Cognitive behavioural therapy

Psychological therapies for the management of chronic pain (excluding headache) in adults.: Background: Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012. Objectives: To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) com

Acceptance and commitment therapy versus cognitive behavioral therapy in the treatment of substance use disorder with incarcerated women.: Objectives: This randomized controlled study compared acceptance and commitment therapy (ACT), cognitive-behavioral therapy (CBT), and a control group. Method: The participants were 50 incarcerated women diagnosed with current substance use disorder. Two psychologists carried out pre- and posttreatment assessment and a 6-month follow-up assessment using the following instruments: Anxiety Sensitivity Index, Addiction Severity Index-6, Mini International Neuropsychiatric Interview, and Acceptance

Cognitive mediators of treatment for social anxiety disorder: comparing acceptance and commitment therapy and cognitive-behavioral therapy.: Objective: To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder. Method: Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n=25) or ACT (n=25) for DSM-IV social anxiety disorder. Results: Multilevel m

Acceptance and Commitment Therapy in group format for anxiety and depression. A systematic review.: Background: Emotional disorders, such as anxiety and depression, are one of the main causes of disability worldwide. Recent reviews suggest that Acceptance and Commitment Therapy is effective in treating emotional disorders. However, they appraise mainly individual approaches. This review aimed to analyze published studies regarding the usefulness of Acceptance and Commitment Therapy, applied on a group basis, in the treatment of anxiety and depression. Methods: A systematic review of the litera

Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review.: Background: Anxiety conditions are debilitating and prevalent throughout the world. Acceptance and Commitment Therapy (ACT) is an effective, acceptance-based behavioral therapy for anxiety. However, there are treatment barriers (eg, financial, geographical, and attitudinal), which prevent people from accessing it. To overcome these barriers, internet-delivered ACT (iACT) interventions have been developed in recent years. These interventions use websites to deliver ACT information and skill train

Internet-Based Acceptance and Commitment Therapy: A Transdiagnostic Systematic Review and Meta-Analysis for Mental Health Outcomes.: Internet-based acceptance and commitment therapy (iACT) primarily targets the process of psychological flexibility. Its accessibility and low-intensity delivery are applicable across different treatment and prevention scenarios. This transdiagnostic meta-analysis reviews the effectiveness of iACT on anxiety, depression, quality of life, and psychological flexibility across individuals with different psychological and somatic conditions/complaints, or undiagnosed complaints. Seven databases were

A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa.

Background: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). Method: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). Results: Both treatments were associated with significant improvement in bulimic sympt…

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Treating prolonged grief disorder: a randomized clinical trial.

Importance: Prolonged grief disorder (PGD) is a potentially disabling condition that affects approximately 10% of bereaved people. Grief-focused cognitive behavior therapy (CBT) has been shown to be effective in treating PGD. Although treatments for PGD have focused on exposure therapy, much debate remains about whether exposure therapy is optimal for PGD. Objective: To determine the relative efficacies of CBT with exposure therapy (CBT/exposure) or CBT alone for PGD. Design, setting, and participants: A randomized clinical trial of 80 patients with PGD attending the outpatient University of New South Wales Traumatic Stress Clinic from September 17, 2007, through June 7, 2010. Interventions: All patients received 10 weekly 2-hour group therapy sessions that consisted of CBT techniques. Patients also received 4 individual sessions, in which they were randomized to receive exposure therapy…

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Evaluation of a brief treatment program of cognitive behavior therapy for insomnia in older adults.

Objective: To evaluate the efficacy of a brief 4-w group-administered treatment program of cognitive behavior therapy for insomnia (CBT-I) for older adults with sleep maintenance insomnia. Design: Randomized controlled trial of CBT-I compared to waitlist control with comparisons at pretreatment, posttreatment, and 3-mo follow-up. Setting: Flinders University Sleep and Circadian Rhythm Research Laboratory, Adelaide, South Australia. Participants: One-hundred eighteen adults with sleep maintenance insomnia (mean age = 63.76 y, standard deviation = 6.45 y, male = 55). Interventions: A 4-w, group-based treatment program of CBT-I including bedtime restriction therapy, sleep education, and cognitive restructuring. Measurements: Seven-day sleep diaries, actigraphy, and several self-report measures to assess perceived insomnia severity, daytime functioning, and confidence in and beliefs about sl…

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Prevention of generalized anxiety disorder using a web intervention, iChill: randomized controlled trial.

