A Cost-Effectiveness Analysis of Cognitive Behavior Therapy and Fluoxetine (Prozac) in the Treatment of Depression

David Antonuccio, Michael Thomas, and William G. Danton, University of Nevada School of Medicine

Depression affects at least 11 million Americans per year and costs the U.S. economy an estimated 44 billion dollars annually. Comprehensive review of the existing scientific evidence suggests that psychotherapy, particularly cognitive behavior therapy (CBT), is at least as effective as medication in the treatment of depression, even if severe. These conclusions hold for both vegetative and social adjustment symptoms, especially when patient-rated measures are used and long-term follow-up is considered, In addition, several well-controlled studies with long-term follow up suggest that CBT may be more effective than drug treatment at preventing relapse. the relative effectiveness of psychotherapy for depression, particularly CBT, has been reinforced by meta-analyses reported in both psychiatry and psychology journals. In the era of managed care, it is not enough to be effective; treatments must be cost-effective. This paper considers the outcome studies as the basis for a cost-effectiveness comparison of drugs and psychotherapy in the treatment of unipolar depression. The analysis shows that over a 2-year period, fluoxetine alone may result in 33% higher expected costs than individual CBT treatment and the combination treatment may result in 23% higher costs than CBT alone. Supplemental analysis shows that group CBT may only result in a 2% ($596) cost savings as compared to individual treatment.



Computers in Assessment and Cognitive Behavioral Treatment of Clinical Disorders: Anxiety as a Case in Point

Michelle G. Newman, Penn State University, Andrés Consoli, San Francisco State University, and C. Barr Taylor, Stanford University

Computers have the potential to provide effective assessment and to assist in the provision of therapy at relatively low cost. this article reviews the research on computer programs for the assessment and cognitive behavioral treatment of anxiety disorders. Empirical findings on the use of computers for clinical diagnoses, as substitutes for paper and pencil assessment measures, as the sole providers of behavior therapy, and as an adjunct to clinician guidance are presented. In addition to being the first critical review of the methodology of this research, this paper describes desktop and ambulatory computer technology and programs, discusses their advantages and disadvantages, and provides suggestions for future research. Although this review focuses on anxiety disorder research, most of the basic points that are made with respect to the computer technology and research apply to computer assessment and therapy as it relates to other disorders.



People Who Seek Help for Fear of Flying: Typology of Flying Phobics

Lucas J. Van Gerwen, Philip Spinhoven, Rene F. W. Diekstra, Leiden University, Netherlands, and Richard Van Dyck, Vrije University at Amsterdam, Netherlands

The objective of this study was to examine sociodemographic and clinical characteristics of 419 patients who were self-referred to a treatment agency because of fear of flying. With the use of homogeneity analyses to explore the association between flight-anxiety and different types of phobia, four specific subtypes of flying phobics were identified. The subtypes differed in terms of flight-anxiety level, age, sex, complaints like "fear of aircraft accidents, the need to have control over the situation, fear of losing control over themselves," and phobias underlying their fear of flying, such as claustrophobia, acrophobia, social phobia, and symptoms of panic attacks. It is argued that the typology identified could have implications for the selection of treatment components.



Cognitive Behavioral and Pharmacological Treatment of Generalized Anxiety Disorder: A Preliminary Meta-Analysis

Robert A. Gould, Michael W. Otto, Mark H. Pollack, and Liang Yap, Massachusetts General Hospital and Harvard Medical School

This study provides a meta-analytic review of controlled trials examining cognitive behavior therapy (CBT) and pharmacotherapy for generalized anxiety disorder (GAD). Thirty-five studies, published or presented between 1974 and January 1996, were identified, and provided 61 separate treatment interventions. Both modalities of treatment offered clear efficacy to patients, and the overall ES (ES) for CBT (ES = .70) was not statistically different from pharmacotherapy (ES = 0.60) for measures of anxiety severity. CBT was associated with significantly greater effects on depression severity, and was associated with clear maintenance of treatment gains, whereas the long-term efficacy of pharmacologic treatment was attenuated following medication discontinuation. Data concerning the efficacy of specific cognitive behavioral and pharmacologic interventions are provided, as are analyses of the influence of methodological factors (e.g., gender distribution, length of treatment) on the efficacy of treatments.



