1 APA practice guidelines for the treatment of psychiatric disorders
2 L EFFICACIA DELLA PSICOTERAPIA Perché affidarsi a trattamenti psicoterapici la cui efficacia sia stata sottoposta a verifiche sperimentali? In fondo qualsiasi psicoterapeuta, corredato di una buona formazione e sufficiente esperienza clinica, è in grado di orientarsi nel trattamento dei pazienti. In realtà, la convinzione che un determinato approccio terapeutico funzioni non può fondarsi unicamente sulla propria esperienza clinica: la verifica sperimentale ci consente di superare la trappola pericolosa dell'auto-inganno, sostenuto dal desiderio di proteggere la fiducia nel metodo terapeutico abbracciato (Migone, 2001). I disturbi mentali costituiscano un grande problema di sanità pubblica per una serie di ragioni: presentano un'elevata frequenza nella popolazione generale, in tutte le fasce d età; sono fortemente invalidanti nella vita quotidiana, nel lavoro/scuola, nelle relazioni interpersonali; infine, sono onerosi i costi economici e sociali che ne derivano per i pazienti e per i familiari (Tansella e de Girolamo, 2001). Tutto ciò rende indispensabile lo sforzo di offrire ai pazienti trattamenti elettivi per i loro disturbi, la cui efficacia sia stata provata scientificamente (Barcaccia e Mancini, 2006). In questi ultimi decenni c è stata una vera e propria esplosione delle ricerche scientifiche sui disturbi psichiatrici. Se ciò da un lato produce un continuo ampliamento delle conoscenze, dall altro rischia di generare confusione e disorientamento nel paziente e nel clinico che dovrà occuparsi della sua cura. L APA (American Psychiatric Association) ha cominciato ad occuparsi di questi temi sulla spinta del più vasto movimento EBM (Evidence-Based Medicine, medicina basata su prove di efficacia), nato nel Regno Unito e fondato su alcuni semplici principi: se il clinico fa costantemente riferimento a conoscenze scientifiche aggiornate, il trattamento dei pazienti migliora, in caso contrario è destinato a peggiorare nel tempo; i clinici devono poter attingere agevolmente a compendi selezionati da esperti sugli interventi più nuovi ed efficaci, e queste informazioni devono ricevere ampia diffusione (Cochrane, 1999). Proprio ispirandosi a questi principi, l APA sviluppa linee-guida pratiche che nascono da revisioni rigorose della letteratura scientifica sui diversi disturbi psichiatrici. Tali guide, rinnovate ogni cinque anni circa, sintetizzano le conoscenze disponibili con lo scopo di assistere il curante nelle sue decisioni cliniche affinché possa offrire a ciascun paziente il trattamento, farmacologico e/o psicoterapico, dimostratosi più efficace per quel disturbo. Da un attenta analisi delle linee-guida stilate dall APA (Practice Guidelines) emerge che la psicoterapia Cognitivo-Comportamentale, con le sue diverse tecniche e strategie, rappresenta ad oggi il trattamento di prima linea, la terapia da consigliare al paziente come primo ed elettivo intervento, per molti disturbi psichiatrici (segue tabella sintetica con le linee-guida APA). È d obbligo, d'altronde, ricordare che l assenza di alcune psicoterapie dall elenco dei trattamenti raccomandati non significa necessariamente che non funzionano, ma può, ad esempio, derivare dalla mancanza o scarsità di ricerche rigorose condotte per valutarne l efficacia (evidencebased).
