Summary

In the practice of a family physician, it is common to see psychological problems like anxiety and depression. Cognitive behaviour therapy has been proven to be an effective treatment. The present case study illustrates how the patient suffering from anxiety and depression can be helped by her family physician using cognitive behaviour techniques. A 49 years old woman, suffering from anxiety and/or depression attending a family practice clinic in Hong Kong , was offered counselling by a family physician. Psychological tests administered before and after treatment showed improvement in all aspects of anxiety, depression, dysfunctional thoughts, stress coping strategies and quality of life, to a varying degree. CBT counselling offered by a family physician can potentially be an effective treatment of anxiety and/or depression in a GP setting. Practitioners who are willing to apply these techniques can be offered training and supervision to provide counselling services to the community. 

摘要

家庭醫生的診治中，病人焦慮和抑鬱等心理問題很常見。認知行為療法(CBT)已被證明是有效的治療方法。本案例研究陳述顯示了香港某家庭醫療診所，家庭醫生如何採用認知行為技術，幫助一位患有焦慮和/或抑鬱的49歲女性病人。在接受家庭醫生提供的心理治療前、後進行的心理測驗顯示，在焦慮、抑鬱、思維障礙、壓力應對策略和生活品質的各方面都有不同程度的改善。家庭醫生提供的CBT心理治療可以成為全科醫生診所治療焦慮和/或抑鬱的一種有效方法。希望採用此方法的醫生經過培訓後可在指導下為社區提供心理治療服務。

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Introduction

Prevalence of psychological disorders

Anxiety disorder is a condition characterized by excessive worry and tension. Depression is a mental disorder characterized by sadness, loss of interest in activities and decreased energy.¹ Published in the WHO (World Health Organisation) World Mental Health Survey, it is estimated that the twelve-month prevalence of anxiety disorders world-wide ranges from 3.3% to 18.2%.² When the presence of anxiety symptoms rather than disorders is surveyed, community estimates range from 10% to 20%.³

The WHO has estimated that 121 million people currently suffer from depression.⁴ An estimated 5.8% of men and 9.5% of women will experience a depressive episode in any given year. If patients who experience depressive symptoms to an extent that daily functioning has been affected are included, then the lifetime prevalence of depression will be estimated to be about 60-70%.⁵ 

Local prevalence

In the Population Health Survey, it was shown that 2% of people self-reported that they were told by a doctor to have anxiety disorder. The prevalence of self-reported doctor-diagnosed depression was 1.5%.⁶ A seemingly lower local prevalence compared with Western countries needs to be interpreted with caution. Somatization is commonly reported and treated locally. Both doctors and patients may focus on physical symptoms so that underlying psychological problems are under-diagnosed. Although psychological problems only accounted for 2.1% of all problems encountered in primary care clinics, such problems have been under-diagnosed.⁷

Generalized anxiety disorder typically runs a fluctuating and often chronic course associated with heavy demands on health service resources.⁸ Depression also imposes a great burden on medical resources. In a study of global disease burden, it is estimated that by 2020, depression will be the second most important cause of medical expenses.⁹ Other than direct cost from medical treatment, psychological problems may have other impacts on the society including costs of absence from work, early retirement as well as disability allowance.

Psychological problems seen in primary care practice

Many depressive illnesses of different types can be successfully treated in primary care.¹⁰ The management of anxiety and depression relies greatly on general practitioners in the community and many patients are managed solely by their family doctors.¹¹ Referral to specialist care can be impeded by long waiting list, and patients may refuse to see psychiatrists because of the stigmatization of having a mental illness. Thus patients often visit their general practitioners instead and adds much time-consuming demands on the already over-loaded primary care services.¹² Equipping oneself to provide effective treatments to patients with psychological problems is an unavoidable role and responsibility of a primary care doctor.

Psychological treatments

Psychological treatment covers a wide variety of different approaches. This ranges from brief counselling sessions to more intensive, theory-based approaches, focusing on individuals, married couples, family or group therapies.

