Authored by Nada Lukkahatai
Background: Cognitive behavioral
therapy (CBT) is a self-management strategy used by patients with
chronic diseases. Studies consistently
report the effectiveness of this therapy in managing symptoms and
improving patients’ quality of life. However, evidence also shows that
not all
patients benefit from the therapy.
Methods: This article presents findings from an integrative review of studies published between 2010 and 2014 that investigated outcome
predictors of CBT in chronic illness. The use of CBT in psychological disorders was excluded from the review.
Result: Eleven studies were included into this review. Every
study supported the effectiveness of CBT for both immediate and
long-term
outcomes. The intervention components of CBT used in these studies were
varied in the number and duration of sessions and the methods of
identifying the effectiveness of the CBT. Most studies investigated the
significant predictability of the psychological variables. Only one
study
investigated physiological predictors, and none investigated biological
predictors.
Conclusion: This result highlighted the importance of
consistency in the CBT components and methods used to identify the
effectiveness of
therapy. Furthermore, including physical and biological predictors of
CBT outcomes is warranted, specifically in patients with a chronic
illness.
Keywords: Cognitive behavioral therapy; Outcome predictors; Chronic diseases
Chronic illnesses are rapidly becoming a major health concern
in the United States. Over half of the adult population is reported
to have at least one major chronic condition. Chronic illnesses
often cause permanent and irreversible physiological changes
that impact the individual’s physical, psychological, social, and
economic status. Chronic conditions are associated with substantial
disability and considerable health care cost [1]. Despite differences
in disease etiology, people living with chronic illnesses encounter
similar diseases management challenges. These challenges include
adjusting their lifestyle, dealing with emotion and psychological
responses to chronic illnesses, identifying associated symptoms,
and adhering to a medication regimen [2]. While there are many
self-management strategies or ways to improve self-care activities
and optimize health while living with a chronic illness, cognitive
behavioral therapy (CBT) is one that shows evidence of good
outcomes.
Cognitive-behavioral therapy is a biopsychosocial intervention
that combines techniques such as cognitive restructuring, relaxation,
problem-solving, and stress management [3]. The underlying
concept of CBT is an appraisal of individual behavioral responses
to ways of thinking, mood expression, physical symptoms, and
behavioral responses to an event or events [4]. Therefore, the goals of
CBT focus on challenging cognitive distortions and dysfunctional
underlying beliefs and teaching coping and problem-solving skills
[5]. To achieve cognitive and behavioral changes, the individual
must actively participate in a collaborative problem-solving process
and modify maladaptive behavioral patterns. The overall outcomes
of CBT include symptom reduction, improvement of function,
disease control, and an improved quality of life [6-8].
Since CBT was developed in 1995, it has been extensively used
for the treatment of psychological conditions. It has also been found
to have potential benefits to persons with chronic physical illnesses
who cannot adjust to the disease, or beliefs and behaviors related to
it. Cognitive behavioral therapy has been used in studies of people
with cancer Thomas & Weiss [9], Parkinson’s diseases Dobkin et
al. [10], diabetes Welschen et al. [11], human immunodeficiency
Inouye, Flannelly, Flannelly, Wagner et al. [12], fibromyalgia and
arthritis V. G. Sinclair & Wallston [13], and diabetes K. A. Sinclair
et al. [14,15].
Several studies report that CBT:
a) Improved mood problems such as anxiety and depression.
b) Changed disease-specific beliefs and attitudes.
c) Improved psychological and physiological outcomes and.
d) Changed health behaviors such as medication adherence
and improved quality of life [16-18].
Outcome measurements for these studies included symptom
reduction [19-21], enhanced physical function [22], and improved
psychological conditions, including depression, anxiety, and
fear [23]. The similarity in implementing CBT for a variety of
chronic diseases is that it is delivered by clinicians or healthcare
professionals with a masters-level education or higher, including
nurses and psychologists.
Not all studies report that patients who receive CBT demonstrate
improved outcomes. Systematic reviews have reported inconsistent
findings on the effectiveness of CBT on physical outcomes, such as
pain, fatigue, and sleep [24,25]. A review of randomized control
trails on the self- management of chronic illness found that CBT
was an effective strategy and increased self- efficacy, improved
moods and coping ability, and improved the quality of life in Asians
and Pacific Islanders living with chronic illnesses [26]. Based on
variable outcomes in studies of CBT, investigators have begun to
examine predictors of treatment success.
