In Review

New Psychotherapies for Mood and Anxiety Disorders

Shannon Wiltsey Stirman, PhD'; Katherine Toder, BA^ Paul Crits-Christoph,

Objective: To discuss psychotherapies for depression and anxiety that have emerged In recentyears and to evaluate their current level of empirical support.

Method: An electronic and a manual literature search of psychotherapies for mood and anxietydisorders were conducted.

Results: Five new therapies for mood disorders and 3 Interventions for posttraumatic stressdisorder with co-occurring substance abuse met criteria for inclusion in this review. Fewerpsychotherapies have been developed for other anxiety disorders. Although research for some ofthe psychotherapies has demonstrated superiority to usual care, none have firmly establishedefficacy or specific benefits over other established psychotherapies.

Conclusions: A plurality of the new psychotherapies introduced and established in the past5 years have been different assimilations of previously established cognitive-behavioural,interpersonal, or psychodynamic models. While initial results are promising for some, more rigorousefficacy trials and replications are necessary before conclusions can be drawn regarding theirrelative benefits.

Can J Psychiatry. 2010;55(4):193-201.

Clinical Implications

• Many of the reviewed therapies include cognitive, behavioural, interpersonal, andpsychodynamic therapies.

• As research on most new psychotherapies is in the early stages, further research isnecessary before most of these psychotherapies are disseminated.

• Little advancement has been made in achieving substantially better treatment outcomes forpatients with mood and anxiety disorders.

Limitations

• Applications of established treatments to additional disorders were not addressed.

• Minimal modifications to previously established interventions were not included in this review.

• Many of the psychotherapies reviewed were introduced too recently to have fully establishedefficacy.

Key Words: new psychotherapies, depression, anxiety

In recent years, it has become evident that the clinicalresponse rates for current evidence-based psychotherapies

are limited.''^ A recent meta-analysis' estimated rates ofimprovement at 54% for depression, 63% for panic disorder,and 52% for GAD. Thus a recent focus in the psychotherapyliterature has been the development of alternatives orenhancements to established treatments to improve clinicaloutcomes. In our paper, we describe treatments for prevalentadult mood and anxiety disorders^ that have been introducedor tested for efficacy in the past 5 years.

Determining criteria for designation of psychotherapies as

new is challenging. New psychotherapies often have long

gestation periods. The first article to describe a new therapy

may occur 10 to 15 years before a definitive efficacy trial is

published, and, in the interim, the treatment may become well

known. In addition, some new interventions represent less of

a significant departure from established psychotherapies

than refinements or integrations of established interventions.

Similarly, some psychotherapies that are efficacious for one

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In Review

disorder are then tested, with little modification, for additionaldisorders and cannot be considered novel. A comprehensivediscussion of the entire literature on new developments inpsychotherapy is beyond the scope of this article. In the cur-rent review, we will identify psychotherapies that includenovel interventions or strategies, or represent notable modifi-cations of established psychotherapies, and evaluate their cur-rent level of empirical support.

MethodLiterature SearchWe conducted a computer search of PsycINFO andMEDLINE, using the key words that included the name ofeach disorder and psychotherapy, psychosocial treatment, andthe names of specific psychotherapies known to have beendeveloped in the last 5 years. Additionally, we searchedhigh-quality, high-impact journals that publish psychosocialtreatment-efficacy research (The Journal of the AmericanMedical Association, The American Journal of Psychiatry,Psychotherapy and Psychosomatics, Journal of Clinical andConsulting Psychology, Archives of General Psychiatry, TheBritish Journal ofPsychiatry: The Journal of Mental Science,and The Canadian Journal ofPsychiatry). Finally, we manu-ally reviewed prior meta-analyses and reviews."*"

Abbreviations used in this article

ABP affect-focused body psychotherapy

ACT acceptance and commitment therapy

AD antidepressant

BA behavioural activation

BD bipoiar disorder

CBT cognitive-behavioural therapy

CT cognitive therapy

GAD generalized personaiity disorder

ICM intensive clinical management

IPSRT interpersonal and social rhythm therapy

IPT interpersonal psychotherapy

MDD major depressive disorder

PFPP panic-focused psychodynamic psychotherapy

PPT positive psychotherapy

PTSD posttraumatic stress disorder

RCT randomized controlied trial

SS seeking safety

SST self-system therapy

SUD substance use disorder

TARGET Trauma Adaptive Recovery Group Educationand Therapy

TAU treatment as usuai

TREiVI Trauma Recovery and Empowerment Model

Criteria for Inclusion in the Current ReviewIn the current review, new psychotherapies were defined asintroduced and studied within the past 5 years, or as notablepsychotherapeutic models that were introduced earlier (gen-erally in the past decade), but for which research emergedwithin the past 5 years. Refinements or integrations of estab-lished psychotherapies were included if they differed signifi-cantly from earlier models, or if they were modifiedspecifically for the treatment of a particular disorder. Forexample, in recent years, researchers have been studying theapplication of IPT,^ originally studied for the treatment ofMDD, to anxiety disorders, with little modification.'"' ' How-ever, IPT was modified significantly to address the symp-toms of BD.'^ Thus we will discuss the modification for BD,but not for anxiety disorders.