Psychometric tests

Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression (HAD) Scale is a short and simple assessment of anxiety and depression.¹³ It is found to be valid in the general practice setting.¹⁴ It consists of a total of 14 questions to be scored on a scale of 0-3. Seven of the questions assess anxiety and seven assess depression. It was suggested that the cut-off score of 8 is indicative of possible anxiety and depression whereas scores of 11 indicative of definite cases.¹³

In a local validation study, the Cantonese translation of HAD Scale was found to be valid and the optimal cut-off points include 3 for anxiety and 6 for depression score for elderly.¹⁵

Dysfunctional Attitude Scale (DAS)

It has been hypothesized that cognitive-personality traits are important in depression.¹⁶ People who are very concerned about being rejected or disproved by others and those who try hard to please others to seek acceptance are prone to anxiety and depression at their life events. In contrast, people who enjoy great autonomy, preserve their own freedom and independence and achieve meaningful goals, have less chance to develop such psychological problems.¹⁷

The Dysfunctional Attitude Scale (DAS) is a self-rating questionnaire consists of 40 items about seven major value systems of self worth, approval, love, achievement, perfectionism, entitlement, omnipotence, and autonomy. The DAS is a 7-point scale, assigning a score of 1 to the adaptive end. With no items omitted, scores range from 40 to 280 with lower scores equaling more adaptive beliefs (few cognitive distortions). It is used as a vulnerability measure in cognitive studies of depression.¹⁸ The scale has been shown to identify personality traits independent of the severity of depression.

Other than the use in pre-treatment assessment, the DAS has implications in treatment outcome. In a study clarifying the role of cognitive changes in the recovery from depression, it was found that cumulative change scores on the DAS taken in later part of cognitive-behaviour therapy were significantly related to depression outcome.¹⁹

Ways of Coping Questionnaire

Coping is important in dealing with stressful situations. A psychosocial stressor may or may not be changeable, but one is unsure whether effective coping strategies have been employed to change what is changeable and accept what is not changeable makes a difference to one’s physical and emotional health.

The Ways of Coping Questionnaire (WAYS) measures a person’s style of coping by assessing an individual’s thoughts and actions in response to stresses.²⁰ The version used in this case presentation is a 20-item self-report questionnaire. Respondents are asked how frequent they apply an item to cope with the stressful situation they experience. The response format is a 4-point Likert scale, ranges from 0 (does not apply/not used) to 3 (used a great deal).

Dartmouth Primary Care Cooperative Information Project (COOP) Charts

One of the ultimate goals of any treatment is to restore the functioning of an individual. This is particularly important in the treatment of anxiety and depression as these psychological problems cause much disturbance to one’s quality of life. Beyond safeguarding biological function, care should be concerned with improving patients’ physical, mental, and role function. The functioning of the person as a whole is a more important indicator of health.²¹

The Dartmouth Primary Care Cooperative Information Project (COOP) Charts consist of a title, a question referring to the status of the patient over the past 2-4 weeks, and 5 response choices. Each response is illustrated by a drawing that depicts a level of functioning or well-being along a 5 point ordinal scale. The charts are quick and easy to use, acceptable to patients, and are judged clinically useful by physicians.²²

The drawing illustration makes the Charts appear “friendly” without seeming to bias the responses.²¹ The visual metaphors are attractive and may speed up administration. This also helps to overcome language barriers in cross-cultural applications, where patients are marginally literate, or with patients unfamiliar with thinking in abstract concepts.²³ In a local study, the COOP Charts were shown to be useful in the assessment of functional status of Chinese patients.²⁴

Supportive counselling

Supportive counselling adopts a non-directive approach. Clients control the content of the sessions and the counsellor listens, tries to understand, asks appropriate questions, and generally responds in a warm and supportive way. It is suggested that simple explanation and supportive counselling are sufficient for most patients.²⁵

Cognitive behaviour therapy (CBT)

Cognitive therapy is a form of psychotherapy focusing on patients’ thinking behind their current problems. It aims at changing any dysfunctional beliefs or misinterpretation about the external world that perpetuates anxiety. The process of treatment includes raising the awareness of the patients’ thoughts, feeling and emotion. Patients are taught how to recognize their own automatic thoughts and how to substitute them with more constructive and less anxiety provoking ways of viewing their outside world.   

