Cognitive Behaviour Therapy: The Evidence by David M. Clark
作者: David Clark / 5847次阅读 时间: 2010年9月29日
标签: Clark David therapy Therapy Behaviour Evidence
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Cognitive Behaviour Therapy
The Evidence 
David M. Clark 
Institute of Psychiatry 
Kings College London 
Cognitive Behaviour Therapy: 
The Evidence 
David M. Clark 
Institute of Psychiatry 
Kings College London 
What is CBT? 
. Brief (8-16 sessions) 
. Focuses on problematic beliefs and behaviours 
that maintain disorders (rather than original 
causes). 
. Strong foundation in academic psychology 
. Patient is very active 
What is CBT? 
. Brief (8-16 sessions) 
. Focuses on problematic beliefs and behaviours 
that maintain disorders (rather than original 
causes). 
. Strong foundation in academic psychology 
. Patient is very active 
Does it work? 
Gold Standard Evidence is the randomized controlled 
trial. 
CBT needs to be superior to: 
. no treatment (wait list control) 
. an equally credible alternative psychological 
treatment ( to control for non-specific factors) 
and at least as effective as medication in the short-term. 
Does it work? 
Gold Standard Evidence is the randomized controlled 
trial. 
CBT needs to be superior to: 
. no treatment (wait list control) 
. an equally credible alternative psychological 
treatment ( to control for non-specific factors) 
and at least as effective as medication in the short-term. 
Common Disorders where CBT is 
effective1 as a sole treatment 
recovery rate2 in RCTs 
Major depressive disorder 60% 
Panic disorder 75% 
Posttraumatic stress disorder 75% 
Social Phobia 60% 
Generalised anxiety disorder 50% 
Obsessive compulsive disorder 55% 
Bulimia Nervosa 50% 
1 Effective is defined as meeting the criteria specified on the previous slide. 
2 Most patients show some improvement with CBT. Recovery rate is the approximate proportion of individuals 
who no longer have the disorder at the end of a course of CBT. 
Common Disorders where CBT is 
effective1 as a sole treatment 
recovery rate2 in RCTs 
Major depressive disorder 60% 
Panic disorder 75% 
Posttraumatic stress disorder 75% 
Social Phobia 60% 
Generalised anxiety disorder 50% 
Obsessive compulsive disorder 55% 
Bulimia Nervosa 50% 
1 Effective is defined as meeting the criteria specified on the previous slide. 
2 Most patients show some improvement with CBT. Recovery rate is the approximate proportion of individuals 
who no longer have the disorder at the end of a course of CBT. 
Disorders where CBT enhances 
the effects of medication 
. Schizophrenia 
. Bipolar disorder (manic-depression) 
Disorders where CBT enhances 
the effects of medication 
. Schizophrenia 
. Bipolar disorder (manic-depression) 
Long-term outcome of CBT 
. On average, the gains obtained in CBT are 
well-maintained at follow-ups of several 
years. 
. Recent studies have also shown that CBT 
can reduce relapse in depressed patients 
who were initially treated with medication. 
Long-term outcome of CBT 
. On average, the gains obtained in CBT are 
well-maintained at follow-ups of several 
years. 
. Recent studies have also shown that CBT 
can reduce relapse in depressed patients 
who were initially treated with medication. 
Social Phobia: 5 year Follow-Up 
(Heimberg et al., 1993) 
Pre Post 6m FU 5 yr FU 
Phobic SeveritySupport 
CBT 
Social Phobia: 5 year Follow-Up 
(Heimberg et al., 1993) 
Pre Post 6m FU 5 yr FU 
Phobic SeveritySupport 
CBT 
CBT prevents relapse in recurrent 
depression (Fava et al., 2004) 
CBT prevents relapse in recurrent 
depression (Fava et al., 2004) 
Cost of not treating 
Less than 10% of suitable patients currently receive CBT 
Greenberg et al., (1999) 
Untreated anxiety disorders are very costly 
. Excess non-psychiatric medical treatment 
. Workplace costs due to loss of productivity, sick leave 
and unemployment. 
Salvador-Carulla et al. (1995) 
In the first year alone, successful treatment of one 
anxiety disorder was associated with: 
. 94% decrease in excess non-psychiatric medical 
treatment costs. 
. 80% decrease in workplace costs. 
Cost of not treating 
Less than 10% of suitable patients currently receive CBT 
Greenberg et al., (1999) 
Untreated anxiety disorders are very costly 
. Excess non-psychiatric medical treatment 
. Workplace costs due to loss of productivity, sick leave 
and unemployment. 
Salvador-Carulla et al. (1995) 
In the first year alone, successful treatment of one 
anxiety disorder was associated with: 
. 94% decrease in excess non-psychiatric medical 
treatment costs. 
. 80% decrease in workplace costs. 
Can the results of RCTs be achieved 
in more routine NHS settings? 
Omagh Bomb Example (Gillespie et al, 2002) 
. No local expertise in PTSD treatment at the time 
. Clark team provided specialist training 
. Therapists: psychiatrist, social worker, nurses. 
. All patients with PTSD accepted. No exclusions. 
. Outcome audited 
. Improvement equivalent to that obtained in 
RCTs from specialist centres. 
Can the results of RCTs be achieved 
in more routine NHS settings? 
Omagh Bomb Example (Gillespie et al, 2002) 
. No local expertise in PTSD treatment at the time 
. Clark team provided specialist training 
. Therapists: psychiatrist, social worker, nurses. 
. All patients with PTSD accepted. No exclusions. 
