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Cognitive Behavioural Therapy

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In the SCI population, the application of CBT approaches to aid in the management of anxiety and depression is described as a prudent choice given its demonstrated effectiveness in a wide range of disorders (Craig et al. 1997). CBT strategies can include addressing “irrational” or negative thoughts, increasing opportunities for participating in rewarding activities, and instruction in relaxation, among others. Within this context, issues of assertiveness, social skills and discussions of sexuality have also at times been included to address the unique concerns of SCI individuals. Employing a group setting to provide CBT can also be a cost effective opportunity for peer support, practice of social skills and the opportunity for gaining additional viewpoints. Several authors have described the effects of group CBT interventions for individuals following SCI to reduce psychological distress and/or provide “immunization” against future difficulties.

Table 1: Cognitive Behavioural Therapy Group Interventions

Discussion

In Australia, Craig et al. reported several studies (1997; 1998a; 1998b; 1999) employing a 10 week CBT-based group treatment format involving newly injured SCI rehabilitation inpatients with permanent injuries. They developed a CBT-based treatment protocol implemented by a psychologist and an occupational therapist. Treatment groups consisted of 4-5 individuals and sessions approximated 1.5 to 2 hours weekly. A matched control group of SCI patients received traditional rehabilitation services. Measures of depression, anxiety and self-esteem were completed when individuals were no longer immobilized in bed, after conclusion of therapy (3 months post injury) and at one year post injury. Prior to treatment, the treatment group reported greater self-esteem than did control, but did not differ on other outcome measures. Anxiety did not change over time. Both treatment and control groups reported fewer symptoms of depression at 12 months post injury. Taking into account pretreatment group differences in self-esteem, there was no significant improvement over time for either group. Given that neither group had high levels of depressive mood before treatment, a further analysis of those with elevated scores on depression revealed that the mean score for the treatment group (n= 10) showed improvement after treatment and further gains one year later. Controls (n = 12) who were moderately to severely depressed initially remained at these levels over the year. Patients with initially high levels of anxiety (in either condition) showed decreases in symptoms over the year, with a trend for those in the treatment group to improve more so than did those in the control group. CBT did not significantly impact upon self-esteem in individuals with recent onset SCI. The authors conclude that clinicians servicing SCI rehabilitation wards should evaluate individuals soon after admission to identify those with high levels of depression and/or anxiety and then recommend CBT. Further, not all persons with SCI are depressed, anxious or low in self-esteem, and may not require intervention.

In a follow-up report, Craig et al. (1998a) surveyed a subset of the SCI CBT treatment group participants and SCI controls (noted above) at 24 months post injury. Group differences were not significant for measures of depression and anxiety. At 1 and 2 years post injury, subjects were less depressed but levels of anxiety were essentially unchanged. For those subjects with elevated depressive symptoms prior to treatment, levels of depression over the long term were lower for the treatment than the control group. Differences over time were also noted, with the short-term improvements in the depressive symptoms of the treatment group maintained over the two-year period. In contrast, controls did not show improvement in the short term and were only slightly improved after 1 to 2 years. Interestingly, the authors report that none of the treatment group had sought further treatment for depression between the 12 and 24-month period. Both groups became less anxious over time. The small number of subjects precluded identification of significance, but an inspection of the data revealed that the treatment group lowered their elevated anxiety scores to within the normal range at two years, while the control subjects’ scores averaged approximately one standard deviation above general population norms. The authors conclude that not all individuals with recent onset SCI require specialized psychological intervention. For those with elevated levels of reported depression and anxiety, these symptoms hypothetically could return to normal levels in the absence of intervention. However, such improvements could require a protracted period and result in both increased health costs and a diminished quality of life. This study further suggests the merits of screening and ongoing benefits of an intervention program.

In a related study, Craig et al. (1998b) used the Locus of Control Behaviour Scale (LCB) to assess subjects’ perceptions that circumstances were within or beyond their control. No treatment differences were found when comparing SCI CBT group participants and controls over a two-year post injury period. Both groups averaged scores in the range suggestive of a more internal rather than external orientation. When subjects with scores suggestive of an external locus of control scores were identified (9 treatment subjects and 16 controls), the treatment group showed a significant reduction in externality over time while controls did not. The finding supports the conclusion that CBT was effective for those in the treatment group who perceived living with a SCI (and related concerns) to be out of their control. Associations of locus of control scores and depressive mood (Beck Depression Inventory) almost all reached significance for the control group when assessed pre-treatment, post treatment, and at one and two year intervals. In contrast, no associations were evident between LCB scores and reports of depressive symptoms in SCI treatment subjects, even for those who were external in their perceptions prior to participation in the CBT group. The authors speculated that CBT “positively interfered in the determination of depressive mood”. While there may be a substantial group at risk for developing psychological difficulties following spinal cord injury, the majority did not show problematic levels of externality and helplessness. As such, the authors concluded that CBT for all SCI survivors is costly and unnecessary.  

Craig et al. (1999) continued a long term (2 years post injury) assessment of persons with SCI who previously participated in a non-randomized longitudinal controlled trial of CBT during their inpatient admission to a rehabilitation ward (1991-1992). These responses were compared with those of control subjects who received only traditional rehabilitation services during their hospital stay. Treatment subjects indicated 15% fewer hospital readmissions, 25% less drug use and much more often reported a positive adjustment than did controls. Of concern, approximately 40% of controls frequently used drugs. Forty three percent of controls reported that they had not adjusted well, while only one treatment subject held a similar view. Neither group reported the occurrence of suicide over the two years. Self-reports of adjustment were negatively correlated with Beck Depression Scale scores. The groups did not differ in the frequency of relationship breakups, with the majority of those married at the time of injury remaining so at two years. Further, about half who were unmarried had formed new relationships. The findings again are seen as suggesting benefits of CBT group treatment in encouraging positive adjustment following SCI.

