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CBT/DBT-Informed Intensive Outpatient Treatment for Anxiety and Depression: A Naturalistic Treatment Outcomes Study

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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 prescribed 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 IOP. After completing treatment, 68.1% of participants 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.
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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
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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 = .127, ß = .06, ns), gender = .20,
ß = .01, ns), marital status = .15, ß = .12, ns), educa-
tion = .04 , ß = .03, ns), and income = .04, ß = .17,
ns), as well as number of psychiatric medications
= .05, ß = .08, ns), primary diagnosis = .18,
ß = .32, ns), number of diagnoses = .15, ß = .12,
ns), anxiety severity = .40, ß = .41, ns), depression
severity = .21, ß = .56, ns), and suicidality = .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.
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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
11
CBT/DBT-Informed Intensive Outpatient Treatment
... DBT, ACT, psychodynamic) (McCarty et al., 2014;Hayes et al., 2018). Previously IOPs have been utilised for illnesses such as substance misuse and eating disorders, but more recently have been trialled for patients with anxiety and/or depression (McCarty et al., 2014;Hayes et al., 2018;Falabella et al., 2021). IOPs treating substance misuse and eating disorders are more common in the US, but their use to treat depression, is new to both the US and the UK. ...
... IOPs treating substance misuse and eating disorders are more common in the US, but their use to treat depression, is new to both the US and the UK. Current findings of IOPs suggest that they can be effective alternatives to inpatient admissions resulting in a reduction in functional impairments, cost of treatment, and improvements in quality-of-life (McCarty et al., 2014;Hayes et al., 2018;Falabella et al., 2021). ...
... This would suggest that in a relatively short space of time (average of 5.5 weeks), service users were able to return to a close to pre-morbid level of wellness. The current findings are consistent with those of Falabella et al. (2021); indicating that intensive CBT and DBT-based interventions can be effectively delivered to individuals with acute anxiety and depression in an outpatient setting. The initial findings have clinical implications for a number of reasons. ...
Article
One aspect of the NHS Long Term Plan is to establish a more comprehensive community-based mental health crisis response. NHS trusts have therefore looked to new services to help alleviate in-patient bed pressures. Intensive Outpatient Programmes (IOPs) have been previously used to help support people living with substance-misuse or eating disorders. More recently IOPs have been utilised to support people living with depression and anxiety. The Acute Community Service (ACS) was established as an IOP to support older adults in crisis by providing psychological, nursing, occupational, and physiotherapy interventions. Initial findings are consistent with previous research showing significant improvements in mood, levels of anxiety, and quality of life, with some service users being suitable for discharge to primary care. The ACS looks to build on these promising findings by working towards understanding the impact of the service on the frequency and length of in-patient admissions. Additionally, we would aim to understand the longer term impact of the ACS on service users and re-referrals rates.
... In a pilot intervention of DBT-A diagnosed with bipolar disorder that adolescents stated a significant decrease in depressive symptoms over a 1-year treatment course (Goldstein et al., 2007(Goldstein et al., , 2015. Falabella et al. (2021) reported clinically and statistically significant reductions in anxiety, depression, and suicidality and stated that flexible DBT protocols can be successfully adapted to naturalistic settings (Falabella et al., 2021). In a recent study, the effect of DBT on changing the level of psychological components (anxiety, stress and depression) and problem solving styles in students is reported, and it was recommended that the authorities in the field of research and student health use DBT for depressed students (Yravaisi et al., 2021). ...
... In a pilot intervention of DBT-A diagnosed with bipolar disorder that adolescents stated a significant decrease in depressive symptoms over a 1-year treatment course (Goldstein et al., 2007(Goldstein et al., , 2015. Falabella et al. (2021) reported clinically and statistically significant reductions in anxiety, depression, and suicidality and stated that flexible DBT protocols can be successfully adapted to naturalistic settings (Falabella et al., 2021). In a recent study, the effect of DBT on changing the level of psychological components (anxiety, stress and depression) and problem solving styles in students is reported, and it was recommended that the authorities in the field of research and student health use DBT for depressed students (Yravaisi et al., 2021). ...
