Palliative Medicine 2008; 22: 814-821

The use of cognitive behavioural therapy techniques foranxiety and depression in hospice patients: a feasibilitystudy IT Anderson Belfast City Hospital, Belfast, M Watson Northern Ireland Hospice Care, Belfast; University ofUlster, Ulster; Honorary Consultant, The Princess Alice Hospice, Esher and R Davidson Belfast City Hospitai,Belfast

Anxiety and depression are common in palliative care patients. Cognitive behaviouraltherapy (CBT) has been recommended as one possible treatment, and it has been sug-gested that non-mental health professionals may be able to treat milder disorders withCBT. The aim ofthis study was to assess whether the use of CBT techniques in hospicepatients is an acceptable intervention, and whether a palliative care professional withshort CBT training can usefully apply such techniques. Afeasibility study of a brief CBTintervention following training was conducted. Qualitative analysis was carried out onpatient feedback from semi-structured interviews. Hospital Anxiety and DepressionScale scores pre-and post-intervention were analysed statistically. Eleven patientscompleted a short course using CBT techniques. The intervention was acceptable for10 patients. One patient found it unacceptable due to advanced disease, lethargy andsevere depression. Anxiety or depression symptoms were helped in eight patients.This study showed that a palliative care professional with short training in CBT wasusefully able to apply CBT techniques to hospice patients with mild-to-moderate anxi-ety or depression. Palliative Medicine (2008); 22; 814-821

Key words: anxiety; behavioural; cognitive; depression; hospice; palliative

Introduction

Anxiety and depression Eire common in palliative carepatients and can cause significant distress to patients andcarers.'- There is limited expertise to recognise and treatthese conditions within oncology and palliative caresettings.- "̂ In addition, it is often not appropriate forvery ill patients to be referred to a psychologist or a psy-chiatrist due to physical symptoms, weakness, short prog-nosis and limited capacity for new therapeuticrelationships.^-^

Cognitive behavioural therapy (CBT) is a psychologi-cal intervention which aims to help the patient recognise,prioritise and link thoughts, feelings, behaviours andphysical symptoms'•^•** using both cognitive and beha-vioural techniques. Using cognitive techniques, it aims toidentify and challenge negative thoughts, seeking to helpthe patient find allemative ways of thinking'' and facili-tates identification of causes of anxiety and ways to man-age this. The behavioural aspect of CBT encourages relax-

Correspondence to: Dr Tracy Anderson, Specialist Registrar inPalliative Medicine, Belfast City Hospital, Lisburn Road, Bel-fast BT9 7AB. Northern Ireland, UK.Email: t.anderson(ä.;doctors.oi"g.uk

ation, realistic goal setting and restructuring dailyactivities with an aim to increase enjoyment andsatisfaction.'"-"

Cognitive behavioural therapy has been shown to beuseful for the management of psychological distress in can-cer patients.'^'" ' •̂ It has also been suggested to be of bene-fit for non-cancer patients in treating depression,^'"-'*^anxiety, panic, eating disorders..^ chronic pain'*^ andinsomnia.-"*

The National Institute of Clinical Excellence (NICE)guidelines for depression-' have recommended CBT asthe treatment of choice for management of mild-to-moderate depression and in combination with antide-pressants for severe, treatment resistant or recurrentdepression. It is also recommended in the NICE guide-lines for anxiety-- as the treatment of choice for general-ised anxiety and panic disorder, because of its long-termeffectiveness.

There is little evidence for the use of CBT in palliativecare populations'*^-^ -̂"̂ and no trials of CBT use in a hos-pice to date. However, some studies have suggested that itmay be acceptabie-^-^ and potentially effective for patientswith advanced cancer.*--'--^ The NICE guidelines forimproving supportive and palliative care for adults withcancer-^ suggest CBT as a treatment for psychological dis-tress in this patient group.

