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CBT/DBT-Informed Intensive Outpatient Treatment for Anxiety
and Depression: A Naturalistic Treatment Outcomes Study
Genevieve S. Falabella,
Center for Anxiety and New York State Psychiatric Institute/Columbia
University Medical Center
Benjamin D. Johnides, Center for Anxiety
Arielle Hershkovich, Center for Anxiety and Montclair State University
Jacob Arett, Center for Anxiety and Saint Louis University
David H. Rosmarin, Center for Anxiety and McLean Hospital/Harvard Medical School
Anxiety and depression are highly prevalent and disabling mental health disorders, with comorbidity often posing as a
barrier to successful treatment outcomes, thus creating a need for more intensive treatment options. Outpatient clinicians
are more likely to refer patients with severe symptoms of anxiety and depression to inpatient hospitalizations rather than
partial hospital programs (PHPs) or intensive outpatient programs (IOPs), despite evidence that inpatient hospitalization
is associated with high costs and other risks following discharge. The present study reviews two case studies of patients who
received cognitive-behavioral therapy/dialectical behavior therapy (CBT/DBT)-based IOP treatment in a private New York
clinic. We evaluated treatment outcomes for 73 adult patients (50.7% female) with a mean age of 29.10 years
(SD = 10.30). At intake, patients averaged 2.15 diagnoses (SD = 0.94, range = 4) and the majority (80.8%) were pre-
scribed psychotropic medication. Treatment was structured and individually tailored, with patients receiving an average of
21.77 hours (SD = 15.06) of psychotherapy over 12.63 treatment sessions (SD = 9.76), across 12.21 days (SD = 9.61). We
observed a clinically and statistically significant change in symptoms of anxiety (t = 6.24, p < .001), depression (t = 5.55,
p < .001), and suicidality (t = 2.32, p < .05) over the course of the IOP. After completing treatment, 68.1% of partic-
ipants tapered down to once-weekly treatment. The present study highlights the clinical utility of an IOP and suggests that
this approach can be effective for adult patients presenting with severe symptoms of anxiety and/or depression.
A
NXIETY AND DEPRESSION ARE COMMON
and disabling
mental health disorders, with a lifetime preva-
lence in the U.S. population of 33.7% and 20.9%,
respectively (Kessler et al., 2012). A recent report from
the World Health Organization (2017) identified
depression as the greatest contributor to global disabil-
ity, and anxiety disorders as the sixth. Moreover, symp-
toms of anxiety and depression co-occur in up to 25.0%
of general practice patients and lead to increased sever-
ity of illness and significant functional impairment
(Tiller, 2012). Furthermore, comorbid severe symp-
toms of anxiety and depression are associated with
poor prognosis and decreased likelihood that a patient
will achieve remission as a result of standard outpatient
treatment (Fava et al., 2008; Tiller, 2012; Wiethoff
et al., 2010).
Cognitive-behavioral therapy (CBT; Beck, 2011) has
been established as an effective treatment modality for
symptoms of anxiety and depression (e.g., Cuijpers
et al., 2013; Hofmann & Smits, 2008; Li et al., 2018;
Norton & Price, 2007). In addition, dialectical behavior
therapy (DBT; Linehan, 2015), although originally
designed to treat borderline personality disorder, has
been successfully adapted for treatment-resistant
depression and anxiety (i.e., Harley et al., 2008;
Ritschel et al., 2012). However, symptom severity and
comorbid diagnoses may represent barriers to success-
ful treatment outcomes, and for this reason, patients
experiencing psychiatric crises or severe symptoms
are commonly referred for inpatient hospitalization.
Unfortunately, there are several challenges associated
with hospital-based treatments. First, psychiatric inpa-
tient care is costly. A high proportion of hospital costs
1077-7229/20/Ó2021 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
Keywords: acute treatment; intensive outpatient treatment; suici-
dality; effectiveness; case formulation
www.elsevier.com/locate/cabp
Available online at www.sciencedirect.com
ScienceDirect
Cognitive and Behavioral Practice xxx (2021) xxx–xxx
Please cite this article as: Falabella, Johnides, Hershkovich et al., CBT/DBT-Informed Intensive Outpatient Treatment for Anxiety and Depression: A Nat-
uralistic Treatment Outcomes Study, https://doi.org/10.1016/j.cbpra.2021.05.001
in the United States are attributable to mental health
disorders—one analysis found that hospital visits
involving a primary or secondary mental or substance
use disorder diagnosis accounted for approximately
30% of total hospital costs in 2016 (Owens et al.,
2019). Furthermore, charges to patients were, on aver-
age, 2.5 times higher than the hospital’s reported cost
of care (Stensland, Watson, & Grazier, 2012). With U.S.
health care expenditures continuing to rise (Centers
for Medicare and Medicaid Services, 2019), the finan-
cial burden of inpatient hospitalization represents a
substantial barrier to treatment for many acute patients
and their families. Second, despite increased awareness
of mental health issues in recent years, stigma remains
a concern for psychiatric inpatients and may lead to
untreated mental health challenges and increased
impairment in vocational and social functioning fol-
lowing treatment (Schomerus et al., 2012). Several
studies have observed a high risk of suicide in patients
following discharge from psychiatric inpatient care,
although the factors behind this observation are likely
multidetermined and not fully understood (Goldacre
et al., 1993; Qin & Nordentoft, 2005; Walter et al.,
2017, 2019). Given the high costs and stigma associated
with hospitalization, there is a pressing need for non-
hospital, skills-based treatment alternatives to help
patients suffering from severe symptoms of anxiety
and depression.
In the last several decades, partial hospitalization
programs (PHPs) and intensive outpatient programs
(IOPs) have become increasingly popular in psychi-
atric care (Horvitz-Lennon et al., 2001; Schwartz &
Thyer, 2008). PHPs and IOPs provide acute treatment
in hospital or community settings for patients in crisis
or distress when active suicidal ideation or other risky
behaviors can be managed. In addition, PHPs/IOPs
may be suitable for less acute patients seeking intensive
treatment to significantly reduce symptoms within a
brief period of time (e.g., Lothes & Mochrie, 2014;
Ritschel et al., 2012). Recent research suggests that
PHPs/IOPs are beneficial and more cost-effective than
inpatient hospitalization for patients with moderate to
low levels of psychiatric distress (e.g., Driessen et al.,
2019; Heekeren et al., 2020; Marshall et al., 2011).
