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1.  On the Learning Curve: The Emerging Evidence Supporting Cognitive-Behavioral Therapies for Adolescent Substance Abuse 
Addiction (Abingdon, England)  2004;99(Suppl 2):93-105.
Cognitive–behavioral therapy (CBT) approaches to intervention for adolescent substance use disorders has been limited and formal controlled clinical efficacy trials have been rare. Moreover, the early literature on the efficacy of CBT for adolescent substance abuse has been characterized by significant methodological limitations. Recent innovations in the treatment of adolescent substance abuse and the recent completion of several randomized clinical trials has brightened the picture with respect to establishing the empirical support for CBT. The aim of this review is to integrate the findings from controlled trials of CBT for adolescent substance abuse.
Studies representing randomized clinical trials were reviewed using criteria provided by Lonigan et al. and Nathan & Gorman as a guide.
Findings and conclusions
Despite some prominent differences in design and methodology, the studies reviewed provide consistent empirical evidence that group and individual CBT are associated with significant and clinically meaningful reductions in adolescent substance use. The evidence for the efficacy of group therapy is particularly important, countering the assertion that aggregating problem youths into group treatment settings is associated with iatrogenic effects. The findings from the randomized trials reviewed represent significant developments in treatment outcome research and lay the foundation for validating CBT for adolescent substance use disorders. Future research directions include improving short- and long-term outcomes, enhancing treatment motivation and engagement, and identifying mechanisms and processes associated with positive change, especially for youths with comorbid conditions.
PMCID: PMC1781376  PMID: 15488108
Adolescent substance abuse; cognitive behavior therapy; treatment outcome
2.  Coping Strategy Use following Computerized Cognitive-Behavioral Therapy for Substance Use Disorders 
Coping strategies are emerging as a predictor of treatment outcome for substance users, and may be particularly important among computerized and self-change approaches. We used data from a randomized clinical trial of a computer-based version of cognitive-behavioral therapy (CBT4CBT), in order to: (1) examine the association between observer ratings of coping skills and self-reported coping strategies; (2) evaluate whether participants assigned to the CBT4CBT program reported greater use of coping strategies compared with those not exposed to the program; and (3) examine the differential effect of coping strategies by treatment group on drug-related outcomes. Individuals (N = 77) seeking treatment for substance dependence at a community-based outpatient substance abuse treatment facility were recruited and randomized to receive treatment-as-usual (TAU), or TAU plus CBT4CBT, with the Coping Strategies Scale administered at baseline and post-treatment. Self-reported coping strategy use was strongly correlated with observer ratings on a role-play assessment of coping skills. Although no significant group differences were found across time for coping strategy use, results suggested that as coping strategy use increased, drug use decreased, and this relationship was stronger for participants who received CBT4CBT.
PMCID: PMC3059590  PMID: 21198228
Cognitive-behavioral therapy; coping strategies; coping skills; computer; substance abuse
3.  Cognitive-behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: A preliminary study 
Cognitive behaviour therapy  2010;39(1):24-27.
Lack of motivation may negatively impact cognitive behavioral therapy (CBT) response for pediatric patients with obsessive-compulsive disorder (OCD). Motivational interviewing is a method for interacting with patients in order to decrease their ambivalence and support their self-efficacy in their efforts at behavior change. This paper presents a preliminary randomized trial (N = 16) to evaluate the effectiveness of adding motivational interviewing (MI) as an adjunct to CBT. Patients aged 6–17 who were participating in intensive family-based CBT for OCD were randomized to receive either CBT plus MI or CBT plus extra psychoeducation sessions. Results indicated that after 4 sessions, the mean CY-BOCS score for the CBT+MI group was significantly lower than for the CBT+psychoeducation group (t(14) = 2.51, p < .03, Cohen’s d = 1.34). In addition, the degree of reduction in CY-BOCS scores was significantly greater (t(14) = 2.14, p = .05, Cohen’s d = 1.02) for the CBT+MI group (mean change = 16.75, SD = 9.66) than for the CBT+psychoeducation group (mean change = 8.13, SD = 6.01). This effect decreased over time, and scores at post-treatment were not significantly different. However, participants in the MI group completed treatment on average three sessions earlier than those in the psychoeducation group, providing support for the utility of MI in facilitating rapid improvement and minimizing the burden of treatment for families.