2008 SAGE Publications, Los Angeles, London. New Delhi ¡md Singapore 10.1177/0269216308095157

The use of cognitive behavioural therapy techniques in hospice patients 815

Brief interventions-^-"-^^ and short training^-^ in CBTtechniques have been shown to be efleclive and it hasbeen suggested that it may be appropriate for non-menialhealth professionals to treat milder disorders.^"''• '̂̂

The aim of this study is to assess whether the use ofCBT techniques for anxiety and depression in a palliativecare population is an acceptable intervention, andwhether a palliative care professional with short trainingcan learn to appropriately apply such techniques for thebenefit of hospice patients.

Methods

A prospective feasibility trial was carried out in NorthernIreland Hospice, which provides specialist palliative eareinpatient. outpatient, day hospice and communityservices.

Inclusion criteriaInpatients or patients attending day hospice who were will-ing to participate, were well enough and could communi-cate adequately to be part of a study which involved con-versation, and who were able to give informed consent.

Exclusion criteriaPatients who were confused, had dementia, difficultycommunicating, were too weak or unwell to undergo thestudy or who were suftering from a psychotic disorder.

Eligible inpatients and day hospice patients were iden-tified by the multi-disciplinary team over a 10-weekperiod, and verbally invited to participate by the hospicesocial worker, then by letter, and given an informationleaflet. The Hospital Anxiety and Depression Scale(HADS) was used to screen for anxiety and depressionin the patients who consented to be part of the study asthis has been previously validated in this patientpopulation.'- Patients who obtained a score of 8 or higherin either the anxiety or depression aspect of the scale^"were invited to continue with the study.

The intervention was carried out by a Specialist Regis-trar in palliative medicine who attended two short trainingcourses, totalling 5 days of teaching, in CBT techniquesfor cancer and palliative care patients, and was supervisedthroughout the project by a clinical psychologist.

A protocol was created for three or four sessions lastingbetween 15 and 45 min. based on recommendations fromthe literature.'•"•'•'•'' and discussion with the supervisor,and was used as a guide for session content to allowsome consistency to the intervention provided for eachpatient (Figure 1). A short intervention was chosen toenable it to be easily reproduced in daily practice.

During the first session, problems were identified andthoughts, feelings, behaviours and physical symptomswere linked using Padeskys 'Hot Cross Bun' model (Fig-ure 2). This enabled patient led prioritisation of the pro-blems and created a plan for the following one or twosessions. A summary of these problems was discussed atthe beginning and end of each session, giving the patientan opportunity to change priorities or discuss new issues.

Session protocol

Session 1

• Discuss HADS responses• Identify thoughts, feelings, behaviours,

physical symptoms and link these• Prioritise prooiems

Sessions 2-3 ^^~^^~^

• Review events of week and review homework• PrioritiM Í331JC3 for 3C33ion

• Content of sessions depended on whethermain issues were negative thoughts, anxiety,decreased activity or terminal phase of illness

Session 4• Summary of work• Summary of changes

fur thu Tulure

Planning for how to maintain changes, andprevent previous thoughts and behavioursfrom returningRepeat HADS scaie

Sessions 2 - 3 : Main Issues

Negative thoughts • identify negative Ihoughls, challengethoughts, aeate äl»native statements, use of thoughtdiary

AnxlBty - use diafy. identify ppt factors and symptoms.OiscuM ways o( avoiding and ways of managing anxiety.Learn relaxation techniques

Decreased activity - use pleasufe/maslery dlaiy and lifegrid and make goals aaxKdingly

Terminal phase • focus on QoL and allow some conlrol tobe retained. Create realistic goals and promote acfivityunrelated to cancer. Plan f c others to fulfill goals thatpatient cannot fuifill themselves. Encourage time withbmity. Talk about end of life issues if appropriate

Figure 1 Session protocoi.

816 T Anderson et al.

Figure 2 Padesky's 'Hot Cross Bun'.

