Implementing Cognitive Behavioral Therapy in Specialty Medical Settings

This article is an introduction to the second issue of a two-part special series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.     

Self-help for binge eating disorder in primary care: A randomized controlled trial with ethnically and racially diverse obese patients

Objective

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

Method

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

Results

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

Conclusions

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.     

Behavioral Health Interventions Being Implemented in a VA Primary Care System

The integration of behavioral health and primary care has received much attention in the literature. Behavioral health providers (BHPs) in integrated settings are faced with different treatment constraints than those who work in specialty mental health. The existing literature focuses on what BHPs should do in primary care settings; however, little research exists specifying what BHPs are actually doing. This study provides a glimpse into what types of interventions BHPs are using, and what types of patients they are seeing, in primary care. A chart review was conducted of patients (N?=?180) seen by BHPs in five Veterans Affairs primary care clinics. Depression was the most common diagnosis, while less common presenting problems included substance abuse/dependence, psychosis, and bipolar disorder. Common interventions used were medical management, psycho-education, elements of cognitive-behavioral therapy (CBT), and supportive psychotherapy. Future research should examine the efficacy of brief interventions in primary care settings.     

Prescribing Psychologists in Integrated Primary Care: Introduction to the Special Section

The authority to prescribe could differentiate psychologists from other non-physicians in primary care, achieving a significant step for the growth of our profession. Psychologists are currently prescribing in primary care settings in a number of public service venues, as well as medical school training facilities. In this Special Section of the Journal of Clinical Psychology in Medical Settings, results of a survey of physicians working with a prescribing psychologist indicate that the psychologist is highly valued and seen as a competent prescriber. A series of papers providing case examples demonstrate how psychologists are evolving in these new clinical roles, as well as participating in behavioral and psychopharmacology training of primary care physicians.     

Predicting Treatment Response in Older Adults with Insomnia

This study examined potential predictors of treatment outcome in late-life insomnia. Fifty-four older adults with chronic insomnia were treated with cognitive–behavior therapy (CBT), pharmacotherapy (PCT), or combined CBT plus PCT. Pretreatment characteristics such as demographic, clinical, psychometric, and sleep variables were examined as correlates or potential predictors of treatment response. Treatment response was defined by posttreatment sleep efficiency as measured subjectively by daily sleep diary and objectively by polysomnography. The results indicate that age, insomnia duration, medical illness, and previous use of sleep medications can moderate subjective or objective treatment outcome or both of these in late-life insomnia. However, there are no reliable predictors of outcome across all treatment and assessment modalities. The implications of these findings for the treatment of insomnia in older adults seen in primary care settings are discussed.     

Improving the Transportability of CBT for Internalizing Disorders in Children

Research provides strong support for the efficacy and effectiveness of cognitive behavioral therapy (CBT) for the treatment of childhood internalizing disorders. Given evidence for limited dissemination and implementation of CBT outside of academic settings, efforts are underway to improve its transportability so that more children with mental health needs may benefit from treatment. Creative modifications to existing treatments aim to deliver CBT for anxiety disorders and depression in a more transportable format. Notable progress has been made within the areas of computerized CBT, camp-based CBT, school-based CBT, and CBT delivered through primary care settings. These approaches are discussed within the context of key elements of transportability that are particularly germane to the dissemination and implementation of child treatments.     

Treatment for anxiety disorders: Efficacy to effectiveness to implementation

Anxiety disorders are common, costly and debilitating, and yet often unrecognized or inadequately treated in real world, primary care settings. Our group has been researching ways of delivering evidence-based treatment for anxiety in primary care settings, with special interest to preserving the fidelity of the treatment while at the same time promoting its sustainability once the research is over. In this paper, we describe the programs we have developed and our directions for future research. Our first study evaluated the efficacy of CBT and expert pharmacotherapy recommendations for panic disorder in primary care, using a collaborative care model of service delivery (CCAP). Symptom, disability and mental health functioning measures were superior for the intervention group compared to treatment as usual both in the short term and the long term, although also more costly. In our ongoing CALM study, we have extended our population to include panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic disorder, while at the same time utilizing clinicians with limited mental health care experience. In addition to pharmacotherapy management, we developed a computer-assisted CBT that guides both novice clinician and patient, thereby contributing to sustainability once the research is over. We have also incorporated a measurement based approach to treatment planning, using a web-based tracking system of patient status. To date, the computer-assisted CBT program has been shown to be acceptable to clinicians and patients. Clinicians rated the program highly, and patients engaged in the program. Future directions for our research include dissemination and implementation of the CALM program, testing potential alternations to the CALM program, and distance delivery of CALM.     