Article
Our aim was to evaluate longitudinal data for adolescents who were treated with Dialectical Behavior therapy (DBT) skills groups having been previously diagnosed with depressive disorder. Intervention with an observational cross-sectional design was implemented to evaluate the treatment outcome of a 10-week DBT skills groups with female adolescents with depression. After the patients were identified for enrollment, parents and adolescents were evaluated with psychometric measurements pre-, post-intervention, and at one-year follow-up. Repeated measures analysis was undertaken with the Child Depression Inventory (CDI), Pediatric Quality of Life Inventory (PedsQL) and Strengths and Difficulties Questionnaire (SDQ) for participants. Statistical significance was detected for self-report CDI scores and both self-report and parent SDQ and PedsQL scores. This study is the first DBT intervention in Turkish children, shows that a group DBT skills groups training can be adapted and put into practice successfully with depressed Turkish adolescents.
... 25 There is some evidence to suggest that the gold-standard treatments for depressive symptoms, which include cognitive behavioral therapy, interpersonal psychotherapy, and pharmacological agents, also can improve pain symptoms 15 and substance use risk, 26 while also decreasing anxiety symptoms. 27 However, research on the relationship between reductions in symptoms of depression and improvements in other conditions is limited. ...
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Introduction Depressive symptoms are linked with pain, anxiety, and substance use. Research estimating whether a reduction in depressive symptoms is linked to subsequent reductions in pain and anxiety symptoms and substance use is limited. Methods Using data from the Veterans Aging Cohort Study, a multisite observational study of U.S. veterans, the authors used a target trial emulation framework to compare individuals with elevated depressive symptoms (Patient Health Questionnaire-9 score ≥ 10) who experienced reductions in depressive symptoms (Patient Health Questionnaire-9 score < 10) with those whose symptoms persisted (Patient Health Questionnaire-9 score ≥ 10) at the next follow-up visit (on average, 1 year later). Using inverse probability of treatment weighting, the authors estimated ORs and 95% CIs for associations between depressive symptom reduction status and improvement on the following: anxiety symptoms, pain symptoms, unhealthy alcohol use, and use of tobacco, cannabis, cocaine, and/or illicit opioids. Results Reductions in depressive symptoms were associated with reductions in pain symptoms (OR=1.43, 95% CI=1.01, 2.02), anxiety symptoms (OR=2.50, 95% CI=1.63, 3.83), and illicit opioid use (OR=2.07, 95% CI=1.13, 3.81). Depressive symptom reductions were not associated with reductions in unhealthy alcohol use (OR=0.85, 95% CI=0.48, 1.52) or use of tobacco (OR=1.49, 95% CI=0.89, 2.48), cannabis (OR=1.07, 95% CI=0.63, 1.83), or cocaine (OR=1.28, 95% CI=0.73, 2.24). Conclusions Reducing depressive symptoms may potentially reduce pain and anxiety symptoms and illicit opioid use. Future work should determine whether reductions achieved through antidepressant medications, behavioral therapy, or other means have comparable impact.
... Likewise, the primary goal of Dialectical Behavior Therapy (DBT) is to help patients create a life worth living, thereby focusing on overall well-being and functioning even in the presence of symptoms (Linehan, 2014). Despite de-emphasizing symptom reduction, both ACT and DBT are effective psychotherapy techniques in reducing symptoms for a range of psychiatric disorder (e.g., (Arch et al., 2012;Bai et al., 2020;Cristea et al., 2017;Falabella et al., 2022). ...
