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FRONTLINE REPORTS Francine Cournos, M.D., and Stephen M. Goldfinger, M.D.

, Editors

The Frontline Reports column fea- scribe additional medication. Thus a adding another weekly outpatient ap-
tures short descriptions of novel hemodialysis center is an excellent pointment was onerous, and inter-
approaches to mental health prob- place for psychosocial interventions. vening while patients were being dia-
lems or creative applications of es- Downstate Medical Center, located lyzed was both practical and appreci-
tablished concepts in different set- in central Brooklyn, New York, has a ated by the patients. No patients were
tings. Material submitted for the long and proud history in the treat- lost to follow-through—100% of
column should be 350 to 750 words ment of hemodialysis patients. those who consented to a consultation
long, with a maximum of three au- Downstate housed the first federally were evaluated, a significant im-
thors (one is preferred), and no funded dialysis center in New York provement over the usual rates of fol-
references, tables, or figures. Send State and has continued to be an in- low-up on psychiatric referrals.
material to Francine Cournos, novative force in the treatment of Over the first year of this program,
M.D., at the New York State Psy- ESRD. However, staff social workers beginning in 2005, about 75 dialysis
chiatric Institute (fc15@columbia. have administrative responsibilities patients were evaluated and 50 were
edu) or Stephen M. Goldfinger, and are often not afforded ample engaged in group and individual
M.D., at SUNY Downstate Medical time to address all of the patients’ treatment. Group treatments were
Center ( clinical issues. We created a model in conducted in a conference room at
which social workers serve as liaisons the dialysis center and typically con-
between patients and consulting psy- sisted of six to ten people. The ses-
chologists, identifying and referring sions were scheduled immediately
patients in need. preceding a shift, so that patients
Many models for the delivery of could come early to their appoint-
Use of CBT to Treat treatment were piloted, including ap- ments and attend the group. This tim-
Depression Among pointments at the outpatient psychol- ing enabled patients who required
Patients on Hemodialysis ogy service, meetings at the dialysis ambulette transportation to attend
The rapid pace at which medical center on nondialysis days, appoint- and also fostered supportive relation-
technologies are being developed and ments before or after the patients’ ships between people on the same
utilized is staggering, but responses to treatments and, finally, meetings dur- shift.
the mental health implications of ing dialysis. Clinical experience We chose cognitive-behavioral
these innovations often lag behind. taught us that psychosocial interven- therapy (CBT) as our intervention. Its
Before hemodialysis, there were few tion during dialysis represented the focus on symptom reduction and its
treatment options for patients with most effective model. With some ad- time-limited nature made it palatable
kidney failure. Currently more than justment, the dialysis center offered to patients, and CBT fits well into the
275,000 Americans receive ongoing more privacy than most inpatient set- medical model of treatment that pa-
hemodialysis, which represents 80% tings. Because of patients’ medical tients are accustomed to. The initial
of the population with end-stage re- severity and treatment burden, phase of the program was spent iden-
nal disease (ESRD), or kidney func- tifying the psychological issues
tion below 10%. Life on dialysis unique to this population. Two over-
shares aspects of illness burden with arching themes emerged: patients be-
other chronic disorders: threats to au- lieve that depression is part of the ill-
tonomy, burden of illness, and Editor’s Note: Cognitive-be- ness “package,” and they believe that
changes in functional status. Howev- havioral interventions, long used disability prevents them from enjoy-
er, there are also unique challenges for treating depression, have be- ing life. Believing that depression is a
faced by hemodialysis patients: the gun to be more widely used for necessary comorbid disorder is an ex-
demanding schedule of treatment, di- an array of disorders. These ample of “dysfunctional thinking”
etary restrictions, and ongoing sec- three reports, all representing (70% to 80% of patients with ESRD
ondary medical complications. work done by faculty at Down- are not depressed), and the belief is
Depression is second only to hyper- state Medical Center, State Uni- amenable to the CBT technique of
tension as a comorbid condition versity of New York, in Brook- cognitive restructuring.
among ESRD patients, affecting 20% lyn, represent examples of using The limitations that ESRD disabil-
to 30%. Yet there has been little sys- cognitive-behavioral interven- ity places on people are often a com-
tematic investigation of treatment tions with medically ill pa- bination of both true physical limita-
strategies. Although the newer anti- tients—those with both psychi- tions and depressed attitude. The
depressants are generally considered atric and substance use disor- goal was to have patients attempt
to be safe for dialysis patients, both ders and with histories of vio- modified versions of the activities that
patients and physicians seem to be- lence and psychosis.—STEPHEN they used to enjoy, and a combination
lieve that unless the mood problem is M. GOLDFINGER, M.D. of cognitive restructuring and behav-
unbearable, it is better not to pre- ioral assignments was used. In a non-
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standardized protocol, 16 ESRD pa- To be discharged from the hospital tween patient and therapist. This is
tients who had major depression were facility, patients must pass through a difficult to achieve in a forensic set-
treated individually with a 15-week series of stepwise increases in hospi- ting. Patients expressed concern that
CBT intervention that focused on the tal “privileges” approved by clinical what they said might be used as “tes-
techniques of challenging distorted staff and the Forensic Committee. timony” against them in court. Fur-
thoughts and encouraging behavioral Despite good pharmacological treat- thermore, most psychiatrists in state
activation. All patients showed a sig- ment and good behavior, some pa- facilities are biologically oriented,
nificant decrease in their Beck De- tients fail to progress toward dis- with limited training in individual
pression Inventory (BDI-II) scores at charge because they lack insight into psychotherapies. Even when interest-
the conclusion of treatment. The av- their disorder, remaining confined ed in psychotherapy, psychiatrists oc-
erage BDI-II score fell from 28.9 to years longer than they would have cupied with large caseloads have little
18.5 at the end of treatment and to had they been convicted of a felony time for individual psychotherapy.
