Key Studies That Inform Clinical Practice: Cognitive Behavioral and Mindfulness-Based Therapies

Sy Atezaz Saeed, MD, MS;Oliver Glass, MD;

5 Clinically Relevant Studies on CBT

This month, we have selected 9 articles on cognitive behavioral and mindfulness-based treatments based on their clinical relevance and applicability, as well as their quality. Our goal is to help you stay up to date with the most current evidence-based information in the face of an overwhelming literature.

Brent DA, Brunwasser SM, Hollon SD, et al. Effect of a cognitive- behavioral prevention program on depression 6 years after implementation among at-risk adolescents: a randomized clinical trial. JAMA Psychiatry. 2015;72:1110-1118.

A family history of psychiatric disorders is an important component of history taking. It is now known that parents’ depression can increase the risk of depression in their children.

This randomized study evaluated the usefulness of a cognitive-behavioral prevention (CBP) program in reducing the incidence of depression in adolescents. The program held 90-minute group sessions once a week for 8 weeks, then once monthly for 6 months. CBP plus usual care (family-initiated mental health treatment) was compared with usual care alone.

The 316 participants were aged 13 to 17 years and had at least 1 parent with current or previous depressive episodes. The study included patients with so-called “subsyndromal” depressive symptoms or a previous depressive episode in remission, but it excluded those in a current depressive state. Follow-up was 75 months after the intervention. The Depression Symptoms Rating scale was used to evaluate the participants.

key findings: CBP is a promising intervention for the prevention of depression. Although participants received the most benefit from CBP in the early months of the study, at 75-month follow-up the incidence of depression was still lower among adolescents in the CBP group than among those who received usual care alone. Whether additional “booster” CBP sessions would provide further protection remains to be determined.

Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386: 63-73.

Although maintenance antidepressant therapy is important to prevent recurrent depressive episodes, many patients may be interested in alternative treatments.

This study looked at whether mindfulness-based cognitive therapy with discontinuation of antidepressant treatment (MBCT-TS) was superior to maintenance antidepressant treatment. Participants were eligible if they had 3 or more previous major depressive episodes and were receiving therapeutic dosages of maintenance antidepressants. A total of 424 patients were enrolled: 212 were assigned to MBCT-TS and 212 received maintenance antidepressant therapy. The duration of this single-blind, parallel, randomized, controlled trial was 24 months. The participants were evaluated with the Structured Clinical Interview for DSM-IV (SCID), GRID-Hamilton Rating Scale for Depression, and 21-item self-report Beck Depression Inventory. Psychiatric comorbidity was assessed with the relevant SCID modules; medical comorbidities with the Medical Symptom Checklist; quality of life with the WHO Quality of Life instrument (WHOQOL-BREF); and health-related quality of life with the EQ-5D-3L.

clinical implications: In participants with a history of recurrent depressive episodes, MBCT-TS was not superior to maintenance antidepressant treatment in the prevention of relapse.

Both treatments did, however, seem to have a similar effect on participants’ quality of life and residual depressive symptoms, and they decreased relapse or recurrence. MBCT-TS can be further investigated as a potential alternative to pharmacotherapy for depression maintenance treatment.

Weck F, Neng JM. Response and remission after cognitive and exposure therapy for hypochondriasis. J Nerv Ment Dis. 2015;203:883-885.

CBT can be used for a variety of psychiatric disorders, including hypochondriasis; in this setting, it has significant efficacy. This study was based on the results of a randomized controlled trial that focused on patients with hypochondriasis (N = 75) and their rates of response and remission after they received CBT or exposure therapy. The cognitive therapy group had 38 patients, and the exposure therapy group included 37 patients. After treatment 36.8% of the CBT group went into remission, compared with 54.1% of the exposure therapy group. At 12-month follow-up, 57.9% of CBT patients were in remission vs 51.4% in the exposure therapy group.

clinical implications: After treatment, when the whole sample was combined (patients who underwent CBT and those who had exposure therapy), 45.3% of patients went into remission and 72.0% responded to treatment. At 12 months, the whole sample remission rate was 54.7% and the response rate was 68.0%. The differences between exposure therapy and CBT were not significant. In general, patients’ and therapists’ evaluations of clinical improvement were more comparable to remission rates than to response rates.

Brenes GA, Danhauer SC, Lyles MF, et al. Telephone-delivered cognitive behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72:1012-1020.

Patients in late life can experience generalized anxiety disorder (GAD), but there appear to be age-related differences in its manifestation. Access to psychiatric treatment for older adults may be limited in rural areas, and this problem may worsen as the so-called “baby boomers” continue to age.

This randomized clinical trial evaluated the efficacy of CBT delivered by telephone versus telephone-delivered nondirective supportive therapy (NST) in 141 rural older adults with GAD. Participants were age 60 years and older and had a principal diagnosis of GAD. The study took place in their homes. The telephone CBT group participated in 11 sessions; the telephone NST group had 10 sessions. The participants were evaluated by the Hamilton Anxiety Rating Scale and the Penn State Worry Questionnaire-abbreviated. Follow-up occurred at 2 and 4 months.

bottom line: Both treatments reduced symptoms of worry, depression, and GAD. However, telephone CBT produced superior results. Implementation of telephone CBT may decrease structural barriers that many older adults experience in mental health care.

Rohan KJ, Mahon JN, Evans M, et al. Randomized trial of cognitive- behavioral therapy versus light therapy for seasonal affective disorder: acute outcomes. Am J Psychiatry. 2015;172:862-869.