Article
In treatment studies of depression, response is typically defined as a 50% or greater reduction in symptom severity. However, multiple surveys of depressed patients have found that patients prioritize improved functioning and quality of life objectives over symptom improvement as the most important goal of treatment. The goal of the present study is to widen the lens of assessing outcome by examining response in nonsymptom domains in patients who are, by convention, considered nonresponders to treatment. Eight hundred and forty-four patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. At discharge, the patients made a global rating of the effectiveness of treatment. The 517 patients who were nonresponders on the depression symptom subscale of the RDQ are the focus of this report. The patients showed significant levels of improvement from admission to discharge in all nonsymptom domains, with medium to large effect sizes. Approximately one-third of the patients were responders on at least 1 of the nonsymptom domains. The failure to meet the conventional definition of treatment response based on symptom severity does not preclude significant improvement in nonsymptom domains.
... Similarly, the primary goal of Dialectical Behavior Therapy (DBT) is to help patients create a life worth living, which encompasses overall well-being and functioning even in the presence of symptoms (Linehan, 2014). Despite targeting different processes and goals, both ACT and DBT are effective psychotherapy techniques for promoting symptom reduction and remission for a range of psychopathologies (e.g., (Arch et al., 2012;Bai et al., 2020;Cristea et al., 2017;Falabella et al., 2022). The results from the current study support this approach and help to identify a broader set of treatment outcomes that are more consistent with patient goals in order to provide the most effective and comprehensive treatment possible. ...
Article
Determinations of the efficacy of treatments for depression most commonly are based on changes in scores on symptom severity scales. This narrow symptom-focused approach towards evaluating outcome is at variance with patients’ broader conceptualization of the factors deemed important in evaluating the outcome of depression treatment. In the present report we examine the factors associated with depressed patients’ global ratings of improvement after a treatment intervention. Five hundred and three patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. The patients completed the RDQ at admission and discharge from the treatment program. At discharge, the patients made a global rating of the effectiveness of treatment. The patients significantly improved from admission to discharge on each RDQ subscale. Changes in the well-being/life satisfaction and coping subscales were the only 2 subscales that were independently associated with the patients’ ratings of improvement. These results suggest that when evaluating outcome in the treatment of depression a focus on symptom improvement is too narrow. Consideration of a broader perspective in measuring outcome in treatment studies of depression is more consistent with a biopsychosocial conceptualization.
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For the first time in the Swiss health care system, this evaluation study examined whether patients with acute psychiatric illness who were admitted for inpatient treatment could be treated in an acute day hospital instead. The acute day hospital is characterized by the possibility of direct admission of patients without preliminary consultation or waiting time and is open every day of the week. In addition, it was examined whether and to what extent there are cost advantages for day hospital treatment. Patients who were admitted to the hospital with a referral to an inpatient admission were treated randomly either fully inpatient or in the acute day hospital. As a pilot study, 44 patients were admitted to the study. Evidence of efficacy could be provided for both treatment settings based on significant reduction in psychopathological symptoms and improvement in functional level in the course of treatment. There were no significant differences between the two settings in terms of external assessment of symptoms, subjective symptom burden, functional level, quality of life, treatment satisfaction, and number of treatment days. Treatment in the day hospital was about 45% cheaper compared to inpatient treatment. The results show that acutely ill psychiatric patients of different symptom severity can be treated just as well in an acute day hospital instead of being admitted to the hospital. In addition, when direct treatment costs are considered, there are clear cost advantages for day hospital treatment.