Moreover, studies of intensive treatment programs
have demonstrated effectiveness in treating symptoms
of various disorders, including personality disorders
(Smith et al., 2001), eating disorders (Beintneret al.,
2020), and substance use disorders (McCarty et al.,
2014; Wise, 2010). Although PHPs/IOPs have been
shown to be effective in reducing symptoms of acute
anxiety and depression (Lothes et al., 2014; McHugh
et al., 2014; Wise, 2003), these studies examine inten-
sive treatment within a psychiatric hospital setting.
Hospital-based programs typically involve structured
cognitive-behavioral interventions applied in a group
format and supplemented with individual treatment
sessions (e.g., Neuhaus, 2006). We therefore sought
to support and extend the literature by investigating
the effectiveness of an individualized, flexible CBT/
DBT-based IOP delivered in a private outpatient (non-
hospital) setting for patients experiencing significant
symptoms of anxiety and/or depression.
The goals of the present study were (a) to present
two case studies describing the clinical methods for
implementation of our flexible CBT/DBT-based IOP,
and (b) to evaluate the effectiveness of the program
in reducing symptoms of anxiety, depression, and suici-
dality in a naturalistic treatment setting. More broadly,
we sought to expand the field’s current understanding
of IOPs for treatment of symptoms of acute anxiety and
depression by demonstrating that a flexible IOP can be
an effective alternative to inpatient hospitalization for
patients in crisis and for those with less severe symp-
toms seeking intensive, brief treatment.
Method
Overview of IOP Treatment
All treatment was provided by a multidisciplinary
team of 21 clinicians (62% doctoral level and 38% mas-
ter’s level), all of whom have been previously trained
and received ongoing supervision regarding the appli-
cation of DBT and various CBT protocols. IOP was
delivered in an individualized format, utilizing a
skills-based approach for patients experiencing signifi-
cant symptoms of anxiety and/or depression. At the
outset of each patient’s care, therapist and patient col-
laborated to set specific, individualized goals to target
during the brief intervention before transitioning to
a step-down program (post-IOP). IOP treatment typi-
cally ranged from three to five sessions each week for
2 weeks, and each session varied from 1 to 3 hours
per day, depending on the patient’s symptom severity,
ability to sustain attention, scheduling needs/prefer-
ences, and financial considerations. All IOP treatment
aimed to foster a skills-based approach: Patients were
taught specific CBT/DBT skills (see Table 1) pertinent
to their symptoms over the course of their sessions,
with time to practice skills in between sessions and to
review skill application at each subsequent session.
Rather than following a structured protocol, our IOP
took a flexible data-driven approach in line with case-
formulation models of CBT (Persons, 2005). More
specifically, clinicians devised a customized treatment
plan by formulating hypotheses about the underlying
mechanisms of patients’ symptoms and sequenced
specific components from relevant CBT protocols
2Falabella et al.
along with skills from DBT modules. Each individual
case conceptualization was determined as a team dur-
ing the weekly clinical rounds meetings and any issues
with case formulation and intervention application
were addressed throughout weekly supervision and
case consultation (on an as-needed basis). Clinicians
used routine outcome monitoring to examine the
effectiveness of the individualized intervention. Thera-
pists revised their hypotheses and/or treatment plans
as necessary based on data from routine outcome mon-
itoring, behavioral observations, and patients’ verbal
feedback.
Despite its flexibility to treat each individual
patient’s needs, IOP treatment was structured in three
basic stages: The first stage of treatment (typically Ses-
sions 1–3) focused on psychoeducation of relevant
problem areas and general CBT/DBT principles, symp-
tom monitoring, identification of the patients’ specific
treatment goals, and the development of a plan for the
sequencing of multiple intervention components.
Patients were introduced to the concepts of daily
homework, symptom monitoring, and self-care plan-
ning, such as sleep and wake schedules, and healthy
eating habits to increase energy levels, improve mood,
and maximize treatment engagement. For example,
patients who presented with symptoms of anxiety col-
laborated with their therapists and outlined fear hierar-
chies for exposure therapy, and for those with
symptoms of depression, together with their therapists
created individualized behavioral activation schedules.
In the second stage of treatment (typically Sessions
4–9), the primary CBT/DBT interventions were imple-
mented by therapists and patients working together on
the previously established goals—patients were taught
specific CBT/DBT skills and coached on how to apply
them to their personal life situations.
In the third and final stage of IOP (typically Sessions
10–12), patients were ushered through a step-down
process, whereby the clinicians and patients focused
on a treatment strategy for continued skills use and
relapse prevention strategies after the program. This
stage was commenced only once it was clear that
patients’ main treatment goals were met, and their
levels of anxiety and depression were no longer in
Table 1
CBT/DBT Skills Utilized in Intensive Outpatient Treatment
CBT/DBT skill Description
Behavioral activation Goals: Build healthy approach to specific behaviors, such as engaging in enjoyable activities
and developing healthy problem-solving skills
Strategies: Opposite Action, Pleasant Event Scheduling, Accumulating Positive Emotions in
the Long Term, and Self-Care Planning, Identifying Personal Values, and Mood Monitoring
Exposure/response
prevention
Goals: Face fears and allow obsessive thoughts to occur without tempering them with
compulsions
Strategies: Psychoeducation about Behavioral Treatments for anxiety and related disorders,
Building Fear Hierarchies, Exposure Scripts, In vivo and Interoceptive Exposures (for OCD,
Panic Disorder, Agoraphobia, Specific Phobia, Social Anxiety Disorder)
Cognitive restructuring Goals: Reframing thoughts associated with feelings to transform maladaptive emotional
responses
Strategies: Identifying Core Beliefs, Effective Rethinking, Checking the Facts
Mindfulness Goals: Observing, describing, and participating using one’s five senses with a
nonjudgmental stance
Strategies: Observe, Describe, Participate, Nonjudgmental Stance, One-Mindfully,
Effectively, and Wise Mind
Distress tolerance Goals: Coping strategies to survive during crises when it is difficult or impossible to change a
situation
Strategies: STOP, TIPP, IMPROVE, Effective Rethinking, and Radical Acceptance
Emotion regulation Goals: Managing negative and overwhelming emotions through methods such as
psychoeducation on understanding and naming emotions
Strategies: Check the Facts, Problem Solving, Opposite Action, Building Mastery, Coping
Ahead, and Mindfulness of Current Emotions
Interpersonal
effectiveness
Goals: Effective communication skills to foster healthy interpersonal relationships through
deliberate action, as opposed to impulsive reactions
Strategies: DEAR MAN, GIVE, FAST, and Walking the Middle Path
Safety planning Complete safety plan with interventions for passive and active stages of SI or SH urges,
incorporate phone coaching in accordance with patient need, diary card for daily mood
monitoring.
