Cognitive Behavioural Therapy in ABI. What Works for Whom?

1. Cognitive Behavioural Therapy in ABI. What Works for Whom? Dr Brian Waldron Senior Clinical Neuropsychologist Date: Friday 18th May 2018

2. How much of an issue is Anxiety post ABI? • Prevalence of Anxiety after TBI (Hibbard et al., 1998) • Post Traumatic Stress Disorder (PTSD; 19%) • Obsessive Compulsive Disorder (OCD; 15%) • Panic Disorder (14%) • Generalised Anxiety Disorder (GAD; 9%) • Phobias, including social phobia (10%)

3. How much of an issue is Depression post ABI? • Prevalence of Depression after ABI • 20% - 40% of people with TBI show depression in first year (Fleminger, et al., 2003). • Self reported depression after TBI in a sample of 722 individuals 2.5 years post-injury revealed that 42% met DSM-IV criteria for major depressive disorder (Kreutzer, Seel & Gourley, 2001). • In the acute phase of stroke, depression occurs in 13% to 32% of patients (Hackett, Yapa, Parag & Anderson, 2005).

4. Overview of the Meta Analysis • Previous systematic reviews limited to a few well-designed RCTs • Comper, Bisschop, Carnide, & Tricco, 2005. • Soo & Tate, 2007. • Two comprehensive meta-analyses came out in 2013. • Stalder-Lüthy, Messerli-Bürgy, Hofer, Frischknecht, Znoj, & Barth. (2013). • Waldron, B.A., Casserly, L.M., & O’Sullivan, C. (2013). • Decision to include Single Cases / Single Groups / RCTs • Had to be reporting of anxiety or depression as an outcome • 24 Papers from 1991 to 2011 • TBI / CVA / Anoxia / Hypoxia / Neuro-Surgery • Nine studies were conducted in the UK, six studies in Australia, four in the USA, three in Canada, one in The Netherlands and one in Singapore.

5. Types of Studies on CBT post ABI • Three interventions for OCD (Arco, 2008; Ko, 1997; Williams et al., 2003a). • Nine evaluations of PTSD treatment (Batten & Pollack, 2008; Bryant, Moulds, Guthrie, & Nixon, 2003; Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011; King, 2002; Kneebone & Hull, 2009; McGrath, 1997; McMillan, 1991; McNeil & Greenwood, 1996; Williams, Evans, & Wilson, 2003b). • One intervention for social anxiety (Hodgson et al., 2005). • One intervention for social skills (McDonald et al., 2008).

6. Types of Studies on CBT post ABI • One intervention for a coping skills group*** (Anson & Ponsford, 2006a) • One intervention on anger management (Medd & Tate, 2000). • One study on multidisciplinary rehabilitation (Salazar et al., 2000). • Three studies focused on both depression and anxiety (Arundine et al., 2011; Bradbury et al., 2008; Tiersky et al., 2005). • Four studies focused on depression alone (Lincoln & Flannaghan, 2003; Lincoln, Flannaghan, Sutcliffe, & Rother, 1997; Rasquin, van de Sande, Praamstra, & van Heugten, 2009; Topolovec-Vranic et al., 2010).

7. Method of CBT Delivery • Method of delivery of CBT varies across the studies… • One study evaluated group CBT (Anson & Ponsford, 2006a) and eighteen studies evaluated individual CBT, one of which was delivered via the internet without a therapist (Topolovec-Vranic et al., 2010). • Two papers used a treatment group where some persons received group CBT, and some received CBT individually over the phone (Arundine et al., 2011; Bradbury et al., 2008) • Three studies used a treatment group where each person received a combination of both group and individual one-to-one CBT (Chard et al., 2011; McDonald et al., 2008; Salazar et al., 2000).

8. Methodological Quality of Studies • Each study was rated using the PEDro Scale (Maher, Sherrington, Herbert, Moseley, & Elkins, 2003). [Excluding the SCED studies]. • PEDro scores were rated and used the PsycBITE database (http://www.psycbite.com) as a benchmark of concurrent validity. • There was variability in methodological quality [2/10 to 7/10]. • It is difficult to blind subjects & therapists (two PEDro items). • Clients know if they are getting CBT or not ? • Therapists know if they are providing CBT or not ?

