Potential of a cognitive-behavioural approach to improve patient symptoms in a primary care setting

Patient symptoms

Chronic noncancer pain is the latest symptom shown to be treatable using mind-body therapies, including meditation and CBT.² Garland et al conducted a systematic review of 60 studies in more than 6000 patients with opioid-treated pain and revealed a moderate association of mind-body therapies with pain reduction and a mild association with opioid dose reduction in patients who were already taking these medications. In Canada, chronic noncancer pain is a common, disabling problem, with one study estimating its prevalence at just under 20% of the adult population; among those surveyed, half reported having had their pain for more than 10 years, and one-third described the pain as very severe.³ The lower back was the most common site of pain and arthritis was the most common cause.³ It has been theorized that the mechanism of action of CBT and other mind-body therapies to treat back pain is related to an emotional shift toward acceptance of the sensory information and reappraising those sensations as innocuous.⁴

Cognitive-behavioural therapy has also been shown to alleviate multiple other common yet disabling symptoms. The prevalence of anxiety and associated disorders is 18% in one US study⁵ (lifetime as high as 31% worldwide⁶) and is accompanied by a considerable reduction in quality of life. In a Canadian study, the misdiagnosis rate for anxiety was 71%.⁷ Patients with anxiety respond well to CBT and a number needed to treat of 2 was all that was necessary for older adults with anxiety to benefit from CBT.^8,9

The prevalence of depression in Canada is slightly less than 5% (lifetime more than 11%).¹⁰ The Canadian Network for Mood and Anxiety Treatments recommends CBT as first-line treatment for mild depression and as adjunctive therapy for moderate to severe depression.¹¹ Trauma-focused CBT is effective at reducing posttraumatic stress.¹² Insomnia is another common symptom in Canada, with a prevalence between 20% and 25% for Canadians older than 65.¹³ Multicomponent CBT for insomnia has been shown to improve perceived sleep quality in seniors.¹⁴ This association is relevant because the use of hypnotic medication in this age group is problematic owing to a high risk of adverse effects.¹⁵ Patients with symptoms related to fatigue, fibromyalgia, and irritable bowel syndrome respond well to CBT.^16-18 The mechanism of action in irritable bowel syndrome is purported to be owing to changes in gut reactivity to physiologic sensations that are exaggerated through the autonomic nervous system. That the symptoms of irritable bowel syndrome are relieved by CBT implies a potential benefit in treating other functional gastrointestinal symptoms with mind-body therapies.¹⁹

Medically unexplained symptoms account for as many as 33% of clinical visits.²⁰ These symptoms are strongly associated with coexisting anxiety and depression, high health care use, potentially costly investigations, and difficult patient encounters as perceived by physicians. Further, these symptoms lead to reductions in quality of life that are similar to those of medically defined diseases.²¹ The application of reattribution CBT, a technique in which patients are given a plausible, normalizing explanation for the symptoms of concern, has been shown to improve those symptoms as well as patients’ moods.²² This technique has been shown to decrease patients’ thoughts that the problem was purely physical.²³ On the other hand, nonspecific reassurance about patients’ medically unexplained symptoms without a plausible explanation by physicians can have the paradoxical effect of exacerbating patients’ symptoms.²⁴ A conceptual analysis describes a mechanistic theory behind the benefits of using a cognitive-behavioural approach to the management of medically unexplained and other symptoms.²⁵ Additionally, a recent systematic review described 3 studies in which there was a statistically significant improvement in patients’ medically unexplained symptoms when CBT was provided by primary care physicians.²⁶ It is relevant to note that CBT provided by primary care physicians was as efficacious as CBT provided by other specialists.

Psychology meets medicine

First described by Beck in 1976, CBT explores the links among thoughts, emotions, and behaviour.²⁷ This therapeutic technique aims to alleviate patient distress by helping patients become aware of their cognitive distortions and emotional reactions and assisting them in developing more resilient thoughts and adaptive behaviour.²⁸ With guidance from a clinician and using standardized print or online materials, the work is mainly done by the patient, who reflects on and evaluates the evidence for the rationality of automatic thoughts. For depression, this type of therapy has been shown to be helpful for patients of all ages, levels of education, and cultures.¹¹ Even a few CBT sessions delivered by telephone have been shown to be helpful in treating depression.²⁹

The patient-centred clinical method mentioned above has been shown to improve multiple health outcomes whenever the clinician’s biomedical evaluation is combined with an exploration of the patient’s consciously appreciated concerns, thoughts, feelings, and expectations, and their effects on the patient’s function.^30-35 However, CBT deals with the cognitive attributes of a patient’s presentation. These attributes are often not fully appreciated by patients. It is proposed here that if physicians were able to discern automatic patient thoughts or maladaptive behaviour during a clinical visit for any given patient symptom, having knowledge of the principles of CBT would help physicians better evaluate patients. Based on this more complete evaluation, physicians could efficiently apply a cognitive-based approach to help resolve patient symptoms.

