Book Prescriptions — A Strategy for Delivering Psychological Treatment in the Primary Care Setting

Abstract

ost people who are treated for mental health problems receive their treatment from their GP. A quarter of all consultations in primary care have a significant mental health component and depression is now the third most common reason for consultation in UK general practice (Effective Health Care Bulletin, 2002). The fact that 90% of people treated for mental health problems are treated solely at the primary care level makes it crucial that a range of appropriate and effective treatments is available to patients in this setting. Traditionally, primary care-based treatment for depression, panic disorder, obsessive-compulsive conditions, agoraphobia and other mild or moderate mental health problems has been exclusively pharmacological. Antidepressants and other types of psychotropic medication have benefited millions of patients and continue to be prescribed in large quantities. However, the past decade has seen a growing awareness of the desirability of providing additional psychological therapies in the primary care setting. The ‘talking therapies’, including counselling and various types of psychological intervention, are well established and there is now impressive evidence of their effectiveness for a range of the common emotional problems. In particular, there is very strong evidence for the effectiveness of cognitive-behaviour therapy (CBT), which helps people to examine and change the dysfunctional beliefs and thinking patterns that may underlie their anxiety or depression. Broadly, the evidence suggests that CBT based approaches are M at least as effective as drug therapy (NICE, 2004a; 2004b; 2004c). One advantage of cognitive therapy is that, because it has a strong educational component (teaching the patient positive thinking skills, perspective-taking, etc), it may not only ameliorate the present condition but may also prevent later relapse (Frude, 2004a). While patient surveys and government policy documents point to the need for primary care-based psychological treatment, drug treatment continues to predominate (although a recent expansion of primary care counselling provision is to be warmly welcomed). The continued pre-eminence of pharmacological treatment is easy to explain in terms of logistics. It is simply much easier, in practical terms, to provide pharmacological help by writing a prescription than to arrange for the delivery of psychological help. And whereas there is generally a waiting list for ‘the talking therapies’, the prescription of a drug – if not always the effects of a drug – can be immediate. Psychological therapies tend to be comparatively expensive and, as well as the financial constraints, there are also workforce constraints, with few suitably trained professionals available for employment. Thus it seems inevitable that the current low level of provision will persist for psychological treatments delivered by conventional means. After a career in academic psychology, during which I had long taught students about the highly effective cognitive behavioural methods, I moved to a post as research director of a clinical psychology training course. This also allowed me to practise as a clinician again after many years. Working within a community mental health team, it didn’t take me long