- Email: [email protected]
Cognitive therapy with inpatients
ELSEVIER
Cognitive
Therapy
With Inpatients
Scott Stuart, M.D., Jesse H. Wright, Aaron T. Beck, M.‘B.
M.D., Ph.D., Michael
Abstract: Psychotherapeutic interventions often play a major role in the treatment of patients who are hospitalized for depression. Much of the “therapeutic milieu”of the inpatient unit includes patient participation in group psychotherapy and in one-on-one psychotherapy with staff members. These interventions are designed not only to be primary treatments for depression, but are also used to enhancepatients’ compliance with pharmacotherappy. Cognitive therapy (CT) has been adapted for use with inpatients and has been used as an organizing theory for the hospital milieu in several inpatient units. Research on inpatient CT suggests that it is a beneficial treatment that enhances continuity of care after discharge from the hospital. This paper describes the general principles of inpatient CT, and discusses the various types of inpatient cognitive therapy units (CTU.4 that have beendeveloped. The benefits of such programs are described, and research regarding the effectiveness of inpatient CT is discussed. 0 1997 Elsevier SCience Inc.
Introduction Over the past decade, there has been an increased emphasis on developing cost-effective medical treatments, along with a demand that the benefit of such interventions be empirically demonstrated. An explosion in health care costs has forced medical providers to more closely examine the effectiveness of their treatments and to make difficult decisions regarding the allocation of health care resources. In psychiatry, one of the major ramifications of this Mood Disorders and Psychotherapy Clinic. University of Iowa, Department of Psychiatry, Iowa City, Iowa (S.S.); Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine and Norton Psychiatric Clinic, Louisville, Kentucky (J.H.W.); Mood Disorders Module and Clinical Research Center, Western Psychiatric Institute & Clinic, Pittsburgh, Pennsylvania (M.E.T.); and Philadelphia, Pennsylvania (A.T.B.) Address reprint requests to: Scott Stuart, M.D., University of Iowa, Department of Psychiatry, 200 Hawkins Drive, Iowa City, IA 52242.
42 ISSN 0163-8343/97/$17.00 PI1 SOl63-8343(96)00122-3
E. Thase, M.D.,
and
trend has been increased scrutiny of inpatient treatments [l]. Hospitalization is the most costly portion of psychiatric care and constitutes a major portion of the outlay of federal funds for the treatment of patients with mental disorders. Despite the increased emphasis on efficacy and cost containment, there continues to be, on many inpatient units, widespread reliance on psychotherapeutic interventions of unproven value. The study of inpatient psychotherapy, both in terms of outcome research and service utilization research, requires a systematic program of psychotherapeutic treatment. The intervention should be reproducible, and should be testable regarding benefits to patients and cost-effectiveness. In addition, the psychotherapy should be suitable for delivery by nonphysician personnel because they typically provide the majority of the psychosocial interventions on most inpatient units. Cognitive therapy (CT) has been utilized as a major component of treatment programs in a number of inpatient psychiatric units [21. Although CT was initially developed in an outpatient setting, the cognitive model has been found to be readily adaptable for use in the hospital milieu [2-51. Some of the advantages of CT for inpatient applications include 11 a short-term format; 2) clearly defined procedures; 31 a treatment model that can be understood and utilized by the multidisciplinary team; 4) compatibility with somatic treatments; 51 empirical evidence for effectiveness in the treatment of depression, anxiety disorders, eating disorders, and other clinical problems frequently observed in hospitalized patients [2,61; and 6) efficacy in short-term treatment settings. These features also make CT useful for outcome and cost-effectiveness studies of inpatient psychotherapy. Cognitive therapy methods have been adapted to
General 655 Avenue
Hospital
Psychiatry 19, 42-50, 1997 0 1997 Elsevier Science Inc. of the Americas, New York, NY 10010
Cognitive Therapy With Inpatients suit the goals, resources, and constraints of a wide variety of inpatient programs. In this paper we describe modifications of cognitive therapy techniques for treatment of inpatients, and outline the defining features of several of the more common types of cognitive therapy units (CTUs). Current research regarding the efficacy of inpatient cognitive therapy is also reviewed.
Inpatient
Cognitive
Therapy
The trend toward shorter hospital stays, forced in part by the reimbursement limitations of managed care, has required that psychopharmacological treatment be utilized quickly with most psychiatric inpatients. Inpatient cognitive therapy programs usually adopt a treatment philosophy that blends cognitive therapy principles with somatic treatments. Cognitive therapy is endorsed as the predominant theory to guide psychosocial treatment interventions, and CT principles are often used to deal with medication issues such as compliance and medication side-effects. An integrated cognitive and biological approach to therapy that joins these two major treatment methods on theoretical grounds and in clinical practice has been described [7-101.
Thase and Wright [51, Ludgate et al. 1111, Shaw [12], and Scott [13] have described CT methods designed for individual therapy of inpatients with affective disorders. These methods are based on the form of cognitive therapy for depressed outpatients originally described by Beck et al. [14], but modifications have been necessary because of the differences in patient populations and treatment settings. Inpatients usually have more severe psychiatric symptoms than do ambulatory patients, and commonly have many more associated social stressors. In addition, hospitalized patients often have poorer concentration, greater hopelessness, and deeper levels of suicidal ideation than do outpatients. Consequently, inpatient CT programs place a great deal of emphasis on 1) increasing the frequency of contact with patients; 2) reducing hopelessness as soon as possible; 3) tailoring the individual CT program to the patient’s level of functioning; 4) including family members or significant others as collaborators in the patient’s treatment; and 5) ensuring continuity of care from an inpatient to an outpatient setting. Typically an inpatient CT program for patients with affective or anxiety disorders consists of three
phases, each lasting from 2 or 3 days to a week. Average lengths of stay in the author’s cognitive therapy units are approximately 8-11 days. However, some hospital programs, particularly those in Europe, have longer lengths of stay and this can extend and enrich the phases of inpatient CT. In many American programs, portions of the later phases of CT with inpatients may be accomplished in a partial hospital program or an intensive outpatient program. Inpatient CT sessions are usually shorter than the traditional 50-minute sessions used for outpatients IS]. Severely ill hospitalized patients often are unable to benefit from lengthy sessions early in therapy because of difficulties with concentration or because of high levels of anxiety or agitation. Twenty- to 40-minute sessions (on a daily basis if possible), augmented by contacts with other staff members, are used in the early stages 01 treatment. Later sessions can be lengthened as improvement occurs. The first phase of the program involves the establishment of a working alliance with the patient, the implementation of activity scheduling and other behavioral assignments, and the introduction of the cognitive model 151. A program list is developed, and work is begun on the most pressing issues on the list. Beginning in this portion of treatment and continuing throughout the therapy, relevant homework assignments are developed during each session. Behavioral interventions such as activity scheduling and graded task assignments are utilized frequently in this early phase of inpatient CT. Reduction of hopelessness and suicidal ideation is usually a major focus of treatment during the early therapy sessions. Even in the earliest sessions, the therapist can often help the patient identify and modify a few key cognitive distortions that are associated with hopelessness and selfdefeating behavior. Hopelessness usualiy begins to decline as the patient begins to complete behavioral tasks and improvement can be concretely demonstrated. Psychoeducation is another important component of the opening phase of CT. Explanations, diagrams, readings, and videos may be used to help the patient rapidly assimilate basic cognitive therapy principles and skills. In addition, some inpatient units are beginning to use a new form of computer-assisted cognitive psychotherapy as a treatment adjunct. The interactive video, Cagnitiae Therapy: A Multimedia Learning Program [15,161, is