Behavioural techniques include applied relaxation in which patients are taught how to relax their different groups of muscles by alternately tensing and relaxing them. When such skills have become familiar, patients can apply this method of relaxation at times of tension and worry. Graded task assignment is another activity which can help patients taking up an active role in controlling their emotion in their lives. Problem solving skill, communication skill and assertiveness training are other important components.

When applying cognitive behaviour techniques in psychological treatment, three core components, physiological, cognitive and behavioural, are addressed. Emphasis of these components varies among the different phases of the treatment programme. One treatment protocol for GAD averages 12-15 hourly sessions, held weekly except for the last two sessions which are held biweekly.²⁶

In a review of the effectiveness of psychological treatment of generalized anxiety disorder, it is found that about half of patients regain a normal level of functioning, and cognitive therapy is claimed to be the most efficacious.²⁷ It was predicted that such therapies work best in patients with milder degree of their illness where their anxiety is ascribable to clear cut causes.25 It was suggested that a good outcome after behaviour therapy is predicted by low initial severity of anxiety, while a perception of the outside world as threatening predicts a good response to cognitive-behaviour therapy. When compared to drug treatment, cognitive-behaviour therapy is as effective as drug treatment but with fewer drawbacks.²⁸

In a meta-analysis of 35 randomized controlled trials (RCTs) involving 4002 patients receiving medical treatment, cognitive therapy, or both, cognitive therapy was found to be more effective than remaining on a waiting list (no treatment), anxiety management training alone, or non-directive therapy.²⁹ For mild or moderate depression, cognitive-behaviour therapy and antidepressants were equally effective. For the more severe depression, antidepressant drugs are more effective.¹⁰

Psychological treatment in primary care

Role of family physician

The availability of counselling depends on resources. Specialist psychological treatments may be impractical for most patients in primary care, but brief counselling and structured problem solving techniques are effective and may be delivered in general practice.²⁸ Trained clinical psychologists are in short supply.²⁵ It is suggested that some of the techniques of cognitive behaviour therapy be taught to community nurses. General practitioners, especially those who are willing to spend time applying these techniques, can be offered training and supervision to help expanding psychological services to the community.

Recent randomized controlled trials of the effectiveness of non-directive counselling have suggested that it is no more effective than usual general practitioner care.³⁰ A RCT has shown that psychological therapy was a more effective treatment for depression than usual general practitioner care in the short run, but after one year there was no difference in outcome.³¹ 

Patients’ preference

One survey showed that most patients in primary care settings would prefer psychotherapy, but evidence of effectiveness is limited to particular forms of psychotherapy.¹⁰ Another survey on the general public’s attitudes towards depression found that 91% of respondents thought that people with depression should be offered counselling.³² As many patients have concerns about drug dependency and side effect, they tend to avoid using medication to resolve their psychological problems.

Effectiveness of cognitive behaviour therapy

Although there is good evidence for the effectiveness of cognitive behaviour therapy in a specialist setting, trials in general practice have produced equivocal results.³³ In a randomized controlled trial done in a GP setting, it was found that CBT carried out by practice based counsellors or cognitive-behaviour therapists enabled patients with moderately severe depression to recover faster.³¹

The case study

Clinical information

Mrs A, a 49 years old housewife with good past health was first seen in the author’s clinic on 17.11.2005. The author’s clinic is a group family practice clinic comprising five family doctors, providing primary care to civil servants, pensioners and their dependents. Mrs A complained of feeling depressed because she thought that her marital relationship has deteriorated. After assessment, she was diagnosed as having anxiety-depression and counselling was suggested. She accepted this and nine sessions of counselling were offered, starting from 17.11.2005 to 28.3.2006. A total of 12.5 hours of counselling was arranged.

