The current study explored the use and preliminary outcomes of physical health treatment elements integrated into a traditional brief cognitive behavioral therapy (bCBT) approach for medically ill veterans with depression and/or anxiety. Data were collected as part of a pragmatic randomized trial examining patient outcomes of bCBT versus an enhanced usual care condition. bCBT was delivered to participants by Veterans Health Administration (VA) mental health providers in the primary care setting. Using a skill-based approach, providers and participants selected modules from a list of intervention strategies. Modules included Taking Control of Your Physical Health, Using Thoughts to Improve Wellness, Increasing Pleasant Activities, and Learning How to Relax. Skill module use and impact on treatment completion and clinical outcomes were explored for participants randomized to bCBT who received at least one skill module (n = 127). Utilization data showed that participants and providers most commonly selected the physical health module for the first skill session. Receiving the “physical health” and “thoughts” modules earlier in treatment were associated with a higher likelihood of treatment completion (defined as four or more sessions). Preliminary outcome data suggest that the physical health skill module was equally effective or superior to other bCBT skill modules. Results suggest that incorporating physical health elements with a bCBT approach hold the potential to positively impact treatment engagement/completion and may result in improved outcomes for medically ill patient populations.
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Andersen, P., Toner, P., Bland, M., & McMillan, D. (2016). Effectiveness of transdiagnostic cognitive behaviour therapy for anxiety and depression in adults: A systematic review and meta-analysis. Behavioural And Cognitive Psychotherapy,44, 673–690. https://doi.org/10.1017/S1352465816000229.
Aquin, J. P., El-Gabalawy, R., Sala, T., & Sareen, J. (2017). Anxiety disorders and general medical conditions: Current research and future directions. Focus,15, 173–181. https://doi.org/10.1176/appi.focus.20160044.
Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K.M., Areán, P. A., … & Levkoff, S. E. (2004). PRISM-E Investigators: Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. American Journal of Psychiatry, 161, 1455–1462. https://doi.org/10.1176/appi.ajp.161.8.1455.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology,56, 893–897. https://doi.org/10.1037/0022-006X.56.6.893.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
Beck, A. T., & Steer, R. A. (1990). Beck anxiety inventory manual. San Antonio, TX: The Psychological Corporation.
Beck, A. T., & Steer, R. A. (1991). Relationship between the Beck Anxiety Inventory and the Hamilton Anxiety Rating Scale with anxious outpatients. Journal of Anxiety Disorders, 5(3), 213–223.
Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A meta-analysis of component treatment studies. Journal of Consulting and Clinical Psychology,81, 722. https://doi.org/10.1037/a0033004.
Bennett, J. A., Riegel, B., Bittner, V., & Nichols, J. (2002). Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease. Heart & Lung: The Journal of Acute and Critical Care,31, 262–270. https://doi.org/10.1067/mhl.2002.124554.
Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W., & Wedzicha, J. A. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax,54, 581–586. https://doi.org/10.1136/thx.54.7.581.
Callahan, C. M., Unverzagt, F. W., Hui, S. L., Perkins, A. J., & Hendrie, H. C. (2002). Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care,40, 771–781. https://doi.org/10.1097/00005650-200209000-00007.
Cully, J. A., Armento, M. E., Mott, J., Nadorff, M. R., Naik, A. D., Stanley, M. A., … & Kauth, M. R. (2012). Brief cognitive behavioral therapy in primary care: A hybrid type 2 patient-randomized effectiveness-implementation design. Implementation Science, 7, 64.
Cully, J. A., Paukert, A., Falco, J., & Stanley, M. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice,16, 394–407. https://doi.org/10.1016/j.cbpra.2009.04.004.
Cully, J. A., Stanley, M. A., Deswal, A., Hanania, N., Phillips, L. L., & Kunik, M. E. (2010). Cognitive-behavioral therapy for chronic cardiopulmonary conditions: Preliminary outcomes from an open trial. Primary Care Companion to the Journal of Clinical Psychiatry,12(4), e1–e6.
Cully, J. A., Stanley, M. A., Petersen, N. J., Hundt, N. E., Kauth, M. E., Naik, A. D. … & Kunik, M. E. (2017). Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: A pragmatic randomized clinical trial. Journal of General Internal Medicine, 32, 1014–1024. https://doi.org/10.1186/1748-5908-7-64.
