Cognitive Behavioral Therapy

Importance Anxiety disorders and symptoms are prevalent and burdensome, and patients are most likely to seek treatment in primary care settings. However, anxiety is underdetected and undertreated. This narrative review details behavioral and pharmacological treatment options that are feasible and effective in primary care.

Observations Screening for anxiety is recommended for primary care patients younger than 65 years. Given that anxiety often involves somatic symptoms, assessment should include patient-reported symptom measures, clinical interview, physical examination, and appropriate laboratory tests. For subthreshold symptoms (those that do not meet diagnostic criteria for anxiety disorders) and adjustment-related anxiety, starting with self-help and behavioral treatment is recommended. When deciding between behavioral, pharmacological, or combined treatment for anxiety disorders, consider the presentation, patient preferences, potential adverse effects, and treatment history, and engage in shared decision-making. Cognitive-behavioral therapy (CBT) is the first-line behavioral treatment for anxiety. Brief CBT in primary care delivered by embedded behavioral health clinicians is effective. First-line pharmacotherapy for anxiety disorders includes several selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, which tend to be well tolerated without considerable long-term adverse effects. The main decision for pharmacological treatment is between a daily medication and a short-acting medication taken as needed for intermittent symptoms or while awaiting the effect of a daily medication. Benzodiazepines are not recommended due to risk of adverse effects, especially with long-term use. The Collaborative Care Management model, which involves collaboration between primary care clinicians, consulting psychiatrists, and care managers who monitor patient progress and provide behavioral treatment, improves anxiety outcomes compared to usual primary care.

Conclusions and Relevance Clinicians should recognize common anxiety presentations and understand how to differentiate between anxiety and other psychiatric or medical conditions. Referring patients to behavioral health specialists for CBT and/or prescribing recommended pharmacotherapy with Collaborative Care Management can help to reduce patient morbidity and improve functioning.

Author/s:

Robyn L. Shepardson, Jeffrey S. Khan, Katherine A. Buckheit

Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis

Megan George — Tue, 23 Sep 2025 14:04:10 +0000

Date Added:

September 23, 2025

Journal/Publication:

JAMA Internal Medicine

Publication Date:

September 22, 2025

URL:

Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2025.4610

Keywords

PMID (1):

40982264

MeSH

sleep

Adult

Humans

sleep initiation and maintenance disorders

chronic pain

Sleep Latency

quality of life

Irritable Bowel Syndrome

Neoplasms

stroke

chronic disease

Cognitive Behavioral Therapy

This systematic review/meta-analysis confirms the benefits of cognitive behavioral therapy for patients with insomnia in the face of chronic health challenges. James W. Mold, MD, MPH

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Importance: Insomnia is highly prevalent among individuals with chronic disease (eg, chronic pain, cardiovascular disease, and cancer) and results in poorer disease outcomes and quality of life. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for insomnia. However, concerns remain about its applicability and efficacy in people with chronic disease.

Objective: To evaluate the nature, efficacy, and acceptability of CBT-I in adults with chronic disease, and to identify moderators of treatment outcomes.

Data sources: Systematic searches were conducted in PsycINFO, Medline, Embase, and CENTRAL from database inception to June 5, 2025. Additional records were identified from reference lists of relevant reviews and studies.

Study selection: Eligible studies were randomized clinical trials (RCTs) involving adults (aged ≥18 years) with chronic disease and insomnia. Studies using CBT-I with measured sleep outcomes were included.

Data extraction and synthesis: Two assessors extracted data from RCTs. Hedges g was used to calculate effect sizes, and random effects meta-analyses were conducted. Heterogeneity was assessed via I2. Subgroup analyses examined whether outcomes varied by delivery format, chronic condition type, or control group.

Main outcomes and measures: Primary outcomes included insomnia severity, sleep efficiency, and sleep onset latency. Secondary outcomes included treatment acceptability and adverse effects.

Results: Sixty-seven RCTs (5232 participants) met inclusion criteria, including chronic diseases such as cancer, chronic pain, irritable bowel syndrome, and stroke. CBT-I was associated with significantly improved outcomes for insomnia severity (g = 0.98; 95% CI, 0.81-1.16) and moderate effect sizes regarding sleep efficiency (g = 0.77; 95% CI, 0.63-0.91) and sleep onset latency (g = 0.64; 95% CI, 0.50-0.78). Subgroup analyses revealed some sample, treatment, and methodological moderators (eg, longer treatment yielded better outcomes for sleep efficiency and sleep onset latency). Satisfaction with CBT-I was high, with a mean dropout rate of 13.3%. Treatment-related adverse effects were rare.

Conclusions and relevance: This systematic review and meta-analysis showed that CBT-I demonstrated strong efficacy and acceptability in chronic disease populations, with moderate to large effect sizes that appear comparable to those in non-chronic disease populations. Efficacy of CBT-I was similar across a range of disease subgroups. Future research should explore the role and nature of treatment adaptations for specific populations and increase access to CBT-I in medical settings.

Author/s:

Amelia J. Scott, Ashleigh B. Correa, Madelyne A. Bisby

Cognitive Behavior Therapy for Mental Disorders in Adults: A Unified Series of Meta-Analyses

Alex Haga — Mon, 19 May 2025 15:17:16 +0000

Date Added:

May 19, 2025

Journal/Publication:

JAMA Psychiatry

Publisher:

JAMA

Publication Date:

April 16, 2025

URL:

Cognitive Behavior Therapy for Mental Disorders in Adults: A Unified Series of Meta-Analyses

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamapsychiatry.2025.0482

Keywords

cognitive behavior therapy

mental disorders

counseling

PMID (1):

40238104

MeSH

Cognitive Behavioral Therapy

depression

anxiety disorders

Obsessive-Compulsive Disorder

Stress Disorders

stress disorder, post-traumatic

Cognitive behavioral therapy appears to be effective for treating a wide variety of psychiatric disorders. James W. Mold, MD, MPH

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Importance: Cognitive behavior therapy (CBT) is a first-line treatment for most mental disorders. However, no meta-analytic study has yet integrated the results of randomized clinical trials on CBT across different disorders, using uniform methodologies and providing a complete overview of the field.

Objective: To examine the effect sizes of CBT for 4 anxiety disorders, 2 eating disorders, major depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and psychotic and bipolar disorders on symptoms of the respective disorders using uniform methodologies for data extraction, risk of bias (RoB) assessment, and meta-analytic techniques.

Data sources: Major bibliographical databases (PubMed, PsycINFO, and Embase for all disorders) were searched up to January 1, 2024, for each disorder separately. Data analysis was performed from August 2024 to January 2025.

Study selection: Randomized clinical trials comparing CBT with inactive control conditions in adults with 1 of the mental disorders established through a clinical interview were included.

Data extraction and synthesis: Basic characteristics of patients, CBT, and studies were extracted. RoB was assessed with the Cochrane RoB tool 2. Meta-analyses were conducted using random-effects models.

Main outcomes and measures: The primary outcome was the standardized mean difference (Hedges g) indicating the difference between CBT and controls at posttreatment on symptoms of the respective disorders.

Results: A total of 375 trials (423 comparisons) between CBT and controls were included among 32 968 patients. The overall mean (SD) patient age was 43.4 (13.7) years, and the mean (SD) proportion of women was 0.68 (0.24). Effect sizes for CBT compared to all control conditions (g) were lower than 0.5 for bipolar and psychotic disorder; between 0.5 and 1.0 for panic, social anxiety, and generalized anxiety disorders, bulimia nervosa, binge eating disorders, depression, and OCD; and larger than 1.0 for PTSD and specific phobias (range of effect sizes: 0.31 for bipolar disorder to 1.27 for PTSD). Large effect sizes (g > 0.94) were observed in waitlist-controlled trials, a control condition mostly used in anxiety and eating disorders, PTSD, and OCD. Trials using care as usual showed more modest effect sizes (0.22-1.13). Study dropout rates within the CBT conditions ranged from 8% for specific phobia to 24% for PTSD.

Conclusions and relevance: In this unified series of meta-analyses, CBT was probably effective in the treatment of mental disorders, including major depression, anxiety disorders, PTSD, OCD, and eating disorders, and possibly effective in psychotic and bipolar disorders. However, the effect sizes depended on the type of control condition.

Author/s:

Pim Cuijpers, Mathias Harrer, Clara Miguel, Marketa Ciharova, Davide Papola, Djordje Basic, Cristina Botella

Diagnosis and Management of Obsessive Compulsive Disorders in Children

Alex Haga — Tue, 17 Dec 2024 19:09:18 +0000

Date Added:

December 17, 2024

Journal/Publication:

Agency for Healthcare Research and Quality

Publication Date:

December 6, 2024

URL:

Diagnosis and Management of Obsessive Compulsive Disorders in Children

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Obsessive-Compulsive Disorder

cognitive behavioral therapy

MeSH

Selective Serotonin Reuptake Inhibitors / adverse effects

Cognitive Behavioral Therapy

Obsessive-Compulsive Disorder

An evidence review of the diagnosis and treatment of obsessive-compulsive disorder in children. James W. Mold, MD, MPH

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Background. Obsessive compulsive disorder (OCD) is a common, chronic, and impairing psychiatric disorder that often begins in childhood or adolescence. Early identification and treatment of OCD is important to prevent a cascade of developmental disruptions lasting into adulthood. The 2012 American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter recommends cognitive behavioral therapy that incorporates exposure and response prevention (ERP) as a first-line treatment for mild-to-moderate OCD in youth and recommends combined treatment with ERP (if feasible) and a selective serotonin reuptake inhibitor (SSRI) for some patients, particularly those with more severe symptoms. Clinical uncertainty exists regarding the optimal treatment strategies (and treatment combinations) that work best for specific populations and settings. In this report, we seek to evaluate the accuracy of brief assessment tools to identify OCD in symptomatic youth (Key Question [KQ] 1) and the effects and harms of treatment options for youth with OCD (KQ2).

Methods. We searched Medline®, Cochrane, Embase®, CINAHL®, and ClinicalTrials.gov from inception to May 15, 2024. After double screening, we extracted study data, assessed risk of bias, and conducted network and pairwise meta-analyses. We evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42023461212).

Results. We found 117 studies (reported in 161 papers) that met inclusion criteria. Of these, 31 cross-sectional studies pertained to KQ1, diagnosis of OCD. For KQ 2, treatment of OCD, we included 71 randomized controlled trials, 2 nonrandomized comparative studies, and 13 single-arm studies that reported potential treatment effect modifiers. For KQ1, there is insufficient evidence regarding most brief assessment tools. Based on nine studies, the Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCS) may have sufficiently high sensitivity and specificity to identify patients for specialist referral and diagnostic evaluation (moderate SoE). For KQ2, meta-analyses indicate that in-person ERP is more effective for OCD symptoms when compared to either waitlist (high SoE) or behavioral control (moderate SoE), and for remission when compared to waitlist (high SOE) or behavioral control (moderate SoE). ERP via telehealth is more effective than waitlist for OCD symptoms (high SoE) and remission (moderate SoE). SSRIs are more effective than placebo for OCD symptoms and global severity (high SoE). Clomipramine is probably more effective than placebo (moderate SoE). When used together, ERP and an SSRI are probably more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE). ERP combined with an SSRI are as effective as ERP alone for OCD symptoms (high SoE). The side effects of SSRIs and clomipramine were inconsistently reported, precluding graded conclusions. Augmentation of ERP with D-cycloserine is as effective as ERP alone to reduce OCD symptoms (high SoE) or global severity (moderate SoE). The evidence was insufficient regarding potential effect modifiers.

Conclusion. The diagnosis of OCD relies on expert clinical evaluation, sometimes augmented by semi-structured interviews. The CBCL-OCS may be sufficiently accurate to indicate which youth should be further evaluated for OCD. ERP, delivered in-person or via telehealth, is an effective treatment for OCD in children and adolescents. ERP, alone or in combination with an SSRI, is probably more effective than treatment with an SSRI alone.

Nonpharmacologic Treatments for Maternal Mental Health Conditions

Alex Haga — Tue, 20 Aug 2024 19:53:30 +0000

Date Added:

August 20, 2024

Journal/Publication:

Agency for Healthcare Research and Quality

Publication Date:

July 31, 2024

URL:

Nonpharmacologic Treatments for Maternal Mental Health Conditions

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

Cognitive Behavioral Therapy

counseling

Postpartum period

An evidence-based review of non-pharmocologic treatments for maternal mental health conditions. James W. Mold, MD, MPH

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Objectives. This systematic review evaluates nonpharmacologic treatments for mental health conditions during the perinatal period (pregnancy and up to 12 months postpartum). We evaluated nonpharmacologic treatments for perinatal individuals with depressive disorders, anxiety disorders, bipolar disorder, post-traumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD).

Data sources and review methods. We searched MEDLINE®, PsycINFO®, Embase®, CINAHL®, the Cochrane Register of Clinical Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from January 1, 2000, to January 17, 2024, to identify relevant randomized controlled trials (RCTs). Nonpharmacologic interventions of interest included, among others, cognitive behavioral therapy (CBT), interpersonal therapy (IPT), exercise, non-directive counseling, behavioral activation, bright light therapy, eye movement desensitization and reprocessing (EMDR), and acupuncture. Outcomes of interest were improvement in scores on psychological assessment tools, cure or resolution of symptoms, suicide-related outcomes, and adherence to treatment. PROSPERO registration number: CRD42023440650.