3 Barcaccia B. e Mancini F., Psicoterapia basata su prove di efficacia e protocolli terapeutici in uovo Manuale di Psicoterapia Cognitiva, Bara B. (a cura di), Bollati Boringhieri, Cochrane A. Efficienza ed Efficacia. Riflessioni sui servizi sanitari Il Pensiero Scientifico Editore, 1999 Department of Health Treatment Choice in Psychological Therapies and Counselling. Evidence Based Clinical Practice Guideline Kazdin A.E., Weisz J.R. Evidence-Based Psychotherapies for Children and Adolescents The Guilford Press 2003 Kendall P.C., Chambless D.L., Eds Empirically supported psychological therapies. Journal of Consulting and Clinical Psychology 66:3-167 (special issue) Lyddon W. J., Jones J. V. Jr., L approccio evidence-based in psicoterapia McGraw-Hill 2002 Morosini P., Michielin P. Efficacia delle psicoterapie. In: La salute mentale: Contro il pregiudizio, il coraggio delle cure. Eds. Cassano G.B., Dell Acqua G., Garattini S., Maj M., Morosini P., Muggia E., Munizza C., Racagni G., Tansella M. Roma: Il Pensiero Scientifico Editore Disponibile all indirizzo web Morosini P., de Girolamo G., Picardi A., Polidori G., Fassone G., Mazzotti E. Il Progetto azionale Salute Mentale: motivazioni, storia, organizzazione, prodotti e prospettive In de Girolamo G., Picardi A., Polidori G., Morosini P. (a cura di): Progetto azionale Salute Mentale: rapporto della prima fase. Istituto Superiore di Sanità, serie Rapporti ISTISAN, Roma, Disponibile all indirizzo web Roth A., Fonagy P What Works for Whom? A Critical Review of Psychotherapy Research. New York: Guilford. Ed.it. Roth A., Fonagy P. Psicoterapie e prove di efficacia. Quale terapia per quale paziente Il Pensiero Scientifico Editore 1997
4 Linee-guida pratiche dell APA per il trattamento dei disturbi psichiatrici Tabella Riassuntiva (sintesi a cura di Teresa Cosentino) Disturbo Fonte Trattamento I Linea Altri Trattamenti Riferimenti bibliografici Abuso di Sostanze (nicotina, alcool, cocaina, oppiacei) Practice Guideline 2006 Terapia Cognitivo-Comportamentale (CBT) + Farmaci + Terapia Comportamentale Terapia Motivazionale (MET); 1 Facilitazione in 12-passi (TSF); Terapia Psicodinamica e Interpersonale (IPT); Manuali di auto-aiuto; Auto-controllo comportamentale; Terapia di gruppo, di coppia e familiare Alzheimer Practice Guideline 2007 Farmaci Terapia Comportamentale; Skills Training 2 Bipolare Practice Guideline 2002 Guideline Watch 2005 Farmaci Terapia Cognitivo-Comportamentale; 3 Terapia Interpersonale e Familiare Borderline Practice Guideline 2001 Guideline Watch 2005 Terapia Dialettico-Comportamentale + Farmaci centrati sui sintomi Terapia Cognitiva; Terapia Cognitivo- 4 Analitica; Comportamenti Suicidari Practice Guideline 2003 Terapia Cognitivo-Comportamentale + Farmaci Terapia Dialettico-Comportamentale; 5 Terapia Interpersonale; Psicodinamica Delirium Practice Guideline 1999 Guideline Watch 2004 Farmaci Psicoeducazione; Programmi 6 Comportamentali Depressione Maggiore Practice Guideline 2000 Guideline Watch 2005 Terapia Cognitivo-Comportamentale; Farmaci; Terapia Cognitivo- Terapia Interpersonale; Problem-solving; 7 Psicoeducazione di gruppo
5 Comportamentale + Farmaci Disturbi Alimentari Practice Guideline 2006 Terapia Cognitivo-Comportamentale Terapia Interpersonale; Psicoterapia di gruppo e familiare; Farmaci Disturbo di Panico Practice Guideline 1998 Guideline Watch 2006 Terapia Cognitivo-Comportamentale; Farmaci; Terapia Cognitivo- Comportamentale + Farmaci DOC Practice Guideline 2007 Terapia Cognitivo-Comportamentale; Farmaci; Terapia Cognitivo- Comportamentale + Farmaci Disturbi psichiatrici (depressione) in soggetti con HIV/AIDS Guideline Watch 2006 Farmaci Terapia Cognitivo-Comportamentale; Comportamentale; Terapia Psicodinamica ed Interpersonale; Psicoeducazione; Tecniche per la gestione dello Stress; Schizofrenia (fase stabile) Practice Guideline 2004 Farmaci Terapia Cognitivo-Comportamentale; Comportamentale; Social Skills Training; Interventi Familiari; Training Assertivo Stress Acuto Post-traumatico da stress Practice Guideline 2004 Terapia Cognitivo-Comportamentale; Farmaci; Terapia Cognitivo- Comportamentale +Farmaci Stress Inoculation; Imagery Rehearsal e Tecniche di Esposizione Prolungata