Dickinson, L. M., Rost, K., Nutting, P. A., Elliott, C. E., Keeley, R. D., & Pincus, H. (2005). RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints. Annals of Family Medicine,3, 15–22. https://doi.org/10.1370/afm.216.
Fortney, J. C., Pyne, J. M., Turner, E. E., Farris, K. M., Normoyle, T. M., Avery, M. D., … & Unützer, J. (2015). Telepsychiatry integration of mental health services into rural primary care settings. International Review of Psychiatry, 27, 525–539. https://doi.org/10.3109/09540261.2015.1085838.
Funderburk, J. S., Shepardson, R. L., Wray, J., Acker, J., Beehler, G. P., Possemato, K., … Maisto, S. A. (2018). Behavioral medicine interventions for adult primary care settings: A review. Families, Systems and Health,36(3), 368–399.
Gates, K., Petterson, S., Wingrove, P., Miller, B., & Klink, K. (2016). You can’t treat what you don’t diagnose: An analysis of the recognition of somatic presentations of depression and anxiety in primary care. Families, Systems, & Health,34, 317. https://doi.org/10.1037/fsh0000229.
Gelhorn, H. L., Sexton, C. C., & Classi, P. M. (2011). Patient preferences for treatment of major depressive disorder and the impact on health outcomes: Asystematic review. Primary Care Companion to CNS Disorders. https://doi.org/10.4088/pcc.11r01161.
Green, C. P., Porter, C. B., Bresnahan, D. R., & Spertus, J. A. (2000). Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: A new health status measure for heart failure. Journal of the American College of Cardiology,35, 1245–1255. https://doi.org/10.1016/S0735-1097(00)00531-3.
Guyatt, G. H., Berman, L. B., Townsend, M., Pugsley, S. O., & Chambers, L. W. (1987). A measure of quality of life for clinical trials in chronic lung disease. Thorax,42, 773–778. https://doi.org/10.1136/thx.42.10.773.
Harper, R., Brazier, J. E., Waterhouse, J. C., Walters, S. J., Jones, N. M., & Howard, P. (1997). Comparison of outcome measures for patients with chronic obstructive pulmonary disease (COPD) in an outpatient setting. Thorax,52, 879–887. https://doi.org/10.1136/thx.52.10.879.
Hughes, G., Martinez, C., Myon, E., Taïeb, C., & Wessely, S. (2006). The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: An observational study based on clinical practice. Arthritis and Rheumatism,54, 177–183. https://doi.org/10.1002/art.21545.
Kearney, L. K., Post, E. P., Pomerantz, A. S., & Zeiss, A. M. (2014). Applying the interprofessional patient aligned care team in the Department of Veterans Affairs: Transforming primary care. American Psychologist,69, 399–408. https://doi.org/10.1037/a0035909.
Keeley, R. D., Smith, J. L., Nutting, P. A., Miriam Dickinson, L., Perry Dickinson, W., & Rost, K. M. (2004). Does a depression intervention result in improved outcomes for patients presenting with physical symptoms? Journal of General Internal Medicine,19, 615–623. https://doi.org/10.1111/j.1525-1497.2004.30611.x.
Kroenke, K. (2003). Patients presenting with somatic complaints: Epidemiology, psychiatric co-morbidity and management. International Journal of Methods in Psychiatric Research,12, 34–43. https://doi.org/10.1002/mpr.140.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). ThePHQ-9. Journal of General Internal Medicine,16, 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
Kwan, B. M., Dimidjian, S., & Rizvi, S. L. (2010). Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression. Behaviour Research and Therapy,48, 799–804. https://doi.org/10.1016/j.brat.2010.04.003.
Larson, J. L., Covey, M. K., Berry, J. K., Wirtz, S., & Kim, M. J. (1993). Reliability and validity of the Chronic Respiratory Disease Questionnaire. American Journal of Critical Care Medicine,147, A350.
Linde, K., Sigterman, K., Kriston, L., Rucker, G., Jamil, S., Meissner, K., & Schneider, A. (2015). Effectiveness of psychological treatments for depressive disorders in primary care: Systematic review and meta-analysis. Annals of Family Medicine,13, 56–68. https://doi.org/10.1370/afm.1719.
McMillan, S. S., Kendall, E., Sav, A., King, M. A., Whitty, J. A., Kelly, F., & Wheeler, A. J. (2013). Patient-centered approaches to health care: A systematic review of randomized controlled trials. Medical Cere Research and Review,70(6), 567–596.