The following scenario describes how a reattribution CBT approach could help address a patient’s medically unexplained symptom. Imagine an anxious patient with nonspecific headaches and negative physical examination findings who is very concerned that their head feels like it is going to explode. The physician could appropriately explain that the fundoscopic examination reveals there is no pressure on the brain but muscle tension on the scalp could reasonably explain such a symptom. The key point is that a plausible explanation is provided to the patient rather than rudimentary, ineffective reassurance. Another common clinical example is a patient presenting with acute back pain. If the patient is catastrophizing or engaging in maladaptive, overprotective behaviour regarding the back pain, the physician could, after performing an appropriately detailed physical assessment and addressing the patient’s specific concerns, discuss the typical, uncomplicated natural history of acute back pain. Further, the patient could be informed that a subsequent reassessment might only be required if red flags appear. This approach helps to challenge the patient’s automatic, irrational thinking and maladaptive behaviour. A clinical back pain trial confirmed the success of this approach in that the precise words used by a trusted primary care physician at the first visit affected the resolution of the patient’s back pain.³⁶ In this regard, the incidence of chronic pain would be expected to be reduced simply by incorporating a cognitive-based approach at the first and subsequent visits for acute pain. As the conceptual analysis by Salkovskis et al discusses,²⁵ a cognitive-based approach could be used to help resolve multiple other patient symptoms at the point of care.

This voluminous cognitive and mind-body therapy research leads one to conclude that psychological factors influence many patient symptoms. Further, by addressing these factors during clinical visits, physicians can assist in symptom resolution for patients. Family physicians are in an ideal position to do so, as they are often the first contact for patients presenting with these symptoms. By combining the patient-centred approach with a cognitive one, family physicians would be better equipped to treat their patients’ symptoms. However, formal CBT sessions might be necessary in some cases.

It appears, based on the popularity of workshops in CBT during the annual Family Medicine Forum, that Canadian family physicians are very interested in developing CBT skills. According to Family Medicine Forum records, there was overflow attendance at a large group session on CBT during the 2019 conference. While primary care clinicians acknowledge the benefits of CBT, they cite time restrictions and inadequate compensation as barriers to its application in clinical care.^37-39 However, the evidence presented in this article demonstrates that the cognitive-based principles of CBT can be applied efficiently and effectively at the point of care. Consultation times were not longer when reattribution CBT was used by primary care physicians for patients presenting with medically unexplained symptoms.²⁴ One study revealed that within 4 minutes of the start of the clinical visit (or within 2 minutes, if it was a repeat visit for the same symptom), physicians were able to ascertain that the patient’s presenting symptom would remain unexplained.⁴⁰ Further, the need for multiple follow-up visits and investigations would be mitigated, thus saving a substantial amount of follow-up time. An additional benefit is that both patient and clinician satisfaction would be improved, which might also promote efficiency of care. Whenever physicians judge full, comprehensive CBT to be necessary, explaining the nature of automatic thinking and maladaptive behaviour to the patient would still be a critical first step, as would providing evidence-based resources to patients. It is relevant to note that whenever formal CBT is recommended, patients prefer to follow up with a trusted clinician, even if they are following effective online CBT programs recommended by the clinician.¹¹ However, should it not be possible for a physician to provide full CBT owing to time restrictions, there should be another professional in the patient’s medical home who is adequately trained to provide CBT. This recommendation has already been emphasized in the treatment of chronic pain, given the high degree of efficacy of CBT in treating that disabling condition.²

Implications for family medicine training

The 2020 College of Family Physicians of Canada Assessment Objectives for Certification in Family Medicine emphasize the importance of residents attaining skills in the provision of clinical care using a patient-centred approach.⁴¹ These objectives further recommend the application of the clinical method described by Stewart et al to deliver this approach.¹ However, this method does not include an exploration of patients’ automatic thoughts or maladaptive behaviour, which would be a necessary skill if clinicians wished to incorporate these cognitive-behavioural approaches or therapies into practice. There are many workshops available in Canada to introduce trainees to these fundamental skills.^42-44 A study in the United Kingdom revealed that only 3 workshops 2 hours in length were necessary for primary care physicians to feel confident to deliver reattribution CBT.⁴⁵ Furthering CBT experience in family practice educational settings would improve family physicians’ effective application of these techniques in independent practice.