Recently there has been a growth of interest in mindfulness-based psychotherapeutic approaches across a range of medical problems. Cardiac rehabilitation patients often suffer from stress, worry, anxiety and depression, all of which can lead to poor prognosis and worsening of cardiac symptoms. Using interpretive phenomenological analysis (IPA) of participant experiences, this study reports on the first known Mindfulness-based Cognitive Therapy group adapted for cardiac rehabilitation. Analysis identified the development of awareness, commitment, within group experiences, relating to the material and acceptance as central experiential themes. The use of the approach was supported for this population.

J Health Psychol. 2009 Jul;14(5):675-81. Griffiths K, Camic PM, Hutton JM. Oxleas NHS Foundation Trust, UK.

Therapy process research helps delineate common and specific elements essential to positive outcomes as well as develop best practice training protocols. Child involvement and therapist flexibility were rated in 63 anxious youth (ages 8-14) who received cognitive-behavioral therapy. Therapist flexibility, defined as therapist attempts to adapt treatment to a child's needs, was hypothesized to act as an engagement strategy that serves to increase child involvement during therapy. Flexibility was significantly related to increases in later child engagement, which subsequently predicted improvement in posttreatment diagnosis and impairment. Therapist flexibility was not associated with earlier measures of child engagement, so a mediation model could not be supported. It was also hypothesized that the impact of flexibility would be greatest for cases who began treatment highly disengaged (i.e., early involvement would moderate the effect of flexibility). Basic descriptive data supported this model, but formal analyses failed to confirm. Further descriptive analyses suggest therapists employ a range of adaptations and a profile of flexible applications within a manual-based treatment is provided. Treatment, measurement, and dissemination issues are discussed.

J Clin Psychol. 2009 Jul;65(7):736-54. Chu BC, Kendall PC. Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA. BrianChu@rci.Rutgers.edu

INTRODUCTION: The primary aim of this study was to examine the role of patient characteristics in predicting response to treatment in a sample of HIV-positive patients receiving 12 weekly sessions of a CBT-based pain management protocol. METHOD: A pre/post test single group design was used. Pain-related functioning was assessed at baseline and 12 weeks post-treatment using the Pain Outcomes Questionnaire-VA. DATA ANALYSIS AND RESULTS: Multivariate regression analysis showed that higher baseline levels of pain-related anxiety were related to greater improvement in pain-related functioning at post-treatment, and non-Caucasian participants reported a greater response to treatment when compared to Caucasian participants. Attendance to CBT treatment sessions focused on progressive muscle relaxation and cognitive reconceptualization of pain were also related to treatment outcome. CONCLUSION: Non-Caucasian patients reporting higher levels of pain-related anxiety may respond particularly well to treatment. Treatment sessions focused on progressive muscle relaxation and cognitive reconceptualization of pain may be particularly helpful.

J Behav Med. 2009 Aug;32(4):340-8. Cucciare MA, Sorrell JT, Trafton JA. Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, 795 Willow Road (152), Menlo Park, CA 94025, USA. cucciare@hotmail.com

To compare the relative long-term benefit of family-focused cognitive behavioral therapy (FCBT) and child-focused cognitive behavioral therapy (CCBT) for child anxiety disorders at a 1-year follow-up. METHOD: Thirty-five children (6-13 years old) randomly assigned to 12-16 sessions of family-focused CBT (FCBT) or child-focused CBT (CCBT) participated in a 1-year follow-up assessment. Independent evaluators, parents, and children rated anxiety and parental intrusiveness. All were blind to treatment condition and study hypotheses. RESULTS: Children assigned to FCBT had lower anxiety scores than children assigned to CCBT on follow-up diagnostician- and parent-report scores, but not child-report scores. Exploratory analyses suggested the advantage of FCBT over CCBT may have been evident more for early adolescents than for younger children and that reductions in parental intrusiveness may have mediated the treatment effect. CONCLUSION: FCBT may yield a stronger treatment effect than CCBT that lasts for at least 1 year, although the lack of consistency across informants necessitates a circumspect view of the findings. The potential moderating and mediating effects considered in this study offer interesting avenues for further study.

Child Psychiatry Hum Dev. 2009 Jun;40(2):301-16. Wood JJ, McLeod BD, Piacentini JC, Sigman M. UCLA, Los Angeles, CA, USA. jwood@gseis.ucla.edu

Cognitive behaviour therapy (CBT) has been demonstrated to be the leader in the field of talking therapies concerned with the treatment of severe depression. However, this form of therapy has its limitations in that it is ineffective if given during a severe depressive episode. This is usually because patients suffering from severe depression have difficulties in concentration which severely limits the ability to take in new information such as the practice of strategies that encourage more helpful ways of thinking which could aid recovery. The severely depressed patient who experiences diurnal variations typically experiences low mood in the morning but mood improves towards the evening. Conversely, there are cases where mood is better in the morning becoming worse in the evening. There can be cases of positive diurnal rhythms where adverse symptoms disappear all together and the patient regains something resembling their pre-morbid normality. With this lifting of mood, it could mean that the patient may be more receptive to absorbing new information. Consequently, the hypothesis is that when patients are experiencing positive diurnal rhythms, this could be the optimum time to deliver effective talking treatments such as CBT.

Med Hypotheses. 2009 Jun;72(6):677-8. Frais AT. University of Leeds, 9 Sandhill Oval, Leeds, United Kingdom.

