The efficacy of 90-min versus 60-min sessions of prolonged exposure for PTSD: A randomized controlled trial in active-duty military personnel.

OBJECTIVE: Prolonged exposure (PE) therapy is a first-line posttraumatic stress disorder (PTSD) treatment, but the manualized 90-min session format constitutes a barrier to adopting PE in most settings because they use 60-min sessions for scheduling and billing. We examined whether 60-min PE sessions were as effective and efficient as 90-min PE sessions. METHOD: In total, 160 active-duty military personnel with PTSD were randomized to 8-15 sessions of 60- or 90-min PE sessions and assessed pre- and posttreatment, and 3- and 6-month posttreatment, using the Clinician Administered PTSD Scale for Diagnostic and Statistical Manual for Mental Disorders, 5th edition [DSM-5] (CAPS-5). Participants were also assessed weekly during treatment using the PTSD Checklist for DSM-5 (PCL-5). A 60-min PE was hypothesized to be noninferior to 90-min PE based on preliminary studies. RESULTS: Using intent-to-treat analyses, the 95% CI for the difference between 60- and 90-min PE was less than the noninferiority margin (4.69 for the CAPS-5 and 7.38 for the PCL-5) at all three endpoints, suggesting that the efficacy of 60-min PE was noninferior to that of 90-min PE. Similarly, the rate of improvement per session for 60-min PE was noninferior to the rate for 90-min sessions for the PCL-5. Sensitivity analyses and Bayes factors were consistent with these results. CONCLUSIONS: 60-min sessions of PE are noninferior to 90-min sessions with regard to both efficacy and efficiency. Thus, PE can be effectively delivered in shorter sessions, making it easier for behavioral health providers to implement within the military health system and in other mental health systems that use 60-min session appointments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: a randomized implementation trial.

BACKGROUND: Prolonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to determine the incremental utility of post-workshop consultation. METHODS: This study used a hybrid type III randomized implementation trial at 3 US Army installations. Providers were randomized to receive a 4-day prolonged exposure workshop (Standard training condition, n = 60), or the prolonged exposure workshop followed by 6-8 months of post-workshop expert case consultation (Extended training condition, n = 43). The effects training condition were examined on provider attitudes (self-efficacy in delivering PE, expectations for patient improvement, and beliefs about PE), use of PE and PE components, and clinical outcomes of patients with PTSD (using the Clinician-Administered PTSD Scale (CAPS-5)). RESULTS: Extended condition providers reported greater improvements in self-efficacy, b = .83, 95% CI [.38, 1.27], t(79) = 3.71, p = .001, and d = .63. A greater proportion of patients in the Extended condition (44%) than in the Standard condition (27%) received at least 1 PE session, b = .76, t(233) = 2.53, p = .012, and OR = 2.13. Extended condition providers used more PE components (M = .9/session) than did Standard condition providers (M = .5/session), b = .54, 95% CI [.15, .93], t(68) = 2.70, p = .007, and d = .68. Finally, decrease in patients' PTSD symptoms was faster for patients of Extended condition providers than for patients of Standard condition providers, b = - 1.81, 95% CI [- 3.57, - .04], t(263) = - 2.02, p = .045, and d = .66, and their symptoms were lower at the second assessment, b = - 5.47, 95% CI [- 9.30, - 1.63], t(210) = - 2.81, p = .005, and d = .66. CONCLUSIONS: Post-workshop consultation improved self-efficacy for delivering PE, greater use of PE, faster PTSD reduction, and lower PTSD severity at the second assessment. To our knowledge, this is the first demonstration that post-workshop case consultation for PE improves patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov , NCT02982538 . Registered December 5, 2016; retrospectively registered.

Sleep problems in active duty military personnel seeking treatment for posttraumatic stress disorder: presence, change, and impact on outcomes.

STUDY OBJECTIVES: To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes. METHODS: Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed. RESULTS: At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments. CONCLUSIONS: Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients. CLINICAL TRIAL REGISTRATION: NCT01049516.

Mediating role of experiential avoidance in the relationship between anxiety sensitivity and eating disorder psychopathology: A clinical replication.

