Lovaas, 1987--Behavior therapy and autistic kids
19 autistic children < 4 yrs old were assigned to behavior therapy (BT) for 2+ years. Therapists were trained students who worked with the kids ~40 hours/ week, & parents were trained so treatment actually occurred most waking hours.
Controls had 10 hrs. Per week or less of 1 on 1 therapy. 47% of BT kids achieved normal IQ and Educational functioning vs. 2% of controls when tested at the end of 1st grade. For those main streamed children, treatment was 10 hrs/week during kindergarten and 0 hrs in Grade 1.
Punishment (a “NO” or a thigh slap) for self punitive, aggressive, or non-compliant behaviors was a essential component of treatment.
Klosko et al., 1990--Alprazolam (Zanax) versus BT for Panic disorder
In previous research using Zanax (Rx), the consideration of drop-outs have been important. For example, 8% of those given Rx drop out between 3 and 8 weeks of treatment while 44% of those given placebo (P) drop out between 3 and 8 weeks. Including drop-outs, 55% of Rx group are panic free after 8 weeks compared with 32% of P group (sig). When drop-outs are excluded, 59% of Rx groups are panic free vs. 50% of P group (ns).
In this study BT was comprised of A) Exposure treatment to somatic sensations, B) cognitive therapy for catastrophic thoughts, C) Relaxation training, and D) Respiration training to slow breathing.
All treated groups were required to withdraw from drugs before the study began. The design included a BT group for 15 weeks, an Rx group with 15 weeks of increasing dosage of Zanax and tapering off at 13 weeks, a pill P, and a wait list (WL) control.
Dropouts: P-39%, Rx-6%, BT-17%, WL-6%.
The major dependent measure was a criterion of being panic-free for 2 weeks after treatment.
BT-87% panic free>Rx-50%=P-36%=WL-33%.
As an aside, relapse from Zanax or other benzo is common, 80-95%
Elkin (1994) NIMH Depression Study
250 uni-polar depressed, non psychotic outpatients: 70% female, 89% Caucasian received a drug wash-out before the study. They were assigned to 16 weeks of therapy in the following four groups (% refer to drop-out rates) A) Beck’ Cognitive-Behavior therapy (CBT-32%), (B) Klerman’s Interpersonal Therapy (IPT-23%), (c) Imiprimine + Clinical Management (Rx-33%), or D) placebo + Clinical Management (P-40%).
Three samples were analyzed statistically: The Completer Sample of 155 Ss, who received 12 or more sessions, The end-point 204, who were enrolled at least 3.5 weeks, and the end-point 239, which included 35 Ss, who attended at least 1 session, but dropped out before 3.5 weeks.
The four measures: Hamilton Ratings Scale (Ham), Beck Depression Inventory (BDI), Hopkins Symptoms Checklist (Hop), and the Global Assessment Scale (GAS) times the 3 samples gives a total of 12 statistical analyses that were conservative in nature. The general direction of the results is Rx>IPT=CBT>P. There were only 4 statistical significant analyses.
1, Completer: Rx>P on Hop; 2, End-239: Rx>P on GAS; 3, End-239: Rx=IPT>P on Ham; and 4, End-204, Rx>P on GAS. Technically, analyses 3 and 4 should be considered “trends” only.
Recovery was defined as scores < 6 on the Ham and < 9 on the BDI. Recovery rates for the END 239 sample were IPT (43%) = Rx (42%)>P (21) on the HAM. CBT (36%) was not different from other groups on the HAM. There were no sig. Differences in recovery on the BDI.
Secondary analyses split subjects into 2 groups (more vs. Less severe) with cut-off of 20 on Ham & 50 on GAS.
FOR LESS SEVERE DEPRESSION: THERE WERE NO DIFFERENCES AMONG THE GROUPS.
FOR MORE SEVERE DEPRESSION: 1) Rx>IPT=CBT>P on GAS, and 2) Rx=IPT>P on the HAM with CBT intermediate between IPT and P.
CONCLUSIONS:
1. No evidence therapy more or less effective than drugs.
2. Limited evidence IPT>P; no evidence CBT>P.
3. Large improvement in P may have masked treatment effects.
4. Some evidence that drugs worked faster.
The temporal course of change: by 12 weeks Rx> other 3 treatments, but less of a difference among groups at 16 weeks. There were also site X treatment interactions.
Generalized prognostic signs:
+ Lower cognitive dysfunction; higher patient expectance
- Axis II Personality disorders, they still improved, but were more likely to have some residual
depression.