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one example of this type of computerized therapy. The program can be utilized by a wide range of patients, and requires no previous computer experience or typing skills. Introductory modules from this program can be used in the first phase of treatment to rapidly educate patients about the cognitive model. More intensive segments may be prescribed later to assist with the other phases of inpatient treatment. If possible, psychoeducation sessions are usually conducted with the patient’s spouse and/or family in the first few days of hospitalization. Family members are taught basic principles of CT and are helped to reframe their understanding of psychiatric illness. A collaborative, problem-solving approach is emphasized. These sessions assist in developing a therapeutic alliance with the family, and give family members an opportunity to ask questions about the patient’s diagnosis, prognosis, and treatment. The second phase of inpatient CT addresses patients’ specific problem lists. Patients are taught to recognize the cognitive processes that result in negative automatic thoughts and to use selfmonitoring assignments aimed at elucidating the interrelationship of cognitions, affect, and behavior. They also learn to identify and correct cognitive errors [5,141 (e.g., selective abstraction, arbitrary inference, personalization, absolutistic thinking) and to develop rational responses to dysfunctional automatic thoughts. Patients are encouraged to keep a notebook summarizing the content of their therapy sessions, and to review their homework assignments in order to reinforce learning of cognitive therapy skills. Behavioral work continues during the middle phase of treatment but may be somewhat more challenging than in the beginning of treatment. For example, graded task assignments may be structured to help the patient master feared situations or to begin to reverse significant social skill deficits. Some patients may be able to recognize and change underlying schemas (basic assumptions or cognitive templates) during this phase, but work on schemas often must be delayed until there is an increased capacity for abstract thinking. The final stage of inpatient treatment involves intensive work on changing maladaptive cognitions and behavior, and also focuses on preparation for discharge. Possible triggers for relapse are identified and the therapist assists the patient with practicing problem-solving strategies (e.g., cognitive be-
havioral rehearsal). Material covered in earlier sessions is reviewed and reinforced. Also, in vivo applications of newly learned CT skills are encouraged in both the hospital milieu and on trial home visits. An additional emphasis is placed on using cognitive and behavioral methods to increase adherence with the pharmcotherapy regimen after discharge [5,17]. Completion of all components of the three phases of inpatient CT may not always be possible in the hospital setting. In this era of vigorous managed care, patients are usually discharged when their symptoms are no longer disabling and treatment can be accomplished on an outpatient basis. Thus it is advisable for inpatient CT units to be closely associated with partial hospitalization and intensive outpatient programs that can implement a cognitively oriented treatment plan. In our experience, the CT approach has helped to unite inpatient and outpatient phases of treatment by offering a consistency of approach, clear methods for follow through (e.g., homework, graded task assignments, thought monitoring, cognitive-behavioral rehearsal), and a focus on problem resolution. Outpatient individual or group CT can be performed by the same therapists that treat inpatients and/or additional clinicians trained in cognitive therapy. If outpatient continuation therapy is not possible there may be an increased risk of relapse [18]. Inpatient cognitive therapy has been used to treat patients with a variety of psychiatric disorders. Further modifications of the therapy procedures described above have been outlined for patients with eating disorders 1191, psychoses [20-221, substance abuse 1231, and personality disorders 1241. Specialty programs have also been developed for adolescent 125,261 and elderly inpatients [27].
Cognitive
Therapy
Units
The degree to which cognitive therapy principles are used in the hospital milieu is determined by a wide variety of factors including 1) hospital type (e.g., community, teaching, private, public, not-forprofit vs profit-centered, closed staff vs open staff); 2) staff theoretical orientation, training background, and clinical expertise; 3) administrative support; 4) patient population; and 5) economic factors. Several models for inpatient cognitive therapy have been described 121. The primay therapist model is best suited for inpatient units with a closed staff, or one in which
Cognitive Therapy With inpatients there are a limited number of clinicians who provide psychotherapy. This form of inpatient cognitive therapy has been utilized primarily in academic settings. A core group of primary therapists, usually consisting of psychiatrists, psychologists, and social workers, receives intensive training in CT and then provides cognitive therapy to suitable inpatients. Other staff members such as nurses, aides, and occupational therapists play a secondary role in the CT program. These individuals are oriented to basic cognitive therapy principles and are given short courses in CT so that they can assist with homework assignments and offer other support to the primary therapists. Inpatient facilities that have used this model have been able to develop highly trained groups of primary therapists who can perform CT at a level acceptable for research studies. However, the full resources of the milieu are not used because adjunctive staff members play a rather circumscribed role in the cognitive therapy program. Another form of inpatient CT, the staff model, has been developed for psychiatric hospitals in which there are open staff privileges and in which a number of psychiatrists, often with differing theoretical orientations, admit patients to the facility A special CT unit may be set up as one option among several available at the hospital. Psychiatrists usually are asked to attend a l-day workshop or other educational seminar to familiarize them with the methods that are used on the CT unit. The attending physician’s function is to evaluate the patient, make daily rounds, perform supportive therapy, prescribe somatic treatment, and provide other medical interventions as needed. The psychiatrist also may implement portions of the CT program if he or she is experienced in this form of therapy or has an interest in learning more about cognitively oriented treatment interventions. However, the bulk of the CT is performed by staff members who have received training in this approach. Psychiatric nurses, aides, and adjunct therapists (e.g., occupational or recreational therapists) play a major role in staff unit models. Usually, a unit director who has had extensive experience in CT organizes the program and supervises the staff members. Cognitive therapy concepts and procedures are emphasized to patients in multiple encounters with staff members throughout the day, but patients may not receive the same degree of attention in individual CT that is common in units that utilize the primary therapist model.
