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CHAPTER TWO - LITERATURE REVIEW
2.1 Introduction
The purpose of this literature review is to examine whether or not primary care
general practitioners (GPs) have the information available to them to make a referral
to a counsellor and or psychotherapist, in relation to a client presenting with a mood
disorder or an anxiety disorder. The information will be assessed to see if there is
sufficient evidence for the efficacy of psychotherapeutic, counselling and
psychological interventions, to make a competent and informed decision to refer a
patient for one of the above interventions. It is also important to see if there is
sufficient knowledge available about the different forms of therapy and their
appropriateness for certain diagnoses.
Firstly it is necessary to explain what is meant by mood disorders and anxiety
disorders. For accepted criteria, diagnosis and clinical definitions one needs to refer to
the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV)
(American Psychiatric Association 2000) or the International Statistical Classification
of Diseases and related Health Problems (ICD-10) (World Health Organisation 2007).
2.2 What are Mood Disorders?
The DSM-IV (American Psychiatric Association 2000) simply defines mood
disorders as disorders that have a disturbance in mood as their predominant feature.
They are divided into three groups: Depressive Disorders; Bipolar Disorders and
Mood Disorders based on etiology (Mood Disorder due to General Medical Condition
and Substance-Induced Mood Disorder). Qualification for each group, and consequent
diagnosis, depends on the presence or absence of certain episodes: Major Depressive
Episode; Manic Episode; Mixed Episode and Hypomanic Episode. The DSM-IV
provides clear definitions and criteria for each of these episodes and subsequent
definitions and criteria for the related Mood Disorder diagnosis.
The list and characterisations of the Mood Disorders, as provided by the DSM-IV,
are:
Major Depression: One or more Major Depressive Episodes (at least 2 weeks of
depressed mood or loss of interest accompanied by at least 4 symptoms of
depression).
Dysthymic Disorder: At least 2 years of depressed mood for more days than not,
accompanied by additional depressive symptoms that do not meet the criteria for a
Major Depressive Episode.
Depressive Disorder Not Otherwise Specified: Disorders with depressive features that
do not meet criteria for other Disorders or depressive symptoms that have inadequate
or contrary information.
Bipolar I Disorder: One or more Manic or Mixed Episodes, usually accompanied by
Major Depressive Episodes.
Bipolar II Disorder: One or more Major depressive Episodes accompanied by at least
1 Hypomanic Episode.
Cyclothymic Disorder: at least 2 years of numerous periods of Hypomanic symptoms
that do not meet criteria for a manic episode and numerous periods of depressive
symptoms that do not meet criteria for a Major Depressive Episode.
Bipolar Disorder Not Otherwise Specified: Bipolar features that do not meet the
criteria for any of the specific Bipolar Disorders or bipolar symptoms that have
inadequate or contrary information.
Mood Disorder due to General Medical Condition: A prominent and persistent
disturbance in mood that is judged to be a direct physiological consequence of a
general medical condition.
Substance-Induced Mood Disorder: A prominent and persistent disturbance in mood
that is judged to be a direct physiological consequence of a drug of abuse, a
medication, another somatic treatment for depression, or toxin exposure.
Mood Disorder Not Otherwise Specified: Mood symptoms that do not meet the
criteria for any specific Mood Disorder and are hard to choose between Depressive
Disorder Not Otherwise Specified and Bipolar Disorder Not Otherwise Specified
(American Psychiatric Association 2000).
The International Classification for Diseases (ICD-10) gives similar definitions for the
different types of mood disorders. It also takes into account the severity of the
disorder and gives definitions for them. The divisions are mild, moderate, severe and
severe with psychotic symptoms (World Health Organisation 2007).