A Pain to Practice: Attitudes of Medical Family Therapists Working With Patients With Opioid Use Disorder

ABSTRACT

The prevalence of patients with opioid misuse in medical settings continues to rise, and it is unknown how much exposure medical family therapists (MedFTs) have in treating this issue. This study explored the attitudes of MedFTs (n = 58) when working with patients struggling with opioid use disorder in clinical practice. Results revealed that 43% of MedFTs had a low comfort level in working with this population and preferred to make referrals to primary care providers. Given that opioid use disorder cases are rising in healthcare settings, emerging mental health professionals would benefit from additional training to effectively treat this population.     

Translating Research for Professional Development and Effective Clinical Practice With Older Adults

This paper offers a commentary on the articles in the special series on cognitive behavior therapy with older adults (Carmin, 2012-this issue), noting the commonalities found across discussions of diagnostic interviewing and cognitive-behavioral assessment and treatment for late-life insomnia, depression and suicide risk, PTSD, and OCD. These case studies demonstrate best practices in the application of cognitive-behavioral strategies for assessment and intervention with a diverse range of older adults. Clinicians can improve the effectiveness of their work with aging clients by expanding their skills in assessment and managing interprofessional relationships in integrated health-care settings. Reflected by the papers in this series, ongoing professional development and research attention are both essential as clinicians from the mental health disciplines increase provision of CBT with older adults. Treatments for specific disorders and problems will also benefit from the growing literature on successful aging, and the application of positive psychology in our future collaborations with older adults and their care partners.     

Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review

Background/Objective: To assess the differential efficacy between mindfulness-based interventions and cognitive-behavioral Therapy (CBT) on chronic pain across medical conditions involving pain. Method: ProQuest, Science Direct, Google Scholar, Pubmed, and Embase databases were searched to identify randomized clinical trials. Measurements of mindfulness, pain, mood, and further miscellaneous measurements were included. Results: 18 studies met the inclusion criteria (fibromyalgia, n = 5; low back pain, n = 5; headache/migraine, n = 4; non-specific chronic pain, n = 4). In fibromyalgia, mindfulness based stress reduction (MBSR) was superior to the usual care and Fibroqol, in impact and symptoms. In low back pain, MBSR was superior to the usual care, but not to CBT, in physical functionality and pain intensity. There were no studies on differential efficacy between mindfulness and CBT for headache and non-specific chronic pain, but Mindfulness interventions were superior to the usual care in these syndromes. Conclusions: Mindfulness interventions are superior to usual cares in all diagnoses, but it is not possible to conclude their superiority over CBT. Comparisons between mindfulness interventions are scarce, with MBSR being the most studied. In central sensitization syndromes, variables associated with pain tend to improve with treatment. More research is needed to differentiate diagnosis and intervention.     

Manualized Treatment of Panic Disorder in a Medical Setting: Two Illustrative Case Studies

People who experience panic attacks (PAs) typically present to medical settings, concerned that their symptoms signify a life-threatening condition. Despite the efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD), medical practitioners seldom provide this type of treatment. Physicians may lack the time or expertise to impart such behavioral medicine interventions, while patients may find group or individual CBT too costly even when available. Researchers have begun investigating manualized CBT as a cost-effective alternative when traditional forms of this intervention are prohibited. This article describes two case studies in which women presenting to a medical clinic with PD were treated with 6 weeks of manualized CBT after pharmacotherapy was unsuccessful or unpalatable. Both patients exhibited reductions in panic and depressive symptomatology over baseline levels, along with increases in self-efficacy regarding their ability to manage future PAs. Improvements were maintained over 12 months, supporting continued use of manualized CBT as a supplement or alternative to pharmacological methods of treating PD in the medical setting.     

