Dr Donita Baird, Mr Harjit Bagga, Dr Christina Bryant
Acute Ambulatory Services, Southern Health
beyondblue Victorian Centre of Excellence
Project completion year
People with chronic physical conditions often have a high prevalence of mental health disorders, which can increase morbidity and healthcare costs. However, there are barriers to integrating non-pharmacological, evidence-based treatment for co-morbid chronic physical and mental illnesses. These include a lack of clinicians’ confidence in dealing with these problems and the need for a wide range of activities involving multiple health services.
Recently, generic chronic disease management approaches stressing self-management have replaced traditional disease-specific management programs. However, depression treatment is rarely routinely integrated, and research into the effectiveness of a combined approach has produced mixed results.
Cognitive Behaviour Therapy (CBT) has been shown to improve mental health and functional status in specific chronic illness groups, and group therapy appears especially promising. Less is known about its role in generic chronic disease management programs.
The researchers developed two CBT group programs. One was tailor-made for people with chronic obstructive pulmonary disease (COPD) and depression, as part of a disease-specific management program. The program, titled A Breath of Fresh Air, ran for six weeks. Participants received handouts, worksheets and a relaxation CD with strategies designed for people with physical problems. A range of concepts and strategies were examined in a group setting each week, allowing participants to decide which strategies worked best for them. Participants created Your Health Care Kit, which contained strategies for physical and mental health.
The other program, titled Out of the Blue, was for people with a variety of chronic conditions, depression and complex psychosocial needs who were part of a generic disease management program in the most disadvantaged area in Victoria (as ranked by the Australian Bureau of Statistics). Adapted from the A Breath of Fresh Air program, content was revised to make it suitable for this heterogeneous group.
Patients in both groups showed symptoms of depression and anxiety in the moderate range. Both groups demonstrated low self-efficacy with regard to their ability to manage their health conditions, while the group with the variety of chronic conditions and complex psychosocial needs showed marginally lower confidence. Quality of life was low in both groups in all domains. The groups were similar in the degree of distress they exhibited – there were no significant differences at baseline on measures of anxiety, depression, stress and self-efficacy. The groups were also similar in demographic variables, except that COPD participants were more likely to be male and to be older. The participants differed in one aspect of quality of life, with those in the complex psychosocial needs group having a significantly lower rating on the social dimension of quality of life.
In both groups, participants reported increased confidence in understanding and recognising their symptoms of depression and anxiety and developing strategies to manage their depression and/or anxiety.
The evaluation demonstrated the A Breath of Fresh Air program was successfully implemented into the COPD management program. There was a higher referral rate and a higher completion rate for this group. Furthermore, the mean depression score was reduced, indicating a change from moderate to mild depression at the end of the program. These gains were maintained after three months, with half the patients showing minimal signs of depression and half showing mild symptoms of depression.
The Out of the Blue program was less successful than A Breath of Fresh Air. There was a low referral rate and, of those referred, only 64 per cent enrolled and only 35 per cent completed the program. Reasons for not attending included “lack of time” due to other more pressing medical appointments and feeling that the “groups are not for me”. However, participants enjoyed the intervention and all felt they had achieved their personal goals. Furthermore, group therapy was shown to benefit participants in indirect and unexpected ways that are not necessarily captured by quantitative data. For example, both participants and co-leaders observed positive changes in interpersonal interactions, assertiveness, social connection and self-confidence.
Implications for policy, practice and further research
In this small pilot study, group CBT improved depression, self-efficacy and quality of life for people with depression and COPD. Given the high prevalence of depression and anxiety in patients with chronic conditions, the researchers recommend this intervention be adopted into practice. The therapist manual and patient handouts and worksheets are freely available on request. Participants also suggested the program be offered to carers.
The findings suggest it is better to attach group CBT to a disease-specific management program rather than to a generic program for chronic disease, as only the COPD patients improved on the outcome measures. Group CBT patients are likely to have been exposed to group interventions, such as group exercise programs, and so are better able to weigh up the benefits of attending against the anxiety of “being in a group”.
Group treatment is probably not ideal for patients with chronic disease, depression and complex psychosocial needs. Key questions for further research are how to improve outreach to and engagement with this population.