6 Brani estrapolati dalle linee-guida per il trattamento dei singoli Disturbi A. Coding System Each recommendation is identified as meriting one of three categories of endorsement, based on the level of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence [II] Recommended with moderate clinical confidence [III] May be recommended on the basis of individual circumstances Abuso di Sostanze Practice Guideline (maggio 2006) Psychosocial treatments are essential components of a comprehensive treatment program [I]. Evidence-based psychosocial treatments include cognitive-behavioral therapies (CBTs, e.g., relapse prevention, social skills training), motivational enhancement therapy (MET), behavioral therapies (e.g., community reinforcement, contingency management), 12-step facilitation (TSF), psychodynamic therapy/interpersonal therapy (IPT), self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies. Nicotina Psychosocial treatments are also effective for the treatment of nicotine dependence and include CBTs [I], behavioral therapies [I], brief interventions [II], and MET [II] provided in individual [I], group [I], or telephone [I] formats or via self-help materials [III] and Internet-based formats [III]. The efficacy of treatment is related to the amount of psychosocial treatment received. Alcool Psychosocial treatments found effective for some patients with an alcohol use disorder include MET [I], CBT [I], behavioral therapies [I], TSF [I], marital and family therapies [I], group therapies [II], and psychodynamic therapy/ipt [III]. Recommending that patients participate in self-help groups, such as Alcoholics Anonymous (AA), is often helpful [I]. Cocaina For many patients with a cocaine use disorder, psychosocial treatments focusing on abstinence are effective [I]. In particular, CBTs [I], behavioral therapies [I], and 12-step-oriented individual drug counseling [I] can be useful, although efficacy of these therapies varies across subgroups of patients. Recommending regular participation in a self-help group may improve the outcome for selected patients with a cocaine use disorder [III]. Oppiacei Psychosocial treatments are effective components of a comprehensive treatment plan for patients with an opioid use disorder [II]. Behavioral therapies (e.g., contingency management) [II], CBTs [II], psychodynamic psychotherapy [III], and group and family therapies [III] have been found to be effective for some patients with an opioid use disorder. Recommending regular participation in self-help groups may also be useful [III].
7 Alzheimer Practice Guideline (ottobre 2007) In addition to the general psychosocial interventions subsumed under psychiatric management, a number of specific interventions are appropriate for some patients. Few of these treatments have been subjected to double-blind randomized evaluation, but some research, along with clinical practice, supports their effectiveness. Behavior-oriented treatments are used to identify the antecedents and consequences of problem behaviors and attempt to reduce the frequency of behaviors by directing changes in the environment that alter these antecedents and consequences. Behavioral approaches have not been subjected to large randomized clinical trials but are supported by small trials and case studies and are in widespread clinical use [II]. Bipolare Practice Guideline (aprile 2002) The first-line pharmacological treatment for bipolar depression is the initiation of either lithium [I] or lamotrigine [II]. Small studies have suggested that interpersonal therapy and cognitive behavior therapy may also be useful when added to pharmacotherapy during depressive episodes in patients with bipolar disorder. Trattamento di mantenimento Guideline Watch (November 2005) Knowledge of the utility of psychosocial interventions has expanded recently. Family-focused therapy is a manualized psychosocial program involving all available family members in which weekly psychoeducation, communication enhancement training, and problem-solving skills training occur adjunctively with pharmacotherapy. Another randomized, controlled study examined the utility of cognitive therapy in conjunction with pharmacotherapy over a 12-month period. Those treated with cognitive therapy and pharmacotherapy had significantly fewer bipolar episodes, days in an episode, and number of admissions. Borderline Practice Guideline (ottobre 2001) The primary treatment for borderline personality disorder is psychotherapy, complemented by symptomtargeted pharmacotherapy [I]. Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behavior therapy [I]. Guideline Watch (Marzo 2005) Evidence and opinion continue to support the recommendation of the 2001 guideline that psychotherapy represents the primary, or core, treatment for this disorder and that adjunctive, symptom-targeted pharmacotherapy can be helpful.
