EffECTively Treating Depression: A Pilot Study Examining Manualized Group CBT as Follow-Up Treatment After ECT

Background: There is an urgent need for effective follow-up treatments after acute electroconvulsive therapy (ECT) in depressed patients. Preliminary evidence suggests psychotherapeutic interventions to be a feasible and efficacious follow-up treatment. However, there is a need for research on the long-term usefulness of such psychotherapeutic offers in a naturalistic setting that is more representative of routine clinical practice. Therefore, the aim of the current pilot study was to investigate the effects of a half-open continuous group cognitive behavioral therapy (CBT) with cognitive behavioral analysis system of psychotherapy elements as a follow-up treatment for all ECT patients, regardless of response status after ECT, on reducing depressive symptoms and promoting psychosocial functioning.Method: Group CBT was designed to support patients during the often-difficult transition from inpatient to outpatient treatment. In a non-controlled pilot trial, patients were offered 15weekly sessions of manualized group CBT (called EffECTiv 2.0). The Montgomery-Åsberg Depression Rating Scale was assessed as primary outcome; the Beck Depression Inventory, WHO Quality of Life Questionnaire–BREF, and the Cognitive Emotion Regulation Questionnaire were assessed as secondary outcomes. Measurements took place before individual group start, after individual group end, and 6months after individual group end.Results: During group CBT, Post-ECT symptom reduction was not only maintained but there was a tendency toward a further decrease in depression severity. This reduction could be sustained 6months after end of the group, regardless of response status after ECT treatment. Aspects of quality of life and emotion regulation strategies improved during group CBT, and these improvements were maintained 6months after the end of the group.Conclusion: Even though the interpretability of the results is limited by the small sample and the non-controlled design, they indicate that manualized group CBT with cognitive behavioral analysis system of psychotherapy elements might pose a recommendable follow-up treatment option after acute ECT for depressed patients, regardless of response status after ECT. This approach might not only help to further reduce depressive symptoms and prevent relapse, but also promote long-term psychosocial functioning by improving emotion regulation strategies and psychological quality of life and thus could be considered as a valuable addition to clinical routine after future validation.

A Randomised Controlled CBT Intervention for Maladaptive Perfectionism: Outcome and Predictors

Maladaptive perfectionism has been associated with certain mental health problems. Moreover, studies suggest that the development of perfectionism can be attributed to childhood experiences and, more specifically, to parenting styles. (1) Background: The aims of the present study were first to examine the relationship of perfectionism to perceived parenting and current symptoms of depression and anxiety and, secondly, to study the effectiveness of a group CBT intervention program for high perfectionism; (2) Methods: Participants were 81 young Greek adults with relatively high scores in perfectionism. They were randomly allocated to two conditions: either the intervention group (IG; n = 40) or a non-active control group (CG; n = 41). The intervention group received a CBT intervention of 10 weekly sessions, while assessments were made in two time points for both groups; (3) Results: There was significant correlation of perfectionism with perceived parental indifference, abuse, and overcontrol as well as measures of anxiety and depression. Results showed significant decrease in perfectionism and other symptoms in the IG. Although perceived paternal indifference and abuse could predict perfectionism at pre-intervention, no pre-intervention variable could predict the perfectionism intervention outcome; (4) Conclusions: Overall, the study suggests that maladaptive perfectionism is associated with perceived negative parenting and current anxiety and depression and that a group CBT intervention can address specific dimensions of maladaptive perfectionism.

A redesigned training and staff support programme to enhance job retention in employees with moderate-severe depression

Purpose Closing the treatment gap in depression is vital to prevent people from losing their jobs. Delivering group-based interventions at work could reach more employees than delivering 1:1 interventions in a clinical setting. This study aims to redesign a Treatment Programme to make it more acceptable and accessible for employees with depression. Design/methodology/approach A mixed-methods exploratory sequential design with a high level of stakeholder consultation was used to redesign an interdisciplinary Work-focussed Relational Group CBT Treatment Programme for moderate-severe depression. Qualitative data from focus groups and quantitative data from a small feasibility study were integrated to develop the new Training (and Staff Support) Programme (TSSP), which was fully specified and manualised in line with the Template for Intervention Description and Replication (TIDieR) for future delivery. Findings Focus groups identified a need for improved acceptability and accessibility of the tertiary preventative Work-focussed Relational Group CBT Treatment Programme. This programme was, therefore, simplified for delivery by peer facilitators at the worksite as an intervention for all employees rather than an indicated/targeted intervention for only those with symptoms/risk of depression. The TSSP comprised a compulsory trauma-informed educational/experiential workshop over four days plus optional open-ended, peer-led base groups set up and run by volunteer peer facilitators. Research limitations/implications The focus groups comprised a convenience sample who knew the researchers as a colleague or therapist, so there is a risk of selection or relationship bias. They were not involved in the data analysis which undermines the element of co-production and increases the risk of analytic or confirmation bias. Practical implications Delivering the new intervention in a group format will require peer facilitators to acquire skills in co-facilitation using a structured-directive leadership style and an awareness of the potential side effects of group-based interventions. Social implications The worksite TSSP provides a democratic learning space and empowers employees to stay at work by self-managing their symptoms and by challenging the interpersonal dynamics and organisational structures that might precipitate and perpetuate depression. Originality/value This intervention is fully specified and manualised with an explicit programme theory, unlike most universal worksite-based CBT programmes.

