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      Change Processes in Cognitive Therapy for Social Anxiety Disorder Delivered in Routine Clinical Practice

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          Abstract

          Background

          Most studies examining processes of change in psychological therapy for social anxiety disorder (SAD) have analysed data from randomised controlled trials in research settings.

          Method

          To assess whether these findings are representative of routine clinical practice, we analysed audit data from two samples of patients who received Cognitive Therapy for SAD (total N = 271). Three process variables (self-focused attention, negative social cognitions, and depressed mood) were examined using multilevel structural equation models.

          Results

          Significant indirect effects were observed for all three variables in both samples, with negative social cognitions showing the strongest percent mediation effect. ‘Reversed’ relationships, where social anxiety predicted subsequent process variable scores, were also supported.

          Conclusion

          The findings suggest the processes of change in this treatment may be similar between research trials and routine care.

          Abstract

          • The three process variables examined showed significant indirect effects on subsequent social anxiety.

          • There was evidence of a bidirectional relationship between process and outcome.

          • Results are consistent with the theoretical model underpinning the treatment.

          • The change processes of this treatment in routine practice may be similar to those found in research trials.

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          Most cited references34

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          The PHQ-9: validity of a brief depression severity measure.

          While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
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            A general multilevel SEM framework for assessing multilevel mediation.

            Several methods for testing mediation hypotheses with 2-level nested data have been proposed by researchers using a multilevel modeling (MLM) paradigm. However, these MLM approaches do not accommodate mediation pathways with Level-2 outcomes and may produce conflated estimates of between- and within-level components of indirect effects. Moreover, these methods have each appeared in isolation, so a unified framework that integrates the existing methods, as well as new multilevel mediation models, is lacking. Here we show that a multilevel structural equation modeling (MSEM) paradigm can overcome these 2 limitations of mediation analysis with MLM. We present an integrative 2-level MSEM mathematical framework that subsumes new and existing multilevel mediation approaches as special cases. We use several applied examples and accompanying software code to illustrate the flexibility of this framework and to show that different substantive conclusions can be drawn using MSEM versus MLM.
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              Conceptualizing and testing random indirect effects and moderated mediation in multilevel models: new procedures and recommendations.

              The authors propose new procedures for evaluating direct, indirect, and total effects in multilevel models when all relevant variables are measured at Level 1 and all effects are random. Formulas are provided for the mean and variance of the indirect and total effects and for the sampling variances of the average indirect and total effects. Simulations show that the estimates are unbiased under most conditions. Confidence intervals based on a normal approximation or a simulated sampling distribution perform well when the random effects are normally distributed but less so when they are nonnormally distributed. These methods are further developed to address hypotheses of moderated mediation in the multilevel context. An example demonstrates the feasibility and usefulness of the proposed methods.
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                Author and article information

                Contributors
                Role: Developed the data analysis conceptRole: Performed the analyses and drafted the paperRole: Reviewed and approved the final version of the paper for submission
                Role: Designed the data collection protocolRole: Supervised treatment and data collectionRole: Provided critical revisionsRole: Reviewed and approved the final version of the paper for submission
                Role: Supervised treatment and data collectionRole: Reviewed and approved the final version of the paper for submission
                Role: Supervised treatment and data collectionRole: Reviewed and approved the final version of the paper for submission
                Role: Supervised treatment and data collectionRole: Reviewed and approved the final version of the paper for submission
                Role: Collated, entered, and cleaned the dataRole: Reviewed and approved the final version of the paper for submission
                Role: Developed the data analysis conceptRole: Designed the data collection protocolRole: Supervised treatment and data collectionRole: Provided critical revisionsRole: Reviewed and approved the final version of the paper for submission
                Journal
                Clin Psychol Eur
                Clin Psychol Eur
                CPE
                Clinical Psychology in Europe
                PsychOpen
                2625-3410
                June 2020
                30 June 2020
                : 2
                : 2
                : e2947
                Affiliations
                [a ]Department of Experimental Psychology, University of Oxford , Oxford, United Kingdom
                [b ]Oxford University Hospitals NHS Foundation Trust , Oxford, United Kingdom
                [c ]Oxford Health NHS Foundation Trust , Oxford, United Kingdom
                [d ]Institute of Psychiatry, Psychology and Neuroscience, King’s College London , London, United Kingdom
                [e ]National Institute for Health Research Mental Health Biomedical Research Centre, South London and Maudsley NHS Foundation Trust , London, United Kingdom
                [f ]Sussex Partnership NHS Foundation Trust , Worthing, United Kingdom
                [7]Philipps-University of Marburg, Marburg, Germany
                Author notes
                Graham R. Thew, Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford OX1 1TW, UK. graham.thew@ 123456psy.ox.ac.uk
                Article
                cpe.v2i2.2947
                10.32872/cpe.v2i2.2947
                7612064
                34870201
                c89bfb7c-11a2-44a3-a964-fd961dcfd0ad
                Copyright @ 2020

                This is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY) 4.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 15 March 2020
                : 05 May 2020
                Funding
                Funded by: Wellcome Trust;
                Award ID: 102176
                Award ID: 069777
                Award ID: 200796
                Funded by: NIHR Oxford Biomedical Research Centre;
                Funded by: Oxford Health NIHR Biomedical Research Centre;
                Funded by: NIHR Senior Investigator Awards;
                Funded by: NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London;
                The study was supported by the Wellcome Trust [102176 (GRT); 069777 and 200796 (AE & DMC)], the NIHR Oxford Biomedical Research Centre (GRT), the Oxford Health NIHR Biomedical Research Centre (GRT, AE), NIHR Senior Investigator Awards (AE, DMC), and the NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funding sources had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
                Categories
                Research Articles

                social anxiety,cognitive therapy,change processes,structural equation model,mediation

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