Background: Generalized Anxiety Disorder (GAD) is a high prevalence, chronic disorder. Web-based interventions are acceptable, engaging, and can be delivered at scale. Few randomized controlled trials evaluate the effectiveness of prevention programs for anxiety, or the factors that improve effectiveness and engagement. Objective: The intent of the study was to evaluate the effectiveness of a Web-based program in preventing GAD symptoms in young adults, and to determine the role of telephone and email reminders. Methods: A 5-arm randomized controlled trial with 558 Internet users in the community, recruited via the Australian Electoral Roll, was conducted with 6- and 12-month follow-up. Five interventions were offered over a 10-week period. Group 1 (Active website) received a combined intervention of psycho-education, Internet-delivered Cognitive Behavioral Therapy (ICBT) for anxiety, ph…

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Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial.

Background: Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care. Methods: In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BA…

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Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial.

Background: Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa--focal psychodynamic therapy and enhanced cognitive behaviour therapy--versus optimised treatment as usual. Methods: The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass in…

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Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomised controlled trial.

Background: Exposure-based cognitive-behavioural therapy (CBT) delivered via the internet has been shown to be effective for severe health anxiety (hypochondriasis) but has not been compared with an active, effective and credible psychological treatment, such as behavioural stress management (BSM). Aims: To investigate two internet-delivered treatments - exposure-based CBT v. BSM - for severe health anxiety in a randomised controlled trial (trial registration: NCT01673035). Method: Participants (n = 158) with a principal diagnosis of severe health anxiety were allocated to 12 weeks of exposure-based CBT (n = 79) or BSM (n = 79) delivered via the internet. The Health Anxiety Inventory (HAI) was the primary outcome. Results: Internet-delivered exposure-based CBT led to a significantly greater improvement on the HAI compared with BSM. However, both treatment groups made large improvements o…

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Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial.

Background: Health anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics. Methods: We undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16-75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten ses…

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Uptake and adherence of a self-directed internet-based mental health intervention with tailored e-mail reminders in senior high schools in Norway.

Background: Internet-based cognitive behavioural therapy (ICBT) is a promising approach to the prevention and reduction of depressive symptoms among adolescents. This study aimed to evaluate the feasibility and efficacy of disseminating a self-directed internet-based mental health intervention (MoodGYM) in senior high schools. It also sought to investigate possible effects of tailored and weekly e-mail reminders on initial uptake and adherence to the intervention. Method: A baseline survey was conducted in four senior high schools in two Norwegian municipalities (n = 1337). 52.8% (707/1337) of the students consented to further participation in the trial and were randomly allocated to one of three MoodGYM intervention groups (tailored weekly e-mail reminder (n = 175), standardized weekly e-mail reminder (n = 176 ) or no e-mail reminder (n = 175)) or a waitlist control group (n = 180). We …

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Reductions in negative repetitive thinking and metacognitive beliefs during transdiagnostic internet cognitive behavioural therapy (iCBT) for mixed anxiety and depression.

We explored whether transdiagnostic internet-delivered cognitive behavioural therapy (iCBT) for mixed anxiety and depression effectively reduces repetitive negative thinking (RNT), and whether reductions in RNT and positive metacognitive beliefs mediate symptom improvement during iCBT. Participants with generalized anxiety disorder (GAD), major depressive disorder (MDD), or mixed GAD/MDD diagnoses were randomly allocated to a 6-lesson clinician-guided iCBT anxiety and depression program (n = 46) or wait-list control (WLC, n = 53). Depression (PHQ-9), generalized anxiety (GAD-7), RNT (Repetitive Thinking Questionnaire) and positive beliefs about RNT (Positive Beliefs about Rumination Scale) were assessed at pre-, mid-, and post-treatment or matched time points for WLC. Tests of serial indirect effects explored the potential meditating role of RNT and positive belief reductions on the impa…

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Internet-based guided self-help for several anxiety disorders: a randomized controlled trial comparing a tailored with a standardized disorder-specific approach.

Internet-delivered self-help with minimal therapist guidance has shown promising results for a number of diagnoses. Most of the evidence comes from studies evaluating standardized disorder-specific treatments. A recent development in the field includes transdiagnostic and tailored Internet-based treatments that address comorbid symptoms and a broader range of patients. This study evaluated an Internet-based tailored guided self-help treatment, which targeted symptoms of social anxiety disorder, panic disorder with or without agoraphobia, and generalized anxiety disorder. The tailored treatment was compared both with standardized disorder-specific Internet-based treatment and with a wait-list control group. Both active treatment conditions were based on cognitive-behavioral therapy and lasted for 8 weeks. A total of 132 individuals meeting diagnostic criteria for at least one of the anxie…

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The therapeutic alliance in treatment of traumatized youths: relation to outcome in a randomized clinical trial.

Objective: We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU]). Method: Participants were 156 youths (M age = 15.1 years, range = 10-18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children-Revised (TASC-R). Results: Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d = 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance × Treatment Group interaction: Alliance ra…

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A comparison of cognitive-behavioral couple therapy and lidocaine in the treatment of provoked vestibulodynia: study protocol for a randomized clinical trial.

