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Common mental health problems in primary care

Alan Cohen describes how common mental health problems are in the community, how these problems interact with other areas of people's lives such as diabetes or employment, what sort of interventions are helpful and finally what primary care nurses can do to support their patients and clients

Alan Cohen
FRCGP
Senior Clinical Adviser
Care Services Improvement Partnership (CSIP)
Senior Fellow Sainsbury Centre for Mental Health

You are running a routine clinic on a Wednesday morning, and your sixth patient of the day is a 48-year-old woman whom you are seeing at the request of the GP. He has asked you to see this woman as she is overweight, has perimenopausal symptoms, and has low back pain. He wonders if you can help her to lose weight. She comes into your room, sits down and bursts into tears. She tells you that her husband is drinking too much, her son is in trouble with the police and that she is likely to be made redundant from her job - which is currently the only thing that is keeping her sane. She can see no reason to go on.
Sounds familiar? This is what primary care is about: the connection between physical disorders, mental disorders and social circumstances - the biopsychosocial model. The difficulty is not so much in being able to describe the model, as knowing what to do to help the woman, especially in a time-limited general clinic.

Common mental health problems
Common mental health problems is the umbrella term used to describe a number of well recognised mental health conditions:

  • Depression.
  • Generalised anxiety disorder.
  • Panic disorder.
  • Mixed anxiety and depression.
  • Phobias.
  • Obsessive compulsive disorder.
  • Post-traumatic stress disorder.

Common mental health problems do not include such conditions as psychosis, schizophrenia, bipolar affective disorder or personality disorder.
As the name implies, common mental health conditions are common. The World Health Organization believes that by 2020 depression alone will be the second most common disabling condition (after ischaemic heart disease) worldwide.(1)
In the UK, the Office of National Statistics has published the prevalence of common mental health conditions in the community.(2) See Table 1 for translation of these figures into the likely workload seen in primary care for an average practice of 10,000 people.
As a comparison, diabetes represents about 3% of the population, or 300 people in the example cited above.(3) Depression (mixed anxiety and depression, and depressive disorder) affects about one in six of all adults of working age.

Who cares for people with common mental health problems?
The National Service Framework for Mental Health made clear that those people with a severe and enduring mental health problem, such as a psychosis, schizophrenia and bipolar disorder, should be prioritised for care by specialist mental health trusts.(4) This means that 90% of all people with a mental health problem are managed entirely in primary care. Interestingly, about 25-30% of those with a severe mental illness choose to receive their care just from general practice.(5)
It is not surprising therefore to learn that about 30% of the annual 270 million consultations in general practice have a significant mental health component.(6)
Interventions that can be provided in primary care include the prescribing of medication, the provision of talking therapies such as counselling and cognitive behaviour therapy (CBT), or advice about self-help.(7,8) Access to talking therapies such as counselling or CBT is often poor, with long waiting times - in general waits for CBT can exceed 12 months. Prescribing of antidepressants is increasing and currently costs the country over £100m.(9)

The impact of common mental health problems
Common mental health problems affect not only the mental health of the individual, but also their physical health and their social wellbeing.
The Department of Health has over the last two years supported two demonstration sites providing improved access to psychological therapies.(10) More will be said about this development later, but analysis of the patients attending these improved services is worthy of mention.
Both depression and anxiety can be subdivided into different levels of severity: mild, moderate and severe.(11) It is common when describing a chronic condition to expect that the distribution of severity is that there are more people with a mild condition than a moderate condition, and that there are relatively few people with severe conditions; this provides a typical
"pyramid-shaped" prevalence picture. With depression and anxiety, this is not the case; there are equal proportions of people with mild, moderate and severe conditions (see Figure 1).

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Over half of all people with mental health problems have been suffering for over five years.(10) Common mental health problems are neither shortlived nor have only a slight impact on the individual - people are chronically and severely affected by their disorder.
Depression and anxiety also affect the physical health of people with other conditions. You may already be familiar with the Quality and Outcomes Framework (QOF) - an incentive scheme to deliver high-quality, evidence-based essential care within the GMS contract.(12) The QOF has a specific domain for the care of people with depression, and the first indicator is to "case find" people with diabetes and ischaemic heart disease who also have depression. The evidence is strong that depression is more common in diabetes - three times as common - and that the presence of depression is associated with a greater disease burden, and greater consumption of health resources such as medication and outpatient attendance.(12) The evidence is, however, more equivocal that managing the depression improves glycaemic control. Similar evidence of the impact on ischaemic heart disease of depression also exists and that its presence is associated with poorer outcomes.(12) Detailed references are provided in the evidence base supporting the depression domain.
Depression and anxiety are also associated with other long-term conditions, eg, stroke and chronic obstructive pulmonary disease (COPD). There is quite a lot of experience of studying people who are frequently admitted to hospital for short periods of time as emergencies. One of the largest groups of this set of emergency
admissions are those with COPD; the patient becomes afraid that they will become short of breath and calls an ambulance who takes them to hospital. They are admitted, which calms their fears, and they are discharged a day or two later. Clearly this is both expensive and not helpful for the patient as the reason for admission was a fear of becoming short of breath, rather than a specific exacerbation of the underlying condition. Helping the patient to understand their underlying anxiety could go a long way to helping to prevent this type of behaviour - and providing alternative ways of dealing with their (entirely understandable) anxiety.
Depression and anxiety also affect people in ways other than their health. There are currently just over 2.5 million people unable to work because of their health problems. The largest group are those with a mental health problem - some 40% of the total, or nearly one million people. Over 90% of this group are unable to work because of a common mental health disorder such as anxiety or depression.(13) Helping this group to return to work not only improves their own health, but improves their inclusion within society.(14)