Light therapy is effective in treating seasonal affective disorder (SAD) and may also be beneficial for non-seasonal MDD. The evidence regarding CBT for SAD is limited, however.

This randomized clinical trial compared CBT and light therapy in the treatment of SAD. The study enrolled 177 participants: 88 in the CBT group and 89 in the light therapy group. The CBT group underwent 12 sessions over 6 weeks, and the light therapy group received 30-minute morning treatments over a 6-week period. The participants were evaluated with the Structured Interview Guide for the Hamilton Rating Scale for Depression-SAD version (SIGH-SAD) and Beck Depression Inventory-Second Edition (BDI-II).

clinical take-home: CBT and light therapy may both be considered as options for an acute episode of SAD.

Philipsen A, Jans T, Graf E, et al. Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult attention-deficit/hyperactivity disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72:1199-1210.

While ADHD is commonly associated with children and adolescents, its prevalence in adulthood is high. This 6-year randomized clinical trial examined the efficacy of nonpharmacological treatments (cognitive behavioral group psychotherapy [GPT] versus individual clinical management [CM]) in combination with methylphenidate or placebo in the treatment of adult ADHD. Seven centers in Germany participated in this prospective study. Investigators deemed 518 patients eligible and centrally randomized 433. The GPT and CM sessions occurred weekly for the first 3 months, then monthly for 9 months. Patients received either methylphenidate or placebo for 1 year. The ADHD Index of the Conner’s Adult ADHD Rating Scale was used to assess the primary outcome.

key findings: After 3 months, there was no significant difference between the GPT and CM groups, but methylphenidate was superior to placebo. This finding contrasts with results of previous studies in which preliminary evidence suggested the superiority of structured disorder-oriented GPT over non- specific group control conditions. After 1 year, the treatment effects remained stable. At 1 year, the outcomes were better when CM or GPT was combined with methylphenidate.

Sibinga EM, Webb L, Ghazarian SR, Ellen JM. School-based mindfulness instruction: an RCT. Pediatrics. 2016;137. doi: 10.1542/peds.2015-2532.

In an attempt to develop a treatment to address negative stressors among students, this study evaluated the effectiveness of a mindfulness-based stress reduction (MBSR) program. The participants were low-income, minority, public middle school students from the Baltimore area. The students were randomly assigned by grade to receive health education (Healthy Topics [HT]) or MBSR. Three hundred fifth- to eighth-grade students, with a mean age of 12, were included; 99.7% were African American, and 50.7% were female. The groups were comparable at baseline. Regression modeling was used to compare self-report survey data regarding the MBSR and HT classes.

key point: After participation in MBSR, students had lower levels of depression, negative coping, somatization, negative affect, posttraumatic symptom severity, and self-hostility compared with those in HT classes (P < .05). Mindfulness may be of benefit when it is used to improve psychological functioning in marginalized youth who have experienced trauma or who are undergoing negative stress.

Polusny MA, Erbes CR, Thuras P, et al. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA. 2015;314:456-465.

Many military veterans are burdened by PTSD. Although various therapies may alleviate symptoms, traumatized veterans often continue to struggle.

This randomized clinical study focused on mindfulness as an intervention to reduce symptoms of PTSD in veterans. Participants (N = 116) received either mindfulness-based stress reduction therapy (n = 58) or present-centered group therapy (n = 58), an active-control condition. The mindfulness group had 8 weekly 2.5-hour group sessions and a daylong retreat. The control group had 9 weekly 1.5-hour group sessions that focused on current life problems. The follow-up period was 2 months. The participants were evaluated with the Clinician-Administered PTSD Scale.

bottom line: Veterans with PTSD in the mindfulness-based stress reduction therapy group showed a greater decrease in PTSD symptom severity than those in present-centered group therapy. However, the magnitude of the average improvement was modest.

Guille C, Zhao Z, Krystal J, et al. Web-based cognitive behavioral therapy intervention for the prevention of suicidal ideation in medical interns: a randomized clinical trial. JAMA Psychiatry. 2015;72:1192-1198.

Alarming data show a 4-fold increase in suicidal ideation among intern physicians during the first 3 months of training. This study assessed the effectiveness of a web-based cognitive behavioral therapy (wCBT) program in preventing suicidal ideation in this group.

The program was delivered before the start of the internship year in a randomized clinical trial conducted at 2 university hospitals. Interns were randomly assigned to 2 groups: the wCBT group (100 interns) and the attention-control group (ACG) (99 interns). They also completed study activities that lasted 30 minutes each week for 4 weeks. The Patient Health Questionnaire-9 was used to assess thoughts of suicide before the start of internship and at 3-month intervals throughout the year.

conclusion: During the internship year, 21% of the interns in the ACG group endorsed suicidal ideation, compared with 12% of those in the wCBT group. A free, accessible wCBT program before the internship year may decrease suicidal ideation during an often emotionally burdensome period and should be considered for inclusion in residency programs nationwide.

Disclosures:

Dr. Saeed is Professor and Chairman of the Department of Psychiatry and Behavioral Medicine at the Brody School of Medicine at East Carolina University, Director of the ECU Center for Telepsychiatry and e-Behavioral Health as well as of the North Carolina Statewide Telepsychiatry Program (NC-STeP), and Chief of Psychiatry at the Vidant Medical Center in Greenville, NC. Dr. Glass is a fourth-year Psychiatry Resident at Brody School of Medicine at East Carolina University.

Key Studies That Inform Clinical Practice: Cognitive Behavioral and Mindfulness-Based Therapies

Related content:

5 Clinically Relevant Studies on CBT

Disclosures: