Cognitive Behavioural Therapy: the current state of the evidence

1. Cognitive Behavioural Therapy: the current state of the evidence Glyn Lewis

3. What is CBT? Beck�s original model applied to depression Since then different models applied to different problems/diagnoses Now have CBT for everything from pain, to psychosis via insomnia

4. Beck�s Model for depression Early life events Dysfunctional assumptions Critical life event Automatic thoughts Change in mood and behaviour

5. Ehlers & Clark model for PTSD PTSD becomes persistent when individuals see trauma as current threat because of: Negative appraisal of trauma or sequelae Disturbance of memory of trauma: poor contextualisation and perceptual priming

6. Ehlers & Clark treatment Modify negative appraisals Find �hot spots� in memory Contextualise memories & identify triggers Help develop coherent account Find triggers Change behavioural consequences Modify avoidance behaviour

7. Competencies in CBT

8. Competencies

9. Behavioural activation Began life as a �component� of CBT Counteract patterns of avoidance, withdrawal and inactivity Simpler than CBT but requires detailed behavioural analysis Keeps collaborative framework Maybe as or more effective in more severe depressions

10. Evidence from trials

11. NICE Depression guideline 2004 CBT much better compared to wait list CBT not better than antidepressants alone But compared to antidepressants plus weekly 20 minute sessions No RCT evidence to support pure behaviour therapy

12. Clinical relevance in the NHS Most people who get CBT in the UK are or have been on antidepressants Almost all evidence on previously untreated episodes What is the long term outcome of CBT compared to usual care? Usual care in UK from GPs involves very little follow up and psychological treatment

13. Adherence and competence Adherence to model is associated with good outcome However, this is observational data Could be confounded by patient characteristics Competence can be distinguished from adherence

14. CBT plus antidepressants Combined treatment more effective than antidepressants alone OR 1.86 (1.38-1.52) No evidence that pharmacotherapy and psychotherapy interfere with each other 16 trials and over 1800 patients

15. Treatment refractory depression

16. TRD trial of CBT

17. COBALT New trial funded by NHS R&D Health Technology Assessment Led by Nicola Wiles, Bristol Exeter and Glasgow CBT plus usual care with antidepressants vs usual care Depressed patients not responded to antidepressants Primary care based

18. Relapse prevention

19. Long term follow up CBT teaches skills so ought to have advantages over longer term Suggestion that CBT is more effective in the longer term Only true if compared to patients who stop taking medication Evidence base is currently inadequate

20. Residual depression CBT also effective in preventing relapse in people with residual symptoms Paykel RCT 47% relapse rate reduced to 29% Effects were still present 3� years after randomisation

21. Mindfulness or attentional control Based upon Buddhist meditation techniques Can be taught to groups of people Creates an emotional �distance� from thoughts (�metacognitive awareness�) �Thoughts aren�t facts�

22. Evidence for mindfulness Some trial data suggests mindfulness CBT can reduce relapse risk Patients were recovered but had only received antidepressants Might be a cost-effective and highly acceptable approach

23. Self help

24. Bibliotherapy

25. Computerised CBT

26. World Wide Web

27. webCBT

28. PsychologyOnLine A website providing a link to psychologists throughout the UK Running since 2001 Over 100 patients treated by 2003 Access for anyone with PC and Internet; broadband not required

29. Who might find this useful? Computer Literate Working people Those living in areas poor in psychology services Disabled Social phobics Non-English speakers

30. Self help for depression

31. Self-help Can be helpful but it is not clear how much support people need Most trials provide some kind of support from an expert person Giving a person a book might not be effective without this Probably can�t do any harm

32. Computerised CBT One trial in UK funded by the company that produces the programme Beating the Blues Need independent evaluations The degree of support needed is unknown but is probably required

33. Conclusion

34. Conclusions � what we know CBT, in its various guises, is an effective treatment for depression and anxiety disorders compared to a waiting list Doesn�t seem to be more effective than medication, at least in the short term Combinations of CBT and antidepressants are beneficial in depression and probably not harmful in anxiety

35. Conclusion � what we don�t know How closely does a therapist need to adhere to the CBT model to be effective? What is the CBT like in the NHS and how does it compare with that in trials? CBT as self-help � what degree of support is required? Is it effective for the the more complex cases seen in secondary care?