OBJECTIVE: This study sought to examine whether anxiety sensitivity was associated with eating disorder (ED) symptom severity among patients with severe EDs, and to determine whether this relationship was mediated by experiential avoidance. METHOD: Adolescent and adult females (N = 625) seeking residential ED treatment completed self-report measures of anxiety sensitivity, experiential avoidance, and ED psychopathology. Linear regression evaluated the cross-sectional association between ED symptom severity and three dimensions of anxiety sensitivity (social, physical, and cognitive). Regression-based mediation analysis with bootstrapping tested the associations among the three dimensions of anxiety sensitivity and ED symptom severity through experiential avoidance. RESULTS: The social dimension of anxiety sensitivity was positively associated with severity of ED psychopathology. Experiential avoidance mediated this association. DISCUSSION: ED symptoms in this sample were more severe among patients who endorsed greater concern about appearing nervous or anxious to others. The current results indicate that this relationship was driven by a tendency to avoid experiences that evoke emotional discomfort. If replicated, these findings suggest that targeting both social anxiety sensitivity and experiential avoidance may improve ED treatment outcomes. Further study of the mechanistic relationships among social anxiety sensitivity, experiential avoidance, and ED psychopathology, is warranted.

The efficacy of 90-minute versus 60-minute sessions of prolonged exposure for posttraumatic stress disorder: Design of a randomized controlled trial in active duty military personnel.

OBJECTIVE: Posttraumatic stress disorder (PTSD) can have devastating effects on multiple aspects of functioning. Thus, it is imperative to increase access to evidence-based treatment for PTSD. Prolonged Exposure therapy (PE) has extensive empirical support and is one of the first-line PTSD treatments included in civilian, veteran, and military clinical practice guidelines. However, the standard 90-min PE session format can constitute a significant barrier to its adoption in routine clinical care settings, which typically schedule 60-min appointment sessions. If the length of PE sessions could be reduced from 90 to 60 min without compromising treatment efficacy and efficiency, this would remove a major barrier to PE adoption. METHOD: This paper describes the rationale and methods of a randomized controlled noninferiority trial comparing 90-min versus 60-min PE sessions (including 40- vs. 20-min imaginal exposures, respectively) among 160 active duty military personnel with PTSD. The aims of this study are to: (1) examine the efficacy and efficiency (i.e., rate of symptom improvement) of 90- versus 60-min PE; (2) assess change in psychophysiological markers of treatment response across conditions; and (3) test mechanisms of change underlying the efficacy of PE. RESULTS/CONCLUSIONS: The results of this study will inform dissemination efforts in military, veteran, and civilian sectors. Further, identifying mechanisms of therapeutic change will answer important theoretical questions about how PE works, in order to refine and increase the efficacy and efficiency of PE to better meet the needs of individuals with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The implementation of prolonged exposure: Design of a multisite study evaluating the usefulness of workshop with and without consultation.

This randomized trial examines the dissemination and implementation of prolonged exposure (PE) therapy for posttraumatic stress symptoms in U.S. Army medical treatment facilities. The study compares two PE training models: Standard PE training, comprised of a 4-day workshop only, and Extended PE training, comprised of a 4-day workshop plus expert case consultation. Behavioral health providers (N=180) across three medium-to-large Army installations will be randomly assigned to either Standard PE training or Extended PE training. Changes in provider attitudes will be examined across groups. After completing PE training, the use of PE components with patients reporting posttraumatic stress symptoms and clinical outcomes of these participating patients (N=500) will be examined. This article describes the rationale and methods of the study. In addition, a number of methodological issues in conducting a multisite naturalistic study in the U.S. Army are discussed.

Concurrent varenicline and prolonged exposure for patients with nicotine dependence and PTSD: A randomized controlled trial.

BACKGROUND: Prevalence of smoking among individuals with posttraumatic stress disorder (PTSD) is disproportionately high, and PTSD is associated with especially poor response to smoking cessation treatment. OBJECTIVE: The current study examined whether integrating treatments for smoking cessation (varenicline plus smoking cessation counseling; VARCC) and PTSD (prolonged exposure therapy; PE) enhances smoking outcomes among smokers diagnosed with PTSD. METHOD: 142 adults with nicotine dependence (ND) and PTSD were randomized to a treatment program consisting of varenicline, smoking cessation counseling, and PE (VARCC + PE) or to VARCC only. Seven-day point prevalence abstinence (PPA) at posttreatment (3-months postquit day) and follow-up (6-months postquit day), verified by serum cotinine levels and exhaled carbon monoxide, was the primary smoking outcome. Psychological outcomes were PTSD and depression severity. Mixed effects models included baseline PTSD severity as a moderator of treatment condition effects. RESULTS: Overall, VARCC + PE participants did not show greater PPA than VARCC participants. However, treatment effects were moderated by baseline PTSD severity. For participants with moderate and high PTSD severity, VARCC + PE led to significantly higher PPA than VARCC alone (ps<.05). No differences between treatment conditions emerged for participants with low baseline PTSD severity. Participants who received PE showed significantly greater reduction of PTSD and depression symptoms than those who did not receive PE. CONCLUSIONS: Integrating psychological treatment for PTSD and smoking cessation treatment enhances smoking cessation for participants with moderate or severe PTSD symptom severity, but does not enhance smoking cessation for participants with low baseline PTSD severity. (PsycINFO Database Record

Changes in coping behavior in a randomized controlled trial of concurrent treatment for PTSD and alcohol dependence.