Messer, S. B., & Wampold, B. E. (2002). Let’s face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and Practice,9(1), 21–25.
Mignogna, J., Hundt, N. E., Kauth, M. R., Kunik, M. E., Sorocco, K. H., Naik, A. D., … & Cully, J. A. (2014). Implementing brief cognitive behavioral therapy in primary care: A pilot study. Translational Behavioral Medicine, 4, 175–183. https://doi.org/10.1007/s13142-013-0248-6.
Nieuwsma, J. A., Trivedi, R. B., McDuffie, J., Kronish, I., Benjamin, D., & Williams, J. W. (2012). Brief psychotherapy for depression in primary care: A systematic review of the evidence. International Journal of Psychiatry in Medicine,43, 129–151. https://doi.org/10.2190/PM.43.2.c.
Olfson, M., Kroenke, K., Wang, S., & Blanco, C. (2014). Trends in office-based mental health care provided by psychiatrists and primary care physicians. Journal of Cinical Psychiatry,75, 247–253. https://doi.org/10.4088/JCP.13m08834.
Patten, S. B., Williams, J. V. A., Lavorato, D. H., Wang, J. L., Jetté, N., Sajobi, T. T., … & Bulloch, A. G. M. (2016). Patterns of association of chronic medical conditions and major depression. Epidemiology and Psychiatric Sciences, 27, 42–50. https://doi.org/10.1017/s204579601600072x.
Pomerantz, A. S., Kearney, L. K., Wray, L. O., Post, E. P., & McCarthy, J. F. (2014). Mental health services in the medical home in the Department of Veterans Affairs: Factors for successful integration. Psychological Services,11, 243–253. https://doi.org/10.1037/a0036638.
Rubenstein L. V. (2017). Integrating physical and mental health care in the Veterans Health Administration: A path to the future. In Integrating behavioral health and primary care. New York: Oxford Press.
Sarkisian, C. A., Lee-Henderson, M. H., & Mangione, C. M. (2003). Do depressed older adults who attribute depression to “old age” believe it is important to seek care? Journal of General Internal Medicine,18, 1001–1005. https://doi.org/10.1111/j.1525-1497.2003.30215.x.
Schurr, P. P., Friedman, M. J., Engel, C. C., et al. (2006). Issues in the design of multisite clinical trials of psychotherapy: VA Cooperative Study No. 494 as an example. Contemporary Clinical Trials,26, 626–636.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janays, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59 (suppl 20), 22–23.
Strupp, H. H., & Hadley, S. W. (1979). Specific vs nonspecific factors in psychotherapy: A controlled study. Archives of General Psychiatry, 36(10), 1125–1136.
Tylee, A., & Walters, P. (2007). Underrecognition of anxiety and mood disorders in primary care: Why does the problem exist and what can be done? Journal of Clinical Psychiatry,68(suppl 2), 27–30.
Vogel, M. E., Kanzler, K. E., Aikens, J. E., & Goodie, J. L. (2017). Integration of behavioral health and primary care: Current knowledge and future directions. Journal of Behavioral Medicine,40, 69–84. https://doi.org/10.1007/s10865-016-9798-7.
Yates, W. R., Mitchell, J., Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Warden, D., … & Bryan, C. (2004). Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR* D. General Hospital Psychiatry, 26, 421–429. https://doi.org/10.1016/j.genhosppsych.2004.06.008.
This research was supported by a grant from the Department of Veterans Affairs HSR&D 09-088 (PI: J. Cully), partially supported by a Career Development Award (13-264) awarded to the third author, and partially supported by the resources of the VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey VA Medical Center, Houston, Texas. The views expressed reflect those of the authors and not necessarily the policy or position of the Department of Veterans Affairs, the U.S. Government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Conflict of Interest
Charles P. Brandt, Frances Deavers, Natalie E. Hundt, Terri L. Fletcher, and Jeffrey A. Cully declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
The study was approved by the Veterans Health Administration (VA) Central Institutional Review Board as well as the Houston and Oklahoma City VA facility Research and Development Offices and was reviewed annually by VA’s national Data Safety Monitoring Board.
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Brandt, C.P., Deavers, F., Hundt, N.E. et al. The Impact of Integrating Physical Health into a Brief CBT Approach for Medically Ill Veterans. J Clin Psychol Med Settings 27, 285–294 (2020). https://doi.org/10.1007/s10880-019-09634-2
- Heart failure