In sessions 2 and 3, specific cognitive and behaviouraltechniques were used, depending on whether the mainissues were negative thoughts, anxiety, decreased activityor end of life concerns. Table 1 contains a summary of thetechniques used.

Guided discovery was used to identify negativethoughts and test the reality of those thoughts. Thisinvolved asking questions to clarify what the personbelieved and using diaries to record negative thoughts.We then discussed what evidence there was to supportthose beliefs and thoughts, and whether there was analternative way to look at the situation.

The last session was used to summarise the work donein previous sessions and plan how to maintain anychanges in thought or behaviour, and to create plans forthe future.

Qualitative data was obtained from a taped semi-structured interview carried out at the end of the studyand from summaries of the sessions which included feed-back from the patient after each session. The interviewwas the main source of patient feedback relating to theacceptability of the intervention and was conducted bythe hospice social worker, rather than the researcher, toreduce bias. It involved a discussion based around theexpectations, positives and negatives of the interventionfor the patient and whether they would have furtherCBT themselves, or recommend it to others. The inter-view questions were developed in conjunction with the

educational supervisor and the hospice research commit-tee. The information from the semi-structured interviewprovided the initial framework for the qualitative analysisof data and additional categories were added after review-ing the data and feedback from the sessions. Recurringthemes were identified, grouped into categories andplaced within an overall framework. The data was thenmanually indexed and sorted within the thematicframework.

Quantitative data was obtained from HADS scorespre- and post-intervention and Visual Analogue Scales(VAS) measuring levels of happiness, relaxation, pain,energy and nausea, completed by the patient at each ses-sion. A paired /-test was used to compare the mean HADSscores pre- and post-intervention as this data was approx-imately normally distributed and the /-test is robustagainst moderate departures from normality. The VASwere not normally distributed so the pre- and post-intervention scores were analysed using a WilcoxonSigned Ranks Test. A P-value of <0.Û5 was taken as thesignificance level.

The study was approved by the Local Ethics Commit-tee (ORECNI). :

Results

Forty-six patients were admitted to the inpatient unit orattended day hospice over the 10-week period. They werediscussed by the multi-disciplinary team and 22 of themdid not meet the criteria for inclusion into the study, there-fore 24 patients were invited to take part in the study.

Of the 24 patients approached, six declined, four didnot meet the criteria on HADS. two withdrew after thefirst session and one died after the first session. Of thesix who declined, two of them were not keen to talkthrough issues, and the others did not wish to take partin the study. Of the two who withdrew after one session.one was too unwell and the other chose not to participatefurther. ¡

This left 11 participants, eight females and three males,five were inpatients and six attending day hospice. Theage range was from 28 to 84 years with a mean age of 65

Table 1 CBT techniques used

Cognitive Behavioural Cognitive and behavioural

Linking thoughts, feelings, behavioursand physical symptoms

Identify negative thoughtsChallenge thoughtsCreate alternative statements

Life grid to identify previous activitiesand plan new ones

Create goalsPian activitiesRelaxation techniquesCreate list of questions for doctor

Thought diaryAnxiety diaryIdentify causes of anxietyDiscuss ways of avoiding and managing

anxietyPleasure /mastery diaryWeighing up advantages and

disadvantages

The use of cognitive behavioural therapy techniques in hospice patients 817

and median of 73. Ten of the patients had a variety ofdifferent cancer diagnoses and one patient suffered fromMotor Neurone Disease.

The following results are presented on the data pro-vided by those 11 participants. There is no quantitativedata available on the three patients who completed onlyone session as they had only one set of scores at the start ofthe study, and no follow-up scores for comparison. It wasalso not possible to obtain qualitative data on two of themas one was too unwell and one died. A follow-up interviewwas conducted with the patient who chose to withdrawafter one session, and this is discussed at the end of thequalitative results.