OBJECTIVE: The current study examines changes in coping among 165 adults meeting DSM-IV criteria for co-morbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). METHOD: Participants were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants received supportive counseling focused on alcohol use (BRENDA). Assessments of coping, PTSD, and AD were conducted at pre-treatment, mid-treatment, post-treatment, 3-month follow-up, and 6-month follow-up. RESULTS: Participants exhibited significant decreases in both avoidant coping and adaptive coping from pre-treatment to 6-month follow-up across all groups. Participants who received PE showed faster decreases in avoidant coping during this period than participants who did not receive PE. PTSD symptom reduction was associated with changes in both avoidant and adaptive coping across groups. Improvement in PTSD symptoms was related to a faster rate of reduction in avoidant coping in the PE groups compared to those receiving BRENDA alone. CONCLUSIONS: The current results suggest that concurrent treatment for co-morbid PTSD-AD decreases avoidant and adaptive coping, and participants who show greater reductions in PTSD symptoms also show greater changes in coping style. Consistent with theorized mechanisms of change in PE, the addition of PE to supportive counseling for AD was associated with a greater reduction of avoidant coping than supportive counseling alone.

Cognitive Mediation of Symptom Change in Exposure and Response Prevention for Obsessive-Compulsive Disorder.

This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n=38) or in open treatment following nonresponse to risperidone or placebo in the same trial (n=32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (Weeks 0, 4 and 8) and maintenance treatment (Weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement.

Therapeutic Alliance during Prolonged Exposure Versus Client-Centered Therapy for Adolescent Posttraumatic Stress Disorder.

OBJECTIVES: To examine the relationship between improvements in adolescent ratings of therapeutic alliance and reductions in posttraumatic stress disorder (PTSD) severity over time among adolescent girls during prolonged exposure therapy for adolescents (PE-A) versus client-centered therapy (CCT), as well as to examine differences in changes in alliance between treatment groups. METHOD: A total of 61 adolescent girls (aged 13-18 years) with sexual assault-related PTSD received PE-A or CCT in a randomized controlled trial. Participants rated alliance at session 3, midtreatment, and posttreatment. RESULTS: The rate of improvement in adolescent-rated alliance was greater in PE-A than CCT over the course of treatment. In addition, improvement in adolescent-rated alliance significantly contributed to improvements in PTSD (regardless of treatment condition), but not vice versa. CONCLUSIONS: Contrary to beliefs that trauma-focused treatments fail to establish strong therapeutic alliance in sexually abused adolescents, improvement in adolescent ratings of alliance were greater in PE-A compared to CCT, and improvements in adolescent-rated alliance were significantly associated with better treatment outcome across both types of treatments.

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters.

OBJECTIVE: The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model). METHOD: Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout. RESULTS: Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE. CONCLUSIONS: The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.

Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome.

OBJECTIVE: The present study examined predictors and moderators of treatment response among 165 adults meeting Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD), who were randomized to 24 weeks of Naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use. METHOD: Six domains of predictors or moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview) and AD (days drinking from the timeline follow-back interview) collected every 4 weeks throughout treatment. Multilevel modeling with the Fournier approach was used to evaluate predictors and moderators of rates of symptom improvement and posttreatment outcomes. RESULTS: Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, White race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of AD. CONCLUSION: These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified subgroups of PTSD-AD patients.

The Relationship between Anxiety Sensitivity and Posttraumatic Stress Disorder: What is the Impact of Nicotine Withdrawal?

OBJECTIVES: Anxiety sensitivity (AS) is related to the development and maintenance of posttraumatic stress disorder (PTSD) among cigarette smokers, and is also implicated in the amplification of acute nicotine withdrawal symptoms. The present study sought to examine the role of nicotine withdrawal in moderating the association between AS and PTSD symptom severity among a sample of treatment-seeking smokers with PTSD. METHOD: Participants (n = 117) were enrolled in a randomized controlled trial for the treatment of PTSD and nicotine dependence. Cross-sectional data were randomly sampled from three different study time points. A series of multiple regression models were tested. RESULTS: Results revealed main effects of both AS and withdrawal severity on PTSD severity after controlling for gender, assessment time-point, negative affectivity, and biochemically verified smoking (expired carbon monoxide). The interaction of AS and withdrawal was also significant, and appeared to be specific to PTSD avoidance and hyperarousal symptoms. However, contrary to expectations, the association between AS and PTSD symptoms was only significant at relatively lower levels of nicotine withdrawal. CONCLUSIONS: These findings highlight the complex interplay between AS, nicotine withdrawal, and their synergistic effect in terms of the exacerbation of PTSD symptomology.

