Which therapies are among the most effective psychological interventions for a variety of psychological disorders?

Psychological Approaches

Psychological treatments cover a variety of approaches, from simple attempts to distract attention from tinnitus to improved coping and up to behavioral cognitive therapy. Behavioral cognitive therapy seems to be most effective in the class of psychological treatment and is based on the assumption that because thoughts evoke emotions, it is possible by changing thoughts to modify emotions evoked by tinnitus. There are well-established, effective methods to achieve this goal, and this method is effective in a significant proportion of patients. According to the neurophysiological model of tinnitus, behavioral cognitive therapy nullifies the high loop and therefore decreases stimulation of the limbic and autonomic nervous systems.

Psychological therapy

Psychological treatments are less likely than drugs to cause interaction with medical treatments. However, some medical patients (and their physicians) may be reluctant to accept an explicitly ‘psychological’ treatment. Time devoted to explaining the nature and relevance of this form of treatment as a means to help the patient to cope with the medical problem is well spent. Simple psychological interventions such as information-giving may be of value, for example for patients with alcohol problems (Chick 1991), and could be profitably extended to other conditions. Cognitive–behavioural therapy (CBT) has a proven role in the management of both comorbid depressive and anxiety disorder and also in a wide range of somatoform disorders (Guthrie 1996, Jackson et al 2006).

Concurrent Psychological Treatment

Psychological treatment either alone5379 or combined with tapered withdrawal8081828384 may facilitate medication reduction. In clinical practice settings, Morgan and colleagues79 found that higher anxiety and a less positive attitude toward symptom control predicted a poor response to psychological treatment for HDI. Morin and colleagues74 provide an overview of studies examining the efficacy of behavioral interventions in the management of hypnotic discontinuation. The following randomized clinical trials have been performed.

Morin and colleagues85 recently compared tapered withdrawal, CBT for insomnia, and combined medication withdrawal and CBT in 76 older adults. All three interventions significantly reduced sleep medication usage. However, 85% of participants receiving the combined treatment were medication free at the end of treatment, compared with 48% for tapered withdrawal and 54% for CBT alone. Sleep diary data revealed greater sleep improvements for CBT (alone and combined) than for tapered withdrawal only.

Our laboratory achieved 80% hypnotic medication reduction, modest sleep gains, and minor side effects when testing the results of relaxation81 and stimulus control.84 Preliminary data are available on 35 hypnotic-dependent older adults involved in a placebo-controlled clinical trial comparing combined gradual hypnotic withdrawal and psychological treatment (relaxation, stimulus control, and sleep hygiene) to hypnotic withdrawal only and placebo treatment.80 Despite similar reductions in medication for the three groups (average 84% reduction), self-reported sleep improved only for the combined condition. Polysomnography results revealed no sleep deterioration associated with withdrawal.

General Psychological Treatment

Psychological treatment typically includes education, reassurance, teaching of anxiety reduction techniques, and cognitive-behavioral therapy to target and modify cognitive biases and misattribution. Psychotherapy can also be useful in identifying psychosocial factors contributing to symptom presentation and the teaching of specific coping skills for dealing with psychosocial pressure.38 Early after mTBI, psychological treatment may help protect against developing PCS. One meta-analysis determined that patients who receive brief psychological treatment after mTBI have a significantly reduced incidence of persisting PCS compared to patients who receive standard acute care alone.24 Efficacy data are lacking once PCS is established (i.e., if symptoms persist for >3 months), but physicians often include psychologist referral in their treatment plan.24 In these authors' opinion, referral to a neuropsychologist or psychologist with expertise in PCS is indicated when there is failure to respond to initial treatments, worsening stress, deterioration in function, or significant impairment in vocational or social function. More information on psychological treatment after mTBI can be found in Chapter 5.

Treatment

Psychological treatments have been found to improve outcome in the short term, although they are not superior to spontaneous remission in the long term (Cooper et al 2003).