The “add-on” model is the easiest form of inpatient CT to implement. A special cognitive therapy module is added to the existing milieu without attempting to reorganize the basic treatment program. This model has been used to study the effects of supplementing standard treatment with cognitive therapy, and has been utilized in hospitals where there are insufficient resources to develop a more fully developed CT unit. The add-on format also may be useful when the inpatient team wants to try out cognitive therapy methods before committing to a large-scale retooling of the milieu. Addon CT programs have ranged from limited group therapy interventions to the provision of intensive individual cognitive therapy as a component of controlled research studies. Several inpatient units in the United States and Europe have utilized a comprehenshie C1 model for hospital psychiatry Most, if not all, individual, group, and family therapists receive extensive training in CT and use this approach consistently in therapeutic interchanges with patients and families. In addition, nurses and adjunct therapists are well versed in CT procedures. These individuals deliver a significant portion of the therapy program by offering patients opportunities for testing the validity of their cognitions and for trying out more adaptive behaviors in multiple settings throughout the milieu. The comprehensive model works best in situations where patients can be screened for suitability for CT, and can actively participate in and benefit from cognitive therapy. However, many inpatient programs must admit a wide variety of individuals, including those with organic mental disorders and severe psychoses. A flexible model for inpatient CT can be used when there are rapidly changing mixes of patients on the unit. Primary therapists and staff members may receive training and supervision similar to levels utilized in the comprehensive model, but the amount of cognitive therapy used in the treatment program is adjusted daily to match the needs of the patient population. When the unit is largely comprised of individuals with affective disorders, perand other conditions for sonality disturbances, which CT can be a primary treatment 121, the program may function much like the comprehensive model. However, the intensity of the treatment can be reduced, and substitute therapeutic activities can be employed when the composition of the milieu changes. Typically, flexible model units have two or more tracks for patients with different levels of pa-
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thology and capacities therapy.*
The Cognitive
to participate
in psycho-
Milieu
The degree to which cognitive therapy is utilized in the milieu depends on the model (e.g., comprehensive, staff, add-on, comprehensive, flexible) that is employed. However, most cognitive therapy units (with the exception of add-on programs) share several common features in their overall treatment program: 1) a cognitive-biological treatment philosophy is adopted; 2) treatment planning is used to clearly designate CT interventions and who will implement them; 3) the multidisciplinary team is used to provide a wide range of cognitive therapy interventions throughout the patient’s day; 4) group cognitive therapy is used to supplement individual CT and may, in some cases, be the major form of CT employed on the unit; 5) patients are given homework assignments to carry out cognitive and behavioral procedures within the milieu (e.g., in occupational therapy, “community” meetings, recreational therapy, or family visits); 6) psychoeducational procedures are used to rapidly socialize patients and families to the cognitive model and to reinforce material learned in therapy sessions; 7) families are involved in treatment whenever possible; 8) transition to partial hospitalization or outpatient status begins early in the hospitalization; and 9) training and continuing education in CT is provided for staff members 1301. Patients in well-developed CT units typically will be involved in individual CT and several different cognitively oriented groups. Inpatient group CT may be conducted using an open-ended format, but 1 In addition to these CT models for psychiatric inpatient units, several authors have described the use of CT as a model for psychiatric consultation-liaison services [28,29]. Given the fact that there is a high prevalence of psychiatric problems among patients hospitalized for medical reasons, and that the most common disorders found in this population are depression and anxiety, it is not surprising that such CT programs have been developed. The CT approach advocated in C-L psychiatry is similar to that outlined above, with the addition of several issues unique to a nonpsychiatric medical treatment setting. Special attention must be paid to the patient’s attribution of his or her illness, i.e., whether the patient views the symptoms as “only’ physical, or whether he or she is open to the possibility that they have a psychiatric basis. The C-L psychiatrist should take care to develop a formulation of the patient’s problems in collaboration with the patient, so that realistic and specific treatment goals can be addressed. In addition, the C-L psychiatrist must ensure that the nonpsychiatrist medical team is educated about CT and its use with medically ill patients.
more structured methods for providing group therapy have also been devised. Bowers 131 and Freeman et al. [31] have described the use of rotating theme, programmed, and specialty groups for hospital applications. Cognitively oriented treatment milieus that promote group therapies and rely on the multidisciplinary team to carry out the treatment plan are linked in part to earlier models for inpatient psychiatry, such as the “therapeutic community” [32] and “rational eclecticism” [33] or the “reactive environment” [34], each of which recognized the importance of using multiple psychosocial situations and staff contacts as opportunities for patients to learn. However, in a cognitively oriented milieu, CT concepts are used for specific therapeutic interventions.
Inpatient
Cognitive
Therapy
Research
Outcome research on inpatient CT thus far has been limited to trials of CT as an adjunct to antidepressant medication and several studies of CT as primary treatment (e.g., without medication) for depression [351. Controlled assessments of fully developed cognitive milieus have not yet been conducted.
CT as an Adjunct to Antidepressant Medication Barker et al. I361 treated a series of eight chronically depressed inpatients with CT and pharmacotherapy. All of the patients were selected for treatment as a result of their chronic depression and the fact that they had been refractory to multiple antidepressant treatments, including electroconvulsive therapy (ECT) in most cases. Upon completion of 15 CT sessions in 12 weeks, patients demonstrated a significant improvement in both Hamilton Rating Scale for Depression (HRSD) [37] and Beck Depression Inventory (BDI) [381 scores. The patients did, however, continue to show significant residual symptoms of depression after treatment was completed. In a subsequent study [391, 16 chronically depressed inpatients were treated with three CT sessions per week throughout their hospitalization. Patients received an average of 16 CT sessions. After discharge, outpatient CT was provided for at least 6 months. Patients’ mean HRSD scores decreased from 24.5 to 10.6 and mean BDI scores dropped from 38.7 to 14.7 following 12 weeks of treatment. Eleven of the 16 patients were consid-
Cognitive Thprapv lVith Inpatients ered significantly improved at the conclusion of outpatient treatment. Bowers 1401 reported on a series of 30 inpatients diagnosed with major depression who were randomly assigned to one of three treatment conditions: nortriptyline alone, nortriptyline plus CT, or nortriptyline plus relaxation training. The latter two groups of patients received 12 sessions of CT or relaxation training on a daily basis. At the conclusion of treatment, all three groups were significantly less symptomatic. However, both of the combined treatment groups had significantly lower BDI scores, and had a greater percentage of recovered patients (defined as BDI < 7) than did the group receiving nortriptyline alone. When HRSD scores were compared, the CT plus nortriptyline group had a significantly higher percentage of patients who had recovered (defined as HRSD < 7) than did the other two groups. Several reports regarding the treatment of depressed inpatient with CT have been published by Miller et al. 141441. In their first study [411, six chronically depressed female inpatients were treated in an open trial with a combination of antidepressant medication and either CT or social skills training. Inpatient sessions were held 5 days a week, followed by 16 weeks by weekly outpatient treatment. From intake to the end of treatment, average BDI scores decreased from 25.2 to 6.3, and average HRSD scores decreased from 23.8 to 8.7. Four of the six patients met criteria for recovery (BDI < 10 and HRSD < 8) at the conclusion of treatment. Miller et al. 1411 subsequently conducted a controlled treatment trial with 47 depressed inpatients who were randomly assigned to one of three interventions: standard inpatient treatment (hospital milieu, doctor’s visit, and antidepressant medication), CT plus standard inpatient treatment, or social skills training plus standard inpatient treatment. Patients received therapy on a daily basis. Following discharge, patients in the two psychotherapy conditions were seen weekly as outpatients for 20 weeks. All patients received antidepressant medication (amitriptyline or desipramine) during the entire treatment. At the conclusion of inpatient treatment, all three groups had improved significantly There were no statistically significant differences between the groups in the amount of improvement or in the rate of response (defined as BDI < 10 and HRSD < 7). Upon completion of the 20-week outpatient phase [40], there were no differences between treatments
in HRSD scores. The social skills group had significantly lower BDI scores than the standard treatment group, and there was a similar trend favoring CT patients over the standard treatment group. There also was a trend toward a higher rate of response in the CT group (80% response) than in the standard treatment group (41% response). The rate of response in the social skills groups (50% response) did not offer from either of the other groups. Patients were reassessed at 6 and 12 months after the completion of outpatient treatment 1431. The social skills and CT groups were pooled into a single “psychotherapy” treatment group, because both groups had experienced comparable posttreatment outcomes. There were no significant differences between this psychotherapy group and the standard treatment group on either HRSD or BDI scores, nor in the rate of rehospitalization at either 6 or 12 months. However, there was a trend for patients in the standard treatment group to have a higher rate of relapse compared with those receiving psychotherapy Further, there was a significantly higher rate of recovery 168%) in the pooled psychotherapy groups as compared with the standard treatment group (33%). Miller et al. [441 also found that a specific subgroup of depressed inpatients characterized. by “high cognitive dysfunction” (i.e., high scores on measures of cognitive distortions) responded differentially to CT. Although there were no differences at the end of the inpatient treatment phase between the “high cognitive dysfunction” (HCD) patients who received pharmacotherapy and the HCD patients who received medication and CT, at the end of the 20-week outpatient phase of treatment, the HCD patients receiving combined treatment had significantly lower BDI and HRSD scores than the HCD patients who received only pharmacotherapy. HCD patients who had combined treatment had a significantly higher rate of treatment response (57%) than those HCD subjects who had received standard treatment (18%).
