Many primary care patients suffer from psychosocial and mental health problems. These problems often involve feelings of sadness, nervousness, or stress. Many of these problems can be due to personal and social problems or reactions to life events such as physical illness or unemployment.
“Counseling” is a recognized psychological therapy that is often provided to these patients. Counselors have been frequently employed in the UK to provide psychological therapy to patients in primary care settings. Providing counseling alongside other treatments, such as cognitive-behavioral therapy, means that patients have more options and that alternatives can be found for patients who do not benefit from standard treatments or who do not find them acceptable.
However, recent UK clinical guidelines have highlighted the lack of evidence for psychosocial counseling compared to other treatments, such as cognitive-behavioral therapy, and have not been able to clearly recommend the use of counseling in primary care.
In this review, we found nine studies that included counseling in primary care for 1,384 participants. In some studies, there were some problems with the methods. Evidence indicated that counseling is better than usual family doctor care in improving short-term mental health outcomes, although the benefits are modest. People who received psychosocial counseling in primary care from a trained counselor are more likely to feel better immediately after treatment and are more satisfied than those who receive care from their GP. However, in the long term, counseling does not appear to be better than GP care. Although some healthcare uses could be reduced, counseling does not appear to reduce the overall costs. There is very limited evidence comparing counseling with other psychological therapies (2 studies with 272 participants) or with antidepressant medication (1 study with 83 participants).
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The clinical psychologist in health centers. A joint effort between primary care and mental health
The clinical psychologist in health centers. Joint work between primary care and mental health
From the comprehensive primary care model and under the principle of continuity of care, the development of channels of communication and integration between the first and second levels of care in relation to mental health care is proposed. The pioneering experience established in the Health Service of Lanzarote is presented, in which the figure of the clinical psychologist has been transferred to health centers to develop a joint and community program from primary care. The lines of action have focused on direct work with the patient as well as with the staff, both individually and in groups. The objective is to raise awareness and standardize treatment for mental illness from health centers.
From the model of Integral Primary Care and under the principle of continuity of care, the development of channels of communication and integration between the first and second level of care in relation to mental health care is proposed. It presents the pioneering experience established in the Health Service of Lanzarote in which the figure of the clinical psychologist has been moved to the Health Centers to develop a joint community program from the Primary Care. The lines of action have focused on direct work with the patient, as well as with the staff, both individually and as a group. The objective is the sensitization and standardization of the treatment for mental disease in Health Centers. This work has been carried out with a positive assessment by patients and staff of the centers,
Coordination between primary care (PC) and specialized care (AE) constitutes one of the basic pillars of the National Health System to offer comprehensive, quality care that supports continuity of care. For this reason, the development of instruments and channels of coordination between the different levels of care is proposed.
The PC is the gateway to the health system, where the different physical ailments, mental health problems, or social health conflicts posed by the population are treated in the first instance. From the first level of care, we work in a network with different EC devices. The care must be comprehensive, based on a biopsychosocial model, for which it is necessary to have multi-professional teams. The advantages of receiving mental health care as close as possible to the patient’s home, in a normalizing environment, are highlighted.
Studies carried out in our environment indicate that around 25-55% of the total demand for PC consultations responds to the presence of a mental disorder, of which 80% would be mild or moderate, in the form of depressive states or of anxiety. Of all this demand, only 10% of the cases are referred to Mental Health, with the remaining 90% being followed up on PC services. Despite the low referral rate, mental health services are saturated with the current demand for care. The prevalence rates of mild mental disorders are increasing significantly in recent years. It has been shown that the economic crisis has been a risk factor for mental health. Likewise, at the social level, interest in mental health care seems to be growing. The need to incorporate clinical psychologists in PC centers, in terms of optimizing the care provided to users of these services as well as their demonstrated profitability, has been gaining wide recognition in our society.
The situation is that access to EC is limited to moderate or severe psychopathology, leaving the weight of the common mental disorder in the first level of care. This represents an overload for PC professionals, who, with the resources available to them, cannot carry out evaluations and treatments with the rigor established by clinical practice guidelines. Thus, there is a tendency to overmedicalization, as a faster but less efficient and effective way of approaching, since it entails higher healthcare costs and the possibility of chronicling the problem. Currently, 40% of disability worldwide is due to depression and anxiety. The NICE guidelines say that people with these conditions should be offered evidence-based psychological therapy as an alternative to antidepressants. Psychotherapy has proven to be as effective as antidepressants in the short term and more effective in preventing relapses. The AP claims to promote training in psychotherapeutic interventions in order to avoid overmedicalization of daily adversities.
Both nationally and internationally, programs are beginning to be implemented in which work is carried out in a coordinated manner between mental health and PC facilities for the treatment of people with common mental disorders. In the United Kingdom, the Improving Access to Psychological Therapies program is operating successfully with the incorporation of clinical psychologists to PC services, with long-term results showing recovery levels of 50.9-66.6%, according to the latest published studies. At the national level, it is already being implemented in various autonomous communities. Currently, Antonio Cano Vindel leads the PSICAP Project for which psychological care is being studied and implemented in the PC. It concludes that psychological treatment is up to 3 times more effective than the usual treatment in PC for problems of anxiety, depression, and somatization.