Full psychiatric history, with particular reference to DSH or harm to baby

Counselling/psychotherapy/cognitive behaviour therapy

Antidepressants can be given even if breast-feeding (see below). Lithium should be avoided when breast-feeding

Admit (preferably to specialist mother and baby unit), if illness is severe and there is risk of DSH or harm to the baby.

Abstract

Psychological treatment of neuropathic pain is emerging as an important component of interdisciplinary approaches to the management of this complex problem. Following a brief consideration of the biospsychosocial model of pain and relevant psychological theories, the chapter reviews common standardized assessment approaches that can be employed to design effective treatment plans for neuropathic pain and to evaluate their effectiveness. This is followed by consideration of a range of psychological and behavioral treatment approaches. This review focuses on self-regulatory approaches such as relaxation, biofeedback, and hypnosis and cognitive and behavioral approaches, including cognitive behavioral therapy, acceptance and commitment therapy, and exercise. These therapeutic approaches are described, as is the empirical evidence supporting their efficacy for the management of neuropathic pain. The chapter concludes with discussion of additional roles of psychologists in the management of neuropathy and neuropathic pain especially related to management of mental health comorbidities and health-risk behaviors.

Psychological Treatments

Psychological treatment strategies have used cognitive, behavioral, and motivational approaches in the treatment of individuals with PG. Behavioral strategies include isolating gambling triggers and developing non-gambling sources to compete with reinforcers associated with gambling.6 Cognitive strategies include increased awareness techniques and cognitive restructuring.6 One study147 suggested that cognitive treatment (corrective cognition) can significantly decrease PG, with 88% of treated participants having greater perception of control over their gambling problem. This study emphasized that gambling outcomes are based on random events that cannot be controlled, and that correcting these erroneous perceptions by gamblers can constitute an important component of treatment. Earlier findings148 suggested that when a gambler's erroneous perceptions and understanding of randomness were corrected, the motivation to gamble significantly decreased. In another study, 29 men with PG were randomly assigned to treatment or to a wait-list control group where treatment consisted of cognitive correction of erroneous perceptions about gambling, problem solving and social skills training, and relapse prevention. There were significant gains realized on all outcome measures from 6- to 12-month analyses.149 In the latter two studies, treatment discontinuation was high, only data on those participants completing the study was reported, and despite manualized treatment sessions, no rigorous analysis of therapist competence was undertaken.6

In evaluating the efficacy of psychotherapy, researchers randomly assigned 231 individuals with PG to a workbook-based cognitive–behavioral (CB) treatment, 8-invidualized CB sessions, or a referral to Gamblers Anonymous (GA) alone (all three conditions included a referral to GA). During the treatment period, CB treatment reduced gambling relative to GA referral alone, with clinically significant improvement, and partial maintenance. Other researchers have assigned problem gamblers to cognitive–behavioral therapy (CBT) plus motivational enhancement (telephone interview), CBT workbook alone, or wait-list conditions. At 6 months, rates of abstinence did not differ between groups, although the frequency of gambling, money lost gambling, and South Oaks Gambling Screen scores were lower in the motivational interview group.150,6 A significant reduction in gambling was observed in 84% of study participants (n = 102) over a 12-month follow-up period. At 2-year follow-up, an advantage was observed for participants (n = 67) who received a motivational telephone intervention plus a self-help workbook compared with participants who received only the workbook.151

Imaginal desensitization (ID) has been compared to treatment with other behavioral procedures. In this technique, participants are taught relaxation methods and instructed to imagine experiencing and resisting gambling triggers. In an initial study, 20 compulsive gamblers who were followed for 1 year were randomly allocated, half to receive aversion-relief therapy and half to receive ID. Compared with those who received aversion-relief, gamblers receiving ID reported a significantly greater reduction in gambling urges and behaviors, and showed significant reductions in trait and state anxiety.152,6 In a subsequent larger study of PG (n = 120, 60 patients per group, procedures administered over 1 week),153 26/33 who received ID reported control or cessation of gambling compared with 16/30 who received other behavioral procedures, a difference that reached statistical significance.

