Plan indywidualnej CBT depresji.pdf

CHAPTER 2: INDIVIDUAL COGNITIVE BEHAVIOR THERAPY FOR DEPRESSION

2. INDIVIDUAL COGNITIVE BEHAVIOR THERAPY

FOR DEPRESSION

2.1 BACKGROUND AND RATIONALE

Of all the existing forms of psychotherapy for unipolar depression, cognitive behavior therapy

(CBT: Beck et al., 1979) and interpersonal psychotherapy (Klerman et al., 1984) are best

supported by outcomes research. Both were significantly more effective than placebo plus

clinical management, and nearly as effective as imipramine in the NIMH Treatment of

Depression Collaborative Research Program (TDCRP: Elkin et al., 1989). However, although

other studies of interpersonal therapy have also shown promising results (e.g., Frank et al.,

1990), a much more extensive database supports the efficacy of CBT for depression (AHCPR

Clinical Practice Guidelines: Treatment for Major Depression, 1993; Dobson, 1989; Hollon et

al., 1991; Robinson et al., 1990).

Patients who are both depressed and socially withdrawn or who have poor social skills tend to do

better with CBT than with interpersonal psychotherapy (Rude et al., 1991; Sotsky et al., 1991).

By design, such patients are likely to constitute a large proportion of the ENRICHD sample.

Cognitive-behavioral interventions are also well-matched to the typical psychosocial problems

and the mild-to-moderate severity of depression commonly observed in cardiac populations

(Carney et al., 1987). For example, behavioral activation and desensitization of health-related

anxieties (e.g., overcoming unwarranted fears about and avoidance of returning to work, leisure

activities, sexual intercourse, etc.) are typical themes in the early phases of psychotherapy with

post-MI patients. Cognitive distortions (e.g., "catastrophizing" in response to mild exertional

fatigue, "fortune telling" in response to fears of abandonment, "black and white thinking" in

response to the need to discontinue medically risky leisure activities and to identify safer

alternatives, etc.) are commonly identified during treatment. Finally, as a relatively brief,

goal-oriented, collaborative, and emotionally supportive form of treatment, CBT is generally

well accepted by cardiac and other medical patients.

For these reasons, CBT was chosen as the psychotherapeutic intervention for depression in this

clinical trial. As in other clinical trials, ENRICHD counselors are expected to adhere to a

manualized treatment protocol. However, the ENRICHD protocol is not a rigid cookbook.

Instead, it is a reasonably flexible approach to CBT that provides considerable latitude within

which to deliver the best, most effective clinical care possible. Our overriding goal is to ensure

that our depressed patients get better.

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CHAPTER 2: INDIVIDUAL COGNITIVE BEHAVIOR THERAPY FOR DEPRESSION

The required treatment manuals for ENRICHD are (1) Cognitive Therapy of Depression (Beck,

Rush, Shaw, and Emery, 1979), which is the core CBT protocol and which has been used in most

previous outcome studies of CBT for depression, and (2) Cognitive Therapy: Basics and Beyond

(J.S. Beck, 1995), which supplements the core CBT protocol. The J.S. Beck (1995) manual is

designed to help CBT therapists to increase their clinical sensitivity and flexibility by expanding

their repertoire of cognitive-behavioral techniques. It will help ENRICHD counselors to

maximize effectiveness while working within the core framework of the Beck et al. (1979) CBT

protocol.

Like most other research projects that have used Beck et al. (1979) as their treatment manual, we

have also had to augment the manual in other ways to address the particular needs of the

ENRICHD study. This section of the Manual of Operations thus focuses on issues that go

beyond the material covered in Beck's (1979) core CBT protocol. Specifically, it (1) addresses

critical non-technique aspects of treatment (such as when to refer for pharmacotherapy); (2)

provides case examples involving cardiac patients to illustrate specific cognitive techniques; (3)

discusses strategies for overcoming problems that commonly arise in treating cardiac patients;

and (4) summarizes the use of process and clinical assessment tools for CBT, which are

discussed in greater detail in the appendix entitled “Process Measures and Clinical Tools.