There is evidence that patients with chronic fatigue syndrome (CFS) have mild hypocortisolism. One theory about the aetiology of this hypocortisolism is that it occurs late in the course of CFS via factors such as inactivity, sleep disturbance, chronic stress and deconditioning. We aimed to determine whether therapy aimed at reversing these factors--cognitive behavioural therapy for CFS--could increase cortisol output in CFS. METHODS: We measured diurnal salivary cortisol output between 0800 and 2000 h before and after 15 sessions (or 6 months) of CBT in 41 patients with CDC-defined CFS attending a specialist, tertiary outpatient clinic. RESULTS: There was a significant clinical response to CBT, and a significant rise in salivary cortisol output after CBT. LIMITATIONS: We were unable to control for the passage of time using a non-treated CFS group. CONCLUSIONS: Hypocortisolism in CFS is potentially reversible by CBT. Given previous suggestions that lowered cortisol may be a maintaining factor in CFS, CBT offers a potential way to address this.

J Affect Disord. 2009 May;115(1-2):280-6. Roberts AD, Papadopoulos AS, Wessely S, Chalder T, Cleare AJ. King's College London, Institute of Psychiatry, Department of Psychological Medicine, De Crespigny Park, London SE5 8AF, UK.

The objective of this critical review was to examine the literature regarding the use of cognitive strategies to acquire motor skills in people who have had a stroke, to determine which strategies are in use and to compile evidence of their effectiveness. SEARCH TERMS: A computerized search of a range of databases was conducted using the following search terms: stroke, cerebrovascular accident; combined with strategy training, learning strateg*, cognitive strateg*, metacognitive strateg*, goal setting, goal planning, goal attainment, goal direct*, goal orient*, self talk, imagery, mental practice, self evaluat*, ready*, attentional focus*, problem solv*, goal management; combined with motor, mobility, activit*, skill, task, function, ADL. RESULTS: Twenty-six articles were reviewed. Seven studies investigated general cognitive strategies and 19 investigated task-specific strategies. The most commonly studied task-specific strategy was motor imagery. Findings suggest that general strategy training improves performance in both trained and untrained activities compared to traditional therapy; and that a specific motor imagery protocol can improve mobility and recovery in the affected upper extremity in people living with the chronic effects of stroke. CONCLUSION: This foundational evidence supports the further development of novel cognitive strategy-based interventions with the intention of improving long-term stroke outcomes.

Brain Inj. 2009 Apr;23(4):263-77. McEwen SE, Huijbregts MP, Ryan JD, Polatajko HJ. Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada. sara.mcewen@utoronto.ca

This study was designed to evaluate a new brief cognitive-behavioural intervention to reduce concerns about body shape. DESIGN: Women with high levels of shape concern (N=50) were randomly assigned to cognitive behaviour therapy or applied relaxation (AR). Baseline assessments were made and then women received their treatment immediately after this assessment, ('immediate' treatment) or 5 weeks after this assessment, during which time no treatment was given ('delayed' treatment, DT). METHODS: Shape concern and related cognitions and emotions were assessed at baseline, post-treatment and at 4 and 12 week follow-up (FU). RESULTS: Immediate treatment was superior to DT in reducing shape concerns, and this difference was maintained at 4 week FU. The cognitive behavioural intervention was more effective than AR in changing shape concern and this difference was largely maintained for 3 months. CONCLUSIONS: These initial findings support the further investigation of this brief intervention.

Br J Clin Psychol. 2009 Mar;48(Pt 1):79-92. Shafran R, Farrell C, Lee M, Fairburn CG. Department of Psychology, University of Reading, Reading, UK. r.shafran@reading.ac.uk

Cognitive-behavioral treatments have demonstrated efficacy in the treatment of social phobia. However, such treatments comprise a complex set of procedures, and there has been little investigation of the effects of individual procedures. The current study investigates the effects of two single session procedures that form part of cognitive therapy for social phobia [Clark, D., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy vs fluoxetine in the treatment of social phobia: A randomised placebo controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058-1067; Clark, D., Ehlers, A., McManus, F., Fennell, M., Grey, N., Waddington, L., et al. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 568-578], namely the "self-focused attention and safety behaviors experiment" and the "video feedback experiment." Results suggest that both procedures are effective in achieving their aims, which are: (i) demonstrating to patients the role of self-focused attention, safety behaviors, and excessively negative self-impressions in maintaining social phobia and (ii) reducing the symptoms of social phobia.

J Anxiety Disord. 2009 May;23(4):496-503. McManus F, Clark DM, Grey N, Wild J, Hirsch C, Fennell M, Hackmann A, Waddington L, Liness S, Manley J. University of Oxford, Department of Psychiatry & Oxford Cognitive Therapy Centre, Warneford Hospital, Oxford OX3 7JX, UK. freda.mcmanus@psych.ox.ac.uk

The Self-Regulatory Executive Function model [S-REF; Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: the S-REF model. Behaviour Research and Therapy, 34, 881-888] proposes that metacognitive beliefs, inflexible self-focused attention, and perseverative thinking (rumination and worry) play an important role in maintaining emotional dysfunction. Attention training [ATT; Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: an attentional training approach to treatment. Behavior Therapy, 21, 273-280] is a technique designed to increase attentional control and flexibility, and thereby lessen the impact of these maintaining factors. The main aim of this study was to determine whether or not supplementing cognitive behavioral group therapy (CBGT) with ATT could potentiate greater changes in social anxiety, depression, attentional control, metacognitive beliefs, and anticipatory and post-event processing in a clinical sample with social phobia. Patients (N=81) were allocated to CBGT with ATT or relaxation training (RT). ATT did not potentiate greater change on any outcome variable, with both groups achieving significant improvements on all measures. Exploratory correlational analyses (pre-treatment and changes scores) showed that some metacognitive beliefs were associated with attentional control, anticipatory processing, and symptoms of social anxiety and depression. However, attentional control was more consistently associated with anticipatory processing, post-event processing, and symptoms of social anxiety and depression, than with metacognitive beliefs. Results are discussed with reference to cognitive behavioral models of social phobia. It is tentatively concluded that while supplementing CBGT with ATT does not improve outcomes, increasing attentional control during CBGT is associated with symptom relief.

