www.nmgpsy.com内蒙古心理网Cognitive :
The Evidence
M. Clark
Institute of Psychiatry
Kings College London
Cognitive Behaviour Therapy:
The Evidence
David M. Clark
Institute of Psychiatry
Kings College London
What is CBT?
. Brief (8-16 sessions)
. Focuses on problematic beliefs and behaviours
that maintain disorders (rather than original
causes).
. Strong foundation in academic psychology
. Patient is very active
What is CBT?
. Brief (8-16 sessions)
. Focuses on problematic beliefs and behaviours
that maintain disorders (rather than original
causes).
. Strong foundation in academic psychology
. Patient is very active
Does it work?
Gold Standard is the randomized controlled
trial.
CBT needs to be superior to:
. no treatment (wait list control)
. an equally credible alternative psychological
treatment ( to control for non-specific factors)
and at least as effective as medication in the short-term.
Does it work?
Gold Standard Evidence is the randomized controlled
trial.
CBT needs to be superior to:
. no treatment (wait list control)
. an equally credible alternative psychological
treatment ( to control for non-specific factors)
and at least as effective as medication in the short-term.
Common Disorders where CBT is
effective1 as a sole treatment
recovery rate2 in RCTs
Major depressive disorder 60%
Panic disorder 75%
Posttraumatic stress disorder 75%
Social Phobia 60%
Generalised anxiety disorder 50%
Obsessive compulsive disorder 55%
Bulimia Nervosa 50%
1 Effective is defined as meeting the criteria specified on the previous slide.
2 Most patients show some improvement with CBT. Recovery rate is the approximate proportion of individuals
who no longer have the disorder at the end of a course of CBT.
Common Disorders where CBT is
effective1 as a sole treatment
recovery rate2 in RCTs
Major depressive disorder 60%
Panic disorder 75%
Posttraumatic stress disorder 75%
Social Phobia 60%
Generalised anxiety disorder 50%
Obsessive compulsive disorder 55%
Bulimia Nervosa 50%
1 Effective is defined as meeting the criteria specified on the previous slide.
2 Most patients show some improvement with CBT. Recovery rate is the approximate proportion of individuals
who no longer have the disorder at the end of a course of CBT.
Disorders where CBT enhances
the effects of medication
. Schizophrenia
. Bipolar disorder (manic-depression)
Disorders where CBT enhances
the effects of medication
. Schizophrenia
. Bipolar disorder (manic-depression)
Long-term outcome of CBT
. On average, the gains obtained in CBT are
well-maintained at follow-ups of several
years.
. Recent studies have also shown that CBT
can reduce relapse in depressed patients
who were initially treated with medication.
Long-term outcome of CBT
. On average, the gains obtained in CBT are
well-maintained at follow-ups of several
years.
. Recent studies have also shown that CBT
can reduce relapse in depressed patients
who were initially treated with medication.
Social Phobia: 5 year Follow-Up
(Heimberg et al., 1993)
0
1
2
3
4
5
6
7
Pre Post 6m FU 5 yr FU
Phobic SeveritySupport
CBT
Social Phobia: 5 year Follow-Up
(Heimberg et al., 1993)
0
1
2
3
4
5
6
7
Pre Post 6m FU 5 yr FU
Phobic SeveritySupport
CBT
CBT prevents relapse in recurrent
depression (Fava et al., 2004)
CBT prevents relapse in recurrent
depression (Fava et al., 2004)
Cost of not treating
Less than 10% of suitable patients currently receive CBT
Greenberg et al., (1999)
Untreated anxiety disorders are very costly
. Excess non-psychiatric medical treatment
. Workplace costs due to loss of productivity, sick leave
and unemployment.
Salvador-Carulla et al. (1995)
In the first year alone, successful treatment of one
anxiety disorder was associated with:
. 94% decrease in excess non-psychiatric medical
treatment costs.
. 80% decrease in workplace costs.
Cost of not treating
Less than 10% of suitable patients currently receive CBT
Greenberg et al., (1999)
Untreated anxiety disorders are very costly
. Excess non-psychiatric medical treatment
. Workplace costs due to loss of productivity, sick leave
and unemployment.
Salvador-Carulla et al. (1995)
In the first year alone, successful treatment of one
anxiety disorder was associated with:
. 94% decrease in excess non-psychiatric medical
treatment costs.
. 80% decrease in workplace costs.
Can the results of RCTs be achieved
in more routine NHS settings?
Omagh Bomb Example (Gillespie et al, 2002)
. No local expertise in treatment at the time
. team provided specialist training
. Therapists: psychiatrist, social worker, nurses.
. All patients with PTSD accepted. No exclusions.
. Outcome audited
. Improvement equivalent to that obtained in
RCTs from specialist centres.
Can the results of RCTs be achieved
in more routine NHS settings?
Omagh Bomb Example (Gillespie et al, 2002)
. No local expertise in PTSD treatment at the time
. Clark team provided specialist training
. Therapists: psychiatrist, social worker, nurses.
. All patients with PTSD accepted. No exclusions.
