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1.  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
2.  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
3.  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
4.  The cost-effectiveness of four treatments for marijuana dependence 
Addiction (Abingdon, England)  2007;102(9):1443-1453.
To analyze data from a randomized clinical trial to determine the cost-effectiveness of using contingency management (CM) and motivational/skills building therapy (motivational enhancement therapy/cognitive-behavioral therapy: MET/CBT) to treat young adults with marijuana dependence.
Participants, design and measurements
A total of 136 marijuana-dependent young adults, all referred by the criminal justice system, were randomized to one of four treatment conditions: MET/CBT with CM, MET/CBT without CM, drug counseling (DC) with CM and DC without CM. Patient outcome measures include the longest duration of confirmed marijuana abstinence (LDA) during treatment and the total number of marijuana-free urine specimens provided during treatment. Costs were collected retrospectively from the provider and include the costs of therapy, patient drug testing, and those associated with the incentives component (value of vouchers, time to administer the voucher system).
Out-patient substance abuse clinic in New Haven, Connecticut, USA.
Which treatment is the most cost-effective depends on the threshold values of an additional week of LDA or an additional marijuana-free urine specimen. For example, the most effective treatment, MET/CBT with CM, was also the most cost-effective treatment at the highest threshold values, while the least effective treatment, DC, was the most cost-effective at the lowest values. Because consensus threshold values for these patient outcomes do not exist, results are presented showing the ranges of values over which each treatment would be considered cost-effective compared to the others. Acceptability curves are presented to show the decision uncertainty associated with these ranges. The results are shown to be robust to (i) sensitivity analyses on several key cost parameters and (ii) patient outcomes measured during the 6-month follow-up period.
This study uses incremental cost-effectiveness ratios and acceptability curves to shed light on the relative cost-effectiveness of four interventions for treating young adults with marijuana dependence. Given the relatively small and specialized nature of our study sample, and the fact that we examined a CM procedure with a single reinforcement schedule, additional studies are warranted to determine the reliability and generalizability of our results both to alternative marijuana-using populations and to CM procedures with alternative incentive parameters. Nevertheless, the relative durability of effects of MET/CBT compared to DC through the 6-month follow-up, and its cost-effectiveness over a comparatively wide range of threshold values, underscores the promise of this approach.
PMCID: PMC2398724  PMID: 17645430
Acceptability curves; contingency management; cost-effectiveness; marijuana dependence; motivational/skills building therapy; treatment; young adults
5.  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
6.  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
7.  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
8.  Virtual Reality for Enhancing the Cognitive Behavioral Treatment of Obesity With Binge Eating Disorder: Randomized Controlled Study With One-Year Follow-up 
Recent research identifies unhealthful weight-control behaviors (fasting, vomiting, or laxative abuse) induced by a negative experience of the body, as the common antecedents of both obesity and eating disorders. In particular, according to the allocentric lock hypothesis, individuals with obesity may be locked to an allocentric (observer view) negative memory of the body that is no longer updated by contrasting egocentric representations driven by perception. In other words, these patients may be locked to an allocentric negative representation of their body that their sensory inputs are no longer able to update even after a demanding diet and a significant weight loss.
To test the brief and long-term clinical efficacy of an enhanced cognitive-behavioral therapy including a virtual reality protocol aimed at unlocking the negative memory of the body (ECT) in morbidly obese patients with binge eating disorders (BED) compared with standard cognitive behavior therapy (CBT) and an inpatient multimodal treatment (IP) on weight loss, weight loss maintenance, BED remission, and body satisfaction improvement, including psychonutritional groups, a low-calorie diet (1200 kcal/day), and physical training.
90 obese (BMI>40) female patients with BED upon referral to an obesity rehabilitation center were randomly assigned to conditions (31 to ECT, 30 to CBT, and 29 to IP). Before treatment completion, 24 patients discharged themselves from hospital (4 in ECT, 10 in CBT, and 10 in IP). The remaining 66 inpatients received either 15 sessions of ECT, 15 sessions of CBT, or no additional treatment over a 5-week usual care inpatient regimen (IP). ECT and CBT treatments were administered by 3 licensed psychotherapists, and patients were blinded to conditions. At start, upon completion of the inpatient treatment, and at 1-year follow-up, patients' weight, number of binge eating episodes during the previous month, and body satisfaction were assessed by self-report questionnaires and compared across conditions. 22 patients who received all sessions did not provide follow-up data (9 in ECT, 6 in CBT, and 7 in IP).