Exposure and response prevention helps adults with obsessive-compulsive disorder who do not respond to pharmacological augmentation strategies.

OBJECTIVE: Serotonin reuptake inhibitors (SRIs) are a first-line treatment for obsessive-compulsive disorder (OCD). Yet, most patients with OCD who are taking SRIs do not show excellent response. Recent studies show that augmenting SRIs with risperidone benefits a minority of patients. We evaluated the effectiveness of exposure and response prevention (EX/RP) among nonresponders to SRI augmentation with 8 weeks of risperidone or placebo. METHOD: The study was conducted from January 2007 to August 2012. Nonresponders to SRI augmentation with risperidone or pill placebo (N = 32) in a randomized controlled trial for adults meeting DSM-IV-TR criteria for OCD were offered up to 17 twice-weekly EX/RP sessions. Independent evaluators, blind to treatment, evaluated patients at crossover baseline (week 8), midway through crossover treatment (week 12), post-EX/RP treatment (week 16), and follow-up (weeks 20, 24, 28, and 32). The primary outcome was OCD severity, measured with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Secondary outcomes were depression, quality of life, insight, and social functioning. RESULTS: Between crossover baseline and follow-up, nonresponders to SRI augmentation with risperidone or placebo who received EX/RP showed significant reductions in OCD symptoms and depression, as well as significant increases in insight, quality of life, and social functioning (all P < .001). CONCLUSIONS: Exposure and response prevention is an effective treatment for patients who have failed to respond to SRI augmentation with risperidone or placebo. This study adds to the body of evidence supporting the use of EX/RP with patients who continue to report clinically significant OCD symptoms after multiple pharmacologic trials. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00389493.

Change in obsessive-compulsive symptoms mediates subsequent change in depressive symptoms during exposure and response prevention.

OBJECTIVE: The current study examines the temporal relationship between changes in obsessive-compulsive symptoms and changes in depressive symptoms during exposure and response prevention (EX/RP) therapy for obsessive-compulsive disorder (OCD). METHOD: Participants were 40 adults (53% female) who received EX/RP in a randomized controlled trial comparing serotonin reuptake inhibitor (SRI) augmentation strategies. Participants completed clinician-administered assessments of OCD (Yale-Brown Obsessive Compulsive Scale) and depressive symptoms (Hamilton Depression Rating Scale) every four weeks from baseline to 32-week follow-up. RESULTS: Lagged multilevel mediational analyses indicated that change in OCD symptoms accounted for 65% of subsequent change in depressive symptoms. In contrast, change in depressive symptoms only partially mediated subsequent change in OCD symptoms, accounting for 20% of the variance in outcome. CONCLUSIONS: These data indicate that reductions in co-morbid depressive symptoms during EX/RP for OCD are largely driven by reductions in obsessive-compulsive symptoms.

Client-therapist alliance discrepancies and outcome in cognitive-behavioral therapy for youth anxiety.

BACKGROUND: Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. OBJECTIVE: The current study explored the degree to which youth with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, anxiety disorders and their therapists agree in their ratings of the alliance at multiple assessment points and evaluated whether inter-rater discrepancies predicted treatment outcome. METHOD: Youth (N = 62; Mage = 12.43, SD = .76) received empirically supported CBT. Paired samples t tests assessed for significant disagreement between youth- and therapist-rated alliance at sessions 4, 8, and 12. Regression analyses were conducted to evaluate whether discrepancies between raters at each time point predicted posttreatment anxiety symptom scores. RESULTS: Overall, alliance was positive for both child (aged 7-12 years) and adolescent (aged 13-16 years) clients. Discrepancies between youth and therapist ratings of alliance were statistically significant at session 4 for children and session 8 for adolescents, with youth rating the relationship more favorably than therapists. However, rating discrepancies did not predict youth- or parent-reported treatment outcome. CONCLUSIONS: Considerable variability may exist between youth and therapist perspectives on the therapeutic alliance, indicating potential attunement problems, particularly during earlier phases of treatment. However, these discrepancies did not negatively affect treatment response. Implications for alliance research and clinical practice are discussed.