Results. We identified 103 RCTs. Nonpharmacologic treatments were compared to control or each other in 101 RCTs and to pharmacologic treatments in 2 RCTs. The risk of bias was moderate for the majority of included studies, mostly related to lack of blinding. For perinatal individuals with depressive disorders, CBT was more effective than treatment as usual (TAU) to reduce depressive and anxiety symptoms (both moderate strength of evidence [SoE]); IPT was more effective than TAU to treat depressive symptoms (moderate SoE) and anxiety symptoms (low SoE); and both behavioral activation (a CBT technique, with low SoE) and exercise interventions (moderate SoE) were more effective than TAU to reduce depressive symptoms. Remission rates for depressive symptoms were higher with CBT and IPT compared to TAU (both low SoE) and higher with specific acupuncture than nonspecific or sham acupuncture (low SoE). There were no differences between CBT and non-directive counseling (an active patient-led intervention), between counseling and TAU, and between bright light and placebo light therapy (all low SoE). CBT was more effective than TAU to reduce anxiety and depressive symptoms for individuals with combined depressive and anxiety disorders (low SoE). Few (or no) eligible studies evaluated individuals with anxiety disorder, PTSD, OCD, or bipolar disorders, precluding conclusions for these conditions. There was also insufficient evidence for suicide-related outcomes, potential harms of treatment, and adherence to treatment, and for comparisons of nonpharmacologic with pharmacologic treatments.

Conclusion. Several nonpharmacologic treatments are more effective than TAU for perinatal mental health conditions, with the strongest evidence for CBT and IPT to reduce depressive symptoms among perinatal individuals with depressive disorders or combined depressive and anxiety disorders. Future research is needed to evaluate the comparative effectiveness of lesser studied nonpharmacologic interventions and lesser studied perinatal mental health conditions.

Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials

Erin Blanchette — Tue, 26 Mar 2024 16:46:24 +0000

Date Added:

March 26, 2024

Journal/Publication:

Canadian Medical Association Journal

Publisher:

Canadian Medical Association

Publication Date:

March 17, 2024

Issue:

Volume:

196

Pages:

E327-E340

URL:

Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.230274

Keywords

cognitive behavioural therapy

CBT

telehealth

teletherapy

PMID (1):

38499303

MeSH

anxiety disorders

depression

alcoholism

Cognitive Behavioral Therapy

Feeding and Eating Disorders

Videoconferencing

Telecommunications

Cognitive behavioral therapy seems to be just as effective when delivered virtually. James W. Mold, MD, MPH

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Background: Cognitive behavioural therapy (CBT) has been shown to be effective for several psychiatric and somatic conditions; however, most randomized controlled trials (RCTs) have administered treatment in person and whether remote delivery is similarly effective remains uncertain. We sought to compare the effectiveness of therapist-guided remote CBT and in-person CBT.

Methods: We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to July 4, 2023, for RCTs that enrolled adults (aged ≥ 18 yr) presenting with any clinical condition and that randomized participants to either therapist-guided remote CBT (e.g., teleconference, videoconference) or in-person CBT. Paired reviewers assessed risk of bias and extracted data independently and in duplicate. We performed random-effects model meta-analyses to pool patient-important primary outcomes across eligible RCTs as standardized mean differences (SMDs). We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance to assess the certainty of evidence and used the Instrument to Assess the Credibility of Effect Modification Analyses (ICEMAN) to rate the credibility of subgroup effects.

Results: We included 54 RCTs that enrolled a total of 5463 patients. Seventeen studies focused on treatment of anxiety and related disorders, 14 on depressive symptoms, 7 on insomnia, 6 on chronic pain or fatigue syndromes, 5 on body image or eating disorders, 3 on tinnitus, 1 on alcohol use disorder, and 1 on mood and anxiety disorders. Moderate-certainty evidence showed little to no difference in the effectiveness of therapist-guided remote and in-person CBT on primary outcomes (SMD -0.02, 95% confidence interval -0.12 to 0.07).

Interpretation: Moderate-certainty evidence showed little to no difference in the effectiveness of in-person and therapist-guided remote CBT across a range of mental health and somatic disorders, suggesting potential for the use of therapist-guided remote CBT to facilitate greater access to evidence-based care. Systematic review registration: Open Science Framework (https://osf.io/7asrc).

