Effectiveness of Rational Emotive Behavior Therapy on Attendance and

Psychopharmacological Agents Prescription

Main Author: Carme Rovira Aler (a), Coauthors: María Isabel Fuentes Leiva (b), Jesús Almeda Ortega(c), Xavier Fernandez Bonet (d), Oriol Cunillera Puertolas (e), Silvia Edo Izquierdo (f)

a. Social Worker, MSc Research in Health Psychology, Catalan Institute of Health, PCC Sant Andreu, Barcelona, Spain

b. GP, Catalan Institute of Health, PCC Martorell, Barcelona, Spain,

c.MD, PhD, Catalan Institute of Health, Research Support Unit Costa de Ponent, Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol). PCC Cornellà. Cornellà de Llobregat, Spain.

d. GP, Catalan Institute of Health, PCC Sant Llehy, Barcelona. Spain.

e. Msc Statistics, Research Support Unit Costa de Ponent, Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol) PCC Cornellà. Cornellà de Llobregat, Spain.

f.PhD in Psychology, Universitat Autònoma de Barcelona. Cerdanyola del Vallès, Spain.

Correspondence to: Carme Rovira Aler crovira.bnc.ics@gencat.cat.

Presentation

The aim of our study is to evaluate the effectiveness of a psychosocial interven-

tion in dysthymia patients to reduce attendance to primary care, mental health

and social services and use of psychopharmacological agents. In this study,

clinical social workers have administered Rational Emotive Behavior Therapy

(REBT) in the context of a primary care center. Indeed, the care of patients with

emotional disorders is amongst the responsibilities of social health workers in

Catalonia, and while this type of intervention is common practice, the results are

rarely evaluated. Literature on clinical social work with REBT is scant; more-

over, it is mostly theoretical work where scientific evidence applies to very di-

verse populations. With the evaluation of this psychosocial intervention, our arti-

cle aims to disseminate this aspect of social health workers within primary care,

mental health and social services.

Abstract

Objective: The healthcare costs of patients with dysthymic disorders are high

due to frequent attendance and to high prescription rates of

psychopharmacological agents. The objective of this study is to evaluate the

effectiveness of Rational Emotive Behavior Therapy (REBT) administered by a

social worker (SW) in patients with dysthymia (Intervention Group, IG) in

reducing primary care attendance and prescription of psychopharmacological

agents when compared with standard care (Control Group, CG). 

Methods: Non-randomized clinical trial with a 12-month follow-up period.

Analysis was performed using logistic regression adjusted for propensity

scores.

Results: The reduction in attendance was 47.9% in the CG (n=39) and 77.5% in

the IG (n=51) (OR=3.75, p=0.021). The proportion of patients with a reduced

prescription of psychopharmacological agents was 11.4% in the CG and 47.8%

in the IG (OR=7.14, p=0.006).

Conclusions: REBT decreases the proportion of patients that need prescription

of psychopharmacological agents and frequent attendance to social and

primary care.

Clinical Trials Registry Number: IDNCT02112708

Keywords: Rational Emotive Behavior Therapy; Dysthymia; Social Work;

Propensity scores; Primary Health Care

Introduction

Over 70% of mental health problems are exclusively managed in Primary Care

(PC). The yearly prevalence of depression and anxiety in PC patients in

Catalonia is 30% in women and 14% in men [1]. Serrano-Blanco et al. (2010)

[2] showed a prevalence of 9.6% for major depressive disorder and of 3.1% for

dysthymia in Primary Care Centers (PCC) in our setting. In Mental Health

Centers of Barcelona, the prevalence of major depressive disorder and of

dysthymia is 1.3/1000 and 1.9/1000, respectively [3].

As a consequence of their emotional distress, patients with dysthymia are

typically frequent users of social and medical services and are often prescribed

psychopharmacological agents, which results in an increased risk of

chronification and high pharmacy costs [4].

The National Association of Social Workers has defined the role of the clinical

social worker in the management of dysthymic disorders [5]. For over 10 years

now, PCC have implemented psychoeducational group interventions for

patients with anxiety and depression. The measure has proven to be on the

short and long term effective in patients with mild depression at the national [6]

and international level [7, 8]. Individual treatment achieves similar results [9].