2.3 What are Anxiety Disorders?
Anxiety Disorders have a separate listing in the DSM-IV. We all suffer from anxiety
from time to time. However anxiety leads to a specific Anxiety Disorder diagnosis
when it reaches a level that may be persistent, result in panic attacks, or cause
impairment to normal everyday functioning. Panic Attacks and Agoraphobia are
symptoms of some of the Anxiety Disorders. The Disorders include: Panic Disorder;
Agoraphobia; Specific Phobia; Social Phobia; Obsessive-Compulsive Disorder;
Posttraumatic Stress Disorder; Acute Stress Disorder; Generalised Anxiety Disorder;
Anxiety Disorder due to a General Medical Condition; Substance-Induced Anxiety
Disorder and Anxiety Disorder Not Otherwise Specified (American Psychiatric
Association 2000). The ICD-10 (WHO 2007) offers similar definitions for the anxiety
disorders.
Once a GP has determined that a patient has depression or a specific anxiety disorder
they need to gauge the severity of the disorder and find an appropriate way to treat it.
In his book “Beyond Prozac”, Dr. Terry Lynch (2005) purported that there is a bias
among GPs to prescribe medication in reaction to Mental Health issues. This is due to
the focus on a diagnosis and a quick fix solution in the form of an anti-depressant, as
opposed to spending time with the patient listening and focusing on what the patient
wants. He also cites the influence of the Pharmaceutical companies in marketing their
products directly to GPs. He makes the analogy that “if you only have a hammer then
everything becomes a nail”. He is implying that most GPs only use prescribed
medication to deal with their patient’s distress and therefore they see clinical
diagnosis where there is just the usual normal life events that throw people out every
now and again (Lynch, T. 2005). The question is: is there any basis in the available
literature to substantiate Lynch’s point of view?
In Ireland the Health Services Executive (HSE) in conjunction with the Irish College
of General Practitioners (ICGP) issue guidelines to GPs on dealing with Mental
Health issues. The UK counterpart is the National Institute for Clinical Excellence
(NICE). The Mental Health in Primary Care project (Copty, M. 2003) stated that until
this project most of our data in use in Ireland was taken from the UK. A lot of
clinicians still refer to NICE for guidelines on medical and mental health issues.
2.4 Recommendations for Treatment in the UK
NICE provide very comprehensive and detailed documents on the provision of Mental
Health care. Depression is covered by a 358 page document called the Management of
depression in primary and secondary care (National Collaborating Centre for Mental
Health NCCM 2004). Anxiety guidelines are set out in Clinical Guidelines and
Evidence Review for Panic Disorder and Generalised Anxiety Disorder (Chilvers, C.,
Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B., et al. 2001), a 165 page
document.
The Depression guideline establishes, that out of 130 people per 1000 that have
depression, 80 will present to their GPs or hospitals for treatment (Meltzer et. al. 2000
cited in NCCM 2004). Out of this 80 who present it is shown that only 31 will be
recognised by their doctor as being depressed (Kisely et. al. 1995 cited in NCCM
2004). Out of the 31, most will be treated by the doctor at primary care level, with
only 1 out of every 4 or 5 being referred on to secondary mental health services.
Therefore out of 130 depressed people, representing 13% of the population, only 6-8
or 0.6%-0.8% will end up referred on to specific mental health services. There are
various reasons given for the low detection rates, such as presenting with physical
symptoms that are not detected as psychosomatic, inability on behalf of the patient to
disclose emotional issues to their doctor or a deficit in communication and listening
skills on behalf of the doctors (NCCM 2004). The low rate of people, with depression,
entering specialised mental health services is an area of concern.
There are recommendations set out for dealing with depression in primary care.
Patients should be screened for depression and other mental health problems. Patients
with mild depression or those who do not want a pharmaceutical intervention should
be observed and have a follow up appointment 2 weeks later. Anti-depressants should
not be prescribed for mild depression, as side effects outweigh the benefits. Patients
should be directed to self-help programs based on Cognitive Behaviour Therapy
(CBT). For mild and moderate depression a referral to a psychological therapy
focused on depression (such as CBT or Problem Solving Therapy) should be
considered for 6-8 sessions. If an anti-depressant is prescribed it should be a selective
serotonin reuptake inhibitor (SSRI). The patient should be informed about side effects
and withdrawal from the prescribed drug. For severe depression a combination of
anti-depressants and CBT should be considered. A combination of two or more recent
major depressive episodes and functional impairment should be treated with a two
year course of anti-depressants. CBT should be used for reoccurring depression
(NCCM 2004). It is notable that in this recommendation part of the guideline there is
no mention of any other psychological intervention other than CBT or Problem
solving Therapy.