18 month follow-up: Recovery is defined as no relapse (2+weeks of major depression), and at least 8 consecutive weeks of little or no depressed symptoms:
CBT(30%); IPT (26%); Rx(19%); P(20%)
Relapse (defined as any treatment for 3 consecutive weeks in 18 mo).
(Figures are % relapsed followed by weeks in treatment)
CBT(14%, 4,2 wks); IPT(43%, 11.0wks); Rx(44%, 20.3); P (27%, 7.8wks)
Additional dependent measures were also used in the NIMH study to investigate the possibility of “mode specific outcomes”. The notion here is that certain measures may be more sensitive to specific treatments. For example, The Dysfunctional Attitude Scale (with subscales of Perfectionism and Need for Social Approval) was hypothersized to be more sensitive to CBT. The Social Adjustment Scale (with subscales of work, social, and leisure adjustment) was thought to be more sensitive to IPT. The Endogenous Scale from the Schedule for Affective Disorders was thought to be differentially responsive to Rx. However ONLY 1 ANALYSIS OF 11 showed mode -specific effects: On the completer sample CBT>IPT on N. Social Approval.
Ogles et al. (1995) evaluated the NIMH data for “Clinical Significance”, a more stringent criteria of recovery than “statistical” significance.
Percentages of patients with clinically significant improvement
-----------Rx----CBT----IPT----P
Beck-----66%--50%----64%---46%(NS)
Hamilton74%--68%----70%---62%(NS)
SCL-90--81%--65%----85%---62%(p<.05)
Ogles et al also found clinically significant deterioration in 3-8% of patients, depending on the analysis.
Jacobsen & Hollon (J&H,1996) and Klein (1996) engaged in a discussion of the NIMH study.
J&H claim that the results are perhaps not a robust as it seemed at first glance, especially regarding the superiority of Rx over CBT. A impetus for this claim is to counter-act 2 recent reports regarding the treatment of depression from A) The American Psychiatric Association, and B) The Agency for Health Care Policy and Research. These reports note that 1. CBT was (is) not superior to P, and 2. Perhaps psychotherapy is inappropriate in the treatment of more severe depression. J&H also suggest that there may have been site X treatment interactions in the NIMH study. At one site, CBT=Rx>P; at another site, IPT=Rx>P. Perhaps the NIMH study was actually 3 studies with inconsistent results! J&H also point out that none of the other published studies comparing CBT and Rx have shown that Rx>CBT.
Klein dismisses these studies because of a lack of placebo control, which would be necessary to establish that pharmacology was adequately administered, and that the sample was truely drug responsive. J&H argue that CBT was not adequately implemented at 1 site. J&H reiterate that the NIMH results were not that impressive overall, citing data from Shea et al., 1992 indicating the following relapse rates from “Recovered” patients: CBT(36%), IPT(33%), Rx(50%).
Klein reports a re-analysis of the NIMH data done by Klein & Ross, which found no statistically sig. Treatment by site interactions. Also Klein notes no instance in the NIMH data in which CBT>P. Klein also questions whether Rx was adequately administered in the NIMH study.
D. Klein says, “If the FDA was responsible for the approval of psychotherapy, then no current psychotherapy would be approvable, whereas particular medications are clearly approvable.”
Butler et al. (1991) assigned 51 subjects with generalized anxitey disorder to either behavior therapy (BT), cognitive behavior therapy(CBT), or a waiting list (WL) control. Common features to the 2 treatments were A) An explanation of the vicious cycle as a maintainer of symptoms, B) Development of self-managment skills and self reliance through practice, and C) a goal of reducing medications
BT—Ss were instructed to use Borkovec’s relaxation training in situations of mild anxiety,and were encouraged to build a set of relaxing activities. When possible, a hierarchy of graded, regular and frequent exposure was given. Ss were also told to use self-reward by planning pleasurable activities.
CBT----Ss were instructed to recognize anxious thoughts, seek more realistic and hepful alternatives, and take action to test these in practice/activity schedules. Records of dysfunctional thoughts weere used to identify anxious thoughts, examine them, and formulate alternatives.
Dependent measures: 6 ANXIETY (A) measures (ex., Hamilton, Spielburger State-Trait), 4 DEPRESSION (D) measures (ex., Beck), and 6 COGNITION (C) measures (ex., Dysfunctional attitudes, fear of negative evaluation)
Treatment lasted up to 12 sessions. Both treatments were rated equivalently on pos. expectancy and suitability at the beginning and at 4 weeks.
