Warwick BABCP conference: 2nd day - behavioural activation, Kyrios OCD, 'mind the gap', & DeRubeis on personalization (4th post)
Last updated on 19th July 2018
Yesterday was the second full day of the BABCP summer conference in Warwick. I've already written three earlier posts about being here - on the pre-conference workshop I attended on "Anger dysregulation", the first morning "Trauma memories & a master presentation on four decades of outcome research" and the first afternoon "Treating adolescent anxiety & depression, and depressive rumination". Yesterday I went to a morning symposium on behavioural activation, Mike Kyrios giving a keynote on OCD, an afternoon symposium involving both psychologists & psychiatrists, and a further keynote with Rob DeRubeis discussing how one can predict which depression sufferers might respond best to CBT and which to antidepressants.
So first the symposium on behavioural activation. This was in a windowless, airless little room packed with people ... a slight suspicion that modern CBT can treat behavioural approaches a bit like keeping one's grandad in a discreet corner of the back room. That attitude could take a big jolt when the results of the very impressive COBRA trial on behavioural activation v's CBT come out early next year. Ockham may well be vindicated ... "Entia non sunt multiplicanda praeter necessitatem". The symposium opened with Dave Ekers talking on a "Meta-analysis of behavioural activation interventions". Although the overall results look pretty good, the primary trials are of very mixed quality it seems. Dave made the interesting points that making BA more complex or using more highly trained therapists probably doesn’t add effectiveness. Ciara Masterton then presented on "Sudden gains in behavioural activation for depression". This was a useful reminder of an important subject. She quoted Aderka's paper "Sudden gains during psychological treatments of anxiety and depression: a meta-analysis" and Aderka has also published on sudden gains in social anxiety treatment and sudden gains in OCD treatment. Ciara had found 42% of subjects in her trial made impressive sudden gains, typically some time in the first few sessions of treatment. Particularly in CBT & BA, people who make sudden gains typically do especially well both at the end of treatment and at follow-up. It makes very good sense to monitor for these happy therapeutic events and make much of them, maybe trying to understand how the patient made the gain (possibly so they can do more of it), and boosting optimism by underlining what a good therapeutic sign this is. Interestingly, in the next talk - "Patterns of change in group behavioural activation” - Heather O'Mahen commented that sudden gains in her group therapy didn’t relate to overall outcome … maybe to do with chronic, recurrent pattern that 90% of participants in her trial exhibited. Finally Dave Richards presented on the COBRA trial "Cost and Outcome of BehavioRal Activation: a randomised controlled trial of behavioural activation versus cognitive therapy for depression" carried out in Durham, Leeds, Exeter, London & now Oxford. Nearly 4 years and £2.5 million ... by far the largest trial ever of BA for depression and also one of the largest trials ever of CBT. Results won't emerge publicly until the start of next year and they're likely to be important. A central issue is that the BA intervention was delivered by much less extensively trained therapists than the CBT ... "band 5 qualified Psychological Wellbeing Practitioners v's band 7 qualified CBT therapists". As Dave pointed out, if the PWP's achieve as good results with BA then it will have implications for making effective depression therapy more available worldwide. Fingers crossed!
Then to Mike Kyrios from the Australian National University on "Developments in the treatment of obsessive compulsive disorder: from the internet to the self". I found myself muddling his name with Nick Kyrgios the Ozzie tennis player, but Mike was happily well behaved ... at least during this presentation. The talk seemed to divide nicely into two halves. The first gave information about the excellent online OCD treatment that Mike & colleagues have developed. He talked about a TIAR system of understanding OCD ... Trigger, Intrusion, Appraisal, Response. He discussed the large effect sizes achieved by ERP, CBT & CT, with larger drop-out rates for ERP. He talked about an online trial he & colleagues had done on eCBT v's ePRT (progressive relaxation training). He introduced us to the excellent Australian government "MentalHealthOnline website" with its impressive resources. In the second half of his talk, Mike opened up a fascinating set of ideas about the relevance of "self-ambivalence" in OCD. He has developed a self-ambivalence assessment measure, has published "An investigation of self-ambivalence in obsessive-compulsive disorder" and other researchers have taken up these ideas. This is interesting territory, but as Mike confirmed when I asked him about it after the talk, we don't have any good evidence yet that these ideas add value to basic OCD treatments. Maybe they will. They're certainly interesting and provocative, but there's a long road to go yet before this is well validated.
Then after lunch I went to "Mind the gap: bringing together psychopharmacology and cognitive behavioural therapy". This symposium didn't work for me. Largely my fault, I should have checked more carefully what I was going to. Especially after Pim Cuijpers talk yesterday with its underlining of the potential value of combining antidepressants with psychotherapy, I was interested to explore combination treatments further. Bad mistake ... this wasn't at all what this seminar was about. Hey, with the very good wifi here, I could get on with other things! Then the final option of the day ... a keynote by Rob DeRubeis on "Getting the most out of investigations of therapeutic processes and outcomes: implications for clinical guidelines and evidence-based personalized clinical practice".
More to follow ...
For the next post in this sequence, see "Warwick BABCP conference: 3rd day - even more evidence that therapists themselves are central to improving outcome (5th post)".