8 Persuasive data from randomized, controlled trials (RCTs) of BPD suggest that more than one type of psychotherapy is effective, and additional studies are under way. Dialectical behavior therapy (DBT) has been shown in an RCT to be effective for borderline symptoms in patients with comorbid BPD and substance abuse, though no improvement was shown for the substance abuse itself. In another RCT, in patients with BPD and comorbid opiate use, DBT was compared with comprehensive validation therapy (CVT). Both types of treatment were effective. Promising new psychotherapies for BPD are being piloted in open trials. These include interpersonal therapy; cognitive therapy; cognitive analytic therapy (CAT), a fusion of cognitive and psychodynamic therapy; and systems training for emotional predictability and problem solving (STEPPS), a cognitivebehavioral systems based form of time-limited group treatment for patients with BPD. Comportamenti Suicidari Practice Guideline (novembre 2003) Psychotherapies and other psychosocial interventions play an important role in the treatment of individuals with suicidal thoughts and behaviors [II]. A substantial body of evidence supports the efficacy of psychotherapy in the treatment of specific disorders, such as nonpsychotic major depressive disorder and borderline personality disorder, which are associated with increased suicide risk. For example, interpersonal psychotherapy and cognitive behavior therapy have been found to be effective in clinical trials for the treatment of depression. Therefore, psychotherapies such as interpersonal psychotherapy and cognitive behavior therapy may be considered appropriate treatments for suicidal behavior, particularly when it occurs in the context of depression [II]. In addition, cognitive behavior therapy may be used to decrease two important risk factors for suicide: hopelessness [II] and suicide attempts in depressed outpatients [III]. For patients with a diagnosis of borderline personality disorder, psychodynamic therapy and dialectical behavior therapy may be appropriate treatments for suicidal behaviors [II], because modest evidence has shown these therapies to be associated with decreased self-injurious behaviors, including suicide attempts. In addition to pharmacotherapies and ECT, psychotherapies play a central role in the management of suicidal behavior in clinical practice. Although few rigorous studies have directly examined whether these interventions reduce suicide morbidity or mortality per se, clinical consensus suggests that psychosocial interventions and specific psychotherapeutic approaches are of benefit to the suicidal patient. Furthermore, in recent years, studies of psychotherapy have demonstrated its efficacy in treating disorders such as depression and borderline personality disorder that are associated with increased suicide risk. For example, cognitive behavior therapy, psychodynamic therapy, and interpersonal psychotherapy have been found effective in clinical trials for the treatment of these disorders. Depressione Maggiore Practice Guideline (aprile 2000)
9 In the acute phase, in addition to psychiatric management, the psychiatrist may choose between several initial treatment modalities, including pharmacotherapy, psychotherapy, the combination of medications plus psychotherapy, or ECT [I]. Selection of an initial treatment modality should be influenced by both clinical (e.g., severity of symptoms) and other factors (e.g., patient preference) Cognitive behavioral therapy and interpersonal therapy are the psychotherapeutic approaches that have the best documented efficacy in the literature for the specific treatment of major depressive disorder, although rigorous studies evaluating the efficacy of psychodynamic psychotherapy have not been published [II]. Guideline Watch (settembre 2005) The guideline recommends the serotonin modulator nefazodone as an effective medication for the treatment of depression. As noted in the guideline, there is some evidence that addition of cognitive-behavior psychotherapy may be beneficial for patients who have had only a partial response to pharmacotherapy. Recent studies have provided additional support for the efficacy of a number of psychosocial treatment approaches, including problem-solving treatment, group psychoeducation, and the cognitive behavioral analysis system of psychotherapy. Additional meta-analyses have suggested that among psychotherapeutic approaches, other bona fide psychotherapies have efficacy comparable with CBT for treating depression, although more research with CBT has been done. Given the evidence for the benefits of exercise in older depressed adults, exercise may also be of value in other subgroups of patients with major depression. Recent meta-analysis suggested that a combination of psychotherapy and pharmacotherapy is more effective than pharmacotherapy alone Disturbi Alimentari Practice Guideline (maggio 2006) Anoressia Acuta During acute refeeding and while weight gain is occurring, it is beneficial to provide anorexia nervosa patients with individual psychotherapeutic management that is psychodynamically informed and provides