2.2 INITIAL (PRETREATMENT) CLINICAL EVALUATION

As the treating clinician, you will have access to the results of the screening and baseline

assessments that were conducted by the case coordinator when the patient was recruited to

participate in the trial. However, you are required to conduct an independent clinical evaluation

of your own, prior to beginning counseling. In addition to evaluating the participant, use the

initial evaluation session as an opportunity to start building rapport, to instill hope, and to induct

the participant into counseling.

The principal purposes of the initial clinical evaluation are (1) to assess the participant’s current

problems and concerns; (2) briefly characterize the participant’s social network; (3) diagnose the

participant’s depressive disorder according to the DSM-IV criteria for major depressive episode,

minor depressive episode, and/or dysthymic disorder; and (4) determine the severity of the

current depressive episode. The counselor also has the option to: (1) identify comorbid Axis I

and Axis II psychiatric disorders which may affect the course of treatment; (2) characterize the

participant’s past psychiatric history; and (3) rate the participant’s current functioning on the

DSM-IV Axis V Global Assessment of Functioning Scale. The counselor also assess the

participant’s expectations about treatment and obtains other information that may be needed to

formulate an individualized treatment plan. The initial clinical evaluation includes the DISH,

which assesses current depressive symptoms and the 17-item Hamilton Depression score. You

are also required to administer the Beck Depression Inventory unless the baseline BDI was

obtained less than one week before the initial clinical evaluation.

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CHAPTER 2: INDIVIDUAL COGNITIVE BEHAVIOR THERAPY FOR DEPRESSION

If the participant has had any prior episodes of depression, determine what treatment, if any, was

received, and how well the participant responded to it. If pharmacotherapy was used, the agent

should be identified. The participant’s response to that agent should be noted and this

information should be provided to the study psychiatrist in the event that pharmacotherapy is

considered.

The initial clinical evaluation is initiated at Session Zero and completed as soon as possible after

that. Conduct the initial evaluation and initiate individual counseling as soon as is possible,

preferably while the participant is still in the hospital. If there is not enough time to arrange

Session Zero before discharge, or if the participant is not ready to tolerate a full session, it may

still be possible to arrange a brief visit or telephone contact to start building rapport with the

patient.

2.3 PROCESS MEASURES AND OTHER CLINICAL TOOLS

Starting with the initial clinical evaluation and continuing throughout treatment, you will be

required to utilize several treatment process measures. These measures are mandatory and are

used to assess the participant’s problems, document the implementation of the treatment

protocol, track the participant’s progress in treatment, and determine whether the participant has

successfully completed treatment. A variety of optional clinical tools are also available. The

optional tools may be used when needed, at the discretion of the counselor and his/her

supervisor. See Appendix for further details and instructions.

2.4 CONCURRENT PSYCHOPHARMACOLOGY

Participants who are severely depressed (defined as a Hamilton Depression score of 24 or higher)

will be evaluated for antidepressant therapy in consultation with the study’s psychiatrist and the

participant's cardiologist and/or primary care physician. As the treating counselor, you are to

reassess the severity of the participant's depression as part of your initial clinical evaluation.

You may find that a participant who scored below 24 on the baseline Hamilton Depression scale

now scores 24 or above on the basis of your interview. If so, you should refer the participant to

be evaluated for antidepressant therapy.