Only ECT was effective at improving weight loss at 1-year follow-up. Conversely, control participants regained on average most of the weight they had lost during the inpatient program. Binge eating episodes decreased to zero during the inpatient program but were reported again in all the three groups at 1-year follow-up. However, a substantial regain was observed only in the group who received the inpatient program alone, while both ECT and CBT were successful in maintaining a low rate of monthly binge eating episodes.
Despite study limitations, findings support the hypothesis that the integration of a VR-based treatment, aimed at both unlocking the negative memory of the body and at modifying its behavioral and emotional correlates, may improve the long-term outcome of a treatment for obese BED patients. As expected, the VR-based treatment, in comparison with the standard CBT approach, was able to better prevent weight regain but not to better manage binge eating episodes.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 59019572; (Archived by WebCite at
PMCID: PMC3713949  PMID: 23759286
virtual reality; obesity; binge eating disorders; allocentric lock hypothesis
9.  Adherence to Internet-Based and Face-to-Face Cognitive Behavioural Therapy for Depression: A Meta-Analysis 
PLoS ONE  2014;9(7):e100674.
Internet-based cognitive behavioural therapy (iCBT) is an effective and acceptable treatment for depression, especially when it includes guidance, but its treatment adherence has not yet been systematically studied. We conducted a meta-analysis, comparing the adherence to guided iCBT with the adherence to individual face-to-face CBT.
Studies were selected from a database of trials that investigate treatment for adult depression (see, updated to January 2013. We identified 24 studies describing 26 treatment conditions (14 face-to-face CBT, 12 guided iCBT), by means of these inclusion criteria: targeting depressed adults, no comorbid somatic disorder or substance abuse, community recruitment, published in the year 2000 or later. The main outcome measure was the percentage of completed sessions. We also coded the percentage of treatment completers (separately coding for 100% or at least 80% of treatment completed).
We did not find studies that compared guided iCBT and face-to-face CBT in a single trial that met our inclusion criteria. Face-to-face CBT treatments ranged from 12 to 28 sessions, guided iCBT interventions consisted of 5 to 9 sessions. Participants in face-to-face CBT completed on average 83.9% of their treatment, which did not differ significantly from participants in guided iCBT (80.8%, P  =  .59). The percentage of completers (total intervention) was significantly higher in face-to-face CBT (84.7%) than in guided iCBT (65.1%, P < .001), as was the percentage of completers of 80% or more of the intervention (face-to-face CBT: 85.2%, guided iCBT: 67.5%, P  =  .003). Non-completers of face-to-face CBT completed on average 24.5% of their treatment, while non-completers of guided iCBT completed on average 42.1% of their treatment.
We did not find studies that compared guided iCBT and face-to-face CBT in a single trial. Adherence to guided iCBT appears to be adequate and could be equal to adherence to face-to-face CBT.
PMCID: PMC4100736  PMID: 25029507
10.  The promise and pitfalls of the internet for cognitive behavioral therapy 
BMC Medicine  2010;8:82.