18.8 at a three-month follow-up, indi- and served jail time. Our facility Psychology and social work staff with
cating both a significant and sustained sought an intervention that might in- prior training in CBT for depression
reduction in depressive affect. (Possi- crease insight in this group and revi- and anxiety disorders may see CBT
ble scores on the BDI-II range from talize progress toward discharge. for psychosis as nothing new despite
0 to 63, with higher scores represent- In the past two decades in Great their lack of familiarity with advances
ing more depression.) Britain cognitive-behavioral therapy in techniques specific to a psychotic
ESRD patients have great need for (CBT) has been adapted to the treat- population. In a system with limited
psychiatric services and are often un- ment of psychosis by Kingdon and resources, lonely patients are so hun-
derserved. Individual treatment that Turkington and others and has been gry for individual attention that in
is conducted by consulting therapists shown to increase insight among pa- some cases a time-limited CBT treat-
“chair-side” at the hemodialysis cen- tients with psychosis. It builds on fa- ment was difficult to terminate. Pa-
ter is a novel method of psychothera- miliar CBT techniques but employs tients who improved may have been
peutic intervention that alleviates specialized interventions tailored to responding both to nonspecific sup-
many of the obstacles of traditional the psychotic patient. It departs from portive aspects of the treatment and
referral-based outpatient services. traditional conceptualizations of psy- to the CBT intervention itself.
CBT promises to be a good treatment chosis in assuming a continuum be- Results were encouraging. Despite
choice for treating depression among tween psychosis and ordinary mind, the chronicity of illness, six of eight
ESRD patients. which allows the therapist to foster a patients were judged to have benefit-
Daniel Cukor, Ph.D. therapeutic alliance by “normalizing” ed from the CBT intervention. In the
aspects of the patient’s experience. case of Mr. A, the improvement was
Dr. Cukor is assistant professor in the De-
partment of Psychiatry and Behavioral
Using a patient-centered approach, dramatic. Fifteen years ago he had
Sciences, SUNY Downstate Medical Cen- the patient and clinician identify ex- committed a double homicide while
ter, 450 Clarkson Ave., Box 1203, Brook- periences that are sources of distress in an acute psychotic state, but he had
lyn, NY 11203 (e-mail: daniel.cukor@ to the patient and identify patients’ little prospect of discharge because beliefs about these events. Then as he lacked insight into his disorder. He
“coinvestigators,” they examine “evi- believed that a cult group had cast a
dence” for and against the patient’s spell on him, which led to the mur-
CBT for Psychosis for beliefs. ders. He showed no interest in exer-
Long-Term Inpatients Eight patients, all of whom had cising off-ward privileges and thought
been hospitalized for more than ten frequently of suicide. As a result of
With a Forensic History years, were the focus of a pilot inter- the CBT intervention, Mr. A came to
In New York State individuals who vention in 2006 that employed CBT doubt his cult delusion and to ac-
commit felony assault or homicide for psychosis in individual sessions. In knowledge that mental illness may
and who are judged not guilty by rea- most cases, sessions occurred once a have played a role in the murders. He
son of insanity are typically admitted week for 45 minutes, continuing for was able to express feelings of guilt,
to a high-security inpatient facility and an average of 20 sessions. Experi- remorse, and worthlessness.
then transferred to a lower-security enced therapists trained in CBT for A clear improvement in mood en-
hospital for continued treatment and psychosis treated most of the patients, sued as these feelings were dealt with
assessment. This patient group is di- but other experienced staff were re- in therapy. Mr. A expressed an inter-
agnostically diverse, although most cruited to the effort by providing a est in exercising his pass privileges
have a diagnosis of chronic paranoid weekly seminar and peer supervision but feared he would be attacked by
schizophrenia. Some in this group focused on CBT for psychosis. other patients if he left his ward. Pa-
have not committed acts of violence in A number of obstacles to imple- tient and therapist conducted a be-
many years, and some have not been mentation were immediately appar- havioral experiment in which they
violent at all since the felony that ent. All psychotherapy requires an at- walked together around the hospital
prompted their original admission. mosphere of trust and openness be- grounds. No threat occurred on the
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walk and on subsequent walks. His Interventions for groups at cognitive stage, closing, included a general
“safety behavior” of socially isolating level 5 (exploratory learning) should clean-up of materials and return of
himself gave way to an active interest include multiple means of sensory worksheets to files. Clients were in-
in passes and off-ward activity. He is stimuli and engagement to tap the formed of the next group topic, which
currently making progress toward learner’s attention. In the Let’s Get created anticipation and motivated
discharge. Organized group, wall clocks, calen- future participation. The group end-
Michael Garrett, M.D. dars, file folders, and bulletin boards ed with the Serenity Prayer.
