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Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor of Psychology and Psychiatry Founder and Director Emeritus, Center for Anxiety & Related Disorders Boston University
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Page 1: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Psychological Interventions: Opportunities and Challenges

AheadAPA State Leadership ConferenceMarch 2014

David H. Barlow, PhD, ABPPProfessor of Psychology and PsychiatryFounder and Director Emeritus, Center for Anxiety & Related Disorders Boston University

Page 2: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

How Far Have We Come?

Page 3: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324.

Conclusion: Psychotherapy no more effective than passage of time.

Page 4: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Current Status

Page 5: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Nature: Editorial (September 2012)

Therapy deficit:Studies to enhance psychological

treatments are scandalously under-supported

“Psychological therapies have the potential to make a substantive difference to patients”

Page 6: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Evidence Based Practice: Definition

Integration ofBest research evidence withClinical expertise (advanced clinical skills to diagnose, assess, and treat disorders) andPatient values and preferences(including the patient fully in a risk/benefit analysis of the EBP, using quantitative presentations where possible)

Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B., 2000; Institute of Medicine., 2001

Page 7: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Specific Psychological Treatments (PT) vs. Medication or Alternative Treatments published in JAMA or NEJM

1. Stress Incontinence in the Elderly/Women: PT > Meds + Control at acute and follow-up(Burgio et al., 1998; Goode et al., 2003;

2. Insomnia: PT > Meds or Placebo at acute + follow-up(Morin et al., 1999;Sivertsen et al., 2006 )

3. Depression & Physical Health in Alzheimer’s PT > Routine medical care(Teri, et al., 2003)

5. Depression: PT = Meds with PT + Meds > than either aloneat follow up.(Keller et al., 2000)

6. Panic Disorder: PT = Meds at acute – both > placeboPT > Meds (or PT + Meds) at follow-up(Barlow et al., 2000)

7. PTSD: PT > present centered psychotherapy.(Schnurr, et., al., 2007)

8. Tourette Disorder:. PT > supportive therapy & educationEffect size = .68(Piacentini et al., 2010)

9. Adult ADHD PT > relaxation and educational support (Safren et al., 2010)

Page 8: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

New World Health Organization mhGAPRecommendations

Page 9: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Patient Preferences for Treatment: Meta Analysis of 33 Studies

Studies across diverse settings indicate that, on average, patients prefer psychological treatment to pharmacologic treatment for depression and anxiety at a rate of 3 to 1. Consideration of patient preference, along with treatment efficacy and clinical expertise, may be important to optimizing outcomes in clinical settings.

McHugh et al., 2013 Journal of Clinical Psychiatry

Page 10: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Reasons for Successful Treatment Development

Greater understanding of pathology, resulting in new, more precisely targeted treatmentsSubstantial improvement in clinical research methodologiesHealth care systems and governments promoting evidence based practice

Page 11: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Population-based Survey of Use of Anti-Depressants

1996 2005

Rate of use 5.84%(13 million)

10.12%(27 million)

Also receiving psychotherapy(1 visit or more)

31.5% 19.9%

Adapted from Olfson & Marcus, 2009

Page 12: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Antipsychotics being prescribed for anxiety disorders

Comer, Mojtabai, & Olfson, Am J Psychiatry 2011

Page 13: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Antipsychotics being prescribed for anxiety disorders

• From 1996-2007, antipsychotic prescriptions by psychiatrists for outpatient anxiety disorders increased from 10.6% to 21.3% of anxiety disorder visits

• Largest increase is among new outpatients; Psychiatrists appear increasingly comfortable prescribing antipsychotics for anxious patients before adjusting current meds or initiating trials of other med classes

• Among anxiety disorders, largest increase was observed for visits for panic disorder – no controlled trials have evaluated antipsychotics for the tx of panic disorder

Comer, Mojtabai, & Olfson, Am J Psychiatry 2011

Page 14: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

WHY THE DISCREPANCY

Medications readily available—heavily promotedPsychological interventions—not so much.

The problem of dissemination and implementation

Page 15: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

American Academy of Sleep Medicine (AASM)

AASM: CBT 1st line treatment for all types of insomniaIn 2008, 136 doctoral level sleep specialists certified by AASM—in 2014, 210But, 1600 AASM accredited sleep centers required to have behavioral services available

Page 16: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Staph infections in hospitals

Every year… 2 million acquire an infection 90,000 die in U.S. hospitals

Gawande, 2007; CDC

But, rates of handwashing 33-50%

Page 17: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Improving Handwashing Practices –The problem of implementation

Reasons for not washing handsInconvenientNot enough timeHigh alcohol content noxious building airIrritation to skin (aloe)Aloe stinks (remove aloe)Gel reduces fertilityImproved from 40-70% no drop in infections

Gawande, 2007

Page 18: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Two models for dissemination and implementation

Intensive community training model: (ICT) doctoral level specialists intensively trained to criteria Examples: IAPT, SAMHSA, DBT