Qualitative results

AcceptabilityOverall, 10 of the 11 patients found this to be an accept-able intervention. Their expectations were varied. Five didnot report any expectations and only one had a negativeexpectation, that it may be depressing, but did not fmdthis in reality. Only one patient had apprehensions aboutihc study and was reassured that they could withdraw atany time. Two had apprehensions about committing to acertain number of sessions initially but after the first ses-sion were happy to commit to further. Many of thepatients commented that it was important for them toknow that they could withdraw from the study at anytime.

Nine of the 11 patients were satisfied with the numberof sessions they received. The other two feit that furtherpsychological input would be helpful, so follow-up withan appropriate person was organised. Two others statedthat they were sorry to finish. Seven of the patients hadthree or four sessions as planned. Three patients had fivesessions and one patient chose to stop after two sessions.All patients were assured that support would be availablefrom the social work team in the hospice if they needed todiscuss any issues at a later date.

Despite the plan being for sessions to last between 15and 45 min, two-thirds of the sessions were longer than45 min (Figure 3). Nine patients found the length of ses-sions acceptable, but two found them long and tiring. Thepatients felt that long sessions and homework may beinappropriate for those with very advanced disease, poorenergy and concentration.

The sessions were originally planned on a weekly basisbut of the 42 sessions carried out in this study, nine ofthem were deferred because the patient was too unwell.This meant that the time taken for each patient to com-plete the study ranged from 2 weeks to 14 weeks, with amedian of 4 weeks and a mean of 5.4 weeks (Figure 4).

Nine patients said that they would consider a similarintervention again. The reason that two would not was

20

18

16

O•S 12(A

b °

à 6

^ 4

2

0

0-t5

Data for Figure 3

15-30 30-45 45-60 60-75 75-90

Minutes

Duration ofSessionsNumber ofSessions

0-15 15-30

1 4

30-45

9

45-60 60 - 75 75 - 90

8 1S 2

Figure 3 Bar graph showing duration of sessionscompleted by participants.

tiredness due to advanced disease. All of the patientswould recommend the intervention to other patients, pro-viding that they were well enough and able to concentrate.

Only one putient found the intervention unacceptablebecause of lethargy caused by advanced disease andsevere depression. Two inpatients with advanced diseasefound that they were too tired to talk for long periods oftime. The same two. along with one other inpatient, weretoo tired to complete homework.

Other difficult aspects included the fact that often thenegative thoughts experienced in this patient group arerealistic, and patients can often be unable to fullll theirdesired goals, due to poor physical condition. Twopatients felt inhibited by poor concentration and memoryand one patient found it difficult to think of upsettingthings.

0.

o 15

é 1-0-5-

0-

1

11

1

1!Data for Figura 4

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Time taken to complete study (Weeks)

Time take tocomplete(Weeks)Number ofPatients

1

0

2

1

3

3

4

2

5

3

6

0

7

0

8

0

9

0

10

0

11

1

12

0

13

0

14

1

Figure 4 Bar graph showing time taken for patients tocomplete study.

818 T Anderson et al.

EffectivenessTen of the 11 patients said that they found the CBT inter-ventions very helpful and eight said that they experiencedan improvement in anxiety or mood as a result.

'I changed for the better and have a more positive atti-tude as a result of it'

Patient B

'I found it helpful to diseuss things that were worryingme' and am "coping much better after the sessions"

Patient E

The patients found the time with the therapist helpful,they appreciated the opportunity to talk, have someoneto listen and someone to ask questions of.

'T was glad she was there and prepared to listen, shedrew things out of me'

Patient D

Most helpful cognitive and behavioural techniquesSpeeifie techniques were used in eight of the patients., andall of these patients noted a change in thinking or behav-iour. Of the other three patients., two were too weak andunwell for any techniques to be of benefit and one chosenot to diseuss issues further. The most useful teehniqueswere:

Linking thoughts, feelings, behaviours and physicalsymptomsMany found this a useful exercise which enabled them toidentify and prioritise the problems and have an increasedunderstanding of what they were experiencing. For exam-ple, patient A was able to link that when her friend stayedtoo late, this subsequently caused tiredness, poor sleepand then low mood the following day. She said that itwas helpful to recognise this, and discuss ways of dealingwith the issue.