Unemployment
Strong evidence exists that unemployment is harmful to health. The unemployed:

  • Have a higher mortality.
  • Have poorer general health, longstanding illness and limiting longstanding illness.
  • Have poorer mental health, psychological distress and minor psychological morbidity.
  • Have higher medical consultation, medication consumption and hospital admission rates.

There is strong evidence that re-employment leads to improved self-esteem and improved physical and mental health. The magnitude of this improvement is more or less comparable to the effects of job loss. Detailed references are available from the BOHRF review.(14)

What works for people with common mental health problems?
There are three broad areas of intervention for people with a common mental health problem:(7,8)

  • Self-help interventions.
  • Psychological or talking therapies.
  • Medication.

Self-help
Self-help interventions include exercise, bibliotherapy and computerised CBT. Exercise has a strong evidence base for effectiveness for people with mild anxiety and/or depression. Some PCTs already have an "exercise on prescription" scheme, and including depression and anxiety as one of the reasons for referral is appropriate. Bibliotherapy is using books to deliver a form of CBT - teaching the person about feelings and emotions, how they relate to behaviour changes and finding ways to change thought processes so that behaviour changes. A number of PCTs are working with local libraries to stock the books that are recognised to deliver this type of reading (see Resources).
CBT can also be delivered by computer program - indeed a technology appraisal by NICE has required all PCTs in England to ensure that this service is available if requested by patients (see Resources).(15)

Talking therapies
Talking therapies include a wide range of different types of psychotherapies, but the most common are counselling and CBT.
Counselling is a systematic process that gives individuals an opportunity to explore, discover and clarify ways of living more resourcefully, with a greater sense of wellbeing. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict, or improving relationships with others. Counselling is recommended by NICE for people with mild depression and is frequently delivered in primary care premises.(16) Counsellors are either employed by the practice themselves or by the local PCT. There are a number of different techniques that depend on both the patient and the counsellor.
CBT refers to the pragmatic combination of concepts and techniques from cognitive and behaviour therapies, common in clinical practice. It is recommended by NICE for people with moderate or severe depression, and for people with anxiety
Behaviour therapy is a structured therapy originally derived from learning theory, which seeks to solve problems and relieve symptoms by changing behaviour and the environmental factors that control behaviour. Graded exposure to feared situations is one of the commonest behavioural treatment methods and is used in a range of anxiety disorders.
CBT is a structured treatment approach derived from cognitive theories. Cognitive techniques (such as challenging negative automatic thoughts) and behavioural techniques (such as activity scheduling and behavioural experiments) are used with the main aim of relieving symptoms by changing maladaptive thoughts and beliefs.(17)

Improving access to psychological therapies
The major concern in the past about talking therapies was not the effectiveness of the intervention, but finding a therapist who could deliver the care needed. The government made a commitment in the 2005 election manifesto to "improve access to psychological therapies". This commitment spawned a DH programme, under the same name that first invested in improved access in two demonstration sites (Doncaster and Newham), and then in 11 further pathfinder sites. In October 2007, on World Mental Health Day, the Secretary of State announced that there would be further significant funding in psychological therapies; he announced that £30m, £100m and £170m would be made available over the next three years from new resources to fund a national training and dissemination programme to deliver improved access to psychological therapies. This programme will allow anybody who needs a psychological intervention for a common mental health problem to receive it within 10 working days of referral from their primary care doctor.(10)

Medication
Medication is recommended for people with moderate and severe depression, and for people with anxiety. The medication group of choice is known as selective serotonin-reuptake inhibitors (SSRIs) and include such well-known drugs as fluoxetine [Prozac; Lilly] and paroxetine [Seroxat; GlaxoSmithKline]. Currently the cost of all SSRIs prescribed in England exceeds £100m, and is rising year on year.(9)