empathic understanding, explanations, praise for positive efforts, coaching, support, encouragement, and other positive behavioral reinforcement [I]. Attempts to conduct formal psychotherapy with starving patients who are often negativistic, obsessional, or mildly cognitively impaired may be ineffective [II]. Anoressia dopo il recupero del peso To help prevent patients from relapsing, emerging data support the use of cognitive-behavioral psychotherapy for adults [II]. For patients receiving cognitive-behavioral therapy (CBT) after weight restoration, adding fluoxetine does not appear to confer additional benefits with respect to preventing relapse [II]. Bulimia For treating acute episodes of bulimia nervosa in adults, the evidence strongly supports the value of CBT as the most effective single intervention [I]. Some patients who do not respond initially to CBT may respond when switched to either interpersonal therapy (IPT) or fluoxetine [II] or other modes of treatment such as
10 family and group psychotherapies [III]. Controlled trials have also shown the utility of IPT in some cases [II]. In clinical practice, many practitioners combine elements of CBT, IPT, and other psychotherapeutic techniques. Compared with psychodynamic or interpersonal therapy, CBT is associated with more rapid remission of eating symptoms [I], but using psychodynamic interventions in conjunction with CBT and other psychotherapies may yield better global outcomes [II]. In some research, the combination of antidepressant therapy and CBT results in the highest remission rates; therefore, this combination is recommended initially when qualified CBT therapists are available [II]. In addition, when CBT alone does not result in a substantial reduction in symptoms after 10 sessions, it is recommended that fluoxetine be added [II]. Disturbi alimentari non altrimenti specificati Substantial evidence supports the efficacy of individual or group CBT for the behavioral and psychological symptoms of binge eating disorder [I]. IPT and dialectical behavior therapy have also been shown to be effective for behavioral and psychological symptoms and can be considered as alternatives [II]. Disturbo di Panico Practice Guideline (maggio 1998) Psychotherapy, specifically panic-focused cognitive behavioral therapy (CBT), and medications have both been shown to be effective treatments for panic disorder [I]. There is no convincing evidence that one modality is superior for all patients or for particular subpopulations of patients. The choice between psychotherapy and pharmacotherapy depends on an individualized assessment of the efficacy, benefits, and risks of each modality and the patient's personal preferences (including costs) [I]. In every case, the patient should be fully informed by the psychiatrist about the availability and relative advantages and disadvantages of CBT, antipanic medications, and other forms of treatment.cbt encompasses a range of treatments, each consisting of several elements, including psychoeducation, continuous panic monitoring, development of anxiety management skills, cognitive restructuring, and in vivo exposure. In practice, the types of therapy encompassed by CBT are often quite diverse. It is unknown whether certain elements are more effective for all patients or for specific patients. The efficacy of CBT for the treatment of panic disorder is supported by extensive and high-quality data. Other psychotherapies may be considered in conjunction with psychiatric management [III], but supplementation with (or replacement by) either CBT or an antipanic medication should be strongly considered if there is no significant improvement within 6 8 weeks. Guideline Watch (aprile 2006) Cognitive behavior therapy remains the psychosocial treatment with the largest research base and most demonstrated efficacy for treatment of panic disorder. A clear benefit of adding medication to CBT has yet to be established, and there is a paucity of data examining the addition of CBT to medication. Other psychotherapies either have proved inferior to medication and CBT or have not been evaluated in controlled trials. Finally, more research is needed on assessing the long-term impact of medications and psychosocial
11 treatments, combining medication and psychosocial treatments, identifying factors that predict treatment response, and ameliorating treatment-resistant panic disorder. DOC Practice Guideline (luglio 2007) In choosing a treatment approach, the clinician should consider the patient's motivation and ability to comply with pharmacotherapy and psychotherapy [I]. CBT and serotonin reuptake inhibitors (SRIs) are recommended as safe and effective first-line treatments for OCD [I]. Whether to utilize CBT, an SRI, or combined treatment will depend on factors that include the nature and severity of the patient's symptoms, the nature of any co-occurring psychiatric and medical conditions and their treatments, the availability of CBT, and the patient's past treatment history, current medications, capacities, and preferences. CBT alone, consisting of exposure and response prevention, is recommended as initial treatment for a patient who