Cognitive Therapy And The Emotional Disorders [EXCLUSIVE]
Objective: The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach.
Cognitive Therapy and the Emotional Disorders
Methods: We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded.
Studying the usefulness of contextual and cognitive transdiagnostic therapies calls for an analysis of both their differential efficacy and their specificity when acting on the transdiagnostic conditions on which they focus. This controlled trial compares the post-treatment and 3- and 6-month follow-up effects of Behavioral Activation (BA), Acceptance and Commitment Therapy (ACT) and Cognitive-Behavioral Transdiagnostic Therapy (TD-CBT) on emotional symptomatology, and analyses the role played by Experiential Avoidance, Cognitive Fusion, Activation and Emotion Regulation in the clinical change. One hundred twenty-eight patients who fulfilled diagnostic criteria for anxiety and/or depression (intention-to-treat sample) were randomly assigned to three experimental group-treatment conditions (BA, n = 34; ACT, n = 27; TD-CBT n = 33) and one control group (WL, n = 34). Ninety-nine (77.34%) completed the treatment (per-protocol sample). In the post-treatment, all therapies reduced anxiety and depression symptomatology. In the follow-ups, the reduction in emotional symptomatology was greater in the condition which produced greater and more prolonged effects on Activation. Activation appears to be the principal condition in modifying all the transdiagnostic patterns and BA was the most efficacious and specific treatment. The trial was registered at ClinicalTrials.gov NCT04117464. Raw data are available online
Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.
Although approximately two thirds of patients with depression are treated successfully with medication alone,1 many patients do not respond to medication,2 have residual symptoms,3 or frequently relapse.4 Many patients may prefer a nonpharmacologic therapy or one that is consistent with their model of depression.1 Because cognitive therapy addresses many of these issues, family physicians should be familiar with its nature and uses.
Cognitive therapy was developed as a departure from traditional therapeutic approaches to mental illness.5 While working with patients, Aaron Beck, a pioneer in cognitive therapy, observed that negative moods and behaviors were usually the result of distorted thoughts and beliefs, not of unconscious forces as proposed in Freudian theory.5
The National Institute of Mental Health Treatment of Depression Collaborative Research Program compared the effectiveness of two forms of psychotherapy (i.e., interpersonal therapy and CBT) with imipramine (Tofranil) or placebo in the treatment of 250 patients with major depressive disorder.14 The study14 found no significant differences between the therapies; however, the two psychotherapies were slightly less effective than imipramine but more effective than placebo. A meta-analysis12 of four studies, which included 169 patients with major depression, showed similar results for tricyclic antidepressants and CBT. The evidence suggests that cognitive therapy is a valid alternative to antidepressants for patients with mild to moderate depression and possibly for patients with more severe depression. Figure 1 is an algorithm for determining if CBT is appropriate.
Early studies15,16 on the effectiveness of combination cognitive and antidepressant therapy had conflicting results. Later evidence suggests that this combination may be more effective than either therapy alone for some patients. A meta-analysis17 that included six studies and 595 patients showed that patients with severe depression benefited from the combination of psychotherapy and pharmacotherapy. However, only two trials studied CBT, and patients with less severe depression gained little from the combination.17 A more recent study18 of 681 patients with chronic major depression compared nefazodone (Serzone), CBT, and combination therapy. Patients benefited significantly more from combined CBT and antidepressant therapy than from either treatment alone (85 percent in the combined treatment group versus 55 percent for nefazodone alone and 52 percent for CBT alone; P
In addition to effectively managing acute episodes of unipolar major depression, cognitive therapy also can prevent relapse. One study4 showed that cognitive therapy significantly reduced the risk of relapse compared with discontinuation of medication. Cognitive therapy was similar to maintenance medication in preventing relapse.4 A meta-analysis11 that included eight studies showed that 29.5 percent of patients treated with cognitive therapy relapsed, compared with 60 percent of those treated with antidepressants. However, the studies were small (241 patients total), used tricyclic antidepressants, and did not specify the duration of therapy. Although these studies may not be conclusive for patients previously treated with antidepressants, cognitive therapy does seem to decrease the risk of relapse.
A more recent, larger study19 randomized 158 patients who did not respond to adequate antidepressant therapy to receive cognitive therapy with clinical management or clinical management alone. All patients continued pharmacotherapy, which is a common practice. Remission rates of major depression increased, and relapse rates significantly decreased in patients treated with cognitive therapy compared with those who were not (29 versus 47 percent, NNT = 6).19 Cognitive therapy seems to add to the effect of pharmacotherapy in patients with residual depression.
Family physicians usually are the first to diagnose and treat patients with depression. They should inform patients that psychotherapy and pharmacotherapy are valid options, and that cognitive therapy, and therefore CBT, is the most studied psychotherapy. If the patient and physician initially elect to use pharmacotherapy, and the patient does not respond adequately, the physician should again suggest adding psychotherapy or CBT. CBT should be strongly considered as initial therapy for patients with severe or chronic depression or for adolescents. If the patient declines referral, or if the family physician provides CBT, longer appointments could be scheduled. Resources are available for the physician and patient (Table 2), and further physician training should be considered.
With children and adolescents cognitive therapy is focused on breaking the circle at the thought phase. Having the child focus on the thought and bringing that step in the cycle come more under his or her control can help him or her to see the fallacies in the thoughts and thus repair his or her behavior to the reality of the situation rather than continue in the avoidance behaviors that are inappropriate. In hundreds if studies, cognitive therapy has been shown to be quite effective.
For the most common childhood conditions, like ADHD, behavior disorders, anxiety, or depression, approaches using behavior therapy and cognitive-behavior therapy are more likely to reduce symptoms, but there is limited information about which type of therapy is best for treating each specific childhood mental disorder.
Several randomised controlled trials (RCT) have demonstrated the superiority of transdiagnostic group cognitive-behavioural therapy (TD-CBT) to treatment as usual (TAU) for emotional disorders in primary care. To date, however, no RCTs have been conducted to compare TD-CBT to another active intervention in this setting. Our aim is to conduct a single-blind RCT to compare group TD-CBT plus TAU to progressive muscle relaxation (PMR) plus TAU in adults (age 18 to 65 years) with a suspected emotional disorder. We expect that TD-CBT + TAU will be more cost-effective than TAU + PMR, and that these gains will be maintained at the 12-month follow-up. Seven therapy sessions (1.5 hours each) will be offered over a 24-week period. The study will be carried out at four primary care centres in Cantabria, Spain. The study will take a societal perspective. Psychological assessments will be made at three time points: baseline, post-treatment, and at 12-months. The following variables will be evaluated: clinical symptoms (anxiety, depression, and/or somatic); functioning; quality of life (QoL); cognitive-emotional factors (rumination, worry, attentional and interpretative biases, emotion regulation and meta-cognitive beliefs); and satisfaction with treatment. Data on health service use, medications, and sick days will be obtained from electronic medical records. Primary outcome measures will include: incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICURs). Secondary outcome measures will include: clinical symptoms, QoL, functioning, and treatment satisfaction. Bootstrap sampling will be used to assess uncertainty of the results. Secondary moderation and mediation analyses will be conducted. Two questionnaires will be administered at sessions 1, 4, and 7 to assess therapeutic alliance and group satisfaction. If this trial is successful, widespread application of this cost-effective treatment could greatly improve access to psychological treatment for emotional disorders in the context of increasing demand for mental healthcare in primary care. 041b061a72