3
CBT/DBT-Informed Intensive Outpatient Treatment
the severe range. Step-down plans were flexible, and
adjusted as needed after the IOP, in cases where
patients continued for outpatient care in our program.
Throughout all three stages of IOP treatment, clini-
cians continually monitored patient progress using self-
report measures on Psych-Surveys software to track
symptoms of anxiety and depression, as well as risky
behaviors, that were administered prior to each ses-
sion. In addition, clinicians discussed homework
assignments with clients and assessed for suicidal idea-
tion, as well as other safety or treatment-interfering
behaviors during each session. Throughout treatment,
and especially during the first two stages, clinicians
were available for phone coaching as needed, in order
to provide additional between-session support and to
mitigate risk.
Case Study 1
Charlie D.
1
was a 21-year-old Caucasian male who pre-
sented for IOP treatment in May 2017 with symptoms of
major depressive disorder, generalized anxiety disorder,
social anxiety disorder, panic disorder, and passive suici-
dal ideation. He reported a history of mild depression
and anxiety from childhood and experienced an
increase in symptoms in February 2017, which led to
Charlie taking a medical leave of absence from college.
By the time Charlie came for his intake, he shared that
he felt unable to leave his apartment due to a state of
constant worry about the future, which significantly
impacted his social activities. To cope, he engaged in
daily marijuana use and excessive use of social media/-
electronics (up to 8 hours per day). Although his scores
on the Generalized Anxiety Disorder–7 (GAD-7; Spitzer
et al., 2006) and Patient Health Questionnaire–9
(PHQ-9; Kroenke et al., 2001) indicated severe symp-
toms of anxiety (GAD-7 = 21) and depression (PHQ-
9 = 23), Charlie denied any suicidal behavior or active
suicidal ideation at the time of intake and he verbally
committed to a crisis and safety plan. His immediate
treatment goals revolved around decreasing his symp-
toms of anxiety and depression so that he could leave
his apartment, participate in social engagements, and
be able to return to college in the fall.
Charlie’s treatment plan involved three 120- to 150-
minute sessions per week, supplemented by a weekly
DBT skills group, for an initial period of 3 weeks.
Charlie’s primary clinician identified three central
areas of focus for his IOP treatment: (a) distress toler-
ance skills, (b) emotion regulation skills, and (c)
exposure-related skills to help facilitate learning and
habituation to intense symptoms of anxiety. His first
few sessions began with basic psychoeducation, help-
ing Charlie to understand the foundations of distress
tolerance and emotion regulation. He was encour-
aged to identify his specific triggers for distress, as
well as his associated emotional and behavioral
responses. Charlie learned that his avoidance behav-
iors (e.g., not going to social activities, marijuana
use, excessive social media use) were attempts to sup-
press his experience of negative emotions, which in
turn negatively reinforced his distress. His therapist
selected a variety of distress tolerance and emotion
regulation skills to help Charlie find better ways of
coping with difficult emotions. For example, he
learned the DBT stop, take a step back, observe, pro-
ceed mindfully (STOP) skill, which encouraged him
to choose alternative and more functional coping
methods instead of allowing himself to become over-
whelmed by anxiety. Charlie also identified how his
hopelessness contributed to his overall distress level,
and he learned to recognize the importance of
accepting and tolerating the distress associated with
his emotions. In addition, Charlie learned to alter
his emotional experiences through DBT techniques,
such as modulating temperature, intense exercise,
paced breathing, and paired muscle relaxation
(TIPP), and opposite action, in which he would delib-
erately engage in behaviors opposite to the urges asso-
ciated with emotions he wanted to change. Charlie
practiced all of these skills for the first 2 weeks of
his IOP treatment.
By the fifth session of treatment in the second week
of Charlie’s IOP, his levels of anxiety and depression
had decreased substantially, with anxiety in the moder-
ate range (GAD-7 = 11) and depression in the moder-
ately severe range (PHQ-9 = 17). Charlie’s therapist
then introduced techniques of exposure therapy to
facilitate greater reduction in symptoms of anxiety.
Charlie was provided with additional sessions of psy-
choeducation about the cognitive-behavioral model
of anxiety, including a review of physiological symp-
toms and the relationship among anxiety-related
thoughts, feelings, and behaviors. Charlie identified
that academic and social situations triggered signifi-
cant fear and brought on thoughts such as “I will never
get it together,” and “I can’t even complete this small
task.” Charlie’s clinician taught cognitive restructuring
skills to help with these maladaptive ways of thinking.
Charlie’s clinician also helped him to create a fear hier-
archy that would help him approach worry- and social
anxiety-related situations. Specifically, Charlie identi-
fied the following activities to include in his hierarchy:
composing comprehensive to-do lists, looking at his
bank app, checking his e-mail, remaining focused on
1
Names and some details of both case studies were changed to
protect patient privacy and confidentiality.
4Falabella et al.
one task at a time when “everything is falling apart,”
going outside when he is likely to see peers, going
out with friends, and going to parties.
Charlie also identified compensatory responses/be-
haviors that were interfering with habituation and learn-
ing in the context of his anxiety, and sought to reduce
and ultimately eliminate the following activities:
responding to social media notifications, responding
to unnecessary online communications, cleaning/sort-
ing e-mails, and telling people that he “messed up” when
doing something wrong. Charlie was encouraged to face
each activity, one by one, without engaging in compen-
satory responses, and to remain present and focused
until his fear subsided on its own. Charlie correctly
noted that exposure therapy is a form of opposite action,
which he had found to be helpful the previous week in
treatment. With that said, Charlie needed substantial
coaching throughout his first several exposure activities.
He described feeling overwhelmed and stated that he
felt he may faint or die because of his anxiety. Charlie’s
therapist encouraged him to “stay present” and simply
allow his feelings and thoughts to exist. Together, Char-
lie and his therapist completed multiple exposures dur-
ing which Charlie systematically decreased his level of
fear. Charlie completed his IOP treatment having only
begun to approach his fears in this manner—however,
his hopelessness was substantially diminished and he
reported seeing a “path forward.”
Throughout his 10 IOP sessions conducted over 3
weeks, Charlie experienced clinically significant reduc-
tions in his symptoms of anxiety, with GAD-7 scores
decreasing from 21 (severe) at baseline to 8 (mild) post-
treatment, and PHQ-9 scores dropping from 23 (severe)
at baseline to 14 (moderate) posttreatment. Through-
out treatment, Charlie’s overarching concern was in
relation to becoming a productive and effective member
of society. Charlie’s anxiety in relation to this concern
dramatically reduced and he was able to successfully
accomplish important tasks, check his bank account,
navigate social interactions, and attend classes. Charlie
applied these skills to succeed in school and to approach
interpersonal interactions, and he returned to college
the following fall. He continued sporadic individual
treatment at the clinic for another 9 weeks as a step down
from IOP treatment, and he continued to attend the
weekly DBT skills group for an additional 5 months.
