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Abstract

Objective: To overview the field of psychotherapy in the medically ill. Rather than attempting a systematic review of this very extensive area, the article seeks to capture some of the main threads and issues of importance.

Method: The subject is looked at under four headings: (i) which illnesses have attracted research interest in psychotherapy; (ii) which outcome measures have been chosen; (iii) which modes of intervention have been used; and (iv) finally a review of the methodology and the results obtained.

Results: Some illnesses have attracted much more psychotherapeutic interest than others; the differences are haphazard. Outcome measures on the whole have focused on coping with illness and psychological distress, with a smaller number looking at disease outcome. Only short-term changes have been sought in the main. The most commonly used modalities of therapy have been cognitive-behavioural; additionally, supportive information-giving and group therapy have been trialled. Benefit in terms of all these have been reported, but the majority of studies are weakened by major methodological shortcomings.

Conclusion: There is an overall paucity of well-designed studies that clearly demonstrate psychotherapy as an efficacious treatment in the medically ill. The field is hampered by the lack of a clear conceptual thread recognizing the long-term and diverse experience of patients with medical illness and relating this to the question of the part psychotherapy should play. Future work needs to concentrate on appropriate selection of patients who might benefit, as well as including a wider range of more clinically relevant outcome measures and more stringent methodology.

Keywords

chronic illness medical illness psychosocial intervention psychotherapy

The association between medical illness and psychiat-high in some illnesses. Thus, in asthma, anxiety disorder ric and psychological morbidity was noted even in his-has been quoted as between twice and eight times more torical times [1, 2] and this was taken up by the common than in the general population [16] and the rate psychoanalysts of the last century [3–13]. More recent of depression after stroke is up to 60% [17]. Current and more systematic work has confirmed the increased paradigms include cognitive distortion [18], lack of incidence and prevalence of emotional disturbance social support [19] and what Toombs has called the comorbid with medical illness [14, 15]. This is especially ‘unshareability’ of illness [20].

It would seem then that psychotherapy might have an important role in the treatment regimen of the medically ill. However with the expectation of a clear evidence base for all interventions [21], the need for studies of adequate methodological quality in the area has become paramount.

This overview attempts to delineate issues of importance, as well as to provide a review and critique of some of the studies of psychotherapy for patients whose primary illness is physical in nature.

Method

The overview was conducted based on the following premises:

Psychotherapy is a form of communication between therapist and patient, informed by a theoretical base and with the aim of relieving or treating emotional distress or morbidity. Massage therapy, hypnosis, writing therapy and biofeedback have been excluded. Education and behavioural training are only included where a psychotherapeutic component is integral or added. Thus teaching of breathing techniques alone would be excluded, whereas breathing training as part of a cognitive behavioural treatment is included.

To enable the literature to be properly understood, only English language studies have been included.

So-called functional disorders, such as irritable bowel, chronic pain, chronic fatigue and pseudoseizures, are not regarded as primarily physical illnesses and are therefore excluded.

The data bases searched were MEDLINE, PsycINFO, Cochrane DSR, ACP Journal Club and DARE, using terms for the various illnesses plus ‘Medical Illness’, ‘Chronic Illness’ and ‘Physical Illness’ combined with ‘Psychotherapy’. However, because of the very broad extent of the field being studied, systematic inclusion of all relevant work was impossible.

Results

Illnesses selected for psychotherapy

There is a considerable difference in the frequency with which psychotherapy is used from one illness to another.

This is illustrated in Table 1. It is immediately apparent that the increased level of interest in one illness over another is mostly haphazard. For example, the extensive literature on breast cancer lies in contrast to a virtual absence in the field of bowel cancer. In the field of transplant medicine, the high level of analytic interest in the early years [22, 23] has been only sporadically matched more recently in renal [24] and lung transplants [25], despite a high level of recognized need [26–28]. There is also a surprising dearth of work in the field of neurological illness [29–35].

Table 1.