PMCID: PMC2861340  PMID: 19675960
Children; Anxiety; Treatment outcome; Psychotherapy
4.  Cognitive Behavioral Treatment for Posttraumatic Stress Disorder in Children and Adolescents 
A number of Cognitive Behavioral Therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). Similar to other CBT treatments, particularly those for anxiety disorders, these treatments all include common elements (e.g., psychoeducation, relaxation and affective modulation skills, exposure). The goals of this review are to: 1) delineate common elements in CBT approaches for treating child and adolescent PTSD; 2) provide a detailed review of two CBT approaches with substantial evidence of effectiveness; and 3) describe “Promising Practices,” in the area of CBT approaches to treating child and adolescent PTSD. The two treatments reviewed in detail are Trauma-focused Cognitive Behavioral Therapy (TF-CBT) and Cognitive Behavioral Intervention for Trauma in Schools (CBITS). For these treatments, we describe the research evidence to date, specific elements of the treatment model, and discuss implementation and cultural considerations. In the “Promising Practices” section, other CBT approaches are reviewed that include many of the common elements; however, these approaches have accumulated less evidence of effectiveness to date. Research on CBT approaches to treating PTSD is ongoing, with a growing focus on explicit consideration of the multiple systems in which youth exposed to trauma are involved, and ways to better address co-occurring difficulties (e.g. serious behavior problems, substance use). Future directions for the field are discussed. These include further study of promising practices, cultural applicability of CBT approaches to treating PTSD, and strategies to enhance implementation and dissemination efforts to improve access to high-quality, evidence-based care for children and adolescents with PTSD.
PMCID: PMC3088728  PMID: 21440854
PTSD; children; adolescents; cognitive behavioral; treatment
5.  Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT 
The American journal of psychiatry  2008;165(7):881-888.
To evaluate the efficacy of a computer-based version of cognitive behavioral therapy (CBT) for substance dependence.
This was a randomized clinical trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomized to standard treatment or standard treatment with biweekly access to computer-based training in CBT (CBT4CBT).
Treatment retention and data availability were comparable across the treatment conditions. Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs and tended to have longer continuous periods of abstinence during treatment. The CBT4CBT program was positively evaluated by participants. In the CBT4CBT condition, outcome was more strongly associated with treatment engagement than in TAU; further, completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of treatment involvement.
These data suggest that CBT4CBT is an effective adjunct to standard outpatient treatment for substance dependence and may provide an important means of making CBT, an empirically validated treatment, more broadly available.
PMCID: PMC2562873  PMID: 18450927
Behavior Therapy; Cognitive Therapy; Psychoactive Substance Use Disorder; Computers
6.  Investigating the efficacy of integrated cognitive behavioral therapy for adult treatment seeking substance use disorder patients with comorbid ADHD: study protocol of a randomized controlled trial 
BMC Psychiatry  2013;13:132.
Attention deficit hyperactivity disorder (ADHD) frequently co-occurs with substance use disorders (SUD). The combination of ADHD and SUD is associated with a negative prognosis of both SUD and ADHD. Pharmacological treatments of comorbid ADHD in adult patients with SUD have not been very successful. Recent studies show positive effects of cognitive behavioral therapy (CBT) in ADHD patients without SUD, but CBT has not been studied in ADHD patients with comorbid SUD.
This paper presents the protocol of a randomized controlled trial to test the efficacy of an integrated CBT protocol aimed at reducing SUD as well as ADHD symptoms in SUD patients with a comorbid diagnosis of ADHD. The experimental group receives 15 CBT sessions directed at symptom reduction of SUD as well as ADHD. The control group receives treatment as usual, i.e. 10 CBT sessions directed at symptom reduction of SUD only. The primary outcome is the level of self-reported ADHD symptoms. Secondary outcomes include measures of substance use, depression and anxiety, quality of life, health care consumption and neuropsychological functions.
This is the first randomized controlled trial to test the efficacy of an integrated CBT protocol for adult SUD patients with a comorbid diagnosis of ADHD. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.
Trial registration
This trial is registered in as NCT01431235.