We recently followed up with Charlie by phone and he
reported that he continues to successfully apply the
CBT/DBT skills he learned in his IOP treatment.
Case Study 2
Sarah G. was a 24-year-old Caucasian female who
presented for treatment in January 2018, with symp-
toms of major depressive disorder, generalized anxiety
disorder, and panic disorder. At the time of her intake,
her symptoms of anxiety were in the moderate range
(GAD-7 = 14) and her depression was moderately sev-
ere (PHQ-9 = 18). Sarah was previously employed as a
freelance designer and had recently quit her job due
to “mistakes stemming from symptoms of anxiety and
panic.” She stated that her anxiety had increased over
the previous year and increased significantly in the
prior week, leading her to seek an intensive level of
care. Sarah shared that she had been waking up with
symptoms of anxiety and panic daily. She also had
experienced a loss of libido after recently receiving a
prescription for Prozac. Sarah’s symptoms of anxiety
included feeling unable to leave her bed without
Xanax, fear of vomiting, racing heart, shallow breath-
ing, and fear of nausea. She reported experiencing
panic attacks at least twice weekly in the past year.
Her experience of panic symptoms had caused her to
limit her food selection significantly (e.g., eating only
oatmeal when anxious). She enjoyed performing com-
edy routines but stopped due to symptoms of anxiety
and panic. Sarah developed an irregular sleep schedule
and withdrew from friends. In addition, she reported
feelings of worthlessness, hopelessness, and passive sui-
cidal ideation. She also expressed subclinical symptoms
of agoraphobia, including significant fear and avoid-
ance of crowded places with no clear exit.
Sarah’s treatment plan included four individual
CBT/DBT sessions each week from 60 to 120 minutes
each session, focusing primarily on symptoms of panic
disorder, and then secondary symptoms of depression.
Sarah’s IOP involved psychoeducation, behavioral acti-
vation, stimulus control and sleep hygiene, mindful-
ness, and exposure and response prevention (ERP).
Psychoeducation specifically focused on cognitive-
behavioral models of panic and depression, but DBT
elements of radical acceptance and emotion regulation
were included as well. Sarah began to complete behav-
ioral activation logs and attempted to develop a sense
of mastery in hopes to “lead a life worth living.” These
early sessions continued to prioritize psychoeducation,
particularly regarding her avoidance behaviors and
how the avoidance, excessive checking, and
reassurance-seeking behaviors she had been depend-
ing on would be targeted throughout treatment during
exposure exercises. Although Sarah reported improved
sleep relatively quickly, her energy levels remained low
and she struggled to complete homework consistently.
With her primary clinician, Sarah identified that her
caloric intake was low and that her appetite would
increase when she was not anxious. Through several
additional psychoeducational discussions, Sarah was
presented with information about basic human caloric
5
CBT/DBT-Informed Intensive Outpatient Treatment
needs and encouraged to explore whether eating more
would increase her energy levels and mood, and ulti-
mately help her engage better in activities across all
contexts. Despite her low energy levels, Sarah began
to attend and perform at comedy shows again after
her second session. She reported using coping strate-
gies from her first session with her therapist to reduce
performance anxiety leading up to her routines.
Through psychoeducation and behavioral activa-
tion, Sarah’s motivation for therapy improved, and
she began to reduce her panic symptoms by complet-
ing interoceptive exposures with her therapist. Utiliz-
ing techniques such as overbreathing, holding her
breath, and breathing through straws, Sarah became
acclimated to the feared symptoms of light-
headedness, chest tightness, and nausea. Sarah noted
that the exercises became less distressing after just
two sessions—however, she still feared panic attacks.
In session, Sarah was able to identify automatic
thoughts, such as “I can’t handle this” and “I’m going
to go crazy,” which exacerbated her physical symptoms
of panic. She began to worry that treatment progress
would deteriorate.
After six sessions, which included additional expo-
sure to panic-related fears, Sarah’s panic symptoms
started to abate such that they no longer created a bar-
rier to Sarah’s desired level of life engagement and per-
formance. The focus of sessions then shifted back
toward her feelings of depression and exhaustion.
Without the consistent panic symptoms, Sarah noticed
that she felt melancholic and tired. As a result, Sarah’s
therapist discussed the importance of making minor
behavioral shifts, such as making her bed, wearing
self-described nice shoes, and increasing her meal
quality (alongside increasing caloric intake) to provide
greater motivation, a sense of agency, and reduced
avoidance and rumination. In her final sessions, Sarah
completed mindfulness exercises, such as mindful
attention wandering, wherein Sarah narrated her train
of thought without focusing on the content or making
judgments. This and other mindfulness exercises
helped Sarah observe her thoughts without allowing
them to impact her mood, and therefore notice pat-
terns of thoughts that could be targeted in treatment.
Through these exercises, it became apparent that
Sarah was avoiding thoughts associated with fear of
rumination. Further psychoeducation was given con-
cerning the cognitive triad of depressive beliefs (self,
others, world), to which Sarah was responsive.
Sarah experienced clinically significant improve-
ments over the course of 13 total IOP sessions, span-
ning 4 weeks. Specifically, her symptoms of anxiety
and depression decreased by approximately 50%. She
reduced her Xanax reliance significantly, regularly
going 7 hours at a time without carrying any pills with
her. Moreover, she reported a reduction in panic symp-
toms, having experienced zero panic attacks since
beginning the second week of the program. In addi-
tion, Sarah had resumed performing comedy routines
and attending open mic shows regularly, without
engaging in previous safety behaviors.
Participants and Procedures
Data were collected between January 2017 and
August 2019 from patients participating in IOP treat-
ment (>3 hours of treatment per week) in a private
New York-based clinic. Only patients under 18 were
excluded from our sample. Participants were referred
to the clinic in several ways (e.g., Internet search
results, community referral) and included 73 adult
patients (50.7% female) with a mean age of 29.10 years
(SD = 10.30). At intake, all patients received the Minia-
ture International Neuropsychiatric Interview, English
Version 7.0.0 (MINI-7; Sheehan et al., 1998) for the
fifth edition of Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-5) to determine psychiatric diag-
noses, as well as a general psychosocial interview to
assess for relevant clinical, demographic, familial, cul-
tural, and risk factors that may impact treatment. Pri-
mary diagnoses included major depressive disorder
(45.2%), generalized anxiety disorder (32.9%),
obsessive-compulsive disorder (13.7%), and other diag-
noses (8.2%). Participants presented with an average of
2.15 diagnoses (SD = 0.94, range = 4) and the majority
(80.8%) were taking psychotropic medications during
treatment.