7.11.7.1 Psychotherapeutic Interventions

Psychological treatment approaches for older adults include behavioral, brief psychodynamic, cognitive-behavioral, interpersonal, problem-solving, reminiscence, humanistic approaches or exercise (Edelstein et al., 2015). Psychotherapeutic interventions tend to be the recommended first line of treatment for older adults with mild depression. Some patient factors, such as activity limitation, cognitive functioning, as well as ability to attend and adhere to treatment and access services, may determine feasibility and benefits of the therapeutic approach (Scogin et al., 2014; Power et al., 2017).

Cognitive-behavioral therapy (CBT) involves restructuring distorted and dysfunctional thoughts and modifying maladaptive behaviors in order to improve mood and increase social engagement (Scogin et al., 2014; Power et al., 2017). CBT has considerable evidence of efficacy when provided in both individual and group formats and in various settings (e.g., community dwelling, caregivers, primary care; Shah et al., 2012).

Problem-solving therapy (PST) encourages individuals with depression to approach (vs. avoid) problems and provides skills to (1) define problems and generate goals; (2) identify alternatives to alleviate negative effects of the problem; (3) utilize decision-making to choose a solution to the problem; and (4) evaluate the outcomes of their solution (DiNapoli and Scogin, 2014; Power et al., 2017). This treatment is especially well-suited for older adults with executive dysfunction given its structured nature. It has demonstrated efficacy in older adults with major depressive disorder and subsyndromal depression when compared to treatment as usual, supportive therapy, and waitlist control conditions (Edelstein et al., 2015). It is also effective in various settings such as primary care and home-based care (Edelstein et al., 2015).

Behavior therapy involves increasing frequency of engagement in pleasant activities, decreasing frequency of engagement in activities that maintain depressive moods, and problem-solving around barriers to engaging in pleasant events. Behavioral activation is the most common form of behavior therapy, whereby clients pursue goal-directed activities that are pleasurable in order to improve mood and increase activity level via positive reinforcement (Scogin et al., 2014). Behavior therapy has demonstrated efficacy in older adults with major depressive disorder and minor depression when compared to treatment as usual, wait-list control, and no treatment controls (Edelstein et al., 2015). It has also been evaluated in a variety of settings and older adult samples (e.g., inpatient, outpatient, and nursing homes; Edelstein et al., 2015).

Cognitive bibliotherapy is best described as cognitive-behavioral therapy in an independent, manualized format. In this treatment, patients engage in structured reading and writing formats for several weeks. It is recommended for older adults with mild to moderate depression who are able to self-motivate engagement in treatment. This may be most helpful for older adults with limited access to other forms of treatment, whether due to stigma or living in more rural areas (Edelstein et al., 2015). Cognitive bibliotherapy has demonstrated efficacy for older adults with major depressive disorder, minor/subsyndromal depression, and mild to moderate depressive symptoms (Edelstein et al., 2015).

Brief psychodynamic, interpersonal, and life review therapies have also received support for use with older adults (Scogin et al., 2005; Shah et al., 2012).

Interpersonal therapy (IPT) has a manual adapted for use with older adults (Scogin et al., 2014; Power et al., 2017). It is a time-limited treatment with demonstrated efficacy in young adults and has mounting evidence of efficacy in older adults (e.g., Edelstein et al., 2015).

Life review therapy, which employs Erik Erikson's eighth stage of the life cycle (i.e., ego integrity), is a treatment unique to older adults (Cuijpers et al., 2014). It is recommended by APA as an initial treatment for major depressive disorder and is one of the only interventions with adequate efficacy evidence according to APA's treatment guidelines (2019). There is also a conditional recommendation for its application in a group format but insufficient evidence for individual format for older adults with subclinical depression.

Brief psychodynamic therapy (Scogin et al., 2005) has some support for use with older adults. This treatment focuses on interpersonal relationships and unconscious processes to treat depressed mood in approximately 20 sessions. The goals of treatment can be single or two-fold: (1) symptom reduction; and (2) personality change by decreasing vulnerability and increasing long-term resilience.

