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Open Access 01-02-2020 | Affective Disorder | Original Article

Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

Authors: Emily Widnall, Alice Price, Hester Trompetter, Barnaby D. Dunn

Published in: Cognitive Therapy and Research | Issue 1/2020

Abstract

The primary focus of classic cognitive behavioural therapy (CBT) for depression and anxiety is on decreasing symptoms of psychopathology. However, there is increasing recognition that it is also important to enhance wellbeing during therapy. This study investigates the extent to which classic CBT for anxiety and depression leads to symptom relief versus wellbeing enhancement, analysing routine outcomes in patients receiving CBT in high intensity Improving Access to Psychological Therapy (IAPT) Services in the UK. At intake, there were marked symptoms of anxiety and depression (a majority of participants scoring in the severe range) and deficits in wellbeing (a majority of participants classified as languishing, relative to general population normative data). CBT was more effective at reducing symptoms of anxiety and depression than repairing wellbeing. As a result, at the end of treatment, a greater proportion of participants met recovery criteria for anxiety and depression than had moved from languishing into average or flourishing levels of wellbeing. Given the importance of wellbeing to client definitions of recovery, the present results suggest a greater emphasis should be placed on enhancing wellbeing in classic CBT.

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Over the past forty years cognitive protocols have evolved and proliferated. CBT can therefore be broadly defined as a family of interventions that aim to change how an individual thinks and behaves in an effort to repair mood. We are restricting our analysis to ‘classic’ Beckian protocols. By this we mean ‘second wave’ treatments that combine behavioural and cognitive approaches to modify negatively biased cognitive content in anxiety and depression. We distinguish these from more recent ‘third wave’ cognitive protocols that change the relationship to as well as the content of cognition. These ‘third wave approaches include Acceptance and Commitment Therapy, Dialectical Behaviour Therapy, and Mindfulness Based Cognitive Therapy. CBT protocols have also recently been adapted to have a more explicit recovery focus.

In these studies, the pre-post correlation for each measure was never described, so we assumed in all cases it was 0.5.

The analyses comparing the magnitude of recovery for symptoms versus wellbeing are relying on essentially arbitrary definitions of recovery, particularly for the WEMWBS where no cut-off has yet been established. Another criteria that has been used in the literature is to define anyone who scores no more than one SD below the general population average as being in recovery (which results in a lower cut-off score of 44 for the WEMWBS). Using this approach, at intake a greater proportion of individuals were in recovery for WEMWBS relative to symptoms, McNemar p<.001. At post-treatment, a greater proportion of individuals met recovery for symptoms relative to wellbeing, McNemar, p=.002. We also conducted additional continuous analyses on change on each measure in Z-score units (relative to general population averages) and proportion change units (relative to scale range). These continuous analyses do not rely on arbitrary cut-offs to define recovery. These reached an identical conclusion to the categorical analyses, with greater repair of symptoms relative to wellbeing (see supplementary materials for details).

Ali, S., Rhodes, L., Moreea, O., McMillan, D., Gilbody, S., Leach, C., et al. (2017). How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study. Behaviour Research and Therapy,94, 1–8.PubMed

Al-Janabi, H., Flynn, T. N., & Coast, J. (2012). Development of a self-report measure of capability wellbeing for adults: The ICECAP-A. Quality of Life Research,21, 167–176.PubMed

Beck, A. T., Rush, J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford press.

Böhnke, J. R., & Croudace, T. J. (2016). Calibrating well-being, quality of life and common mental disorder items: Psychometric epidemiology in public mental health research. The British Journal of Psychiatry,209, 162–168.PubMedPubMedCentral

Burr, L. A., Javiad, M., Jell, G., Werner-Seidler, A., & Dunn, B. D. (2017). Turning lemonade into lemons: Dampening appraisals reduce positive affect and increase negative affect during positive activity scheduling. Behaviour Research and Therapy,91, 91–101.PubMed

Chaves, C., Lopez-Gomez, I., Hervas, G., & Vazquez, C. (2017). A comparative study on the efficacy of a positive psychology intervention and a cognitive behavioral therapy for clinical depression. Cognitive Therapy and Research,41, 417–433.

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York: Guilford Press.

Clark, D., & Oates, M. (2014). Improving access to psychological therapies: Measuring improvement and recovery in adult services, version 2. Accessed, 21 June 16

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York: Academic Press.

Coulombe, S., Radziszewski, S., Meunier, S., Provencher, H., Hudon, C., Roberge, P., et al. (2016). Profiles of recovery from mood and anxiety disorders: A person-centered exploration of people’s engagement in self-management. Frontiers in Psychology,7, 584.PubMedPubMedCentral

Craske, M., Meuret, A. E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety. A randomized controlled trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology,87, 457–541.PubMed

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. The Canadian Journal of Psychiatry,58, 376–385.PubMed

Demyttenaere, K., Donneau, A. F., Albert, A., Ansseau, M., Constant, E., & Van Heeringen, K. (2015). What is important in being cured from depression? Discordance between physicians and patients (1). Journal of Affective Disorders,174, 390–396.PubMed

DeRubeis, R. J., Cohen, Z. D., Forand, N. R., Fournier, J. C., Gelfand, L. A., & Lorenzo-Luaces, L. (2014). The Personalized Advantage Index: Translating research on prediction into individualized treatment recommendations. A demonstration. PLoS ONE,9, e83875.PubMedPubMedCentral

Dunn, B. D. (in press). Augmenting cognitive behavioural therapy to build positive mood in depression. In J. Gruber (Ed.), Oxford handbook of positive emotion and psychopathology. New York: Oxford University Press.

