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Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clin...
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... total of 139 youths participated in the long-term follow-up study (77.7% of all participants in the original RCT), including 90.3% of treatment completers. Fig. 1 shows the flowchart for participants from pre-treatment to long-term follow-up. Age varied from 11 to 21 years (M = 15.5, SD = 2.5), and 54.7% were female. The principal diagnoses were SAD (35.3%), SOP (46.0%), and GAD (18.7%). The mean pre- treatment clinician severity rating (CSR; 0-8 scale) for the principal diagnosis was 7.0 and ...
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... With growing international concern over the rising prevalence of mental health problems to date in both children and adults [8,9], efforts to provide evidence based, effective interventions have increased [10]. However, the link between mental health and social class extends beyond incidence, and likely also influences treatment outcomes [11], encompassing both symptom severity but also later social mobility [12]. This not only exacerbates impairment and distress, but also contributes to health inequality. ...
... Seventeen studies examined the relationship between social class (and indicators relating to social class) and mental health treatment outcomes [11,[31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46]. These included randomized controlled trials (RCTs) (K = 9), a before and after trial (K = 1) and cohort studies (K = 7). ...
... There was no significant difference between people from Class I and people from Classes II and III. Another study of unclear ROB [11] found that in adolescents with an anxiety disorder treated with individual CBT, family social class was negatively associated with no longer meeting diagnostic criteria for any anxiety-related disorder at 2-year follow up (OR = 0.07, CI 0.01-0.55, p = 0.03). ...
Purpose
This systematic review aimed to synthesise all quantitative literature on the association between social class and the effectiveness of interventions for mental health disorders.
Methods
Systematic literature searches (inception-March 2021) were conducted across 7 databases, and all quantitative studies meeting inclusion criteria, examining the impact of social class on access to treatment, or intervention effectiveness, or the impact of treatment on social mobility, were synthesised narratively.
Results
Evidence suggests that lower social class may be associated with reduced access to primary and secondary mental health care and increased likelihood of access via crisis services, and patients of lower social class may not benefit from all mental health interventions, with reduced effectiveness. While limited, there was some indication that psychosocial interventions could encourage increased employment rates.
Conclusion
Social class is associated with the effectiveness of psychological interventions, and should be considered when designing new interventions to prevent barriers to access and improve effectiveness.
... 0=no and 1=yes; principal diagnosis, 0=depression, 1=anxiety, and 2=OCD; comorbidity, number of clinical diagnoses, and diagnostic status, 0=does not meet diagnostic criteria and 1=meets diagnostic criteria), dispositional traits (ie, behavioral inhibition and behavioral activation), and symptomatology (anxiety [BAI], depression [BDI-II], and health-related QoL [EQ-5D-3L]). Given that we were interested in long-term changes (ie, 1-year follow-up compared with baseline), we focused on group1×time4 interactions (ie, transdiagnostic iCBT×1-year follow-up) to analyze the long-term effects and predictors [48]. ...
Background: Transdiagnostic internet-delivered cognitive behavioral therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.
Objective: This study aimed to analyze the long-term effectiveness of transdiagnostic iCBT compared with that of treatment as usual (TAU) in specialized care and explore predictors of long-term effectiveness.
Methods: Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (n=99) versus TAU (n=101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition and behavioral activation, comorbidity, and diagnostic status (ie, loss of principal diagnosis) from baseline to 1-year follow-up. Sociodemographic characteristics (sex, age, and education) and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.
Results: Compared with baseline, transdiagnostic iCBT was more effective than TAU in improving symptoms of depression (b=–4.16, SE 1.80, 95% CI –7.68 to –0.67), health-related QoL (b=7.63, SE 3.41, 95% CI 1.00-14.28), diagnostic status (b=–0.24, SE 0.09, 95% CI –1.00 to –0.15), and comorbidity at 1-year follow-up (b=–0.58, SE 0.22, 95% CI –1.00 to –0.15). From pretreatment assessment to follow-up, anxiety symptoms improved in both transdiagnostic iCBT and TAU groups, but no significant differences were found between the groups. Regarding the predictors of the long-term effectiveness of transdiagnostic iCBT compared with that of TAU, higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.
Conclusions:The results suggest that transdiagnostic iCBT is more effective than TAU to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at 1-year follow-up, with no differences between the groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental health care.