Author/s:

Sara Zandieh, Seyedeh Maryam Abdollahzadeh, Behnam Sadeghirad, Li Wang, Randi E McCabe, Liam Yao, Briar E Inness, Ananya Pathak, Rachel J Couban, Holly Crandon, Kian Torabiardakani, Peter Bieling, Jason W Busse

The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

Erin Blanchette — Tue, 12 Mar 2024 16:40:40 +0000

Date Added:

March 12, 2024

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

February 27, 2024

URL:

The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M23-2757

Keywords

PTSD

veterans

Veterans Health

Department of Veterans Affairs

Department of Defense

antidepressants

PMID (1):

38408360

MeSH

Stress Disorders

stress disorder, post-traumatic

Veterans

antidepressive agents

cannabis

Traumatic

Acute

Cognitive Behavioral Therapy

Recommendations from the Depts of Veterans Affairs and Defense regarding diagnosis and management of PTSD and acute stress disorders. James W. Mold, MD, MPH

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Description: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against.

Methods: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed.

Recommendations: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

Author/s:

Paula P Schnurr, Jessica L Hamblen, Jonathan Wolf, Rachael Coller, Claire Collie, Matthew A Fuller, Paul E Holtzheimer, Ursula Kelly, Ariel J Lang, Kate McGraw, Joshua C Morganstein, Sonya B Norman, Katie Papke, Ismene Petrakis, David Riggs, James A Sall, Brian Shiner, Ilse Wiechers, Marija S Kelber

Anticraving medication for moderate to severe alcohol use disorder

Saige Blanchard — Tue, 11 May 2021 05:00:00 +0000

Date Added:

May 11, 2021

Journal/Publication:

CMAJ Joule Inc.

Publisher:

CMAJ Joule Inc.

Publication Date:

May 10, 2021

URL:

Anticraving medication for moderate to severe alcohol use disorder

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Web Page

DOI (1):

10.1503/cmaj.200895

Keywords

MeSH

Cognitive Behavioral Therapy

A concise summary of treatment options for alcohol use disorders.

James W. Mold, MD, MPH

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Alcohol use disorder is characterized by compulsive use, lack of control and harmful consequences of alcohol. Men who have had more than 5 standard drinks and women who have had more than 4 standard drinks on 1 occasion within the past year should be assessed for alcohol use disorder.1 Anticraving medications can play an effective role in overcoming moderate to severe alcohol use disorder and can be prescribed by primary care physicians.

Author/s:

Mong, J., Ahamad, K., Bach, P.

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Devin Evans — Wed, 24 Feb 2021 06:00:00 +0000

Date Added:

February 24, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

February 22, 2021

URL:

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.9049

Keywords

Telephone Cognitive Behavioral Therapy

PMID (1):

33616613

MeSH

aged

sleep initiation and maintenance disorders

Sleep Hygiene

osteoarthritis

Cognitive Behavioral Therapy

Telephone

Cognitive behavioral therapy is apparently the most effective way to help people sleep better, even if provided virtually. James W. Mold, MD, MPH

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Importance: Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

Objective: To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

Design, setting, and participants: This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

Interventions: Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

Main outcomes and measures: The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

Results: Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

Conclusions and relevance: In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

Author/s:

McCurry, Susan M., Zhu, Weiwei, Von Korff, Michael, Wellman, Robert, Morin, Charles M., Thakral, Manu, Yeung, Kai, Vitiello, Michael V.

Overcoming Barriers to the Diagnosis and Treatment of Insomnia

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

The Journal of Family Practice

Publication Date:

September 1, 2020

Issue:

Volume:

Pages:

S45-S50

URL:

Overcoming Barriers to the Diagnosis and Treatment of Insomnia

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Insomnia

cognitive behavioral therapy

Insomnia medications

PMID (1):

33104107

MeSH

sleep initiation and maintenance disorders

Cognitive Behavioral Therapy

Combined Modality Therapy

Patient Care Planning

A nice review of the diagnosis and management of insomnia. James W. Mold, MD, MPH

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Apply evidence-based diagnostic guidelines for patients who have clinical features consistent with insomnia. Use evidence-based guidelines to develop comprehensive treatment plans that include cognitive-behavioral therapy, pharmacologic treatment, and combination therapies to achieve optimal outcomes Identify basic elements of cognitivebehavioral therapy for insomnia Differentiate among medications FDA-approved for treating insomnia by discussing mechanism of action, safety, efficacy, and use.

Author/s:

Roth, Thomas

Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

October 26, 2020

Issue:

Volume:

181

Pages:

104-112

URL:

Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.5651

Keywords

Fibromyalgia

quality of life

cognitive behavioral therapy

pain management

PMID (1):

33104162

MeSH

Cognitive Behavioral Therapy

This meta-analysis found that cognitive behavioral therapy, antidepressants, and CNS depressants like gabapentin had some effect in the short- and medium-term for relieving pain and/or improving quality of life in patients with fibromyalgia. No other therapies were supported by the current evidence. James W. Mold, MD, MPH

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Importance: Fibromyalgia is a chronic condition that results in a significant burden to individuals and society.

