Adjunctive psychotherapy for anxiety and depression
A case scenario
The case that follows provides a practical illustration of when psychotherapy could be integrated into a primary care setting.
Ms. A. made an appointment to see her primary care physician because she had not been feeling well for the past six months. In addition to her episodic tearfulness and five kilogram weight loss, Ms. A. told her physician that she had lost pleasure in most of her day-to-day activities and that she had very little energy during the day. Her inability to concentrate at work and her constant irritability, self-criticism, guilt and pessimism were other issues that she raised with her primary care physician. Ms. A. also reported that she frequently worried about things, and that the worry was almost impossible to control. Over the last six months Ms. A. had also experienced at least one full-blown panic attack a week with tachypnea, hyperventilation, dyspnea, lightheadedness and a feeling of intense dread. This had resulted in a progressive restriction of her life such that she was avoiding using public transit and was avoiding using elevators as well as shopping malls. Finally, Ms. A. also described difficulty sleeping through the night, which was puzzling to her since she was often tired and lethargic during the day.
Ms. A. is a lawyer with three young children. Her husband is frequently away on business, which is an enduring source of resentment and conflict in the marriage. In addition, Ms. A.'s father died exactly one year before the onset of depressive symptoms and at the time of his death, Ms. A. had not had the time to attend the funeral in a distant city due to pressing child care and work obligations. Ms. A. had a conflicted relationship with her father, whom she experienced as harsh, demanding and critical. Ms. A. herself was a perfectionist with harsh, unrelenting standards.
Ms. A.'s primary care physician listened carefully to the history during the 15-minute appointment. She carefully evaluated the risk for suicide and dangerousness to others and ruled these both out as clinical concerns. She then did a brief medical assessment including testing to rule out anemia and hypothyroidism. Ms. A.'s physician was aware of a family history of clinical depression and suspected that major depression and panic disorder with agoraphobia were the most likely diagnoses. The primary care physician prescribed the SSRI escitalopram.
Four weeks later, during a follow-up appointment, Ms. A. reported feeling better, as some of her symptoms had improved. Ms. A.'s primary care physician was glad that the prescribed SSRI medication appeared to be working. She booked a number of brief follow-up appointments with Ms. A. lasting 10 minutes each over the next two months focusing primarily on assessing symptoms of depression and anxiety as well as medication adherence and side-effects. The primary care physician then suggested that Ms. A. could come back in six months.
Four months later, the symptoms of depression had resurfaced. Ms. A. was initially reluctant to return to her primary care physician because she was frustrated with the treatment and had begun to lose hope that she would ever feel better. She began to have thoughts such as, "Maybe this is just me and I just have to accept it." Ms. A. eventually did present to her family physician but complained primarily about her poor sleep, her loss of appetite and her poor energy rather than depression or life issues.
Phase I: Medicalize and psychologize the psychiatric illness
Take an in-depth history
Take a detailed history to identify psychosocial precipitants of the depressive relapse (e.g., losses, role transitions, interpersonal disputes). After identifying precipitants, ask the patient:
- "How have these events affected your view of yourself, the world and the future?"
- "Are these negative views that you have new, or have you carried them for a long time?"
- "If you have carried these views for a long time, where did you learn these beliefs?"
Begin psychoeducation about depression and anxiety (in this case the anxiety disorder is panic disorder with agoraphobia):
- Invite family members to attend the psychoeducation session.
- Present the disorder as a treatable and reversible medical condition that has profound psychological and interpersonal manifestations.
- Provide reading material and suggest useful websites.
Discuss the treatment rationale
Emphasize a broad treatment approach that combines pharmacotherapy with psychotherapy. Discuss the rationale for combining pharmacotherapy with psychotherapy, including:
- more comprehensive treatment of psychosocial problems with psychotherapy
- faster resolution of symptoms with pharmacotherapy
- better overall outcome with combination
- better adherence to medication with psychotherapy
- relapse prevention with psychotherapy
Address stigma and challenge self-critical thinking
Explore together how the patient feels about the disorder and about himself of herself (e.g., "I am defective"). You can begin with this approach:
- "Many patients with depression or anxiety have difficulty accepting their conditions and have negative thoughts. What goes through your mind when you think about your problems with depression and anxiety?"
Examine thoughts that interfere with medication adherence
The patient may not adhere to medication because of certain thoughts about them. Ask the patient:
- "The last time you forgot to take your medication what went through your mind?"
Make a list of the advantages and disadvantages of taking medication from the patient's perspective and try to address the disadvantages.