Mark Lerman, D.O. containing popular articles were in The 16 participants completed two
the training room. pretest and posttest outcome meas-
Dr. Garrett is vice-chairman for clinical
services and Dr. Lerman is clinical assis-
The Let’s Get Organized group was ures, at the beginning of the first
tant professor, Department of Psychiatry, designed as a ten-week module con- group session and at the end of the fi-
SUNY Downstate Medical Center, 450 sisting of two one-hour sessions per nal session. The measures were the
Clarkson Ave., Box 1203, Brooklyn, NY week to provide consistency and rep- time management knowledge scale
11203 (e-mail: michael.garrett@down etition to ensure integration and gen- and the time management behavior Dr. Lerman is also clinical di-
rector of Kingsboro Psychiatric Center in
eralization of new learning and estab- scale, which were designed specifical-
Brooklyn. lish proper habit formation. Each ly for use with this therapeutic group.
group session followed a specific six- Paired-sample t tests were used to
stage format. compare pre- and posttest scores.
In stage 1 clients used the sign-in Scores on the time management
Let’s Get Organized: An sheets in an individualized file folder knowledge scale showed significant
Intervention for Persons for their work sheets, attendance improvement after participation in
With Co-occurring Disorders sheet, and emotion sheet. In stage 2 the group intervention (t=4.06,
An intervention for individuals with appointment books were distributed df=15, p=.001). Results support the
co-occurring emotional and sub- and personalized. At each subsequent efficacy of group intervention for im-
stance use disorders was conducted in session, participants reviewed and en- proving knowledge related to time
2006 at the Starhill facility of Palladia, tered new information into their ap- management. The lack of a statistical-
a residential therapeutic drug facility pointment books, proudly sharing ly significant improvement on the
located in the Bronx, New York. The various ways of personalizing them time management behavior scale may
program, The Occupational Thera- through the use of color coding, fam- be due to type II errors with a small
py—Let’s Get Organized Life Skills, ily photographs, Post-Its, and alliga- sample and the limited number of
was sponsored by Target Needs tor clips. Habit-building experiences items on the scale.
Funding from the United Way of and resistance to using the appoint- Punctuality improved over time.
New York City to establish a Life- ment book were discussed. All participants kept their appoint-
line/Life Support Program. Interven- In stage 3 time management and ment books beyond the ten-week
tions were designed to educate par- organization activity work sheets from program. They commented on how
ticipants in time management and Precin’s Living Skills for Recovery many appointments they used to miss
daily organizational skills and trial- Workbook were used with modifica- before they began using their ap-
and-error learning strategies. tions of the activities to conform to pointment books.
Participants were individuals who Allen’s level 5. In stage 4 discussion of Few interventions address the cog-
had difficulty managing their daily the completed worksheet or activity nitive needs of this population. This
routines. Three screening tools were by clients reassured members that us- occupational therapy intervention
used to identify potentially eligible ing trial and error to correct mistakes provided practical skills needed in
participants: the Educational and was an acceptable and valuable learn- everyday living and directed the fo-
Health Survey from Substance Use ing tool. The group norm “mistakes cus of recovery to creating stable rou-
Disorder Treatment for People With are OK” promoted respect for each tines, keeping track of time and ap-
Physical and Cognitive Disabilities other’s efforts, lowered clients’ per- pointments, becoming organized,
(number 29 of the Treatment Im- formance anxiety, and encouraged and following through with responsi-
provement Protocol Series), the willingness to try out new behaviors. bilities in a supportive, novel, and ex-
Kohlman Evaluation of Living Skills, Clients were encouraged to notice ploratory atmosphere of shared
and the Allen Cognitive Level their own and others’ learning style. learning.
Screen. In stage 5 clients were given home- Suzanne White, M.A., O.T.R.
Participants were selected on the work. The homework was to use their
basis of Allen’s cognitive model level appointment books daily, and this Ms. White is clinical assistant professor in
5, whereby an individual is capable of new habit was reinforced in the resi- the Occupational Therapy Program, Col-
lege of Health Related Professions, SUNY
new learning, although he or she may dential community at large. Home- Downstate Medical Center, 450 Clarkson
have difficulty planning ahead or an- work was also stimulated by the work- Ave., Box 1203, Brooklyn, NY 11203 (e-
ticipating consequences of actions. sheets or activities. The sixth and final mail:

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