Objective: To investigate the effectiveness of therapies for reducing pain and improving quality of life (QOL) in people with fibromyalgia.

Data sources: Searches were performed in the MEDLINE, Cochrane, Embase, AMED, PsycInfo, and PEDro databases without language or date restrictions on December 11, 2018, and updated on July 15, 2020.

Study selection: All published randomized or quasi-randomized clinical trials that investigated therapies for individuals with fibromyalgia were screened for inclusion.

Data extraction and synthesis: Two reviewers independently extracted data and assessed risk of bias using the 0 to 10 PEDro scale. Effect sizes for specific therapies were pooled using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

Main outcomes and measures: Pain intensity measured by the visual analog scale, numerical rating scales, and other valid instruments and QOL measured by the Fibromyalgia Impact Questionnaire.

Results: A total of 224 trials including 29 962 participants were included. High-quality evidence was found in favor of cognitive behavioral therapy (weighted mean difference [WMD], -0.9; 95% CI, -1.4 to -0.3) for pain in the short term and was found in favor of central nervous system depressants (WMD, -1.2 [95% CI, -1.6 to -0.8]) and antidepressants (WMD, -0.5 [95% CI, -0.7 to -0.4]) for pain in the medium term. There was also high-quality evidence in favor of antidepressants (WMD, -6.8 [95% CI, -8.5 to -5.2]) for QOL in the short term and in favor of central nervous system depressants (WMD, -8.7 [95% CI, -11.3 to -6.0]) and antidepressants (WMD, -3.5 [95% CI, -4.5 to -2.5]) in the medium term. However, these associations were small and did not exceed the minimum clinically important change (2 points on an 11-point scale for pain and 14 points on a 101-point scale for QOL). Evidence for long-term outcomes of interventions was lacking.

Conclusions and relevance: This systematic review and meta-analysis suggests that most of the currently available therapies for the management of fibromyalgia are not supported by high-quality evidence. Some therapies may reduce pain and improve QOL in the short to medium term, although the effect size of the associations might not be clinically important to patients.

Author/s:

Mascarenhas, Rodrigo O., Souza, Mateus B., Oliveira, Murilo X., Lacerda, Ana C., Mendonca, Vanessa A., Henschke, Nicholas, Oliveira, Vinicius C.

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

November 4, 2019

Issue:

Volume:

180

Pages:

91-105

URL:

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2019.4917

Keywords

Mind-Body Therapies

meditation

hypnosis

cognitive behavioral therapy

pain reduction

opioids

Opioid Epidemic

PMID (1):

31682676

MeSH

Cognitive Behavioral Therapy

opioid-related disorders

Adult

In this meta-analysis, moderate to large improvements in pain outcomes were found for meditation, hypnosis, suggestion, and cognitive behavioral therapy. James W. Mold, MD, MPH

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Importance: Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective: To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data sources: For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study selection: Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data extraction and synthesis: Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main outcomes and measures: The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results: Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and relevance: The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

Author/s:

Garland, Eric L., Brintz, Carrie E., Hanley, Adam W., Roseen, Eric J., Atchley, Rachel M., Gaylord, Susan A., Faurot, Keturah R., Yaffe, Joanne, Fiander, Michelle, Keefe, Francis J.

Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

Brian Desmarais — Mon, 22 Jun 2020 15:22:14 +0000

Date Added:

June 22, 2020

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

June 1, 2020

Issue:

Volume:

URL:

Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.8279

Keywords

substance abuse

treatment

MeSH

motivational interviewing

Cognitive Behavioral Therapy

behavior therapy

counseling

The most effective treatment of substance abuse disorders includes the combination of medications and cognitive behavioral therapy. James W. Mold, MD, MPH

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Abstract

Importance: Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD.

Objective: To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs.

Data sources: PubMed, Cochrane Register, MEDLINE, PsychINFO, and Embase databases from January 1, 1990, through July 31, 2019, were searched. Keywords were specified in 3 categories: treatment type, outcome type, and study design. Collected data were analyzed through September 30, 2019.

Study selection: Two independent raters reviewed abstracts and full-text articles. English language articles describing randomized clinical trials examining CBT in combination with pharmacotherapy for AUD and SUD were included.

Data extraction and synthesis: Inverse-variance weighted, random-effects estimates of effect size were pooled into 3 clinically informative subgroups: (1) CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included assessment of study quality, pooled effect size heterogeneity, publication bias, and primary substance moderator effects.