DiariesFour patients used diaries and reported that they foundthem very helpful, giving them more of an awareness ofpositive and negative activities and an increased aware-ness of negative thoughts and causes of anxiety, anger.low mood or pain. This allowed the patients to regainmore of a sense of control and plan differently. The diariesused were aetivity. anxiety, anger, medieation and paindiaries.

'It did bring out the awareness of what had happenedat a time when I was anxious, and when I went into areally low mood, having the sessions helped me to iden-tify the cause of it. The diary was helpful. I will keep itgoing when I go home. At the start I didn't think 1

would find it useful but I did. When I read it back tomyself I can see the patterns of things that happened'

Patient J

Weighing up advantages and di.sailvantagcsThis technique was helpful for a number of patients invarious different ways. One illustration is from patient J.who did not want to use a wheelchair as they were:

'worried about what others would think, and worriedabout people seeing me. but after weighing it up 1 rea-lised that using it would enable me to go outside, whichI really want to do because it is a beautiful day"

Identifying and challenging negative thoughtsEight of the 11 patients said that they found this helpful.They commented that being more aware of these thoughtsand challenging them, took the focus away from negativethoughts and allowed them to think more positively andfoeus on other aspects of life.

'It helped me to think in a more structured way andhelped me to think more positively about things'

Patient A

Creating alternative statements to challenge negativethoughts was helpful for three of the patients. Patient Ehad a CT scan followed by an oncology appointmentevery 3 months and prior to the appointment was anxiousand preoecupied with what would be discussed. Herthoughtsduring these times were identified and a list of alter-native statements was created. Her comment on this was:

'She gave me a list to help me have a positive attitude. Iread it when I am feeling sorry for myself and it helpsme*

Creating goals and planning activitiesThese were created from what was revealed in the diary,or through conversation, to be a source of enjoyment orachievement, or from reviewing things the patient previ-ously enjoyed doing. New and realistic goals were thenereated accordingly.

Creating a Us! of questions for the doctorFive of the 11 patients said that they had unansweredquestions and found it beneficial to create a list of these.Examples of these were questions about medication, driv-ing, scans, symptoms and questions about the future.

The patient who chose not to continue with the studyafter one session agreed to an interview for feedback. Shesaid that during that session she enjoyed talking aboulthings she could not talk to others about as she was feelingdown at that particular time and needed to talk. She also

The use of cognitive behavioural therapy techniques in hospice patients 819

stated that it made her more aware of difficult issues,which she found helpful. Her reason for not continuingwas that usually when she is feeling down she does notwant to talk, and when she is feeling well she does notwant to dwell on negative things. She did think it couldbe helpful to others and would recommend it, and wouldalso consider it again herself in the future.

The patient who withdrew after two sessions did sobecause there were things which he chose not to talkabout, things that were stored in 'boxes' which he feltmay cause more harm than good to talk about. He didsay that it was helpful to identify difficult issues, and didnot fmd this distressing.

'We delved deep enough to satisfy me but not embar-rass me"

He did not feel that any changes in thinking or behaviourresulted from the intervention but did comment that hismood had improved.

Quantitative results

HADSNine of the 11 patients had an improvement in HADSscores. There was a decrease in anxiety and depressionscores for seven patients, one patient had a decrease indepression scores only and one had a decrease in anxietyscores only. The mean HADS scores are illustrated in Fig-ure 5. and the statistical data are summarised in Table 2.