Internet-administered cognitive behavior therapy is a promising new way to deliver psychological treatment. There are an increasing number of controlled trials in various fields such as anxiety disorders, mood disorders and health conditions such as headache and insomnia. Among the advantages for the field of cognitive behavior therapy is the dissemination of the treatment, being able to access treatment from a distance, and possibilities to tailor the interventions. To date, studies in which large effects have been obtained have included patient support from a clinician. Recent trials suggest that this support may come from non-clinicians and that therapist effects are minimal. Since studies also suggest that internet-delivered cognitive behavior therapy can be equally effective as face-to-face cognitive behavior therapy, this is a finding that may have implications for CBT practitioners. However, there are other aspects to consider for implementation, as while clinicians may hold positive attitudes towards internet-delivered CBT a recent study suggested that patients are more skeptical and may prefer face-to-face treatment. In the present work, I argue that internet-delivered CBT may help to increase adherence to treatment protocols, that training can be facilitated by means of internet support, and that research on internet interventions can lead to new insights regarding what happens in regular CBT. Moreover, I conclude that internet-delivered CBT works best when support is provided, leaving an important role for clinicians who can incorporate internet treatment in their services. However, I also warn against disseminating internet-delivered CBT to patients for whom it is not suitable, and that clinical skills may suffer if clinicians are trained and practice mainly using the internet.
PMCID: PMC3004806  PMID: 21138574
11.  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
12.  Effect of Telephone-Administered vs Face-to-face Cognitive Behavioral Therapy on Adherence to Therapy and Depression Outcomes Among Primary Care Patients 
Primary care is the most common site for the treatment of depression. Most depressed patients prefer psychotherapy over antidepressant medications, but access barriers are believed to prevent engagement in and completion of treatment. The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery.
To examine whether telephone-administered cognitive behavioral therapy (T-CBT) reduces attrition and is not inferior to face-to-face CBT in treating depression among primary care patients.
Design, Setting, and Participants
A randomized controlled trial of 325 Chicago-area primary care patients with major depressive disorder, recruited from November 2007 to December 2010.
Eighteen sessions of T-CBT or face-to-face CBT.
Main Outcome Measures
The primary outcome was attrition (completion vs non-completion) at posttreatment (week 18). Secondary outcomes included masked interviewer-rated depression with the Hamilton Depression Rating Scale (Ham-D) and self-reported depression with the Patient Health Questionnaire-9 (PHQ-9).
Significantly fewer participants discontinued T-CBT (n=34; 20.9%) compared with face-to-face CBT (n=53; 32.7%; P=.02). Patients showed significant improvement in depression across both treatments (P<.001). There were no significant treatment differences at posttreatment between T-CBT and face-to-face CBT on the Ham-D (P=.22) or the PHQ-9 (P=.89). The intention-to-treat posttreatment effect size on the Ham-D was d=0.14 (90% CI,-0.05 to 0.33), and for the PHQ-9 it was d=−0.02 (90% CI,-0.20 to 0.17). Both results were within the inferiority margin of d=0.41, indicating that T-CBT was not inferior to face-to-face CBT. Although participants remained significantly less depressed at 6-month follow-up relative to baseline (P<.001), participants receiving face-to-face CBT weresignificantly less depressed than those receiving T-CBT on the Ham-D (difference,2.91; 95% CI, 1.20-4.63;P<.001) and the PHQ-9 (difference, 2.12; 95% CI, 0.68-3.56; P=.004).
Among primary care patients with depression, providing CBT over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression at posttreatment. At 6-month follow-up, patients remained less depressed relative to baseline; however, those receiving face-to-face CBT were less depressed than those receiving T-CBT. These results indicate that T-CBT improves adherence compared with face-to-face delivery, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.
PMCID: PMC3697075  PMID: 22706833
13.  A Pilot Randomized Controlled Trial of Brief Cognitive-Behavioral Therapy for Anxiety in Patients with Terminal Cancer 
The Oncologist  2012;17(10):1337-1345.
This article presents a pilot randomized controlled trial that examined the feasibility and potential efficacy of brief cognitive-behavioral therapy to reduce anxiety in patients with terminal cancer.
Learning Objectives
After completing this course, the reader will be able to: Explain the current state of evidence-based treatment for anxiety in patients with cancer and the need for tailored intervention, especially for those with terminal cancer.Discuss and utilize methods for increasing access to psychosocial intervention for patients with cancer who suffer significant physical and psychological morbidity.Describe the effect of a brief cognitive-behavioral therapy intervention tailored to the needs of patients with terminal cancer and comorbid anxiety symptoms.
