Psychiatric Annals

CME Article 

Intensively Delivered Cognitive-Behavioral Therapies: An Overview of a Promising Treatment Delivery Format for PTSD and Other Mental Health Disorders

Philip Held, PhD; Jenna M. Bagley, BS, BA; Brian J. Klassen, PhD; Mark H. Pollack, MD

Abstract

Although cognitive-behavioral therapy (CBT) is considered a treatment of choice for a variety of mental health conditions, many patients who could benefit either do not initiate treatment or they drop out early. Intensive models, in which CBT is delivered in multiple sessions per day over the course of 1 to 3 weeks, may be a promising model to address both underuse of CBT and premature dropout, but many questions remain about the clinical utility and feasibility of intensively delivered CBT. In this brief overview, we consider evidence that various models of intensively delivered CBT are associated with promising outcomes, low rates of patient drop out, and high rates of patient satisfaction. Directions for future research are also discussed [Psychiatr Ann. 2019;49(8):339–342.]

Abstract

Although cognitive-behavioral therapy (CBT) is considered a treatment of choice for a variety of mental health conditions, many patients who could benefit either do not initiate treatment or they drop out early. Intensive models, in which CBT is delivered in multiple sessions per day over the course of 1 to 3 weeks, may be a promising model to address both underuse of CBT and premature dropout, but many questions remain about the clinical utility and feasibility of intensively delivered CBT. In this brief overview, we consider evidence that various models of intensively delivered CBT are associated with promising outcomes, low rates of patient drop out, and high rates of patient satisfaction. Directions for future research are also discussed [Psychiatr Ann. 2019;49(8):339–342.]

Cognitive-behavioral therapies (CBTs) have substantial evidence supporting their effectiveness for a range of mental health problems. In their study that involved the review of 291 meta-analyses, Hofmann et al.1 concluded that CBTs are effective for reducing symptoms associated with anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. CBTs are often considered the gold standard and first-line option for the treatment of a variety of mental health disorders.2

Despite their well-documented effectiveness, a substantial minority of people who could potentially benefit from CBTs do not receive adequate amounts of the intervention. Meta-analytic research suggests that 15.9% of all people offered CBTs did not initiate treatment.3 Another significant issue affecting CBTs is premature discontinuation, with approximately every fourth patient (26.2%) who begins a CBT program dropping out of treatment prior to completing the protocol.3 Research suggests that treatment dropout tends to be higher in outpatient compared to residential settings.3 Common reasons for dropout are logistical barriers,4 such as competing demands (eg, work/family and provider scheduling availability), as well as pathology,4,5 such as avoidance, which can make it challenging for patients to regularly attend outpatient psychotherapy sessions. In outpatient settings, CBTs are commonly delivered once per week over the course of several weeks or months. As a result, patients may not clearly notice the effects of treatment until several weeks into traditionally delivered CBTs, which may reduce motivation to continue. Moreover, depending on scheduling availability, sessions are sometimes spaced out, which lengthens the overall duration of treatment and may contribute to the relatively high dropout rates that have been observed.

To overcome barriers commonly associated with traditionally delivered CBTs, increase the number of people who receive adequate doses of the intervention, and achieve rapid symptom reduction, CBTs are increasingly being delivered in intensive formats. Such formats may include the delivery of CBTs over condensed periods of time (such as 1–3 weeks) and often involve daily sessions. In some circumstances, CBTs are combined with adjunctive services to increase patient engagement and to address more complex clinical presentations. In this article, we discuss different intensive treatment structures, clinical outcomes, as well as feasibility and patient satisfaction with this condensed delivery format. We conclude with directions for future research. We primarily focus on intensive treatments for posttraumatic stress disorder (PTSD), as most of the current research on intensive CBTs is emerging in this field.