9. Methodological Quality of Studies • Lower PEDro scores tended to be caused by not having a control group(Arundine et al., 2011; Chard et al., 2011; Lincoln et al., 1997; Topolovec-Vranic et al., 2010) which precluded a score for random allocation, allocation being hidden, or groups being similar at baseline. • Additionally, (a) provision of adequate follow up and (b) analysis of data on an intention to treat basis were possible features of studies (even with just a single treatment group), yet these features were sometimes absent, lowering the PEDro score further and increasing the potential for bias. • Effect Sizes calculated using Glass’s Δ. d=(M1-M2)/SD2

10. Findings – Treatment focus –vs- therapeutic effect • If a CBT programme is aimed at a particular problem, for example coping skills, or social skills, or anger management, it can be effective for coping skills or social skills or anger management, but will not necessarily generalise to have a significant therapeutic effect on anxiety or depression (Anson & Ponsford, 2006a; McDonald et al., 2008; Medd & Tate, 2000). • In those studies where the CBT focused on social skills, coping skills or anger management effect sizes ranged from 0.00 to 0.46 for depression and 0.00 to 0.42 for anxiety. • The average effect size was 0.16 for depression (small effect) and 0.17 for anxiety (small effect) indicating that the average case fared better than only 58% of untreated cases.

11. Findings – Treatment focus –vs- therapeutic effect • CBT interventions that target anxiety disorders and depression specifically, appear to generate better therapeutic effects on anxiety and depression after intervention (Arundine et al., 2011; Bradbury et al., 2008; Bryant et al., 2003; Chard et al., 2011; Hodgson et al., 2005; Lincoln et al., 1997; Rasquin et al., 2009; Tiersky et al., 2005; Topolovec-Vranic et al., 2010). • For studies that targeted the treatment of depression with CBT,effect sizes ranged from 0 to 2.39 with an average effect size of 1.15 for depression (large effect) indicating the average CBT treated case fared better than 87% of untreated cases. • For studies that targeted the treatment of anxiety with CBT, effect sizes ranged from 0 to 3.47 with an average effect size of 1.04 for anxiety (large effect) indicating the average CBT treated case fared better than 85% of untreated cases.

12. Findings - Any generalisation at all? • For the anxiety disorders, the Williams et al. (2003a) study, the Bryant et al. (2003) study and the Hodgson et al. (2005) study show that when the treatment focus is on an anxiety disorder (PTSD and social anxiety respectively) there appeared to be generalisation to improvement in a broader spectrum of anxiety symptoms. • The implication for mood disorders is less clear. The Hodgson et al. (2005) study showed generalisation to depression symptoms on the basis of intervention for social anxiety. • However Bryant et al. (2003) did not interpret their results as showing generalisation of treatment effects to depression on the basis of intervention for PTSD.

13. Findings – Statistical -vs- clinical significance • The current review indicates that CBT regularly shows either • a within group pre to post-treatment statistical difference for depression and anxiety problems, or… • a statistical significance between those treated with CBT and the various control groups after therapy. • Care should be taken in interpreting individual effect sizes across studies in as many factors in an individual study can give rise to a large effect size. • For example Internet Delivered CBT without a therapist. • What does this mean for clinical significance as opposed to purely statistical significance?

14. Findings – Statistical -vs- clinical significance • Clinical significance (normal / mild / moderate / severe on BDI / BAI / HADS / SCL-90-R / DASS-21 / CES-D / IES etc.). • There are many studies that do not show remission of depression or anxiety symptoms in case studies or CBT treated groups. • Studies frequently indicate only partial reduction in anxiety or depression symptoms. CBT is not a Panacea. • These issues are the case for studies even where the CBT focus has been targeted on anxiety and depression… Why? • Questions around overlap of Depression / ABI symptoms***

15. What Works ? Question is still open • Anecdotally CBT is an effective treatment method in non ABI populations and in ABI populations. • Number of CBT sessions – authors in published literature question the number of CBT sessions being too few. • This is more of an issue in the “group based” studies rather than the single case studies (and is linked with manualised treatment). • Single case studies give more of a flavour of longer times in therapy with standard CBT and suggestions of additional Person Centred / Gestalt approaches being used. • Linked issue of Therapeutic Alliance – not a single study addresses this question.

