Medical Illness as a Target of Treatment

Other chapters have considered whether to treat comorbid conditions sequentially or concurrently. This is a clearly pivotal question for CT with patients who have multiple psychiatric conditions, but is it relevant to the treatment of comorbid depression in medical illness? Depressed medical patients, too, can have multiple psychiatric and psychosocial problems (Bankier,Januzzi, & Littman, 2004). For example, if depression is the reason for referral of a patient with CHF, he/she may also have clinically significant anxiety. Thus, sequencing of treatments for multiple psychiatric conditions may be necessary in the context of medical illness.

Most cognitive therapists who work with medically ill patients are mental health professionals with no medical training and no license to treat medical illnesses. Those who do have medical training usually limit their practice to the treatment of psychiatric problems and leave the treatment of medical comorbidities to other specialists or primary care physicians. This does not mean, however, that cognitive therapists play no role whatsoever in their patients' medical care. To the contrary, therapists often recognize untreated medical problems and are instrumental in bringing them to the attention ofpatients' physicians. They help patients with both medical problem solving and decision making, and with the assertiveness and communication skills needed to interact with health care providers, third-party payers, employers, and assistance agencies. Also, the targets of treatment in CT for depression in medical patients often include health behavior problems such as smoking, lack of exercise, or medication nonadherence. Thus, therapists often play an important role in their patients' medical care.

CT has the potential to produce adverse medical consequences in some cases. For example, a patient may feel discouraged and isolated after an acute MI because he has stopped joining his friends on the golf course. Behavioral activation might be used to encourage him to get back out on the tee, but this could be a risky activity under the circumstances. Behavioral activation is an essential component of CT for depressed medical patients, but consultation with the patient's physician is necessary if there is any question about the safety of an activation plan.

CT could have unintended consequences by increasing the overall burden of health care. Weekly visits with a cognitive therapist might make it difficult for patients to keep up with other aspects of their health care, such as frequent visits to physicians and adherence to multiple medication regimens. This was observed in a trial of CT for depression in patients with diabetes (Lustman, Griffith, Freedland, Kissel, & Clouse, 1998b). The participants were randomly assigned to 10 weeks of CT or to a control group. Participation in CT helped to improve patients' glycemic control in the long run, but it decreased their adherence to the diabetes self-care regimen in the short run (Lustman, Freedman, Griffith, & Clouse, 1998a). Thus, medical patients with complex, demanding treatment regimens may have difficulty in adhering simultaneously to CT and to self-care for medical illness. It may be possible to mitigate this by integrating CT into a broader interdisciplinary care plan.

CT might also produce unintended adverse effects by being intrusive, particularly for medical patients who are recruited or referred rather than self-referred. When a patient has been recruited for a trial of CT for depression or referred for clinical CT services, it is advisable to assess whether the patient acknowledges feeling distressed, and whether he/she welcomes treatment and sees it as potentially beneficial rather than as intrusive.

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