Domestic violence in primary care: The psychologist's role

This paper highlights the difficulties facing medical and mental health professionals in helping families in which there is violence. Emphasis is placed on how domestic violence presents in primary care medical settings. Physician and patient characteristics that interfere with domestic violence detection are reviewed. A role is outlined for psychologists in primary care settings to facilitate detection and treatment. Facilitative efforts include educating physicians through collaboration and serving as an on-site resource for information and consultation.     

A randomized pilot study of motivation enhancement therapy to increase utilization of cognitive–behavioral therapy for social anxiety

Despite the efficacy of cognitive–behavioral therapy (CBT), most socially anxious individuals do not seek treatment or seek treatment only after many years of suffering. This study evaluated the efficacy of a three-session motivation enhancement therapy (MET) designed to increase CBT utilization among socially anxious individuals. Twenty-seven non-treatment-seeking socially anxious individuals (92.6% met current DSM-IV criteria for social anxiety disorder) were randomly assigned to either MET for CBT (n = 12) or a control condition (n = 15). The primary outcome was attendance at first CBT appointment. Secondary outcomes included openness to therapist contact and willingness to schedule a CBT appointment. After the intervention, seven of the 12 (58.3%) participants in the MET condition attended a CBT appointment compared to two of 15 (13.3%) control participants. Eight of 11 (72.7%) participants in the MET condition indicated they would like a CBT therapist to contact them compared to four of 12 (33.3%) controls. Further, willingness to schedule a CBT appointment increased at a significantly greater rate in the MET condition. Results suggest MET for CBT may be a time-efficient means to increase CBT utilization among socially anxious individuals.     

Experimental and Behavioral Approaches to Alcoholism: Kongressrapport

Hypochondriasis is highly prevalent in medical settings, has detrimental effects for affected individuals, and is associated with high societal costs. Although cognitive behavior therapy (CBT) has been shown to be effective in the treatment of hypochondriasis, it is not widely available because of a lack of properly trained therapists. Therefore, it is essential to evaluate therapy forms that require less therapist time. The authors investigated the effect and economic impact of group CBT delivered in a psychiatric setting among 24 people with hypochondriasis. A within-group design with prolonged baseline was used, and all participants received 10 weeks of group-based treatment. The primary outcome measures were the Health Anxiety Inventory and the Illness Attitude Scales. Results indicate significant improvement on both measures at posttreatment and 6-month follow-up (Cohen's d = 1.03–1.72). Medical and nonmedical costs were substantially lowered. The authors conclude that group-based CBT delivered in a psychiatric setting is an effective and potentially highly cost-effective treatment for hypochondriasis.     

Primary Care and Clinical Psychology: Assessment Strategies in Medical Settings

There is ample evidence regarding medical-psychological comorbidity to consider clinical psychology as a viable component of health care services in medical settings. Psychologists can become valuable assets to primary care physicians who treat a high number of primary psychiatric cases as well as medical cases with secondary psychological symptoms. Psychologists who function in hospital-based clinics as well as affiliates with primary care (PC) offices can provide empirically supported assessment services that can make treatment more effective and efficient. Multiple studies indicate high prevalence rates of psychiatric patients in PC settings using various instruments. This paper reviews selected assessment tools that have established diagnostic validity and reliability that can be both strategic for patient care and useful to reinforce psychologist collaboration with primary care physicians (PCP).     

Behavioral Health Services Influence Medical Treatment Utilization Among Primary Care Patients with Comorbid Substance Use and Depression

Although research has shown benefits of integrating psychological care in primary care settings, it is unclear how this form of treatment impacts individuals with comorbid substance use and depression. The findings are also mixed concerning how frequently this comorbid population seeks primary care services. This study examined the associations between substance use, depression, and medical treatment utilization among 224 primary care patients. The aim of the investigation was twofold. First, to determine if depression increases medical treatment utilization among patients with substance use disorders; second, to evaluate if behavioral health treatment reduces medical service utilization. A moderated mediation model with bootstrapping analyses revealed that depression strengthened the relationship between substance use and primary care treatment utilization (both medical and behavioral health). The model also indicated that behavioral health services were associated with fewer primary care visits for individuals with comorbid substance use and depression. Clinical and social implications are discussed.