At intake and at each treatment session, participants
completed self-report measures of symptoms of anxiety
and depression (described below) using Psych-Surveys.
Within 1 week of intake, clinicians met as a team dur-
ing weekly clinical rounds to reach consensus on diag-
noses and treatment plans. Individual IOP treatment
included two or more sessions per week, each consist-
ing of 1–3 hours of individual therapy per session, with
a minimum of 3 total hours of treatment each week.
Treatment plans were conceptualized as a team (e.g.,
clinical rounds, supervision, consultation) to target
each patient’s specific goals and accounted for symp-
tom severity, functional impairment, ability to sustain
attention, scheduling needs/preferences, and financial
considerations. On average, patients received 21.77
total hours (SD = 15.06) of treatment across 12.63 treat-
ment sessions (SD = 9.76), over 12.21 days (SD = 9.61).
The average cost of IOP treatment was $3,126.81 (SD =
$2,145.01). The majority of patients (68.1%) tapered
to once weekly psychotherapy after completing IOP
treatment.
6Falabella et al.
Measures
Anxiety was measured using the GAD-7 (Spitzer
et al., 2006), a seven-item scale commonly used to
screen for generalized anxiety disorder in a variety of
clinical settings. This self-report measure uses a
Likert-type scale to assess the frequency and severity
of common generalized anxiety symptoms. It yields a
single score between 0 and 21, but also establishes four
validated levels of anxiety: 0–4 = minimal, 5–9 = mild,
10–14 = moderate, and 15–21 = severe. Extensive research
supports the reliability and validity of the GAD-7 as a
measure of anxiety in the general population (Lo
¨we
et al., 2008).
Depression was measured using the PHQ-9
(Kroenke et al., 2001), a nine-item self-report measure
of depressive symptoms. Similar to the GAD-7, items
are presented in a Likert-type scale to assess the fre-
quency and severity of depressive symptoms. It yields
a single score from 0 to 27, but also establishes four val-
idated levels of depression: 0–4 = minimal, 5–9 = mild,
10–14 = moderate, 15–19 = moderately severe, and 20–
27 = severe. Previous research shows strong validity
and reliability of the PHQ-9 in assessing for depression
(Kroenke et al., 2001)
Suicidality/self-injury was evaluated using the final
item of the PHQ-9, which assesses for “thoughts that
you would be better off dead, or of hurting yourself.”
Analytic Plan
First, we computed descriptive statistics for the sam-
ple as a whole (n= 73), including demographics and
clinical characteristics (see Table 2). We then exam-
ined levels of anxiety, depression, and suicidality at pre-
treatment and posttreatment with paired-samples t
tests and calculated difference scores (see Table 3).
Finally, we utilized linear regression analyses to evalu-
ate whether pretreatment demographic and clinical
characteristics predicted the degree to which patients
responded to treatment.
Results
On average, symptoms of anxiety decreased by 3.6
points on the GAD-7, representing a 25.4% decrease
from initial symptom levels. Similarly, symptoms of
depression decreased by 3.8 points on the PHQ-9, rep-
resenting a 24.5% decrease from initial symptom levels.
Change scores (Cohen’s d) were 0.65 for anxiety and
0.62 for depression, equivalent to a decrease in nearly
two thirds of a standard deviation for both main out-
comes. Suicidality decreased by 0.25 points on Item 9
of the PHQ-9, representing a 26.9% decrease from ini-
tial levels of suicidality. The effect size for change
scores for suicidality was 0.24, equivalent to a drop of
approximately one quarter standard deviation. Look-
ing more closely at our data, we identified that the aver-
age patient started treatment with high–moderate
levels of anxiety (14.1) and severe levels of depression
(15.6), and ended treatment with low–moderate levels
of anxiety (10.5), and moderate levels of depression
(11.7). Demographic and clinical characteristics did
not predict these main treatment outcomes. Specifi-
cally, age (ß = .127, ß = .06, ns), gender (ß = .20,
ß = .01, ns), marital status (ß = .15, ß = .12, ns), educa-
tion (ß = .04 , ß = .03, ns), and income (ß = .04, ß = .17,
ns), as well as number of psychiatric medications
(ß = .05, ß = .08, ns), primary diagnosis (ß = .18,
ß = .32, ns), number of diagnoses (ß = .15, ß = .12,
ns), anxiety severity (ß = .40, ß = .41, ns), depression
severity (ß = .21, ß = .56, ns), and suicidality (ß = .13,
ß = .34, ns), were all not associated with change scores
in anxiety or depression.
Discussion
In this paper, we present a program description, two
case studies, and results from a CBT/DBT-informed
IOP delivered in a private naturalistic treatment setting
for patients with severe symptoms of anxiety and/or
depression. On average, our IOP approach was effec-
tive in that patients experienced statistically significant
and clinically meaningful reductions in symptoms of
anxiety, depression, and suicidality. Moreover, patients
experienced a categorical decrease in anxiety and
depression scores, from severe to moderate symptoms,
in less than 2 weeks (M= 12.21 treatment days,
SD = 9.61). Although effect size for change scores for
suicidality was small (d= 0.24), this may be explained
by a floor effect, as nearly 44% of our sample did not
report suicidality. Furthermore, nearly three quarters
(74%) of our sample presented with at least two diag-
noses, suggesting that the present IOP is effective for
a variety of symptoms (e.g., major depressive disorder,
generalized anxiety disorder, panic disorder).