Systematic reviews and meta-analyses have reported the
effectiveness of CBT and predictors of treatment outcomes in
different psychological disorders, including schizophrenia, bipolar
disorder, major depression, anxiety disorder, eating disorders, and
obesity [27,28]. Fewer studies have investigated the effectiveness
of CBT in physiological illnesses such as cancer, fibromyalgia,
arthritis, chronic pain, diabetes, and HIV [29]. One review article
included the outcome predictors as part of the review of behavioral
and cognitive-behavioral treatment in persons with chronic pain
McCracken & Turk [30]. These authors reviewed studies published
between 1989 and 1999 using both behavioral treatment and
CBT but limited their search to a population with chronic pain. A
more recent systematic review published in 2013 reported the
predictors of treatment outcomes for patients with fibromyalgia de
Rooij et al. [31]. Although they found that the level of depression,
belief, disability, and pain were predictors of treatment outcomes,
the treatment used in this review was not specific for CBT. The
purpose of this paper is to review the predictors of outcomes of
CBT intervention among the people with chronic diseases.
Study selection
We searched PubMed, PsycINFO, SCOPUS, and EMBASE for
articles published between 2010 and 2014 that included clinical
trials of adults aged 18 years and older, published in English, and
with the following keywords as all fields: “Cognitive Behavioral
Therapy” OR “Cognitive Behavioral Intervention” AND “Predictor.”
The search yielded 3,701 articles, but the removal of duplicates left
2,999. To investigate the use of CBT in chronic physical illnesses,
these studies were then screened by title to remove those that
focused on psychological disorders and weight control. The refined
search yielded 607 articles. Abstracts from these articles were
reviewed to determine if they met the final inclusion criterion of
including the predictors of the cognitive behavioral intervention.
Ninety-eight articles remained after the abstract review. Finally,
the full text of the 98 articles was reviewed for inclusion of the
predictors of CBT effectiveness. Eleven articles met the criteria and
were included in this review (Figure 1).
Quality assessment
Four reviewers independently evaluated the quality of 11
studies using the Jadad Scoring of Quality of Reports of Randomized
Clinical Trials instrument Jadad, Carroll, Moore, & McQuay [32].
This is a validated instrument used to evaluate the quality of
randomized clinical trials. It emphasizes specific parts of a study,
including randomization, blinding, withdrawal, and dropouts. It is
an 11-item assessment the reviewer uses to evaluate the quality of
a study based on the description of the study and its methodology.
Each item is rated either 0 = does not describe, or 1 = describe.
Two extra points can be added if the methods of randomization
and a double-blind are described. Therefore, the total Jadad quality
score ranges from 0 to 13 with the higher score indicating better
quality. Of the 11 articles reviewed, 6 reported the details of their
intervention and methodology in the original studies. Therefore,
the reviewers evaluated the quality of these six articles based on
the descriptions in the original studies [33,34]. The reviewers
discussed the item scores among themselves until they came to a
consensus (Table 1).
Table 1: The baseline physiological variables (n=88).
Of the 11 articles evaluated, 9 (82%) were in an outpatient
setting. Only two studies (18%) were done with inpatients receiving
treatment at a tertiary rehabilitation center. The participants’ ages
ranged from 34 to 65 years. The number of participants in each
study varied from 13 to 261 and in 9 studies, the majority was
female, ranging from 62 to 88%. Most of the studies in Europe and
Australia did not report race or ethnicity, Studies conducted in the
United States, however, reported a majority of white/Caucasians
(76 to 93%). Clinical populations investigated in the 11 articles had
chronic nonmalignant pain, such as temporomandibular disorder,
chronic low back pain (n = 4 articles, 36%), chronic fatigue
syndrome (n = 2 articles, 18%), irritable bowel syndrome (n = 1
article, 10%), posttraumatic stress disorders in cancer survivor
and civilian trauma (n = 2 articles, 18%), Parkinson’s disease (n =
1 article, 10%), and unexplained physical symptoms (n = 1 article,
10%). (Table 1) summarizes the characteristics of studies used in
this review paper. The quality of the 11 articles based on the Jadad
score ranged from 3 to 11.