Structural Neuroplasticity Following Cognitive Behavioral Therapy for the Treatment of Chronic Musculoskeletal Pain: A Randomized Controlled Trial with Secondary MRI Outcomes

The extent of white matter (WM) and Grey matter (GM) structural neuroplasticity following cognitive behavioral therapy for chronic pain management remains undetermined. In the current study, we investigated structural alterations in GM morphometry, as well as WM complexity and connectivity, before and after an 11-week group CBT for the treatment of chronic musculoskeletal pain. We hypothesized that effective pain management would influence WM structural metrics indicative of brain plasticity, particularly within cognitive and limbic circuitry as well as GM volume within pain matrix structures. To determine this, patients were randomized into two groups: 1) CBT group that received CBT once-weekly for 11-weeks, or 2) EDU group consisting of an active patient control group that received educational materials by mail. All subjects completed behavioral assessments and underwent neuroimaging at: baseline prior to any intervention (TP1), 11-weeks following either CBT or EDU (TP2), and four months following completion of the intervention (TP3). CBT resulted in significant clinical improvements, assessed via behavioral self-reports, compared to EDU. Compared to EDU, region of interest WM analysis revealed several fiber tracts that had significantly increased WM complexity following CBT intervention, including the bilateral posterior internal capsule and the left cingulum within the temporal lobe. Conversely, several tracts exhibited a decrease in WM complexity including the right external capsule, the left posterior internal capsule, and the right cingulum within the temporal lobe. Changes in clinical outcomes were predictive of alterations in WM complexity metrics immediately following intervention and at long-term follow-up. No between-group differences were observed in either WM connectivity or GM volume. In conclusion, psychotherapeutic interventions such as group CBT influence coping strategies for effective pain relief that influence WM microstructure, however, the mechanisms of these changes remain undetermined. Future studies will be required to uncover the biological underpinnings of these alterations in pain populations.

Face-to-face versus Video Teleconference Group Cognitive Behavioural Therapy for Anxiety and Related Disorders: A Preliminary Comparison: Thérapie cognitivo-comportementale de groupe en personne contre par vidéo téléconférence pour l’anxiété et les troubles connexes: une comparaison préliminaire

Objective: Telehealth is being increasingly incorporated into the delivery of mental health care and has received widespread attention during the COVID-19 pandemic for its ability to facilitate care during physical distancing restrictions. Videoconferencing is a common telehealth modality for delivering psychotherapy and has demonstrated similar outcomes to those of face-to-face therapy. Cognitive behavioural therapy (CBT) is the most common psychotherapy evaluated across various telehealth modalities; however, studies on CBT delivered via videoconference, particularly in a group therapy format, are lacking. Further, little research exists on videoconference group CBT for anxiety disorders. Accordingly, the present study compared the outcomes of group CBT for anxiety and related disorders delivered via videoconference versus face-to-face. Method: Using a non-randomized design, data on attendance, dropout, clinical outcomes, and functional impairment were collected from 413 adult outpatients of a tertiary care anxiety disorders clinic who attended a CBT group for panic disorder/agoraphobia, social anxiety disorder, generalized anxiety disorder (GAD), or obsessive-compulsive disorder delivered either face-to-face (pre-COVID-19 pandemic) or via videoconference (since the onset of COVID-19 pandemic). Outcomes were assessed using well-validated self-report measures. Data were collected pre-treatment, across 12 weekly sessions, and post-treatment. Intent-to-treat analyses were applied to symptom outcome measures. Results: Face-to-face CBT conferred only a slight benefit over videoconference CBT for symptom outcomes across all groups, but when assessed individually, only the GAD group showed greater symptom improvement in the face-to-face format. Effect sizes for significant differences between the delivery formats were small. Participants in videoconference groups tended to have slightly higher attendance rates in some instances, whereas functional improvement and treatment dropout were comparable across the delivery formats. Conclusions: Results provide preliminary evidence that videoconference group CBT for anxiety and related disorders may be a promising and effective alternative to face-to-face CBT. Additional research is needed to establish equivalence between these delivery formats.

A review of research-supported group treatments for drug use disorders

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women’s recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

“Despite the Differences, We Were All the Same”. Group Cohesion in Diagnosis-Specific and Transdiagnostic CBT Groups for Anxiety and Depression: A Qualitative Study

Group cohesion refers to a sense of belonging, mutual support and identification with other group members. Group cohesion has been associated with better outcomes, lower drop-out rates, more interpersonal support and better participation in psychotherapy. Nevertheless, the role of group cohesion in CBT has not yet received much attention. The rationale for delivering CBT in groups is that patients can model themselves through each other due to their similarities in symptoms. However, there has recently been a shift towards transdiagnostic CBT protocols, in which patients with varied diagnoses participate in the same groups. This shift challenges the rationale of delivering CBT in groups, and it is therefore highly important to understand if and how group cohesion develops in mixed diagnoses CBT groups. The current study used a qualitative comparative framework to investigate the patients’ experiences of group cohesion in diagnosis-specific versus transdiagnostic CBT groups. Twenty-three patients were interviewed with semi-structured interviews upon completion of the treatment. Participants had a primary diagnosis of MDD, panic disorder, agoraphobia or social anxiety disorder. A comparative thematic analysis was carried out. Three themes were found: the move from differences to similarities, the role of group cohesion in group CBT and factors helpful and hindering to group cohesion. Group cohesion developed across groups and was considered highly important in both diagnosis-specific and transdiagnostic CBT groups.

Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study

Background There are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy. Objective We aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent. Methods A cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews. Results Data from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45. Conclusions Although bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits.

583 Treating Insomnia in Youth Depression: A Randomized Controlled Trial of CBT for Depression vs. CBT for Insomnia

Introduction Insomnia is often comorbid with depression in youths and both may reciprocally exacerbate clinical outcomes and lead to a constellation of detrimental consequences. The present study aimed to test the efficacy of cognitive behavioral therapy (CBT) for insomnia (CBT-I) and CBT for depression (CBT-D), when compared with waitlist control, in youths with comorbid insomnia and depression. Methods 112 participants aged 12–24 years old (67.9% female) with insomnia and depression according to DSM-5 diagnostic criteria were randomised to one of the following conditions: 8-week group CBT-I (n=33), 8-week group CBT-D (n=39), or waiting-list control (n=40). Insomnia (Insomnia Severity Index, ISI) and depressive symptoms (Hamilton Rating Scale for Depression, HAMD) were assessed at baseline and post-intervention. The two active treatment groups were additionally followed up at post-treatment one-month. Results Linear mixed model showed that both treatment groups (CBT-D: Cohen’s d = -0.44, p&lt;.001; CBT-I: Cohen’s d =-0.56, p&lt;.001) had significantly lower ISI scores at post-intervention follow-up, as compared to the waitlist group. There was a significant difference in clinically meaningful improvement in insomnia (a reduction of ISI score ≥ 6 from baseline to post-intervention follow-up) between the groups (CBT-I: 73.1%; CBT-D: 40.0%; WL: 28.6%; p=.002). Moreover, there was a significant difference in remission of depression (HAMD≤7) at post-intervention follow-up (CBT-D: 75.9%; CBT-I: 81.5%; WL: 22.9%) (p &lt;.001). Both CBT-D and CBT-I resulted in comparable improvements in insomnia and depressive symptoms at one-month follow-up (p&gt;.05). Conclusion Preliminary evidence from this study supports the efficacy of CBT-I for improving both sleep and mood in youths with comorbid insomnia and depression. Support (if any) This work was supported by Early Career Scheme, Research Grants Council, Hong Kong SAR (Ref. 27613017).

371 Insomnia and Metacognitive abilities: a new treatment target?

Introduction Metacognition is defined as the ability to reflect on one’s mental state. Literature showed that dysfunctional metacognitive activity (such as worry and rumination) plays an important role in insomnia genesis and maintenance. The aim of this study is (i) to evaluate metacognition differences between insomnia disorders (ID) patients and good sleepers (GS)and (ii) to assess Cognitive-Behavioral Therapy for Insomnia (CBT-I) effectiveness on both insomnia and metacognitive abilities. Methods We compared 27 GS (Insomnia Severity Index, ISI&lt;10) (63.0% female, mean age 33±13.7yrs) and 27 ID patients (51.9% female, mean age 46.4±13.7yrs) evaluated both by ISI and Metacognition Insomnia Questionnaire (MCQ-I). ID patients underwent 7-session of group CBT-I and were evaluated pre- (T0) and post- (T1) treatment. Results GS and ID patients differed in MCQ-I total score (GS=105.6±20.5 vs ID= 138.1±26.2). All ID patients’ scores were above the clinical cutoff of 110. ID patients showed significant improvements both at ISI (T0=14.67±4.67 vs T1=7.07±4.37, p&lt;0.001) and Sleep Diary parameters (T0 vs T1, p&lt;0.05) as sleep latency, wake after sleep onset and sleep efficiency at T1. ID patients also showed an improvement of MCQ-I scores at T1, nevertheless, maintaining MCQ-I the mean score above the clinical cutoff level (MCQ-I_T0=138.1±26.2 vs MCQ-I_T1=123.7±28.6; p&lt;0.05). Indeed, 29.6% of ID patients maintained equal or worse MCQ-I score at T1 compared to T0; 63% of ID patients still had a MCQ-I score above the clinical cutoff at T1. Conclusion CBT-I results effective on insomnia symptoms. Metacognitive dysfunctions appears to be a core feature in ID patients compared to good sleepers. Although the score reduction was significant after CBT-I, metacognitive dysfunction did not show remission after treatment possibly indicating the need of a specific intervention on this aspect. Metacognitive dysfunction in ID needs to be further investigated and may represent a new treatment target, in order to improve CBT-I effectiveness. Support (if any) None