At termination:
CBT>WL on all 6 A measures, 2 of 4 D measures, and 5 of 6 C measures.
BT>WL on 1 or 6 A measures, 1 of 4 D measures, and 2 of 6 C measures.
CBT>BT on 3 of 6 A measures, 1 of 4 D measures, and 2 of 6 C measures
At the 6 mo. Follow-up, CBT>BT on 3 of 6 A, 1 of 4 D, and 5 of 6 C. There were no differential effects of treatments on medication use, which declined in general.
Borkovec & Costello (1993): Assigned 66 clients with Generalized Anxiety Disorder (chronic clients with M=17.1 yrs. Of symptoms) to either Non-directive therapy (ND), Applied Relaxation (AR), or CBT. The design featured 4 therapists crossed with condition.
ND featured self-reflection, and instructions that increased awareness would change anxious experiences and lead to increased self-confidence.
AR featured self-monitoring of the spiral process of anxious reactions, and interventions with progressive relaxation. AR had a focus on the present (rather than the past or future).
CBT used AR procedures, except that AR cue detection and relaxation interventions were replaced by self-control desensitization and brief cognitive therapy (involving belief identification, logical analysis, the development of alternative thoughts and beliefs, and the behavioral testing of beliefs along with catastrophization. The therapist also used the Socratic method. CBT was brief, lasting 10-15 min. per session. There were a total of 14 sessions, twice per week
There were 8 anxiety dependent measures and 2 depression measures. Rating of treatment credibility and expectancy of success were equivalent across groups at the beginning of treatment There was within group change on 5 measures for ND and all 10 measures for both AR and CBT. Between groups analyses showed that CBT=AR>ND on all anxiety measures. At a 1 year follow-up, there were no group differences, but this was confounded because more of the ND group went back into therapy. Data for HIGH END-STATE FUNCTIONING: CBT=58%, AR=38%, and ND=27%. There was a mode specific effect in that on a process measure of "Depth of emotional processing" ND>AR=CBT.
Conclusions: Can not reject the hypothesis that AR was the sole determinant of gain in AR and CBT. AR and CBT contain active ingredients independent of non-specific factors.
Jacobsen et al. (1996) in a Component analysis of Cognitive Therapy for Depression assigned 152 patients with major depression to 1 of 3 conditions:
A) BEHAVIORAL ACTIVATION (BA), involving
1. Monitoring of activities
2. Assessing pleasure of doing various activities
3. Assigning increasingly more difficult tasks that are expected to bring pleasure (PA)
4. Cognitive anticipatory rehearsal of PA
5. Discussion of problems and behavioral techniques to deal with them
6. Social skills training
B) BA plus modification of dysfunctional (automatic) thoughts (AT), involving
1.Noticing mood shifts in sessions and identifying preceding thoughts.
2. Daily record of AT
3. Re-examining thoughts
4. Helping P respond more functionally to AT
5. Examining attributional biases and mistakes in thoughts
6. Homework of assessing validity of negative interpretations
C) BA plus AT plus MODIFICATION OF CORE SCHEMA=COMPLETE COGNITIVE THERAPY, involving
1.Identification of core beliefs
2. Explicit identification of underlying assumptions
3. Identification of alternative assumptions or core beliefs (CB)
4. Discussion of pros and cons of various CB, both short and long term
5. Home work concerning use of core beliefs
6. Techniques to modify CB
There were 3 data sets: (A) Completers attending at least 12 sessions, (B) Maximum completers completing the full 20 sessions, and (c) Dropouts attending at least 1 session.
Results for all three data sets: BA=AT=CT; Interpretation that there is no evidence that CT is any more effective than any of its components at post-treatment and 6 mo. Follow-up.
Abramowitz meta-analyzed 8 studies of psychotherapy with OCD and 24 studies of drug treatment. Interestingly, none of the psychotherapy studies had no-treatment controls. Psychotherapy was most often "Exposure plus Response Prevention (ERP). COMPARISONS----------------------------------EFFECT SIZES
-------------------------------------PATIENT RATING--CLINICIAN RATING
ERP vs. Relaxation----------------------1.18-------------NA
ERP vs. cognitive therapy-------------neg.19-ns----------NA
ERP vs. single component-----------------.59-ns----------NA
SSRIs vs. placebo-------------------------.71-----------1.09
nonSSRIs vs. placebo----------------------.14-ns---------.20-ns
clomipramine vs. nonSSRIs-----------------.70------------.37
also the correlation of Effect Size with no. of hours of exposure treatment in psychotherapy was r = .87