Intervention implementation
Cognitive behavioral interventions used in the 11 articles
(Table 2) varied in terms of the CBT features of treatment modality,
delivery methods, and format. Several reviewed articles indicated
that detailed information of their CBT intervention was published
elsewhere. Therefore, the original articles were reviewed except
for one study Kempke et al. [35], which was referenced in a nonpublished
paper. The cognitive restructuring was the key CBT
feature used in eight of the studies. Only two studies included
relapse prevention (18%) and three included the homework/
workbook requirement (27%). Relative to treatment modality four studies (36%) evaluated the effectiveness of CBT as a single
intervention, while the majority used CBT as an adjunct intervention
(n = 7, 64%). CBT was primarily delivered in a face-to-face format
(n = 9, 82%) with individual participants (n = 6, 55%). Two studies
used either the telephone or internet (Table 3). The length of an
intervention varied from 1 to 5 hours per session and the number
of sessions ranged from 6 to 75. The most common length a session
was 60 to 90 minutes (n = 4, 36%) with 10 sessions (n = 5, 45%) to
complete the study (Table 3).
Table 2: Study characteristics.
Table 3: Intervention Features, Treatment Modality and Delivery Methods, and Format.
In all studies, therapists who delivered the CBT intervention
were required to have at least a master’s level of education and
were either trained or accredited for conducting CBT intervention.
The integrity of the interventions was monitored using a variety of
methods, such as supervision by a senior clinician and psychologist,
videotaping the session [36,37], and discussion of the patient’s
progress with a supervisor.
Methodology and identification of clinically significant outcomes
(Table 4) describes the study design, outcome variables,
clinically significant outcomes identification methods, predictors,
and results. Four studies only investigated the immediate
effectiveness of CBT by measuring pre- and post-treatment
outcomes [38,39]. Seven studies evaluated both short- and longterm
outcomes by evaluating participants for up to one year
following the intervention [40]. Methods used to identify the
success or responsiveness to the intervention were varied. Gersh
et al. [41] identified criteria to classify participants into different
groups based on the stage of change scores. Five studies classified
participants into clinical improvement and nonclinical improvement
groups using the cut-off score of outcome variables such as fatigue,
function, and depression. One study used a sophisticated statistical
method to analyze the pattern of change in outcomes over time and
then used it as a criterion to group responders to the intervention
Litt & Porto [42]. Ten other studies investigated the predictability
of the predictors on either the outcome variables post-treatment.
Table 4: Methodology and Clinically Significant Outcome Identification Methods and Results.
(Table 4) describes the study design, outcome variables,
clinically significant outcomes identification methods, predictors,
and results. Four studies only investigated the immediate
effectiveness of CBT by measuring pre- and post-treatment
outcomes [38,39]. Seven studies evaluated both short- and longterm
outcomes by evaluating participants for up to one year
following the intervention [40]. Methods used to identify the
success or responsiveness to the intervention were varied. Gersh
et al. [41] identified criteria to classify participants into different
groups based on the stage of change scores. Five studies classified
participants into clinical improvement and nonclinical improvement
groups using the cut-off score of outcome variables such as fatigue,
function, and depression. One study used a sophisticated statistical
method to analyze the pattern of change in outcomes over time and
then used it as a criterion to group responders to the intervention
Litt & Porto [42]. Ten other studies investigated the predictability
of the predictors on either the outcome variables post-treatment.
Psychosocial predictors of CBT success
Most of the predictors in these 11 articles were psychosocial.
The predictors included: states of change Gersh et al. [41,42]
post-intervention psychiatric and somatic conditions Kempke
et al. Litt & Porto, Ljotsson, Andersson, et al., 2013; Zonneveld et
al., self-efficacy Kempke et al., Schreurs et al., behaviors such as
avoidance, worrying, fear, helplessness, and acceptance Samwel
et al., skills such as problem solving, discussion, and verbal skills
Siemonsma et al., therapeutic alliance Applebaum et al., and
caregiver participation Dobkin et al. Only one study investigated
the functional brain circuit in association with the response to the
CBT intervention Falconer et al.
All 11 studies determined that patients with physical illnesses
benefit from CBT in both the short and long term. However, these
results also found that not all participants receive the same level
of benefit. Several factors may influence the effectiveness of a
CBT intervention. First, although the 11 articles used the term
CBT intervention, they differed in their intervention components,
treatment modalities, and delivery methods. Although evidence
suggests that the phone/internet-based CBT intervention and a
face-to-face CBT intervention can have comparable effects, [43-47]
the intervention components of CBT used in these studies varied
(Table 3). The recommended intervention features for CBT as an
adjunctive treatment in chronic physical illnesses include cognitive
intervention (e.g., goal setting, education, cognitive restructuring,
identifying thoughts/beliefs) and behavior intervention (e.g.,
behavioral activation, grade exposure, behavioral experiments and
pacing, stress reduction training, and relapse prevention; Halford
& Brown, 2009). To ensure that patients use these techniques,
homework or workbook assignments are needed. However, the
CBT studies described in these articles do not include all of these
features (Table 3). Second, social support may have had a major
influence on the effectiveness of studies that compared group
sessions to individual sessions. Third, the number of sessions and
time spent for each session varied widely among the reviewed
articles. Finally, 7 of the 11 studies used CBT as an adjunct treatment
with other interventions. These differences of treatment modality
and methods may have led to differences in outcomes.