The responsibilities of the Catalan Health Institute (CHI) primary care Social

Worker (SW) include the individual management of patients with emotional

disorders referred by health professionals. Following the recommendations of

the National Institute for Health and Care Excellence [10], World Health

Organitation [11] and other authors [12, 13], SW use interventions based on

Cognitive Behavioral Therapy to provide individual psychosocial care. In

particular, they use Rational Emotive Behavior Therapy (REBT), which has

been tested by psychologists and psychiatrists in patients with different

conditions and from different settings [14, 15]. In REBT, emotions and behavior

are believed to originate in the beliefs and the interpretation of reality of the

individual. To promote more adaptive emotions and behavior, the therapist

helps the patients identify their dysfunctional beliefs and thoughts by means of

written records and psychological sessions.

Though evidence in medical literature on the subject is still scant, several

theoretical publications present an updated overview of REBT for medical social

workers [16].

In addition to its social and scientific interest, REBT as implemented by medical

social workers was introduced in Catalonia in 2000 with the main aim to provide

self-help tools for patients with mild psychiatric disorders associated to the

resolution of everyday life problems.

An observational, descriptive study was carried out in 2008 in the primary care

services of Martorell (Barcelona) with 37 patients diagnosed of depression,

anxiety and bereavement. After the REBT sessions, the average number of

visits to the PCC decreased from 11.4% (SD 11.2) to 1.3% (SD 1.7). In addition,

the use of psychopharmacological agents also diminished: sedative-hypnotics

from 53.8% to 7.7% and anxiolytic agents from 69.2% to 23.1% [17].

This study aims to evaluate the effectiveness of REBT as implemented by

medical SW in decreasing attendance to health services and the prescription of

psychopharmacological agents in patients with dysthymia after a year of follow-

up.

Methods

Design: Non randomized clinical trial. The intervention group received REBT by

the purposely trained SW and the control group the standard medical care by

their General Practitioner (GP).

Participants were patients with a diagnosis of dysthymia according to the

Diagnostic and Statistical Manual of Mental Disorders–IV (DSM-IV), recruited

from two PCC with similar sociodemographic characteristics in the Barcelona

metropolitan area. Inclusion criteria were: patients over 14 years of age with a

registered diagnosis of dysthymia by their GP in the electronic medical records

(EMR). Exclusion criteria were: cognitive impairment, illiteracy, refusal of

treatment, severe psychiatric disorder and participation in psychoeducational

groups and similar therapies.

Sample size calculation was estimated based on the least favorable comparison

between the two outcome variables, which assumed a final proportion of

sedative-hypnotic drug intake of 8% in the IG group and 37% in the CG. With a

5% significance level, 80% statistical power and a case-control ratio of 1:1 with

a predicted drop-out rate of 20%, the estimated sample size per group was 50

individuals in the CG group and 50 in the IG.

Study period from October 2009 to May 2013.

Outcome variables: frequency of use of primary care services related to the

diagnosis of dysthymia and prescription of psychopharmacological agents

(sedative-hypnotics, antidepressants and anxiolytic drugs) as registered in the

EMR during the previous 12 months.

The frequency of visits to PC was categorized as “improvement” and “no

improvement”. “Improvement” means a lesser number of visits in comparison to

the previous year, comparing baseline data with data after a 12-month follow

up. An improvement in the prescription of sedative-hypnotics, antidepressants

and anxiolytic drugs was considered when baseline prescription was higher

than after the 12-month follow up.

Other study variables: sociodemographic variables, group (IG/CG), level of

education (primary/secondary and further), living arrangements (lives on his/her

own/with other people), Beck Depression Inventory (BDI) [18] and comorbidities

at baseline. Comorbidities included chronic conditions such as: hypertension,

diabetes, dyslipidemia, asthma, chronic obstructive pulmonary disease, heart

failure, ischemic heart disease, cerebrovascular disease, cancer, thyroid

disease, liver disease, fibromyalgia and musculoskeletal disorders.

Recruitment and data collection are shown in Figure 1.

The professionals in charge of recruitment received a one hour training session

with a psychiatrist to guarantee the diagnosis and comparability between

groups.

Patients of the IG were recruited in a PCC (Sant Andreu, Barcelona) different

from the PCC where the CG patients were recruited (Martorell) to prevent

contamination bias from the possible REBT effects. In the IG, the GP

systematically referred to the SW all patients with inclusion criteria during the

study period. The GP treated the CG as usual. All patients signed the informed

consent form at baseline

The number of visits to PCC and data on prescription of psychopharmacological

agents was obtained from the EMR in both groups. Other information was

obtained during the interviews at baseline and after 4 and 12 months. The data

collection forms and the database were anonymized to guarantee

confidentiality; a list that could link the cases with the real names was securely

kept.