Evaluation of EfficacyIn evaluating the empirical status of each psychotherapy, wewere guided by the following standards for efficacy, effec-tiveness, and specificity,''' although we recognize that newerpsychotherapies are unlikely to have met all of these stan-dards. To be fully established as an efficacious and specifictreatment,''' efficacy, relative to an adequate control group orcomparison treatment, in a large-scale randomized trialshould be demonstrated. Replication, ideally by a differentresearch group, should occur. The specific benefits of thepsychotherapy should be established through comparisonwith an established psychotherapy. Before widespreadimplementation, the new treatment should also be demon-strated to be effective (again, compared with a control groupor alternative active treatment) in a large-scale study thatincludes the types of patients, providers, and settings thatwould be typical for the application of the treatment in rou-tine practice.

New Psychotherapies for Mood DisordersMajor Depressive DisorderIn the past 5 years, the new psychotherapies that have beenintroduced and studied for depression have generally fallenwithin a cognitive or behavioural framework. Each has beenmodified in clinically meaningful ways, through novel inter-ventions or emphasis on different constructs. Thus a typicalsession for these newer variations should be easily distin-guishable from more established cognitive-behaviouralpsychotherapies.

Acceptance and Commitment TherapyACT' ' ' " " ' is a behavioural psychotherapy that departs fromtraditional behavioural models by positing that people learnand relate events within situationally or historically definedcontexts. ACT targets 2 processes by which problematicbehaviours and distressing emotions are maintained. Thefirst is experiential avoidance, in which people attempt toalter negative experiences by changing their form, fre-quency, or the contexts in which they occur. The second pro-cess is cognitive fusion, a process by which behaviours are

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determined more by verbal networks than by experiencedenvironmental consequences. A precursor to the full ACTmodel (called comprehensive distancing'''*) placed lessemphasis on the identification and clarification of values thanthe current model and did not include exercises to helppatients identify or act in ways consistent with their centralvalues.

A recent randomized study" was conducted at a universitystudent clinic at which 99 students with depression or anxietydisorders received ACT or standard CT for an average of15 sessions. The average age of participants, 28 years, wasyounger than that of samples in other clinical trials for depres-sion. Although rates of specific disorders were not described,the authors noted that 33% of the sample had a depressive dis-order.'^ No significant differences in outcomes were found,and 61% of the total were considered recovered from theirdepressive symptoms. This study" did not target MDD oranalyze results separately for different diagnoses. Earlierstudies that targeted depression''"'^ used small, female sam-ples and tested comprehensive distancing rather than ACT.Thus research will be necessary to further examine the effi-cacy and effectiveness of ACT for MDD.

Behavioural ActivationA new and expanded model of BA^" was recently developedand tested. In contrast to earlier BA interventions,^' theexpanded model emphasizes idiographic functional analysisfor the understanding of depressive behaviour and makes useof contextual interventions to change these behaviours. BAfocuses on the role of contextual changes associated withdecreased access to reinforcers in the development and main-tenance of depressive symptoms. The model places emphasison identifying and changing patterns of avoidance and with-drawal, and seeks to promote engagement with reinforcingactivities and contexts that are consistent with a person'slong-term goals.

The expanded version of BA has been tested in one clinicaltrial. A large (n = 241), methodologically rigorous random-ized comparison of 16 weeks of BA, CT, and ADs for MDDwas recently completed.^" BA outperformed CT (by 76% and48% for response or remission, respectively) and producedsimilar outcomes when compared with ADs among a severelydepressed subset of patients (n = 138). These findingsappeared largely to be due to extreme nonresponse by a subsetof patients who received CT,^" and, if replicated, may indicatethat some patients with long histories of depression may bene-fit more from attention to behavioural interventions.^^Statistically significant differences were not found betweenthe 3 treatments among the less severely depressed patients.Both CT and BA reduced the risk of recurrence by about 63%relative to medication withdrawal over a 2-year follow-up.' ^If these findings are replicated by an independent researchgroup, they could have implications for the dissemination ofevidence-based psychotherapies, as some have posited thattraining to competence in BA may be easier than in CT.

20

24

Positive PsychotherapyInstead of directly targeting symptoms of depression,was developed to foster engagement, meaning, and positiveemotion. Patients work with their therapist to identify signa-ture strengths and find practical ways of using these strengthsmore often through a series of exercises. Clients are coachedto refocus their attention and memory to positive aspects oftheir lives with the goal of developing a more balanced viewof their negative experiences. PPT appears to overlap in somesense with CT. However, discussions of problems and symp-toms are minimized in PPT sessions in favour of efforts tostrengthen existing positive aspects, rather than to reinterpretthe negative aspects. Although PPT may be used alone formild levels of depression, the developers intend it as anadjunct to established therapies for moderate-to-severe lev-els of unipolar depression.^^

Two small pilot studies have been conducted to examine theefficacy of PPT. ^ The first study compared group PPT toeclectic, client-centered psychotherapy (TAU) for40 mildly-to-moderately depressed students (diagnosedusing an unstructured diagnostic interview) in a universityclinic and found significant differences in symptom reduc-tion. A second study (n = 46) randomized students diagnosedwith MDD to individual PPT or TAU, and comparedthese 2 groups to a matched comparison group of patientswho received TAU with medications. Significantly morepatients who received PPT met criteria for remission by theend of treatment. Additional research that is adequately pow-ered to detect between-group differences and conducted withmore representative samples is needed. A larger clinical trialis ongoing.

Self-System TherapySST^* was designed to translate the principles of regulatoryfocus theory^^ into an intervention for examining and modi-fying a person's goals and strategies for pursuing them. Themodel purports that depression is a result of a chronic failureto attain personal goals owing to a disorder in motivation andgoal pursuit. People whose socialization histories did notinclude consistent emphasis on promotion goals (advance-ment, achievement, or growth) would have difficulty pursu-ing such goals in adulthood. The goals of SST are to improveself-regulation to attain personal goals. The 20- to 25-sessiontreatment uses strategies from CT, IPT, and BA to define thepatient's goals, identify activities that will facilitate thesegoals, clarify barriers to progress, and develop a plan to attainthese goals.

