Predictors and moderators of treatment outcome from high- and low-intensity cognitive behavioral therapy for anxiety disorders Association between patient and process factors, andthe outcome from guided self-help,stepped care, and face-to-face cognitive behavioral therapy Thomas Haug Dissertation for the degree philosiphiae doctor (PhD) at the University of Bergen 2014 © Copyright Thomas Haug The material in this publication is protected by copyright law. Print: AIT OSLO AS / University of Bergen ii Scientific environment The professional milieu involved in this thesis was the Anxiety Disorders Research Network, Haukeland University Hospital and The Bergen Group of Treatment Research,Department of Clinical Psychology, University of Bergen, Norway. This PhD projectis a part of theadult part of theresearch project “Assessment and Treatment-Anxiety in Children and Adults. Adult part”(ATACA)and has received support from the Western Norway Regional Health Authority, through project no. 911366 and project no. 911253 iii Table of contents ACKNOWLEDGEMENTS 1 LIST OF PAPERS 3 ABSTRACT 4 SAMMENDRAG(ABSTRACT IN NORWEGIAN) 7 ABBREVIATIONS 10 1. INTRODUCTION 13 1.1.ANXIETY DISORDERS 15 1.1.1.PANIC DISORDER 16 1.1.2.SOCIAL ANXIETY DISORDER 18 1.2.COGNITIVE BEHAVIORAL THERAPY (CBT) 19 1.2.1.CBT FOR PANIC DISORDER 21 1.2.2.CBT FOR SOCIAL ANXIETY DISORDER 22 1.3.LOW INTENSITY CBT 24 1.3.1.PSYCHOEDUCATION 25 1.3.2.SELF-HELP TREATMENT 26 1.3.2.1.SELF-HELP COMPARED WITH FACE-TO-FACE TREATMENT 27 1.4.ORGANIZATION OF SERVICES: STEPPED CARE TREATMENT 28 1.5.PREDICTORS AND MODERATORS OF TREATMENT OUTCOME 29 1.5.1.STRUCTURAL FACTORS AS PREDICTORS OF TREATMENT OUTCOME 30 1.5.1.1.SELF-HELP TREATMENT FORMAT 30 iv 1.5.1.2.THERAPIST CONTACT: GUIDED VERSUS NON-GUIDED SELF-HELP 31 1.5.1.3.CLINICAL VERSUS COMMUNITY SETTINGS 32 1.5.2.“WHAT WORKS FOR WHOM?” PATIENT CHARACTERISTICS AS PREDICTORS AND MODERATORS 32 1.5.2.1.DEMOGRAPHICS, SOCIAL FUNCTIONING AND SEVERITY 33 1.5.2.2.COMORBIDITY 34 1.5.2.3.PATIENT CHARACTERISTICS AS MODERATORS OF TREATMENT OUTCOME FROM SELF-HELP TREATMENT 36 1.5.3.FACTORS ASSOCIATED WITH THE THERAPY PROCESS 36 1.5.3.1.THE WORKING ALLIANCE 37 1.5.3.2.THERAPIST COMPETENCE 38 1.6.RESEARCH AIMS 39 2. METHODSAND RESULTS 40 2.1.THE RESEARCH PROJECT “ASSESSMENT AND TREATMENT-ANXIETY IN CHILDREN AND ADULTS” (ATACA) 40 2.1.1.PROCEDURE AND METHODS 41 2.1.1.1.RANDOMIZATION 41 2.1.1.2.ASSESSMENT 41 2.1.1.3.TREATMENT 42 2.1.1.4.TREATMENT INTEGRITY 43 2.1.1.5.OUTCOME ASSESSMENT 44 2.1.1.6.BASELINE PREDICTORS 44 2.1.1.7.WORKING ALLIANCE 45 2.1.1.8.THERAPIST COMPETENCE 45 v 2.1.2.STATISTICAL ANALYSES 45 2.1.3.SUMMARY OF THE OUTCOME FROM THE ATACA STUDY 46 FIGURE 1 CONSORT FOR THE ATACA STUDY 47 TABLE1DESCRIPTIVE STATISTICS FOR THE OUTCOME MEASURES 48 TABLE2 DESCRIPTIVE STATISTICS FOR THE PROCESS MEASURES 49 TABLE 3 DESCRIPTIVE STATISTICS FOR THE PREDICTOR VARIABLES 50 TABLE 4TIME-POINTS FOR ASSESSMENTS IN THE ATACA STUDY 51 2.2.PAPER I 52 2.2.1.RESEARCH AIMS 52 2.2.2.PROCEDURES AND METHODS 52 2.2.3.STATISTICAL ANALYSES 52 2.2.4.SUMMARY OF THE RESULTS 53 2.3.PAPER II 54 2.3.1.RESEARCH AIMS 54 2.3.2.PROCEDURE 54 2.3.2.1.OUTCOME ASSESSMENT 54 2.3.2.2.PREDICTORS AND MODERATORS 54 2.3.3.STATISTICAL ANALYSES 54 2.3.4.SUMMARY OF THE RESULTS 55 2.3.4.1.PREDICTORS 55 2.3.4.2.MODERATORS 55 2.3.4.3.ANALYSES INCLUDING ALL PREDICTORS 56 vi 2.4.PAPER III 56 2.4.1.RESEARCH AIMS 56 2.4.2.PROCEDURE AND METHODS 56 2.4.2.1.OUTCOME MEASURES 57 2.4.2.2.PREDICTORS 57 2.4.3.STATISTICAL ANALYSES 57 2.4.4.SUMMARY OF THE RESULTS 58 3. DISCUSSION 58 3.1.EFFECT OF SELF-HELP TREATMENT FOR ANXIETY DISORDERS 59 3.2.SELF-HELP COMPARED WITH