Dunn, B. D., Widnall, E., Reed, N., Owens, C., Campbell, J., & Kuyken, W. (2019). Bringing light into darkness: a multiple baseline mixed methods case series evaluation of Augmented Depression Therapy (ADepT). Behaviour Research and Therapy. https://doi.org/10.1016/j.brat.2019.103418.CrossRefPubMed

Elliot, A. J., Sheldon, K. M., & Church, M. A. (1997). Avoidance personal goals and subjective well-being. Personality and Social Psychology Bulletin,23, 915–927.PubMed

Fava, G. A. (2016). Well-being therapy: Current indications and emerging perspectives. Psychotherapy and Psychosomatics,85, 136–145.PubMed

Fava, G. A., Rafanelli, C., Cazzaro, M., Conti, S., & Grandi, S. (1998a). Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders. Psychological Medicine,28, 475–480.PubMed

Fava, G. A., Rafanelli, C., Grandi, S., et al. (1998b). Prevention of recurrent depression with cognitive behavioural therapy: Preliminary findings. Archives of General Psychiatry,55, 816–820.PubMed

Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2004). Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. American Journal of Psychiatry,161, 1872–1876.PubMed

Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Salmaso, L., Mangelli, L., et al. (2005). Well-being therapy of generalized anxiety disorder. Psychotherapy and Psychosomatics,74, 26–30.PubMed

Gadeikis, D., Bos, N., Schweizer, S., Murphy, F., & Dunn, B. (2017). Engaging in an experiential processing mode increases positive emotional response during recall of pleasant autobiographical memories. Behaviour Research and Therapy,92, 68–76.PubMedPubMedCentral

Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. L. (2010). Upward spirals of positive emotions counter downward spirals of negativity: Insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical Psychology Review,30, 849–864.PubMedPubMedCentral

Geschwind, N., Arntz, A., Bannink, F., & Peeters, F. (2019). Positive cognitive behaviour therapy in the treatment of depression: A randomized order within-subject comparison with traditional cognitive behaviour therapy. Behaviour Research and Therapy,116, 119–130.PubMed

Goddard, E., Wingrove, J., & Moran, P. (2015). The impact of comorbid personality difficulties in response to IAPT treatment for depression and anxiety. Behaviour Research and Therapy,73, 1–7.PubMed

Guidi, J., Brakemeier, B., Bockting, C. L. H., Fava, G. A., et al. (2018). Methodological recommendations for trials of psychological interventions. Psychotherapy and Psychosomatics,87, 276–284.PubMed

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press.

Hofmann, S. G., Curtiss, J., Carpenter, J. K., & Kind, S. (2017). Effect of treatments for depression on quality of life: A meta-analysis. Cognitive and Behaviour Therapy,46, 265–286.

Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry,69, 621–632.PubMedPubMedCentral

Huppert, F. A. (2014). The state of wellbeing science: Concepts, measures, interventions and policies. In G. Cooper (Ed.), Introduction to wellbeing: A complete reference guide (Vol. 6). New Jersey: Wiley.

Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology,59, 12–19.

Jakobsen, J. C., Gluud, C., Wetterslev, J., & Winkel, P. (2017). When and how should multiple imputation be used for handling missing data in randomised clinical trials—A practical guide with flowcharts. BMC Medical Research Methodology,17, 162.PubMedPubMedCentral

Kessler, R. C., Angermeyer, M., Anthony, J. C., De Graaf, R. O. N., Demyttenaere, K., Gasquet, I., et al. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry,6, 168–176.PubMedPubMedCentral

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry,62, 593–602.

Keyes, C. L. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior,43, 207–222.PubMed

Keyes, C. L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology,73, 539–548.PubMed

Keyes, C. L., & Lopez, S. J. (2002). Toward a science of mental health: Positive directions in diagnosis and intervention. New York: Oxford University Press.