Public health model: telehealth --remotely supervised health workers Examples: Roy-Byrne et al., 2010; Proudfoot

et al., 2004; Rollman et al., 2005

Page 19: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

THE NATIONAL HEALTH SERVICE IN THE UK

By 2015, the NHS will have spent more than €700m on psychological therapies, this investment in improving Access to Psychological Therapies (IAPT) will mean:

Over 600 more newly trained psychological therapists providing evidence –based treatment

(60% high intensity—40% PWP)

All GP practices having access to psychological therapies as the program rolls out

Page 20: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

DEPARTMENT OF VETERANS AFFAIRS AS A

LOCUS OF CHANGE

– Largest health care system in the United States

– Serves over 6 million veterans annually

– Serves over 1 million veterans with mental health concerns annually

Page 21: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

MHSP IMPLEMENTATION

$316 million spent in FY 2007 Over $380 million spent in FY 2008Over $510 million spent in FY 2009Over 2,000 new programs nation-wide to date Over 6,000 new mental health professionals and support staff hired since FY 2005, for a total mental health staff in the system of over 20,000

(Ruzek, Karlin, & Zeiss, 2012)

Page 22: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

VAH D+I Efforts

$20 million through 2010 on these efforts alone & 3,800 VAH staff trained:

Prolonged exposure + cognitive processing for PTSD

CBT+ ACT for Depression

Social skills training for SMI

(Ruzek et al., 2012)

Page 23: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Transferring Prolonged Exposure PTSD Treatment to Mental Health

Professionals: Making it Work

Afsoon Eftekhari, Ph.D., Josef I. Ruzek, Ph.D., Jill Crowley, Ph.D., Craig Rosen, Ph.D., Andrea Chambers, Ph.D., Gina Gregory,

National Center for PTSD, Dissemination and Training Division&

Bradley E. Karlin, Ph.D.Office of Mental Health Services, VACO

Please Note: These slides are not to be duplicated/reproduced without the author’s written

Page 24: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Numbers Trained

Total # Clinicians Trained through VA rollout 1125

Total # Clinicians Completed Consultation 680

Total # Currently in Consultation 281

Total # Dropped/Removed 164

Consultants 70

Trainers 16

Total # Clinicians Trained outside of but in coordination with the VA rollout 241

Page 25: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Change in PCL and BDI Scores From Session 1 to Final Session*

*Graphic displays outcomes for completed cases.*PCL Average drop of 20.5 points. BDI Average drop of 10.9 points.

62.00

28.12

41.50

17.19

0

10

20

30

40

50

60

70

PCL Scores BDI Scores

Session 1

t(599)=32.33, p<.001 t(585)=25.04, p<.001

Page 26: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

National Child Traumatic Stress Network Sites

LOS ANGELES

Category I - National Center for Child Traumatic Stress

MA

CT

NY

PA

NM

UT CO MO

OH

VA

Category II – Intervention Development and Evaluation Centers

Category III – Community Treatment and Service Centers

ME

FL

AL

CA

OR

WA

IL DC

Terrorism and Disaster Branch

NCDURHAMOK

MT

ID WIMI

SC

NJMD

TX

TN

GA

LA

MS

NYC

Page 27: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Procedures for Comprehensive Assessment and Training in Leading

Dissemination Programs

Needs and barrier assessmentTraining structureDidactic trainingCompetence trainingOutcomes collectedSustainability

Adapted from McHugh & Barlow, 2010

Page 28: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Training for 140 Community Practitioners Learning Treatments for Panic Disorder in

AdolescentsTraining Conditions

Text Only (Text) Interactive Online Training (OL)OL+Learning Community– weekly conference calls + Twitter (OL+LC)

Satisfaction: OL, OL+LC > TextProficiency: OL+LC > OL, Text

Ehrenreich-May, J. et al., submitted

Page 29: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Two models for dissemination and implementation

Intensive community training model: doctoral level specialists intensively trained to criteria(iapt,samhsa,dbt)

Public health model: telehealth -- remotely supervised health workers

e.g., CRASKE, ROY-BYRNE ET. AL., 2010

Page 30: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Results from the CALM trialRCT of Coordinated Anxiety Learning and Management (CALM) compared with usual care17 primary care settings in 4 U.S. cities1004 patients4 most common anxiety disorders (PD, GAD, SAD, PTSD)Web-based CBT (with or w/out meds – 9% chose meds alone) supervised by “Anxiety Clinical Specialists” mostly nurses and social workers

Roy-Byrne et al., 2010

Page 31: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Results from the CALM trial

Roy-Byrne et al., 2010

CALM Usual CareResponders 63.7% 44.7%Remitters 51.5% 33.3%

Page 32: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Cognitive-behavior therapy-based intervention by community health workers for mothers with depression and

their infants in rural Pakistan

Rahman et al., The Lancet 2008; 372:902-909 (DOI:10.1016/S0140-6736(08)61400-2)