The presenting problem

The problem began two years ago, when Mrs A noticed a decrease in the sexual activities with her husband. Mr A (age 52) attributed this to a problem of impotence because of ageing. However, Mrs A thought that this signified that her husband did not love her anymore. As a result, she lost her temper in front of her husband. 

Current impact of the problem

Because of the sexual disharmony, Mrs A felt unloved by her husband. Everyday she felt depressed and she could not concentrate on her household work. Also, she was quite anxious of further deterioration in their marital relationship. She became angry and jealous when her husband was popular among his female colleagues in his workplace.

Mrs A also felt that her son (age 13) and daughter (age 19) did not care for her enough. They were not listening to her or respecting her. They argued with each other and she felt angry frequently. She was worrying about their future as she thought they were not obedient.

Coping of the problem

It was obvious in many examples that she gave showing Mrs A did not have effective coping methods. When her husband attributed the sexual problem to his impotence because of his age, she just asked him to see a doctor to check out for organic causes. As she felt embarrassed to talk about sex, she made no attempt to express her concern of losing her husband's love. 

Patient’s background

Mrs A was born to a family with traditional Chinese beliefs. Her parents liked boys much better than girls. Being a girl, the eldest daughter out of eight siblings, Mrs A found the only value she has was to earn money for the family. She did not feel loved and her parents were only concerned about their income from her. 

Case conceptualization

Diagram 1 illustrates details for case conceptualization. Ever since her childhood, Mrs A felt neglected and not loved. She became sensitive to this issue and often looked at herself as an unattractive woman not being treasured or loved by others. This gave rise to her problem and ineffective coping strategies like nagging her husband and avoiding communication for fear of worsening the situation, leading to a vicious cycle.

The case conceptualization was discussed with Mrs A with her agreement. Psycho-education on the ABC model and explanation of her problem using the cognitive model was provided. Afterwards, Mrs A understood how her background history had shaped her core beliefs. These, in turn, have triggered many negative automatic thoughts in different situations. As a result, she has reacted in negative feelings and emotion.

Pre-treatment psychometric tests

Mrs A was asked to fill in the array of pre-treatment tests. The results (Table 2) showed that Mrs A suffered from anxiety and depression. Her anxiety score of 9 and depression score of 12 in the HADS were in the moderate/severe range. Items of the DAS revealed that she has fear of rejection (item 27) and loneliness (item 39). She sets high standards for herself and has a fear of failure (items 3, 4, 14). In the WAYS, she coped with her problems with a “narrow mind” (items 9, 10). Toward her problems, she was pessimistic (item 3) and could not avoid “catastrophizing” her worries (item 5). In the COOP Charts, many aspects of the quality of life were perceived to be below average, e.g. feelings, pain, health and social support.

Treatment protocol of cognitive behaviour therapy

The treatment programme was designed as an eight-session one with reference to standardized treatment protocols.²⁶ The flow of therapy is conformed to the protocol (Table 1) as much as possible. However, it was expected to be variable as this is dependent on the complexity of the problem, the availability of service and the daily schedule of the client.

Cognitive behaviour therapy

Treatment scheduling

At the end of the first session, Mrs A was assisted to plan activities that would interest her. This can help to keep her interest in life and make her feel less depressed. The homework handed in showed that Mrs A has participated in and enjoyed activities like hiking and watching TV. She went out with her husband for lunch and she started communicating with him.

Relaxation techniques

In the second session, various relaxation techniques were taught to Mrs A. Each one was described in details, and she was led to practice them step by step during the session. Techniques taught included deep breathing control technique and progressive muscle relaxation. She was told to keep practicing them at times of her stress and anxiety, so that she could relax better.