Main outcomes and measures: Substance use frequency and quantity outcomes after treatment and during follow-up were examined.

Results: The sample included 62 effect sizes from 30 unique randomized clinical trials that examined CBT in combination with some form of pharmacotherapy for AUD and SUD. The primary substances targeted in the clinical trial sample were alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The mean (SD) age of the patient sample was 39 (6) years, with a mean (SD) of 28% (12%) female participants per study. The following pharmacotherapies were used: naltrexone hydrochloride and/or acamprosate calcium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or mixture of pharmacotherapies (20 of 62 [32%]). Random-effects pooled estimates showed a benefit associated with combined CBT and pharmacotherapy over usual care (g range, 0.18-0.28; k = 9). However, CBT did not perform better than another specific therapy, and evidence for the addition of CBT as an add-on to combined usual care and pharmacotherapy was mixed. Moderator analysis showed variability in effect direction and magnitude by primary drug target.

Conclusions and relevance: The present study supports the efficacy of combined CBT and pharmacotherapy compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality (eg, motivational enhancement therapy, contingency management) in this context or as an add-on to combined usual care and pharmacotherapy. These findings suggest that best practices in addiction treatment should include pharmacotherapy plus CBT or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

Author/s:

Ray, L.A., Meredith, L.R., Kiluk, B.D., Walthers, J., Carroll, K.M., Magill, M.

Treatment of Depression in Children and Adolescents: A Systematic Review. Comparative Effectiveness Review No. 224

John Bayhi — Fri, 17 Apr 2020 17:32:46 +0000

Date Added:

April 17, 2020

Journal/Publication:

AHRQ Publication No. 20-EHC005-EF

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

April 10, 2020

URL:

Treatment of Depression in Children and Adolescents: A Systematic Review. Comparative Effectiveness Review No. 224

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER224

Keywords

cognitive behavioral therapy

selective serotonin reuptake inhibitors

MeSH

serotonin uptake inhibitors

paroxetine

Depressive Disorder

depressive disorder, major

united states food and drug administration

risk

Inpatients

Confidence Intervals

antidepressive agents

Cognitive Behavioral Therapy

The key findings are listed on the third page (page ii). James W. Mold, MD, MPH

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Background. Depressive disorders can affect long-term mental and physical health functioning among children and adolescents, including increased risk of suicide. Despite access to several nonpharmacological, pharmacological, and combined treatment options for childhood depression, clinicians contend with sparse evidence and are concerned about harms associated with treatment.

Methods. We conducted a systematic review to evaluate the efficacy, comparative effectiveness, and moderators of benefits and harms of available nonpharmacological and pharmacological treatments for children and adolescents with a confirmed diagnosis of a depressive disorder (DD)—major depressive disorder (MDD), persistent depressive disorder (previously termed dysthymia) or DD not otherwise specified. We searched five databases and other sources for evidence available from inception to May 29, 2019, dually screened the results, and analyzed eligible studies.

Results. We included in our analyses data from 60 studies (94 articles) that met our review eligibility criteria. For adolescents (study participants’ ages range from 12 to 18 years) with MDD, cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine and CBT may improve depressive symptoms (1 randomized controlled trial [RCT] each, n ranges from 212 to 311); whether the magnitude of improvement is clinically significant is unclear. Among adolescents or children with MDD, CBT plus medications (8–17 years) may be associated with lower rates of relapse (1 RCT [n = 121]). In the same population (6–17 years), selective serotonin reuptake inhibitors (SSRIs) may be associated with improved response (7 RCTs [n = 1,525]; risk difference [RD], 72/1,000 [95% confidence interval (CI), 2 to 24], I2 = 9%) and functional status (5 RCTs [n = 941]; standardized mean difference, 0.16 [95% CI, 0.03 to 0.29]; I2 = 0%). For adolescents or children with any DD (7–18 years), CBT or family therapy may be associated with improvements in symptoms, response, or functional status (1 RCT each, n ranges from 64 to 99). Among children with any DD (7–12 years), family-based interpersonal therapy may be associated with improved symptoms (1 RCT, n = 38). Psychotherapy trials did not report harms. SSRIs may be associated with a higher risk of serious adverse events among adolescents or children with MDD (7–18 years; 9 RCTs [n = 2,206]; RD, 20/1,000 [95% CI, 1 to 440]; I2, 4%) and with a higher risk of withdrawal due to adverse events among adolescents with MDD (12–18 years; 4 RCTs [n = 1,296], RD, 26/1,000 [95% CI, 6 to 45]; I2, 0%). Paroxetine (1 RCT [n = 180]) may be associated with a higher risk of suicidal ideation or behaviors among adolescents with MDD (12–18 years). Evidence was insufficient to judge the risk of suicidal ideation or behavior for other SSRIs for adolescents and children with MDD or other DD (7–18 years) (10 RCTs [n = 2,368]; relative risk, 1.14 [95% CI, 0.89 to 1.45]; I2, 8%). However, this report excluded data on inpatients and those without depressive disorders, whom the Food and Drug Administration included in finding an increased risk of suicidality for all antidepressants across all indications.