J Anxiety Disord. 2009 May;23(4):519-28. McEvoy PM, Perini SJ. Clinical Research Unit for Anxiety and Depression, University of New South Wales at St Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, 2010, Australia. peter.mcevoy@health.wa.gov.au

Evidence suggests that comorbid depression influences the outcome of cognitive-behavioral treatment for patients presenting with social phobia. Little is known, however, about the influence of comorbid social phobia on the response to cognitive therapy (CT) for depression among adults presenting with recurrent major depressive disorder (MDD). These analyses seek to clarify this relationship. METHODS: Patients (N=156) with recurrent DSM-IV MDD entered CT (20% also met DSM-IV criteria for social phobia). Every week during the course of CT, clinicians assessed depressive symptoms and patients completed self-report instruments measuring severity of depression and anxiety. RESULTS: At presentation, outpatients with comorbid social phobia reported greater levels of depressive symptoms and clinicians rated their impairment as more severe, compared to their counterparts without social phobia. Patients with or without comorbid social phobia did not differ significantly in (1) attrition rates; (2) response or sustained remission rates; (3) time to response or sustained remission; or (4) rate of improvement in symptoms of depression or anxiety. LIMITATIONS: The lack of domain-specific measures limits inference with respect to the improvements in social anxiety that occur with CT of depression. CONCLUSIONS: These findings introduce the hypothesis that CT for depression may be flexible enough to treat the depressive symptoms of patients presenting with MDD who also suffer from social phobia.

J Affect Disord. 2009 Apr;114(1-3):271-8. Smits JA, Minhajuddin A, Jarrett RB. Department of Psychology, Southern Methodist University, Dedman College, P.O. Box 750442, Dallas, TX 75275, United States. jsmits@smu.edu

To address the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, this article provides a simple, easy-to-learn, unified approach to the diagnosis, care management, and pharmacotherapy of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders; a validated method for monitoring treatment outcome; and an algorithmic approach for the selection of initial medication treatment, the selection of alternative or adjunctive treatments when the initial approach has not produced optimal results, and indications for mental health referral.

J Am Board Fam Med. 2009 Mar-Apr;22(2):175-86. Roy-Byrne P, Veitengruber JP, Bystritsky A, Edlund MJ, Sullivan G, Craske MG, Welch SS, Rose R, Stein MB. Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, USA. roybyrne@u.washington.edu

To address the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, this article provides a simple, easy-to-learn, unified approach to the diagnosis, care management, and pharmacotherapy of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders; a validated method for monitoring treatment outcome; and an algorithmic approach for the selection of initial medication treatment, the selection of alternative or adjunctive treatments when the initial approach has not produced optimal results, and indications for mental health referral.

J Am Board Fam Med. 2009 Mar-Apr;22(2):175-86. Roy-Byrne P, Veitengruber JP, Bystritsky A, Edlund MJ, Sullivan G, Craske MG, Welch SS, Rose R, Stein MB. Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, USA. roybyrne@u.washington.edu

Behavioral medicine is based on the biopsychosocial theory that biological, psychological, and environmental factors all play significant roles in human functioning. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of migraine including cognitive behavioral therapy and biobehavioral training (ie, biofeedback, relaxation training, and stress management). These techniques have demonstrated efficacy when learned and practiced correctly and may be used individually or in conjunction with pharmacologic and other interventions. Data are also reviewed regarding patient education, support groups, psychological comorbidities, modifiable risk factors for headache progression, strategies for enhancing adherence and motivation, and strategies for effective medical communication.

Neurol Clin. 2009 May;27(2):445-465. Buse DC, Andrasik F. Department of Neurology, Albert Einstein College of Medicine of Yeshiva University, NY, USA; Clinical Health Psychology Doctoral Program, Ferkauf Graduate School of Psychology of Yeshiva University, NY, USA; Montefiore Headache Center, 1575 Blondell Avenue, Suite 225, Bronx, NY 10461, USA.

Due to treatment accessibility and cost issues, interest in self-help programs (e.g., bibliotherapy, telehealth) for common psychological disorders is growing. Research supporting the efficacy of such a program for social anxiety, however, is limited. The present study examined the efficacy of an 8-week self-directed cognitive behavioral treatment with minimal therapist involvement for social phobia based on a widely available self-help book. Twenty-one adults with social phobia initially received either treatment (i.e. assigned readings in the workbook with limited therapist contact) or were wait-listed. Wait-listed patients eventually received the same self-directed treatment. Results revealed that the self-help/minimal therapist contact treatment was superior to wait-list on most outcome measures. Across the entire sample, reductions in social anxiety, global severity, general anxiety, and depression were observed at posttest and 3-month follow-up. These findings provide preliminary support for using this self-help workbook for individuals with mild to moderate social anxiety in conjunction with infrequent therapist visits to reinforce the treatment principles. Study limitations and future directions are discussed.