One RCT, comparing SST with CT for 45 patients withdepression,' ^ has been conducted to date. The treatmentdevelopers hypothesized that patients with a poor promotionsocialization history would show greater improvements withSST than with CT. Because the inclusion criteria allowedpatients with various affective disorders to participate, not allof the patients had MDD, and the sample was less depressedthan samples in other clinical trials. Treatment length was notstandardized for either treatment. Although there were no

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significant differences in depression outcomes between the 2treatments for the overall sample, the outcomes for patientswith problematic self-regulation were significantly better ifthey received SST. It remains to be seen whether SST is moreefficacious than established treatments for a particular sub-group of depressed patients.

Bipolar Disorder

Interpersonal and Social Rhythm Therapy

Only one treatment, IPSRT,^^ was identified as new under thecriteria for inclusion in this review. IPSRT is a form of IPTdeveloped specifically for BD, and it includes several ele-ments not found in the original IPT model. IPSRT is intendedto provide insight into the relation between mood and inter-personal events, stabilize endogenous circadian rhythms bystabilizing daily routines and sleep cycles, and address inter-personal problems related to grief, role transitions, role dis-putes, and interpersonal deficits.'^' In the initial phase, theclinician takes a history of the illness and of interpersonalfunctioning, provides psychoeducation about the disorder,and identifies interpersonal problem areas. In the intermediatephase, the clinician works with the patient to manage symp-toms, implement social rhythm stabilization strategies, andaddress interpersonal problem areas. In the preventativephase, treatment goals are solidified and potential threats tocontinued stability are identified. In the termination phase,treatment successes and areas of continued vulnerability arereviewed.

To date, IPSRT has been tested in 3 studies with adults, 2 ofwhich were RCTs. A large (n = 175), methodologically rigor-ous randomized clinical trial compared pharmacotherapywith either IPSRT or a medication management protocol,ICM, followed by a maintenance phase in which participantsreceived IPSRT or ICM. People diagnosed with BD I orschizoaffective disorder, manic type, participated in the study.Treatment with IPSRT during the acute phase resulted in alonger survival time without a new affective episode, regard-less of the maintenance strategy, and patients who receivedIPSRT were more likely to remain well over a 2-yearfollow-up.'''

Miklowitz et al''*' ' randomized 300 patients with BD to a3-session psychoeducation condition (collaborative care) or1 of 3 intensive psychotherapies (CBT, IPSRT, or family-focused therapy). The psychotherapies resulted in signifi-cantly better relationship functioning and life satisfaction atthe end of a 9-month acute phase and significantly higher ratesof recovery at the end of a 12-month follow-up.^"'" Differ-ences between the 3 psychotherapies were not significant,although the study was not adequately powered to detect suchdifferences.

New Psychotherapies for Anxiety DisordersPosttraumatic Stress DisorderRecently, owing to the high incidence of co-occurring SUDsand the challenges to treatment in the context of substanceabuse or dependence, 3 interventions designed to addressPTSD and substance abuse or dependence have been intro-duced and tested. Each includes multiple modules and com-ponents, which are intended to develop skills for coping withcravings and PTSD symptoms.

Seeking SafetySS^^ is a structured treatment package consisting of 24 mod-ules, evenly divided between cognitive, behavioural, andinterpersonal coping skills. Skills that are relevant to bothdisorders, such as identifying and fighting triggers, askingfor help, and setting boundaries, are taught and practiced ineach session. The intervention includes weekly individual-ized commitments to practicing the skills discussed in eachmodule. The primary emphasis of the treatment is patientsafety, defined as abstinence from all substances, reductionin self-destructive behaviour, establishment of a support net-work, and self-protection from dangers associated with thedisorders. SS was developed to be used in group or individualformats, although most of the research to date has examinedgroup interventions.

SS has been examined in 13 studies. Preliminary researchyielded promising decreases in PTSD symptoms and sub-stance use, compared with usual care conditions.•' "•''' How-ever, the findings of more recent large-scale studies,including 2 fairly rigorous RCTs,^''^^ have not been asfavourable. One of them compared SS with TAU, and foundsignificantly greater reduction in PTSD symptoms, but moresubstance use, among SS patients.''^

The largest {n = 353) study was a hybrid efficacy-effectiveness comparison of a 12-session modification of SSplus standard substance abuse treatment (TAU) to aWomen's Health Education Group plus TAU for womenwith PTSD (or subthreshold PTSD) and substance abuse.^^Treatments were implemented in nonresearch settings withTAU varying somewhat by site. Rolling admission into treat-ment groups was permitted, and less stringent inclusion andexclusion criteria were employed. Neither PTSD nor sub-stance use outcomes differed between the 2 active treatments,although both produced significant reductions in symptoms.Secondary analyses indicated that SS patients had greaterreductions in high-risk sexual behaviours." As the activepsychotherapies or psychoeducation interventions were notcompared with a no-treatment control or TAU, it is difficultto draw conclusions regarding the relative efficacy of eithercombined treatment to standard care.

Trauma Recovery and Empowerment ModelTREM is a 33-session, manualized group treatmentdesigned to address the emotional and interpersonal conse-quences of physical or sexual abuse for women. The

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treatment uses a supportive, skill-building curriculum thatallows members to acknowledge the impact of abuse whilefocusing on the development of techniques for mastery andenhancing existing strengths and coping skills. The interven-tion focuses on empowerment, trauma education, andskills-building in 11 different areas.