Conclusion. Efficacious treatments exist for adolescents with MDD. SSRIs may be associated with increased withdrawal and serious adverse events. No evidence on harms of psychotherapy were identified.

Author/s:

Viswanathan, M, Kennedy, SM, McKeeman, J, Christian, R, Coker-Schwimmer, Cook Middleton, Bann, C, Lux, L, Randolph, Forman-Hoffman, V

Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents Comparative Effectiveness Review No. 203

John Bayhi — Fri, 01 Nov 2019 16:52:29 +0000

Date Added:

November 1, 2019

Journal/Publication:

AHRQ Website

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

January 25, 2019

URL:

Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER203

Keywords

ADHD

attention deficit disorder with hyperactivity

ADHD treatment

children

adolescent

MeSH

attention deficit disorder with hyperactivity/therapy

Cognitive Behavioral Therapy

Complementary Therapies

Fatty Acids/administration & dosage

Humans

Neurofeedback

Parents/education

The key points can be found on page 4 (from 2011 report) and page ii (from this report).

Objectives. Attention deficit hyperactivity disorder (ADHD) is a common pediatric neurobehavioral disorder often treated in the primary care setting. This systematic review updates and extends two previous Agency for Healthcare Research and Quality (AHRQ) systematic evidence reviews and focuses on the comparative effectiveness of methods to establish the diagnosis of ADHD, updates the comparative effectiveness of pharmacologic and nonpharmacologic treatments, and evaluates different monitoring strategies in the primary care setting for individuals from birth through 17 years of age.

Data sources. We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2011, through November 7, 2016.

Review methods. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects when sufficient data were available for meta-analysis.

Results. Evidence was contributed from 103 articles describing 90 unique studies. Twenty-one studies related to diagnosis, 69 studies related to treatment, and no studies were identified on monitoring. The Attention and Executive Function Rating Inventory and Childhood Executive Functioning Inventory performed better than the Cambridge Neuropsychological Test Automated Battery for the diagnosis of ADHD for ages 7–17 years (strength of evidence [SOE]=low). Evidence was insufficient on the use of electroencephalography (EEG) or neuroimaging to establish the diagnosis of ADHD for ages 7–17 years. No studies directly assessed the harms to children labeled as having ADHD. Limited additional evidence published since the original 2011 report was available on ADHD medications approved by the Food and Drug Administration (FDA) compared with placebo or compared to different FDA-approved ADHD medications (SOE=insufficient). For atomoxetine and methylphenidate, the most commonly reported adverse events were somnolence and mild gastrointestinal problems. Atomoxetine had slightly higher gastrointestinal effects than methylphenidate (SOE=low). Cognitive behavioral therapy improved ADHD symptoms (SOE=low). Child or parent training improved ADHD symptoms (SOE=moderate) but made no difference in academic performance (SOE=low). Omega-3/6 fatty acid supplementation made no difference in ADHD symptoms (SOE=moderate). Across all treatments, little evidence was reported on the risk of serious adverse events, including cardiovascular risk.

Conclusions. The 2011 AHRQ systematic review highlighted the benefit of psychostimulants for children 6–12 years of age with ADHD for up to 24 months and found that adding psychosocial/behavioral interventions to psychostimulants is more effective than psychosocial/behavioral interventions alone for children with ADHD and oppositional defiant disorder. This targeted update found insufficient evidence regarding new approaches to the diagnosis (e.g., EEGs, neuroimaging). Little is known about the impact of being labeled as having ADHD. Although cognitive behavioral therapy or child or parent training may decrease symptoms of ADHD, more information is needed regarding the relative benefit of these approaches compared to, or combined with, medication treatment. Omega-3/6 supplementation does not appear to improve ADHD outcomes. No information was identified regarding the optimal strategy for monitoring after diagnosis.

Author/s:

Kemper, AR, Maslow, GR, Hill, S, Namdari, B, Allen LaPoint, NM, Goode, AP, Coeytaux, RR, Befus, D, Kosinski, AS, Bowen, SE, McBroom, AJ, Lallinger, KR, Sanders, GD