The SW carried out the individual psychosocial intervention, with a maximum of

8 fortnightly sessions of 30 minutes. Each session aimed at identifying and

analyzing the dysfunctional thoughts of the patients in order to suggest healthier

alternatives. The information about intervention was assessed at baseline and

during de last visit by the SW.

Analysis: The study data were entered systematically in a Microsoft Access

database to facilitate the correction of discrepancies in data entry. Categorical

variables distributions are described by absolute and relative frequencies.

Continuous variables are described by their means and standard deviations.

Baseline data from participants in the IG and CG were compared using a chi-

square test (proportions of categorical variables) and the t-test (mean of

continuous variables).

To compensate baseline differences between the CG and the IG caused by the

non-randomization of participants, we used propensity scores (PS) [19]. PS

were validated by PS-adjusted baseline characteristics balance -by linear and

logistic regression models-, discrimination ability between treatment groups -

using Receiver Operating Characteristic (ROC) curves, and area under the

ROC-, and appropriate distribution for the PS (histogram).

Two logistic regression analyses with adjustment for the PS (introduced as

continuous variables or by quintiles) were carried out to evaluate the effect of

the intervention in the improvement of attendance and of prescription of

psychopharmacological agents. All analyses were carried out by intention-to-

treat and per-protocol (results of the per-protocol analyses are only shown as

supplementary material). For the per-protocol analysis, the intervention was

considered finished when after a minimum of 3 sessions the SW perceived

clinical improvement, confirmed by a decrease in the score of the BDI post-

intervention or by the patient him or herself acknowledging improvement.

All statistical analyses were performed using the statistical package R

(Foundation for Statistical Computing, Vienna, Austria).

All graphics were perfomed using the MS Office Visio.

Ethics: This study was approved by the Ethics Committee of the Primary Care

University Research Institute (IDIAP) Jordi Gol (Protocol Number: 13/035).

Clinical Trials Registry number IDNCT02112708.

Results

A total of 79 and 50 patients were included in the IG and CG, respectively. Of

those, 16 in the IG and 11 in the CG did not attend their first visit. In addition, in

the intervention group 12 patients were found to meet exclusion criteria; there

were no exclusions in the CG (Figure 1).

The average number of REBT sessions in the IG was 5.2 (SD 2.25); 9 patients

(17.7%) attended fewer than 3 sessions. A total of 77 patients completed the

study, 39 in the IG and 38 in the CG.

Of the total participants, 92.2% were women, with a mean age at the start of the

study of 62.9 years (SD 12.4). With regard to education, 60% had attended

primary school and 34.4% secondary schooling and further education; 21.6% of

participants lived on their own and 88.9% used some psychopharmacological

agents. The average number of visits to primary care services was 3.2 (SD 2.9),

mean prescription of psychopharmacological agents was 1.5 (SD 0.8) during

the previous year, and average number of chronic diseases 3.5 (SD 1.8) at the

start of the study.

Table 1 compares the baseline characteristics by intention-to-treat between the

CG and the IG with PS adjustment. Before adjusting for PS, educational level

and frequency of yearly visits to the GP were significantly higher in the IG,

whereas baseline comorbidity was significantly higher in the CG.

Table 1. Comparative analysis of baseline characteristics by treatment group,

raw and adjusted by Propensity Score (Intention-to-treat analysis)

Control Group

Intervention Group p

Intervention Group adj.

Control Group adj. Adj. P

n % n % % %Male 5 12.8 2 3.9 4.3 4.6Female 34 87.2 49 96.1 95.7 95.4Primary Schooling 32 82.0 27 52.9 75.9 71.0Secondary schooling and University

7 17.9 24 47.1 24.1 29.0

Lives on his/her own 5 13.5 14 27.4 18.2 18.4Lives with other people 32 86.5 37 72.5 81.8 81.6no treatment 4 10.3 6 11.7 12.5 9.1Treatment 35 89.7 45 88.2 87.5 90.9no 28 71.8 44 86.2 83.4 82.8yes 11 28.2 7 13.7 16.6 17.2no 7 17.9 8 15.7 18.7 15.1yes 32 82.0 43 84.3 81.3 84.9no 17 43.6 28 54.9 53.1 47.4yes 22 56.4 23 45.1 46.9 52.6