This article is available for continuing medical education credit at
Patients with terminal cancer often experience marked anxiety that is associated with poor quality of life. Although cognitive-behavioral therapy (CBT) is an evidence-based treatment for anxiety disorders, the approach needs to be adapted to address realistic concerns related to having cancer, such as worries about disease progression, disability, and death. In this pilot randomized controlled trial ( identifier NCT00706290), we examined the feasibility and potential efficacy of brief CBT to reduce anxiety in patients with terminal cancer.
We adapted CBT by developing treatment modules targeting skills for relaxation, coping with cancer worries, and activity pacing. Adults with incurable malignancies and elevated anxiety based on the Hamilton Anxiety Rating Scale (HAM-A) were randomly assigned to individual CBT or a waitlist control group. Primary outcomes included the number of completed CBT visits and the change in HAM-A scores from baseline to 8-week follow-up per a treatment-blind evaluator. The feasibility criterion was 75% adherence to the intervention.
We randomized 40 patients with terminal cancers to CBT (n = 20) or waitlist control (n = 20) groups; 70% completed posttreatment assessments. Most patients who received CBT (80%) participated in at least five of the required six therapy sessions. Analysis of covariance models, adjusted for baseline scores, showed that those assigned to CBT had greater improvements in HAM-A scores compared to the control group, with an adjusted mean difference of –5.41 (95% confidence interval: –10.78 to –0.04) and a large effect size for the intervention (Cohen's d = 0.80).
Providing brief CBT tailored to the concerns of patients with terminal cancer was not only feasible but also led to significant improvements in anxiety.
PMCID: PMC3481900  PMID: 22688670
Cancer; Anxiety; Cognitive behavior therapy; Quality of life
14.  Evaluation of Cognitive Behavioral Therapy/Motivational Enhancement Therapy (CBT/MET) in a Treatment Trial of Comorbid MDD/AUD Adolescents 
Addictive behaviors  2011;36(8):843-848.
Behavioral therapies developed specifically for co-occurring disorders remain sparse, and such therapies for comorbid adolescents are particularly rare. This was an evaluation of the long-term (2-year) efficacy of an acute phase trial of manualized cognitive behavioral therapy/motivation enhancement therapy (CBT/MET) versus naturalistic treatment among adolescents who had signed consent for a treatment study involving the SSRI antidepressant medication fluoxetine and CBT/MET therapy for comorbid major depressive disorder (MDD) and an alcohol use disorder (AUD). We hypothesized that improvements in depressive symptoms and alcohol-related symptoms noted among the subjects who had received CBT/MET would exceed that of those in the naturalistic comparison group that had not received CBT/MET therapy.
We evaluated levels of depressive symptoms and alcohol-related symptoms at a two-year follow-up evaluation among comorbid MDD/AUD adolescents who had received an acute phase trial of manual-based CBT/MET (in addition to the SSRI medication fluoxetine or placebo) compared to those who had received naturalistic care.
In repeated measures ANOVA, a significant time by enrollment status difference was noted for both depressive symptoms and alcohol-related symptoms across the two-year time period of this study, with those receiving CBT/MET demonstrating superior outcomes compared to those who had not received protocol CBT/MET therapy. No significant difference was noted between those receiving fluoxetine versus those receiving placebo on any outcome at any time point.
These findings suggest long-term efficacy for an acute phase trial of manualized CBT/MET for treating comorbid MDD/AUD adolescents. Large multi-site studies are warranted to further clarify the efficacy of CBT/MET therapy among various adolescent and young adult comorbid populations.
PMCID: PMC3094504  PMID: 21530092
Cognitive behavioral therapy; motivational enhancement therapy; comorbidity; adolescents; alcohol use disorder; major depression; follow-up
15.  Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary care settings 
Depression and anxiety  2009;26(3):235-242.
This paper describes a computer assisted CBT program designed to support the delivery of evidenced-based cognitive-behavioral therapy (CBT) for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary care settings. The purpose of the current report is to (1) present the structure and format of the computer-assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients.
13 clinicians using the computer-assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management (CALM) study provided Likert-scale ratings and open-ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected
Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression and expectations for improvement.
