# Presentation: 017578

## Cognitive Behavioral Therapy for Medically Ill Patients

- Jeffrey A. Cully, PhD
- Michael E. DeBakey VAMC
- Baylor College of Medicine
- Houston Center for Quality of Care and Utilization Studies

## Outline

- Background – Depression/Anxiety in Medical Illness
- ACCESS Project (CBT for Medically Ill)
- Summary / Opportunities for Rural MH Applications

## Medical Illness, Depression, Anxiety

- Depression and anxiety are highly prevalent
- Primary care settings = 15%-20%
- Chronic illness (e.g. COPD, CHF) = 25%-50%
- Depression and anxiety associated with increased morbidity, mortality, health service use and cost (Katon, 2003)
- Few medically ill patients with depression and/or anxiety are recognized and adequately treated

## Why are so many going without mental health care?

- Patient barriers
- Negative MH attitudes, beliefs, and treatment expectations
- Often present with physical rather than psychological concerns
- Mismatch between preferences and availability of care.  Patients prefer psychotherapy to medications

## SC MIRECC Pilot Grant (funded Oct 2007)

- Purpose/Goals
- 1)To develop a manual-driven psychosocial intervention to meet the unique needs of medically ill patients with depression and/or anxiety.
- 2) To conduct an open trial to assess feasibility and preliminary outcomes for depression, anxiety, and quality of life

## Aim 1: Treatment Development

- Modular skill-based approach
- Physical Health / Self-Management Skills
- Traditional CBT Skills (thoughts, behaviors)
- Brief / Time Limited Treatment
- 45 minute sessions
- Active treatment = 6 sessions
- Booster sessions at weeks 8,10,12
- Sessions offered in-person and by telephone
- Therapist Manual and Patient Workbook

## Intervention Components

_**A**_djusting to _**C**_hronic _**C**_onditions using _**E**_ducation, _**S**_upport, and _**S**_kills (ACCESS)
- Core Modules (weeks 1 and 2)
- Chronic Cardiopulmonary Disease and Stress
- Understanding Personal Impact and Increasing Control
- Elective Modules (sessions 3 through 6)
- Disease Management (exercise, diet, sleep, etc)
- The Power of Thoughts
- Increasing Pleasant Activities
- Learning How to Relax
- Problem Solving

## Aim 2: ACCESS Open Trial

- To examine feasibility, acceptability, and outcomes
- Outcome Measures:
- Beck Depression Inventory – Second Edition
- State Trait Anxiety Inventory
- Disease Specific Quality of Life
- General Quality of Life
- Assessments
- Baseline
- Post-treatment (8 weeks)
- Follow-up (20 weeks)

## ACCESSParticipants

- VA patients with Congestive Heart Failure (CHF) or Chronic Obstructive Pulmonary Disease (COPD)
- Must have CHF/COPD functional impairment and clinically significant symptoms of depression (BDI-II) or anxiety (STAI-T)

## ACCESS Participants (data from April 2008)

- VA Recruitment recently ended
- 23 patients enrolled
- Average age 71.4 (SD 8.23)
- 22 men and 1 woman
- 18 Caucasian and 5 African American
- CHF only (n=8), COPD only (n=5) both (n=10)
- Depression only (n=6), anxiety only (n=5) both (n=12)

## ACCESS Results - Acceptability

- Low attrition
- 83% attended first session
- Average number of sessions 5.5 (out of 6)

## Satisfaction CSQ-8 

| Response | 8 Week 
(N=16) | 3 Month 
(N=8) |
| --- | --- | --- |
|  |  |  |
| Received desired services | 100% | 100% |
|  |  |  |
| Program met needs | 87.5% | 87.5% |
|  |  |  |
| Would recommend program | 100% | 100% |
|  |  |  |
| Satisfied with the amount of help received  | 100% | 75% |
|  |  |  |
| Helped to deal more effectively with problems | 93.8% | 100% |
|  |  |  |
| Overall satisfaction | 100% | 100% |

## ACCESS Modules / Modalities

- What modules did patients and clinicians select?
- What modalities (in-person or telephone) did patients most frequently utilize?