Page 33: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Present Status

Effective treatment, but plentyof room for improvement

Too many distinct protocols–manuals

Protocols still relatively complex-restricting dissemination

Page 34: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

SOME CURRENT TRENDS

Transdiagnostic treatments with core psychological principles of change in primary care settings .Advances in telehealth based interventions.Emerging role for specialty psychological clinics.Direct to consumer advertising

Page 35: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Unified Protocol for Transdiagnostic Treatment of

Emotional Disorders

Directly targeting temperament; specifically : neuroticism---positive affect

Page 36: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Unified Protocol: A Modular ApproachModule 1: Motivation Enhancement for Treatment Engagement

(1 session)

Module 2: Psychoeducation and Treatment Rationale (1-2 sessions)

Module 3: Emotional Awareness Training (1-2 sessions)

Module 4: Cognitive Appraisal and Reappraisal (1-2 sessions)

Module 5: Emotion Driven Behaviors (EDBs) and Emotional Avoidance (1-2 sessions)

Module 6: Interoceptive Awareness and Tolerance (1-2 sessions)

Module 7: Situational Exposures (3-6 sessions)

Module 8: Relapse Prevention (1 session)Barlow et al., 2011

Page 37: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

NIMH Research Domain Criteria (RDoC)

Brain circuits: 5 broad mental domainsNegative emotionality– Stress and anxiety (CRF & HPA systems)– Fear (amygdala & connected regions)– Aggression (hypothalamus, amygdala,

neurohormones)

Page 38: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Multi-dimensional emotional disorders inventory (MEDI)

Page 39: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Effects on Neuroticism

Significant effect of time on N (F1,13=10.55, p<.001)Clinical significance of change in N:– Pre-treatment – 27% patients achieved

scores within normal range– Post-treatment – increased to 67% (as

compared to 56% in study 1)– 6-month follow-up – increased further to 82%

Ellard et al., 2012

Page 40: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Web Intervention for OEF/OIF Veterans with Problem Drinking

and PTSD Symptoms:A Randomized Clinical Trial

By: Deborah Brief, Amy Rubin, Terence M. Keane, Justin L. Enggasser, Monica Roy, Eric Helmuth, John

Hermos, Mark Lachowicz, Denis Rybin, & David Rosenbloom

In Press: JCCP

Page 41: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Advantages of WWWIncreased confidentiality.Easy to use within schedule.Low costs per capita involvement.Addresses public health nature of trauma.Military would utilize evidence based treatments for adaptation, coping, & recovery.

Page 42: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

DesignRCT with a wait-list control group

2:1 ratio to IIG or a DIG

Based on EBPs, so likely to be of benefit.

Anonymous web-based treatment.

Amazon.com gift codes for assessments.

Page 43: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

RECRUITMENT

Page 44: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

The Facebook CampaignConcerns about security led to Facebook

Facebook allowed us to track if people came from correct link and, combined with IP address, they were likely to be legitimate participants.

Cost = $30 per randomized participant.

Page 45: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Sample Facebook Ads• Seen by at

least 317,000 users likely to be returning veterans, over 43 recruiting days.

• $30 per subject ($1.27 per click, $17,964 total)

Page 46: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor
Page 47: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Drinking and Alcohol-Related Outcomes

* p < .001

* *

*

Page 48: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

PTSD Symptom Changes

33

35

37

39

41

43

45

Time 1 Time 2

PCL5 Total Scores *

IIG

DIG

* p < .001

Page 49: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Occasional case against broad dissemination and implementation to

generalist providers

We must be cautious against putting all of our eggs in the broad dissemination and implementation basket– What about complex EBPs?– What about EBPs for low base rate disorders?

Need for a Specialty Behavioral Telehealthworkforce, transacting with the generalist practitioner workforce

See Comer & Barlow, in press, American Psychologist

Page 50: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Telehealth

The use of electronic media to facilitate real-time interactions for the provision of care usually delivered in person

Page 51: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Internet-delivered treatmentMay expand the reach of expert mental health careExtend availability of expert servicesOvercome geographic barriers to care; Address regional workforce shortages in care

• Families dwelling in rural or impoverished regions can participate in real-time treatment conducted by experts, regardless of geographic proximity to a clinic

• May enhance ecological validity

• May overcome issues of stigma

Page 52: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor
Page 53: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Internet-delivered PCITInstead of:

We do:

Page 54: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Empirically examining direct-to-consumer advertising

• DTC marketing has been utilized for many years in the U.S.• Similar mechanisms are not in place to inform the public about

effective psychological treatments.• A recent randomized controlled study examined the preliminary

utility of direct-to-consumer (DTC) advertising of psychological treatments Participants who were randomized to a marketing campaign for psychological treatments demonstrated increases from baseline in newly considering and intending psychological treatments (as compared to participants randomized to a marketing campaign for drug interventions or to a control condition).

• (Gallo, Barlow, Clarke, Antony, and Comer, in preparation).

Page 55: Opportunities and Challenges Ahead · Psychological Interventions: Opportunities and Challenges Ahead APA State Leadership Conference March 2014 David H. Barlow, PhD, ABPP Professor

Thank you for your attention


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