PMCID: PMC3659028  PMID: 23663651
ADHD; SUD; Cognitive behavioral therapy; Adult; Integrated treatment
7.  Cognitive-Behavioural Therapy for Individuals with Bulimia Nervosa and a Co-Occurring Substance Use Disorder 
A significant percentage of individuals with bulimia nervosa (BN) also can be diagnosed with a co-occurring substance use disorder (SUD). Although studies have addressed the frequency of overlap between the disorders, etiology and shared personality traits, limited research is available about the treatment of these comorbid patients. Adapting cognitive-behaviour therapy (CBT) to serve as an integrated treatment for patients with both BN and a SUD is a viable option, as studies of CBT suggest that this form of treatment is efficacious for both disorders independently. The shared strategies in CBT for BN and SUDs facilitate the development of a combined treatment for individuals with both disorders with the addition of modules designed to address some common features of these disorders, such as motivation, difficulty with interpersonal relationships, reward sensitivity and impulsivity. Future research should begin to evaluate the efficacy of an integrated CBT in treating individuals with BN and a SUD.
PMCID: PMC2990777  PMID: 19130465
cognitive behavioural therapy; eating disorders; bulimia nervosa; substance use disorders
8.  The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods 
This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7–17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.
PMCID: PMC2646688  PMID: 19183470
9.  Efficacy of “seeking safety” in a Dutch population of traumatized substance-use disorder outpatients: study protocol of a randomized controlled trial 
BMC Psychiatry  2013;13:162.
Traumatic experiences and, more specifically, posttraumatic stress disorder (PTSD) are highly prevalent among substance use disorder (SUD) patients. This comorbidity is associated with worse treatment outcomes in substance use treatment programs and more crisis interventions. International guidelines advise an integrated approach to the treatment of trauma related problems and SUD. Seeking Safety is an integrated treatment program that was developed in the United States. The aim of the current study is to test the efficacy of this program in the Netherlands in an outpatient SUD population.
A randomized controlled trial (RCT) will be used to test the efficacy of Seeking Safety compared to Cognitive Behavioral Therapy (CBT) in a population of SUD outpatients. Each treatment will consist of 12 group sessions. The primary outcome measure will be substance use severity. Secondary outcome measures are PTSD and trauma symptoms, coping skills, functioning, and cognitions. Questionnaires will be administered at the start of treatment, at the end of treatment (three months after the start of treatment) and at follow-up (six months after the start of treatment).
This study protocol presents a RCT in which the efficacy of an integrated treatment for comorbid PTSD and SUD, Seeking Safety, is evaluated in a SUD outpatient population compared to CBT. It is expected that the intervention group will show significantly more improvement in substance use severity compared to the control group at end-of-treatment and at follow-up. Furthermore, a lower drop-out rate is expected for the intervention group. If the intervention proves to be effective, it can be implemented. A cost-effectiveness analysis will be conducted to evaluate the two treatments.
Trial registration
The protocol for this study is registered with the Netherlands Trial Register with number NTR3084 and approved by the local medical ethical committee (METC\11270.haa).
PMCID: PMC3679962  PMID: 23735118
Seeking safety; Randomized controlled trial; CBT; Substance use; PTSD; Comorbidity
10.  The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses 
Cognitive therapy and research  2012;36(5):427-440.
Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.
PMCID: PMC3584580  PMID: 23459093
CBT; efficacy; meta-analyses; comprehensive review
11.  Quality vs. Quantity: Acquisition of Coping Skills Following Computerized Cognitive Behavioral Therapy for Substance Use Disorders 
Addiction (Abingdon, England)  2010;105(12):2120-2127.
To evaluate the changes over time in quality and quantity of coping skills acquired following cognitive behavioral therapy (CBT), and examine potential mediating effects on substance use outcomes.
A randomized controlled trial (RCT) evaluating the effectiveness of a computerized version of CBT (CBT4CBT) as an adjunct to standard outpatient treatment over an 8-week period.
Data were collected from individuals seeking treatment for substance dependence in an outpatient community setting.
Fifty-two substance abusing individuals (50% African American), with an average age of 42 years, and a majority reporting cocaine as their primary drug of choice.
Participants’ responses to behavioral role-plays of situations associated with high risk for drug and alcohol use were audio-taped and independently rated to assess their coping responses.
