Adaptation Of Standard Ct In The Treatment Of Depression In Medically Ill Patients

There are more similarities than differences between standard CT and cognitive-behavioral interventions for depressed medical patients. Some of the differences stem from the fact that many of these patients are referred by their physician, urged by their spouse to see a therapist, or recruited for participation in a clinical trial. Their demographic profile tends to differ from that of depressed but otherwise healthy patients who seek CT on their own initiative. Although some chronic illnesses are prevalent among young adults, most of the major chronic illnesses are more common among middle-aged and older individuals. Consequently, patients with conditions such as arthritis or heart disease who are referred for CT are older on average than the majority of patients who are seen in more typical cognitive-behavioral practices.

It is not uncommon for medical patients to feel insulted, humiliated, or angry when their physician refers them to a mental health professional, or to arrive at the therapist's doorstep with erroneous ideas about the purpose and process of therapy. This is an especially important consideration for older patients, those with no prior history of psychiatric problems and no prior contacts with mental health professionals, and individuals who are wary of being mistreated by health care professionals. These considerations place a premium on the process of inducting the patient into therapy and on establishing a collaborative therapeutic relationship.

When working with seriously medically ill patients, there is often a greater emphasis on the utility of distressing cognitions than on their validity. Medical illnesses often create a daunting cascade of financial, occupational, interpersonal, and practical problems. It is counterproductive, for example, to discuss "catastrophizing" with patients who are facing genuine personal catastrophes. It is better to address the utility of distressing thoughts about these problems, to provide ample emotional support, and to help with problem solving.

However, dysfunctional cognitions are neither off-limits nor irrelevant in CT for depressed medically ill patients, who often have the same kinds of depressogenic cognitions about self, world, and future that are common among healthier depressed patients (Beck, Rush, Shaw, & Emery, 1979). Depressogenic and anxiogenic cognitions about medical illness and its consequences are also common. Because health-related dysfunctional cognitions are not explicitly included in the Dysfunctional Attitudes Scale (DAS; Burns, 1980; Weissman & Beck, 1978), we recently developed a 20-item supplement to the DAS to assess ones that are often reported by chronically ill patients. The Dysfunctional Attitudes about Health supplementary scale includes items such as "It's unfair for me to have health problems," "People will resent it if they have to take care of me," and "Because of my illness, I'm not the same person I used to be." It is useful for assessing self-blame for the medical illness, unfounded fears about its interpersonal consequences, and other health-related dysfunctional cognitions. The entire scale is included in Skala, Freedland, and Carney (2005).

Some health-related cognitions are distressing not because they reflect cognitive distortions, but because they are misconceptions about illness or treatment. For example, it is not unusual for patients with CHD to hold the mistaken belief that every episode of angina is a small heart attack that causes permanent damage. This stems from a misunderstanding about angina rather than from a cognitive distortion such as catastrophizing. Patients who hold this distressing misconception tend to avoid physical activity and exercise, which contravenes the recommendations that they were probably given by their cardiologist or cardiac rehabilitation specialist (Furze, Bull, Lewin, & Thompson, 2003). Although these misconceptions constitute a different kind of cognitive error than the ones that are emphasized in standard CT, they can be modified by a combination of health education and cognitive-behavioral techniques (Lewin et al., 2002).

One of the most important adaptations of CT is in how it is delivered to medically ill patients. Some patients are able to come in for weekly therapy outpatient sessions, and doing so may be a component of their behavioral activation plan. Others, however, cannot, or will not, participate in frequent clinic visits for reasons such as being too ill, disabled, weak, or fatigued; lack of transportation; scheduling conflicts with work or with other clinic visits, treatments, rehabilitation programs, or support groups; or an appraisal that frequent clinic visits for CT are not worth the time or effort. The latter does not necessarily indicate a lack of motivation or interest in treatment. It may instead represent a rational cost-benefit analysis, if medical illness and medical care are severely disrupting the patient's daily life.

Many medically ill patients who cannot, or will not, participate in weekly clinic visits can still benefit from CT if their therapists are willing to reach out to them. In the ENRICHD trial, for example, therapists often conducted sessions at the patient's home or at bedside if the patient had been rehospitalized. Many sessions were also conducted via telephone. Telephone-based therapy has been used in several recent cognitive-behavioral trials with generally favorable results (Bastien, Morin, Ouelette, Blais, & Bouchard, 2004; Blumenthal et al., 2006; Mohr et al., 2000; Simon, Ludman, Tutty, Operskalski, & Von, 2004).

Timing and duration of treatment are also important considerations in adapting CT to the needs of medically ill patients. Aside from limitations imposed by third-party payers or other practical constraints, the duration of CT is usually determined by considerations such as the severity and chronicity of depression, the presence of psychiatric comorbidities, and the complexity of the patient's psychosocial problems. When working with medical patients, the course of the medical illness also has to be taken into account. For example, many survivors of a acute MI are too ill to tolerate CT immediately after their hospitalization, at least not in the usual hour-long, weekly or biweekly format. Consequently, it may be necessary to start with brief, supportive contacts and to postpone intensive therapy until the patient is ready. Other medical problems can follow distinctly different trajectories. For example, CHF is a progressive illness with a poor long-term prognosis. Patients with CHF typically experience a decline over time in their health status and physical functioning, so patients with comorbid depression often require 6 months or more of CT to reach complete remission of depression.

It may not be possible to conduct a typical "linear" course of CT for depression in seriously medically ill patients; it may be necessary to intervene in a series of bouts instead. Patients may require more frequent sessions during particularly stressful phases of their illness and less frequent sessions during more favorable periods. It may be necessary to interrupt intensive therapy for weeks or months at a time during rehospitalizations or other medical crises, and to resort to brief, supportive contacts. Furthermore, patients may have different needs and different treatment goals after an acute medical event, major surgery, and so forth, than they did before.

Thus, the nature and course of the patient's medical condition can affect the timing and duration of CT for depression. Flexibility and individual tailoring of treatment are essential in delivering CT to these patients. Treatment protocols that are too rigidly standardized cannot accommodate the complexity of CT for depression in the context of major medical illnesses.

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