Mind the gap: Improving the dissemination of CBT

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Abstract

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Section snippets

The problem

Over the last 30 years considerable progress has been made in developing effective psychological treatments for a wide range of psychiatric disorders. Among these evidence-based treatments forms of cognitive behaviour therapy (CBT) have been consistently shown to be effective across a wide range of disorders. Data from multiple randomized controlled trials (RCTs) indicate that disorder-specific forms of CBT are potent sole interventions in anxiety disorders, eating disorders and unipolar

Evidence that patients are not receiving CBT

Data from the UK and USA indicate that few patients with a detected psychiatric disorder receive CBT. For generalized anxiety disorder, panic disorder and social phobia, the most common psychosocial treatment in 1996 was psychodynamic (Goisman, Warshaw, & Keller, 1999). Overall in the NCS-R dataset of over 9000 people in the USA, complementary and alternative medicine treatments accounted for 31.3% of all mental health visits (Wang et al., 2005). The most common treatment offered to patients

Evidence that CBT is being delivered suboptimally

When CBT is being delivered, it appears that it is often being delivered suboptimally. In an analysis of the NCS-R dataset for mood disorders only (Kessler, Merikangas, & Wang, 2007), no more than 20.9% of all people with 12-month Major Depressive Disorder were considered to have received adequate pharmacological/psychological treatment. Minimally adequate psychological treatment was defined based on available evidence-based guidelines and at least 8 sessions were required based on the fact

Why is CBT so unavailable and so poorly delivered?

The dissemination of the treatments is hampered by a combination of factors. The funding issue is beyond the remit of this paper but it is important to note there is evidence that CBT is a cost-effective treatment (van Asselt et al., 2008, Layard et al., 2007, Myhr and Payne, 2006). There has been relatively little written in the cognitive-behavioural literature about barriers to dissemination with some notable exceptions (Addis, 2002, Barlow, 2004, Barlow et al., 1999, Carroll and Rounsaville,

Research trials have limited applicability to clinical practice

The belief that research trials have limited relevance to clinical practice is based on beliefs about the nature of the patients treated in trials, the generalizability of research findings to routine settings and the discrepancy between resources in research trials and clinical settings. Each of these views is discussed below.

Gaps in knowledge about CBT

Gaps in our current knowledge about training, measuring competence, the mechanism of action of CBT and the minimum dose required for treatment limit the adoption of the protocols to clinical settings.

Key recommendations

A number of key recommendations are made to facilitate the utilisation of empirically supported CBT protocols in routine practice.

  • Treatment developers should state how the existing trials address comorbidity and produce treatment guidelines and manuals; such manuals should be easily accessible and available at a reasonable cost.

  • Clinicians should have easy access to training in diagnostic assessments and routine outcome measures. They should be encouraged to use outcome measures at regular

Acknowledgements

The stimulus for this paper was a meeting on the Dissemination of Psychological Treatments held at the Wellcome Trust, London (December 2006) convened by David M. Clark and Christopher G. Fairburn. We are grateful to the Wellcome Trust for funding this meeting and to Carolyn Black Becker for helpful comments on an earlier version of this manuscript.

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