Randomized controlled trials of psychotherapy medical illness

Condition	<5 studies reported	Studies using randomized controlled design	Intervention	Main outcome measures	Duration of study	Major methodological shortcomings	Intervention effective in terms of stated purpose
Rheumatoid arthritis	Yes	Sharpe et al. [87]	CBT	Mood, coping, arthritis disability, disease measures	2 years	Control group not matched for attention	Improvement in depression, anxiety and disability
		Parker et al. [126]	CBT	Depression, coping, stress, pain, arthritis self-efficacy	15 months	Small numbers, little description of treatment, none of randomization	No difference
		Evers et al. [88]	CBT	Depression, disability, fatigue, pain, social functioning, stress, disease activity	6 months	Low enrolment from initial sample, no power calculation, no description of randomization, treatment package ‘tailor made’, i.e. varied between patients	Improvement in depression and fatigue
Osteoarthritis	No
Asthma	Yes	Put et al. [127]	CBT	QOL, mood, asthma symptoms	6 months	Very small numbers, only 25% of those invited enrolled	Positive at 3 months
		Sommaruga et al. [89]	CBT	Mood	1 year	No description of withdrawals or blinding procedure, no power calculation for sample size	No difference
		Perez et al. [90]	CBT	Asthma management, parent's knowledge and management, asthma morbidity	3 months	Very small numbers and high drop-out rate, no description of randomization or blinding	Improvement in morbidity
Chronic obstructive airways disease	No	Rosser et al. [128]	Analytic vs supportive vs nurse	Lung function symptoms, psychological distress, psychodynamic state	6 months	Randomization design alluded to but not defined, exclusion criteria unclear, treatments poorly validated and defined, small numbers	Improvement in psychological distress in support group intervention
		De Godoy et al. [129]	Group psychotherapy	Depression, walking ability	12 weeks	No description of randomization single blinding only, very small numbers, no description of treatment, analysis done within not between groups	improvement in depression
Type 1 diabetes	Yes	Didjurgeit et al. [91]	Problem-orientated	Diabetes control, depression, self-defined psychological problem	6 months	Very small numbers, no description of randomization, no standardization of therapy, short follow up, poorly matched groups on psychological measures	Improvement in diabetes control
		Fosbury et al. [92]	Cognitive analytic	Interpersonal difficulties, diabetes control	9 months	Very small numbers, poorly standardized therapy, no description of randomization or blinding	No difference
		Wysocki et al. [83]	Behavioural family systems therapy	Family relationships, adjustment to illness, diabetes control	12 months	No power calculation, limited standardization of therapy, no description of randomization	Improvement in family relationships
Type 2 diabetes	Yes	Kenardy et al. [54]	Group CBT	Eating disorder pathology, bingeing, psychological wellbeing, diabetes control	3 months	Unclear how many originally approached to take part, small numbers, no placebo control	No difference between treatments
		Lustman et al. [93]	CBT	Depression, diabetes control	6 months	Small numbers, short follow up	Improvement in depression
		Pibernik-Okanovic et al. [130]	Empowerment-based	QOL, diabetes control	6 months	Unequal numbers in intervention and control arms, no power calculation, no description of randomization, no blinding, no standardization of treatment, very low takeup of treatment	Improvement
Thyroid disease	No
Ischaemic heart disease	Yes	Frasure-Smith et al. [131]	Home-based psychosocial nursing intervention	Mood, psychological distress, survival	1 year		No difference
		Jones et al. [132]	Psychological therapy, group and individual	Mood, cardiac outcome, disability, health care utilization, survival	12 months	Intervention poorly defined	No difference
		Rahe et al. [55]	Group therapy	Cardiac morbidity, disability, coronary-prone behaviours, survival	4 years	No description of randomization or blinding, very small numbers, poorly defined intervention	Improvement on all measures
Sudden cardiac arrest	No	Cowan et al. [117]	Individual CBT	Survival, non-fatal cardiac events	2 years	No power calculation, no attentional control	Significant reduction in risk of cardiovascular death
Congestive heart failure	No
Cancer – all	Yes	Cain et al. [56]	Supportive group	Mood, illness knowledge, interpersonal relationships, disability	6 months	Very small numbers, no description of randomization or dropouts, no standardization of treatment	Improvement in mood
		Evans et al. [94]	CBT vs social support	Mood, interpersonal functioning	6 months	Small numbers, poorly described treatment, short follow up	No difference
		Forester et al. [133]	Individual supportive	Mood, physical symptoms	10 weeks	Poorly described treatment, no power calculation, short follow up	Improvement on all measures
		Greer et al. [134]	Problem focused CBT	Mood, adjustment to cancer, symptoms of cancer	4 months	No power calculation, no description of randomization, short follow up	Improvement in adjustment to cancer
Breast cancer	Yes	Kissane et al. [57]	Cognitive existential group	Mood, adjustment to cancer, family function, satisfaction with treatment offered	12 months		Improvement in satisfaction with treatment