CT as a Primary Treatment Modality The first open trial of inpatient CT for depression was reported by Shaw 1121. Eleven medication-free inpatients were openly assigned to treatment with three sessions of CT per week. Mean BDI scores dropped from 29.8 at admission to 15.6 at discharge over a mean hospitalization period of 8.1 weeks. Patients maintained their level of improvement
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S. Stuart et al. (mean BDI score of 13.5) at a follow-up evaluation 46 weeks after discharge. Thase et al. [18J reported on the use of CT with a series of 16 medication-free depressed inpatients. All patients met criteria for DSM-III-R 1451 for major depression and Research Diagnostic Criteria 1461 for probable or definite endogenous major depression. Patients received daily individual CT sessions for up to 4 weeks (average number of sessions = 12.8). Thirteen of 16 patients (81%) met criteria for treatment response (HRSD score < 10) at discharge. Mean HRSD scores decreased from 21.7 to 7.7, and mean BDI scores decreased from 32.4 to 6.9. Of the seven responders who received 4 months of outpatient continuation therapy, only one patient (14%) relapsed following discharge. In contrast, three of four responders who declined outpatient treatment experienced a relapse within the same time frame. Based on this experience the authors subsequently modified their treatment protocol so that all patients were required to enroll in an outpatient CT program following discharge from the hospital. In a later analysis of an enlarged and more heterogenous sample of 30 inpatients with major depression, a response rate of 70% (21 responders out of 30 patients) was observed for those patients treated with inpatient CT [471. All nine nonresponders had either complicated depressive syndromes (e.g., comorbid substance abuse disorders) and/or hypercortisolemia. DeJong et al. [481 have published the only controlled study using inpatient CT as the primary treatment for depression. Thirty chronically depressed patients were randomly assigned to one of three treatment conditions. The first group received inpatient CT, while the second group received individual cognitive restructuring sessions only. Patients in the third group, who were considered to be control subjects, were treated with supportive outpatient psychotherapy every 10 days. All groups were treated for a maximum of 6 weeks. None of the patients received psychotropic medication. Six (60%) of the patients receiving cognitive behavioral treatment, three (30%) of the patients in the cognitive restructuring group and one (10%) of the patients in the outpatient control group were classified as “responders” to treatment. Improvement in BDI scores was significantly greater in patients treated with CT as compared with both the cognitive restructuring group and the control group. However, there were no differences between the two inpatient groups in HRSD ratings at discharge. Unfortunately, the use of an outpatient waiting list
control makes it difficult to separate the effects of the general hospital milieu on the overall outcome from the specific effects of inpatient CT, particularly since the form of therapy utilized for both of the hospitalized groups was similar.
Summary
and Conclusion
Many inpatient units have begun to utilize cognitive therapy as a specific treatment modality and as an organizing theory for inpatient psychotherapeutic treatment. Several different models (primary therapist, staff, “add-on,” comprehensive, and flexible) for cognitively oriented inpatient therapy have been applied in varied treatment settings. With inpatients, CT procedures usually are modified to provide a greater frequency of contact with the patient, increased structure, intensive use of psychoeducational tools, a behavioral emphasis early in treatment, and frequent opportunities for learning cognitive therapy skills in the treatment milieu. Some inpatient cognitive therapy programs are based primarily on individual CT, but most use cognitively oriented group therapy, family therapy, and adjunctive therapies such as occupational therapy and recreational therapy to implement treatment procedures. Research on inpatient CT has examined the effect of adding individual CT to pharmacotherapy for depression and has tested the efficacy of cognitive therapy without antidepressants. The limited data available suggest that CT can have an additive effect in some cases and that cognitive therapy is an effective treatment for severely depressed inpatients, even if biological treatments are not used. Randomized, controlled studies of fully developed inpatient cognitive therapy programs, however, remain to be conducted. The continued use of inpatient CT will hopefully stimulate further research regarding the cost-effectiveness and benefits of inpatient psychotherapy, and facilitate development of specific strategies of psychotherapeutic interventions for the wide variety of disorders that require inpatient treatment.
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S. Stuart et al. 39. Scott J: Chronic depression: can cognitive therapy succeed when other treatments fail? Behav Psychother 20:25-36, 1992 40. Bowers WA: Treatment of depressed inpatients: cognitive therapy plus medication, relaxation plus medication, and medication alone. Br J Psychiatry 156:7378, 1990 41. Miller IW, Bishop SB, Norman WH: Cognitive behavioral therapy and pharmacotherapy with chronic, drug-refractory depressed inpatients: a note of optimism. Behav Psychother 13:320-327,1985 42. Miller IW, Norman WH, Keitner GI: Cognitive behavioral treatment of depressed inpatients. Behav Ther 20125-47, 1989 43. Miller IW, Norman WH, Keitner GI: Cognitive behavioral treatment of depressed inpatients: six and twelve month follow-up. Am J Psychiatry 14631274 1279, 1989
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44. Miller IW, Norman WH, Keitner GI: Treatment response of high cognitive dysfunction depressed inpatients. Compr Psychiatry 30:62-71, 1990 45. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised. Washington DC, American Psychiatric Association, 1987 46. Spitzer RL, Endicott J, Robins E: Research Diagnostic Criteria: rationale and reliability. Arch Gen Psychiatry 35:773-782,1978 47. Thase ME: Cognitive behavior therapy of severe unipolar depression. In Grunhaus L, Greden JF teds), Severe Depressive Disorders. Washington DC, American Psychiatric Press, 1994 48. DeJong R, Treiber R, Henrich G: Effectiveness of two psychological treatments for inpatients with severe and chronic depression. Cognitive Ther Res 10:645663,1986
Cognitive
Therapy
With Inpatients
Scott Stuart, M.D., Jesse H. Wright, Aaron T. Beck, M.‘B.
M.D., Ph.D., Michael
Abstract: Psychotherapeutic interventions often play a major role in the treatment of patients who are hospitalized for depression. Much of the “therapeutic milieu”of the inpatient unit includes patient participation in group psychotherapy and in one-on-one psychotherapy with staff members. These interventions are designed not only to be primary treatments for depression, but are also used to enhancepatients’ compliance with pharmacotherappy. Cognitive therapy (CT) has been adapted for use with inpatients and has been used as an organizing theory for the hospital milieu in several inpatient units. Research on inpatient CT suggests that it is a beneficial treatment that enhances continuity of care after discharge from the hospital. This paper describes the general principles of inpatient CT, and discusses the various types of inpatient cognitive therapy units (CTU.4 that have beendeveloped. The benefits of such programs are described, and research regarding the effectiveness of inpatient CT is discussed. 0 1997 Elsevier SCience Inc.