is not too depressed, anxious, or severely ill to cooperate with this treatment modality, or who prefers not to take medications and is willing to do the work that CBT requires [II]. An SRI alone is recommended for a patient who is not able to cooperate with CBT, has previously responded well to a given drug, or prefers treatment with an SRI alone [II]. Combined treatment should be considered for patients with an unsatisfactory response to monotherapy [II], for those with co-occurring psychiatric conditions for which SRIs are effective [I], and for those who wish to limit the duration of SRI treatment [II]. In the latter instance, uncontrolled follow-up studies suggest that CBT may delay or mitigate relapse when SRI treatment is discontinued [II]. Combined treatment or treatment with an SRI alone may also be considered in patients with severe OCD, since the medication may diminish symptom severity sufficiently to allow the patient to engage in CBT [II]. CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support [I]. Some data support the use of CBT that focuses on cognitive techniques [II]. Cognitive-behavioral therapies have been delivered in individual, group, and family therapy sessions, with session length varying from less than 1 hour to 2 hours. One group has explored a computer-based approach coupled with a touch-tone telephone system accessible 24 hours a day. CBT sessions should be scheduled at least once weekly [I]. Five ERP sessions per week may be more effective than once-weekly sessions but are not necessarily more effective than twice-weekly sessions [II]. The number of treatment sessions, their length, and the duration of an adequate trial have not been established, but expert consensus recommends weekly sessions for most patients [I]. Clinicians should consider booster sessions for more severely ill patients, for patients who have relapsed in the past, and for patients who show signs of early relapse [II]. HIV/AIDS Guideline Watch (aprile 2006) Psychotherapeutic or psychopharmacological treatments shown to be effective in other populations are useful also in the HIV-infected patient with co-occurring psychiatric disorders. Cognitive behavior therapy groups, educational programs, and stress management techniques have also been shown to improve
12 depression in patients with HIV. Psychodynamic, cognitive behavior, and interpersonal therapies are also applicable to the HIV population. Schizofrenia Practice Guideline (febbraio 2004) A number of psychosocial treatments have demonstrated effectiveness during the stable phase. They include family intervention [I], supported employment [I], assertive community treatment [I], skills training [II], and cognitive behaviorally oriented psychotherapy [II]. In the same way that psychopharmacological management must be individually tailored to the needs and preferences of the patient, so too should the selection of psychosocial treatments [I]. The selection of appropriate psychosocial treatments is guided by the circumstances of the individual patient's needs and social context [II] Stress Acuto e Post Traumatico da stress Practice Guideline (November 2004) Some evidence is available about the effectiveness of psychotherapeutic intervention immediately after trauma in preventing development of ASD or PTSD. Studies of cognitive behavior therapy in motor vehicle and industrial accident survivors as well as in victims of rape and interpersonal violence suggest that cognitive behavior therapies may speed recovery and prevent PTSD when therapy is given over a few sessions beginning 2 3 weeks after trauma exposure [II]. For patients with a diagnosis of ASD or PTSD, available evidence and clinical experience suggest that a number of psychotherapeutic interventions may be useful. Patients with ASD may be helped by cognitive behavior therapy and other exposure-based therapies [II]. In addition, cognitive behavior therapy is an effective treatment for core symptoms of acute and chronic PTSD [I]. EMDR is also effective [II]. Stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be indicated for treatment of PTSD and PTSD-associated symptoms such as anxiety and avoidance [II]. The shared element of controlled exposure of some kind may be the critical intervention. SELEZIO E DEI RIFERIME TI BIBLIOGRAFICI CITATI ELLE LI EE-GUIDA DEI SI GOLI DISTURBI CHE RIMA DA O ALLA CBT 1. Abuso di Sostanze Hall SM, Reus VI, Munoz RF, Sees KL, Humfleet G, Hartz DT, Frederick S, Triffleman E: Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry 1998; 55: Brown RA, Kahler CW, Niaura R, Abrams DB, Sales SD, Ramsey SE, Goldstein MG, Burgess ES, Miller IW: Cognitive-behavioral treatment for depression in smoking cessation. J Consult Clin Psychol 2001; 69: Perkins KA, Marcus MD, Levine MD, D'Amico D, Miller A, Broge M, Ashcom J, Shiffman S: Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. J Consult Clin Psychol 2001; 69: Patten CA, Martin JE, Myers MG, Calfas KJ, Williams CD: Effectiveness of cognitive-behavioral therapy for smokers with histories of alcohol dependence and depression. J Stud Alcohol 1998; 59:
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