Our findings support and extend the growing litera-
ture that IOP and similar approaches can be an effec-
tive alternative to inpatient hospitalization for
patients needing a high level of care (Driessen et al.,
2019; Ritschel et al., 2012; Wise, 2003, 2010). In con-
trast to hospital-based programs, our naturalistic treat-
ment approach allows patients to apply the skills
learned in session within their natural environments,
potentially resulting in better generalization of skills
to real-world settings. Furthermore, intensive treat-
ment in a naturalistic treatment environment is typi-
cally less disruptive to patients’ daily lives than
hospital-based environments. Discharged inpatients
are often referred to outpatient care as they transition
7
CBT/DBT-Informed Intensive Outpatient Treatment
Table 2
Demographic and Clinical Characteristics of Patients
Age (years)
M29.10
SD 10.30
Female gender (%) 50.7
Marital status (%)
Single 66.7
Married 23.6
Divorced 4.2
Cohabitating 4.2
Other 1.4
Ethnicity
a
(%)
White 74.0
Other 17.8
Education
a
(%)
College degree 50.7
No college degree 39.7
Income
<$25,000 33.3
$25–50,000 11.1
$50–75,000 9.5
$75–100,000 7.9
$100–130,000 6.3
>$130,000 31.7
Office location (%)
Manhattan 55.6
Brooklyn 29.2
Rockland County 12.5
Out of Office 2.8
Use of psychiatric medication (%) 80.8
Primary diagnoses (%)
Anxiety 32.9
Depression 45.2
Obsessive-compulsive 13.7
Other 8.2
Number of diagnoses (%)
One 26.0
Two 42.5
Three or more 31.5
Anxiety severity (%)
Severe 50.7
Moderately severe 26.0
Moderate 19.2
Mild 4.1
Depression severity (%)
Severe 56.2
Moderately severe 26.0
Moderate 15.1
Mild 2.7
Suicidality (%)
Nearly every day 12.3
Most days 12.3
Several days 31.5
Not at all 43.9
Number of sessions
M12.63
8Falabella et al.
back into their communities, but less than 50.0% of
these referrals lead to continued care (Boyer, 1997).
Notably, a majority (68.1%) of IOP patients, including
our two case study examples, transitioned to weekly or
as-needed outpatient treatment with their IOP thera-
pist. Sudden withdrawal from inpatient care may be
related to an incomplete recovery and has been impli-
cated as a risk factor in discharge-related risks to inpa-
tients (Walter et al., 2019), highlighting the
importance of this postinpatient IOP support.
Prior studies examining the moderating effects of
acute symptoms on CBT/DBT treatment outcomes
have yielded mixed results. For example, Lewis et al.
(2012) reported higher pretreatment symptom severity
as a predictor of treatment outcome, whereas Merrill
et al. (2003) reported lower pretreatment symptom
severity as a predictor of treatment outcome. In addi-
tion, higher treatment outcome expectations and
fewer past hospitalizations were associated with a more
favorable treatment outcome for symptoms of depres-
sion in a PHP setting (Beard et al., 2016). Contrary
to these findings, we did not observe any pretreatment
demographic or clinical factors to predict treatment
outcomes. It is possible that predictive effects could
not be detected in our relatively small sample size.
Alternatively, IOP models of treatment may be ideally
suited to deliver CBT/DBT to acute patients. Notably,
other studies have also found that demographic and
clinical factors do not predict IOP treatment outcomes
(e.g., Driessen et al., 2019; Rudy et al., 2014). Further
research is needed to examine the potential utility of
IOP models to deliver relatively noninvasive psychoso-
cial treatment to clinically and demographically diverse
patients with acute symptoms.
As detailed in our case study examples, our IOP
approach is flexible and not fixed, and relevant to an
array of symptoms. While this is seen as a key feature
of this innovative clinical method, it is also associated
with variation in treatment, which serves as a method-
ological limitation to our study. Although our results
demonstrate the effectiveness of our flexible IOP for
acute patients, generalizability is hard to assess given
that treatment was tailored to each individual. Along
these lines, it is difficult to assess the feasibility of dis-
seminating a case formulation-driven IOP. Persons
(2005) encouraged the development of idiographic
assessment procedures to accompany case
formulation-driven protocols in clinical practice, but
challenges related to the intensive delivery of the pro-
gram may arise. For example, the multidisciplinary
team-based approach utilized in our study may have
played a role in establishing effective individualized
treatment plans and preventing clinician burnout.
However, this may not be possible for smaller outpa-
tient clinics or therapists practicing independently.
Therefore, further investigation of the dissemination
of intensive case formulation-driven protocols is
warranted.
SD 9.76
Total hours of treatment
M21.77
SD 15.06
Total days of treatment
M12.21
SD 9.61
Note.M= mean; SD = standard deviation. Sample size: n= 73. Clinical characteristics were collected during the pretreatment
assessment.
a
Denotes missing data.
Table 3
Intensive Outpatient Treatment Outcomes
Pretreatment Posttreatment
Variable MSDMSDt d
Anxiety 14.11 5.01 10.52 5.94 6.24
**
0.65
Depression 15.53 5.60 11.73 6.67 5.55
**
0.62
Suicidality 0.93 1.03 0.68 1.03 2.32*0.24
Note. M = mean; SD = standard deviation. Sample size: n= 73. Symptoms of anxiety, depression, and suicidality were measured using
the Generalized Anxiety Disorder–7 (GAD-7), Patient Health Questionnaire–9 (PHQ-9), and final question of the PHQ-9, respectively.
*
p< .05.
**
p< .001.
9
CBT/DBT-Informed Intensive Outpatient Treatment
Furthermore, our study was limited by the absence
of a control group and small sample size, both of which
represent common challenges in naturalistic treatment
settings. If possible, future studies may seek to include
wait-list control groups and more sophisticated
research designs (e.g., randomized controlled trials of
IOPs in private practice; multilevel modeling to
include all available session data) to further assess the
effectiveness of IOPs in a real-world setting. In addi-
tion, long-term follow-up studies may also be helpful
in examining durability of treatment effects given the
rapid delivery of treatment in IOP. Future studies
may also seek to investigate the effectiveness of IOP
on more complex comorbidities (i.e., >2 diagnoses).
A final limitation is that some patients are ill suited
to IOP treatment due to high risk. Patients who are
acutely suicidal, actively engage in risky behaviors, or
have intent to harm themselves or others, may need
hospital-level care prior to engaging in an IOP. Despite
these limitations, our findings support existing litera-
ture that suggests both CBT and DBT can be used
for acute patients in a naturalistic treatment setting
(e.g., Bjo
¨rgvinsson et al., 2014; Ritschel et al., 2012)
and that flexible treatment protocols can produce sim-
ilar therapeutic effects to those obtained in random-
ized controlled trials of structured protocols
(Persons, 2007). Further, our findings have greater
ecological validity than laboratory-based studies of
CBT and DBT, and underscore the notion that
evidence-based psychosocial approaches can be readily
disseminated to the “real world.” More broadly, our
results speak to the great promise of skills-based psy-
chotherapy for the treatment of acute symptoms.
References
Beard, C., Stein, A. T., Hearon, B. A., Lee, J., Hsu, K. J., &
Bjo
¨rgvinsson, T. (2016). Predictors of depression treatment
response in an intensive CBT partial hospital. Journal of Clinical
Psychology, 72(4), 297–310. https://doi.org/10.1002/jclp.22269.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd
ed.). Guilford Press. doi: 10.1017/CBO9781107415324.004.