16. Conclusions (1) General Points • Firstly there is no evidence for generalisation or ‘knock on effect’ of CBT treatments for Anger, Social Skills or Coping. • Clinicians working with persons with ABI need to target specifically those outcomes that they wish to change with a specifically honed CBT program for that outcome. • Secondly, it is clear that while CBT can be effective it will not result in a positive outcome for every person with an ABI. • It is worth noting that CBT is not a ‘magic bullet’ or panacea in non ABI populations either (about 66% get better). • Thirdly, there is almost zero evidence base for running CBT groups. All the published evidence for anxiety disorder and depression intervention work is for one-to-one individual CBT.

17. Conclusions (2.1) CBT “Dosage” • The following assumes 60 minute sessions where the study does not report how many minutes were in a session but does report how many weeks of therapy there were • Our review shows that for OCD, published studies indicate improvements for total CBT input of 360 minutes (Ko, 1997) and for 480 minutes (Arco, 2008). • For PTSD, studies show improvements for input (spread between five and twenty weeks) of 420 minutes (McNeil & Green- wood, 1996); 450 minutes (Bryant et al., 2003); 840 minutes (Chard et al., 2011); 960 minutes (McMillan, 1991); 1140 minutes (Batten & Pollack, 2008); and 1200 minutes (Kneebone & Hull, 2009); but one single-case study demonstrated treatment abreaction and no change despite 1080 minutes over 28 weeks (King, 2002).

18. Conclusions (2.2) CBT “Dosage” • In terms of depression and anxiety in general, post-TBI specifically, for CBT delivered over a period of six to eleven weeks, studies show maintenance rather than benefit for 480 minutes (Salazar et al., 2000) but improvement for 660 minutes (Arundine et al., 2012; Bradbury et al., 2008) and 720 minutes (Topolovec-Vranic et al., 2010), although one study shows only marginal benefits despite 1650 minutes of CBT over eleven weeks (Tiersky et al., 2005). • For depression and anxiety in general, post-CVA specifically, studies report that 53% of people showed some improvement with 504 minutes of CBT (average of 8.4 sessions of 60 minutes) over about ten weeks (Lincoln et al., 1997) and 60% of people showed some improvement with 480 minutes over eight weeks (Rasquin et al., 2009), yet there was lack of improvement in one study of 600 minutes over ten weeks (Lincoln & Flannaghan, 2003).

19. Future Directions – A.C.T. - R.C.T.s • Bomyea, J., Lang, A.J., Schnurr, P.P. (2017).TBI and Treatment Response in a Randomized Trial of Acceptance and Commitment Therapy. Journal of Head Trauma Rehabilitation: Jan 05, 2017. doi:10.1097/HTR.0000000000000278 • Secondary analysis from a 2-group randomized controlled trial including US veterans. The main trial analysis results are not out. • Whiting, D. L., Simpson, G. K ., Mcleod, H. J., Deane, F. P. & Ciarrochi, J. (2012). Acceptance and Commitment Therapy (ACT) for Psychological Adjustment after Traumatic Brain Injury: Reporting the Protocol for a Randomised Controlled Trial. Brain Impairment, 13 (3), 360-376. • Participants will be recruited from Liverpool Brain Injury Unit and randomly allocated to one of two groups, Acceptance and Commitment Therapy (ACT) or an active control (Befriending).

20. Future Directions – A.C.T. Case Studies • Gillanders, S. & Gillanders, D. (2014). An Acceptance and Commitment Therapy Intervention for a Woman With Secondary Progressive Multiple Sclerosis and a History of Childhood Trauma, Neuro-Disability & Psychotherapy, 2 (1/2), 19–40. • Single case: Treatment involved individual & couples therapy. Measures of acceptance and psychological distress were gathered pre-, mid-, and post-treatment. At the end of therapy, depression and anxiety scores had reduced to non-clinical levels. • Whiting, D.L., Deane, F.P., Simpson, G.K., Ciarrochi, J. & McLeod, H.J. (2017). Acceptance and Commitment Therapy delivered in a dyad after a severe traumatic brain injury: A feasibility study. Clinical Psychologist. doi:10.1111/cp.12118 • Two single-cases (with a good treatment response in one of the two participants)

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