. Outcome audited 
. Improvement equivalent to that obtained in 
RCTs from specialist centres. 
Conclusions 
. CBT works 
. It’s effects are enduring (& can prevent future disorder) 
. Most patients in the NHS don’t get CBT 
. With additional trained therapists, successful 
dissemination is possible 
. Therapist attrition is very low ( approx 1% pa for 
clinical psychologists1) 
. Likely Cost benefits (indirect medical and workplace) 
1 Lavender et al. Survey of 1993 graduates from South-East Thames Course. 
Conclusions 
. CBT works 
. It’s effects are enduring (& can prevent future disorder) 
. Most patients in the NHS don’t get CBT 
. With additional trained therapists, successful 
dissemination is possible 
. Therapist attrition is very low ( approx 1% pa for 
clinical psychologists1) 
. Likely Cost benefits (indirect medical and workplace) 
1 Lavender et al. Survey of 1993 graduates from South-East Thames Course. 
Illustrative References (1) 
Nice Guidelines (www.nice.org.uk) 
. CG22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia, 
and generalised anxiety disorder) in adults in primary, secondary and community care – 
Full guideline. 22 December 2004. (www.nice.org.uk/page.aspx?o=cg022) 
. CG22 Depression: management of depression in primary and secondary care – Full 
Guidance and Appendices. 15 December 2004. (www.nice.org.uk/page.aspx?o=cg023) 
. CG01 Schizophrenia: core interventions in the treatment and management of 
schizophrenia in primary and secondary care – Nice Guideline. 
(www.nice.org.uk/page.aspx?o=cg1) 
Illustrative References (1) 
Nice Guidelines (www.nice.org.uk) 
. CG22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia, 
and generalised anxiety disorder) in adults in primary, secondary and community care – 
Full guideline. 22 December 2004. (www.nice.org.uk/page.aspx?o=cg022) 
. CG22 Depression: management of depression in primary and secondary care – Full 
Guidance and Appendices. 15 December 2004. (www.nice.org.uk/page.aspx?o=cg023) 
. CG01 Schizophrenia: core interventions in the treatment and management of 
schizophrenia in primary and secondary care – Nice Guideline. 
(www.nice.org.uk/page.aspx?o=cg1) 
Illustrative References (2) 
Some reviews, meta-analyses and individual randomized controlled trials 
Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin and 
Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley. 
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive 
therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72. 
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy 
versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting & 
Clinical Psychology, 71(6), 1058-1067. 
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A 
comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British 
Journal of Psychiatry, 164, 759-769. 
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological 
treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225. 
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized 
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for 
posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032. 
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(10), 1872-1876. 
Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled 
study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. 
Archives of General Psychiatry, 60(2), 145-152. 
Illustrative References (2) 
Some reviews, meta-analyses and individual randomized controlled trials 
Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive behavioral therapies. In M. J. Lambert (Ed.), Bergin and 
Garfield's Handbook of Psychotherapy and Behavior Change (pp. 447-492). New York: Wiley. 
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive 
therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72. 
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy 
versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting & 
Clinical Psychology, 71(6), 1058-1067. 
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A 
comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British 
Journal of Psychiatry, 164, 759-769. 
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological 
treatments for hypochondriasis: A randomised controlled trial. British Journal of Psychiatry, 173, 218-225. 
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., et al. (2003). A randomized 
controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for 
posttraumatic stress disorder.[see comment]. Archives of General Psychiatry, 60(10), 1024-1032. 
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(10), 1872-1876. 
Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled 
study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. 
Archives of General Psychiatry, 60(2), 145-152. 
Illustrative References (3) 
Costs and Cost-Effectiveness 
Issakidis, C., Sanderson, K., Corry, J., Andrews, G., & Lapsley, H. (2004). Modelling the population 
cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders. 
Psychological Medicine, 34(1), 19-35. 
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T., et al. 
(1999). The economic burden of anxiety disorders in the 1990s. 60(7), 427-435. 
Lam, D. H., McCrone, P., Wright, K., & Kerr, N. (2005). Cost-effectiveness of 30 month study of 
relapse prevention cognitive therapy for bipolar disorder. British Journal of Psychiatry, in press. 
Salvador-Carulla, L., Segui, J., Fernandez-Cano, P., & Canet, J. (1995). Costs and offset effect in panic 
disorders. British Journal of Psychiatry Supplement(27), 23-28. 
Dissemination of evidence based treatment 
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in 
the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research 
and Therapy, 40, 345-357. 
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for 
panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and 
Clinical Psychology, 66, 231-239. 
Illustrative References (3) 
Costs and Cost-Effectiveness 
Issakidis, C., Sanderson, K., Corry, J., Andrews, G., & Lapsley, H. (2004). Modelling the population 
cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders. 
Psychological Medicine, 34(1), 19-35. 
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T., et al. 
(1999). The economic burden of anxiety disorders in the 1990s. 60(7), 427-435. 
Lam, D. H., McCrone, P., Wright, K., & Kerr, N. (2005). Cost-effectiveness of 30 month study of 
relapse prevention cognitive therapy for bipolar disorder. British Journal of Psychiatry, in press. 
Salvador-Carulla, L., Segui, J., Fernandez-Cano, P., & Canet, J. (1995). Costs and offset effect in panic 
disorders. British Journal of Psychiatry Supplement(27), 23-28. 
Dissemination of evidence based treatment 
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in 
the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research 
and Therapy, 40, 345-357. 
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for 
panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and 
Clinical Psychology, 66, 231-239. 

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