TREM has been the subject of 2 studies, 1 of which alsoincluded a comparison to SS. In a quasi-experimental studyinvolving 170 women,'^ participants who received a24-session modification of TREM in addition to standardcare were compared with those who received standard care ina residential substance abuse setting. Participants were eligi-ble if they had a diagnosis of current substance abuse, a his-tory of trauma, and a current Axis I or II disorder. Participantswho received the TREM intervention experienced signifi-cantly greater improvements in trauma-related symptoms atthe 12-month outcome assessment; however, group differ-ences were not found in substance abuse outcomes. Theresults of this study^' must be interpreted with caution, as notall of the participants met full criteria for PTSD, and the studywas not randomized.

A large (n = 2026) multisite, quasi-experimental study ofmulticomponent treatment models for women with historiesof trauma and SUD compared SS, TREM, and usual care (inoutpatient mental health settings)."** Usual care was not stan-dardized across sites, although, at each site, an integrated,trauma-informed approach was used. As in the previouslydescribed study, ^ not all participants were diagnosed withPTSD, and participants were not randomized. Neitherapproach outperfomied the usual care condition, but somebenefits were found in PTSD and mental health symptomreduction when the data for SS and TREM were aggregatedand compared with usual care."" As with the previouslydescribed study, methodological considerations limit theinterpretability of the results. More rigorous study will be nec-essary to investigate the efficacy of TREM. In addition,although research indicates that both SS and TREM producesignificant symptom change, no research has demonstratedbenefits for a specific combined treatment package, and nei-ther treatment has been compared with established treatmentsfor PTSD or substance abuse alone.

Trauma Adaptive Recovery Group Education andTherapy

TARGET"" isa 12-session,trauma-focused,present-centred,emotion self-regulation model for concurrent treatment ofPTSD and SUDs. It consists of 3 parts: education about PTSDas a biological change in response to trauma; teaching of skillsfor managing traumatic stress, which complement skills usedin SUD treatments for coping with cravings; and an experien-tial exercise to facilitate the processing of emotionallycharged memories through a nonverbal, creative arts modal-ity. Unlike TREM and SS, which do not include exposure,exposure work is optional in the TARGET intervention.

To date, the effectiveness of TARGET has been assessed inone study, which took place in community-based outpatientclinic. The study included 213 men and women with a traumahistory, SUD, and an additional Axis I diagnosis who wererandomized to TARGET or TAU. Findings for one of the pri-mary outcome analyses, sobriety self-efficacy, approachedstatistical significance, but differences were not foundbetween groups for PTSD symptoms. Secondary analysesrevealed differential effects for some demographic sub-groups.''^ Consequently, modifications may be necessary toaddress the needs of minority patients.

Panic DisorderPanic-Focused Psychodynamic PsychotherapyFew developments in psychotherapies for panic disorderhave emerged recently, other than the integration of technol-ogy into established psychotherapies. However, a twice-weekly, 24-session PFPP was developed. The interventiontargets core confiicts about anger recognition, ambivalentfeelings about autonomy, and fears of loss or abandonmentcommonly found in panic disorder. Over the course of thesessions, therapists work to uncover unconscious meaningsto panic symptoms, understand and change the core confi icts.

Three studies,"'"^^ 2 of which were RCTs, have examinedPFPP. Most recently, 49 adults with primary Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, panicdisorder were assigned to either 12 weeks of twice-weeklysessions of PFPP or applied relaxation training."^ Patientswho received PFPP experienced a significantly higherdecrease in panic severity than the applied relaxation group(73%, compared with 39%), and greater reduction in func-tional impairment and depressive symptoms. One potentiallimitation of this trial is the use of applied relaxation training,which has been found to be less effective than CBT, as a com-parison- treatment. These preliminary results suggest thatPFPP may be an efficacious intervention for panic disorder;however, further comparison to approaches such as CBT thatincorporate homework and exposure strategies is warranted.A larger clinical trial is currently in progress.

Generalized Anxiety DisorderAffect-Focused Body PsychotherapyOnly one psychotherapy, ABP,"^ has emerged as a new treat-ment for GAD in recent years. ABP is based on a treatmentthat was originally applied to chronic pain, but its applicationto GAD is the first study that evaluates its efficacy for anAxis I disorder. Based in part in psychodynamic theory, ABPintegrates bodily techniques and the exploration of affect intoa psychodynamic frame of reference. Clinicians focus ondeveloping an understanding of the information latent inaffects and increasing the tolerance for anxiety and previ-ously withheld affect. As the bodily interventions allow thepatient to focus on whatever the body tells him or her, thetreatment includes a mindfulness component.

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ABP has been examined in an RCT with 61 patients diagnosedwith GAD, most of whom were also diagnosed with an Axis IIdisorder.''* Patients were randomized into ABP or TAU.Fewer than one-half of the TAU patients received psychother-apy, while others visited the doctor or had unspecified inter-mittent therapeutic contact. ABP patients were seen for anaverage of 37 sessions over 1 year, and treatment length forthe TAU condition varied. Although patients in the ABP con-dition experienced significantly greater reductions in generalpsychiatric symptoms as measured by 1 of 3 self-reports usedto assess outcomes, differences in anxiety were not significantbetween the 2 groups. The methodological limitations associ-ated with this study,''* including the use of self-report mea-sures, heterogeneous sample, differences in TAU, andvariable treatment length, limit the conclusions that can bedrawn from it.