The role of the practice nurse
Practice nurses and nurse practitioners working in primary care are experienced and skilful at managing people with chronic conditions in a structured fashion. As nurses become more experienced they will have more regular contact with patients with chronic disorders than the GP with which they work. It is therefore appropriate that nurses use these opportunities to start to identify people who have a common mental health problem. The QOF depression indicator DEP 1 is an incentive for practices to undertake this, and although the evidence for diabetes and ischaemic heart disease is strong, there is also considerable evidence for people with strokes and other long-term neurological conditions.(12)
However, while using the patient health questionnaire (PHQ-2), as recommended in the DEP 1 indicator, is straightforward in itself, it is important to know how to manage and understand the results of the case finding. What processes/procedures are there in your practice if the response is positive? What procedures are in place if the response is negative? What happens if the patient starts crying?
In many practices these questions will have been addressed, and it is not the place of this article to tell practice staff how they should behave. What is helpful is a clear process and confidence that the patient is supported. Having the knowledge to offer the patient simple interventions while they are waiting to see the GP or practice counsellor/mental health nurse for a fuller assessment is helpful. Not being embarrassed or distressed by the patient crying is very supportive for the patient. Being able to offer them something constructive in the way of information, such as the self-help materials described earlier, will go a long way to enabling them to engage effectively with further treatment if it is necessary.
It is also worth remembering that the patient has turned to you for advice, not the GP, nor the mental health nurse; that is because you are a familiar, friendly face, whom they know and can trust. Encouraging them to seek more specialist advice and opinion is an important and worthwhile role, while maintaining that original contact with you is important.
Finally, there is sometimes a concern that raising the issue of self-harm or asking about suicide might in some way make the patients more likely to harm themselves. There is no evidence that this is true.18 While it is inappropriate for a nurse who is not trained in mental health assessments to routinely enquire about suicidality, the patient may themselves bring up the issue. If you are concerned about something that the patient has said, it is entirely reasonable to ask the opinion of a GP; if you had a patient with central chest pain radiating down the left arm and a BP of 200/120, you wouldn't think twice about contacting the GP. If a patient tells you that they are considering harming themselves, it is equally appropriate to ask the GP for advice.

References

  1. WHO. Mental health problems: the undefined and hidden burden. Geneva: WHO; 2001. Available from: www.who.int/mediacentre/factsheets/fs218/en/index.html
  2. Office for National Statistics. Psychiatric morbidity among adults living in private households. Technical Report. London: ONS; 2000.
  3. DH. Diabetes. Available from: www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Diabetes/in...
  4. DH. National Service Framework for Mental Health: modern standards and service models for mental health. London: DH; 1999.
  5. Burns T, Cohen A. Item-of-service payments for GP care of severely mentally ill persons. Br J Gen Pract 1998;48:1415-6.
  6. Cohen A, editor. Delivering mental health in primary care. London: RCGP; 2008 (in press). ch. 6.
  7. National Institute for Health and Clinical Excellence. Depression, management of depression in primary and secondary care. London: NICE; 2004.
  8. NICE. Anxiety, management of anxiety in primary and secondary care. London: NICE; 2004.
  9. Cohen A, editor. Delivering mental health in primary care. London: RCGP; 2008 (in press). ch. 12.
  10. Choices in mental health. Available from: http://www.mhchoice.csip.org.uk
  11. WHO. International classification of diseases. Available from: http://www.who.int/classifications/icd/en
  12. The NHS Confederation. New GMS Contract 2003. Investing in general practice. London: NHS Confederation; 2003.
  13. Sainsbury Centre for Mental Health. Work and wellbeing: developing primary mental health care services. London; Sainsbury Centre for Mental Health; 2007.
  14. Seymour L, Grove B. Workplace interventions for common mental health problems. London: BOHRF; 2005.
  15. NICE. Computerised cognitive behaviour therapy (CBT) for anxiety and depression. Technology Appraisal 097. London: NICE; 2005.
  16. Mind. Understanding depression. London: Mind; 2007. Available from: http://www.mind.org.uk
  17. McPherson I. In Cohen A, editor. Delivering mental health in primary care. London: RCGP; 2008 (in press). ch. 11.
  18. Hague J. In Cohen A, editor. Delivering mental health in primary care. London: RCGP; 2008 (in press). ch. 15.


Resources

Bibilotherapy
Particular titles that people have found helpful include: Understanding Depression and Understanding Anxiety.
Other helpful resources can be found on the following websites: 

Royal College of Psychiatry
W www.rcpsych.org.uk

Mental Health Foundation
W www.mhf.org.uk.

Computerised CBT
The two programmes are Beating the Blues and FearFighter. For more information on these and other sites, go to:
W www.mhchoice.csip.org.uk