J Behav Ther Exp Psychiatry. 2009 Mar;40(1):98-105. Epub 2008 Apr 26. Abramowitz JS, Moore EL, Braddock AE, Harrington DL. University of North Carolina at Chapel Hill, NC 27599, USA. jabramowitz@unc.edu

We systematically reviewed empirical studies that investigated the use of cognitive-behavioral therapy (CBT) for premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Our multi-database search identified seven published empirical reports. Three were identified as randomized controlled trials (RCTs). The methods utilized to investigate therapeutic efficacy of CBT in these studies varied widely from case reports to RCTs with pharmacotherapy comparison groups. Initially we provide a brief overview of CBT and justifications for its potential use to treat PMS/PMDD. Next, we provide critical evaluations of the analyses used in each study focusing on the detection of intervention effects assessed by statistically significant time by group interactions. When possible we calculate effect sizes to elucidate the clinical significance of results. Our review revealed a dearth of evidence providing statistically significant CBT intervention effects. Issues such as overall time investment, latency to treatment effects, and complementary and combined therapies are considered. We present a theoretical argument for applying mindfulness- and acceptance-based CBT interventions to PMS/PMDD and suggest future research in this area. In conclusion, to produce the necessary evidence-base support for PMS/PMDD given the limited empirical evidence reported here, researchers are called on to produce methodologically rigorous investigations of psychosocial interventions for PMS/PMDD.

Arch Womens Ment Health. 2009 Apr;12(2):85-96. Lustyk MK, Gerrish WG, Shaver S, Keys SL. Lustyk Women's Health Lab, School of Psychology, Family, and Community, Seattle Pacific University, Seattle, WA, USA. klustyk@spu.edu

This multiple case study of cognitive-behavioral treatment (CBT) for chronic fatigue syndrome (CFS) compared self-report and behavioral outcomes. Eleven relatively high-functioning participants with CFS received 6-32 sessions of outpatient graded-activity oriented CBT. Self-report outcomes included measures of fatigue impact, physical function, depression, anxiety, and global change. Behavioral outcomes included actigraphy and the 6-minute walking test. Global change ratings were very much improved (n=2), much improved (n=2), improved (n=5), and no change (n=2). Of those reporting improvement, clinically significant actigraphy increases (n=3) and decreases (n=4) were found, as well as no significant change (n=2). The nature of clinical improvement in CBT trials for high-functioning CFS patients may be more ambiguous than that postulated by the cognitive-behavioral model.

J Clin Psychol. 2009 Apr;65(4):423-42. Friedberg F, Sohl S. Stony Brook University. Fred.Friedberg@stonybrook.edu

Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults.

J Psychiatr Pract. 2009 Mar;15(2):103-12. Paukert AL, Phillips L, Cully JA, Loboprabhu SM, Lomax JW, Stanley MA. Veterans Affairs Medical Center, Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA. Amber.Paukert@va.gov

Profound neuronal dysfunction in the entorhinal cortex contributes to early loss of short-term memory in Alzheimer's disease. Here we show broad neuroprotective effects of entorhinal brain-derived neurotrophic factor (BDNF) administration in several animal models of Alzheimer's disease, with extension of therapeutic benefits into the degenerating hippocampus. In amyloid-transgenic mice, BDNF gene delivery, when administered after disease onset, reverses synapse loss, partially normalizes aberrant gene expression, improves cell signaling and restores learning and memory. These outcomes occur independently of effects on amyloid plaque load. In aged rats, BDNF infusion reverses cognitive decline, improves age-related perturbations in gene expression and restores cell signaling. In adult rats and primates, BDNF prevents lesion-induced death of entorhinal cortical neurons. In aged primates, BDNF reverses neuronal atrophy and ameliorates age-related cognitive impairment. Collectively, these findings indicate that BDNF exerts substantial protective effects on crucial neuronal circuitry involved in Alzheimer's disease, acting through amyloid-independent mechanisms. BDNF therapeutic delivery merits exploration as a potential therapy for Alzheimer's disease.

Nat Med. 2009 Mar;15(3):331-7. Nagahara AH, Merrill DA, Coppola G, Tsukada S, Schroeder BE, Shaked GM, Wang L, Blesch A, Kim A, Conner JM, Rockenstein E, Chao MV, Koo EH, Geschwind D, Masliah E, Chiba AA, Tuszynski MH. Department of Neurosciences-0626, 9500 Gilman Drive, University of California-San Diego, La Jolla, California 92093, USA.

The development of evidence-based treatments for anxiety disorders is a major achievement of clinical psychology, and cognitive behavior therapy is the best-established and most widely used method. The first form of this therapy, behavior therapy, was a combination of Pavlovian and Behavioristic ideas and methods and was particularly successful in reducing fears. The infusion of cognitive ideas in the late 1970s generated the wider and more flexible cognitive behavior therapy that independent agencies in the United States and United Kingdom now recommend as the treatment of choice for most of the anxiety disorders. Remaining theoretical problems and clinical limitations need to be tackled. Expected final online publication date for the Annual Review of Clinical Psychology Volume 5 is March 27, 2009. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

Annu Rev Clin Psychol. 2008 Dec 16. Rachman S. Department of Psychology, University of British Columbia, Vancouver, British Columbia V6T 1Z4 Canada; email: rachman@interchange.ubc.ca.

