The Need to Teach Cognitive-Behavioural Therapy

It is the purpose of this editorial to advocate for an inclusion of the teaching of specific psychotherapeutic skills, i.e. in evidence-based cognitive behavioural therapy (CBT), to psychiatric residents and other mental health practitioners because it is both therapeutically efficacious and cost-effective. I shall concentrate on anxiety disorders and major depression because of their prevalence and because of the considerable scientific evidence concerning their treatment.

Although CBT has been shown to be efficacious in the psychological treatment of post-traumatic stress disorder, I purposely will not refer to it because of the great variation in prevalence and reporting.

Epidemiology

Anxiety disorders (panic disorder with or without agoraphobia, obsessive compulsive disorder (OCD), general anxiety disorder, and social anxiety disorder) as a group will affect 17–21% of the people during their lifetime.1 Major depression may affect 6–8% of the population in a given year and as many as 20% of women and 10–13% of men during their lifetime.1 These are serious disorders in which full recovery is, by far, less than optimal. It behoves us therefore to search for and propose those treatments that are demonstrated to be efficient.

Treatments

Antidepressants, particularly the newer serotonin reuptake inhibitors are the first line treatments of choice for these types of disorders particularly by family physicians.2 It is not the purpose of this paper to review the several hundred reports of randomised controlled studies demonstrating the efficacy of antidepressants, rather we want to make the case that there exist valid alternatives, the most researched being CBT.

CBT is based on the principle that our emotional and behavioural responses to events or situations are impacted by what we think of this event, this perspective being influenced by our beliefs about ourselves, the world around us and what the future holds for us given these thoughts. For example, if I consider that I will obviously be wrong in what I say in a discussion because I always make mistakes and thus I am inferior to others, then I will have a tendency to not speak up, not assert myself, and avoid public events. As a result, I will eventually think even less of myself and could become depressed and socially anxious. The therapy therefore will aim at helping the patient to identify and challenge his distorted thoughts and assumptions, and modify his behaviour to a more adaptive style by exposure to feared situations. The CBT therapist will educate as to the disorder and its treatments and then, in collaboration with the patient, will help him estimate more appropriately potential danger or disaster, test hypotheses of failure or loss, and thus modify his way of seeing things. Therapy focuses mostly on the present and future, is goal-oriented and time-limited (10–20 sessions). The sessions are structured and use guided discovery as opposed to free association as in the psychoanalytic approaches. Having experienced personally the treatment with Middle Eastern subjects, I can attest to CBT’s capacity to help patients of these cultures.

This therapy has been shown to be at least as efficient as medication in major depressive disorder whether mild, moderate or severe.3,4, The evidence is even stronger for certain anxiety disorders (panic with and without agoraphobia, social anxiety) in which CBT has been shown to be even superior to medication particularly in the prevention of relapse.5,6 This prevention of relapse seems to be true in depression as well and is attributed to the skills learned by the patient to anticipate a down turn in mood and to implement therapeutic strategies even when his/her treatment is terminated.7,8,9 These approaches have been shown in several meta-analyses to be superior to other psychological interventions particularly in anxiety disorders.6 At times, the addition of CBT is helpful when medications have had only a partial response in a major depressive disorder. In chronic depressive disorder, a special form of CBT proposed by McCullough has been shown to increase response rate by 30% points when added to medication.10,11

In other disorders such as OCD however, the addition of medication may have no added advantage.12 But it is important to consider that a deleterious effect may result from the added use of medication such as in panic disorders with or without agoraphobia. This negative outcome may be because the patient attributes his improvement to the drug and relies on its effect if experiencing a return of symptoms.

Several randomised controlled trials have also shown CBT to be effective in the monotherapy of personality disorders, addictions, gambling, sleep problems etc. Recently, several studies have also shown that CBT added to the medication benefits of schizophrenic and bipolar patients.6,13

Cost effectiveness

Because of the ease of giving medication, the rapidity of the response to it when there is one, and because of the intensity and length of CBT, even if it is known to be efficacious, it has been presumed that CBT was more expensive. Yet the review of analyses of these costs has shown that CBT is no more expensive than medication because of a number of factors, the most important to the patient being a sense of empowerment. Myhr recently reviewed this literature.14 Also, because of the acquired cognitive and behavioural skills as well as a learned tolerance to lowered mood or anxiety with CBT, patients have been shown to require shorter follow-ups and have fewer relapses and hospitalisations. These numbers hold for both anxiety disorders and major depressive disorders.

Training programmes

It has been said that never has such a psychotherapeutic treatment been so well shown to be efficient and yet so little practised by mental health professionals, particularly psychiatrists. Because of the emphasis on evidence-based medicine, the accreditation bodies of psychiatric residency programmes have begun to change requirements. In the United States, it is now compulsory to learn CBT well enough to be able to conduct simple cases and refer more complicated ones to the appropriate therapists. Several Canadian residency programmes have made a working knowledge of CBT a requirement.

Obviously, some psychology departments in the United Kingdom, the US, and Canada as well as a number of European countries, now offer training in CBT. In some countries, therapy programmes have focused on training nurses thus further reducing costs.

The McGill University’s Department of Psychiatry has offered a programme for over 20 years, but recent developments have been extensive. There are several levels of academic interaction for trainees, the most basic being a semester of seminars for all categories of mental health workers. Second, the trainee desiring to acquire therapeutic skills takes on responsibility for patients (usually a minimum of 6) for 6 months to a year. During that time, s/he also participates in a weekly evaluation of the suitability of potential patients for CBT in a live interview behind a one-way mirror situation.15 At least 2 hours of supervision with audio-visual aids are an integral part of the programme. Finally, a few selected trainees join the McGill University Health Centre CBT Unit to do a fellowship of one or two years with a considerable research component. These candidates usually return to their institutions to become trainers themselves. A splendid example of this is a recent trainee, who has returned to Dharan, Saudi Arabia, after several years at McGill. She has now started her own CBT training programme.

Besides regular resident evaluations on the Royal College of Physicians and Surgeons of Canada model, the Unit conducts specific cognitive therapy evaluations following the model of the Academy of Cognitive Therapy. Several of our alumni have also gone through the Academy’s own rigorous evaluation process in order to become members.

Conclusion

In summary, CBT has been shown to be a cost-efficient strategy of treatment for several psychiatric disorders the most prevalent being major depressive disorder and anxiety disorders. Training programmes have been elaborated in several university settings, but there is still an overwhelming dearth of trained physicians and other mental health workers to administer these therapies in a competent fashion.