Beintner, I., Hu
¨tter, K., Gramatke, K., & Jacobi, C. (2020).
Combining day treatment and outpatient treatment for eating
disorders: Findings from a naturalistic setting. Eating and Weight
Disorders, 25(2), 519–530. https://doi.org/10.1007/s40519-019-
00643-6.
Bjo
¨rgvinsson, T., Kertz, S. J., Bigda-Peyton, J. S., Rosmarin, D. H.,
Aderka, I. M., & Neuhaus, E. C. (2014). Effectiveness of
cognitive behavior therapy for severe mood disorders in an
acute psychiatric naturalistic setting: A benchmarking study.
Cognitive Behaviour Therapy, 43(3), 209–220. https://doi.org/
10.1080/16506073.2014.901988.
Boyer, C. A. (1997). Meaningful linkage practices: Challenges and
opportunities. New Directions for Mental Health Services, 1997(73),
87–101. https://doi.org/10.1002/yd.23319977310.
Centers for Medicare and Medicaid Services (2019). National
health expenditure projections, 2019–28 [Fact sheet]. https://
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
Trends-and-Reports/NationalHealthExpendData/NHE-Fact-
Sheet.
Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., &
Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural
therapy for adult depression, alone and in comparison with
other treatments. Canadian Journal of Psychiatry, 58(7), 376–385.
https://doi.org/10.1177/070674371305800702.
Driessen, M., Schulz, P., Jander, S., Ribbert, H., Gerhards, S.,
Neuner, F., & Koch-Stoecker, S. (2019). Effectiveness of
inpatient versus outpatient complex treatment programs in
depressive disorders: A quasi-experimental study under
naturalistic conditions. BMC Psychiatry, 19(1), 380. https://doi.
org/10.1186/s12888-019-2371-5.
Fava, M., Rush, A. J., Alpert, J. E., Balasubramani, G. K., Wisniewski,
S. R., Carmin, C. N., ... Trivedi, M. H. (2008). Difference in
treatment outcome in outpatients with anxious versus
nonanxious depression: A STAR*D report. American Journal of
Psychiatry, 165(3), 342–351. https://doi.org/10.1176/appi.
ajp.2007.06111868.
Goldacre, M., Seagroatt, V., & Hawton, K. (1993). Suicide after
discharge from psychiatric inpatient care. Lancet, 342(8866),
283–286. https://doi.org/10.1097/00006527-198909010-00008.
Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008).
Adaptation of dialectical behavior therapy skills training group
for treatment-resistant depression. Journal of Nervous and Mental
Disease, 196(2), 136–143. https://doi.org/10.1097/
NMD.0b013e318162aa3f.
Heekeren, K., Antoniadis, S., Habermeyer, B., Obermann, C.,
Kirschner, M., Seifritz, E., Ro
¨ssler, W., & Kawohl, W. (2020).
Psychiatric acute day hospital as an alternative to inpatient
treatment. Frontiers in Psychiatry, 11, 471. https://doi.org/
10.3389/fpsyt.2020.00471.
Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral
therapy for adult anxiety disorders: A meta-analysis of
randomized placebo-controlled trials. Journal of Clinical
Psychiatry, 69(4), 621–632. https://doi.org/10.4088/jcp.
v69n0415.
Horvitz-Lennon, M., Normand, S. L. T., Gaccione, P., & Frank, R. G.
(2001). Partial versus full hospitalization for adults in psychiatric
distress: A systematic review of the published literature (1957–
1997). American Journal of Psychiatry, 158(5), 676–685. https://
doi.org/10.1176/appi.ajp.158.5.676.
Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M.,
& Wittchen, H. U. (2012). Twelve-month and lifetime
prevalence and lifetime morbid risk of anxiety and mood
disorders in the United States. International Journal of Methods
in Psychiatric Research, 21(3), 169–184. https://doi.org/
10.1002/mpr.1359.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9.
Journal of General Internal Medicine, 16(9), 606–613. https://doi.
org/10.1046/j.1525-1497.2001.016009606.x.
Lewis, C. C., Simons, A. D., & Kim, H. K. (2012). The role of early
symptom trajectories and pretreatment variables in predicting
treatment response to cognitive behavioral therapy. Journal of
Consulting and Clinical Psychology, 80(4), 525. https://doi.org/
10.1037/a0029131.
Li, J. M., Zhang, Y., Su, W. J., Liu, L. L., Gong, H., Peng, W., & Jiang,
C. L. (2018). Cognitive behavioral therapy for treatment-
resistant depression: A systematic review and meta-analysis.
Psychiatry Research, 268(March), 243–250. https://doi.org/
10.1016/j.psychres.2018.07.020.
Linehan, M. M. (2015). DBT skills training manual (2nd ed.).
Guilford Press.
Lothes, J. E., Mochrie, K. D., & St. John, J. (2014). The effects of a
DBT informed partial hospital program on: Depression, anxiety,
hopelessness, and degree of suffering. Journal of Psychology and
10 Falabella et al.
Psychotherapy, 4(3), 1. https://doi.org/10.4172/2161-
0487.1000144.
Lo
¨we, B., Decker, O., Mu
¨ller, S., Bra
¨hler, E., Schellberg, D., Herzog,
W., & Herzberg, P. Y. (2008). Validation and standardization of
the generalized anxiety disorder screener (GAD-7) in the
general population. Medical Care, 266–274. https://doi.org/
10.1097/MLR.0b013e318160d093.
Marshall, M., Crowther, R., Sledge, W. H., Rathbone, J., & Soares-
Weiser, K. (2011). Day hospital versus admission for acute
psychiatric disorders. Cochrane Database of Systematic Reviews, 2011
(12). https://doi.org/10.1002/14651858.cd004026.pub2.
McCarty, D., Braude, L., Lyman, D. R., Dougherty, R. H., Daniels, A.
S., Ghose, S. S., & Delphin-Rittmon, M. E. (2014). Substance
abuse intensive outpatient programs: Assessing the evidence.
Psychiatric Services, 65(6), 718–726. https://doi.org/10.1176/
appi.ps.201300249.
McHugh, R. K., Kertz, S. J., Weiss, R. B., Baskin-Sommers, A. R.,
Hearon, B. A., & Bjo
¨rgvinsson, T. (2014). Changes in distress
intolerance and treatment outcome in a partial hospital setting.
Behavior Therapy, 45(2), 232–240. https://doi.org/10.1016/
j.beth.2013.11.002.