Other Anxiety DisordersNovel treatments for social anxiety disorder and obsessive-compulsive disorders have not emerged in the past 5 years.ACT, described more fully in the depression section above,has been investigated in very small open trials for each disor-jgj.47,48. jjoy igygj. given the preliminary nature of these stud-ies, more rigorous clinical trials will be necessary to determinewhether it is an efficacious and viable alternative to moreestablished psychotherapies for these disorders.

DiscussionOur brief overview of Selected new psychotherapies raisesquestions about: the nature of new psychotherapies in relationto preyious psychotherapies; the clinical applicability of suchnew psychotherapies' biased on available empirical evidence;implications of such new psychotherapies for training and dis-sernination; and directions for future research. We addresseach of these questions here, with examples drawn from thetypes of new psychotherapies contained in our brief review.

What rnakes a new psychotherapy new? Many of thepsychotherapies that have been studied iii recent years can becharacterized moré as refihements or extensions of existingtherapeutic niodels (cOgnitive-béhavioural, interpersonal, orpsychodynamic), rather than as significant departures fromestablished psychotherapies. the refinements and modifica-tions to these therapies generally represent efforts to applyexisting models to additional disorders. Often by bringingtogether several techniques that were previously used in otherseparate cont:éxts. Thus, in many ways, the newpsychotherapies aré not really hew. For example, IPSRT is anew psychotherapy for BÖ that largely uses the techniques ofIPT but also adds stabilization of daily routines and sleepcycles. This careful attention to cues for circadian rhythms(for example, mealtime and bedtime) borrows from cognitive-behavioural treatments for insomnia that also address suchcues. However, this is not to say that such a repackaging andrefinement is not an advancement that may lead to substan-tially better clinical outcomes in certain new contexts.

One psychotherapy that is more than a repackaging is PPT.While the goals of PPT (for example, self-actualization andpositive mental health) have long been addressed in the men-tal health and psychotherapy literature,'"'^" many of the spe-cific interventions used in PPT are novel. For example,homework assignments in PPT can include writing a storyillustrating one's character strengths or giving one's time in away that calls on one's signature strengths to serve somethingmuch larger than the self ^

The clinical applicability of these new psychotherapiesshould ultimately be based on available empirical evidence.In general, it is too early to tell whether these newpsychotherapies will succeed, as most of them have not yetbeen examined in adequately powered, methodologicallyrigorous studies. Among the 4 psychotherapies (BA, SS,IPSRT, and PFPP) that have been tested in adequately pow-ered, high-quality clinical trials, only BA has demonstratedsuperiority to an established, first-line psychotherapy for asubset of patients. As none of the treatments reviewed havefirmly established efficacy or specificity, more rigorous rela-tive efficacy trials and replications are necessary before con-clusions can be drawn regarding their relative benefits.

The advent of new psychotherapies raises the issue of whento disseminate these treatments and how best to train thera-pists in the new methods. Historically, new psychotherapieswere disseminated regardless of the extent of their empiricalsupport. The rise of behavioural, and later cognitive, treat-ments was in part anchored in the concept that decisionsabout what to practice—and, therefore, train anddisseminate—needed to be based on scientific evidenceabout effectiveness. Despite this current widespread belief,new psychotherapies are still often disseminated before theirefficacy is firmly established. For challenging clinical phe-nomena for which no empirically supported treatment hasemerged, practising clinicians are eager for clinical guidanceand may seek promising or innovative approaches beforethey are fully investigated. Similarly, new treatments mightgenerate widespread interest if they yield comparable resultsto an established psychotherapy in preliminary research, par-ticularly if their therapeutic models are well received by clini-cians. Given the substantial amount of time required to securefunding and conduct large clinical trials, it is not surprisingthat individual clinicians would make such decisions whenworking with nonresponsive or challenging patients. Further,developers of new psychotherapies can reap substantialfinancial rewards through books, workshops, and traininginstitutes. Thus clinician demand, the length of time requiredto establish efficacy, and financial incentives can workagainst waiting for definitive tests of efficacy and effective-ness to disseminate a new psychotherapy. Given the clinicalimplications of disseminating ineffective treatments, theexpense of providing adequate training, and challengesrelated to the implementation of new therapeutic models, werecommend that strong empirical support be establishedbefore large-scale implementation.

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Insufficient data are available regarding implications fortreatment matching. Adequate tests of moderators have notyet been conducted for most of these treatments. However,some interventions (for example, SFT, SS, TARGET, andTREM) are being developed specifically for segments of thelarger population diagnosed with a particular disorder. Byfocusing on a subgroup within a disorder, such newpsychotherapies are implicitly addressing treatment modera-tion: the new treatment is expected to be especially effectivefor one type of patient and, by inference, not for another typeof patient. Thus clinical ideas about moderators of treatmenteffectiveness have been a driving force behind the develop-ment of new psychotherapies.

An alternative to the development of new psychotherapies forincreasingly narrowly defined populations is the developmentof approaches that would apply broadly across many disor-ders. Such approaches, if found to be effective with a broad setof disorders, have the potential to be implemented more easilythan different, highly specific approaches for different disor-ders. The applications of IPT and ACT to multiple disorderswithout significant modifications, and a recent unified treat-ment model for depression and anxiety,^''" follow thismethod. These models are consistent with the view that manydisorders stem from an underlying common diathesis, andpropose a more simplified and distilled approach to treatment.