Background: Provoked vestibulodynia (PVD), a frequent form of chronic genital pain, is associated with decreased sexual function for afflicted women, as well as impoverished sexual satisfaction for women and their partners. Pain and sexuality outcomes for couples with PVD are influenced by interpersonal factors, such as pain catastrophizing, partner responses to pain, ambivalence over emotional expression, attachment style and perceived relationship and sexual intimacy. Despite recommendations in the literature to include the partner in cognitive-behavioral therapy targeted at improving pain and sexuality outcomes, no randomized clinical trial has tested the efficacy of this type of intervention and compared it to a first-line medical intervention. Methods: This bi-center, randomized clinical trial is designed to examine the efficacy of cognitive-behavioral couple therapy compared to top…

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Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients?

Objectives: This secondary analysis of data from a randomised controlled trial explores associations between common symptom clusters and evaluates pre-treatment to post-treatment changes in clinical levels of these symptoms following cognitive behaviour therapy for insomnia (CBT-I). Methods: Baseline data from 113 participants with insomnia were explored to establish rates of and associations between clinical levels of fatigue, anxiety and depression across the sample. Effects of CBT-I on this symptom cluster were also explored by examining changes in pre-treatment to post-treatment levels of fatigue, anxiety and depression. Results: At baseline, the most common symptom presentation was insomnia + fatigue, and 30% of the sample reported at least three co-morbid symptoms. Post-CBT, the number of those experiencing clinical insomnia and clinical fatigue decreased. There were no changes in …

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Feasibility of two modes of treatment delivery for child anxiety in primary care.

In this study, we examine the feasibility of cognitive behavior therapy (CBT) for children with anxiety in primary care, using two modes of treatment delivery. A total of 48 parents and youth (8-13) with anxiety disorders were randomly assigned to receive 10-sessions of CBT either delivered by a child anxiety specialist in the primary care clinic or implemented by the parent with therapist support by telephone (i.e., face-to-face or therapist-supported bibliotherapy). Feasibility outcomes including satisfaction, barriers to treatment participation, safety, and dropout were assessed. Independent evaluators, blind to treatment condition, administered the Anxiety Disorders Interview Schedule for Children (ADIS) and the Clinical Global Impression of Improvement (CGI-I) at baseline, post-treatment and 3-month follow-up; clinical self-report questionnaires were also administered. Findings reve…

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Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists' perceptions and experiences.

Background: The importance of the biopsychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists' learning and delivering of psychological interventions within the practice context. Objective: The aim of this study was to investigate physical therapists' experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis. Design: A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST). Methods: Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT pe…

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Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial.

Objective: We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS). Method: Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures. Results: Three baseline variables pr…

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Trajectories of change in emotion regulation and social anxiety during cognitive-behavioral therapy for social anxiety disorder.

Cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD) may decrease social anxiety by training emotion regulation skills. This randomized controlled trial of CBT for SAD examined changes in weekly frequency and success of cognitive reappraisal and expressive suppression, as well as weekly intensity of social anxiety among patients receiving 16 weekly sessions of individual CBT. We expected these variables to (1) differ from pre-to-post-CBT vs. Waitlist, (2) have differential trajectories during CBT, and (3) covary during CBT. We also expected that weekly changes in emotion regulation would predict (4) subsequent weekly changes in social anxiety, and (5) changes in social anxiety both during and post-CBT. Compared to Waitlist, CBT increased cognitive reappraisal frequency and success, decreased social anxiety, but had no impact on expressive suppression. During CBT, weekly c…

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Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial.

Background: Abnormal forms of grief, currently referred to as complicated grief or prolonged grief disorder, have been discussed extensively in recent years. While the diagnostic criteria are still debated, there is no doubt that prolonged grief is disabling and may require treatment. To date, few interventions have demonstrated efficacy. Methods: We investigated whether outpatients suffering from prolonged grief disorder (PGD) benefit from a newly developed integrative cognitive behavioural therapy for prolonged grief (PG-CBT). A total of 51 patients were randomized into two groups, stratified by the type of death and their relationship to the deceased; 24 patients composed the treatment group and 27 patients composed the wait list control group (WG). Treatment consisted of 20-25 sessions. Main outcome was change in grief severity; secondary outcomes were reductions in general psycholog…

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Group cognitive behavioural therapy and group recreational activity for adults with autism spectrum disorders: a preliminary randomized controlled trial.