Formats

The boundaries of what constitutes “intensive treatment” are not currently well defined. For the purposes of this article, we consider intensive CBTs to be those that are delivered over the course of 4 weeks or less and involve multiple CBT sessions per week. The duration of most of the intensive CBTs published to date ranges from 1 to 3 weeks. For example, Hendricks et al.6 have condensed prolonged exposure (PE) for PTSD, which is commonly delivered over the course of 9 to 12 weekly sessions, into a single week with up to three 90-minute PE sessions per day. Similarly, Held et al.7 have detailed how cognitive processing therapy (CPT) can also be delivered over the course of a single week with two daily CPT sessions. In these models, patients are also assigned homework. These treatments can be delivered on an outpatient schedule, as they do not require patients to reside at or near the treatment facility. For example, the patient described by Held et al.7 lived within driving distance and commuted to treatment daily for the week. Both of these intensive treatments align closely with the established protocols of PE and CPT, respectively, and therefore make it relatively easy for clinicians to adopt. Several of the 1-week-long treatment models include booster sessions after treatment completion to ensure the maintenance of clinical gains achieved over the condensed treatment period.6,8,9 Unlike more comprehensive intensive programs described below, these week-long models did not involve adjunctive services during the active treatment phase.

Other programs deliver CBT over the course of 2 to 3 weeks.10 Unlike the 1-week-long models described above, many of these multiweek programs involve the combination of existing evidence-based CBTs with adjunctive services, such as psychoeducation, wellness, and other skill-building activities like relaxation training. In addition, evidence-based CBTs, such as PE and CPT, are frequently delivered in both individual and group formats in these programs.10 The combination of interventions is intended to address more complex clinical presentations, such as comorbid substance use disorder and depression. In these programs, treatment typically lasts the entire day, and patients are often housed at or near the treatment facility. The comprehensiveness of these programs and the requirement for housing increases the amount of resources required to implement these programs and may become a barrier to their adoption outside of specialty clinics built to deliver intensive treatments.

Outcomes

Despite their brevity, intensively delivered CBTs have yielded encouraging symptom reductions. Specifically, several studies have demonstrated that intensively delivered CBTs produce statistically significant and clinically meaningful reductions in symptoms, with many patients no longer meeting diagnostic criteria by the end of treatment. For example, Hendriks et al.6 reported that 71% of people who received 1-week PE for PTSD showed partial or complete posttreatment response. Moreover, 30.1% fell beneath the diagnostic threshold for PTSD, and 13.7% achieved posttreatment remission of PTSD. Similar remission rates have been reported for multiweek programs. According to Beidel et al.,11 participation in a 3-week-long exposure-based program with daily evidence-based and adjunctive services, called trauma management therapy, resulted in statistically significant decreases in PTSD and depression symptoms. A total of 65.9% of participants no longer met diagnostic criteria for PTSD by the end of treatment. In their 3-week CPT-based intensive treatment program, Zalta et al.12 reported large reductions in PTSD and depression symptoms from intake to posttreatment; effect sizes were comparable with those obtained in efficacy trials (d = 1.40 self-reported PTSD symptoms and 1.04 self-reported depression symptoms). These findings suggest that intensively delivered CBTs can result in large and clinically meaningful symptom reductions over relatively short periods of time, potentially surpassing results observed in settings where CBTs are delivered once per week. Additionally, the findings of Zalta et al.12 suggest that there may be a generalized treatment effect of intensively delivered CBTs across disorders that are commonly comorbid, such as PTSD and major depression. It is possible that intensively delivered CBTs target shared mechanisms of psychopathology, such as avoidance and maladaptive cognitions. This effect is not well understood, however, and merits further study.

Additionally, the published literature9,11 suggests that symptom reductions achieved during intensive treatments were either maintained long-term or continued to decrease after treatment. The published literature also suggests that relapse rates associated with intensive treatment are low. Effect sizes for 3- and 6-month follow-up assessments for intensive 1-week PE were large (d = 1.23–1.42 for clinician-rated PTSD measures).6 Similarly promising long-term results were reported for the 3-week trauma management therapy protocol. All treatment gains were maintained at 3- and 6-month follow-up assessment timepoints. Most notably, only 1% of participants relapsed.11 Held et al. (unpublished data, March 2019) evaluated long-term outcomes for a 3-week CPT-based intensive treatment program. Symptoms increased minimally from the completion of the program to the 3-month follow-up timepoint but then plateaued through the 6-month and 12-month follow-ups. The initial increase in symptoms after treatment completion may have been due to returning home from a relatively structured treatment environment. It is important to note that overall changes across all measured time points were large and clinically meaningful for both PTSD (d = 1.20) and depression symptoms (d = 1.25) (Held et al., unpublished data, March 2019).