Introduction Over the past decade, there has been an increased emphasis on developing cost-effective medical treatments, along with a demand that the benefit of such interventions be empirically demonstrated. An explosion in health care costs has forced medical providers to more closely examine the effectiveness of their treatments and to make difficult decisions regarding the allocation of health care resources. In psychiatry, one of the major ramifications of this Mood Disorders and Psychotherapy Clinic. University of Iowa, Department of Psychiatry, Iowa City, Iowa (S.S.); Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine and Norton Psychiatric Clinic, Louisville, Kentucky (J.H.W.); Mood Disorders Module and Clinical Research Center, Western Psychiatric Institute & Clinic, Pittsburgh, Pennsylvania (M.E.T.); and Philadelphia, Pennsylvania (A.T.B.) Address reprint requests to: Scott Stuart, M.D., University of Iowa, Department of Psychiatry, 200 Hawkins Drive, Iowa City, IA 52242.
42 ISSN 0163-8343/97/$17.00 PI1 SOl63-8343(96)00122-3
E. Thase, M.D.,
and
trend has been increased scrutiny of inpatient treatments [l]. Hospitalization is the most costly portion of psychiatric care and constitutes a major portion of the outlay of federal funds for the treatment of patients with mental disorders. Despite the increased emphasis on efficacy and cost containment, there continues to be, on many inpatient units, widespread reliance on psychotherapeutic interventions of unproven value. The study of inpatient psychotherapy, both in terms of outcome research and service utilization research, requires a systematic program of psychotherapeutic treatment. The intervention should be reproducible, and should be testable regarding benefits to patients and cost-effectiveness. In addition, the psychotherapy should be suitable for delivery by nonphysician personnel because they typically provide the majority of the psychosocial interventions on most inpatient units. Cognitive therapy (CT) has been utilized as a major component of treatment programs in a number of inpatient psychiatric units [21. Although CT was initially developed in an outpatient setting, the cognitive model has been found to be readily adaptable for use in the hospital milieu [2-51. Some of the advantages of CT for inpatient applications include 11 a short-term format; 2) clearly defined procedures; 31 a treatment model that can be understood and utilized by the multidisciplinary team; 4) compatibility with somatic treatments; 51 empirical evidence for effectiveness in the treatment of depression, anxiety disorders, eating disorders, and other clinical problems frequently observed in hospitalized patients [2,61; and 6) efficacy in short-term treatment settings. These features also make CT useful for outcome and cost-effectiveness studies of inpatient psychotherapy. Cognitive therapy methods have been adapted to
General 655 Avenue
Hospital
Psychiatry 19, 42-50, 1997 0 1997 Elsevier Science Inc. of the Americas, New York, NY 10010
Cognitive Therapy With Inpatients suit the goals, resources, and constraints of a wide variety of inpatient programs. In this paper we describe modifications of cognitive therapy techniques for treatment of inpatients, and outline the defining features of several of the more common types of cognitive therapy units (CTUs). Current research regarding the efficacy of inpatient cognitive therapy is also reviewed.
Inpatient
Cognitive
Therapy
The trend toward shorter hospital stays, forced in part by the reimbursement limitations of managed care, has required that psychopharmacological treatment be utilized quickly with most psychiatric inpatients. Inpatient cognitive therapy programs usually adopt a treatment philosophy that blends cognitive therapy principles with somatic treatments. Cognitive therapy is endorsed as the predominant theory to guide psychosocial treatment interventions, and CT principles are often used to deal with medication issues such as compliance and medication side-effects. An integrated cognitive and biological approach to therapy that joins these two major treatment methods on theoretical grounds and in clinical practice has been described [7-101.
Thase and Wright [51, Ludgate et al. 1111, Shaw [12], and Scott [13] have described CT methods designed for individual therapy of inpatients with affective disorders. These methods are based on the form of cognitive therapy for depressed outpatients originally described by Beck et al. [14], but modifications have been necessary because of the differences in patient populations and treatment settings. Inpatients usually have more severe psychiatric symptoms than do ambulatory patients, and commonly have many more associated social stressors. In addition, hospitalized patients often have poorer concentration, greater hopelessness, and deeper levels of suicidal ideation than do outpatients. Consequently, inpatient CT programs place a great deal of emphasis on 1) increasing the frequency of contact with patients; 2) reducing hopelessness as soon as possible; 3) tailoring the individual CT program to the patient’s level of functioning; 4) including family members or significant others as collaborators in the patient’s treatment; and 5) ensuring continuity of care from an inpatient to an outpatient setting. Typically an inpatient CT program for patients with affective or anxiety disorders consists of three
phases, each lasting from 2 or 3 days to a week. Average lengths of stay in the author’s cognitive therapy units are approximately 8-11 days. However, some hospital programs, particularly those in Europe, have longer lengths of stay and this can extend and enrich the phases of inpatient CT. In many American programs, portions of the later phases of CT with inpatients may be accomplished in a partial hospital program or an intensive outpatient program. Inpatient CT sessions are usually shorter than the traditional 50-minute sessions used for outpatients IS]. Severely ill hospitalized patients often are unable to benefit from lengthy sessions early in therapy because of difficulties with concentration or because of high levels of anxiety or agitation. Twenty- to 40-minute sessions (on a daily basis if possible), augmented by contacts with other staff members, are used in the early stages 01 treatment. Later sessions can be lengthened as improvement occurs. The first phase of the program involves the establishment of a working alliance with the patient, the implementation of activity scheduling and other behavioral assignments, and the introduction of the cognitive model 151. A program list is developed, and work is begun on the most pressing issues on the list. Beginning in this portion of treatment and continuing throughout the therapy, relevant homework assignments are developed during each session. Behavioral interventions such as activity scheduling and graded task assignments are utilized frequently in this early phase of inpatient CT. Reduction of hopelessness and suicidal ideation is usually a major focus of treatment during the early therapy sessions. Even in the earliest sessions, the therapist can often help the patient identify and modify a few key cognitive distortions that are associated with hopelessness and selfdefeating behavior. Hopelessness usualiy begins to decline as the patient begins to complete behavioral tasks and improvement can be concretely demonstrated. Psychoeducation is another important component of the opening phase of CT. Explanations, diagrams, readings, and videos may be used to help the patient rapidly assimilate basic cognitive therapy principles and skills. In addition, some inpatient units are beginning to use a new form of computer-assisted cognitive psychotherapy as a treatment adjunct. The interactive video, Cagnitiae Therapy: A Multimedia Learning Program [15,161, is