 The cognitive model (ABC Model)

Towards the end of the second session, Mrs A was taught the cognitive model and how activating events trigger automatic thoughts and hence lead to different emotional consequences. She was introduced to the various types of dysfunctional thoughts. As homework of the session, she was asked to pay attention to her feelings and underlying thoughts at each of her unhappy/stressful encounter. 

At the beginning of the third session, her homework was reviewed together. Mrs A realized that her common dysfunctional thoughts were “catastrophization”, “jumping to conclusion”, “over-generalization”, “shoulds” and “elective negative focus”. In the session, she looked frustrated about her various negative automatic thoughts. She was reassured that it was common to hold such thoughts and beliefs. Instead, she was encouraged to commit to learning and changing such negative thoughts to positive ones. 

Cognitive restructuring

Starting from the later part of session 3 through session 6, cognitive restructuring was carried out with Mrs A. After each session, Mrs A agreed to do homework and her compliance was good throughout. The homework for these sessions was a dysfunctional thought record (DTR). Each time, the homework was reviewed to look for the underlying thought/belief. Mrs A was taught to ask herself questions to check whether the thoughts/beliefs she held were rational or dysfunctional. Sample questions were printed in the DTR sheet for her easy reference. The questions guided her to look for any evidence supporting/disproving her beliefs, any possible alternatives to her original thought or any possible impact if her worries are true.

Challenging the dysfunctional thoughts

At the earlier stage, Mrs A could only get her underlying thoughts. She demonstrated difficulty in self disputation. The self-disputation process was worked out with a real example from her. She thought her husband’s disagreement with the dinner arrangement implied that he was not considerate to her and treated her just as a servant to him. She was encouraged to look for evidence that confirmed her belief that her husband treated her as a servant. Also, she was asked to think of any other possible alternative explanation to her husband’s behaviour. Mrs A then thought of the misery of her husband at the problem of impotence. He may be much frustrated at his own sexual dysfunction that he became quick-tempered. So, the argument about the dinner arrangement did not really imply that he no longer loved her. After this successful dispute, she became less angry.

Once Mrs A has successfully mastered the skill of self disputation, she applied this method to help herself calm down from her anger and worry when she saw her two children arguing with each other.

Enhancement of communication skills

Poor communication between the couple worsened Mrs A’s distress. Starting from session 5 onwards, Mr A came along with his wife. In the session, “communication skills” were introduced to the couple. These included choosing the right time to talk, use of verbal and non-verbal skills, as well as the objective and content of the communication. They learnt questioning technique and ways to express a supportive attitude to facilitate the other party to continue the conversation. As homework, they were asked to practise the skills learnt at home.

Termination

The treatment ended after session 9, which was held on 28.3.2006. Post-treatment assessments were administered and the results were listed in Table 2.

After 9 sessions of CBT counselling, Mrs A’s anxiety and depression has remarkably improved. The anxiety score was 3 and the depression score was 6. Both were below the threshold of diagnosis of anxiety and depression. The DAS score was improved much as well. The score in WAYS was improved, although less prominent. Finally, Mrs A felt the quality of her life has improved a lot, as reflected by the overall score and all the sub-scores of the COOP Charts.

Self evaluation

A short questionnaire on post-treatment evaluation was carried out as well. The result showed that Mrs A has learnt to view matters and her loved ones from different perspectives. She learnt to accept unpredictable or unfavourable outcomes. She made changes after the therapy. She is more forgiving of others. She feels grateful towards others and sees things in a positive way. She tried to avoid focusing on negative thinking. She feels much happier and enjoys a more stable mood. 

Mrs A was discharged from active treatment on 28.3.2006. She did not require any drug treatment throughout. She was advised to come back for follow up if she felt anxious/depressed again.