Although adults with autism spectrum disorder are an increasingly identified patient population, few treatment options are available. This preliminary randomized controlled open trial with a parallel design developed two group interventions for adults with autism spectrum disorders and intelligence within the normal range: cognitive behavioural therapy and recreational activity. Both interventions comprised 36 weekly 3-h sessions led by two therapists in groups of 6-8 patients. A total of 68 psychiatric patients with autism spectrum disorders participated in the study. Outcome measures were Quality of Life Inventory, Sense of Coherence Scale, Rosenberg Self-Esteem Scale and an exploratory analysis on measures of psychiatric health. Participants in both treatment conditions reported an increased quality of life at post-treatment (d = 0.39, p < 0.001), with no difference between interventi…

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Can intermittent theta burst stimulation as add-on to psychotherapy improve nicotine abstinence? Results from a pilot study.

Smoking is among the leading causes of mortality worldwide. Discontinuing smoking can increase life expectancy to the presmoking level. Unaided attempts are often ineffective, strengthening the necessity of cognitive-behavioral therapy (CBT), nicotine replacement or pharmacotherapy. Still, relapse rates are high. Recently, a modulation of nicotine craving, which predicts relapse, through transcranial magnetic stimulation to the prefrontal cortex was shown. In a pilot study, we investigated whether 4 sessions of intermittent theta burst stimulation (iTBS) as add-on treatment to CBT reduces nicotine craving and improves long-term abstinence (at 3, 6 and 12 months). Smokers were randomly assigned to a treatment (n = 38) or a sham group (n = 36). Although we did not find reduced craving, we could show higher abstinence rates in the treatment group at 3 months. At 6 and 12 months abstinence r…

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Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial.

Background: The evidence base for the efficacy of cognitive behaviour therapy (CBT) for treating body dysmorphic disorder (BDD) is weak. Aims: To determine whether CBT is more effective than anxiety management (AM) in an outpatient setting. Method: This was a single-blind stratified parallel-group randomised controlled trial. The primary endpoint was at 12 weeks, and the Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS) was the primary outcome measure. Secondary measures for BDD included the Brown Assessment of Beliefs Scale (BABS), the Appearance Anxiety Inventory (AAI) and the Body Image Quality of Life Inventory (BIQLI). The outcome measures were collected at baseline and week 12. The CBT group, unlike the AM group, had 4 further weekly sessions that were analysed for their added value. Both groups then completed measures at their 1-month follow-up. Forty-six participants with…

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Maintenance treatment with varenicline for smoking cessation in patients with schizophrenia and bipolar disorder: a randomized clinical trial.

Importance: It is estimated that more than half of those with serious mental illness smoke tobacco regularly. Standard courses of pharmacotherapeutic cessation aids improve short-term abstinence, but most who attain abstinence relapse rapidly after discontinuation of pharmacotherapy. Objective: To determine whether smokers diagnosed with schizophrenia and bipolar disease have higher rates of prolonged tobacco abstinence with maintenance pharmacotherapy than with standard treatment. Design, setting, and participants: Randomized, double-blind, placebo-controlled, parallel-group, relapse-prevention clinical trial conducted in 10 community mental-health centers. Of 247 smokers with schizophrenia or bipolar disease recruited from March 2008-April 2012, 203 received 12-weeks' open-label varenicline and cognitive behavioral therapy and 87 met abstinence criteria to enter the relapse prevention …

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Attribution, cognition and psychopathology in persistent insomnia disorder: outcome and mediation analysis from a randomized placebo-controlled trial of online cognitive behavioural therapy.

Objectives: Insomnia patients complain that mental events keep them awake. This study investigates how cognitive behavioural therapy (CBT) affects such events and considers how attributional, cognitive and psychopathological symptoms may mediate sleep improvement. Method: A pragmatic, parallel-group randomized controlled trial of 164 adults (120 F: (mean 49 years (18-78 years)) meeting Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for insomnia disorder, assigned to CBT (n=55; 40 F), imagery relief therapy (IRT placebo; n=55; 42 F), or treatment as usual (TAU; n=54; 38 F), was conducted. CBT/IRT comprised six online sessions delivered by an animated therapist, with automated web/e-mail support. CBT users had access to a moderated community. TAU comprised 'usual care'. Participants completed the Sleep Disturbance Questionnaire (SDQ), Glasgow Content of…

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Feasibility of a prototype web-based acceptance and commitment therapy prevention program for college students.

Objective: This study examined the feasibility of a prototype Web-based acceptance and commitment therapy (ACT) program for preventing mental health problems among college students. Participants: Undergraduate first-year students (N = 76) participated between May and November 2011. Methods: Participants were randomized to ACT or a waitlist, with assessments conducted at baseline, posttherapy, and 3-week follow-up. Waitlist participants accessed the program after the second assessment. Results: Program usability/usage data indicated high program acceptability. Significant improvements were found for ACT knowledge, education values, and depression with ACT relative to waitlist. Subgroup analyses indicated that ACT decreased depression and anxiety relative to waitlist among students with at least minimal distress. Within the ACT condition, significant improvements were observed from baselin…

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