43
S. Stuart et al.
one example of this type of computerized therapy. The program can be utilized by a wide range of patients, and requires no previous computer experience or typing skills. Introductory modules from this program can be used in the first phase of treatment to rapidly educate patients about the cognitive model. More intensive segments may be prescribed later to assist with the other phases of inpatient treatment. If possible, psychoeducation sessions are usually conducted with the patient’s spouse and/or family in the first few days of hospitalization. Family members are taught basic principles of CT and are helped to reframe their understanding of psychiatric illness. A collaborative, problem-solving approach is emphasized. These sessions assist in developing a therapeutic alliance with the family, and give family members an opportunity to ask questions about the patient’s diagnosis, prognosis, and treatment. The second phase of inpatient CT addresses patients’ specific problem lists. Patients are taught to recognize the cognitive processes that result in negative automatic thoughts and to use selfmonitoring assignments aimed at elucidating the interrelationship of cognitions, affect, and behavior. They also learn to identify and correct cognitive errors [5,141 (e.g., selective abstraction, arbitrary inference, personalization, absolutistic thinking) and to develop rational responses to dysfunctional automatic thoughts. Patients are encouraged to keep a notebook summarizing the content of their therapy sessions, and to review their homework assignments in order to reinforce learning of cognitive therapy skills. Behavioral work continues during the middle phase of treatment but may be somewhat more challenging than in the beginning of treatment. For example, graded task assignments may be structured to help the patient master feared situations or to begin to reverse significant social skill deficits. Some patients may be able to recognize and change underlying schemas (basic assumptions or cognitive templates) during this phase, but work on schemas often must be delayed until there is an increased capacity for abstract thinking. The final stage of inpatient treatment involves intensive work on changing maladaptive cognitions and behavior, and also focuses on preparation for discharge. Possible triggers for relapse are identified and the therapist assists the patient with practicing problem-solving strategies (e.g., cognitive be-
havioral rehearsal). Material covered in earlier sessions is reviewed and reinforced. Also, in vivo applications of newly learned CT skills are encouraged in both the hospital milieu and on trial home visits. An additional emphasis is placed on using cognitive and behavioral methods to increase adherence with the pharmcotherapy regimen after discharge [5,17]. Completion of all components of the three phases of inpatient CT may not always be possible in the hospital setting. In this era of vigorous managed care, patients are usually discharged when their symptoms are no longer disabling and treatment can be accomplished on an outpatient basis. Thus it is advisable for inpatient CT units to be closely associated with partial hospitalization and intensive outpatient programs that can implement a cognitively oriented treatment plan. In our experience, the CT approach has helped to unite inpatient and outpatient phases of treatment by offering a consistency of approach, clear methods for follow through (e.g., homework, graded task assignments, thought monitoring, cognitive-behavioral rehearsal), and a focus on problem resolution. Outpatient individual or group CT can be performed by the same therapists that treat inpatients and/or additional clinicians trained in cognitive therapy. If outpatient continuation therapy is not possible there may be an increased risk of relapse [18]. Inpatient cognitive therapy has been used to treat patients with a variety of psychiatric disorders. Further modifications of the therapy procedures described above have been outlined for patients with eating disorders 1191, psychoses [20-221, substance abuse 1231, and personality disorders 1241. Specialty programs have also been developed for adolescent 125,261 and elderly inpatients [27].
Cognitive
Therapy
Units
The degree to which cognitive therapy principles are used in the hospital milieu is determined by a wide variety of factors including 1) hospital type (e.g., community, teaching, private, public, not-forprofit vs profit-centered, closed staff vs open staff); 2) staff theoretical orientation, training background, and clinical expertise; 3) administrative support; 4) patient population; and 5) economic factors. Several models for inpatient cognitive therapy have been described 121. The primay therapist model is best suited for inpatient units with a closed staff, or one in which
Cognitive Therapy With inpatients there are a limited number of clinicians who provide psychotherapy. This form of inpatient cognitive therapy has been utilized primarily in academic settings. A core group of primary therapists, usually consisting of psychiatrists, psychologists, and social workers, receives intensive training in CT and then provides cognitive therapy to suitable inpatients. Other staff members such as nurses, aides, and occupational therapists play a secondary role in the CT program. These individuals are oriented to basic cognitive therapy principles and are given short courses in CT so that they can assist with homework assignments and offer other support to the primary therapists. Inpatient facilities that have used this model have been able to develop highly trained groups of primary therapists who can perform CT at a level acceptable for research studies. However, the full resources of the milieu are not used because adjunctive staff members play a rather circumscribed role in the cognitive therapy program. Another form of inpatient CT, the staff model, has been developed for psychiatric hospitals in which there are open staff privileges and in which a number of psychiatrists, often with differing theoretical orientations, admit patients to the facility A special CT unit may be set up as one option among several available at the hospital. Psychiatrists usually are asked to attend a l-day workshop or other educational seminar to familiarize them with the methods that are used on the CT unit. The attending physician’s function is to evaluate the patient, make daily rounds, perform supportive therapy, prescribe somatic treatment, and provide other medical interventions as needed. The psychiatrist also may implement portions of the CT program if he or she is experienced in this form of therapy or has an interest in learning more about cognitively oriented treatment interventions. However, the bulk of the CT is performed by staff members who have received training in this approach. Psychiatric nurses, aides, and adjunct therapists (e.g., occupational or recreational therapists) play a major role in staff unit models. Usually, a unit director who has had extensive experience in CT organizes the program and supervises the staff members. Cognitive therapy concepts and procedures are emphasized to patients in multiple encounters with staff members throughout the day, but patients may not receive the same degree of attention in individual CT that is common in units that utilize the primary therapist model.
The “add-on” model is the easiest form of inpatient CT to implement. A special cognitive therapy module is added to the existing milieu without attempting to reorganize the basic treatment program. This model has been used to study the effects of supplementing standard treatment with cognitive therapy, and has been utilized in hospitals where there are insufficient resources to develop a more fully developed CT unit. The add-on format also may be useful when the inpatient team wants to try out cognitive therapy methods before committing to a large-scale retooling of the milieu. Addon CT programs have ranged from limited group therapy interventions to the provision of intensive individual cognitive therapy as a component of controlled research studies. Several inpatient units in the United States and Europe have utilized a comprehenshie C1 model for hospital psychiatry Most, if not all, individual, group, and family therapists receive extensive training in CT and use this approach consistently in therapeutic interchanges with patients and families. In addition, nurses and adjunct therapists are well versed in CT procedures. These individuals deliver a significant portion of the therapy program by offering patients opportunities for testing the validity of their cognitions and for trying out more adaptive behaviors in multiple settings throughout the milieu. The comprehensive model works best in situations where patients can be screened for suitability for CT, and can actively participate in and benefit from cognitive therapy. However, many inpatient programs must admit a wide variety of individuals, including those with organic mental disorders and severe psychoses. A flexible model for inpatient CT can be used when there are rapidly changing mixes of patients on the unit. Primary therapists and staff members may receive training and supervision similar to levels utilized in the comprehensive model, but the amount of cognitive therapy used in the treatment program is adjusted daily to match the needs of the patient population. When the unit is largely comprised of individuals with affective disorders, perand other conditions for sonality disturbances, which CT can be a primary treatment 121, the program may function much like the comprehensive model. However, the intensity of the treatment can be reduced, and substitute therapeutic activities can be employed when the composition of the milieu changes. Typically, flexible model units have two or more tracks for patients with different levels of pa-