Explain the cognitive model
Explain the cognitive model to the patient and apply it to a situation in the patient's life. Use the following activity:
- Draw a triangle with thoughts, feelings and behaviour at each of the three points. Choose a situation where the patient experiences a negative mood shift (e.g., medication non-adherence, feeling shame about diagnosis). Ask the patient to identify thoughts, feelings and behaviours – either internal physical reactions or external overt behaviour – that occur in that situation.
- After dissecting the problematic situation, write down the patient's thoughts, feelings and behaviour on the three points of the triangle.
- Ask the patient whether the cognitive model seems relevant in dealing with the problem. If the patient can identify thoughts and recognize their importance in the first session, cognitive interventions such as cognitive restructuring will be feasible. If the patient does not understand the relevance of the cognitive model, consider behavioural activation, exposure strategies and problem-solving approaches in psychotherapy.
Establish activities and goals for psychotherapy
Determine concrete goals for therapy and explain activities for the patient to do to work toward those goals:
- Draft a contract for 12 to 16 psychotherapy sessions.
- Ask the patient to commit in writing to doing self-help reading and writing exercises for one to two hours between sessions. Explain the rationale for writing things in a log.
- Have the patient write a "problem list" in the first session and from this list generate two or three specific behavioural goals for therapy. At least one of these goals should be interpersonal in nature (e.g., addressing a conflict with another person).
- As homework after the first session, ask the patient to create a concrete vision of his or her preferred future.
Phase II: Gather information about dysfunctional behaviour, thoughts and interpersonal problems
- Measure symptoms of depression with the Patient Health Questionnaire (PHQ-9) or Beck Depression Inventory II (BDI-II).
- Try to meet twice a week (15–30 minutes per session) over the first month of treatment to create momentum.
- Set an agenda and follow the general structure of CBT sessions outlined in Table 14.1 Recommended structure for CBT session.
- Always review homework assignments early in the session.
- Regularly address medication adherence and medication side-effects at the beginning of each session, but for no more than five minutes.
- Assign chapters for the patient to read about overcoming depression and anxiety in the Mind Over Mood workbook.
- If the patient is able to understand the cognitive model, assign chapters 1–5 from the Mind Over Mood workbook. Ask the patient to track negative automatic thoughts by filling out the first three columns of the automatic thought record.
- If lethargy is a major problem for the patient, begin behavioural activation by assigning two activities for the patient to do every day and have the patient record these activities in a log for the next two to four weeks for you to review.
- If anxiety and avoidance are major problems for the patient, teach controlled breathing and assign it for homework. Ask the patient to create a hierarchy of feared situations that he or she is avoiding day to day.
- Assess the patient's interpersonal relationships by asking the patient to create an inventory of significant past and current relationships, the current frequency of contact and the current quality of these relationships.
Phase III: Begin cognitive restructuring and focused behavioural interventions
- Continue to track mood (with PHQ-9 or BDI-II), feedback from sessions and medication adherence.
- Assign the automatic thought record and chapters 6–7 from the Mind Over Mood workbook.
- For anxiety, begin graded exposure assignments using the fear hierarchy the patient developed in Phase II as a guide.
- Address two salient interpersonal issues (e.g., loss, role transition, conflict, interpersonal deficits).
- If unassertiveness is a significant problem, teach interpersonal effectiveness via role playing. Also assign chapters 18–22 about communication skills from The Feeling Good Handbook. You can also assign chapter 8 on behavioural experiments from Mind Over Mood.
- Consider one or two couple sessions if marital stress is a major complicating factor and the patient and partner agree to participate.
- If the patient is psychologically minded and capable of reflecting on deeper patterns of behaviour revealed in the automatic thought records, assign chapter 9 about assumptions and core beliefs and chapter 12 about guilt and shame from Mind Over Mood.
- For deeper reflection on enduring dysfunctional personality patterns (e.g., perfectionism, interpersonal submissiveness, excessive mistrust) assign Reinventing Your Life.
Phase IV: Relapse prevention and treatment termination
- Continue to track mood (with PHQ-9 or BDI-II), feedback and medication adherence.
- Attribute improvement to the patient's actions rather than to medication alone.
- Review what problems brought the patient into treatment, future scenarios that could precipitate relapse, what the patient learned to cope with mood and anxiety problems and what the patient needs to keep practising.
- Consider assigning meditation as a relapse prevention strategy. Assign reading and listening to a meditation CD from The Mindful Way through Depression.
- Provide booster sessions (monthly, tapered to bimonthly over the course of one year).