Full Title: Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies

The efficacy of cognitive-behavioral therapy (CBT) for anxiety in adults is well established. In the present study, the authors examined whether CBT tested under well-controlled conditions generalizes to less-controlled, real-world circumstances. Fifty-six effectiveness studies of CBT for adult anxiety disorders were located and synthesized. Meta-analytic effect sizes are presented for disorder-specific symptom measures as well as symptoms of generalized anxiety and depression for each disorder, and benchmarked to results from randomized controlled trials. All pretest-posttest effect sizes for disorder-specific symptom measures were large, suggesting that CBT for adult anxiety disorders is effective in clinically representative conditions. Six studies included a control group, and between-groups comparisons yielded large effect sizes for disorder-specific symptoms in favor of CBT. Benchmarking indicated that results from effectiveness studies were in the range of those obtained in selected efficacy trials. To test whether studies that are more representative of clinical settings have smaller effect sizes, the authors coded studies for 9 criteria for clinical representativeness. Results indicate an inverse relationship between clinical representativeness and outcome, but the magnitude of the relationship is quite small.

J Consult Clin Psychol. 2009 Aug;77(4):595-606. Stewart RE, Chambless DL. Department of Psychology, University of Pennsylvania, Solomon Laboratories, Philadelphia, PA 19104, USA. restewar@psych.upenn.edu

Therapist competence has consistently been associated with therapy outcomes, although the nature of this relationship varies considerably across studies.

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Coronary heart disease (CHD) is the leading cause of death and disability in the United States and in highly industrialized countries. Many modifiable psychosocial risk factors have been identified and can affect the course of cardiac illness. These include the negative emotional states of depression, anxiety, stress, anger/hostility, and social isolation. Anxiety has been found to increase the risk of developing CHD in healthy subjects and can lead to worsening of existing CHD. There is much overlap and confusion throughout the research literature between what authors define as anxiety, stress, Type A behavioral pattern, and anger/hostility.There is a need for better screening within the practice of cardiology for these psychosocial risk factors to ensure better integration of mental health services. Established screening tools such as the Beck Anxiety Inventory, Patient Health Questionnaire-9, Zung Self-Rating Anxiety Scale, and the Hamilton Anxiety Scale are described and compared with the newer Screening Tool for Psychologic Distress as part of the initial work-up of every cardiac patient. Recommendations are made using the author's Anxiety Treatment Algorithm regarding when to refer to a mental health professional along with how to reduce stigma and provide more integrated care. The diagnosis and treatment of anxiety disorders is reviewed, with attention to selective serotonin reuptake inhibitors, benzodiazepines, cognitive-behavioral therapy, stress reduction, and behavioral medicine group programs. These group programs are recommended because they help to overcome social isolation and counsel patients on how to adapt to a healthy lifestyle. Better clinical outcome research is needed that specifically addresses the question of whether the treatment of anxiety and anxiety disorders can affect the course of cardiac illness.

Cardiol Rev. 2009 Jan-Feb;17(1):36-43. Janeway D. Department of Psychiatry, New York Medical College, Valhalla, NY, USA. DavidJaneway@aol.com

PURPOSE OF REVIEW: The aim is to summarize recent evidence from the National Institute for Health and Clinical Excellence clinical guidelines and high-quality systematic reviews for the use of cognitive behavioural therapy to treat children and adolescents with mental health problems. RECENT FINDINGS: Data from meta-analyses of randomized controlled trials suggest that the best evidence for the potential of cognitive behavioural therapy is in the treatment of children and adolescents with generalized anxiety disorder, depression, obsessive compulsive disorder and posttraumatic stress disorder. More limited evidence suggests that attention deficit hyperactivity disorder and behavioural problems may also respond to cognitive behavioural therapy. We found no or insufficient evidence to determine whether cognitive behavioural therapy is useful for the treatment of antisocial behaviour, psychotic and related disorders, eating disorders, substance misuse and self-harm behaviour. SUMMARY: Clinical guidelines and recent systematic reviews establish that cognitive behavioural therapy has a potentially important role in improving the mental health of children and adolescents.

Curr Opin Psychiatry. 2008 Jul;21(4) Muñoz-Solomando A, Kendall T, Whittington CJ. Child and Family Centre Tonteg, Wales, UK.

The diverse clinical presentation of refugee children and adolescents after their traumatic experiences requires a treatment model that can mitigate a number of internalizing and externalizing symptoms. Refugee populations also require interventions that can adjust to the wide-ranging experiences likely encountered during preflight, flight, and resettlement. There is some evidence that immigration stressors or social stressors, such as discrimination, are associated with symptoms of posttraumatic stress disorder in refugee youth. Therefore refugee youth may benefit from multiple levels of services, ideally integrated. This article focuses on the mental and behavioral health component of services for refugee youth.

Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3) Murray LK, Cohen JA, Ellis BH, Mannarino A. Boston University School of Public Health, Center for International Health and Development, 85 E. Concord Street, 5th Floor, Boston, MA 02118, USA.

The diverse clinical presentation of refugee children and adolescents after their traumatic experiences requires a treatment model that can mitigate a number of internalizing and externalizing symptoms. Refugee populations also require interventions that can adjust to the wide-ranging experiences likely encountered during preflight, flight, and resettlement. There is some evidence that immigration stressors or social stressors, such as discrimination, are associated with symptoms of posttraumatic stress disorder in refugee youth. Therefore refugee youth may benefit from multiple levels of services, ideally integrated. This article focuses on the mental and behavioral health component of services for refugee youth.

Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3) Murray LK, Cohen JA, Ellis BH, Mannarino A. Boston University School of Public Health, Center for International Health and Development, 85 E. Concord Street, 5th Floor, Boston, MA 02118, USA.

Cognitive-behavior therapy and exposure and response prevention are the most effective psychological treatments for obsessive-compulsive disorder (OCD). However, these approaches often produce variable results with the majority of treated individuals remaining symptomatic. This study evaluated a new form of cognitive therapy based on Wells' metacognitive model of OCD. Treatment efficacy was assessed using single case methodology in 4 consecutively referred individuals. At post-treatment, all participants made clinically significant change on a range of standardized outcome measures and these gains were largely maintained through to 6-month follow-up. Metacognitive therapy could be an effective and time efficient treatment for OCD.

J Behav Ther Exp Psychiatry. 2008 Jun;39(2):117-32. Fisher PL, Wells A. Department of Clinical Psychology, University of Liverpool, Brownlow Hill, Liverpool L69 3GB, UK.

Although there is evidence that cognitive behavioral therapy (CBT) is effective in the treatment for fear of flying (FOF), there are no studies that specifically examine which skills taught in treatment are being used by clients after treatment is completed. This study examines whether participants report using skills taught in treatment for FOF after treatment is completed and whether the reported use of these skills is associated with reduced flying anxiety in the face of fear-relevant event, the September 11th terrorist attacks, and over the long-term. One hundred fifteen participants were randomly assigned to and completed eight sessions of individual CBT treatment for FOF. Fifty-five participants were reassessed in June 2002, an average of 2.3 years after treatment. Surveys were also collected from 33 individuals who did not receive treatment for FOF. Results indicated that treatment completers were more likely to report using skills taught in treatment than individuals who had not received treatment. In addition, self-reported use of skills among previously treated individuals was associated with lower levels of flying anxiety. These findings suggest that use of skills taught in CBT treatment is associated with reduced flying anxiety in the face of a fear-relevant event and over the long term.

J Anxiety Disord. 2008;22(2):301-9. Kim S, Palin F, Anderson P, Edwards S, Lindner G, Rothbaum BO. Georgia State University, Atlanta, GA, USA.

This paper reviews predictors of treatment response in open and controlled trials of cognitive-behavioral therapy for obsessive-compulsive disorder (OCD). We focus on demographic characteristics, aspects of OCD symptoms, comorbidity, family factors, cognitive influences, and treatment-specific characteristics as predictor variables. Although inconsistent findings characterize much of the literature, several relatively consistent and salient predictors have emerged, including symptom severity, symptom subtype, severe depression, the presence of comorbid personality disorders, family dysfunction, and the therapeutic alliance. Implications of findings and recommendations for future research are discussed.

Clin Psychol Rev. 2008 Jan;28(1):118-30. Keeley ML, Storch EA, Merlo LJ, Geffken GR. Department of Clinical & Health Psychology, University of Florida, Gainesville, Florida, United States; Department of Psychiatry, University of Florida, Gainesville, Florida, United States.

To illustrate a multidisciplinary group treatment for patients with fibromyalgia (FM) tailored to the patient's cognitive-behavioral pattern. METHOD: In a case-study design the tailored treatment approaches of two FM patients were described. One patient characterized by avoidance behavior (pain-avoidance pattern) participated in a group treatment aimed at changing pain-avoidance mechanisms and one patient characterized by continuing with activities in spite of pain (pain-persistence pattern) participated in a group treatment aimed at changing pain-persistence mechanisms. Assessments were made at baseline, post-treatment and at 6-months follow-up. RESULTS: Comparison of the pretest, post-test and follow-up scores on pain, functional disability, fatigue and psychological distress showed clinically significant improvements for both patients. CONCLUSION: The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms has been proposed to underlie varying treatment outcomes in FM patients. These results demonstrate that a group treatment tailored to pain-avoidance and pain-persistence patterns is feasible and can result in clinically significant changes for FM patients. PRACTICE IMPLICATIONS: FM offers a great challenge for clinicians due to the lack of effective treatment options. These case studies suggests that tailored CBT and exercise training directed at specific patient patterns can contribute to the improvement of the care of FM patients.

Patient Educ Couns. 2008 Jan 8 van Koulil S, van Lankveld W, Kraaimaat FW, van Helmond T, Vedder A, van Hoorn H, Cats H, van Riel PL, Evers AW. Department of Medical Psychology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

This study compared imagery rescripting, in vivo exposure therapy and their combination in the treatment of snake fear. Imaginal ability was assessed pre-treatment, and was correlated with baseline avoidance. Snake fearful individuals were randomly assigned to cognitive therapy involving imagery rescripting, in vivo exposure, a combination of the two, or a relaxation control. All active treatment groups improved significantly more than the control group in both fearfulness and behavioral approach. There were no significant differences between the active treatment groups, although the combined treatment tended to be slightly more efficacious.

J Behav Ther Exp Psychiatry. 2007 Sep 21 Hunt M, Fenton M. University of Pennsylvania, 3720 Walnut Street, Philadelphia, PA 19104-6241, USA.