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Background: Due to long waiting periods for outpatient psychotherapy and the high resource requirements of inpatient treatment, there is a need for alternative treatment programs for patients with depressive disorders. Thus, we investigated the effectiveness of the "Bielefeld Outpatient Intensive Treatment Program of Depression" (BID) in comparison with a typical inpatient treatment program by using a prospective quasi-experimental observational study. We assumed (i) that both complex programs are effective in pre-post analyses after 6 weeks and (ii) that inpatient treatment is more effective compared with the outpatient program. Methods: Four hundred patients with depressive psychopathology - a majority with depressive episodes (ICD-10 F3X) - took part in the BID and 193 in the inpatient program. Different self- (i.e., BDI) and expert measures (i.e., MADRS) of psychopathology at baseline (t1) and 6 weeks later (t2) were applied to examine treatment effects. Results: Treatment effects were high in separate analyses of both groups with Cohen's d ranging from 1.10 to 1.76., while ANOVA comparative analyses did not reveal any significant differences between both treatment settings nor did a set of independent covariates analyzed here. Response rates of BDI (p = .002) and MADRS (p = .001) were higher in the outpatient group. Results indicate BID not to be inferior compared to an inpatient program, although diverging pathways to treatment, higher rates of clinical recurrent depressive disorders and severe episodes as well as lower rates of employment and partnership in the inpatient treatment group have to be considered. Conclusion: Outpatient intensive treatment programs may represent a solution for patients needing more than a treatment session once per week but less than a complex inpatient or day clinic program.
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Background: Discharged psychiatric inpatients are at elevated risk of serious adverse outcomes, but no previous study has comprehensively examined an array of multiple risks in a single cohort. Methods: We used data from the Danish Civil Registration System to delineate a cohort of all individuals born in Denmark in 1967-2000, who were alive and residing in Denmark on their 15th birthday, and who had been discharged from their first inpatient psychiatric episode at age 15 years or older. Each individual in the discharged cohort was matched on age and sex with 25 comparators without a history of psychiatric admission. Data linked to each individual were also obtained from the Psychiatric Central Research Register, Register of Causes of Death, National Patient Register, and the National Crime Register. We used survival analysis techniques to estimate absolute and relative risks of all-cause mortality, suicide, accidental death, homicide victimisation, homicide perpetration, non-fatal self-harm, violent criminality, and hospitalisation following violence, until Dec 31, 2015. Findings: We included 62 922 individuals in the discharged cohort, and 1 573 050 matched comparators. Risks for each of all eight outcomes examined were markedly elevated in the discharged cohort relative to the comparators. Within 10 years of first discharge, the cumulative incidence of death, self-harm, committing a violent crime, or hospitalisation due to interpersonal violence was 32·0% (95% CI 31·6-32·5) in the discharged cohort (37·1% [36·5-37·8] in men and 27·2% [26·7-27·8] in women). Absolute risk of at least one adverse outcome occurring within this timeframe were highest in people diagnosed with a psychoactive substance use disorder at first discharge (cumulative incidence 49·4% [48·4-50·4]), and lowest in those diagnosed with a mood disorder (24·4% [23·6-25·2]). For suicide and non-fatal self-harm, risks were especially high during the first 3 months post-discharge, whereas risks for accidental death, violent criminality, and hospitalisation due to violence were more constant throughout the 10-year follow-up. Interpretation: People discharged from inpatient psychiatric care are at higher risk than the rest of the population for a range of serious fatal and non-fatal adverse outcomes. Improved inter-agency liaison, intensive follow-up immediately after discharge, and longer-term social support are indicated. Funding: Medical Research Council, European Research Council, and Wellcome Trust.
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Day treatment programs for individuals with eating disorders (ED) have been the subject of research and are promoted as an alternative to inpatient treatment due to their therapeutic and economic advantages, but have not regularly been implemented in regular care. We investigated the long-term effectiveness of a transdiagnostic combined eating disorder treatment program which consisted of an 8-week day treatment phase followed by an average of 19 sessions of outpatient treatment over an average of 39 weeks in a naturalistic setting. We accepted 148 patients with different diagnoses of eating disorders into our combined treatment program. We assessed weight, behavioral eating disorder symptoms and eating disorder related cognitions and attitudes at the beginning and end of the day treatment phase and after 6, 12 and 26 months. Over the course of the 8-week day treatment phase, patients with initial binge eating, purging and/or fasting behavior reduced these symptoms by 91%, 90% and, 86%. Patients who were underweight at baseline gained on average 1.05 BMI points (d = 0.76). In addition, eating disorder related cognitions and attitudes of all patients significantly improved with large effect sizes (d = 1.12). On average, all improvements remained stable during the follow-up period. Our findings add to the existing studies on day treatment and support previously found encouraging effects of treatment programs that combine day treatment and consecutive outpatient treatment for eating disorders.