Analysis of these mean scores using a paired Mestrevealed that the improvement was significant for depres-sion {P = 0.04), anxiety {P = 0.03) and combined scores

VASVAS scores for happiness, relaxation, pain, energy andnausea pre- and post-intervention were analysed usingWilcoxon Signed Ranks test and the only significantchange found was an improvement in energy levels

Discussion

10

tl

Data for Figure 5

t2

Combined

Anxiety

Depression

t l

19.9

10

9.9

t2

13,8

6.6

7.2

Figure 5 Graph demonstrating change in mean HADSscores from t l (pre-intervention) to t2 (post-intervention).

Three or four structured sessions were acceptable, andwere an adequate number for most of the patients in thisstudy. Long sessions were felt to be inappropriate forpatients with very advanced disease with poor energy,concentration or memory. Therefore, it may be more suit-able in a day hospice population or with inpatients thatare not at the tenninal stage of illness, and may be moreappropriate if brief teehniques are used as part of dailypractice instead of planned sessions. Flexibility is neces-sary as some patients may want to complete sooner, andsome may need further follow-up.

Such an intervention may be appropriate, along withantidepressants. in patients with severe depression-' butthat was not shown in this study, as the patient with severedepression did not find the intervention beneficial, insevere depression, it may be more appropriate for CBTto be provided by mental health professionals with moreadvanced training, but it may not always be appropriateto refer palliative care patients.

This study shows that the use of CBT techniques wasacceptable to a proportion of palliative care patientswith anxiety, depression or adjustment disorders, buthighlights that the patients need to be chosen carefully.

It is not appropriate in patients who are confused orhave difficulty communicating and may be less appropri-ate in patients who have poor energy, concentration andmemory, and patients in the terminal stage of their illness.

Table2 Mean and standard deviation (SD) values ofHADS scores pre (tl) and post (t2) intervention

AnxietyDepressionCombined

Mean

109.9

19.9

t l

SD

4.734.436.9

Mean

6.67.2

13.8

12

SD

4.675.37.2

P

0.030,040.03

820 T Anderson et al.

This study and other literature^*'**"' suggest that it maybe appropriate for mild-to-moderate disorders to be trea-ted by a palliative care professional with training andsupervision and suggest that training in CBT, along withsupervision, may equip palliative care professionals tomanage psychological problems more eflectively.

The therapeutic relationship is important, but it isimportant to respeet that not all patients want to talkabout thoughts or feelings and it is important that theydo not feel under pressure to do so.

The most useful techniques for the patients in this studywere the use of diaries, identifying and challenging nega-tive thoughts, weighing up advantages and disadviintages,linking thoughts, feelings and behaviours and creatinggoals. A written summary of the session was useful tohelp patients remember and review the issties discussed.

Eight of the 11 patients felt that their thinking orbehaviour had changed as a result of the intervention,and anxiety and depression were improved in eight ofthe 11 patients. However, it is difficult to prove thatthese changes are due to the use of CBT techniques, as itwas a small feasibility study without controls. Therefore,the quantitative data should be interpreted with this inmind. The interpretation of the VAS scores relating tophysical symptoms needs to be done with particularcare, because those symptoms will have been managedin other ways by the hospice team and we cannot makean assumption that any changes were a result of the CBTintervention.

A much larger sample would be necessary to test forsignificance and further studies would be appropriate toassess the efTectiveness of the use of CBT techniques inthis patient population.

If the results of a further trial confirmed evidence of theeffectiveness of the use of CBT techniques in palliativecare patients, this would be a useful intervention as it isnon-pharmacological, is acceptable to most patients, andthe training is short and inexpensive, and so can be pro-vided to many members of the multi-disciplinary team toenable them to use these techniques as part of dailypractice.

Acknowledgements

We would like to thank Northern Ireland Hospice forsponsoring the project and all the patients who agreed totake part in the study. We would also like to thank MaeveMcCann and Dolorus Sweeney for their assistance andTracy McTernaghan and Hazel Taylor for administrativesupport. A special thanks to Dr Anthony Byrne, who isthe course organiser for the MSe in Palliative Medicine atCardiff University which this project was part of, for allhis teaching, advice and encouragement.

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