Merrill, K. A., Tolbert, V. E., & Wade, W. A. (2003). Effectiveness of
cognitive therapy for depression in a community mental health
center: A benchmarking study. Journal of Consulting and Clinical
Psychology, 71(2), 404. https://doi.org/10.1037/0022-
006X.71.2.404.
Neuhaus, E. C. (2006). Fixed values and a flexible partial hospital
program model. Harvard Review of Psychiatry, 14(1), 1–14.
Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult
cognitive-behavioral treatment outcome across the anxiety
disorders. Journal of Nervous and Mental Disease, 195(6),
521–531. https://doi.org/10.1097/01.
nmd.0000253843.70149.9a.
Owens, P. L., Fingar, K. R., Mcdermott, K. W., Muhuri, P. K., &
Heslin, K. C. (2019). Inpatient stays involving mental and
substance use disorders, 2016: Statistical brief #249. Healthcare
Cost and Utilization Project (HCUP) Statistical Briefs.
Persons, J. B. (2005). Empiricism, mechanism, and the practice of
cognitive-behavior therapy. Behavior Therapy, 36(2), 107–118.
Persons, J. B. (2007). Psychotherapists collect data during routine
clinical work that can contribute to knowledge about
mechanisms of change in psychotherapy. Clinical Psychology:
Science and Practice, 14(3), 244–246. https://doi.org/10.1111/
j.1468-2850.2007.00083.x.
Qin, P., & Nordentoft, M. (2005). Suicide risk in relation to
psychiatric hospitalization. Archives of General Psychiatry, 62(4),
427. https://doi.org/10.1001/archpsyc.62.4.427.
Ritschel, L. A., Cheavens, J. S., & Nelson, J. (2012). Dialectical
behavior therapy in an intensive outpatient program with a
mixed-diagnostic sample. Journal of Clinical Psychology, 68(3),
221–235. https://doi.org/10.1002/jclp.20863.
Rudy, B. M., Lewin, A. B., Geffken, G. R., Murphy, T. K., & Storch,
E. A. (2014). Predictors of treatment response to intensive
cognitive-behavioral therapy for pediatric obsessive-compulsive
disorder. Psychiatry Research, 220(1–2), 433–440. https://doi.
org/10.1016/j.psychres.2014.08.002.
Schomerus, G., Schwahn, C., Holzinger, A., Corrigan, P. W., Grabe,
H. J., Carta, M. G., & Angermeyer, M. C. (2012). Evolution of
public attitudes about mental illness: A systematic review and
meta-analysis. Acta Psychiatrica Scandinavica, 125(6), 440–452.
https://doi.org/10.1111/j.1600-0447.2012.01826.x.
Schwartz, W. L., & Thyer, B. A. (2008). Partial hospitalization
treatment for clinical depression. Journal of Human Behavior in
the Social Environment, 3(2), 13–21. https://doi.org/10.1300/
J137v03n02.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs,
J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998).
The Mini-International Neuropsychiatric Interview (M.I.N.I.):
The development and validation of a structured diagnostic
psychiatric interview for DSM-IV and ICD-10. Journal of Clinical
Psychiatry, 59(Suppl. 20), 22–33.
Smith, G. W., Ruiz-Sancho, A., & Gunderson, J. G. (2001). An
intensive outpatient program for patients with borderline
personality disorder. Psychiatric Services, 52(4), 532–533.
https://doi.org/10.1176/appi.ps.52.4.532.
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lo
¨we, B. (2006). A
brief measure for assessing generalized anxiety disorder: The
GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.
https://doi.org/10.1001/archinte.166.10.1092.
Stensland, M., Watson, P. R., & Grazier, K. L. (2012). An
examination of costs, charges, and payments for inpatient
psychiatric treatment in community hospitals. Psychiatric
Services, 63(7), 666–671. https://doi.org/10.1176/appi.
ps.201100402.
Tiller, J. W. G. (2012). Depression and anxiety. Medical Journal of
Australia, 199(6), 28–32. https://doi.org/10.5694/
mjao12.10628.
Walter, F., Carr, M. J., Mok, P. L. H., Antonsen, S., Pedersen, C. B.,
Appleby, L., Fazel, S., Shaw, J., & Webb, R. T. (2019). Multiple
adverse outcomes following first discharge from inpatient
psychiatric care: A national cohort study. Lancet Psychiatry, 6
(7), 582–589. https://doi.org/10.1016/S2215-0366(19)30180-4.
Walter, F., Carr, M. J., Mok, P. L. H., Astrup, A., Antonsen, S.,
Pedersen, C. B., Shaw, J., & Webb, R. T. (2017). Premature
mortality among patients recently discharged from their first
inpatient psychiatric treatment. JAMA Psychiatry, 74(5), 485–492.
https://doi.org/10.1001/jamapsychiatry.2017.0071.
Wiethoff, K., Bauer, M., Baghai, T. C., Mo
¨ller, H.-J., Fisher, R.,
Hollinde, D., Kiermeir, J., Hauth, I., Laux, G., Cordes, J.,
Brieger, P., Kronmu
¨ller, K.-T., Zeiler, J., & Adli, M. (2010).
Prevalence and treatment outcome in anxious versus
nonanxious depression. Journal of Clinical Psychiatry, 71(8),
1047–1054. https://doi.org/10.4088/jcp.09m05650blu.
Wise, E. A. (2003). Empirical validation of a mental health intensive
outpatient program in a private practice setting. American Journal
of Orthopsychiatry, 73(4), 405–410. https://doi.org/10.1037/
0002-9432.73.4.405.
Wise, E. A. (2010). Evidence-based effectiveness of a private practice
intensive outpatient program with dual diagnosis patients.
Journal of Dual Diagnosis, 6(1), 25–45. https://doi.org/
10.1080/15504260903498862.
World Health Organization (2017). Depression and other common
mental disorders: Global health estimates. Author.
The authors have no conflicts of interest to disclose and affirm
that this manuscript is an honest, accurate, and transparent
account of the study being reported; that no important aspects of
the study have been omitted; and that any discrepancies from the
study as planned have been explained. Names and other
identifying details in the case studies have been changed to
protect patient privacy and confidentiality. This research did not
receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Address correspondence to David H. Rosmarin, Ph.D., ABPP,
McLean Hospital/Harvard Medical School, 115 Mill Street, Bel-
mont, MA 02478. e-mail: drosmarin@mclean.harvard.edu.
Received: December 6, 2020
Accepted: May 3, 2021
Available online xxxx
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CBT/DBT-Informed Intensive Outpatient Treatment