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Factors Promoting and Inhibiting the Development and Use of Clinical Practice Guidelines
Steven C. Hayes and Jennifer Gregg, University of Nevada, Reno

Several of the factors that are currently promoting or inhibiting the development and use of clinical practice guidelines are reviewed. While many factors are moving the field toward the use guidelines, a great deal remains to be learned about how to disseminate empirical knowledge through this means.

Practice Guidelines for Eating Disorders
G. Terence Wilson, Rutgers University, and W. Stewart Agras, Stanford University

The American Psychiatric Association's (2000) "Practice Guideline for the Treatment of Patients With Eating Disorders" (PGED) provides useful, practical advice on the clinical and medical management of eating disorders, and an informative summary of the evidence on their epidemiology, nature, and treatment. The main limitation is the methodological adequacy and application of the coding system used to establish level of clinical confidence in treatment recommendations. The PGED represents a mix of science and expert clinical judgment that results in an overinclusiveness and several questionable conclusions. The PGED provides a balanced analysis of pharmacological treatment of anorexia and bulimia nervosa but not binge-eating disorder. Although it notes that cognitive behavior therapy enjoys the most scientific support of any treatment for bulimia nervosa, the PGED misses an opportunity to promote dissemination of this approach. The guideline misleadingly characterizes core cognitive-behavioral treatment strategies as "nutritional rehabilitation."

Treatment Guidelines for Major Depressive Disorder
Steven D. Hollon and Richard C. Shelton, Vanderbilt University

Treatment guidelines represent attempts to describe a set of best practices based on the available empirical evidence and current clinical consensus. The American Psychiatric Association has recently revised its guideline for the treatment of major depression. The revised guideline clearly improves upon the original in many respects and is more closely tied to the empirical literature. It provides an excellent overview of the nature of depression and its pharmacological treatment. It also does a better job than the original of differentiating between those psychosocial interventions that have done well in empirical trials (like the cognitive behavioral interventions and interpersonal psychotherapy) versus those that have not, like the more traditional dynamic interventions. Nonetheless, it still understates the case for the empirically supported psychosocial interventions, which compare favorably to drugs in the reduction of acute distress and may have broader and more enduring effects.

Consideration of the APA Practice Guideline for the Treatment of Patients With Panic Disorder: Strengths and Limitations for Behavior Therapy
Michelle G. Craske and Bonnie G. Zucker, University of California, Los Angeles

The need to disseminate information about empirically supported treatments is becoming paramount in the current cost-minimizing health care climate. Cognitive-behavioral treatments are clearly effective for panic disorder, and yet the majority of persons suffering from panic disorder do not receive this treatment. Publications like the American Psychiatric Association's "Practice Guideline for the Treatment of Patients With Panic Disorder" (1998) potentially have a widespread influence on mental health - care practitioners, and therefore it is essential that the guideline be accurate and up-to-date. In this paper, we critique the guideline's presentation of cognitive-behavioral therapy (CBT) in terms of scientific basis, clinical practice, training of behavior therapists, and diversity issues. Although the guideline appropriately highlights CBT as a primary treatment for panic disorder, the discussions of its breadth, techniques, and utility are understated.

The American Psychiatric Association Practice Guidelines for Schizophrenia: Scientific Base and Relevance for Behavior Therapy
Alan S. Bellack, VA Capitol Health Care Network MIRECC and University of Maryland School of Medicine, and Robert W. Buchanan and James M. Gold, University of Maryland School of Medicine

The American Psychiatric Association's practice guidelines for schizophrenia provide a general blueprint for treating people with the illness. They are primarily oriented toward psychiatrists and pharmacological management. However, the guidelines also discuss the importance of psychosocial treatments, including behavioral therapy techniques. We provide an overview of the treatment guidelines and their empirical base. The pharmacological recommendations are generally consonant with the literature, albeit they have become somewhat dated due to the rapid progress in studies of the effects of new generation antipsychotics. We next review recommendations concerning social skills training, cognitive therapy and rehabilitation, behavioral family therapy, and vocational rehabilitation. Overall, the guidelines are quite positive about the potential benefit of these interventions, but they are appropriately conservative in interpreting the literature. There are promising data to support the efficacy of each of these approaches, but effectiveness data are lacking and questions remain about their actual impact on community functioning. Schizophrenia has not received sufficient attention from behavior therapists since the early successes achieved by operant programs. The optimistic stance taken by the guidelines should, if anything, encourage students to pursue careers working with this very needy population.