In the quest for new and better psychotherapies, it is alsoimportant to consider the role of common factors. Most exist-ing psychotherapies include the elements of a positive thera-peutic alliance, a new corrective emotional experience thatallows the patient to experience past problems in new andmore benign ways, positive expectations for change, therapistempathy and positive regard, and provision of an explanationfor understanding the cause or maintenance of a problem.Empirical evidence exists supporting the role of these factorsin relation to psychotherapy outcome." Efforts should bemade to design research to investigate the role of common,compared with specific, factors when comparing newpsychotherapies to established treatments,'"* particularlywhen there is overlap between the therapeutic models. Analternative strategy to developing new psychotherapies wouldbe to create and test therapy models that attempt to maximizeone or more of these common factors, as has been done for thealliance,^'

The above discussion makes clear several directions for futureresearch, Basic efficacy and effectiveness studies are stillneeded for many of the new psychotherapies. Rather thanassuming that a new psychotherapy is appropriate only for aspecialized subpopulation, this hypothesis should be tested instudies of moderators of treatment effectiveness orpatient-treatment matching designs. Combining some of thenew treatments with existing psychosocial treatments or med-ications is also likely to be a fruitful direction for research. Forexample, adding in PPT interventions to treatment (whetherpsychodynamic or cognitive-behavioural) may be useful,especially as a second phase of treatment occurring after

major psychiatric symptoms have been alleviated and func-tioning is improved. To combine quite different approaches,some long-held beliefs about treatment may need to bechanged, such as the need for a psychodynamic therapist toremain relatively neutral and to not be directive. Alterna-tively, treatment models that rely on 2 therapists, each skilledin administering their respective techniques, could be devel-oped to address these concerns. The use of more than one cli-nician may be particularly needed if it is difficult for a singleclinician to learn multiple approaches and feel fully commit-ted to each of them.

Although we remain optimistic that additional research willadvance our knowledge of the clinical usefulness of newpsychotherapies, there is also an impression that there hasbeen relatively little advancement in the past decade inachieving substantially better treatment outcomes forpatients with mood and anxiety disorders. Is there some pro-cess (for example, the nature of training in graduate school,the allegiance to existing schools of therapy, and fundingopportunities) that is restricting the development of trulyinnovative new approaches that would potentially be break-throughs? Are there inherent restrictions on how much cer-tain behavioural problems, or certain people, can change?^''Does the uniqueness of each person's past experiences andcurrent circumstances require sophisticated approaches thatuse a range of techniques depending on the person? We hopefurther research on new psychotherapies provide someanswers to these questions.

AcknowledgementsThe preparation of this article was funded in part by NationalInstitute of Mental Health grants K99-MH080100,R34-MH072678, R24-MH070698, and P30-MH45178, TheCanadian Psychiatric Association proudly supports the In Reviewseries by providing an honorarium to the authors.

The authors acknowledge Jessica Olli's assistance in preparingand editing the manuscript.

References

1. Westen D, Morrison K. A multidimensional meta-analysis of treatments fordepression, panic, and generalized anxiety disorder: an empirieal examinationof the status of empirically supported therapies. J Consult Clin Psychol.2001;69:875-899.

2. Mitehell JE, Agras S, Wonderlieh S. Treatment of bulimia nervosa: where arewe and where are we going? Int J Eat Disord. 2OO7;4O:95-IO1.

3. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalenee and age-of-onsetdistribtjtions of DSM-IV disorders in the National Cotnorbidity SurveyReplication. Arch Gen Psyehiatry. 2005;62:593-602.

4. Powers MB, Zum Vorde Sive Vording MB, Emmelkamp PM. Acceptance andcommitment therapy: a meta-analytic review. Psyehother Psyehosom.2009;78:73-80.

5. Beynon S, Soares-Weiser K, Woolacott N, et al. Psyehosocial interventions forthe prevention of relapse in bipolar disorder: systematie review of controlledtrials. Br J Psychiatry. 2008; 192:5-11.

6. Lau MA. New developments in psychosoeial interventions for adults withunipolar depression. CurrOpin Psychiatry. 2008;21:30-36.

7. Miklowitz DJ, Otto MW. New psyehosocial interventions for bipolar disorder:a review of literature and introduction of the Systematic TreatmentEnhancement Program. J Cogn Psyehother. 2006;20:2I5-230. Special Issue:Positive Psychology.

8. Weissman MM, Markowitz JC, Klerman GL. Comprehensive guide tointerpersonal Psyehotherapy. New York (NY): Basic Books, Ine; 2000.

The Canadian Journal of Psychiatry, Voi 55, No 4, Aprii 2010 199

in Review

9. Krupnick JL, Green BL, Stockton P, et al. Group interpersonal psychotherapy for, low-ineome women with posttraumatic stress disorder. Psychother Res.2008; 18:497-507. • ' • " •' ' .'

10. Lipsitz JD, Gur M, Vermes D, et al. A randomized trial of interpersonal therapyversus supportive therapy for social anxiety disorder. Depress Anxiety..2008;25:542-553; , , • . ; . ,

11. Bleiberg KL, Markowitz JC. A pilot study of interpersonal psychotherapy for. posttraumatic, stress disorder. Aril J Psychiatry. 2005;162:181-183. '

12. Fi"änk E,' Kupfer DJ, Thase ME, et al..Two-year outcomes for interpersonal andsocial rhythrri therapy in individuals with bipolar I disorder. Arch GenPsychiatry. 20Ó5;'62:99;6-Í004. .•• . ,.'• î . , , •'.••_

13. Chambless DL, HoUon SD.Deñning einpirically supported therapies. J ConsultClinPsychol. 1998;66:7-18.

14. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: anexperiential approach to behavior change. New York (NY): Guilford Press;

1999. . . . - ' • ' • ' ' • ' ' ' ' ' .15. Strosahl K, Hayes S, Bergan J, etal. Assessing the field effectiveness df

acceptance and comriiitmeht therapy: ah example of the manipulated trainingresearch method: Be"havther.l998;29:35-64. ''

16. Hayes SC. Acceptance and commitment therapy, relational frame theory, and thethird wave of behavioral and cognitive therapies. Behav Ther. 2004;35:639-665.

