Case Illustration

R. D., a 54-year-old African American woman identified as depressed by a nurse at her cardiac surgeon's office, reported low mood, crying, irritability, fatigue, poor concentration, disrupted sleep, and suicidal thoughts. At her initial visit, R. D. was diagnosed with major depression. She reported loss of interest for nearly 2 years and long-standing problems with low self-esteem. Most of her symptoms had been present for at least 2 months. Her Beck Depression Inventory (BDI) score was 28 and her Beck Anxiety Inventory (BAI) score was 24. On the SF-36, she described her health as poor, getting worse, and limiting her in all but basic self-care activities. She was randomly assigned to the CT arm of a trial of treatment for depression after coronary bypass surgery.

R. D.'s initial clinical evaluation revealed that she had been divorced for 7 years after a long marriage. She had lost a sibling in an accident a few months earlier and reported thinking, "Why wasn't it me? I'm sick and lonely, and I can't accomplish anything anymore." She had been on disability for 5 years after doing clerical work for 17 years at a firm where her reliability and competence had been well recognized. Her early years included financial hardships and a debilitating childhood accident from which she fully recovered over a period of years without medical care. She recalled that other children rejected her because of her disability.

R. D. had several major medical problems, including diabetes with severe complications. Despite the severity of her illness, her husband had accused her of faking symptoms to get out of doing housework. She had had coronary artery bypass graft (CABG) surgery about 10 years earlier and a second CABG operation 10 months prior to enrollment in the study. She stated that her first CABG surgery was not at all like her second experience, in that her recovery from the latter seemed slow and incomplete. Other health problems included hypertension and asthma. R. D. was on 14 different daily medications. After discussing the pros and cons with her therapist, she asked her physician to prescribe an antidepressant; escitalopram (10 mg per day) was added to her regimen. R. D. reported one prior episode of depression during her fourth pregnancy. She sought counseling at the time and described it as "helpful."

At the beginning of CT, she appeared very tired. She produced a one-item problem list, "my health problems," but she talked mostly about other concerns, particularly feelings of shame about her depression. R. D.'s problem list was revised to include her depression and her thoughts about it. Because of her fatigue, she was given a light CT homework assignment.

She completed her homework and read Beck's Coping with Depression booklet. When R. D. reported that she was not doing anything that she enjoyed anymore, she was asked to try doing some needlework, one of her favorite activities. Time-based pacing with frequent rest was introduced as a way for R. D. to accomplish her chores without experiencing severe fatigue. At the next session, R. D. reported that her children questioned her rest breaks in the middle of doing chores; this made her realize that she had accepted unfair blame for her illnesses and for the breakup of her marriage. When asked to explain these beliefs, she realized that the facts did not support them. Her mood brightened considerably when she discussed this. She began to recognize her self-blaming thoughts and to dispute them. With her therapist's assistance, she also developed a set of coping cards for situations in which believes she was being unfairly blamed.

Testing her thoughts and disputing worries became the cornerstone of therapy for the next several sessions. Several stressful events occurred during this period and were opportunities R. D. to practice new coping skills. By the fourth week of therapy, she was readily identifying and challenging her automatic thoughts, and her BDI score had dropped to 16. During a frightening health crisis, she used her homework forms to test her thoughts, but she did not achieve the results she had come to expect. She called her therapist, and they collaboratively reviewed her thinking about the situation and developed a new coping card.

At her sixth session, R. D.'s problem list was reevaluated. She believed that others did not understand her diabetes-related symptoms. She felt alone with her health problems and was uncomfortable about asking others for help. She developed a set of responses to her distressing automatic thoughts about these issues, and wrote them on her coping cards. Her social network was also examined, and strategies were developed to improve her social functioning. Problem-solving strategies included returning to her church and associating with others who accepted depression as an illness rather than a weakness or lack of faith; calling the American Diabetes Association to inquire about joining a support group; and obtaining educational materials about diabetes for her children to read. She was also given homework assignments to borrow household items from a neighbor, and to decline to offer help when someone called her about a problem that could realistically be solved, or at least tolerated, without her assistance. At her eighth session, R. D.'s BDI score was 10 and her BAI score was 13.

During the next phase of the intervention, R. D.'s cognitive conceptualization was discussed at length and regularly reviewed. After examining several situations, along with her automatic thoughts, emotions, and behaviors, and considering the contributions of her early years to her current thinking, the therapist suggested that R. D. seemed to hold core beliefs about being defective and unlovable. She affirmed this, as well as her longstanding intermediate belief that she would be acceptable to others only if she did all she could for them, while hiding her own pain. She also confirmed that she had relied on the compensatory strategies of pushing herself to do all she could for others, while ignoring her limitations, then isolating herself from others to avoid having to say "no" and to escape the harsh judgments that she expected. Her response to this intervention was to state that she had no reason to continue on the same path, especially since she believed that changing her thoughts and behaviors was helping her.

Although R. D. was slow to make contact with the American Diabetes Association, she had taken the initial steps. She had borrowed a kitchen item from her neighbor, and she had attended some church services. At Session 10, her BDI score was 7 and her BAI was 8. A relapse prevention plan was collaboratively formulated. At R. D.'s 11th and final session, her BDI score was 5 and her BAI was 7. Dysfunctional attitudes and the use of various techniques to overcome depression were assessed at the beginning and end of therapy. The changes in both of these areas were reviewed. She was given a copy of her questionnaires to review in case of relapse.

At her follow-up assessments, R. D. continued to do remarkable well. She had joined a support group and had found ways to remain active despite her need for rest. Her BDI score was below 3, and all of her other scores remained at a much-improved level. During a phone call after she had completed the study, R. D. shared some of her thoughts about the process. She reported that she had not wanted to start therapy because it seemed too exhausting, and she had secretly hoped that her therapist would give up and leave her alone. She had wondered why "these white women wanted to bother with her" even though she had "so little to offer anyone." R. D. said that the fact that someone who genuinely cared about her kept showing up made all the difference, and that after the third or fourth week, she had decided that she could trust her therapist.

R. D.'s case reflects not only the challenge of overcoming racial and other demographic barriers to a trusting relationship with a therapist, but also one of the chief difficulties of working with medically ill patients. In many cases, these patients are tired and overwhelmed, and they have exhausted their personal resources. Many patients who need help are unable to come to a clinic for therapy visits. Consequently, they remain "under the radar screen" of the health care system and are underserved. Cognitive therapists may be able to help their depressed, medically ill patients to overcome some of these barriers via phone contacts, as well as home visits, as long as they are feasible for the therapist and welcomed by the patient.

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