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Comorbid depression and anxiety disorders occur in up to 25% of general practice patients. About 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. Symptomatology may initially seem vague and non-specific. A careful history and examination with relevant investigations should be used to make the diagnosis. Once the diagnosis is made, rating scales may identify illness severity and help in monitoring treatment progress. Both the depression disorder and the specific anxiety disorder require appropriate treatment. Psychological therapies, such as cognitive behaviour therapy, and antidepressants, occasionally augmented with antipsychotics, have proven benefit for treating both depression and anxiety. Benzodiazepines may help alleviate insomnia and anxiety but not depression. They have dependency and withdrawal issues for some people, and may increase the risk of falls in older people. Despite the availability of treatments, 40% of patients with depression or anxiety do not seek treatment, and of those who do, less than half are offered beneficial treatment.
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Cognitive behavioral therapy (CBT) is a common psychotherapy characterized as treating mental diseases, such as depression. Though multiple studies have reported its effect in treatment-resistant depression, no qualified meta-analysis has ever assessed this effect before. In this study, we evaluated the efficacy of CBT for treatment-resistant depression patients and its continuous effect. We comprehensively searched PubMed, Embase, and Cochrane Library from inception to February 2018 for eligible randomized controlled trials (RCTs). A total of six RCTs involving 847 participants were included. Pooled analysis indicated that CBT was an efficient invention in reducing depression symptoms. Besides, CBT was also superior to control group in increasing response and remission rates. These effects could take effect at post-treatment, and last for 6 months, or even 1 year long. No publication bias was detected. These findings suggested that compared with routine antidepressant treatment, CBT has greater potential in taking immediate effect and has better mid-term and long-term prognosis.
Article
Importance: Nationwide cohorts provide sufficient statistical power for examining premature, cause-specific mortality in patients recently discharged from inpatient psychiatric services. Objective: To investigate premature mortality in a nationwide cohort of patients recently discharged from inpatient psychiatric treatment at ages 15 to 44 years. Design, setting, and participants: This single-cohort design included all persons born in Denmark (N = 1 683 385) between January 1, 1967, and December 31, 1996. Exactly 48 599 of these Danish residents were discharged from an inpatient psychiatric unit or ward on or after their 15th birthday, which took place during this study's observation period from January 1, 1982, through December 31, 2011. This group of patients was followed up beginning on their 15th birthday until their death, emigration, or December 31, 2011, whichever came first. Individuals discharged from inpatient psychiatric care at least once before their 15th birthday (n = 5882) were excluded from the study. All data were obtained from the Danish Civil Registration System, Psychiatric Central Research Register, and Register of Causes of Death. Data analysis took place between February 1, 2016, and December 10, 2016. Main outcomes and measures: Incidence rates and incidence rate ratios (IRRs) for all-cause mortality and for an array of unnatural and natural causes of death among patients recently discharged from an inpatient psychiatric unit vs persons not admitted to a psychiatric facility. Primary analysis considered risk within the year of first discharge. Results: Of the 48 599 discharged patients who were included in the study, 25 006 (51.4%) were female, 35 660 (73.4%) were aged 15 to 29 years, and 33 995 (70.0%) had a length of stay of 30 days or less. Compared with persons not admitted, patients discharged had an elevated risk for all-cause mortality within 1 year (IRR, 16.2; 95% CI, 14.5-18.0). The relative risk for unnatural death (IRR, 25.0; 95% CI, 22.0-28.4) was much higher than for natural death (IRR, 8.6; 95% CI, 7.0-10.7). The highest IRR found was for suicide at 66.9 (95% CI, 56.4-79.4), followed by alcohol-related death at 42.0 (95% CI, 26.6-66.1). Among the psychiatric diagnostic categories assessed, psychoactive substance abuse conferred the highest risk for all-cause mortality (IRR, 24.8; 95% CI, 21.0-29.4). Across the array of cause-specific outcomes examined, risk of premature death during the first year after discharge was markedly higher than the risk of death beyond the first year of discharge. Conclusions and relevance: Clinicians may help protect patients after discharge by serving as a liaison between primary and secondary health services to ensure they are receiving holistic care. Early intervention programs for drug and alcohol misuse could substantially decrease the greatly elevated mortality risk among these patients.