45
S. Stuart et al.
thology and capacities therapy.*
The Cognitive
to participate
in psycho-
Milieu
The degree to which cognitive therapy is utilized in the milieu depends on the model (e.g., comprehensive, staff, add-on, comprehensive, flexible) that is employed. However, most cognitive therapy units (with the exception of add-on programs) share several common features in their overall treatment program: 1) a cognitive-biological treatment philosophy is adopted; 2) treatment planning is used to clearly designate CT interventions and who will implement them; 3) the multidisciplinary team is used to provide a wide range of cognitive therapy interventions throughout the patient’s day; 4) group cognitive therapy is used to supplement individual CT and may, in some cases, be the major form of CT employed on the unit; 5) patients are given homework assignments to carry out cognitive and behavioral procedures within the milieu (e.g., in occupational therapy, “community” meetings, recreational therapy, or family visits); 6) psychoeducational procedures are used to rapidly socialize patients and families to the cognitive model and to reinforce material learned in therapy sessions; 7) families are involved in treatment whenever possible; 8) transition to partial hospitalization or outpatient status begins early in the hospitalization; and 9) training and continuing education in CT is provided for staff members 1301. Patients in well-developed CT units typically will be involved in individual CT and several different cognitively oriented groups. Inpatient group CT may be conducted using an open-ended format, but 1 In addition to these CT models for psychiatric inpatient units, several authors have described the use of CT as a model for psychiatric consultation-liaison services [28,29]. Given the fact that there is a high prevalence of psychiatric problems among patients hospitalized for medical reasons, and that the most common disorders found in this population are depression and anxiety, it is not surprising that such CT programs have been developed. The CT approach advocated in C-L psychiatry is similar to that outlined above, with the addition of several issues unique to a nonpsychiatric medical treatment setting. Special attention must be paid to the patient’s attribution of his or her illness, i.e., whether the patient views the symptoms as “only’ physical, or whether he or she is open to the possibility that they have a psychiatric basis. The C-L psychiatrist should take care to develop a formulation of the patient’s problems in collaboration with the patient, so that realistic and specific treatment goals can be addressed. In addition, the C-L psychiatrist must ensure that the nonpsychiatrist medical team is educated about CT and its use with medically ill patients.
more structured methods for providing group therapy have also been devised. Bowers 131 and Freeman et al. [31] have described the use of rotating theme, programmed, and specialty groups for hospital applications. Cognitively oriented treatment milieus that promote group therapies and rely on the multidisciplinary team to carry out the treatment plan are linked in part to earlier models for inpatient psychiatry, such as the “therapeutic community” [32] and “rational eclecticism” [33] or the “reactive environment” [34], each of which recognized the importance of using multiple psychosocial situations and staff contacts as opportunities for patients to learn. However, in a cognitively oriented milieu, CT concepts are used for specific therapeutic interventions.
Inpatient
Cognitive
Therapy
Research
Outcome research on inpatient CT thus far has been limited to trials of CT as an adjunct to antidepressant medication and several studies of CT as primary treatment (e.g., without medication) for depression [351. Controlled assessments of fully developed cognitive milieus have not yet been conducted.
CT as an Adjunct to Antidepressant Medication Barker et al. I361 treated a series of eight chronically depressed inpatients with CT and pharmacotherapy. All of the patients were selected for treatment as a result of their chronic depression and the fact that they had been refractory to multiple antidepressant treatments, including electroconvulsive therapy (ECT) in most cases. Upon completion of 15 CT sessions in 12 weeks, patients demonstrated a significant improvement in both Hamilton Rating Scale for Depression (HRSD) [37] and Beck Depression Inventory (BDI) [381 scores. The patients did, however, continue to show significant residual symptoms of depression after treatment was completed. In a subsequent study [391, 16 chronically depressed inpatients were treated with three CT sessions per week throughout their hospitalization. Patients received an average of 16 CT sessions. After discharge, outpatient CT was provided for at least 6 months. Patients’ mean HRSD scores decreased from 24.5 to 10.6 and mean BDI scores dropped from 38.7 to 14.7 following 12 weeks of treatment. Eleven of the 16 patients were consid-
Cognitive Thprapv lVith Inpatients ered significantly improved at the conclusion of outpatient treatment. Bowers 1401 reported on a series of 30 inpatients diagnosed with major depression who were randomly assigned to one of three treatment conditions: nortriptyline alone, nortriptyline plus CT, or nortriptyline plus relaxation training. The latter two groups of patients received 12 sessions of CT or relaxation training on a daily basis. At the conclusion of treatment, all three groups were significantly less symptomatic. However, both of the combined treatment groups had significantly lower BDI scores, and had a greater percentage of recovered patients (defined as BDI < 7) than did the group receiving nortriptyline alone. When HRSD scores were compared, the CT plus nortriptyline group had a significantly higher percentage of patients who had recovered (defined as HRSD < 7) than did the other two groups. Several reports regarding the treatment of depressed inpatient with CT have been published by Miller et al. 141441. In their first study [411, six chronically depressed female inpatients were treated in an open trial with a combination of antidepressant medication and either CT or social skills training. Inpatient sessions were held 5 days a week, followed by 16 weeks by weekly outpatient treatment. From intake to the end of treatment, average BDI scores decreased from 25.2 to 6.3, and average HRSD scores decreased from 23.8 to 8.7. Four of the six patients met criteria for recovery (BDI < 10 and HRSD < 8) at the conclusion of treatment. Miller et al. 1411 subsequently conducted a controlled treatment trial with 47 depressed inpatients who were randomly assigned to one of three interventions: standard inpatient treatment (hospital milieu, doctor’s visit, and antidepressant medication), CT plus standard inpatient treatment, or social skills training plus standard inpatient treatment. Patients received therapy on a daily basis. Following discharge, patients in the two psychotherapy conditions were seen weekly as outpatients for 20 weeks. All patients received antidepressant medication (amitriptyline or desipramine) during the entire treatment. At the conclusion of inpatient treatment, all three groups had improved significantly There were no statistically significant differences between the groups in the amount of improvement or in the rate of response (defined as BDI < 10 and HRSD < 7). Upon completion of the 20-week outpatient phase [40], there were no differences between treatments
in HRSD scores. The social skills group had significantly lower BDI scores than the standard treatment group, and there was a similar trend favoring CT patients over the standard treatment group. There also was a trend toward a higher rate of response in the CT group (80% response) than in the standard treatment group (41% response). The rate of response in the social skills groups (50% response) did not offer from either of the other groups. Patients were reassessed at 6 and 12 months after the completion of outpatient treatment 1431. The social skills and CT groups were pooled into a single “psychotherapy” treatment group, because both groups had experienced comparable posttreatment outcomes. There were no significant differences between this psychotherapy group and the standard treatment group on either HRSD or BDI scores, nor in the rate of rehospitalization at either 6 or 12 months. However, there was a trend for patients in the standard treatment group to have a higher rate of relapse compared with those receiving psychotherapy Further, there was a significantly higher rate of recovery 168%) in the pooled psychotherapy groups as compared with the standard treatment group (33%). Miller et al. [441 also found that a specific subgroup of depressed inpatients characterized. by “high cognitive dysfunction” (i.e., high scores on measures of cognitive distortions) responded differentially to CT. Although there were no differences at the end of the inpatient treatment phase between the “high cognitive dysfunction” (HCD) patients who received pharmacotherapy and the HCD patients who received medication and CT, at the end of the 20-week outpatient phase of treatment, the HCD patients receiving combined treatment had significantly lower BDI and HRSD scores than the HCD patients who received only pharmacotherapy. HCD patients who had combined treatment had a significantly higher rate of treatment response (57%) than those HCD subjects who had received standard treatment (18%).