Kocalevent, R. D., Hinz, A., & Brähler, E. (2013). Standardization of the depression screener patient health questionnaire (PHQ-9) in the general population. General Hospital Psychiatry,35, 551–555.PubMed

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine,16, 606–613.PubMedPubMedCentral

Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry,32, 345–359.PubMed

Lambert, M. J. (2017). Maximizing psychotherapy outcomes beyond evidence-based medicine. Psychotherapy and Psychosomatics,86, 80–89.PubMed

Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., et al. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care,46, 266–274.PubMed

Madley-Dowd, P., Hughes, R., Tilling, K., & Heron, J. (2019). The proportion of missing data should not be used to guide decisions on multiple imputation. Journal of Clinical Epidemiology,110, 63–73.PubMedPubMedCentral

Mazzucchelli, T. G., Kane, R. T., & Rees, C. S. (2010). Behavioral activation interventions for well-being: A meta-analysis. The Journal of Positive Psychology,5, 105–121.PubMedPubMedCentral

Medalia, A., Beck, A. T., & Grant, P. M. (2019). Cognitive therapies for psychosis: Advances and challenges. Schizophrenia Research,203, 1–2.PubMed

Moran, P., Leese, M., Lee, T., Walters, P., Thornicroft, G., & Mann, A. (2003). Standardised assessment of personality—Abbreviated scale (SAPAS): Preliminary validation of a brief screen for personality disorder. British Journal of Psychiatry,183, 228–232.PubMed

Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. M. (2002). The Work and Social Adjustment Scale: A simple measure of impairment in functioning. The British Journal of Psychiatry,180, 461–464.PubMed

Provencher, H. L., & Keyes, C. L. (2011). Complete mental health recovery: Bridging mental illness with positive mental health. Journal of Public Mental Health,10, 57–69.

Roskes, M., Elliot, A. J., & De Dreu, C. K. W. (2014). Why is avoidance motivation problematic, and what can be done about it? Current Directions in Psychological Science,23, 133–138.

Salvador-Carulla, L., Lucas, R., Ayuso-Mateos, J. L., & Miret, M. (2014). Use of the terms “wellbeing” and “quality of life” in health sciences: A conceptual framework. European Journal of Psychiatry,28, 50–65.

Slade, M. (2010). Mental illness and well-being: The central importance of positive psychology and recovery approaches. BMC Health Services Research,10, 26.PubMedPubMedCentral

Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine,166, 1092–1097.PubMed

Stangier, U., Hilling, C., Heidenreich, T., Risch, A. K., Barocka, A., Schlösser, R., et al. (2013). Maintenance cognitive-behavioural therapy and manualized psychoeducation in the treatment of recurrent depression: A multicenter prospective randomized controlled trial. American Journal of Psychiatry,170, 624–632.PubMed

Stewart-Brown, S. L., Platt, S., Tennant, A., Maheswaran, H., Parkinson, J., Weich, S., et al. (2011). The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): A valid and reliable tool for measuring mental well-being in diverse populations and projects. Journal of Epidemiology and Community Health,65(Supplement 2), A38–A39.

Stewart-Brown, S., Tennant, A., Tennant, R., Platt, S., Parkinson, J., & Weich, S. (2009). Internal construct validity of the Warwick-Edinburgh mental well-being scale (WEMWBS): A Rasch analysis using data from the Scottish health education population survey. Health and Quality of Life Outcomes,7, 15.PubMedPubMedCentral

Taylor, C. T., Lyubomirsky, S., & Stein, M. B. (2017). Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention. Depression and Anxiety,34, 267–280.PubMed

Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., et al. (2007). The Warwick-Edinburgh mental well-being scale (WEMWBS): Development and UK validation. Health and Quality of life Outcomes,5, 63.PubMedPubMedCentral

Trompetter, H. R., Lamers, S. M. A., Westerhof, G. J., Fledderus, M., & Bohlmeijer, E. T. (2017). Both positive mental health and psychopathology should be monitored in psychotherapy: Confirmation for the dual-factor model in acceptance and commitment therapy. Behaviour Research and Therapy,91, 58–63.PubMed

Tudor, K. (1996). Mental health promotion: Paradigms and practice. East Sussex: Routledge.

Van Ginkel, J. R., Linting, M., Rippe, R. C. A., & van der Voort, A. (2019). Rebutting existing misconceptions about multiple imputation as a method for handling missing data. Journal of Personality Assessment. https://doi.org/10.1080/00223891.2018.1530680.CrossRefPubMed

White, I. R., Royston, P., & Wood, A. M. (2010). Multiple imputation using chained equations: Issues and guidance for practice. Statistics in Medicine,30, 377–399.PubMed

Wood, A. M., & Joseph, S. (2010). The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders,122, 213–217.PubMed

World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. Geneva: World Health Organization.

Zimmerman, M., McGlinchey, J. B., Posternak, M. A., Friedman, M., Attiullah, N., & Boerescu, D. (2006). How should remission from depression be defined? The depressed patient’s perspective. American Journal of Psychiatry,163, 148–150.PubMed

Title: Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing
Authors: Emily Widnall
Alice Price
Hester Trompetter
Barnaby D. Dunn
Publication date: 01-02-2020
Publisher: Springer US
Keywords: Affective Disorder
Behavioural Therapy
Affective Disorder
Anxiety
Published in: Cognitive Therapy and Research / Issue 1/2020
Print ISSN: 0147-5916
Electronic ISSN: 1573-2819
DOI: https://doi.org/10.1007/s10608-019-10041-y

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Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

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