Computer-assisted CBT programs provide a practice-based system for disseminating evidence-based mental health treatment in primary care settings while maintaining treatment fidelity, even in the hands of novice clinicians.
PMCID: PMC2906395  PMID: 19212970
16.  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
17.  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
18.  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
19.  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
20.  Bulimia nervosa 
Clinical Evidence  2010;2010:1009.
Up to 1% of young women may have bulimia nervosa, characterised by an intense preoccupation with body weight, uncontrolled binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa may be of normal weight, making it difficult to diagnose. After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for bulimia nervosa in adults? What are the effects of discontinuing treatment in people with bulimia nervosa in remission? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 27 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy (CBT; alone or plus exposure/response prevention enhancement), cognitive orientation therapy, dialectical behavioural therapy, discontinuing fluoxetine in people with remission, guided self-help cognitive behavioural therapy, hypnobehavioural therapy, interpersonal psychotherapy, mirtazapine, monoamine oxidase inhibitors (MAOIs), motivational enhancement therapy, pharmacotherapy plus psychotherapy, pure or unguided self-help cognitive behavioural therapy, reboxetine, selective serotonin reuptake inhibitors (SSRIs), topiramate, tricyclic antidepressants (TCAs), and venlafaxine.
Key Points
Up to 1% of young women may have bulimia nervosa, characterised by an intense preoccupation with body weight, uncontrolled binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa may be of normal weight, making it difficult to diagnose.Obesity has been associated with both an increased risk of bulimia nervosa and a worse prognosis, as have personality disorders and substance misuse.After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms.
Cognitive behavioural therapy for bulimia nervosa (CBT-BN) may improve clinical problems of bulimia nervosa compared with no treatment, and may be as effective in reducing symptoms as interpersonal psychotherapy at 1 year, or as other psychological treatments, or antidepressants. However, we found no RCTs meeting eligibility criteria comparing the efficacy of interpersonal psychotherapy with waiting list control. We don't know whether other psychological therapies such as cognitive orientation therapy, hypnobehavioural therapy, dialectical behavioural therapy, or motivational enhancement therapy are more effective than a waiting list control at improving symptoms, as we found only a few trials. We found insufficient evidence to support enhancing CBT-BN with exposure and response prevention (ERP). Pure or unguided self-help CBT is likely to be no more effective than waiting list control at reducing binge eating. The evidence we found for guided self-help CBT is insufficient to judge this intervention because of high attrition in trials.
Some antidepressant drugs (fluoxetine, citalopram, desipramine, and imipramine) may improve symptoms in people with bulimia nervosa compared with placebo. Monoamine oxidase inhibitors (MAOIs) may increase remission rates compared with placebo, but may not reduce bulimic symptoms or depression scores.We don't know whether other antidepressants (topiramate, mirtazapine, reboxetine, or venlafaxine) can improve symptoms or remission in people with bulimia nervosa.
We don't know whether continuation of antidepressant treatment may maintain a reduction in vomiting frequency compared with withdrawing treatment in people in remission.
We don't know if combining pharmacotherapy with psychotherapy enhances outcome. Trials that have suggested combinations may enhance outcomes have been limited in power.
PMCID: PMC3275326  PMID: 21418667
21.  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
22.  An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment 
Archives of general psychiatry  2011;68(6):577-584.
Although depression frequently co-occurs with substance abuse, few individuals entering substance abuse treatment have access to effective depression treatment.
The Building Recovery by Improving Goals, Habits and Thoughts (BRIGHT) study is a community-based effectiveness trial that compared residential substance abuse treatment to residential treatment plus group cognitive behavioral therapy (CBT) for depression delivered by substance abuse treatment counselors. The authors hypothesized that intervention clients would have improved depression and substance use outcomes as compared to clients receiving usual care.
A nonrandomized controlled trial using a quasi-experimental intent-to-treat design in which four sites were assigned to alternate between the intervention and usual care conditions every four months over a two-and-a-half-year period.