During the course of counseling, you should also refer participants with major depression to the

study psychiatrist for evaluation and consideration of additional treatment with an antidepressant

if their BDI scores have not decreased by at least 50% by the fifth week of treatment or if they

become more severely depressed. Moreover, if the participant scores >20 on the Hamilton

Depression Scale at the time of the 6-month conclusion of treatment, referral to the study

psychiatrist is also indicated. Not every participant will necessarily be prescribed an

antidepressant following psychiatric evaluation. However, referral for psychopharmacology is

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CHAPTER 2: INDIVIDUAL COGNITIVE BEHAVIOR THERAPY FOR DEPRESSION

an option at any time during treatment if, the counselor’s judgment, the participant is not

responding to CBT. (see chapter 3)

2.5 TREATMENT SCHEDULE

During the initial phase of treatment, participants with major or minor depression will receive

individual CBT. If possible, participants should be scheduled for twice-a-week sessions for the

first two weeks of treatment, as this may help to promote more rapid improvement. Most

participants will be seen once per week for the remainder of the initial phase of treatment.

However, twice-weekly sessions may be scheduled for participants if, in the counselor’s

judgment, this would be advisable (e.g., due to severe depression or suicidal ideation).

Once-or twice-weekly 50-minute sessions of individual CBT and/or weekly sessions of group

CBT will continue until the participant has met the criteria for successful counseling . The

criteria are met when the participant has completed at least 6 sessions of individual or group

counseling, has met the CBT performance criteria, and has scored 7 or below on the BDI for at

least two consecutive weeks (see section 1.3). Ordinarily, participants will be seen for no more

than 16 sessions of individual CBT. However, more sessions may be required in particularly

difficult or unusual cases, or in cases in which the participant has remitted and then relapsed.

2.6 CBT PERFORMANCE CRITERIA

As noted above, one of the factors to consider when deciding whether to terminate CBT is

whether the participant meets certain criteria that suggest a mastery of CBT skills. You may

have additional criteria of your own for an individual participant. The following are

performance criteria that are to be applied to all of your depressed participants and that are

derived from the Beck (1979) and J.S. Beck (1995) treatment manuals. Refer to these sources

for additional information. All participants should be rated on these criteria after every session

using the CBT Performance Criteria Scale (See Appendix).

1. The participant initiates and utilizes behavioral activation techniques.

2. The participant identifies problematic situations and emotions.

3. The participant identifies dysfunctional thoughts in problematic and/or emotionally arousing

situations.

4. The participant uses cognitive-behavioral techniques to evaluate and modify dysfunctional

thoughts and beliefs.

5. The participant uses cognitive-behavioral techniques for active problem solving.

6. The participant demonstrates the willingness and ability to apply cognitive-behavioral skills

to new and future problems and relapses.

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2.7 SESSION-BY-SESSION GUIDELINES

The following is a model treatment outline based on the Beck et al. (1979) and J.S. Beck (1995)

manuals. It is not intended to be a rigid schedule, but you are expected to use it as a guideline for

treatment planning. Counselors should read the 2 manuals and the CBT training materials

carefully and completely. They describe many techniques and procedures which will be helpful

in treating depressed patients in the ENRICHD trial.

2.7.1 Pre-Treatment Visit or Call

If it is not possible to hold a full Session Zero immediately after randomization, call or visit the

participant to start building rapport and interest in the treatment program.

2.7.2 Session Zero

1. Start building rapport and interest in the treatment program.

2. Conduct an initial clinical evaluation (see Appendix). Complete as much of the evaluation as

possible in Session 0, and complete any remaining portions of the evaluation in subsequent

sessions.

2.7.3 First Session

1. Continue buildingrapport.

2. Finish the initial clinical evaluation.

3. Discuss participant’sexpectations about counseling and recovery.

4. Check participant’s present mood.

5. Review post-heart attack recovery since discharge from hospital, including adherence to

medication and overall treatment regime.

6. Elicit negative attitudes regarding self, counseling, or counselor.

7. Pinpoint most urgent and accessible problem (e.g., hopelessness, suicidal wishes, loss of

functioning, severe dysphoria).

8. Describethe cognitive model of depression.

9. Explain cognitive-behavioral strategies with emphasis on the rationale for behavioral

assignments and homework.

10. Review Activity Chart for recording activities until next session.

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