		Simpson et al. [135]	Social support group	Depression, social interaction, psychological distress	2 years
		Edelman et al. [58]	Group CBT	Survival, mood, self-esteem	5 years		Improvement in mood and self-esteem in short-term only
		Edmonds et al. [59]	Supportive plus cognitive	Mood, QOL, adjustment to cancer, survival	5 years	‘profound changes’ noted as outcome but not defined, no power calculation	Improvement in mood only in the short term
		Goodwin et al. [60]	Supportive expressive group	Survival, mood, psychosocial functioning, pain	1 year		Improvement in pain
		Spiegel et al. [61]	Supportive expressive group	Survival, mood, psychosocial functioning, pain	10 years	Small control group, internally inconsistent psychological sequelae not discussed, survival advantage non-replicable	Improvement
		Heiney et al. [62]	Group by telephone	Psychological distress	4 months	82/192 declined, no power calculation	No difference
		Antoni et al. [95]	CB stress management	Cortisol and immune function, self-assessed benefit	3 months	No power calculations, no description of dropouts, very small numbers, no description of randomization, poorly defined intervention	Improvement on all measures
		Marchioro et al. [136]	Cognitive individual plus family	Depression, QOL	Up to 9 months	Tiny numbers, no rationale for therapy package, variable length of follow up	Improvement in depression and QOL
		Larson et al. [137]	Individual or group problem solving and support	Depression, impact of illness, immune function	1 week postsurgical	Small numbers, no blinding, diverse interventions	No difference
Melanoma	No	Fawzy et al. [63]	Group CBT	Recurrence and survival	10 years	No power calculation	Improved survival
Testicular cancer	No	Moynihan et al. [138]	Psychological support	Mood	12 months	‘Not suicidal’ used as exclusion criterion without further definition, only 40% agreement to participate although non-participants well described	No difference
Lung cancer	No	Linn et al. [139]	Supportive counselling	QOL, depression, self-esteem	1 year	Poorly specified intervention	Improvement, but not maintained over time
		Goldberg et al. [84]	Social support and counselling	Mood, social function, physical wellbeing	6 months	Poorly specified intervention, no power, no description of randomization	No difference
Bowel cancer	No	Kuchler et al. [140]	Supportive while in hospital only	QOL, survival	2 years	No power, mixture of diagnoses, extremely brief and of variable length	Improvement in survival
Haematological cancer	No	Syrjala et al. [141]	Relaxation vs CBT vs support vs control	Pain from oral mucositis	5 weeks	No power, no description of randomization, narrowly defined pain, no other measures	Improvement with relaxation, no additional benefit from others
HIV	Yes	Evans et al. [64]	CBT	Pain, psychological distress, depression	6 weeks	Very small numbers, poor description of recruitment, exclusion criteria, randomization, high dropout
		Goodkin et al. [65]	Bereavement group	Grief, psychological distress	10 weeks	No power calculation, short time frame
		Markowitz et al. [142]	IPT vs supportive therapy	Depression, physical function	15 weeks	Very small numbers, no placebo group	IPT significantly better than support condition on all measures
		Kelly et al. [66]	Group CBT vs social support group	Psychological distress, drug use, dangerous behaviour	3 months	Convenience sample, intervention non-standardized and ill-defined, small numbers
		Szapocznik et al. [67]	Structural ecosystems therapy vs group support	Psychological distress, family function	18 months	No power calculation	Family function
Inflammatory bowel disease	No
Peptic ulcer	No	Sjodin et al. [143]	Psychodynamic	Psychopathology – unrecognized rating scale, pain and dyspepsia	15 months	No power calculation, no description of randomization, marked difference between groups for disease severity, treatment poorly described and standardized	Improvement in pain and dyspepsia
Renal transplant	No	Baines et al. [68]	Group vs Individual	Depression	1 year	Poorly standardized therapy	Improvement; greater in individual than group treatment
Heart transplant	No
Lung transplant	No	Napolitano et al. [25]	Telephone counselling	Psychological distress, QOL, transplant-related stress, social support	8 weeks	No description of randomization or blinding, no power calculation, poorly defined intervention	Improvement in psychological distress, QOL, social support
Bone marrow transplant	No
Stroke	Yes	Lincoln et al. [29]	CBT	Depression	6 months	Dementia an exclusion criterion but no screen used, recent depression also an exclusion criterion without rationale, very high refusal/non-response rate, no power calculation, poorly standardized therapy	No difference
		Davis [30]	Life review therapy	Depression, life satisfaction	Not specified	Very small numbers, limited description of treatment	Improvement
Multiple sclerosis	Yes	Tesar et al. [31]	Group CBT	Mood, body image, coping	4 months	Very small numbers, unclear randomization or blinding, unmatched groups re social support	No difference
		Larcombe et al. [96]	CBT	Depression	4 weeks	Very small numbers, no placebo control, no description of randomization, no blinding	Improvement
		Mohr et al. [13,97]	Telephone CBT	Depression, adherence to treatment	4 months	Very short follow up	Improvement
Parkinson's disease	No
Huntington disease	No