Binge eating frequency and regular eating adherence: the role of eating pattern in cognitive behavioral guided self-help.

Cognitive behavioral guided self-help (CBTgsh) is an evidence-based, brief, and cost-effective treatment for eating disorders characterized by recurrent binge eating. However, more research is needed to improve patient outcomes and clarify treatment components most associated with symptom change. A main component of CBTgsh is establishing a regular pattern of eating to disrupt dietary restriction, which prior research has implicated in the maintenance of binge eating. The present study used session-by-session assessments of regular eating adherence and weekly binge totals to examine the association between binge frequency and regular eating in a sample of participants (n = 38) receiving 10 sessions of CBTgsh for recurrent binge eating. Analyses were conducted using Hierarchical Linear Modeling (HLM) to allow for data nesting, and a likelihood ratio test determined which out of three regression models best fit the data. Results demonstrated that higher regular eating adherence (3 meals and 2-3 planned snacks daily) was associated with lower weekly binge frequency in this sample, and both the magnitude and direction of the association were maintained after accounting for individual participant differences in binge and adherent day totals. Findings provide additional empirical support for the cognitive behavioral model informing CBTgsh. Possible clinical implications for treatment emphasis and sequencing in CBTgsh are discussed.

Trajectory and predictors of alliance in cognitive behavioral therapy for youth anxiety.

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7-17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel "alliance rupture" model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

Mental Health Evaluations for Adolescents Prior to Bariatric Surgery: A Review of Existing Practices and a Specific Example of Assessment Procedures.

OBJECTIVE: Best practice guidelines for adolescents considering bariatric surgery recommend a pre-operative mental health evaluation. However, only general information about these assessments appears in the literature, which makes consistency of administration challenging. This review proposes a specific empirically-derived format for pre-surgical mental health evaluations and summarizes currently available data on the psychiatric functioning of adolescents seeking bariatric surgery. DESIGN: Studies of mental health evaluations for adults preparing for bariatric surgery are reviewed, as is the limited literature relevant to adolescent evaluations. A specific and detailed example of an evaluation (clinical interview, self-report questionnaires, cognitive assessment) used for younger patients at a major metropolitan hospital center is presented, followed by data from an initial group of adolescents completing this evaluation. SUBJECTS: 200 adolescents (n=139 female; age: 14-18 y, BMI: 35.4-83.3 kg/m2) presenting for bariatric surgery. RESULTS: A notable subset of adolescents reported current Axis I conditions (31.5%) and current mental health treatment (29.5%), but reports of current illicit drug use (1.5%) and regular alcohol use (0.5%) were relatively rare. Procedures for using the completed evaluation and post-surgery monitoring of psychosocial issues are discussed. CONCLUSIONS: Adolescents considering weight loss surgery should receive comprehensive pre-surgical mental health evaluations, but additional data are needed to develop specific recommendations the use of these evaluations in post-operative care.

Shape of change in cognitive behavioral therapy for youth anxiety: symptom trajectory and predictors of change.

OBJECTIVE: Multilevel growth analysis was used to establish the mean growth trajectory (shape of change) for cognitive behavioral therapy (CBT) for youth with anxiety disorders. Two-level growth analysis was conducted to identify important between-youth predictors of session-by-session symptom change. METHOD: Fifty-five youth (ages 7-17; 50.9% male) and their parents participated in a 16- to 20-week CBT that emphasized affective, cognitive, and exposure-based exercises. Multilevel growth models (MLMs) were estimated to model session symptom data taking into account an "anxiety spike" hypothesized to occur at initiation of exposure sessions. Three models were compared: a cubic curve, a log-linear curve plus an exposure covariate, and a linear curve plus exposure covariate. Two-level MLM examined the effect of demographic traits (sex, age, race/ethnicity), pretreatment symptom severity, comorbid school refusal, early treatment factors (use of selective serotonin reuptake inhibitor medication, therapeutic alliance, treatment attrition), and pretreatment coping (engagement, disengagement, and involuntary coping). RESULTS: Fit indices provided support for the cubic growth model using either parent or youth anxiety data. Level 2 analysis identified youth age, symptom severity (anxiety, externalizing), early attrition, and engagement and disengagement coping as significant predictors of symptom trajectories. Predictors accounted for 34%-37% of between-youth variance in midtreatment anxiety scores. CONCLUSIONS: Findings suggest that the symptom course of CBT, and the effect of between-youth factors on treatment outcomes, is more complex than previously thought. Educating therapists and clients about findings can aid treatment expectations and dissemination efforts of empirically supported treatments.