Although the aforementioned discussion primarily focused on outcomes for intensive PTSD treatment, intensive CBTs have been applied to a range of other disorders, such as panic disorder,13 social anxiety disorder/social phobia,14,15 obsessive-compulsive disorder,16 and other comorbid disorders.17,18 Outcomes from these studies have been quite encouraging, as effect sizes have fallen into the medium to large range.

Feasibility and Satisfaction

In addition to significant reductions in mental health symptoms, intensive treatment programs appear to be able to retain a larger number of patients compared to CBT delivered on average once per week. Hendricks et al.6 reported a 0% dropout during the intensive phase of 1-week PE treatment and 5% during the 4-week-long booster phase. Retention rates are reported for multicomponent programs; the Warrior Care Network intensive treatment programs (Road Home Program, the Emory Healthcare Veterans Program, Home Base, and Operation Mend) combined have an overall completion rate of 95%.10 Similarly, merely 2% of participants dropped out of the 3-week trauma management therapy program.11 These treatment completion rates compare favorably to the almost 40% dropout observed when evidence-based CBTs for PTSD are delivered weekly.19 People who attend an intensive treatment program also report high satisfaction with the treatment programs.20 Taken together, the low dropout rates and high satisfaction ratings associated with these intensive treatments suggest that they are both feasible and tolerable treatment options.

Looking Toward the Future

As we detailed above, intensively delivered CBTs appear to offer great promise with regard to treatment completion and effectiveness. Despite these initial promising results, many challenges lie ahead before intensive treatment delivery can become fully integrated into routine clinical practice. Specifically, although the studies discussed above demonstrate that the intensively delivered treatments are effective, it has yet to be determined for whom the intensive models are most effective. In other words, what characteristics predispose a person to be likely to benefit from intensive treatments? Conversely, what characteristics suggest that a person may benefit from longer or more traditionally delivered (ie, weekly) CBTs? A potentially more important question is whether patients like intensively delivered CBTs and which patients may prefer such condensed treatments to the traditional delivery models. Answering these important clinical questions requires a venture into the direction of precision medicine, which requires much larger datasets. A more attainable first step to determine how intensively delivered interventions compare to traditionally delivered CBTs is to conduct rigorous head-to-head trials. As we highlighted above, only a small number of studies have taken this approach to date, making it currently impossible to draw robust conclusions about the comparative effectiveness of the two delivery formats (intensive vs traditional).

Although some of the existing research highlights short- and medium-term follow-up data, it has also yet to be determined what kind of follow-up care, if any, may be necessary to help patients maintain gains made during the intensive treatment. For some patients, a brief course of treatment may be sufficient, whereas other may need additional care after treatment completion. The type of follow-up care may differ; whereas some people may need an additional course of psychotherapy, others may benefit from a brief set of booster sessions or case management to ensure they are continuing to practice the cognitive-behavioral skills learned during treatment and are connected to any necessary resources. Additional research is needed to determine which type of follow-up care is most appropriate for each patient.

Future research should also evaluate the providers' experience of delivering intensive CBTs. For example, it needs to be determined whether providers can feasibly deliver intensive CBTs, what training they may need prior to delivering these treatments, and what ongoing supports they may require (eg, additional supervision, consultation). It will also be important to determine the impact of delivering intensive CBTs on clinicians' well-being and impairment, as well as job satisfaction. Once intensively delivered CBTs become more widely used, it will also be important to review reimbursement for this type of approach. Despite these unanswered questions, we have detailed emerging evidence that intensively delivered CBTs are a promising avenue for the treatment of a variety of mental health disorders, especially PTSD.

References

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Authors

Philip Held, PhD, is an Assistant Professor of Psychiatry. Jenna M. Bagley, BS, BA, is a Clinical Research Coordinator. Brian J. Klassen, PhD, is an Assistant Professor of Psychiatry. Mark H. Pollack, MD, is a Professor and the Chair. All authors are affiliated with Rush University Medical Center, Department of Psychiatry and Behavioral Sciences.

Address correspondence to Philip Held, PhD, Rush University Medical Center, Department of Psychiatry and Behavioral Sciences, 1645 West Jackson Boulevard, Suite 602, Chicago, IL 60612; email: Philip_Held@rush.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190711-01

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