Academic journal article Journal of Cognitive Psychotherapy

Cognitive Therapy with Inpatients: Review and Meta-Analysis

Academic journal article Journal of Cognitive Psychotherapy

Cognitive Therapy with Inpatients: Review and Meta-Analysis

Article excerpt

Cognitive therapy has shown promise as a treatment for depressed outpatients. Despite recent increases in its use with inpatients, the treatment itself has not been well substantiated empirically. This article reviews the literature on cognitive- behavior therapy (CBT) with inpatients, and uses meta-analysis to assess the efficacy of this approach to treatment. The results suggest that CBT can be beneficial with inpatients both as a primary treatment and as an adjunct to antidepressant medication. More controlled research needs to be completed to fully confirm CBT's role in an inpatient setting.

The advances in psychotherapeutic treatment of major depression with outpatients have been well documented over the last 15 years (Nietzel, Russell, Hemmings, & Gretter, 1987; Robinson, Berman, & Neimeyer, 1990). There has been, however, substantially less research addressing the efficacy of psychotherapeutic interventions for depressed inpatients. The trend toward shorter hospital stays (Black & Winokur, 1988) and the current economic Zeitgeist highlights the need to focus more attention on inpatient research, and to identify psychosocial interventions that are efficacious, cost effective, and readily applicable to acute care inpatient settings. Cognitive-behavior therapy (CBT) is a treatment well suited for research in these areas.

The suitability of CBT for inpatient treatment has led to the development of various inpatient treatment programs throughout the country. In their recently published book on cognitive therapy in an inpatient setting, Wright, Thase, Beck, and Ludgate (1992) list 26 programs (private, public and university hospitals) that have some type of inpatient CBT treatment unit. The growth of these units and the application of CBT principles to depressed inpatients appears to be the wave of the future. However, since few empirical data regarding the efficacy of CBT with depressed inpatients are available, this expansion in the use of inpatient CBT may be premature. Though a number of studies have been conducted using CBT in the treatment of depressed inpatients, the results of these studies have not been synthesized in such a way that general conclusions about appropriate applications of inpatient CBT can be drawn. The purpose of this article is to look at the literature on CBT with inpatients and to assess its general effectiveness within an inpatient setting using meta-analysis.

Literature Review

Several authors have modified Beck's Cognitive Therapy (Beck, Rush, Shaw, & Emery, 1979) for use with various inpatient populations. Detailed descriptions of these programs may be found in various books and journals (Bowers, 1989; Freeman & Greenwood 1987; Shaw, 198l;Thase& Wright, 1991; Wright etal., 1992). In general, these programs, as compared to outpatient treatment, use more intensive treatment over a shorter time span. Behavioral interventions are a mainstay of the early phases of treatment and homework assignments are reinforced by the inpatient staff as well as the patient's primary therapist. All programs emphasize the need for continued outpatient treatment once discharge occurs. Both open and controlled trials of inpatient CBT have been conducted as part of several of these programs.

Open Trials

The first open trial of inpatient CBT for depression was reported by Shaw (1980). Ten of 11 medication-free inpatients openly assigned to treatment with CBT (average three sessions per week), reported significant improvement in depressive symptoms as measured by the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, &Erbaugh, 1961). Over an average of 8.1 weeks' hospitalization, mean BDI scores dropped from 29.8 to 15.6 at discharge. Follow-up data at four to six weeks' post-discharge indicated that these patients had maintained their level of improvement (mean BDI13.5).

In a pilot study (Miller, Bishop, Norman, & Keitner, 1985), six chronically depressed female inpatients were treated in an open trial with a combination of pharmacotherapy and CBT. …

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