Compare and Contrast

Notes on CBT for MS, cancer and depression

In treating patients with medical conditions, cognitive-behaviour therapy (CBT) is used as an adjunct, an optional treatment, for patients who have become and are likely to become very distressed. It is not advocated as a means of treating the actual illness, as is the case in CFS (cf. Wessely and Sharpe).

There have been a number of studies assessing CBT for both MS and cancer. For instance, Larcombe and Wilson (1984) selected 20 depressed MS patients and randomly allocated them to either CBT or a waiting list control condition. Therapy sessions (90 minutes for six weeks) examined unhelpful thoughts and beliefs. Assessments were conducted prior to treatment, after treatment and four weeks later. The patients in the CBT group showed significant improvements on most measures (e.g. BDI and Hamilton Rating scale). These results were maintained at follow-up.

Another interesting study treated 32 MS patients with depression by telephone (8 weeks). Mohr et al (2000) included measures of neurological impairment as well as mood. Patients were taught how to identify cognitive distortions, to find pleasurable activities and to manage fatigue. The attrition (drop-out) rate was 28%. It was found that this intervention decreased depressive symptoms compared to usual care controls and their adherence to treatment (interferon) was significantly better at the four month follow-up.

CBT has also been assessed in patients with cancer, both to treat depression and to prevent it developing in those most at risk (i.e. individuals with advanced disease). There are only a few reports of controlled trials, but on the whole, the results have been positive. For instance, 124 women with metastatic breast cancer were randomised to receive either CBT or no therapy (Edelman et al 1999). Both groups received standard medical/surgical care but the patients in the CBT group also attended 8 weekly sessions of group therapy. This was focused on “the acquisition of cognitive and behavioural coping skills”, instructions on improving communication and managing emotions, goal setting and dealing with self-defeating thoughts and included a family night and three further monthly sessions. No one had a concurrent psychiatric disorder. Two follow-up assessments were conducted (3 and 6 months post treatment). The results revealed reduced depression and total mood disturbance as well as improved self-esteem compared to controls after treatment, but not at follow-up. According to the researchers “the CBT model may not have adequately addressed patients’ emotional needs. It is possible that a greater focus on existential issues may have generated better or more sustained improvements”. There was no effect on survival at 2 years (Edelman et al 1999b).

Another study, by Evans and Connis (1995) compared 8 weeks of Group CBT (one hour sessions focused on learning coping skills, challenging dysfunctional beliefs and establishing a supportive network) with 8 weeks of socially supportive counselling (encouraging members to describe their feelings, identifying shared problems, discussing how these issues were handled and adopting supportive roles towards the other group members). A comparison group received no treatment. All patients had stage II cancer as well as depression. The results showed that both types of therapy relieved depression and reduced “maladaptive somatic preoccupation” after treatment. However, at the 6 months follow-up, only the survivors receiving the social support experienced less depression than the no-treatment controls. The social support group also reported less overall distress symptoms and lower anxiety. “One reason may be that social support groups do not require structured learning activities, which may be inherently distress-producing and cause iatrogenic problems.”

In short, CBT can help in the treatment and perhaps prevention of some depression and mood disturbances in patients with MS and cancer. However, the effects may be limited and it is unclear whether it is more effective for cancer patients than broad-based interventions e.g. social support and counselling¹.

More information about broad-based programmes for medical patients

Most broad-based programmes described to date provide information about the illness, teach coping skills/ stress management and in some cases, offer supportive counselling (e.g. Cunningham et al 1993, Fawzy et al 1990). They are generally used to help people cope with their illness, improve communication with significant others, promote hope, and in short, limit emotional distress². For example, Antoni et al (2001) assessed stress management and emotional support in 100 women being treated for early-stage breast cancer. (Stress management is a form of cognitive therapy directed primarily at one problem). The group therapy involved 2 hour sessions for 10 weeks. A control group received a condensed version of the information (about stress, relaxation techniques and other coping strategies). About one third of the sample reported moderate depressive symptoms on initial assessment. The intervention reduced the prevalence of moderate depression but did not affect other measures of emotional distress. Other benefits were the increased number of reports of experiencing benefit from having breast cancer and the increase in generalized optimism about the future. The positive effects were maintained at 3 months follow-up and analysis revealed that the treatment was particularly helpful for women who had lower levels of optimism at baseline. According to the researchers, the programme also helped patients deal with anger and improved communication with others.

However, the best known example of a psycho-social intervention for cancer patients is the study by Spiegel (1989). Here a group of patients with metastatic breast cancer received information on coping with specific problems and provided each other with support. Self-hypnosis was taught to help pain control and patients were encouraged to be more assertive with their doctors. (This approach is sometimes referred to as ‘supportive-expressive’, being aimed at encouraging the expression of thoughts, feelings and concerns within a supportive environment). It was not only helpful, but these patients survived much longer than the controls who had received routine care. However, the researchers were unsure what was responsible, e.g. the expression of feelings, the social support etc.

Group therapy for cancer patients has the advantage of offering more role models, more sources of support and more information about different coping strategies, while the participation in groups also relieves depression by restoring feelings of power and usefulness by helping others. On the down side, those with advanced disease often drop out, and this can adversely affect the rest of the group. (Spiegel et al allowed new members to join as others left).

CBT for depression

CBT was originally developed to treat people with clinical depression. It was hypothesized that depressive symptoms resulted from (or were perpetuated by) irrational beliefs and distorted attitudes towards the self and environment. The aim of CBT was to challenge and reverse these beliefs and thus reduce the depression.

