Patients who are treated with psychotropics may experience better recovery from their symptoms and improved quality of life when they receive targeted treatment with cognitive-behavioral therapy (CBT). Clinicians can use certain CBT techniques to “jump-start” recovery in patients before prescribed medications produce their intended therapeutic effects. When practitioners are familiar with their use, techniques such as behavioral activation and tools that enhance adherence can be employed during a brief medication management (“med check”) visit.
Take these steps to implement brief CBT interventions into your patient’s routine visits:
- develop a clear, formulation-driven treatment target
- design an intervention that can be explained during a brief visit
- have handouts and worksheets available for patients to use
- provide written explanations and reminders for patients to use in out-of-session practice.
We present a case report that illustrates incorporating brief CBT interventions in a patient with major depressive disorder (MDD).
Using CBT to help a patient with MDD
Mr. L, age 52, presents with moderate MDD, and is started on fluoxetine, 20 mg/d. Mr. L has significant anhedonia and poor energy, and has been avoiding going to work and seeing friends. The psychiatrist explains to him how individuals with depression often want to refrain from activity and “shut down,” but that doing so will not improve his quality of life, and his mood will worsen.
The psychiatrist asks Mr. L to identify a pleasurable or important activity to complete before his next appointment. Mr. L decides that he would like to call a friend, because he has been isolated and his friends have been calling him. The psychiatrist encourages him to call one of his golf buddies. She instructs Mr. L to set reminders, such as cell phone alarms and notes on the refrigerator, to prompt him to “Call Phil Saturday at 10 am.” She uses a prescription pad to write an “action prescription”1 to remind Mr. L of the importance of engaging in this activity.
To increase the likelihood that Mr. L will make this call, he and his psychiatrist discuss anticipated obstacles and potential facilitators of this behavior. Mr. L says that he might not be able to reach his friend, or that his negative self-talk might prevent him from making the call. With his psychiatrist’s help, Mr. L selects a second friend to call if the first friend does not answer the phone. They create a coping card2 with encouraging and factual statements (eg, “My friend will be happy to hear from me” and “This will make me feel good”) for Mr. L to refer to if his negative self-talk interferes with his desire to make the call.
The psychiatrist also encourages Mr. L to complete a Behavioral Activation Worksheet (for examples, see http://www.cci.health.wa.gov.au/docs/ACF3B92.pdf or https://www.therapistaid.com/worksheets/behavioral-activation.pdf) to track his depression, pleasure, and sense of achievement before and after completing this activity.
As illustrated by this case, collaborating with the patient is critical to developing a realistic treatment plan that incorporates CBT techniques. With your help and encouragement, patients can use these tools to reach their goals and target the symptoms of their illnesses.