17. Zettle RD, Rains JC. Group cognitive and contextual therapies in treatment ofdepression. J Clin Psychol.l989;45:436-445.

18. Zettle. RD, Hayes SC.'Component anil.process analysis.of cognitive therapy.Psychol Rep. 1987;61:939r953. / ' . ' ; , , . : -. •

19. Forman EM, Herbert JD, Moitra E, et al. À randomized controlled effectivenesstrial .of acceptance and cotmiiitment therapy and cognitive therapy for anxietyand depression. Behav Modif.2007;31:772-799. , ; , ' i .

20. Dimidjian S, HoUdn SD, Dobson KSj et al. Randomized trial of behavioralactivation, cognitive therapy, and.antidèpréssant riiedication in the acutetreatment of adults with itiajor depression. J Consult Clin Psychol.2006;74:658-670. ' ", } ;. ^" ' , '

21. Jacobson NS, Dobson KS, tniax PA, et al. A component analysis ofcoghitive-behavioral treatment for depression. J Consult Clin Psychol.

• 1996;64:295-304. . > ' , ' ' •22. Coffman SJ, Martell CR, Dimidjian S, et al. Extreme nonresponse in cognitive

therapy: can behavioral activatioii succeed where cognitive therapy fails?J Consult Clin Psychol. 2~007;75:531-541.' . • \ /

23. Dobson KS, Hollbn SD, Dimidjian S, et al. Randomized trial of behavioralactivation, cognitive therapy, and antideptessant medication in the preventioh ofrelapse and recurrence in major depression. J Consult Clin Psychol.2008;76:468-477. ' , _ ' •

24. HoUon SD. Behavioral activation treatment for depression: a commentary. ClinPsychol: Sei Pract. 2001;8:271-274.

25. Seligman MEP, Rashid T, Parks AC. Positive psychotherapy. Am Psychol.2006;61:774-788. . . . .

26. Vieth AZ, Strauman TJ, Kolden GG, et al. Self-system therapy (SST):a theory-based psychotherapy for depression. Clin Psychol: Sei Pract.2003;10:245-268. . . . . , ' '

27. Higgins ET. Beyond pleasure and pain. Am Psychol. 1997;52:1280-1300.28. Strauman TJ, Vieth AZ, Merrill KA, et al. Self-system therapy as an intervention

for self-regulatory dysfunction in depre'ssioii: a randoniized comparison withcognitive therapy. J Consult Clin Psychol.,2006;74;367-376. ,

29. Frank E, Swartz HA, Kupfer DJ. Interpersonal and social rhythin thei-apy:managing the chaos of bipolar disorder.,Biol Psychiatry. 2000;48:593-604.

30. Miklowitz DJ, Otto MW, Frank E, et al. Intensive psychosocial intervention ,enhances functioning in patients with bipolar depression: results from a 9-monthrandomized controlled trial. Am J Psychiatry. 2007;164:1340-1347.

31. Miklowitz DJ, Otto MW, Frank E, et al. Psychosocial treatments for bipolardepression: a 1-year randomized trial from the Systematic TreatinentEnhancement Progi-am. Arch Gen Psychiatry. 2007;64:419-427.

32. Najavits LM, Weiss RD, Shaw SR, et al. "Seeking safety": outconie ofa newcognitive-behavioral psychotherapy for women with posttraumatic stressdisorder and substance dependence. J Trauma Stress. 1998;11:437—456.

33. Najavits LM, Schmitz M, Gotthardt S, et al. Seeking safety plus exposuretherapy: an outcome study on dual diagnosis men. J Psychoactive Drugs.2005;37:425-435. • .

34. Najavits LM, Gallop RJ, Weiss RD. Seeking safety therapy for adolescent girlswith PTSD and substance use disorder: a randomized controlled trial. J BehavHealth Serv Res. 2006;33:453-463.

35. Hien DA, Cohen LR, Miele GM, et al. Promising treatments for women withcomorbid PTSD and substance use disorders. Am J Psychiatry.2004;161:1426-1432.

36. Hien DA, Wells EA, Jiang H, et al. Multisite randomized trial of behavioralinterventions for women with co-occurring PTSD and substance use disorders.J Consult Clin Psychol. 2009;77:607-619.

37. Hien DA, Campbell AN, Killeen T, et al. The impact of trauma-focused grouptherapy upon HIV sexual risk behaviors in the NIDA clinical trials network"Women and Trauma" multi-site study. AIDS Behav. 2009 May 19; [Epubahead of print].

38. Fallot RD, Harris M. The Trauma Recovery and Empowerment Model(TREM): conceptual and practical issues in a group intervention for women.Community- Ment Health J. 2002;38:475^85.

39. Toussaint DW, VanDeMark NR, Bomemann A, et al. Modifications to thetrauma recovery and empowerment model (TREM) for substance-abusingwomen.with histories of violence: outcomes ahd lessons learned at a Coloradosubstance abuse treatment center. J Community Psychol. 2007;35:879-894.