Mean SD Mean SD p Adj.mean Adj.mean Adj. P

65.5 13.2 60.8 11.5 0.085 64.9 61.3 0.2642.2 2.7 4.0 2.9 0.002 2.9 3.4 0.5461.7 0.9 1.4 0.8 0.192 1.5 1.6 0.64822.2 11.7 24.5 9.9 0.310 23.0 23.8 0.7674.3 2.1 2.9 1.2 <0.001 3.6 3.4 0.607

SD:Standard DeviationAdj: Adjusted

Beck Depression Inventory Score at baselineNumber of Comorbidities

Anxiolytic0.395 0.667

AgeNumber of visits to GP during previous yearNumber of psycopharmacological agents at baseline

0.9520.151Sedative-Hypnotics

Antidepressants1.000 0.706

0.9840.191Living arrangements

0.6521.000Psycopharmacological agents baseline

0.244 0.941Gender

Educational Level 0.008 0,674

To obtain the PS we calculated a logistic regression model to predict the

allocation to treatment group (Table A.1 in the supplementary material). The

resulting PS are adequate to control for imbalances in baseline characteristics,

as shown in Table 1, with a correct discrimination between treatment groups

(AUC: 0.823; 95%CI: [0.737, 0.909]; Figure A.1 in the supplementary material),

a plausible overlap between both groups (Figure A.2 and Table A.2 in the

supplementary material), and a representation of both groups in all the PS

quintiles.

After adjustment for PS and taking into account the whole sample, a decrease

of attendance was observed in 55 (65.3%) patients and a reduction in

prescription of psychopharmacological agents in 25 (31.1%) patients.

Table 2 shows the results of the regression model adjusted for PS, entered in

the model as a continuous variable, both for reduction in attendance and for

prescription of psychopharmacological agents; the improvement in relation to

attendance and prescription of psychopharmacological agents is higher in the

IG (OR = 3.75, 95%CI 1.23-11.83, p = 0.021; and OR = 7.14, 95%CI 1.91-

33.46, p = 0.006, respectively).

Table 2. Results of logistic regression models adjusted by Propensity Score

(introduced as a continuous variable) evaluating the effect of the intervention

(intention-to-treat analysis) on improvement of frequent attendance and

prescription of psycopharmacological agents

OR P value OR P valueIntervention Group 3.75 (1.23, 11.83) 0.021 7.14 (1.91, 33.46) 0.006

Propensity score 2.13 (1.18, 3.99) 0.014 0.99 (0.52, 1.86) 0.982

Intercept 0.92 (0.42, 2.01) 0.832 0.13 (0.04, 0.35) 0.000

Improvement frequent attendanceImprovement prescription of

psychopharmacologycal agents

This model shows that the expected proportion of patients with a decrease in

attendance adjusted for PS was 47.9% in the CG and 77.5% in the IG, and the

decrease in prescription of psychopharmacological agents was 11.4% and

47.8%, respectively.

Similar results were obtained by adjusting the model with the introduction of the

PS by quintiles (Table A.3 in the supplementary material).

Finally, the supplementary material includes the results of the same analyses

carried out per-protocol: baseline comparison of CG and IG (Table A.4 in the

supplementary material), logistic regression with continuous PS (Table A.5 in

the supplementary material), and logistic regression with PS by quintiles (Table

A.6 in the supplementary material).

Discussion

The results of this study indicate that REBT carried out by clinical Social Worker

is effective in the treatment of dysthymia, as reflected in the decreased use of

psychopharmacological agents and consequently, the expected decreased

derivation to social services and mental health care services.

Based on the adjusted results, standard medical care and standard prescription

of psychopharmacological agents decrease number of visits in 47.9% of

patients. With REBT, another 29% is added to this percentage. The reported

percentage of patients that reduces the prescription of sedative-hypnotics,

antidepressants and anxiolytic drugs with standard medical care and

prescription is 11.4%. With REBT, this proportion increases four-fold. In

conclusion, this study shows a significant decrease in the number of visits and

in the prescription of psychopharmacological agents after a year of the REBT

intervention, both in the intention-to-treat and the per-protocol analyses.