There were statistically significant increases in mean ratings of the quality of participants’ coping responses for those assigned to CBT4CBT compared to treatment as usual, and these differences remained significant three months after treatment completion. Moreover, quality of coping responses mediated the effect of treatment on participants’ duration of abstinence during the follow-up period.
These findings suggest that assignment to the computerized CBT program improved participants’ coping skills, as measured by independent ratings of a role playing task. It is also the first study to test and support quality of coping skills acquired as a mediator of the effect of CBT for substance use.
PMCID: PMC2975828  PMID: 20854334
Coping skills; Mediator; Computer-assisted therapy; CBT; Substance Use
12.  History of Cognitive-Behavioral Therapy (CBT) in Youth 
CBT represents a combination of behavioral and cognitive theories of human behavior and psychopathology, and a melding of emotional, familial, and peer influences. The numerous intervention strategies that comprise CBT reflect its complex and integrative nature and include such topics as extinction, habituation, modeling, cognitive restructuring, problem-solving, and the development of coping strategies, mastery, and a sense of self-control. CBT targets multiple areas of potential vulnerability (e.g., cognitive, behavioral, affective) with developmentally-guided strategies and traverses multiple intervention pathways. Although CBT is often considered the “first line treatment” for many psychological disorders in youth, additional work is necessary to address treatment non-responders and to facilitate the dissemination of efficacious CBT approaches.
PMCID: PMC3077930  PMID: 21440849
Cognitive-behavioral therapy; CBT; cognitive therapy; behavior therapy; children; adolescents; history
13.  The Impact of Disruptive Behavior Disorder on Substance Use Treatment Outcome in Adolescents 
Journal of substance abuse treatment  2012;44(5):10.1016/j.jsat.2012.11.003.
The current study examined the impact of disruptive behavior disorder (DBD) on substance use outcomes in an adolescent sample. Sixty-eight adolescents and their caregivers were randomized to one of two fourteen-week, outpatient treatments: Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT) + Parent Management Training + Contingency Management (CM; experimental) and MET/CBT + Parent Drug Education (attention control). This study assessed abstinence, substance use, externalizing behavior, and parenting outcomes over five assessment periods for youth with DBD (DBD+) and without DBD (DBD−). Results showed DBD+/experimental adolescents reported fewer days of marijuana use than DBD+/control adolescents. Results also showed that parents of DBD− adolescents in the experimental condition reported significantly better parenting outcomes compared to DBD−/control. Substance abuse treatment for adolescents with DBD which includes a component such as contingency management and parent training has the potential to contribute to substance use outcomes. Such treatment strategies, however, should include additional support for parents.
PMCID: PMC3882152  PMID: 23228436
contingency management; adolescents; substance abuse; disruptive behavior disorder; marijuana
14.  Relationship of Cognitive Function and the Acquisition of Coping Skills in Computer Assisted Treatment for Substance Use Disorders 
Drug and alcohol dependence  2010;114(2-3):169-176.
Coping skills training is an important component of cognitive behavioral therapy (CBT), yet cognitive impairment and related limitations that are often associated with chronic substance use may interfere with an ability to learn, retain, or use new information. Little previous research has examined the cognitive or neuropsychological factors that may affect substance users' ability to learn new coping skills in CBT.
Fifty-two substance dependent individuals randomized to receive a computerized version of cognitive behavioral therapy (CBT4CBT) or treatment as usual (TAU) were administered several cognitive and neuropsychological measures, as well as a coping skills measure prior to and upon completing an 8-week treatment period.
Across treatment conditions, participants who scored above the median on a measure of IQ demonstrated greater improvement in the quality of their coping skills than those below the median on IQ (Group × Time, F(1,49) = 4.31, p<.05). Also, IQ had a significant indirect effect on substance use outcomes through an effect on the quality of coping skills acquired, specifically for those who received CBT4CBT.
Individuals with higher IQ at baseline improved the quality of their coping skills more than those with lower IQ, which in turn reduced rates of substance use following treatment. This highlights the impact of substance users' cognitive functioning and abilities on the acquisition of coping skills from CBT, and suggests need for greater awareness and tailoring of coping skills training for those with poorer functioning.