... As more consistent predictors of negative outcomes, in her review, Newman mentions longer duration of illness, previous mental health treatment, comorbidity with depression, partner hostility, and marital tension, among others (Newman et al., 2013). Recently, there has been an increase in research activity for both primary studies and reviews with varying emphasis and different methodological approaches regarding intake predictors of treatment outcomes in GAD symptoms (e.g., Jakubovski & Bloch, 2016;Kodal et al., 2018;Malivoire et al., 2020;Mohlman, 2020). While Malivoire et al. (2020) identified interpersonal dysfunction as a predictor of treatment outcome in GAD in their systematic review, primary studies identified intake predictors including age (Kelly & Mezuk, 2017), socioeconomic status (Jakubovski & Bloch, 2016;Kodal et al., 2018), and comorbid depression (Jakubovski & Bloch, 2016), although not simultaneously and consistently throughout. ...
... Recently, there has been an increase in research activity for both primary studies and reviews with varying emphasis and different methodological approaches regarding intake predictors of treatment outcomes in GAD symptoms (e.g., Jakubovski & Bloch, 2016;Kodal et al., 2018;Malivoire et al., 2020;Mohlman, 2020). While Malivoire et al. (2020) identified interpersonal dysfunction as a predictor of treatment outcome in GAD in their systematic review, primary studies identified intake predictors including age (Kelly & Mezuk, 2017), socioeconomic status (Jakubovski & Bloch, 2016;Kodal et al., 2018), and comorbid depression (Jakubovski & Bloch, 2016), although not simultaneously and consistently throughout. In addition to the different predictors examined, the studies differ in their sample characteristics such as age (e.g., youths, older adults), psychotherapy approaches, settings (e.g., university or community setting), and in symptom measurement in terms of both timing (post-treatment up to 3.9 years FU) and outcome definitions (e.g., remission, symptom change, absolute symptom scores). ...
Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual’s symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients’ strengths for clinical practice.
... 0=no and 1=yes; principal diagnosis, 0=depression, 1=anxiety, and 2=OCD; comorbidity, number of clinical diagnoses, and diagnostic status, 0=does not meet diagnostic criteria and 1=meets diagnostic criteria), dispositional traits (ie, behavioral inhibition and behavioral activation), and symptomatology (anxiety [BAI], depression [BDI-II], and health-related QoL [EQ-5D-3L]). Given that we were interested in long-term changes (ie, 1-year follow-up compared with baseline), we focused on group1×time4 interactions (ie, transdiagnostic iCBT×1-year follow-up) to analyze the long-term effects and predictors [48]. ...
Background: Transdiagnostic Internet-delivered Cognitive Behavioral Therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.
Objective: In this study we aimed to a) analyze the long-term effectiveness of transdiagnostic iCBT compared to treatment as usual in specialized care, and b) to explore predictors of long-term effectiveness.
Methods: Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (EmotionRegulation) (n= 99) versus treatment as usual (n = 101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition/behavioral activation, comorbidity, and diagnostic status (i.e., loss of principal diagnosis) from baseline to one-year follow-up. Sociodemographic characteristics (sex, age, education), and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.
Results: compared to baseline, EmotionRegulation was more effective than treatment as usual (TAU) in improving symptoms of depression (b= -4.16, s.e. = 1.80, 95% CI [-7.68, -.67]) , health-related QoL (b= 7.63, s.e. = 3.41, 95% CI [1.00, 14.28]), diagnosis status (b= -.24, s.e. = .09, 95% CI [-1.00, -.15]), and comorbidity at one-year follow-up (b= -.58, s.e. = .22, 95% CI [-1.00, -.15]). Pre-treatment to follow-up anxiety symptoms improved in both EmotionRegulation and TAU, but no significant differences were found between groups. Regarding the predictors of long-term effectiveness, compared to treatment as usual, a) higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; b) fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and c) fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.
Conclusions: The results support that transdiagnostic iCBT is more effective than treatment as usual to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at one-year follow-up, with no differences between groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental healthcare.
CLINICALTRIAL
Trial Registration: ClinicalTrials.gov NCT02345668, 27 July 2015
... Treatment techniques are recommended that encourage the individual to discover how social anxiety is main-tained and target cognitive distortions (Leigh & Clark, 2018;Lisk et al., 2018;Neufeld et al., 2020). Unfortunately, individuals with SAD treated with CBT have demonstrated poorer outcomes and lower likelihood of remission than other anxiety disorders (Hudson, Rapee, et al., 2015;Kodal et al., 2018;Leigh & Clark, 2018;Lundkvist-Houndoumadi & Thastum, 2017). Possible reasons cited include parental psychopathology, diffi culties establishing a therapeutic relationship with the practitioner, longer time to SAD diagnosis leading to more resistant behaviors, generic manualized CBT programs, and comorbid mood disorders (Adams et al., 2016;Hudson, Keers, et al., 2015;Hudson, Rapee, et al., 2015;Kodal et al., 2018). ...
