: CBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions. Limitations: The samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples. Conclusions: CBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.

Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia

Objectives: To investigate whether intensive cognitive behaviour therapy results in significant improvement in positive psychotic symptoms in patients with chronic schizophrenia.

Modified Dialectical Behavior Therapy Program Applied Within a Time-Limited Corrections Setting

Dialectical Behavioral Therapy (DBT) is an empirically supported therapy developed to treat individuals with Borderline Personality Disorder that has sustained efficacy following completion of the treatment (Linehan, 1993; Van Den Bosch et al., 2005). The core concepts of DBT include mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance, which seek to foster more functional ways of interacting with others, coping with distress, and managing difficult emotions. Using a standard DBT format in a corrections setting can be difficult due to the population's multifaceted composition. The Denver County Jail is a unique corrections setting because it contains a unit specifically developed for male inmates with mental health issues. A corrections modified, time-limited DBT curriculum was developed to fit the needs of this unique population. During the course of the group, staff appeared to be accepting of the group material and initial feedback from inmates and officers was positive.

Gene-environment interactions between adult lead exposure and Apolipoprotein E4 on adult hippocampal neurogenesis and cognitive behavior in mice

Thesis (Ph.D.)--University of Washington, 2016-06

Alcohol dependence: the impact of cognitive behaviour therapy with or without naltrexone on subjective health status

Objectives: To examine the health-related quality of life of alcohol-dependent patients across a 12-week cognitive behaviour treatment (CBT) program and identify whether the patient selection of the anticraving medication naltrexone further enhanced these outcomes. Method: One hundred and thirty-six consecutive alcohol-dependent subjects voluntarily participated and were offered naltrexone, of which 73 (54%) participants declined medication. A matched design was used. Of the 136 subjects, 86 (43 naltrexone and CBT; 43 CBT only) could be individually matched (blind to outcome measures) for gender, age, prior alcohol detoxification and dependence severity. Measures of health status and mental health wellbeing included the Rand Corporation Medical Outcomes Short Form 36 Health Survey (SF-36) and the General Health Questionnaire (GHQ-28). Results: Pre-treatment, all had SF-36 and GHQ-28 scores markedly below national norms. Post-treatment, significant improvement in seven of the eight SF-36 subscales and all of the GHQ-28 subscales occurred, approximating national normative levels. Patients in the CBT + naltrexone group were significantly more likely to have increased days abstinent (p = 0.002) and to complete the program abstinent (p = 0.051). The adjunctive use of naltrexone did not provide additional benefit as reflected in SF-36 and GHQ-28 scores, beyond CBT alone. Conclusions: Patients who completed the CBT-based treatment program reported significant improvements in self-reported health status (SF-36) and wellbeing (GHQ-28). The adjunctive use of naltrexone demonstrated no additional improvement in these measures.

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.