PMCID: PMC3046302  PMID: 21050679
Coping Skills; Cognitive Behavioral Therapy; Cognitive Function; Indirect Effects
15.  Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less 
Addiction (Abingdon, England)  2012;107(9):1650-1659.
To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive–behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence.
Community-based out-patient treatment program in New Haven, Connecticut, USA.
Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion.
A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years).
Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method.
Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups.
Combining contingency management and cognitive–behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.
PMCID: PMC3509418  PMID: 22404223
Cannabis dependence; cognitive behavioral therapy; contingency management; criminal justice system; randomized clinical trial
16.  Adolescent Health-Risk Sexual Behaviors: Effects of a Drug Abuse Intervention 
AIDS and behavior  2011;15(8):1664-1676.
Adolescents who abuse substances are more likely to engage in health-risking sexual behavior (HRSB) and are at particularly high risk for HIV/AIDS. Thus, substance abuse treatment presents a prime opportunity to target HIV-risk behaviors. The present study evaluated a one-session HIV-risk intervention embedded in a controlled clinical trial for drug-abusing adolescents. The trial was conducted in New Mexico and Oregon with Hispanic and Anglo adolescents. Youths were randomly assigned to individual cognitive behavior therapy (CBT) or to an integrated behavioral and family therapy (IBFT) condition, involving individual and family sessions. The HIV-specific intervention was not associated with change. IBFT and CBT were both efficacious in reducing HIV-risk behaviors from intake to the 18-month follow-up for high-risk adolescents. For low-risk adolescents, CBT (versus IBFT) was more efficacious in suppressing HRSB. These data suggest that drug abuse treatments can have both preventative and intervention effects for adolescents, depending on their relative HIV-risk.
PMCID: PMC3215274  PMID: 21833690
Adolescent; Substance-abuse; Treatment; HIV-risk
Psychotherapy (Chicago, Ill.)  2008;45(2):135-147.
Cognitive– behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed.
PMCID: PMC2770198  PMID: 19881891
integrative therapy; cognitive-behavioral therapy; generalized anxiety disorder
18.  Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study 
Generalized anxiety disorder (GAD) is a prevalent psychiatric condition in older adults with deleterious effects on health and cognition. Although selective serotonin reuptake inhibitor (SSRI) medications have some efficacy as acute treatments for geriatric GAD, incomplete response is the most common outcome of monotherapy. We therefore developed a novel sequential treatment strategy, using personalized, modular cognitive-behavioral therapy (mCBT) to augment SSRI medication.
In an open label pilot study (N =10), subjects received a sequenced trial of 12 weeks of escitalopram followed by 16 weeks of escitalopram augmented with mCBT. We also examined the maintenance effects of mCBT over a 28-week follow-up period following drug discontinuation and termination of psychotherapy.
Results suggest that (1) adding mCBT to escitalopram significantly reduced anxiety symptoms and pathological worry, resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn.
Findings suggest that mCBT may be an effective augmentation strategy when added to SSRI medication and provide limited support for the long-term benefit of mCBT after discontinuation of pharmacotherapy.
PMCID: PMC4070295  PMID: 20872925
aged; elderly; cognitive therapy; behavior therapy; drug therapy; psychotherapy; selective serotonin reuptake inhibitor
19.  Peer mentorship to promote effective pain management in adolescents: study protocol for a randomised controlled trial 
Trials  2011;12:132.
This protocol is for a study of a new program to improve outcomes in children suffering from chronic pain disorders, such as fibromyalgia, recurrent headache, or recurrent abdominal pain. Although teaching active pain self-management skills through cognitive-behavioral therapy (CBT) or a complementary program such as hypnotherapy or yoga has been shown to improve pain and functioning, children with low expectations of skill-building programs may lack motivation to comply with therapists' recommendations. This study will develop and test a new manualized peer-mentorship program which will provide modeling and reinforcement by peers to other adolescents with chronic pain (the mentored participants). The mentorship program will encourage mentored participants to engage in therapies that promote the learning of pain self-management skills and to support the mentored participants' practice of these skills. The study will examine the feasibility of this intervention for both mentors and mentored participants, and will assess the preliminary effectiveness of this program on mentored participants' pain and functional disability.