Four treatment programs in Los Angeles County
1,262 clients were screened for persistent depressive symptoms (Beck Depression Inventory-II (BDI-II) >17). 299 clients were assigned to receive either usual care (N=159) or usual care plus the intervention (N=140). Follow-up rates at three and six months after the baseline interview were 88.1% and 86.2% for usual care and 85.7% and 85.0% for the intervention group.
Sixteen two-hour group sessions of CBT for depression
Main Outcome Measures
Change in depression symptoms, mental health functioning, and days of alcohol and substance use.
BRIGHT clients reported significantly fewer depressive symptoms (p<0.001 at three and six months) and had improved mental health functioning (p<0.001 at three-months and p<0.01 at six months). At six months, BRIGHT clients reported fewer drinking days (p<0.05) and fewer days of problem substance use (p<0.05) on days available.
Providing group CBT for depression to clients with persistent depressive symptoms receiving residential substance abuse treatment is associated with improved depression and substance use outcomes. These results provide support for a new model of integrated care.
PMCID: PMC3230556  PMID: 21646576
23.  Anxiety and Related Outcomes in Young Adults 7 to 19 Years after Receiving Treatment for Child Anxiety 
Journal of consulting and clinical psychology  2013;81(5):10.1037/a0033048.
This study evaluated follow-up outcomes associated with cognitive-behavioral therapy (CBT) for childhood anxiety by comparing successfully and unsuccessfully treated participants 6.72 to 19.17 years after treatment.
Participants were a sample of 66 youth (ages 7 to 14 at time of treatment, ages 18 to 32 at present follow-up) who had been diagnosed with an anxiety disorder and randomized to treatment in a randomized clinical trial on average 16.24 (SD = 3.56, Range = 6.72–19.17) years prior. The present follow-up included self-report measures and a diagnostic interview to assess anxiety, depression, and substance misuse.
Compared to those who responded successfully to CBT for an anxiety disorder in childhood, those who were less responsive had higher rates of Panic Disorder, Alcohol Dependence, and Drug Abuse in adulthood. Relative to a normative comparison group, those who were less responsive to CBT in childhood had higher rates of several anxiety disorders and substance misuse problems in adulthood. Participants remained at particularly increased risk, relative to the normative group, for Generalized Anxiety Disorder and Nicotine Dependence regardless of initial treatment outcome.
The present study is the first to assess the long-term follow-up effects of CBT treatment for an anxiety disorder in youth on anxiety, depression, and substance abuse through the period of young adulthood when these disorders are often seen. Results support the presence of important long-term benefits of successful early CBT for anxiety.
PMCID: PMC3881178  PMID: 23688146
Cognitive-behavioral therapy; anxiety; child anxiety; treatment outcome; long-term follow-up
24.  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
25.  Randomized, controlled trial of atomoxetine for ADHD in adolescents with substance use disorder 
To evaluate the effect of atomoxetine hydrochloride versus placebo on attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in adolescents receiving motivational interviewing / cognitive behavioral therapy (MI/CBT) for SUD.
This single-site, randomized, controlled trial was conducted between December 2005 and February 2008. Seventy adolescents (13-19 years) with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) ADHD, a DSM-IV ADHD checklist score greater than or equal to 22, and at least one non-tobacco SUD were recruited from the community. All subjects received 12 weeks of atomoxetine hydrochloride + MI/CBT versus placebo + MI/CBT. The main outcome measure for ADHD was self-report DSM-IV ADHD checklist score. For SUD, the main outcome was self-report number of days used non-tobacco substances in the past 28 days using the Timeline Followback interview.
Change in ADHD scores did not differ between atomoxetine + MI/CBT and placebo + MI/CBT (F4,191 = 1.23, p = 0.2975). Change in days used non-nicotine substances in the last 28 days did not differ between groups (F3,100 = 2.06, p = 0.1103).
There was no significant difference between the atomoxetine + MI/CBT and placebo + MI/CBT groups in ADHD or substance use change. The MI/CBT and/or a placebo effect may have contributed to a large treatment response in the placebo group.
PMCID: PMC2876346  PMID: 20494267
attention-deficit/hyperactivity disorder; adolescent; atomoxetine; substance use disorder

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