CBT, cognitive behaviour therapy; QOL, quality of life.

Finally, the need for specific studies looking at the psychotherapeutic needs of children and adolescents has been only partially recognized [36–39].

Outcome measures selected

In what remains a superb review, Fries describes five domains in which an outcome measures choice must be made [40]. Of these, the two of most relevance to chronic physical illness are the choice between use of numeric as opposed to more subjective variables, and how long a timeframe will be used. Exclusion of the patient experience in favour of ‘hard’ measures leads to the error described by Kleinman [41] of confusing the priorities of doctors with those of patients; using a short timeframe is virtually meaningless in the timeframe of an illness which may span a lifetime.

There are two main categories of outcome. The first relates to psychological factors such as depression or anxiety, coping, social interaction, self-esteem or quality of life. Despite the clear expression from patients that such subtle issues as body image, sexuality and selfesteem have considerable impact on their wellbeing [42, 43], the difficulty in valid measurement means that they are rarely included. The second concentrates on disease markers including self-management, physical functioning and survival.

Table 1 summarizes the outcome measures used in controlled studies.

Interventions

The most basic issue to be considered in terms of interventions is whether the medically ill require different treatment from the medically healthy in any way [44, 45]. Clearly, good doctor–patient communication is an essential starting point for any psychosocial intervention, though often not achieved [46, 47]. Without understanding their illness, it is impossible for patients to begin problem-solving, or developing coping strategies, much less managing the process of grieving and coming to terms with their altered selves and lives – the essential tasks of managing illness.

Minden in her excellent review of psychotherapy in multiple sclerosis [48] raises a number of points, suggesting that different techniques may be required. She notes that there are often distinguishing features in the treatment of the medical patient, from the referral which may come from the doctor rather than the patient, to concerns relating to whether the therapist comprehends the particular issues raised by illness. Furthermore, the frame may need major adaptation to the specific, and changing, needs imposed by sickness and disability. There is also the issue of which patients in the end follow through with psychotherapy, and which drop out, or choose not to have it, and which groups of patients may need special treatment of one kind or another to prevent this. In the only study found which looks systematically at this question [49], the only predictor of dropout was depression – a finding with worrying implications.

The earliest kind of intervention used for physically ill patients was, as described above, psychoanalysis. Its claims to success were almost entirely based on case reports [8, 10, 13, 50].

Surprisingly, despite its promising results in functional bowel disease interpersonal psychotherapy has rarely been studied [51–53].

Group psychotherapy, providing a chance to share experience, has obvious advantages and has been frequently used, either in a supportive or a cognitive behaviour therapy format [9, 31, 32,54–82]. Family therapy and therapy for family members acknowledges the burden illness places on carers [9, 76, 78,83–86].

In the realm of individual therapy, cognitive behavioural therapy has emerged as promising, relating both to the need for patients to assimilate considerable amounts of information, and the relative ease of standardizing the therapy for research purposes. Interventions target coping, stress management, education and interpersonal support [29, 38, 57, 58, 66, 70, 78, 79, 83,87–105].