FACE-TO-FACE TREATMENT 59 3.3.STRUCTURAL FACTORS ASSOCIATED WITH THE OUTCOME of SELF- HELP TREATMENT 61 3.4.PATIENT CHARACTERISTICS ASSOCIATED WITH THE OUTCOME 63 3.5.PROCESS FACTORS ASSOCIATED WITH THE OUTCOME 66 3.6.IMPLICATIONS FOR CLINICAL PRACTICE 70 3.7. STRENGTHS AND LIMITATIONS 72 4. REFERENCES 74 1 Acknowledgments Western Norway Regional Health Authorityand the Anxiety Disorder Research Network at Haukeland University Hospital funded this PhD project. I want to express my gratitude and appreciation to all the people who have contributed to the work with my PhD thesis in the last seven years. First and foremost I would like to thank my supervisor, Odd E. Havik for your guidance, support and supervision throughout these years. I am particularly grateful for your availability, welcoming attitude and broad perspectives, and I have experienced it as a privilege to have you as a supervisor. I would also like to thank my co-supervisor Lars-Göran Öst. Your feedback has always been swift and the point, and very helpful. I have also appreciated that you have given me the opportunity to present my work at international congresses through arranging and chairing numerous symposia at international congresses. I also thank the other members of the “Assessment and Treatment-Anxiety in Children and Adults” (ATACA) project group;Einar Heiervang, Gerd Kvale, Gerd Bjørkedal,Tone Tangen,Bente Storm Mowatt Haugland, Ole Johan Hovland, Kikki Øding, IngvarBjelland, Tine Nordgreen, Krister Westlye Fjermestad, Gro-Janne Henningsen Wergelandand Jon Bjåstad. Being able to take part in a large research clinical trial throughoutall its phases, and being surrounded with such competence and experience has given me valuable insight and experiences. I thank you all for interesting discussions and social events in Bergen and on conferences around the world. In particular, I would like to thank Tine for our cooperation and sharing of successes, failures, joys and frustrations for seven years. Also, a special thanks 2 to the two research coordinators, Stine Hauge and Kristine Fonnes Griffin, whose contributions to the logistics and operating of the ATACA project has been invaluable. I would also like to thank the staff at my clinical work place through my PhD period, the Årstad Outpatient mental health clinic. You are great colleagues and have been important to preserve my clinical perspective in these years. In particular, I thank the leaders who have been very flexible and accommodating in adapting to the occasionally unpredictable progress of the work with my thesis. I am very grateful to all the clinicians who have conducted all the assessment and treatment and all the patients who have participated in the ATACA project. Your contribution has been the cornerstone of the ATACA project and this PhD project. Most importantly, I thank my beloved partner Lina and our two children, Aslak and Eira for your love, patience, and support throughout these years. You are the source of my most joyful and meaningful experiences, and a constant reminder of the important things in life. Also, I thank my mum, dad and my siblings, Cathrine, Elisabeth andChristian, and their families. You are a great family which I always enjoy spending time with. As both my parents are health researchers, you have probably inspired me more than I have always given you credit for. Finally I will also thank all my friends, the 18+ film-club in particular. You have been the primary source of my non-domestic fun-experiences throughout my PhD period. I always enjoy spending time with you and share high-and low cultural events. Bergen June 24, 2014