Following the recommendations the report gives guidelines for recognising different
forms of depression and further recommendations on treatment. It also introduces the
notion of a stepped approach to treatment. There is a large emphasis on CBT and
SSRI treatment. However, there is a brief mention of considering longer forms of
psychological therapy for complex comorbidities with anxiety disorders or personality
disorders. Psychodynamic therapy is recommended here (NCCM 2004).
It is seen that at a primary care level the tools available to a GP are anti-depressants
and communication. There is no mention that some GPs have postgraduate training in
psychological therapies. So what are the secondary mental health options available to
a GP? The next section, of the NCCM guidelines, gives a definition for different
interventions and evidence for the efficacy of such treatments. These are guided Selfhelp books based on a CBT model; Computerised CBT; Exercise; Organisational care
such as telephone support and nurse led care support; Non-Government voluntary
organisations; Crisis Intervention and Home Treatment Teams; Day Hospitals;
Electroconvulsive therapy; Inpatient Psychiatric care and Psychological Therapy
Interventions (NCCM 2004). The area of interest here for the purpose of this study is
the Psychological Therapy Interventions section.
The NCCM state that they have been conservative in their presentation of the various
therapies on offer. This is due to a real lack of Randomised Control Trails (RCTs) to
assess efficacy. The trials that they did find were inconclusive due to unclear
definitions; definition of therapist competence and, in some cases, use of other
treatments in conjunction with the therapies provided. It is hard to establish, what
effect the therapeutic relationship has on the treatment, and indeed because of the
length of time involved, it is hard to determine whether or not the depression had
actually ran its natural course (NCCM 2004).
The therapies the NCCM choose to review are: CBT; behavioural therapy;
interpersonal therapy; problem solving therapy; non-directive counselling; short-term
psychodynamic therapy and couple-focused therapies. According to Boyne (2003) the
main therapies available in Ireland are: psychoanalysis; child psychoanalytic
psychotherapy; Jungian analysis; psychosynthesis and transpersonal therapy;
constructivist psychotherapy; family therapy; CBT; Gestalt therapy; person centered
therapy and an integrative approach in psychotherapy. From the comparison of the
two mentioned references there is a difference between what is considered by the
NCCM and what is on offer in Ireland.
To examine the efficacy of psychotherapy as proposed by NCCM we will look at the
types of therapy common to both lists, namely CBT; psychoanalysis and non-directive
counselling (by NCCM’s definition this equates to person centered therapy).
In order to judge the efficacy of CBT, NCCM identified 30 acceptable trials to form
their opinion. Their conclusions were as follows. There is insufficient evidence to
suggest the effectiveness of individual CBT in comparison to placebo (plus clinical
management) or to other psychotherapies. However it can be established that CBT is
as effective as anti-depressant treatment in reducing depressive symptoms across the
spectrum of depression severity. Tolerability is higher to CBT than to antidepressants. Adding a course of CBT to anti-depressant treatment is more effective
than treating with anti-depressants alone. There is evidence that group CBT is more
effective than other group therapies (NCCM 2004).
For non-directive counselling NCCM downloaded 1027 references for counselling
efficacy. Only 3 studies satisfied their criteria for RCTs. NCCM concluded that there
is evidence for efficacy in comparison to anti-depressants, GP care and other
psychological interventions in mild and moderate depression. There is no evidence for
efficacy for chronic depression. There is no evidence for tolerability (NCCM 2004).
The Chilvers, C., Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B., et al.
