Key messages
Guided self-help can be an effective way to treat the common mental health problems of anxiety and depression in the primary care setting. This is a new way to deliver cognitive behavioural therapy that seems to be valued by patients.
Offering guided self-help in primary care may be a way to offer psychological help to those whose mental health problems are not severe enough to warrant the more intensive therapy offered in secondary care services.
Why this matters to us
Although mild to moderate mental health problems are very common in general practice, only a minority are able to access psychological help when they need it. Guided self-help is potentially a way to disseminate the key skills and ideas of cognitive behavioural therapy so that sufferers can learn how to overcome their difficulties.
The role of the primary care mental health worker (PCMHW) can sometimes be unclear. In this article we hope to explain this role and how it fits into the stepped care model of mental health services
Keywords: cognitive behaviour therapy, guided self-help, psychological therapy, stepped care
Abstract
We describe a new service offering cognitive behavioural therapy in the form of guided self-help to patients experiencing mild mental health problems. The referral pathway is outlined and the various treatment options are illustrated with case descriptions of depression and panic disorder. Patients' responses to this new service are reported and discussed.
Introduction
Psychological services for people with common mental health problems are rapidly expanding. One new development is the primary care mental health worker (PCMHW) role. This term can be confusing and this article aims to explain the role of a PCMHW and to look at the service they offer from the point of view of the patients who receive it.
The Westminster Primary Care Psychology Service
Since June 2008 four PCMHWs have been working in 10 of the 51 GP surgeries across the borough of Westminster and there are plans to expand the service. The PCMHWs are trained to offer evidence-based, brief, structured psychological interventions based on cognitive behavioural therapy (CBT) principles. They are employed to treat people with mild to moderate mental health problems such as depression, anxiety, panic disorder, sleep problems and specific phobias.
The stepped care approach and guided self-help
Stepped care involves providing the most efficient, least intensive and least restrictive treatment for each individual. There are five steps within the stepped care approach1 which range from recognition of a problem in primary care (step one), seeing a mental health worker (step two), seeing a psychologist or CBT therapist (step three), receiving help from specialist services or a Community Mental Health Team (step four), to inpatient treatment (step five). The pathway is self-correcting: each patient's progress is monitored and if there is no clinically significant improvement then they can be ‘stepped-up’ at any time.
PCMHWs offer self-help interventions at step two of the stepped care pathway to people suffering from mild to moderate mental health conditions. Self-help involves the patient learning CBT techniques through written materials or information technology. These materials can simply be provided to patients (pure self-help) or they may be facilitated with support from a PCMHW (guided self-help). There is an emerging evidence base to suggest that self-help is effective, and guided self-help seems to be more effective than self-help alone.2 Types of help offered at this level include:
Bibliotherapy: The PCMHW will recommend a specific self-help book for the patient to work through in their own time.
Guided self-help: The patient works with the PCMHW at the surgery for up to eight face-to-face sessions lasting 45 minutes. Between sessions the patient will read materials and complete assignments such as mood diaries which are then reviewed with the PCMHW.
Computerised CBT: ‘Beating the Blues’ is a structured eight week programme that the patient works through on their own, although a PCMHW is available to offer support if needed.
Anxiety management group: A self-help group to help patients understand and cope with common anxiety symptoms.
Behavioural activation group for depression: Helps patients learn to manage their mood by increasing the amount of meaningful activity in their lives.
Referral pathway
Referrals are made by GP's, nurses, psychiatric liaison nurses, counsellors and therapists directly to the PCMHW based in their surgery. When referred, a patient is asked to complete a screening questionnaire which includes the PHQ-93 and GAD-74 (brief, standardised, self-report measures). This allows the PCMHW to gather details about the patient's perspective of their current difficulties and assess the severity of the difficulties described. The PCMHW, in collaboration with their clinical supervisor, uses this information to consider whether self-help methods may benefit the patient. Following this, a telephone interview is conducted to discuss the patient's motivation to use the available treatment options. The patient then chooses a treatment option they feel would be helpful from a choice of interventions within step 2, for example they can receive guided self-help, computerised CBT or group CBT. After completing the treatment, they are discharged back to the care of their GP unless an onward referral to a relevant statutory or voluntary service is indicated. If a patient's needs cannot be met by self-help methods then they may be stepped up to step 3.
The following three case studies illustrate this referral pathway and the types of referrals we receive (see Boxes 1–3).
Box 1. Using guided self-help for depression.
Richard, 67, had been experiencing low mood, poor sleep and reduced activity levels for nine months. His GP established that Richard had recently retired and was worried about his financial situation, and that this was his first episode of depression. Although Richard did have some suicidal thoughts he had no intention of carrying these out. Different treatment options of anti-depressants, sleeping tablets, counselling and guided self-help were discussed. Richard chose to try guided self-help. Richard's mood improved considerably over the six treatment sessions. He worked hard to complete a weekly activity-mood monitoring diary and found that the self-help material applied to him well. Richard realised that he had been putting off his daily tasks and responsibilities around the house and had a tendency to ruminate about disappointments in his life. He was able to recognise that these behaviours had been maintaining his depression and learnt how to build alternative, healthy behaviours into his lifestyle. In the final session Richard was worried about no longer having the support of a PCMHW, but recognised that he had developed skills that he could further develop to more effectively deal with future depressive episodes. Two months later, in a follow-up telephone call, Richard reported that he continued to be much more active and was now moving forward with his life.