Neurofunctional mechanisms underlying cognitive behavior therapy (CBT) are still not clearly understood. This functional magnetic resonance imaging (fMRI) study focused on changes in brain activation as a result of one-session CBT in patients suffering from spider phobia. Twenty-six female spider phobics and 25 non-phobic subjects were presented with spider pictures, generally disgust-inducing, generally fear-inducing and affectively neutral scenes in an initial fMRI session. Afterwards, the patients were randomly assigned to either a therapy group (TG) or a waiting list group (WG). The scans were repeated one week after the treatment or after a one-week waiting period. Relative to the non-phobic participants, the patients displayed increased activation in the amygdala and the fusiform gyrus as well as decreased activation in the medial orbitofrontal cortex (OFC) during the first exposure. The therapy effect consisted of increased medial OFC activity in the TG relative to the WG. Further, therapy-related reductions in experienced somatic anxiety symptoms were positively correlated with activation decreases in the amygdala and the insula. We conclude that successful treatment of spider phobia is primarily accompanied by functional changes of the medial OFC. This brain region is crucial for the self-regulation of emotions and the relearning of stimulus-reinforcement associations.

Eur Arch Psychiatry Clin Neurosci. 2007 Sep 27 Schienle A, Schäfer A, Hermann A, Rohrmann S, Vaitl D. Clinical Psychology, Karl-Franzens-Universität Graz, Universitätsplatz 2/III, 8010, Graz, Austria.

While cognitive behavior therapy has been found to be effective in the treatment of generalized anxiety disorder (GAD), a significant percentage of patients struggle with residual symptoms. There is some conceptual basis for suggesting that cultivation of mindfulness may be helpful for people with GAD. Mindfulness-based cognitive therapy (MBCT) is a group treatment derived from mindfulness-based stress reduction (MBSR) developed by Jon Kabat-Zinn and colleagues. MBSR uses training in mindfulness meditation as the core of the program. MBCT incorporates cognitive strategies and has been found effective in reducing relapse in patients with major depression (Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 6, 615-623). METHOD: Eligible subjects recruited to a major academic medical center participated in the group MBCT course and completed measures of anxiety, worry, depressive symptoms, mood states and mindful awareness in everyday life at baseline and end of treatment. RESULTS: Eleven subjects (six female and five male) with a mean age of 49 (range=36-72) met criteria and completed the study. There were significant reductions in anxiety and depressive symptoms from baseline to end of treatment. CONCLUSION: MBCT may be an acceptable and potentially effective treatment for reducing anxiety and mood symptoms and increasing awareness of everyday experiences in patients with GAD. Future directions include development of a randomized clinical trial of MBCT for GAD.

J Anxiety Disord. 2007 Jul 22 Evans S, Ferrando S, Findler M, Stowell C, Smart C, Haglin D. Department of Psychiatry, Weill Cornell Medical College, United States.

Attention-deficit/hyperactivity disorder (ADHD) has been commonly thought of as a childhood disorder that diminished over time. It is one of the most common developmental disorders and it is estimated that ADHD affects 5-10% of children. Two-thirds of children with ADHD will continue to have symptoms of ADHD that persist throughout adolescence. Longitudinal studies have demonstrated that symptoms of ADHD can also remain in adulthood, affecting 4.4% of the adult population. However, diagnosing adults with ADHD can prove difficult because they often find that their symptoms are egosyntonic. In addition, the development of comorbid conditions, such as anxiety, depression, personality disorders or substance abuse, can often overshadow underlying ADHD symptoms. Nonetheless, treatments such as stimulant and nonstimulant medication (e.g., atomoxetine), and cognitive-behavior therapy have been effective in treating adults with ADHD. This article reviews the prevalence of adults with ADHD, followed by a discussion of the neurobiological and genetic underpinnings of the disorder. Issues regarding the diagnosis and treatment of ADHD are also addressed.

Expert Rev Neurother. 2007 Oct;7(10):1375-90. Cumyn L, Kolar D, Keller A, Hechtman L. McGill University, Department of Educational & Counselling Psychology, 3700 McTavish St., Montreal, Quebec, H3A 1Y2. lucy.cumyn@mail.mcgill.ca

Research over the last decade has identified Internet addiction as a new and often unrecognized clinical disorder that impact a user's ability to control online use to the extent that it can cause relational, occupational, and social problems. While much of the literature explores the psychological and social factors underlying Internet addiction, little if any empirical evidence exists that examines specific treatment outcomes to deal with this new client population. Researchers have suggested using cognitive behavioral therapy (CBT) as the treatment of choice for Internet addiction, and addiction recovery in general has utilized CBT as part of treatment planning. To investigate the efficacy of using CBT with Internet addicts, this study investigated 114 clients who suffered from Internet addiction and received CBT at the Center for Online Addiction. This study employed a survey research design, and outcome variables such as client motivation, online time management, improved social relationships, improved sexual functioning, engagement in offline activities, and ability to abstain from problematic applications were evaluated on the 3rd, 8th, and 12th sessions and over a 6-month follow-up. Results suggested that Caucasian, middle-aged males with at least a 4-year degree were most likely to suffer from some form of Internet addiction. Preliminary analyses indicated that most clients were able to manage their presenting complaints by the eighth session, and symptom management was sustained upon a 6-month follow-up. As the field of Internet addiction continues to grow, such outcome data will be useful in treatment planning with evidenced-based protocols unique to this emergent client population.

Cyberpsychol Behav. 2007 Oct;10(5):671-9. Young KS. Center for Online Addiction, Bradford, Pennsylvania.