Reminiscence therapy is another treatment unique to older adults with demonstrated efficacy in older adults with clinically significant depressive symptoms (DiNapoli and Scogin, 2014; Power et al., 2017). This treatment calls for clients to reflect on significant aspects of positive and negative events in their life. Through this process, clients are thought to gain self-confidence, socialization, conflict-resolution, and enhanced perspective on both the successes and failures of their lives (DiNapoli and Scogin, 2014; Power et al., 2017).

Support groups and psychoeducational interventions for depression in family care-partners of people with dementia are also of particular importance when discussing treatment approaches for depression in older adults. Family care-partners of persons with dementia tend to be spouses or adult children who are either middle aged adults or older adults (Gilhooly et al., 2016). Psychoeducational interventions, whereby caregivers are taught strategies to manage the psychological stress of caring for their loved one, in addition to behavioral techniques to address behaviors exhibited by their loved one that are challenging, have demonstrated efficacy (Gilhooly et al., 2016). Similarly, support groups may provide social-emotional support, which is also crucial in coping with caring for a family member with dementia (Gilhooly et al., 2016).

Finally, exercise interventions have demonstrated efficacy for older adults with major depressive disorder, minor depression, and dysthymia when compared with controls (Edelstein et al., 2015). These interventions appear to be just as efficacious as antidepressant medication. However, some studies examining efficacy have mixed findings. Thus, further research is warranted.

Treatment

Combination psychological and pharmacological treatment is most effective for long-term benefit for patients with GAD. Psychological therapy, particularly relaxation, cognitive and cognitive-behavioural therapy has shown long-term benefits. Antidepressants, such as paroxetine and venlafaxine are effective as anxiolytics and also have benefits in targeting the often co-morbid depression. Buspirone and benzodiazepines have anxiolytic properties and are effective in the short term; however, both lack antidepressant effects (Gorman 2002). Benzodiazepines prescribed for more than 4 weeks can cause rebound anxiety and may lead to withdrawal symptoms (Rynn & Brawman-Mintzer 2004).

Referral to a Mental Health Provider

Referral for psychological treatment is often very helpful but may be difficult to arrange in many communities. It can be useful to talk with physician colleagues about their relationships with mental health care providers to identify recommended clinical psychologists, psychiatrists, social workers, or counselors. Many mental health professionals do not have adequate training in pain management or in a biopsychosocial model of care. For identification of appropriate mental health providers, it is useful to inquire about their experience with children and adolescents, with treatment of children with medical problems, and in use of cognitive-behavioral therapy. The best referral options will have affirmative responses to each of these areas of inquiry.

There have been numerous studies that focus on treatment of recurrent and chronic pain, especially abdominal pain and headaches, with psychological interventions. About a dozen controlled trials of psychological therapy for children and adolescents with chronic pain were recently reviewed (Eccleston et al, 2002). These authors concluded that there is strong evidence that psychological therapies, principally relaxation and cognitive-behavioral therapy, are effective in reducing the severity and frequency of chronic pain in children and adolescents. The cognitive-behavioral therapy interventions primarily involved brief, standardized treatments in which children were taught specific coping skills (e.g., positive self-statements, relaxation).

For example, in a recent study, cognitive-behavioral family intervention was compared with standard pediatric care for recurrent abdominal pain (Robins et al, 2005). Children in the cognitive-behavioral family intervention group received five 40-minute sessions and were trained in relaxation skills and positive self-talk, and parents were taught to limit secondary gains from sick behavior. The standard medical care group received customary medical treatment consisting of follow-up office visits, education, support, and medications as deemed appropriate by the treating physician. Children who received the cognitive-behavioral intervention reported significantly less pain after treatment and at 1-year follow-up compared with children receiving standard care, providing support for the use of cognitive-behavioral family interventions in children with abdominal pain (Robins et al, 2005).