Finally, there has been the recent development of existential and spiritually based psychotherapy. This draws from the work of existentialists like Victor Frankl [106] and attempts to explore possible personal meanings that may be found in illness [77, 107, 108].

Methodological issues

Psychotherapy research is a challenging endeavour [21, 109] and the presence of physical illness creates another level of complexity [81,110–112].

The most fundamental issue is the choice of patients to enrol. In the physically ill, except where depressive or anxiety disorders are being treated, there are no clear parameters for who should be offered psychotherapy. Perhaps because of this, the takeup of an offered psychological intervention is low and dropout is high [81], even where patients had initially expressed a need for such a service [113, 114]. Those who do use such therapy are mostly white, educated and middle class, making generalizability questionable [114]. The second major shortcoming relates to sample size. This has been almost uniformly too low, and rarely determined by power calculations. For example, a review of psychotherapy for adults with asthma [115] found only one study with a sample size of over 100. This study in fact used only music therapy [116] rather than psychotherapy as defined in this paper. Methods of randomization and blinding are often not specified and sometimes clearly inadequate. Finally, variations in factors such as medication and other comorbid medical conditions makes the construction of control groups problematic.

Studies using survival as the main outcome measure have been particularly difficult to interpret. For example, the study of a cognitive intervention in survivors of sudden cardiac arrest, showed a significantly reduced mortality of 86% in those receiving therapy despite no measured difference in most of the psychosocial variables measured [117]. Other claims to effects on survival have proved impossible to replicate [60, 118]. Table 1 presents a summary of some of the more prominent examples of randomized controlled research in the area, providing a snapshot of the issues described above.

Discussion

This review has covered a large and complex area, and in doing so has necessarily summarized and abbreviated many issues. Capturing all articles in the field was impossible. The decision to include only psychotherapy as narrowly defined, left out some interesting and useful work using educational interactions or relaxation methods. The exclusion of non-English papers introduced a bias away from psychoanalytically based therapies. However, some conclusions do emerge.

First, it is still not clear who will warrant psychotherapeutic intervention. Certainly, patients with anxiety or depression deserve the same level and quality of care whether or not they have comorbid medical illnesses [104,119–122], and this implies the need for better understanding of these disorders by the health-care team; currently recognition is low [119, 121]. However, the need for psychotherapy for the purposes of emotional adjustment in the absence of psychiatric illness has not yet been established. The diagnosis and ongoing trajectory of illness create a variety of psychological challenges to patients [120], but there is no clear understanding of how to separate out the groups of patients who might benefit from psychotherapy from those who will do perfectly well with standard care alone. Bereavement research shows that most people will grieve normally, with only a subgroup developing pathological responses requiring treatment [85, 123]. By analogy, it is likely that most people confronting the various losses created by illness will manage using their own resources.

Second, there must be a systematic attempt to find which interventions work, with attention to the question of which components may constitute the ‘active ingredient’ [124, 125] and whether these therapies need to be disease-specific, or whether they can be generalized from one illness to another.

Third, to determine the effectiveness of interventions, greater attention will need to be paid to the economic feasibility of introducing interventions in the medical setting. Brief therapies administered by members of the medical health team show promise as being accessible and attractive enough to become part of the repertoire of treatments. Group interventions, for which the evidence base is beginning to emerge, provide advantages at an economic level.

Increasingly, it seems unlikely that illness can be cured or survival lengthened simply by tending to the psyche – the ‘fool's gold’ of some research [71]. Attempts to demonstrate this have been too patchy, and too difficult to replicate.

In summary, the case for psychotherapy as an automatic adjunct to medical treatment has not yet been established. Nor is there sufficient evidence that psychotherapy can play a meaningful role in indices of survival. However, in the presence of the high levels of psychiatric illness and psychological distress accompanying physical illness, there is urgent need for well-designed and methodologically sound studies addressing the question of which interventions should be directed to whom and how they are best delivered.

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Psychotherapy in the Medically Ill: A Commentary

Abstract

Keywords

Method

Results

Illnesses selected for psychotherapy

Outcome measures selected

Interventions

Methodological issues

Discussion

References