"Attention" to Pain in Persons With Chronic Pain: A Behavioral Approach

Lance M. McCracken, University of Chicago

Preoccupation with or attention to pain may influence perceived pain severity and other pain responses. The purpose of this study was to investigate attention to pain in persons with chronic pain. Participants for this study were patients (N= 80, 58.8% female) with chronic low back pain referred to a university pain clinic. A measure of attention to pain, the Pain Vigilance and Awareness Questionnaire (PVAQ), was constructed for this study. It was intended to assess a number of related responses including awareness, vigilance, preoccupation, and observation of pain. The PVAQ showed adequate internal consistency and temporal stability over a short interval. PVAQ scores were positively correlated with private body consciousness and cognitive disability, and negatively correlated with a measure of ignoring pain, supporting their validity. The results of this study show that persons with chronic low back pain who report greater attention to pain also report higher pain intensity, emotional distress, psychosocial disability, and pain-related health care utilization. Regression analyses showed that level of attention to pain remained a significant predictor of distress, disability, and health care utilization independent of pain intensity and relevant demographic variables. These results provide preliminary support for a behavioral conceptualization of attention to pain.



Programming Generalization of Social Skills in Adults With Developmental Disabilities: Effects on Generalization and Social Validity

Dorothy Griffiths, Brock Univeristy, Ontario, Canada, Maurice A. Feldman, Queen's University and Ongwanada Centre, Ontario, Canada, Susan Tough, York Central Hospital, and Richmond Hill, Ontario, Canada

Although many studies have demonstrated the acquisition of social skills in persons with developmental disabilities in the training setting, in vivo generalization has been more difficult to obtain. In this study, squads comprising 3 to 4 adults with developmental disabilities from the same group home were randomly assigned to a "game" condition (n = 15) with three generalization strategies, a "social life" condition (n = 13), which added to the game condition four generalization strategies, or a "no-training" control group (n = 15). After training, the social life group was significantly superior to the no-training control group on all the generalization and social validity measures; the game condition was significantly better than the control group on one posttest generalization measure only. Furthermore, the social life condition was significantly superior to the game condition on percentage correct in the last game session and in a 3-month follow-up on the frequency of target skills displayed in the participants' natural settings. The findings indicate that meaningful generalization and social validity can be obtained when sufficient generalization strategies are explicitly programmed in the social skills game format.



Lifestyle Modification and Relapse-Prevention Training During Treatment for Weight Loss

Susan Head, Duke University Diet and Fitness Center, and Alan Brookhart, University of California, Berkeley

A program evaluation involving the assessment of return patients at the Duke University Diet and Fitness Center (DDFC) was undertaken with the intention of improving relapse-prevention training for patients during weight-loss treatment. Two-hundred and fifty-two patients (143 women, 109 men) who had previously lost weight at the DDFC were assessed on the first day of their return visit regarding their lifestyles at home, most frequently encountered high-risk situations, and strategies used to prevent relapse. The study was designed to determine which of these factors were associated with continued weight-loss and maintenance after discharge. Regression analysis (F = 19.89, p < .0001) indicated that time elapsed since treatment was associated with weight gain. Multiple regression analysis controlling for the effect of time on weight change indicated strategies associated with decreased weight during follow-up included "planning and monitoring" (t = -2.19, p < .03), and "positive self-talk, putting self first" (t = -2.51, p < .01). Lifestyle factors associated with success after discharge included "support" (F = 10.83, p < .001), "amount of daily activity" (F = 10.98, p < .001), and "quality of daily activity" (F = 7.69, p < .006). When we examined the "most successful" versus the "least successful" patients after discharge, "planning and monitoring" (F = 8.15, p < .005) and "positive self-talk, putting self first" (F = 8.85, p < .004) were associated with the "most successful," while "using no strategies" (F = 7.47, p < .007) was associated with the "least successful." In light of the findings, suggestions are made for including lifestyle modification as a major part of relapse-prevention training.