... Unfortunately, individuals with SAD treated with CBT have demonstrated poorer outcomes and lower likelihood of remission than other anxiety disorders (Hudson, Rapee, et al., 2015;Kodal et al., 2018;Leigh & Clark, 2018;Lundkvist-Houndoumadi & Thastum, 2017). Possible reasons cited include parental psychopathology, diffi culties establishing a therapeutic relationship with the practitioner, longer time to SAD diagnosis leading to more resistant behaviors, generic manualized CBT programs, and comorbid mood disorders (Adams et al., 2016;Hudson, Keers, et al., 2015;Hudson, Rapee, et al., 2015;Kodal et al., 2018). Parental involvement in treatment is essential, as problematic parenting behaviors, psychopathology, and stress may perpetuate the child's social anxiety (Garcia-Lopez et al., 2014;Leigh & Clark, 2016;Manassis et al., 2014;Schleider et al., 2015;Weijers et al., 2018;Yang et al., 2019). ...
The purpose of the current article is to explore familial factors that influence the development of social anxiety disorder (SAD) in children and adolescents, including parenting, sibling relationships, and family environment. A multitude of interrelated genetic and familial factors have been found to cause and maintain SAD in children and adolescents. There are many challenges in diagnosing and treating the disorder. Knowledge and awareness of familial factors provide insight on targeted treatments that prevent or ameliorate SAD. [Journal of Psychosocial Nursing and Mental Health Services, 59(7), 23-34.].
... Long-term outcomes did not vary according to initial treatment with CBT, medication, or their combination. Predictors of poor acute treatment outcomes include more severe symptoms, more functional impairment [29,31], low socioeconomic status (SES) [32], and a primary diagnosis of social phobia [31,32]. More residual symptoms and functional impairment following acute treatment predict relapse, suggesting that treatment should aim to achieve remission from all anxiety disorders, and with as few residual symptoms of any kind of anxiety as possible [29]. ...
... Long-term outcomes did not vary according to initial treatment with CBT, medication, or their combination. Predictors of poor acute treatment outcomes include more severe symptoms, more functional impairment [29,31], low socioeconomic status (SES) [32], and a primary diagnosis of social phobia [31,32]. More residual symptoms and functional impairment following acute treatment predict relapse, suggesting that treatment should aim to achieve remission from all anxiety disorders, and with as few residual symptoms of any kind of anxiety as possible [29]. ...
... Also termed patient "tailoring variables", these factors modify treatment response. Candidates for tailoring variables include baseline individual, family, and context characteristics, some of which relate directly to child anxiety and its clinical portrait: ethnicity [30], SES [32], past treatment response [29,31], and family history of anxiety; and variables that are potentially modifiable, such as overall symptom severity [29,31], functional impairment [29,31], the nature and severity of comorbid illnesses, treatment fidelity and adherence, and treatment setting (community or university; primary pediatric or specialty mental health clinic). ...
Background
Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn’t working well—whether to optimize the treatment already begun or to add the other treatment.
Methods
This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8–17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first (“Main Effect 1”). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment (“Main Effect 2”). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.
Discussion
Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.
Trial registration
This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .
... Insgesamt kann die Wirksamkeit von Psychotherapie bei Angststörungen im Kindes-und Jugendalter [In-Al-bon und Schneider, 2007;Silverman et al., 2008;Reynolds et al., 2012] als gut belegt angesehen werden. Für die Therapie der sozialen Angststörung [Kodal et al., 2018a[Kodal et al., , 2018b sowie depressiver Störungen [Weisz et al., 2017[Weisz et al., , 2019 zeigt sich jedoch in Bezug auf die Wirksamkeit bestehender Therapieansätze ein deutlicher Nachholbedarf. So zeigt sich bei der Therapie depressiver Störungen im Jugendalter eine insgesamt eher niedrigere Wirksamkeit von Psychotherapie im Vergleich zu anderen Störungen [Weisz et al., 2017]. ...
... So zeigt sich bei der Therapie depressiver Störungen im Jugendalter eine insgesamt eher niedrigere Wirksamkeit von Psychotherapie im Vergleich zu anderen Störungen [Weisz et al., 2017]. Ebenso findet sich bei Jugendlichen mit sozialen Ängsten eine deutlich geringere Wirksamkeit kognitiv-verhaltenstherapeutischer Interventionen als bei anderen Angststörungen [Hudson et al., 2015;Kodal et al., 2018a], möglicherweise auch aufgrund der sehr hohen Komorbidität mit anderen Angst-und depressiven Störungen [Ohayon und Schatzberg, 2010;Canals et al., 2019;Koyuncu et al., 2019]. ...