Effectiveness of cognitive behaviour therapy

Her anxiety and depression

Patients visited their GP for psychological problems.¹² Besides, Chinese patients tended to somatize when they were anxious.³⁴

Cognitive therapy was the most efficacious psychological treatment of generalized anxiety disorder.²⁷ However, patients with anxiety disorder are rarely offered this treatment.³⁵ When compared to drug treatment, cognitive-behaviour therapy was as effective as drug treatment but with fewer drawbacks.²⁸ For mild or moderate depression, cognitive-behaviour therapy and antidepressants are equally effective.

This present case study demonstrated that Mrs A’s anxiety and depression did improve after counselling.

Dysfunctional thoughts

In our patient, the DAS dropped from a pre-treatment score of 130 to the post-treatment score of 105. This showed a good improvement of the subject in changing her dysfunctional thoughts. Through cognitive restructuring, many of her dysfunctional attitudes were corrected. From the post-treatment questionnaire evaluation, the subject expressed her learning in accepting the unpredictable or unfavourable outcomes. She was more forgiving of others and could show her gratitude towards others and see things in a positive way. She tried to avoid focusing on negative thinking. 

Coping strategies

A person’s style of coping reflects his/her thoughts and actions in response to stresses.20 Good scores mean that effective coping strategies have been employed. The difference of the pre-treatment and post-treatment scores in the WAYS was only small in our case.

The improvement in coping strategies of the subject was more apparent when she described her improved problem solving skills in the post-treatment evaluation questionnaire.

Quality of life

In the assessment using the COOP Charts, all areas showed improvement. The functioning of the person as a whole is an important indicator of health. It is shown that psychological treatment can have prominent effect in all the physical-psycho-social issues, leading to overall improvement in the quality of life. Also, improvement in one domain may be related to improvement in another, although it is difficult to conclude a definite cause-effect relationship in the present study.

Discussion

In concluding the effectiveness of counselling in this case, there exists a potential selection bias. The subject was highly motivated, facilitating good rapport building and hence good therapeutic alliance. Co-operation with the therapist and compliance to homework and assignments was good. As a result, the overall effectiveness may be positively skewed. On the other hand, anxious or depressed patients with less motivation to meet and solve their psychological problems may not present themselves for treatment. Even if they did so, they would be less likely to agree with a psychological diagnosis. Instead, they would usually insist that their somatic symptoms originated from organic causes and would only to physical treatment alone. In such cases, psychological diagnosis and treatment offered may not be accepted.

The result of psychometric tests may not always be accurate. In the present case, the subject did not possess good coping skills, although her pre-treatment score in the WAYS was high. Information gathered from direct conversation and case interview is also an important part of assessment.

Although there was remarkable improvement in the subject’s anxiety and depression after treatment, the duration of such effectiveness was not measured in the present study. Re-assessment at various intervals may address this issue.

The training and experience of the therapist may play a role in the overall effectiveness in the counselling. In the present study, counselling was done by the same doctor who is a family medicine specialist with a Master degree in counselling.

Finally, cost effectiveness is another important issue to be considered before a doctor/organization decides a commitment on provision of psychotherapy to a patient. It may take a doctor many working hours to accomplish the whole course of treatment. Professionals like clinical psychologists, social workers and various types of counsellors are some alternatives.

Conclusion

In the present study, CBT counselling was offered to a subject with anxiety and depression. The HADS was used to assess anxiety and depression. The validity of such has been confirmed.^14,15 After treatment, there was remarkable improvement in anxiety and depression. The subject showed less dysfunctional beliefs and had enhanced coping skills. Her quality of life was improved as well. This confirmed what has been suggested that depressive illness of can be successfully treated in primary care,10 and that the management of anxiety and depression can be relied greatly on GPs.¹¹

Acknowledgements

I wish to thank Dr Gracemary Leung, my clinical supervisor, for her professional advice and patient guidance throughout the project. I also wish to thank my group members, Miss Wendy Chan, Mr Ray Cheung, Miss Karman Ling, Miss Diana Wong and Miss Suki Wong, for the generous support in all phases of the project.

Last but not least, I wish to thank my dearest wife, Mabel, for all the love and care she has shown to me during my hardest times of the year.

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References