American Psychiatric Association Practice Guideline for Substance Use Disorders
Barbara S. McCrady, Rutgers - The State University of New Jersey, and Douglas Ziedonis, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School

The American psychiatric Association has published a practice guideline for treatment of patients with substance use disorders. This review focuses on scientific and clinical strengths and limitations of the guideline, and the relevance of the guideline to behavior therapy. The guideline incorporated a thorough review of the scientific literature, presented substance use disorders as complex and multifaceted problems, recommended pharmacological and psychosocial interventions where appropriate, and noted the limits of scientific knowledge. The guideline focuses on the strong empirical support for a number of major behavioral and cognitive-behavioral interventions. Expansion of the guideline to consider less severe cases, expanded information about specific population subgroups, more careful attention to assessment and diagnosis, and more objective criteria for classifying studies that are applied more systematically would strengthen future editions.

Do Changes in Dysfunctional Attitudes Mediate Changes in Depression and Anxiety in Cognitive Behavioral Therapy?
David D. Burns, Stanford University School of Medicine, and Diane L. Spangler, Brigham Young University

Using structural equation modeling (SEM), four hypotheses about the causal linkages between dysfunctional attitudes (DAs), anxiety, and depression were tested in a group of 521 outpatients treated with cognitive behavioral therapy (CBT) over a 12-week period. The four hypotheses were as follows:
changes in DAs lead to changes in depression and anxiety during treatment (the cognitive mediation hypothesis);
changes in depression and/or anxiety lead to changes in DAs (the mood activation hypothesis);
DAs and negative emotions have reciprocal causal effects on each other (the circular causality hypothesis); and
there are no causal links between DAs and emotions - instead, a third variable simultaneously activates DAs, depression and anxiety (the "common cause" hypothesis).

Consistent with previous reports, DAs were significantly correlated with levels of depression and anxiety at intake and at 12 weeks; in addition, changes in DAs were significantly correlated with changes in depression and anxiety during treatment. However, the results were inconsistent with the first three hypotheses. There did not appear to be any causal effects linking the DAs on depression or anxiety at intake or at 12 weeks. Instead, the analyses suggested the existence of an unknown variable with simultaneous causal effects on dysfunctional attitudes, depression, and anxiety. This common cause accounted for all the correlations between the attitude and mood variables, and also appeared to mediate the effects of psychotherapy and medication on dysfunctional attitudes, depression, and anxiety.

Efficacy of Dialectical Behavior Therapy in Women Veterans With Borderline Personality Disorder
Cedar R. Koons, Durham VA Medical Center, Clive J. Robins, Duke University Medical Center and Duke University, J. Lindsey Tweed, Thomas R. Lynch, and Alicia M. Gonzalez, Duke University Medical Center, Jennifer Q. Morse, Duke University, G. Kay Bishop, Durham VA Medical Center, and Marian I. Butterfield and Lori A. Bastian, Durham VA Medical Center and Duke University Medical Center

Twenty women veterans who met criteria for borderline personality disorder (BPD) were randomly assigned to Dialectical Behavior Therapy (DBT) or to treatment as usual (TAU) for 6 months. Compared with patients in TAU, those in DBT reported significantly greater decreases in suicidal ideation, hopelessness, depression, and anger expression. In addition, only patients in DBT demonstrated significant decreases in number of parasuicidal acts, anger experienced but not expressed, and dissociation, and a strong trend on number of hospitalizations, although treatment group differences were not statistically significant on these variables. Patients in both conditions reported significant decreases in depressive symptoms and in number of BPD criterion behavior patterns, but no decrease in anxiety. Results of this pilot study suggest that DBT can be provided effectively independent of the treatment's developer, and that larger efficacy and effectiveness studies are warranted.

Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effects on Drug-Using Behavior and Relationship Adjustment
William Fals-Stewart, University at Buffalo, The State University of New York, Timothy J. O'Farrell, Harvard Medical School and Veterans Affairs Medical Center, and Gary R. Birchler, Veterans Affairs Medical Center and Univeristy of California, San Diego School of Medicine

Married or cohabiting substance-abusing men (N = 36) who were entering methadone maintenance (MM) treatment were randomly assigned to receive either individual-based methadone maintenance (IBMM) services (i.e., twice-weekly individual counseling plus methadone) or an equally intensive behavioral couples therapy (BCT) treatment condition (i.e., once-weekly couples therapy involving their female partner, once-weekly individual counseling, and methadone). Drug use and relationship satisfaction measures were collected at baseline, weekly during treatment , and at posttreatment. Male partners in the BCT condition had fewer opiate- and cocaine-positive urine samples during treatment than male partners in the IBMM condition. Couples who participated in BCT also reported higher levels of relationship happiness during treatment and higher dyadic adjustment at posttreatment than couples in which male partners participated in IBMM. Furthermore, patients in the BCT condition reported greater reductions in drug use severity and family and social problems from baseline to posttreatment than patients in the IBMM condition. These findings suggest BCT may improve treatment response for married or cohabiting MM patients.