This protocol will recruit adolescents ages 12-17 with chronic pain and randomly assign them to either peer mentorship or a treatment-as-usual control group. Mentored participants will be matched with peer mentors of similar age (ages 14-18) who have actively participated in various treatment modalities through the UCLA Pediatric Pain Program and have learned to function successfully with a chronic pain disorder. The mentors will present information to mentored participants in a supervised and monitored telephone interaction for 2 months to encourage participation in skill-building programs. The control group will receive usual care but without the mentorship intervention. Mentored and control subjects' pain and functioning will be assessed at 2 months (end of intervention for mentored participants) and at 4 month follow-up to see if improvements persist. Measures of treatment adherence, pain, disability, and anxiety and depression will be assessed throughout study participation. Qualitative interviews for mentors, mentored participants, and control subjects will also be administered.
Trial registration NCT01118988.
PMCID: PMC3113991  PMID: 21600053
20.  Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial 
The evidence base for trauma-focused cognitive behavioral therapy (TF-CBT) to treat posttraumatic stress disorder (PTSD) in youth is compelling, but the number of controlled trials in very young children is few and limited to sexual abuse victims. These considerations plus theoretical limitations have led to doubts about the feasibility of TF-CBT techniques in very young children. This study examined the efficacy and feasibility of TF-CBT for treating PTSD in three through six year-old children exposed to heterogeneous types of traumas.
Procedures and feasibilities of the protocol were refined in Phase 1 with 11 children. Then 64 children were randomly assigned in Phase 2 to either 12-session manualized TF-CBT or 12-weeks wait list.
In the randomized design the intervention group improved significantly more on symptoms of PTSD, but not on depression, separation anxiety, oppositional defiant, or attention deficit/hyperactivity disorders. After the waiting period, all participants were offered treatment. Effect sizes were large for PTSD, depression, separation anxiety, and oppositional defiant disorders, but not attention-deficit/hyperactivity disorder. At six-month follow-up, the effect size increased for PTSD, while remaining fairly constant for the comorbid disorders. The frequencies with which children were able to understand and complete specific techniques documented the feasibility of TF-CBT across this age span. The majority were minority race (Black/African-American) and without a biological father in the home, in contrast to most prior efficacy studies.
These preliminary findings suggest that TF-CBT is feasible and more effective than a wait list condition for PTSD symptoms, and the effect appears lasting. There may also be benefits for reducing symptoms of several comorbid disorders. Multiple factors may explain the unusually high attrition, and future studies ought to oversample on these demographics to better understand this understudied population.
PMCID: PMC3116969  PMID: 21155776
posttraumatic stress disorder; cognitive behavioral therapy; children
21.  Cognitive Behavioral Therapy for Anxiety Disorders in Youth 
Cognitive behavioral therapies (CBTs) have been shown to be efficacious for the treatment of anxiety disorders in children and adolescents. Randomized clinical trials indicate that approximately two-thirds of children treated with CBT will be free of their primary diagnosis at posttreatment. Although several CBT treatment packages have been investigated in youth with diverse anxiety disorders, common core components have been identified. A comprehensive assessment, development of a good therapeutic relationship and working alliance, cognitive restructuring, repeated exposure with reduction of avoidance behavior, and skills training comprise the core procedures for the treatment of anxiety disorders in youth.
PMCID: PMC3091167  PMID: 21440852
anxiety; cognitive therapy; behavioral therapy; children; adolescents
22.  Counselor training in several evidence-based psychosocial addiction treatments in private US substance abuse treatment centers 
Drug and Alcohol Dependence  2011;120(1-3):149-154.
Given that most addiction counselors enter the field unprepared to implement psychosocial evidence-based practices (EBPs), surprisingly little is known about the extent to which substance abuse treatment centers provide their counselors with formal training in these treatments. This study examines the extent of formal training that treatment centers provide their counselors in cognitive behavioral therapy (CBT), motivational interviewing (MI), contingency management (CM), and brief strategic family therapy (BSFT).
Face-to-face interviews with 340 directors of a nationally representative sample of privately funded US substance abuse treatment centers.