. Outcome audited
. Improvement equivalent to that obtained in
RCTs from specialist centres.
Conclusions
. CBT works
. It’s effects are enduring (& can prevent future disorder)
. Most patients in the NHS don’t get CBT
. With additional trained therapists, successful
dissemination is possible
. Therapist attrition is very low ( approx 1% pa for
clinical psychologists1)
. Likely Cost benefits (indirect medical and workplace)
1 Lavender et al. Survey of 1993 graduates from South-East Thames Course.
Conclusions
. CBT works
. It’s effects are enduring (& can prevent future disorder)
. Most patients in the NHS don’t get CBT
. With additional trained therapists, successful
dissemination is possible
. Therapist attrition is very low ( approx 1% pa for
clinical psychologists1)
. Likely Cost benefits (indirect medical and workplace)
1 Lavender et al. Survey of 1993 graduates from South-East Thames Course.
Illustrative References (1)
Nice Guidelines (www.nice.org.uk)
. CG22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia,
and generalised anxiety disorder) in adults in primary, secondary and community care –
Full guideline. 22 December 2004. (www.nice.org.uk/page.aspx?o=cg022)
. CG22 Depression: management of depression in primary and secondary care – Full
Guidance and Appendices. 15 December 2004. (www.nice.org.uk/page.aspx?o=cg023)
. CG01 Schizophrenia: core interventions in the treatment and management of
schizophrenia in primary and secondary care – Nice Guideline.
(www.nice.org.uk/page.aspx?o=cg1)
Illustrative References (1)
Nice Guidelines (www.nice.org.uk)
. CG22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia,
and generalised anxiety disorder) in adults in primary, secondary and community care –
Full guideline. 22 December 2004. (www.nice.org.uk/page.aspx?o=cg022)
. CG22 Depression: management of depression in primary and secondary care – Full
Guidance and Appendices. 15 December 2004. (www.nice.org.uk/page.aspx?o=cg023)
. CG01 Schizophrenia: core interventions in the treatment and management of
schizophrenia in primary and secondary care – Nice Guideline.
(www.nice.org.uk/page.aspx?o=cg1)
Illustrative References (2)
Some reviews, meta-analyses and individual randomized controlled trials
Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin and
Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley.
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive
therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72.
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy
versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting &
Clinical Psychology, 71(6), 1058-1067.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A
comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British
Journal of Psychiatry, 164, 759-769.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological
treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225.
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for
posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032.
Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2004). Six-year outcome of cognitive behavior
therapy for prevention of recurrent depression. American Journal of Psychiatry, 161(10), 1872-1876.
Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled
study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year.
Archives of General Psychiatry, 60(2), 145-152.
Illustrative References (2)
Some reviews, meta-analyses and individual randomized controlled trials
Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin and
Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley.
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive
therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72.
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy
versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting &
Clinical Psychology, 71(6), 1058-1067.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A
comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British
Journal of Psychiatry, 164, 759-769.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological
treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225.
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for
posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032.
Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2004). Six-year outcome of cognitive behavior
therapy for prevention of recurrent depression. American Journal of Psychiatry, 161(10), 1872-1876.
Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled
study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year.
Archives of General Psychiatry, 60(2), 145-152.
Illustrative References (3)
Costs and Cost-Effectiveness
Issakidis, C., Sanderson, K., Corry, J., Andrews, G., & Lapsley, H. (2004). Modelling the population
cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders.
Psychological Medicine, 34(1), 19-35.
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T., et al.
(1999). The economic burden of anxiety disorders in the 1990s. 60(7), 427-435.
Lam, D. H., McCrone, P., Wright, K., & Kerr, N. (2005). Cost-effectiveness of 30 month study of
relapse prevention cognitive therapy for bipolar disorder. British Journal of Psychiatry, in press.
Salvador-Carulla, L., Segui, J., Fernandez-Cano, P., & Canet, J. (1995). Costs and offset effect in panic
disorders. British Journal of Psychiatry Supplement(27), 23-28.
Dissemination of evidence based treatment
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in
the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research
and Therapy, 40, 345-357.
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for
panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and
Clinical Psychology, 66, 231-239.
Illustrative References (3)
Costs and Cost-Effectiveness
Issakidis, C., Sanderson, K., Corry, J., Andrews, G., & Lapsley, H. (2004). Modelling the population
cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders.
Psychological Medicine, 34(1), 19-35.
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T., et al.
(1999). The economic burden of anxiety disorders in the 1990s. 60(7), 427-435.
Lam, D. H., McCrone, P., Wright, K., & Kerr, N. (2005). Cost-effectiveness of 30 month study of
relapse prevention cognitive therapy for bipolar disorder. British Journal of Psychiatry, in press.
Salvador-Carulla, L., Segui, J., Fernandez-Cano, P., & Canet, J. (1995). Costs and offset effect in panic
disorders. British Journal of Psychiatry Supplement(27), 23-28.
Dissemination of evidence based treatment
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in
the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research
and Therapy, 40, 345-357.
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for
panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and
Clinical Psychology, 66, 231-239.
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