Methods used to identify the success of CBT were inconsistent
among the articles. These Two main methods were used by
the reviewed articles include the use of criteria to classify the
participants into treatment responders and non-responders
and the use outcome variables at the treatment complication or
the level of outcome change at completion from baseline. These
inconsistencies can have a major impact on the identification of
predictors and make it difficult to determine who will benefit from
CBT intervention. The standard criteria or expected outcomes
for the CBT intervention should be developed to identify the
effectiveness.
Consistent with McCracken & Turk’s (2002) review article on
the predictors of outcomes of CBT in patients with chronic pain,
we found that most of the significant predictors were psychosocial
predictors. Unlike McCracken and Turk’s review, however, our
results showed that the patients’ level of readiness to change,
acceptance, rational problem-solving, and depression predicted
improvement of the outcomes. These outcomes included a shortterm
effectiveness of the CBT intervention on pain, fatigue, and
physical activity. Interestingly, these predictors often overlapped
or were associated with each other. For example, the stage of
readiness to change “contemplation,” requires persons to think
rationally about their situation and its solution, which can overlap
with rational problem solving. The association among states of
readiness to change, acceptance, and rational-problem solving with
depression were reported in three of the studies [48-50]. These
associations and overlapping outcome predictors could influence
the results of a study. Each of these predictors was studied
separately and no study investigated all of the predictors in one
disease phenomenon.
To investigate the predictors that help identify responders
to CBT intervention, seven studies identified predictors of both
immediate and long-term effectiveness [51]. However, results
among the studies were inconsistent, with different significant
predictors for immediate and long-term outcomes. In patients
with chronic fatigue syndrome, for example, physical activity and a
feeling of control over symptoms predicted an immediate outcome
improvement, but disability benefit was a predictor for outcomes at
6 months Schreurs et al. [52]. For patients with unexplained physical
symptoms, the mental component was a significant outcome
predictor of CBT at 3 months, but not significant for the immediate
and long-term (1 year after the intervention) outcomes. Using
a sophisticated statistical technique, Growth Mixture Modeling,
Litt and Porto demonstrated that the change of catastrophizing,
persons’ negative evaluation and attention on a specific event,
predicted the member of CBT responders’ group. Two studies
found consistent significant predictors of immediate and long-term
outcomes. Dopkin et al. discovered that caregiver participation
was the only significant predictor of the CBT responders at the
end of the intervention and one month after. Applebaum et al. [53]
determined that the therapeutic alliance significantly predicted
immediate outcomes and outcomes one year after the intervention.
In one study there was no significant outcome predictor for CBT in
people with irritable bowel syndrome. A number of studies reported
the biological predictors of the CBT outcomes in the psychological
disorder [54-56]. Moreover, a recent study reported the expression
change of genes associated with mood states in major depression
patients Keri, Szabo, & Kelemen [57,58]. This information will not
only help identify the biological mechanism associated with the CBT
effectiveness but also identity person potentially will benefit from
the intervention. Based on the articles reviewed, only one study
investigated the association of physiological outcome predictors
of CBT outcomes posttraumatic stress disorder in civilian trauma.
The study result suggested the neural activation pattern of the
left-lateralized front striatal inhibitory control associated with the
response to CBT. This finding suggested future research should
examine the biological pathways or mechanisms associated with
CBT outcomes.
This rigorous, targeted review of 11 randomized control trials
adds to the field of knowledge on CBT outcome predictors for
physical illnesses. The results can be used as a guide for future
researchers in investigating CBT intervention outcomes predictors
in people with chronic physical illnesses, especially physiological and
biological predictors. Furthermore, psychological predictors such
as acceptance, therapeutic alliance, self-efficacy, physical ability, and
depression should be tested for their predictability among people
with different physical illnesses. Finally, a standardized guideline of
CBT intervention with common components applicable to physical
illnesses should be developed and tested.
Limitations
The sample size was small because our search was limited to randomized control trials that included an investigation of the outcome predictors. Therefore, several comparable but nonrandomized trials were not reviewed. Additionally, the review only included physiological illnesses, so numbers of studies investigating biological predictors associated with CBT outcomes on depression and most other psychological disorders were not included.
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