The development of cognitive behavioral therapy in psychiatric nurses of Hong Kong

Abstract

Cognitive-behavioral Therapy (CBT) is widely recognized as an effective treatment for depression; however, its accessibility remains a challenge. This thesis focuses on addressing the challenge, with specific emphasis on the role of psychiatric nurses in Hong Kong (HK). The objectives are to examine the professional development of psychiatric nurses in CBT training, investigate the differences in delivering group CBT (gCBT) for individuals with depression among various healthcare professionals, develop an evidence-supported manual for gCBT delivered by psychiatric nurses, and evaluate its effectiveness in improving outcomes for individuals with depression. Thirteen Chinese psychiatric nurses trained in CBT were interviewed. The overarching theme was “challenges of psychiatric nurses in CBT learning and implementation and reasons to continue learning CBT without a clear role in CBT delivery.” The main themes were challenges in learning and implementing CBT and positive CBT experience. The role of psychiatric nurses in delivering CBT in HK needs to be clearly defined. gCBT might be a potential method for psychiatric nurses to deliver CBT. However, there is no empirical evidence supporting their ability to do so. Then, a systematic review of randomized controlled trials (RCTs) was conducted to evaluate gCBT and compare it to inactive controls in adults with a clinical diagnosis of depression. A total of 33 RCTs were included for analysis. Both psychologists and nurses/psychiatric nurses demonstrated significant effectiveness in delivering gCBT, with psychologists showing a large effect size of -0.78 (95% CI, -1.25 to -0.30, p<0.01) and nurses/psychiatric nurses showing a medium effect size of -0.45 (95% CI, -0.85 to -0.05, p=0.03). The certainty of evidence for both professionals was moderate. These results have significant implications for the delivery of mental healthcare, as nurses/psychiatric nurses may be more accessible and cost-effective than psychologists in certain settings. Additionally, a culturally attuned nurse-led CBT manual was developed. The development process was thorough and rigorous, involving various stakeholders providing feedback, including cognitive-behavioral therapists, psychiatric nurses, patients who had previously participated in similar gCBT, Chinese language teacher and hospital's administrative staff. Finally, a parallel-arm, RCT was conducted in two psychiatric clinics in HK, comparing five weekly sessions of group CBT delivered by psychiatric nurses to usual care. Out of the 110 outpatients who provided consent, 56 received CBT with 100% attendance rate. After five weeks, significant reductions in depressive symptoms (PHQ-9 scores: β=-1.81, 95% CI=-3.34 to -0.29, p=0.021) and anxiety symptoms (GAD-7 scores: β=-1.39, 95% CI=-2.73 to -0.05, p=0.043) were observed. Additionally, participants reported increased subjective happiness (SHS scores: β=2.33, 95% CI=1.30 to 3.36, p<0.001) and improved psychological well-being (psychological subscale of WHOQOL-BREF: β=0.77, 95% CI=0.01 to 1.53, p=0.047). The study demonstrates the feasibility and benefits of integrating nurse-led CBT into routine psychiatric outpatient care for individuals with depression. In conclusion, this thesis illustrates that the most effective method for mobilizing psychiatric nurses to implement CBT is through a group format. With the support of an evidence-based gCBT manual, psychiatric nurses have the potential to enhance CBT accessibility at a low cost, though they require sufficient guidance and support.