40. Morrisséy )P, Jackson EW, Ellis AR, et al. Twelve-month outcomes oftrauma-informed interventions for women with co-occurring disorders.PsychiatrSety. 2005;56:1213-1222. .. - . • , .

41. Ford j p , Russo E. Trauma-focused, present-centered, emotional self-regulationapproach to integrated ti'batment for posttraumatic stress and addiction: traumaàdaptivé/ecqvery group education and therapy (TARGET). Am J Psychother.

' 2006;¿Ó:335-355; ' •' '

42. Frisman L, Ford JD, Lin H, et al. Outcomes of trauma treatment using theTARGET model. J Groups Addict Recover. 2008;3:285-303.

43. Milrod B, Busch F, Leon AC, et al. Open trial of psychodynamic psychotherapyfor panic disorder: a pilot smdy. Am j Psychiatry. 2000; 157:1878-1880.

44. Milrod B, Busch F, Leoh AC, et al. A. pilot open trial of brief psychodynamicpsychotherapy for panic disorder. J Psychother Pract Res. 2001;10:239-245.

45. Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial ofpsychoanalytic psychotherapy for panie disorder. Am J Psychiatry.

^ • 2007;Ï64:265-272.46. Levy Berg A, Sandell R, Sandahl C. Affect-focused body psychotherapy in

patients with generalized anxiety disorder: evaluation of an integrative tnethod.J PsychoÄer Integration. 2009;19:67-85.

47. Dalrymple KL, Herbert JD. Acceptance and commitment therapy forgeneralized social anxiety disorder: a pilot study. Behav Modif2007;31:543-568. ' ' '

48. Twohig MP, Hayes SC, Masuda A. Increasing willingness to experienceobsessions: acceptance and commitment therapy as a treatment foróbsessive-cbhipuisivé disorder: Behav Ther. 2006;37:3-13.

49. Jahoda M. Current eoncepts of positive inental health. New York (NY): BasicBooks, Inc;, 1958. . ' ' ' • ' •

50. Maslow AH. The farther reaches of human nature. New York (NY): PenguinGroup; 1971.

51. Allen LB, McHugh RK, Barlow DH. Emotional disorders: a unified protocol.New York (NY): Guilford Press; 2008.

52. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotionaldisorders. Behav Ther. 2004;35:205-230.

53. Castonguay LG, Beutler LE, editors. Principles of therapeutic change that work.New York (NY): Oxford University Press; 2006.

54. DeRubeis RJ; Brotman MA, Gibbons CJ. A conceptual and methodologicalanalysis of the nonspecifics argument. Clin Psychol: Sei Pract.2005;12:I74-183.

55. Crits-Christoph P, Connolly Gibbons MB, Crits-Christoph K, et al. Cantherapists be trained to improve their alliances? A preliminary study ofalliance-fostering psychotherapy. Psychother Res. 2006; 16:268-281.

56. Seliginan MEP. What you can change and what you can't: the complete guideto successibl self-improvement. New York (NY): Knopf; 1993.

Manuscript received atid accepted September 2009.' Staff Psychologist, National Center for Posttraumatic Stress Disorder,Veterans Affairs Boston Healthcare System, Boston, Massachusetts;Assistant Professor, Department of Psychiatry, Boston University,Boston, Massachusetts. [Much of the work on the paper was conductedwhile Dr Stirman was a Research Associate in the Department ofPsychiatry at the University of Pennsylvania.]

^ Research Assistant, Department of Psychiatry, University ofPennsylvania, Philadelphia, Pennsylvania.

^ Professor of Psychology in Psychiatry, Center for PsychotherapyResearch and Department of Psychiatry, University of Pennsylvania,Philadelphia, Pennsylvania.

Address for correspondence: Dr P Crits-Christoph, 3535 Market Street,6th Floor, Philadelphia, PA 19104; crits@mail.med.upenn.edu

200 La Revue canadienne de psychiatrie, voi 55, no 4, avrii 2010

New Psychotherapies for Mood and Anxiety Disorders

Résumé : Nouvelles psychothérapies pour les troubles de l'humeur et anxieux

Objectif : Discuter des psychothérapies pour la dépression et l'anxiété qui ont fait leur apparition cesdernières années et évaluer le niveau actuel de leur soutien empirique.

Méthode : Une recherche documentaire électronique et manuelle des psychothérapies pour lestroubles de l'humeur et anxieux a été menée.

Résultats : Cinq nouvelles thérapies pour les troubles de i'humeur et 3 interventions pour le troublede stress post-traumatique avec abus de substances co-occurrent satisfaisaient aux critèresd'inciusion pour cette étude. Un moins grand nombre de psychothérapies ont été mises au point pourd'autres troubies anxieux. Bien que la recherche pour certaines des psychothérapies ait démontréune supériorité sur les soins habituels, aucune n'a prouvé fermement une efficacité ou desavantages spécifiques par rapport aux autres psychothérapies établies.

Conclusions : Une pluraiité des nouvelles psychothérapies introduites et établies dans les5 dernières années constituent différentes assimilations de modéies cognitivo-comportementaux,interpersonnels ou psychodynamiques établis antérieurement. Bien que les premiers résultats soientprometteurs pour certaines, des essais d'efficacité plus rigoureux sont nécessaires avant de pouvoirtirer des conclusions quant à leurs avantages relatifs.

TheCanadian Journal of Psychiatry, Vol 55, No 4, April 2010 ^ 201

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