CT as a Primary Treatment Modality The first open trial of inpatient CT for depression was reported by Shaw 1121. Eleven medication-free inpatients were openly assigned to treatment with three sessions of CT per week. Mean BDI scores dropped from 29.8 at admission to 15.6 at discharge over a mean hospitalization period of 8.1 weeks. Patients maintained their level of improvement
47
S. Stuart et al. (mean BDI score of 13.5) at a follow-up evaluation 46 weeks after discharge. Thase et al. [18J reported on the use of CT with a series of 16 medication-free depressed inpatients. All patients met criteria for DSM-III-R 1451 for major depression and Research Diagnostic Criteria 1461 for probable or definite endogenous major depression. Patients received daily individual CT sessions for up to 4 weeks (average number of sessions = 12.8). Thirteen of 16 patients (81%) met criteria for treatment response (HRSD score < 10) at discharge. Mean HRSD scores decreased from 21.7 to 7.7, and mean BDI scores decreased from 32.4 to 6.9. Of the seven responders who received 4 months of outpatient continuation therapy, only one patient (14%) relapsed following discharge. In contrast, three of four responders who declined outpatient treatment experienced a relapse within the same time frame. Based on this experience the authors subsequently modified their treatment protocol so that all patients were required to enroll in an outpatient CT program following discharge from the hospital. In a later analysis of an enlarged and more heterogenous sample of 30 inpatients with major depression, a response rate of 70% (21 responders out of 30 patients) was observed for those patients treated with inpatient CT [471. All nine nonresponders had either complicated depressive syndromes (e.g., comorbid substance abuse disorders) and/or hypercortisolemia. DeJong et al. [481 have published the only controlled study using inpatient CT as the primary treatment for depression. Thirty chronically depressed patients were randomly assigned to one of three treatment conditions. The first group received inpatient CT, while the second group received individual cognitive restructuring sessions only. Patients in the third group, who were considered to be control subjects, were treated with supportive outpatient psychotherapy every 10 days. All groups were treated for a maximum of 6 weeks. None of the patients received psychotropic medication. Six (60%) of the patients receiving cognitive behavioral treatment, three (30%) of the patients in the cognitive restructuring group and one (10%) of the patients in the outpatient control group were classified as “responders” to treatment. Improvement in BDI scores was significantly greater in patients treated with CT as compared with both the cognitive restructuring group and the control group. However, there were no differences between the two inpatient groups in HRSD ratings at discharge. Unfortunately, the use of an outpatient waiting list
control makes it difficult to separate the effects of the general hospital milieu on the overall outcome from the specific effects of inpatient CT, particularly since the form of therapy utilized for both of the hospitalized groups was similar.
Summary
and Conclusion
Many inpatient units have begun to utilize cognitive therapy as a specific treatment modality and as an organizing theory for inpatient psychotherapeutic treatment. Several different models (primary therapist, staff, “add-on,” comprehensive, and flexible) for cognitively oriented inpatient therapy have been applied in varied treatment settings. With inpatients, CT procedures usually are modified to provide a greater frequency of contact with the patient, increased structure, intensive use of psychoeducational tools, a behavioral emphasis early in treatment, and frequent opportunities for learning cognitive therapy skills in the treatment milieu. Some inpatient cognitive therapy programs are based primarily on individual CT, but most use cognitively oriented group therapy, family therapy, and adjunctive therapies such as occupational therapy and recreational therapy to implement treatment procedures. Research on inpatient CT has examined the effect of adding individual CT to pharmacotherapy for depression and has tested the efficacy of cognitive therapy without antidepressants. The limited data available suggest that CT can have an additive effect in some cases and that cognitive therapy is an effective treatment for severely depressed inpatients, even if biological treatments are not used. Randomized, controlled studies of fully developed inpatient cognitive therapy programs, however, remain to be conducted. The continued use of inpatient CT will hopefully stimulate further research regarding the cost-effectiveness and benefits of inpatient psychotherapy, and facilitate development of specific strategies of psychotherapeutic interventions for the wide variety of disorders that require inpatient treatment.
References 1. Morrem EH: The new economics of medicine: new challenges for psychiatry. J Med Philos 15:97-119, 1990 2. Wright JH, Thase ME, Beck AT, Ludgate JW: Cognitive therapy with inpatients. New York, Guildford Press, 1993 3. Bowers WA: Cognitive therapy with inpatients. In
Cognitive Freeman A, Simon KM, Arkowitz A (eds), Handbook of Cognitive Therapy New York, Plenum Press, 1989 4. Davis MH, Casey DA: Utilizing cognitive therapy on the short-term psychiatric inpatient unit. Gen Hosp Psychiatry 12:170-176,199O 5. Thase ME, Wright JH: Cognitive behavior therapy manual for depressed inpatients: a treatment protocol outline. Behav Ther 22:579-595,199l 6. Wright JH, Beck AT: Cognitive therapy. In Hales RE, Yudofsky SC, Talbott JA (eds), The American Psychiatric Textbook of Psychiatry (2nd ed). Washington DC, American Psychiatric Press, 1994 7. Wright JH: Cognitive therapy and medication as combined treatment. In Freeman A, Greenwood VB (eds), Cognitive Therapy: Applications in Psychiatric and Medical Settings. New York, Human Sciences Press, 1987 8. Wright JH, Schrodt GR: Combined cognitive therapy and phannacotherapy. In Freeman A, Simon KM, Beutler LE, Arkowitz H (eds), Comprehensive Handbook of Cognitive Therapy New York, Plenum Press, 1989 9. Wright JH, Thase ME, Sensky T: Cognitive and biological therapies: a combined approach. In Wright JH, Thase ME, Beck AT, Ludgate JW (eds), Cognitive Therapy with Inpatients. New York, Guilford Press, 1993 10. Wright JH, Thase ME: Cognitive and biological therapies: a synthesis. Psychiatric Ann 22451-45, 1992 11 I Ludgate JW, Wright JH, Bowers WA: Individual cognitive therapy with inpatients. In Wright JH, Thase ME, Beck AT, Ludgate JW (eds), Cognitive Therapy with Inpatients. New York, Guilford Press, 1993 12. Shaw BF: Cognitive therapy with an inpatient population. In Freeman A, Greenwood VB (eds), Cognitive Therapy: Applications in Medical and Psychiatric Settings. New York, Human Sciences Press, 1987 13. Scott J: Cognitive therapy with depressed inpatient. In Dryden W, Trower P (eds), Developments in Cognitive Psychotherapy. London, Sage Publications, 1988 14. Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive Therapy of Depression. New York, Guilford Press, 1979 15. Wright JH, Salmon P, Wright AS, Beck AT. Cognitive therapy, a multimedia learning program. American Psychiatric Association Annual Meeting 1995, Miami, Florida. 16. Wright JH, Salmon P, Wright AS, Beck AT, Cognitive Therapy: A Multimedia Learning Program, MindStreet: Louisville, Ky, 1995 17. Rush AJ: Cognitive approaches to adherence. In Frances AJ, Hales RE (eds), American Psychiatric Press Review of Psychiatry. Washington DC, American Psychiatric Press, 1988 18. Thase ME, Bowler K, Hardin T Cognitive behavior therapy of endogenous depression: part 2: Preliminary findings in 16 unmedicated inpatients. Be Res Ther 22r469-477, 1991 19. Bowers WA: Cognitive therapy for eating disorders. In Wright JH, Thase ME, Beck AT, Ludgate JW (eds), Cognitive Therapy with Inpatients. New York, Guilford Press, 1993
Therapy
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