Box 2. Using guided self-help for anxiety.
John, a 30 year old Hungarian man, approached his GP for help with his panic attacks after seeing a poster advertising CBT in the waiting room at his surgery. John was experiencing frequent panic attacks in a number of situations: on the tube to work, using elevators, in cinemas and whilst driving. He had learnt to avoid these situations or endured them by taking beta-blockers and distracted himself with crossword puzzles. John had recently started a new job and was afraid that he might have a panic attack in his office.
John opted for guided self-help. Through psycho-education and a self-directed exposure programme, with weekly support from the PCHMW, John managed to start approaching some of the situations that he had previously been avoiding. He was able to confront his catastrophic fears and overcome his avoidance of travelling on the tube to his office. He reported that these changes greatly improved the quality of his life. He felt so confident that he was able to stop taking beta-blockers.
At a follow-up appointment two months later he still felt very positive about the changes he had been able to make. Although there were still some situations that he avoided (such as elevators) he was motivated to continue using CBT and made a structured plan with the PCMHW about how best to work towards his long-term goals.
Box 3. Stepping up to secondary care.
Aaliyah, a 42 year old woman from Iran, sought help from her GP for her acute anxiety. During a consultation with her GP Aaliyah was asked to complete the screening questionnaire to return to the PCMHW. This indicated that Aaliyah had a history of post-traumatic stress disorder (PTSD) resulting from previous traumatic experiences in her home country. As guided self-help is not a recommended treatment for PTSD it was decided that she should be stepped up to step 3 of the stepped care model to receive individualised CBT for PTSD. Aaliyah was happy for this to be discussed with her GP and grateful that she would soon be receiving some help for her difficulties.
These cases demonstrate three different journeys through the referral pathway. In some cases (such as PTSD) guided self-help will not be sufficient. However, in many cases of mild–moderate anxiety and depression, offering support to patients while they make use of self-help material can lead to significant improvement in patients' functioning.
Outcome data
In the first seven months of the service 157 patients have been offered help and 110 (70%) have accepted. We currently have data for 53 patients who have completed treatment. The mean PHQ-9 scores were 12.98 (indicating mild depression) at assessment and these had reduced to 6.57 by the end of treatment. Mean GAD-7 scores were 12.26 at assessment (indicating moderate anxiety) and 6 by the end of treatment (indicating mild anxiety). This data shows a 51% reduction in depression symptoms and 49% reduction in anxiety symptoms. Following treatment, 12 of these patients (22.6%) were then ‘stepped up:’ 7 to psychology services, 4 to counselling services and 1 to a community mental health team.
Patient feedback
Qualitative responses on feedback forms indicate that patients find the self-help materials they are given both relevant and useful. The following comments about guided self-help reflect the high levels of satisfaction with the service.
‘[PCMHW] helped instil confidence in me to cope with the worst that I think can happen. She took my problems seriously and I felt I could really open up.’
‘The treatment is really hard work to do properly. It requires as much concentration as trying to learn the violin, but the more I practice the more hopeful I feel about what can be achieved’
‘The book is easy to read and explains concepts in a simple to understand way’
Patients found the guidance of a PCMHW beneficial as a way of motivating themselves to do the reading and to put the CBT exercises into practice between sessions:
‘I felt it was really helpful reading the book at the same time as having someone who really understood about CBT’
‘I knew I would do the reading because I would be seeing you next week and talking about it’
‘Couldn't have done it on my own’
The self-help materials helped patients to understand the links between their thoughts, behaviours, physiology and mood. They reported an increased awareness of their thinking styles and an ability to change them:
‘I am much more in tune with the way I think and react to certain things and now I am in the process of trying to change this for the better’
‘I am more able to think rationally about things and to stop being so self critical’
‘I have learnt to stop and analyse negative thoughts that come to mind and try to reframe them to more balanced points of view. The programme has helped me think about my successes too’
Conclusion
In Westminster, the introduction of PCMHWs providing guided self-help shows promise at making a valuable addition to existing primary care mental health services for patients with common mental heath problems. It has offered a new treatment option to those who may not want to see a counsellor or to be referred to secondary care psychology services. So far, the service seems to be both acceptable and effective for patients with mild symptoms of depression and anxiety.
Contributor Information
Louise Falbe-Hansen, Primary Care Mental Health Worker.
Corin Le Huray, Primary Care Mental Health Worker.
Brendar Phull, Primary Care Mental Health Worker.
Clare Shakespeare, Primary Care Mental Health Worker.
Jon Wheatley, Chartered Clinical Psychologist, BABCP Accredited Practitioner, Superviser and Trainer, The Westminster Primary Care Psychology Service, Central & North West London NHS Trust, UK.
CONFLICTS OF INTEREST
None.
REFERENCES
- 1.Myles PG, Rushforth D. A Complete Guide to Primary Care Mental Health. London: Robinson, 2007. [Google Scholar]
- 2.Bower P, Gilbody S. Stepped care in psychological therapies: access, effectiveness and efficiency. British Journal of Psychiatry 2005;186:11–17. [DOI] [PubMed] [Google Scholar]
- 3.Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092–97. [DOI] [PubMed] [Google Scholar]