Although a substantial number of treatment centers provide their counselors with formal training in EBPs that they use with their clients, coverage is far from complete. For example, of those centers that use CBT, 34% do not provide their counselors with any formal training in CBT (either initially or annually), and 61% do not provide training in CBT that includes supervised training cases. Sizable training gaps exist for MI, CM, and BSFT as well.
The large training gaps found in this study give rise to concerns regarding the integrity with which CBT, MI, CM, and BSFT are being delivered by counselors in private US substance abuse treatment centers. Future research should examine the generalizability of our findings to other types of treatment centers (e.g., public) and to the implementation of other EBPs.
PMCID: PMC3275814  PMID: 21831536
dissemination; implementation; training; evidence-based practice
23.  All Might Have Won, But Not All Have the Prize: Optimal Treatment for Substance Abuse Among Adolescents with Conduct Problems 
Considerable evidence from the literature on treatment outcomes indicates that substance abuse treatment among adolescents with conduct problems varies widely. Treatments commonly used among this population are cognitive-behavioral therapy (CBT), 12-step facilitation, multisystemic therapy (MST), psychoeducation (PE), and motivational interviewing (MI). This manuscript thoroughly and systematically reviews the available literature to determine which treatment is optimal for substance-abusing adolescents with conduct problems. Results suggest that although there are several evidence-based and empirically supported treatments, those that incorporate family-based intervention consistently provide the most positive treatment outcomes. In particular, this review further reveals that although many interventions have gained empirical support over the years, only one holds the prize as being the optimal treatment of choice for substance abuse treatment among adolescents with conduct problems.
PMCID: PMC3498967  PMID: 23170066
substance use; adolescence; treatment outcome; conduct problems
24.  A controlled trial of the adjunct use of D-Cycloserine to facilitate cognitive behavioral therapy outcomes in a cocaine-dependent population 
Addictive Behaviors  2012;37(8):900-907.
Cocaine dependence is a chronically relapsing disorder for which its predominant behavioral therapies are associated with only partial efficacy. The goal of this study was to determine if the N-methyl-D-aspartate (NMDA) glutamate receptor partial agonist and cognitive enhancer, D-Cycloserine (DCS), could boost the cocaine abstinence and treatment retention goals of cognitive behavioral therapy (CBT). This study employed a placebo-controlled, randomized double-blind trial design of 44 cocaine-dependent men enrolled in a 4-week outpatient Substance Abuse Treatment Program (SATP) at the Atlanta Veteran’s Administration Medical Center. Subjects received 50 mg of DCS or placebo prior to four weekly sessions of a condensed version of a manual-based CBT for cocaine dependence. Cocaine abstinence and treatment retention measures represented primary outcome variables. Relative to a 12-step based treatment-as-usual, an under-dosed CBT was associated with significant improvements in drug abstinence and treatment retention at 4-weeks and for maintenance of drug abstinence after four more weeks of follow-up. The robust response to the under-dosed CBT was not enhanced by the adjunct administration of DCS at either the 4- or 8- week endpoints. This controlled clinical trial failed to demonstrate an ability of DCS to boost the relapse prevention or treatment retention goals of CBT.
PMCID: PMC3366369  PMID: 22578380
D-Cycloserine; addiction; cognitive behavioral therapy; cocaine; clinical trial; memory
25.  Engaging Resistant Adolescents in Drug Abuse Treatment 
In the first phase of a two-part treatment development study, families with a treatment-resistant, drug-abusing adolescent (n=42) were offered 12 sessions of Community Reinforcement and Family Training (CRAFT). This parent-focused intervention was designed to help parents facilitate their adolescents' entry in treatment and support adolescents' subsequent behavior change and to improve parent and family functioning. In the second phase, successfully engaged adolescents (n=30) were offered 12 sessions of a multicomponent individual cognitive behavioral therapy (CBT) targeting substance use and related problem behaviors. Measures were collected at pre- and post-treatment for parents and adolescents, with an additional follow-up assessment for parents at 3-months post-treatment. Parents in the CRAFT intervention experienced a significant reduction in negative symptoms and 71% of parents were successful in engaging their resistant youth in treatment. The CBT intervention for the engaged youth was associated with a statistically significant, but not clinically significant, reduction in marijuana use.
PMCID: PMC2175207  PMID: 17306722
Adolescents; substance abuse; treatment engagement; CRAFT; treatment outcome

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