Two studies conducted at the National Spinal Cord Injuries Centre (NSCIC) in the UK investigated group Coping Effectiveness Training (CET). CET includes CBT, didactic, and practical elements. The first (King & Kennedy 1999) was a pilot study of CET, and the second (Kennedy et al. 2003) continued the work with additional subjects and measures. Both studies used matched historic controls from the NSCIC database, although there did remain some significant pre-intervention differences between groups. Results suggest that their intervention package produced a number of positive changes, including less depression and anxiety, less use of alcohol, and more positive self-perception. Participants said that they found the sharing of views and experiences and reviews of “real life” scenarios to be most valuable aspects of the group.

In an RCT conducted by Duchnick et al. (2009), 41 individuals from an inpatient rehabilitation hospital were randomized into either a CET group or supportive group therapy (SGT). The SGT group received minimal structure and skills training compared to the CET group. Both groups were led by two doctoral level psychologists with SCI rehabilitation experience. Sessions were 1 hour each week for the duration of their inpatient rehabilitation (8-12 weeks). No significant difference was initially evident at baseline in the Center of Epidemiologic Studies of Depression Scale (CESD) and State Trait Anxiety Inventory (STAI) scores between the two groups. Both groups showed significant improvement in depression and anxiety scores at discharge (p<0.05). However, both depression and anxiety scores at 3 month follow-up had returned to initial levels.

In a level 2 study Norrbrink et al. (2006) investigated the effects of an outpatient comprehensive pain management program for individuals with SCI and neuropathic pain. The intervention group received education, CBT, relaxation and body awareness training totaling five hours weekly over a 10 week period while matched controls received no treatment. At 1 year follow up, the sign test showed no significant change in depression and anxiety levels (Hospital Anxiety and Depression Scale (HADS)) in the treatment group from baseline. However, the treatment group showed a systematic decrease in anxiety and depression as measured by relative change in position (95% confidence interval) at one year follow up. Depression also decreased systematically in the treatment group compared to the control group at 1 year follow up; however, the sign test showed no significant change. Reported levels of pain intensity, health related quality of life and life satisfaction did not differ between groups or over time.

Dorstyn et al. (2010) conducted a small prospective controlled trial to examine the effectiveness of CBT on the mood of individuals with SCI. In the study, those with subclinical DASS-21 scores were assigned to the control group, while patients with moderate to severe scores were offered individual CBT treatment for a range of 7 to 22 sessions (30-60mins each). Low dose amitriptyline was prescribed for a subset of the treatment group to help manage their distress while several control participants were similarly medicated for neuropathic pain. The authors found mood had no effect on the functional outcome of patients at admission or discharge. In the treatment group, the total DASS-21 scores did not change significantly over the treatment course; however depression, anxiety and stress subscale scores were found to decrease significantly post intervention and then increase significantly at 3 month follow-up post discharge. The control groups’ remained stable over the period of investigation. At 3 month follow-up, 78% of individuals in the treatment group met clinical levels of “caseness” on 1 or more clinical subscales while only 1 individual in the control group met these criteria.

In another study, Dorstyn et al. (2012) conducted a randomized controlled trial in which SCI inpatients were randomly assigned to a telecounseling or standard care group. The study found improvement in depressive and anxiety symptoms in the telecounseling group; while those in the standard care group reported increase in symptomotology.

In a prospective controlled trial, Perry et al. (2010) placed SCI individuals with chronic pain into a multidisciplinary cognitive behavioural pain management, involving pharmacological and CBT treatment, or a usual care control group. A trend towards improved HADS score was also seen in the treatment group post treatment; however, scores returned to pre-treatment scores by 9 month follow-up. In this study, CBT was aimed at improving symptoms of pain rather than depression. This may explain the non-significant improvement of depressive symptoms post treatment and the deterioration of depressive symptoms back to baseline at follow up.

In a unique study, Schulz et al. (2009) examined the effectiveness of CBT on improving the quality of life in caregivers and care recipients. The study found significant improvement in depressive symptoms in the dual target group compared to the caregiver-only group (p=0.014). However, no significant improvement was seen in the CES-D scores of the care receivers.

Migliorini et al. (2011) conducted a pilot study examining a computer based CBT intervention for individuals with SCI found all 3 patients experienced reduced anxiety; while two patients also experienced reduction in depression and stress based on the DASS-21. A large number of individuals did not complete the study; however, no significant differences were seen in their baseline characteristics compared to those who completed the study.

In an RCT, Heutink et al. (2012) found SCI individuals in a 10 week interdisciplinary pain management program showed no improvements in depressive symptoms compared to those in standard care. However, significant improvements in anxiety and participation in activities was seen.

Conclusion

  • There is level 2 evidence (from several studies; Table 2) to support the use of small group CBT based treatment packages to decrease depressive symptoms following SCI.

    Follow-up findings (1 year post treatment) showed maintenance of affective improvement in four level 2 studies; conversely, evidence from two level 2 studies found that post intervention reduction of depressive symptoms were not sustained at follow up of up to one year.

    There is level 1b evidence (from one randomized controlled trial; Schulz et al. 2009) that providing CBT to caregivers and care receivers results in improved depressive symptoms in care receivers.

    There is level 4 evidence (from a pre-post study; Migliorini et al. 2011) that computer based CBT may improve symptoms of depression, anxiety and stress post SCI.

  • Cognitive behavioural interventions provided in a group setting appear helpful in reducing post-SCI depression and related difficulties.

    CBT interventions aimed at both caregivers and care receivers may be effective in reducing symptoms of depression post SCI.

    Computer based CBT may improve symptoms of depression, anxiety and stress post SCI.