While numerous studies have previously used prescription of

psychopharmacological agents and frequency of visits as outcome measures in

cost-effectiveness studies of different psychological interventions, [20, 21], no

studies have been published to date on the effectiveness of REBT in relation to

these indicators in patients with dysthymia. The results of this study show that

these indicators are adequate to evaluate the efficacy of REBT in patients with

dysthymia.

Most studies that evaluate the effectiveness of REBT use improvement in the

BDI as outcome measure. These studies show a higher effectiveness of REBT

when compared with standard medical care and prescription in patients with

depression [22-25]. The results of our study on the use of health resources

complement this evidence of the improvement with REBT as perceived by

patients with a diagnosis of dysthymia. Indeed, the results of this intervention

are similar to those published in a previous study in patients with anxiety and

depression that did not have a control group [17].

The aim of our intervention is to empower the patient so that they achieve a

greater autonomy to solve everyday conflicts within the health-disease process.

Indeed, whereas psychopharmacological agents might provide short-term

benefits, REBT is expected to have a medium-long term effect. We have not

found other studies that compare the effectiveness of REBT with standard

medical care and prescription of psychopharmacological agents after a year of

follow up.

Most clinical social work investigations face the challenge to conduct

randomized clinical trials [26]. While randomized trials are ideal designs to infer

causality, often this type of design is unsuited for the social sciences.

Propensity scores are now a commonly used statistical technique. The

adjustment of baseline differences between groups has allowed to eliminate

bias in the estimation of the potential effects of the intervention [19]. However,

this methodology does not allow to adjust for possible differences between

groups according to other variables not studied. Some of these variables have

not been taken into account in our study, for instance the expectations of

patients in relation to therapy and the doctor-patient relationship, which is

known to reduce attendance [27] and psychopharmacological prescription.

These factors must be taken into account in future research to optimize the

balance between groups.

Conclusion

This study shows that the SW can assume the implementation of REBT in

primary care obtaining integrated approach between primary care, social and

mental health services. REBT translates into a great improvement in the

healthcare of the patient with dysthymia, which is usually on chronic medication

and not usually prioritized by mental health specialists. Additionally, REBT

would also increase the efficiency of PCC. Following the initiative of several

universities in the USA, [28] we suggest for REBT to be included in the training

program of SW so that they are prepared to deliver REBT when required by

their colleagues in Social services an Primary Care.

Taking into account a broader, biopsychosocial perspective on health, further

studies on the effectiveness of REBT to improve quality of life and mood states

are needed. Also, patient perception of REBT should be evaluated and the

qualitative and quantitative results compared by means of methodological

triangulation [29]. Finally, cost-effectiveness of REBT in the medium and long

term in PC must be determined.

Acknowledgement

The study was financed by the Catalan Institute of Health, Research Grants XB

of the Barcelona Research Support Unit, 2008 Call for Proposals.

The fieldwork was carried out in the context of the everyday activities of the pri-

mary care centers from October 2009 to May 2013. This study was partially pre-

sented in the Research Workshop XB of the Catalan Institute of Health, March

2014; in the VIII Meeting of Mental Health and Primary Care of the Catalan So-

ciety of Family and Community Medicine (CAMFIC), May 2014; in the 1 Innova-

tion Day of the Catalan Institute of Health, March 2015; in the 35th Meeting of

the Spanish Society of Family and Community Medicine (SEMFYC) in Gijón,

Asturias, June 2015, in the 10th Meeting IDIAP Jordi Gol in Barcelona, April

2016 and the 16th International Conference on Integrated Care in Barcelona,

May 2016.

Ethical approval: This study was approved by the Ethics Committee of the Pri-

mary Care University Research Institute (IDIAP) Jordi Gol (Protocol Number:

13/035). All procedures were in accordance with the ethical standards of the

1964 Helsinki declaration and its later amendments.  Clinical Trials Registry

number IDNCT02112708.

Informed Consent: Informed consent was obtained from all individual

participants included in the study.

Conflict of Interest: The authors declare that they have no conflict of interest.

All authors have taken part in drafting the manuscript and in the design, devel -

opment and final writing of the study.

We thank the management of the primary care centers for their active support.

Also, we thank the Research Support Unit of the Primary Care Management

Costa de Ponent of the Catalan Institute of Health for the methodological and

statistical support. Finally, we are grateful to the Primary Care Research Insti-

tute-IDIAP Jordi Gol for the translation of the manuscript into English.

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