CBT is clearly helpful for many people, but it’s not effective in everyone. A recent study (Keller et al 2000) compared CBT (12 weeks) with an antidepressant in 681 patients with chronic major depression. A third group was given a combination of both. Of the 519 patients who completed the study, the rates of response was 55% in the antidepressant group, 52% in the CBT group and 85% in the combination group. These findings thus support the use of combination treatments.

Summarising twenty years of research on clinical depression, the American Psychiatric Association (2000) concluded that CBT is probably as good as drug treatment (see above) and better than other forms of psychotherapy (e.g. interpersonal psychotherapy). However, they support my impression (from reading the literature) that it is not effective across the board. For instance, one study found it to be less effective than antidepressants in severe depression. “Factors suggested as being associated with poor response to CBT include unemployment, male gender, comorbidity, dysfunctional attitudes and several laboratory test values… On the other hand, results from several analyses have suggested that CBT may be more effective than other treatments for depressed patients with personality disorders” (p. 471). If CBT is not useful for all patients with depression for whom it was developed, why should help everyone with CFS?

How this information relates to CFS

The claims that CBT is helpful for all patients with CFS, as opposed to the subgroup with dysfunctional beliefs and behaviours, reflects the underlying view of proponents of the CBT model that the illness is perpetuated almost entirely by psycho-social factors. Indeed, the model depends on the assumption that whatever triggered the initial illness no longer plays a significant role during the chronic phase. (Those concerned have yet to elucidate when this switch occurs, why thoughts and behaviours cause the exact same symptoms as the initial (viral?) trigger and why the patients don’t notice the switch.) The descriptions of the perpetuating factors resemble accounts of patients with depression and somatisation. There’s an assumption that all these patients respond in a uniform way to their illness and there is little recognition of individual differences, let alone the growing evidence to the contrary. More details of the inadequacies of the model can be found elsewhere. The important thing to remember is that the model’s basic premise, i.e. that most patients become pathologically inactive, continues to rely heavily on supposition and conjecture. There is virtually no scientific evidence which supports the model . The psychological attributes and maladaptive behaviours have only been documented in a small subgroup of patients selected using broad criteria (e.g. CDC ’94 and Oxford). It can therefore be argued that CBT (with graded activity) may be appropriate and beneficial for this subgroup, but there is as yet no good evidence that it is equally helpful for other patients. In this respect, it is noteworthy that Ridsdale et al (2001) found CBT to be no more effective than counselling.

Broad-based programmes similar to those offered to patients with cancer are available at some centres but so far, only one of these has been assessed in a controlled trial (Goudsmit and Ho-Yen 1996). The results showed that 80% of the treated patients felt better or much better after six months and that a quarter required no further treatment. However, over half the waiting list controls also reported some improvement (which is consistent with reports on the course of this particular illness).

To conclude, I believe that CBT should be offered as an adjunct for those patients who require it. However, supportive counselling is arguably the most appropriate psychological intervention for the majority of patients with CFS since it offers information on both the illness and effective coping strategies as well as emotional support. It is not so theory-based, and since it is not focused primarily on dealing with irrational thoughts and behaviours, more patients are likely to benefit.

1. Counselling or programmes focusing on general coping strategies and social support may be more appropriate for the majority of patients since much of the distress one feels in these circumstances is not a result of irrational beliefs and attitudes but because of a lack of accurate information and quite understandable fears about the illness and treatment. Most counsellors\therapists can advise on stress management and use other cognitive and behavioural techniques where required.

I’m not sure that it is helpful to use the term CBT when one is teaching general skills to otherwise sensible people who simply lack information. It’s not exactly inaccurate but then it dilutes a concept and it may lead to confusion and misunderstanding. There’s also the issue of pathologising what is essentially a normal experience. If people are not aware of certain coping strategies, why should informing them be referred to in terms of a psychiatric intervention. Even if it is a matter of thinking differently or doing something differently, why use terminology so closely associated with psychiatric morbidity? On the other hand, if patients are well aware of adaptive strategies but they reject them without good reason, then a term like CBT is justified.

2. It’s important to note that standard CBT is not directed at helping the average patient to cope; it’s aimed at those individuals whose unhelpful beliefs and negative attitudes are actually impeding adaptive coping (Lovejoy and Matteis 1997). It’s about changing thoughts and behaviours which are increasing distress or undermining recovery. Those promoting this treatment sometimes describe it as a means of teaching patients better coping skills. That’s perhaps a little too simplified and thus rather misleading.

References

American Psychiatric Association. Practice Guidelines for the Treatment of Psychiatric Disorders. Chapter on major depressive disorder. 2000.

Antoni MH et al. Health Psychology 2001, 20, 1, 20-32.

Cunningham AJ et al. International Journal of Psychiatry in Medicine, 1993, 23, 383-398.

Edelman S et al. Psycho-Oncology 1999, 8, 295-305.

Edelman S et al. Psycho-Oncology, 1999b, 8. 474-481.

Evans RL and Connis RT. Public health Reports 1995, 110, 306-311.

Fawzy et al. Archives of General Psychiatry 1990, 47, 720-725.

Goudsmit E. The Psychological Aspects and Management of Chronic Fatigue Syndrome. Doctoral thesis. Brunel University. 1996.

Keller et al. New England Journal of Medicine 2000, 342, 20, 1462-1470.

Larcombe NA and Wilson PH. Br J Psychiatry 1984, 145, 366-371.

Lovejoy NC and Matteis M. Cancer nursing 1997, 20, 3, 155-167.

Mohr DC et al. J Consult Clin Psychol 2000, 68, 2, 356-361.

Ridsdale, L et al. British Journal of General Practice, 2001, 51, 19-24.

Spiegel D et al. Lancet 1989, 2, 888-891.

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