Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial

It is often thought that primary care clinics are only able to help with physical health challenges, but a new study shows that this may not be the case. In the study, published in the Journal of General Internal Medicine, researchers at Baylor College of Medicine and the Michael E. DeBakey VA Medical Center found that brief cognitive behavioral therapy (CBT) delivered in the primary care setting helped improve not only physical functioning but also symptoms of depression and anxiety in medically ill veterans.

“For this study, what we tried to do is take cognitive behavioral therapy, which we know works to treat mental health, and move it into primary care. However, we wanted to make it more streamlined and helpful to veterans and primary care patients so we shortened our treatment and included a focus on physical health,” said first author Dr. Jeffrey Cully, professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor and health services researcher at the Center for Innovations in Quality, Effectiveness and Safety.

Cully explained that cognitive behavioral therapy is a treatment that focuses on changing the way people think and behave to help them improve their lives and their functioning. It is designed to try to help patients identify when their thinking patterns are not as helpful as they could be and help them replace negative or distressful thoughts with more helpful ones. When it comes to changing behavior, CBT helps people stay active and engaged in their daily lives.

Researchers focused on a select group of patients suffering from heart failure and chronic obstructive pulmonary disease (COPD) for the study because often patients with these diseases have an elevated risk of anxiety, depression and physical health challenges. A total of 302 veterans were enrolled in the study, randomly assigned to either brief CBT or to an enhanced usual care group. Both groups received a physical and mental health assessment at the time of study entry.

A total of 180 patients received brief CBT, which was delivered by mental health providers in the primary care clinics at the Michael E. DeBakey and Oklahoma City VA Medical Centers. The CBT treatment was delivered over the course of four months using six weekly/biweekly sessions; however, there was some flexibility offered to providers so that they could deliver treatment the best way they saw fit to meet the patient’s needs. In addition, patients and their providers were given a workbook to help guide sessions. After the treatment period, researchers followed participants for 12 months to see how they did and to compare them to the enhanced usual care group.

For the primary outcomes, researchers found significant changes for symptoms of depression and anxiety, and they found that those changes were statistically and clinically meaningful compared to the enhanced usual care group. For COPD patients, the results showed dramatic changes in the way they perceived their COPD. They felt their overall quality of life had improved and that they were doing better both physically and emotionally. Although these improvements did not continue through the full 12 months after the initial four-month treatment, researchers said it lets them know that additional support in the four to 12 month period may be needed.

For heart failure patients, there was improvement in their depression and anxiety, but unlike COPD patients, they did not have significant changes in their perceptions of how they were functioning.

One of the keys to the success of integrating cognitive behavioral therapy into primary care is that it helps providers and patients openly discuss emotional health issues that are common but often not recognized or discussed as part of a patient’s overall health plan, Cully said. Further, the integration of emotional and physical health meant that patients were actively involved in the selection of treatment elements – ensuring that the focus of the intervention was aligned with the patient’s most pressing concerns.

Population of focus: Veterans

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Date: 2017

Journal: Journal of General Internal Medicine