PURPOSE: A dietitian-administered, shortened form of the Apple and Agras cognitive-behavioural therapy (CBT) method was evaluated in a group setting to determine its effect on improving obese women's self-esteem and reducing binge-eating behaviours, depression, and negative body image. METHODS: Participants were recruited through newspaper and radio advertisements. Respondents who met study selection criteria were randomly assigned to either a CBT group (n=13) or a delayed group (D-CBT) (n=9). The treatment was administered over six weekly sessions to the CBT group, and then twice weekly over three weeks to the D-CBT group. Two measures of bingeing behaviour (severity and frequency), three measures of mood (depression, body image, and self-esteem), and body weight were assessed. RESULTS: The intervention did not result in any changes in body weight. There were statistically significant and clinically important changes after treatment (p<0.05) for all five measures. Binge-eating severity and frequency decreased, depression decreased, body image improved, and self-esteem improved. All changes were greater in the six-week treatment group. CONCLUSIONS: The dietitian-administered, group setting CBT program is effective for reducing binge eating and improving emotional state in obese women.

Can J Diet Pract Res. 2007 Autumn;68(3):139-42. Shelley-Ummenhofer J, MacMillan PD. Integrated Health Centre, Penticton, BC.

Acceptance and commitment therapy (ACT) has a small but growing database of support. One hundred and one heterogeneous outpatients reporting moderate to severe levels of anxiety or depression were randomly assigned to traditional cognitive therapy (CT) or to ACT. To maximize external validity, the authors utilized very minimal exclusion criteria. Participants receiving CT and ACT evidenced large, equivalent improvements in depression, anxiety, functioning difficulties, quality of life, life satisfaction, and clinician-rated functioning. Whereas improvements were equivalent across the two groups, the mechanisms of action appeared to differ. Changes in "observing" and "describing" one's experiences appeared to mediate outcomes for the CT group relative to the ACT group, whereas "experiential avoidance," "acting with awareness," and "acceptance" mediated outcomes for the ACT group. Overall, the results suggest that ACT is a viable and disseminable treatment, the effectiveness of which appears equivalent to that of CT, even as its mechanisms appear to be distinct.

Behav Modif. 2007 Nov;31(6):772-99. Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. Department of Psychology, Drexel University. evan.forman@drexel.edu.

RATIONALE: This study examines the effect of Skill Training In Affect Regulation (STAIR) on a cohort of 24 inpatients with Schizophrenia with histories of significant trauma and Complex PTSD. METHOD: Using a model of Trauma Healing proposed by the NYS Office of Mental Health, 24 patients underwent 12 weeks of group-based Cognitive Behavior Therapy. Treatment modalities focused on trust, safety, affect-regulation, identification of trauma triggers, and disrupting abuse-driven behaviors. A comparison group of patients received 12 weeks of supportive psychotherapy by therapists unfamiliar with Trauma Management. Treatment outcome was compared using the Modified Impact of Events, and Brief Psychiatric Rating Scales. RESULTS: Following completion of 12 weeks of therapy, only those patients undergoing therapy in Trauma Recovery showed improvement on items such as tension, excitement, hostility, suspiciousness, and anger-control. CONCLUSION: These findings are an encouraging first step in trauma recovery of patients with chronic mental illness, histories of prolonged trauma, and Complex PTSD.

Psychiatr Q. 2007 Dec;78(4):317-25. Trappler B, Newville H. SUNY Downstate, Kingsboro Psychiatric Center, Clarkson Avenue, Brooklyn, NY, 11203, USA, kbmdbtt@omh.state.ny.us.

Patients with schizophrenia are at high risk of suicide. Cognitive behavior therapy (CBT) has been shown to reduce symptoms in schizophrenia. This study examines whether CBT also changes the level of suicidal ideation in patients with schizophrenia compared to a control group. Ninety ambulatory patients with symptoms of schizophrenia resistant to conventional antipsychotic medication were randomized to CBT or befriending. They were assessed using the Comprehensive Psychopathological Rating Scale, including a rating of suicidal ideation at baseline, post intervention, and after 9 months. Post-hoc analysis revealed that CBT provided significant reductions in suicidal ideation at the end of therapy, and sustained at the follow-up. Further research is required to substantiate these findings and determine the process and mechanisms through which this reduction is achieved.

Suicide Life Threat Behav. 2007 Jun;37(3):284-90.

Bateman K, Hansen L, Turkington D, Kingdon D.

University of Newcastle, UK.

We describe the development of a cognitive therapy intervention for chronic insomnia. The therapy is based on a cognitive model which suggests that the processes that maintain insomnia include: (1) worry and rumination, (2) attentional bias and monitoring for sleep-related threat, (3) unhelpful beliefs about sleep, (4) misperception of sleep and daytime deficits and (5) the use of safety behaviors that maintain unhelpful beliefs. The aim of cognitive therapy for insomnia is to reverse all five maintaining processes during both the night and the day. In an open trial 19 patients meeting diagnostic criteria for primary insomnia were treated with cognitive therapy for insomnia. Assessments were completed pretreatment, posttreatment and at 3-, 6- and 12-month followup. The significant improvement in both nighttime and daytime impairment evident at the posttreatment assessment was retained up to the 12 month followup. Behav Res Ther. 2007 Apr 22; [Epub ahead of print]

Harvey AG, Sharpley AL, Ree MJ, Stinson K, Clark DM.

Department of Psychology, Sleep and Psychological Disorders Lab, University of California, 3210 Tolman Hall #1650, Berkeley, CA 94720-1650, USA.