Hintergrund: Angst- und depressive Störungen sind die häufigsten psychischen Störungen im Jugendalter und weisen untereinander eine hohe Komorbiditätsrate auf. Während kognitive Verhaltenstherapie (KVT) in der Behandlung von Angststörungen bei Jugendlichen wirksam ist, weist die Behandlung von depressiven Störungen nur moderate Wirksamkeit auf. Es liegen jedoch kaum Studien vor, die die Wirksamkeit der KVT in der Behandlung komorbid vorliegender Angst- und depressiver Störungen bei Jugendlichen untersuchen. Der transdiagnostische Ansatz des Unified Protocols (UP) für emotionale Störungen konnte seine Wirksamkeit im englischsprachigen Raum bereits im Jugend- und Erwachsenenalter nachweisen. Eine deutsche Übersetzung und Überprüfung des UP für Jugendliche steht bislang noch aus. Falldarstellung: In dieser Kasuistik wird eine 17-jährige Patientin vorgestellt, die die Kriterien einer sozialen Angststörung nach ICD-10 und DSM-5 erfüllt und zudem eine depressive Symptomatik aufweist. Nach einer umfassenden Diagnostik mithilfe eines strukturierten klinischen Interviews und Selbstberichtverfahrens wurden 17 Sitzungen KVT basierend auf dem UP für Adoleszente (UP-A) durchgeführt. Ziel der vorliegenden Fallbeschreibung ist die Vorstellung des Therapierationals und der Umsetzung des Manuals. Nach der Therapie erfüllte die Jugendliche die Kriterien der sozialen Angststörung nicht mehr, es zeigte sich zudem eine Abnahme der depressiven Symptomatik. Schlussfolgerungen: Die Fallvorstellung verweist auf die Umsetzbarkeit der deutschen Übersetzung des UP-A für die transdiagnostische Behandlung von Angst- und depressiven Störungen bei Jugendlichen. Eine randomisiert kontrollierte Studie zur Wirksamkeitsprüfung steht noch aus.
Multiple theoretical frameworks have been proposed to provide a more comprehensive picture of the risk factors that influence anxiety-related developmental trajectories. Nonetheless, there remains a need for an integrative model that outlines: (1) which risk factors may be most pertinent at different points in development, and (2) how parenting may maintain, exacerbate, or attenuate an affective style that is characterized by high negative emotional reactivity to unfamiliar, uncertain, and threatening situations. A developmentally informed, integrative model has the potential to guide treatment development and delivery, which is critical to reducing the public health burden associated with these disorders. This paper outlines a model integrating research on many well-established risk mechanisms for anxiety disorders, focusing on (1) the developmental progression from emotional reactivity constructs early in life to those involving higher-level cognitive processes later in youth, and (2) potential pathways by which parenting may impact the stability of youth’s cognitive-affective responses to threat-relevant information across development.
Psychiatric epidemiologists, developmental psychopathologists, prevention scientists, and treatment researchers have long speculated that treating child anxiety disorders could prevent alcohol and other drug use disorders in young adulthood. A primary challenge in examining long-term effects of anxiety disorder treatment from randomized controlled trials is that all participants receive an immediate or delayed study-related treatment prior to long-term follow-up assessment. Thus, if a long-term follow-up is conducted, a comparison condition no longer exists within the trial. Quasi-experimental designs (QEDs) pairing such clinical samples with comparable untreated epidemiological samples offer a method of addressing this challenge. Selection bias, often a concern in QEDs, can be mitigated by propensity score weighting. A second challenge may arise because the clinical and epidemiological studies may not have used identical measures, necessitating Integrative Data Analysis (IDA) for measure harmonization and scale score estimation. The present study uses a combination of propensity score weighting, zero-inflated mixture moderated nonlinear factor analysis (ZIM-MNLFA), and potential outcomes mediation in a child anxiety treatment QED/IDA (n = 396). Under propensity score–weighted potential outcomes mediation, CBT led to reductions in substance use disorder severity, the effects of which were mediated by reductions in anxiety severity in young adulthood. Sensitivity analyses highlighted the importance of attending to multiple types of bias. This study illustrates how hybrid QED/IDAs can be used in secondary prevention contexts for improved measurement and causal inference, particularly when control participants in clinical trials receive study-related treatment prior to long-term assessment.
