interventions have been demonstrated to be effective in reducing symptoms associated with anxiety and ... OCD) and depressive disorders treated with CBT were significant among clients treated in a training clinic setting. Moreover, these ...
CBT for Anxiety and Depression is Effective Regardless of Social and Work Impairment Severity Raymond C. Hawkins, II1,2 & Christopher B. Harte2 1Fielding Graduate University 2University of Texas at Austin 3Harte Behavioral Health, LLC Abstract
Table 2: 3: Proportions of the diagnostic groups showing reliable change (RC) or Table clinically significant improvement (CS)
Table 1: Demographics of the participant sample
Symptom reduction and recovery rates for anxiety disorders (social anxiety disorder, GAD, panic disorder, OCD) and depressive disorders treated with CBT were significant among clients treated in a training clinic setting. Moreover, these results were unsusceptible to pre-treatment levels of social and work impairment.
§ Clients across all diagnostic groups showed generally reliable improvement or clinically significant change (40% - 80%), and 63% met criteria for recovery on at least one outcome measure (71% were clinically significant). § In terms of moderation by pre-treatment measures of social and work impairment severity as estimated by the baseline OQ-45 and Sheehan Disability Scales, the SP and MDD groups had higher levels of both social and work difficulties compared with the PD group, whereas the PD group showed lower levels of social impairment compared with the GAD and OCD groups. § Findings were not significant for the association between social and work impairments and effectiveness of CBT symptom response (reliable change) and recovery (recovered vs. non-recovered). Also, symptom-recovered cases generally reported significant improvements in both social and occupational functioning at end-treatment. § Study limitations include the small sample sizes of the treatment groups having complete pre-treatment and outcome measures, and the reliance upon client selfreport measures of social and work functioning without confirmation from collateral informants. § Although these findings are in need of replication and verification via randomized controlled experiments, we provisionally conclude that manualized CBT for anxiety and depressive disorders is robust to interference from social and work impairments, even when these disorders are treated by graduate student trainees.
Introduction § Manualized CBT interventions have been demonstrated to be effective in reducing symptoms associated with anxiety and depressive conditions.1,3 These findings have been observed not only among clinical trials but also among effectiveness studies.2,5 § In an effort to extend these prior findings, we examined: (1) the effectiveness of manualized CBT for mood and anxiety conditions delivered in a naturalistic setting; and (2) whether pre-treatment characteristics such as social and work impairments influenced treatment outcomes. § CBT outcomes were gathered from a practice research database. Cases were categorized into 1 of 5 diagnostic groups according to SCID-I primary diagnosis (social anxiety disorder [SP], generalized anxiety disorder [GAD], panic disorder with or without Agoraphobia [PD], obsessive-compulsive disorder [OCD], and major depressive disorder / dysthymia [MDD]). Treatment was provided according to empirically-supported CBT treatment manuals. § Rates of positive treatment response (reliable change) and recovery (both reliable change and clinically significant change to below pre-determined cut-off scores4) were assessed using gold-standard CBT domain-specific outcome measures. § Our second purpose was to determine if pretreatment levels of social and work functioning affected treatment results. Several scale scores from the Outcome Questionnaire 45.2 and the Sheehan Disability Scale were examined as pre-treatment variables.
Method § In our training clinic archival database (N=606) there were 340 cases (140 men, 200 women) treated with manualized CBT for anxiety and/or depression (i.e., for the 5 diagnostic groups, see Table 1) for a mean of 15 sessions (SD 15.2; Median = 13 sessions). § Cases were categorized into one of five diagnostic groups according to SCID-I primary diagnosis. § Several scale scores from the Outcome Questionnaire 45.2 (i.e. Interpersonal Relations and Social Role Functioning) and the Sheehan Disability Scales (i.e., Work, Social, Family, Global Score) were examined as pre-treatment variables to determine if they moderated treatment outcomes on CBT measures (Table 2).
Table 2:
Discussion
Outcome measures - baseline & end-treatment scores
References
Results § Rates of positive treatment response (reliable change), clinically significant improvement, and recovery (both reliable change and clinically significant change to below predetermined cut-off scores) were assessed using gold-standard CBT domain-specific outcome measures. § Results indicated that all diagnostic groups demonstrated significant reductions in targeted axis I symptoms (Table 2). § Table 3 shows clients across all diagnostic groups had generally reliable improvement or clinically significant change (40% - 80%) and 63% met criteria for recovery on at least one outcome measure (71% CS).
§ After controlling for client's sex, age, psychiatric comorbidity, and # of CBT sessions, there were statistically significant differences among the five diagnostic groups with respect to social and work impairment levels (F = 2.03, p =.04, partial eta2=.06). § Specifically, the SP and MDD groups had higher levels of both social and work difficulties compared with the PD group, whereas the PD group showed lower levels of social impairment compared with the GAD and OCD groups. § Analyses were not significant with respect to the association between social and work impairment levels on the effectiveness of CBT symptom outcomes in terms of symptom response (reliable change) and recovery (recovered vs. non-recovered).
§ Moreover, symptom-recovered cases generally reported significant improvements in both social and occupational functioning at end-treatment. ABBREVIATIONS: Pre-treatment and Outcome measures -
OQ45 IR, Interpersonal Relationships; SR - Social Role Functioning; Sheehan Disability Scales; LSAS (Leibowitz Social Anxiety Scale), ASC (Appraisal of Social Concerns), SPAI (Social Phobia Appraisal Inventory) for SP; PSWQ (Penn State Worry Questionnaire) for GAD; ASI (Anxiety Sensitivity Scale), PAI (Panic Appraisal Inventory) for PD; YBOCS (YaleBrown OC Scale) for OCD; and BDI-II and ATQ30 (Automatic Thoughts Questionnaire) for MDD.
1. Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31. 2. Hans, E., & Hiller, W. (2013). Effectiveness of and dropout from outpatient cognitive behavioral therapy for adult unipolar depression: A meta-analysis of nonrandomized effectiveness studies. Journal of Consulting and Clinical Psychology, 81, 75-88. 3. Hofmann, S.G., Asnaani, A., Vonk, I.J., Sawyer, A.T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-anlayses. Cognitive Therapy & Research, 36, 427-440. 4. Jacobson, N.S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19. 5. Stewart, R., & Chambless, D. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A metaanalysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77, 595-606.
Acknowledgments We thank Martita Lopez, Ph.D., Jasper Smits, Ph.D., Michael Telch, Ph.D., David Collins, Ph.D., and all graduate student clinicians who supervised, screened, assessed, and treated these patients. We also thank all patients who took part in this study.