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La profesion –formacion- docente es un tema crucial en los actuales debates educativos. La existencia de dos decretos y el desplazamiento del verdadero sentido del ser maestro reclaman de los analisis un ejercicio de comprension del orden discursivo oficial. La calidad es el sustrato de la sociedad de control. En este marco se agencia nuevas practicas de subjetivacion del maestro los cuales podriamos situar en la calidad, flexibilidad, adaptabilidad, eficiencia, eficacia. En cualquier caso, el esfuerzo por hacer del maestro un intelectual de la educacion fue borrado. La gran cuestion consiste en saber que discursos regula el saber del docente a la luz de la sociedad de control.
Article
Objective: Despite the effectiveness of cognitive behavioral therapy (CBT) for depression, a significant number of patients do not respond. Data examining predictors of treatment response in settings in which CBT is delivered naturalistically are lacking. Method: Treatment outcome data collected at a CBT-based partial hospital (n = 956) were used to examine predictors of two types of treatment response: (a) a reliable and clinically significant change in depressive symptoms and (b) a self-rating of "very much" or "much" improved. In multiple logistic regression models, we examined predictors of response in the total sample and separately for patients with a primary diagnosis of major depressive disorder (MDD) versus patients with other primary diagnoses. Results: In the total sample, higher treatment outcome expectations and fewer past hospitalizations predicted clinically significant improvement in depression symptoms, and higher treatment expectations and ethnoracial minority background predicted global improvement. In patients with primary MDD, higher treatment outcome expectations and being referred from the community (vs. inpatient hospitalization) predicted better depression response, and higher treatment outcome expectations predicted global improvement. In patients with other primary diagnoses, higher treatment outcome expectations and fewer borderline personality disorder traits predicted depression reduction, and higher treatment outcome expectations, less relationship difficulty, and female gender predicted global improvement. Conclusions: Results are generally consistent with data from randomized controlled trials on longer term outpatient CBT. Interventions that increase treatment expectancy and modifications to better target men may enhance treatment outcome. Future research should include objective outcome measures and examine mechanisms underlying treatment response.
Article
Intensive outpatient treatments for pediatric obsessive-compulsive disorder (OCD) have demonstrated efficacy for treating youth with OCD and may be especially useful for youth with severe symptomology and/or those who are partial- or non-responders to other forms of intervention. However, participation in these treatments can present challenges for youth and their families, and it is unclear if intensive treatments are more appropriate for certain individuals than others. Identification of potential predictors of treatment response and viability of intensive treatment at an individual level may aid families in their decision to participate in intensive cognitive-behavioral therapy (CBT). The present study aimed to examine the effects of three categories of predictors (demographics, OCD symptom characteristics, and comorbidity) on key target outcomes (post-treatment symptom severity, remission, and treatment response). Participants included 78 youth with a primary diagnosis of OCD who received 14 sessions of family based intensive CBT treatment over 3 weeks. Of the entire sample, 88.5% were classified as treatment responders, with 62.8% of the sample achieving clinical remission. Results identified three significant predictor variables (i.e., symptom severity, family accommodation, and gender) for post-treatment symptom severity and remission status within the context of the examined predictive models. No variables were identified as predictive of treatment response, and comorbidity was not identified as a predictor variable for any treatment outcome.