## Frequency of Module by Patient

**63%**** **

**75%**** **

**88%**** **

**31%**** **

**25%**** **

- % = percentage of patients receiving this module during treatment

## Module Usage

## Healthy Behavior Module

**63%**** **

**38%**** **

**31%**** **

**13%**** **

**0%**** **

- % = percentage of patients receiving this module during treatment

## Telephone vs. Person

- Out of 64 potential sessions (3 through 6)
- 42 sessions occurred in-person (66%)
- 22 sessions occurred by telephone (34%)
- Preferences by patient
- 7 participants in-person sessions only
- 9 participants used telephone sessions

## Post-Treatment (8 week) Outcomes:Depression & Anxiety

- N = 16

|  | Baseline | Post Tx | Effect Size |
| --- | --- | --- | --- |
| Depression (BDI-II) | 16.94 | 9.44 | 1.07 |
| State Anxiety (STAI) | 35.69 | 32.38 | 0.28 |
| Trait Anxiety (STAI) | 40.63 | 33.38 | 0.66 |

## Post-Treatment (8 week) Outcomes:SF-36

|  | Baseline | Post Tx | Effect Size |
| --- | --- | --- | --- |
| General Health | 31.56 | 36.88 | 0.31 |
| Phys Functioning | 20.00 | 25.94 | 0.42 |
| Role Limit Physical | 6.25 | 26.56 | 1.11 |
| Role Limit Emotion | 31.25 | 56.25 | 0.60 |
| Energy/Fatigue | 34.06 | 45.31 | 0.64 |
| Emotion Wellbeing | 59.00 | 74.75 | 1.11 |
| Social Functioning | 52.34 | 73.44 | 0.92 |
| Pain | 42.34 | 53.91 | 0.49 |

- N = 16; Mean = 50, Higher scores indicate better health

## Post-Treatment (8-week) Outcomes:Disease Specific Quality of Life

|  | Baseline | Post Tx | Effect Size |
| --- | --- | --- | --- |
| CHF QoL | 38.31 | 55.44 | 1.19 |
|  |  |  |  |
| COPD QoL |  |  |  |
|    Dyspnea | 46.39 | 47.78 | 0.07 |
|    Fatigue | 36.46 | 54.17 | 1.04 |
|    Emotion | 60.12 | 75.99 | 1.06 |
|    Mastery | 58.68 | 71.18 | 0.66 |

- Total N = 16; KCCQ n =10; CRQ =12

## 3-Month Follow-up Outcomes:Depression (n=8)

**BDI-II Effect Size =0.81**

## 3-Month Follow-up Outcomes:Anxiety (n=8)

**STAI-S Effect Size =0.99**

**STAI-T Effect Size =0.51**

## Baseline to 3-month Outcomes:SF-36

|  | Baseline | 3 month | Effect Size |
| --- | --- | --- | --- |
| General Health | 28.13 | 28.75 | 0.05 |
| Phys Functioning | 18.13 | 19.38 | 0.09 |
| Role Limit Physical | 6.25 | 15.63 | 0.61 |
| Role Limit Emotion | 41.67 | 45.83 | 0.11 |
| Energy/Fatigue | 33.13 | 36.25 | 0.22 |
| Emotion Wellbeing | 56.00 | 65.00 | 0.54 |
| Social Function | 45.31 | 65.63 | 1.16 |
| Pain | 31.56 | 46.25 | 0.61 |

- N = 8 Mean = 50, Higher scores indicate better health

## Summary

- Preliminary results suggest ACCESS may be a highly effective treatment for depression and anxiety in the medically ill
- Unlike other psychosocial interventions ACCESS shows the potential to improve physical quality of life outcomes

## Summary (2)

- Physical changes appear to be diminishing over time
- Intervention improvements?
- Longer follow-up duration
- Consolidation of modules
- More therapist attention to physical health in later sessions
- Need additional trials (e.g. comparison to usual care with larger sample of patients)

## Avenues for Rural MH Applications

- Telephone-based psychotherapy
- Internet-based platform for psychotherapy
- My Healthe Vet?
- CBT training for rural MH providers
- Patient Workbook critical for telephone / internet CBT applications

## Challenges for Rural MH Applications

- Many patients prefer face to face therapy (interaction with therapist)
- Patient factors – hearing, reading level, education, internet access
- Crisis management
- Availability of rural MH providers
- Others ....

## Acknowledgements

- Research Team
- Mark Kunik MD MPH
- Melinda Stanley PhD
- Anita Deswal, MD FACC
- Nicola Hanania, MD
- Jessica Skinner (project coordinator)
- VA and BCM Interns and Fellows (study clinicians)
- Funding
- VA HSR&D – Career Development Award
- VA South Central MIRECC – Pilot Study Program
- Houston Center for Quality of Care and Utilization Studies