(2001) study would concur with this, but it also highlights the need for the patient to
be involved in the decision on what course of treatment they pursue. The Ward, E.,
King, M., Lloyd, M., Bowen, P., Sibbald, B., Farrelly, S., et al. (2000) study had
similar findings.
There was no existing review available for psychoanalysis. The NCCM analysis
consisted of 4 trials (out of 188) that matched their criteria. They point out that, even
though it is one of the longest established forms of therapy, good trials are a rare find.
After treatment it is clear but not definite that CBT combined with anti-depressant
treatment is more effective than psychodynamic therapy, but this potential for more
effectiveness, is not maintained when the study is followed up later. Psychodynamic
(psychoanalytic) psychotherapy may have its strength in the treatment of depression
with complex comorbidities with other mental health disorders (NCCM 2004).
In relation to Anxiety, McIntosh, A., Cohen, A., Turnbull, N., Esmonde, L., Dennis,
P., Eatock, J., Feetam, C., Hague, J., Hughes, I., Kelly, J., Kosky, N., Lear, G.,
Owens, L., Ratcliffe, J., Salkovskis, P. (2004) outline that a combination of antidepressants, psychological therapy and self help should be used in treatment in
primary care. CBT is the only form of therapy mentioned in these guidelines.
Research was readily available for the interventions and by compiling the studies the
general conclusion is that there is no significant difference in the various treatments
and the combinations of various treatments for treating panic disorders. It is up to the
GP to assess along with the patient what will work for the individual client.
In both of these UK guidelines there is an emphasis on costs (Bower, P., Byford, S.,
Sibbald, B., et al 2000). It seems that the orientation and preference towards
medication and short forms of therapy may also be due to the substantial cost of long
term therapy. This would have consequences for NHS budgets when dealing with
public patients.
2.5 Recommendations for treatment in Ireland
Mimi Copty, from the Irish College of General Practitioners, is the main contributor
to the Irish Health Services Executive (HSE) guidelines on mental health. These
guidelines are based around a report that Copty completed in 2003 (Copty, M. 2003).
In this report patients and primary carers were involved. It was both quantitative and
qualitative including responses from GPs, Mental Health providers and Service users.
It was limited qualitatively (focus groups) in the number of GPs who participated and
notably there were none from a rural practice. There was also a low representation
from consultant Psychiatrists (1 in total). In its recommendations to the former South
Western Area Health Board (SWAHB) it concluded that mental health training is
lacking among GPs even though 95% of mental illness is being dealt with in primary
care. Training needs and deficits need to be identified and appropriate training should
be provided for GPs. Protocols must be developed for detection, assessment,
treatment, referral and interface between primary and secondary care, discharge, and
communication with the patient.
There also needs to be more collaboration between GPs and Mental Health Service
Providers. This can be helped by employing counsellors, psychologists and
community psychiatric nurses in the general practice. Mental health providers can
relocate to a primary care setting thus facilitating the communication between
psychiatric staff and GPs. If there is a regular interface between GPs and Psychiatrists
there could be case discussion before referral. Link workers, such as community
psychiatric nurses could provide a link from psychiatry to general practice in order to
facilitate communication and training needs (Copty 2003). This is calling for a
multidisciplinary approach to Mental Health care in the community. There is a lack of
knowledge among GPs of the psychological services available. The onus is on allied
mental health providers to make themselves known to GPs. It was also found that
there was a lack of knowledge concerning various psychological service providers,
GPs and the public did not understand the difference between different psychological
approaches. It is up to these service providers to educate the public and GPs about
licensing and accreditation and the various therapeutic approaches. Media such as
leaflets, tapes and posters on Mental Health should be available in GP practices
(Copty 2003). There is no specific mention of psychotherapy in this report.
The “Guidelines for the Management of Depression and Anxiety Disorders in primary
care” (HSE 2006) provide guidelines for screening, assessment, diagnosis and
management of depression and anxiety in primary care. It specifically states it is of
interest to GPs, pharmacists, psychiatric nurses, psychiatrists, clinical psychologists,
service users and all other people caring for depression and anxiety (again counselling
and psychotherapy are not mentioned by name).
