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Published on the 28^th May 2007 in the IRISH MEDICAL NEWS

THE ROLE OF PSYCHOTHERAPY IN PRIMARY CARE

By Dr. Brion P. Sweeney

There are a number of reasons why primary care is seen as a pivotal role in the delivery of care to modern populations. In a sense, it reflects the development of medicine beyond the paradigm of diagnosis and treatment to one of risk identification and management. This is very good news as it has the potential for prevention of illness and for prevention of progression of illness, if managed properly. For example, proper management of blood pressure or indeed diabetes can ameliorate the risk of these conditions down the line. In the area of mental health too, there are huge opportunities for primary care in identifying and managing risk. Primary Care is well placed to deliver early intervention and thereby prevent more severe and chronic illness later on.

General practitioners are being resourced, both in terms of diagnostic facilities and the building of multi-disciplinary teams in order to enhance the capacity to provide specialist primary care within the context of family and community[1].

EVIDENCE BASE FOR PSYCHOLOGICAL INTERVENTIONS

In a context where there is huge demand on funding and where healthcare provision has become increasingly expensive, it is very necessary to target interventions that are effective. It is reasonable that evidence therefore should drive funding and resourcing.  Under the economic pressures of the 1970s and 1980s there was a withdrawal of resources from psychotherapy provision and psychological intervention because there was an insufficient evidence base to justify such interventions.

Twenty years on, the evidence for psychotherapy and psychological interventions in general has been greatly enhanced. The flood of evidence for psychotherapeutic interventions continues to grow.

The first modality to show significant evidence has been Cognitive Behavioural Therapy.This is in part because these interventions being already standardised have lent themselves easily to measurement, and also because practitioners working in this area have been trained from an early stage to understand the need for scientific investigation of the method. Evidence has accumulated for brief interventions using other theoretical frameworks for example Motivational Interviewing based on Client-Centred Psychotherapy (Humanistic/Rogerian) and perfected by William Miller and collaborators (Miller,W et al[2]).

In a recent review of the literature on psychotherapy Professor Alan Carr, of UCD (Professor Alan Carr: “The Effects of Psychotherapy: A Review of Research) on behalf of the Irish Council for Psychotherapy in press), has shown other methods, including Systemic and Family Psychotherapy, Constructivist Psychotherapy and Psychoanalytic Psychotherapy to be effective in a broad range of mental health disorders. There is also evidence emerging that slightly longer interventions, of perhaps six months to one year, can bring benefit to the more complex problems. For example, Psychoanalytic Psychotherapy has been shown to be effective with more disturbed patients who would normally attract a diagnosis of personality/developmental disorder[3].

In a primary care context, perhaps there are certain conditions which are particularly important to highlight where evidence based psychotherapy interventions can be of assistance to general practitioners in their care of patients. In particular, of course, we must start with the mention of Cognitive Behavioural Therapy for affective and phobic disorders and more recently, increasing evidence of their effectiveness in intervention with substance misuse disorders (Carroll and Onken[4]).

A recent study in the North East of the provision of counselling/psychotherapy services within a primary care context has been very encouraging. Fiona Ward[5] s review of counselling and psychotherapy provision within the primary care units in the North East has shown that they have been highly successful and that psychological provision and psychotherapy services can be provided in a primary care context in Ireland and contribute significantly to the overall care delivered through the primary care services. Evaluation of the pilot project concluded that the pilot project had been effective in providing an accessible, high quality, accountable counselling/therapy service in line with the primary care strategy.”

Often in primary care, the question of prescribing medication arises, in particular, prescribing of benzodiazepines. It is understandable that GPs have become increasingly reluctant to prescribe benzodiazepines because of the abuse potential and because of the fact that many patients can become dependent on these substances.Yet, with patients who present with phobic disorders or anxiety or panic disorders, often GPs have little alternative but to prescribe. The provision of psychotherapy services gives a real alternative route of referral. It is shown in the pilot study in the North East, that GPs will use these referral pathways and that patients would benefit, thereby avoiding prescribing of benzodiazepines and the longer term dependence, which those who suffer from anxiety disorders can so easily develop.

It is also clear from Government strategy review on Suicide[6] that the vast majority of those who kill themselves never have any contact with mental health services and are most likely to have visited their GP in the month prior to the suicide. It is a truism, and well understood at this point, that young males are at seven times higher risk of suicide than females.

It is also clear that these young men are quite unwilling to access the necessary support. It makes sense, therefore, that outreach to such vulnerable young men, and indeed women, is more likely to be effective if provided in a user friendly primary care context. Primary care is particularly well placed to provide such intervention, as patients are most likely to approach their General Practitioner in the first instance with such difficulties. Having on tap a well trained psychotherapist whom the GP can confidently refer such complex cases makes sense. These types of interventions are envisaged in  A Vision for Change the expert report on Mental Health Services 2006[7].

Primary care is therefore ideally placed for the early intervention and management of risk factors and the treatment, at an early stage, of disorders that can lead to chronic mental health problems longer term. In particular, the provision of early intervention for phobic disorders can prevent these disorders from becoming chronic. Such examples are obvious. Patients, who present with an early agoraphobic pattern can, with vigorous treatment at an early stage, pre-empt a long term chronic phobic avoidance pattern which may have arisen in the context of a recent trauma or relationship difficulty. Such early intervention can nip in the bud the chronic pattern of inadequate coping,

Such interventions may be highly significant in those who may be contemplating suicide. Prof.Apleby in a psychological autopsy of 100 persons who killed themselves in Manchester concluded that acute on top of chronic relationship problems were co-factors in completed suicides[8].

In conclusion with the increasingly important role that primary care is playing in the provision of health care within our society, then primary care needs to be resourced to play this key role. Such resourcing would ideally include the appointment of a well trained professional psychotherapist as a member of each primary group care team. The argument for a psychotherapist in this context is that they can work with a range of complex disorders which are increasingly faced by General Practitioners. This may be everything from anxiety disorders to substance misuse, depression, or indeed, more severe mental health problems such as schizophrenia and bi polar depression.

If we are going to really see primary care as the backbone of healthcare delivery, then we need to resource primary care to deliver comprehensive services at a community level. This will only happen when we have the range of specialist skills that are required to handle the range of problems that present in general practice. Many surveys have shown that up to 40% of those who consult with General Practitioners have a strong psychological component to their presentation. There have been further studies that have shown that where patients are provided with psychotherapy, their attendance at A & E departments is greatly reduced, and also their recurrent presentation in the primary care setting is decreased. At present, the HSE is planning that such psychological therapy will be provided. Professor Carr’s paper has outlined that longer term therapy may be appropriate for certain groups of patients, while brief manualised interventions may be most useful for certain disorders.

 The Irish Council for Psychotherapy (ICP[9]) is playing its part in terms of ensuring that psychotherapists are properly trained before they are entered on the Register. ICP is working with the Government to bring in statutory regulation and registration for all psychotherapists. Effectively, the psychotherapy area has become a self-regulated profession, ensuring a certain quality of standard of training and practice. This includes a four year part time post graduate level specialist training in psychotherapy; working under Ethical Codes and Guidelines. Psychotherapists are therefore well placed to be key members of primary care teams, and greatly enhance the options available to General Practitioners and their patients.

Refs on request

Dr. Brion Sweeney is Chairman of the Irish Council of Psychotherapy and a consultant psychiatrist specialising in substance abuse.

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