For both depression and anxiety the format is the same. High risk groups are
identified. A brief psychiatric assessment guideline is provided for GPs. GPs are
asked to consider using one of the widely available psychological instruments to
assess depression. There is also a brief summary of the diagnostic criteria as set out in
the DSM-IV for diagnosis purposes. The two forms of treatment prescribed are
pharmacological
treatment
and
Psychological
treatment.
There
are
no
recommendations made in relation to providing both.
The Psychological section is brief and a little unclear. It does provide a distinction
between counselling and psychotherapy but also states that the two overlap. In this
section it addresses the lack of primary care psychological services provided by the
HSE. However there is a commitment to their development. It is significant that it is
believed that this service will be provided by counselling psychologists rather than by
any other discipline. Users of the guidelines are also provided with accreditation
information. It states that patients with mild to moderate mental health problems
should be referred to primary therapy services. More severe cases should be referred
to secondary and tertiary services. These are not clearly defined but it assumed Copty
means Psychiatric Institutions. The shortcomings of this document are offset by the
“Guidance document for the provision of counselling in a primary care setting” (HSE
2006).
This guideline document gives definitions of counselling and a brief summary of
different approaches. However it does not provide a clear distinction between
counselling and psychotherapy. It states that the preferred method of counselling is
CBT. The document briefly distinguishes between a counsellor/therapist, a clinical
psychologist, a counselling psychologist and an addiction counsellor, but again one
would be none the wiser as to what a counsellor/therapist is after reading it. It does
however
state
that
only
accredited
counsellors/psychotherapists
and
clinical/counselling psychologists would be qualified to provide counselling in
primary care. Only in the section entitled “Access to Counselling” do we get an
insight into the differences between counselling and psychotherapy. Mild stress
related problems, struggling with life events and losses are appropriate for primary
care. For severe and complex mental disorders or personality disorders “generic
counselling” is not recommended. Patients with trauma, unsuccessful treatment,
complex social problems, severe depression, severe anxiety or comorbidity should be
referred from a primary care counselling setting to a community mental health team
or psychotherapy service.
2.6 Limitations of this literature review
The specific limitation to this study is that the literature, although extensive, is not
abundant. This highlights the need for more research to be done into the efficacy of
counselling and psychotherapy.
2.7 Conclusion
Was Dr. Terry Lynch right when he talked about the over-prescription of medications
and the influences of the drug companies? There is no indication in this review that
GPs unnecessarily prescribe medication for mood disorders or anxiety disorders.
There is a warning in the NCCM guidelines that anti-depressant medication should
not be prescribed for mild depression as the side-effects offset any benefit (NCCM
2004). However it is indicated that more people with depression remain undiagnosed
by the primary care system than are diagnosed. This does not lend itself to the
argument that anti-depressants are over-prescribed. There does not seem to be enough
available information for GPs to make a clear informed decision when it comes to
referring to a counselling or psychotherapy service, GPs are unaware of the difference
in theoretic approaches and what such services can provide for their patients (Copty
2003). In the case of evidence of the efficacy of psychological interventions there is
clearly not enough research done. There is however clear evidence for the efficacy of
CBT. However GPs may not be aware that counsellors and psychotherapists in their
area have had training in CBT and specific therapists who exclusively practice CBT
are rare in Ireland. In the absence of such information it is no wonder that GPs rely on
treatment that they know there is evidence for, and that they have access to, namely
anti-depressants.
Copty (2003) makes a very valid recommendation. It is up to psychological service
providers to inform and educate GPs and the general public about the services they
provide. Until there is movement and interaction from these parties, primary care
provision for mental health could remain stagnant. It will also help if the profession of
Counselling and Psychotherapy were regulated by the Government. This would give it
the validity it needs to inspire confidence in the GPs to refer to the services.