In the autonomous community of the Canary Islands, a joint work program is being carried out between the Psychiatry service of the Lanzarote Health Area and Primary Care. This initiative began to take shape in October 2016, with the first coordination meetings in which the project and the implementation phases have been outlined.
The project is proposed as a joint and flexible work between PC and mental health that adjusts to the healthcare reality and the possibilities of a multidisciplinary approach.
The Psychiatry Service has reconfigured its care activity, relocating 3 clinical psychologists in regular periods to health centers belonging to 3 basic health areas, Arrefice I, with an attached population of 46,540 users, Arrecife II, with 27,919 users, and Tías with 19,472. In Arrecife I there is a clinical psychologist 4th and a half a week, while in Arrecife II and Tías they have the referring mental health professional 2 times a month for 4h and a half every day they come. These 3 basic health zones account for 70.68% of the total demand received by the Mental Health Unit of Lanzarote. By assuming the displacement of physicians from the Mental Health Unit to health centers, there is an initial impairment in the Psychiatry Service, but at the same time, the joint work with primary school means that patients with mild pathology are placed in the first level of care, offering a more specific service. Ideally, over time there will be a clinical psychologist fully assigned to these functions.
The work consists of selecting from the inter consultations that are referred to mental health those that correspond to common mental disorders and attending them in PC, either as a single consultation or in a group format. The clinic attended is of the range of anxiety states, depressed mood, adaptive reactions, and psychosomatic disorders.
Particularly noteworthy is the joint work with primary school professionals. To do this, a coordination time is established, either at the request of primary school professionals or by specialists. In the coordination meetings, the case is elaborated to favor its understanding and guide the intervention that the reference personnel will follow. When required, joint interventions are made with 2 professionals in consultation with the patient. A group approach has been started with professionals to reflect on clinical practice. The health centers, with special nursing representation, develop a preventive health promotion and education program. Workers from the Psychiatry Service collaborate in the preparation of material and the development of some workshops that are taught in various sectors of the community. Overall, the continuity of care channeled through intermediate figures is favored.
The objective of the project is the integration of the clinical psychologist in primary school as one more member of the team so that people with common pathology are treated in primary services from a psychotherapeutic approach, reducing drug costs and seeking the well-being of patients. afflicted with said problem, following the lines of recommendation established by the clinical practice guidelines. As the clinical psychologist is located in the center, activation of the personnel is sought in the development of programs and awareness and learning in the area of mental health.
The lines of action are the following:
- Individual interviews : On the basis of the information provided in the interconsultation, the cases that could be candidates for treatment placed in PC are selected. The clinical psychologist conducts a first interview in PC to assess the adequacy of the patient to the psychotherapeutic group. Another possibility is discharge after a first assessment and possible intervention in a single session. If the seriousness of the case requires it, it is referred to the Mental Health Unit. Approximate half an hour is established for individual consultation.
- Group psychotherapy:Groups of 6-8 patients gathered in 5 sessions of an hour and a quarter of duration. It is proposed as a psychoeducational group for the acceptance and coping of emotional distress, defining this as the task of the group. The frame is established and techniques that are increasing in complexity are implemented, starting with relaxation practice, going through mindfulness and ending with a focus on acceptance and commitment therapies and the approach to interpersonal problems. The idea is to offer techniques to regulate the levels of discomfort, explore their own problems and associated emotions, set goals and seek ways to achieve them, alluding to the difficulties and richness of interpersonal relationships. Beyond the formal part of the group, it is its own dynamics that enhances its therapeutic power. Personal reflection and debate among the members is encouraged, so that it goes from a radial organization centered on the therapist to a circular one, of interaction between the members, coordinated by the clinical psychologist. The configuration itself establishes a framework of empowerment of the participants, who become the protagonists and responsible in the search for their problems and possible solutions.
- Individual coordination: During an established schedule, the clinical psychologist is available for coordination with other professionals. This is an active job in which you have to locate the person you want to work with and leave your own office.
- Group of professionals:To facilitate coordination and training while fostering a space for teamwork, a group called the “clinical practice reflective group” has been established. It is inspired by the Balint format in the sense that it is understood that patient care is mediated by the relationship established between the professional and the user. Different experiences are discussed in relation to complicated patients or those with symptoms that do not fit with a certain diagnosis or those who come and it is not known what they are looking for … It is a space to work on the role of the professional and their difficulties at work . The clinical psychologist, in addition to coordinating the group, provides specific knowledge focused on the importance of the relationship, the bond, diagnosis, treatment, interview, psychopathological exploration and theoretical understanding of the mental clinic, always according to the problem that the group itself is raising. Aspects related to organization and teamwork are also discussed.
What does it mean for the doctor to have a clinical psychologist in the health center itself?
Faced with the increase in health demand, the lack of professionals, and the limited time for consultation, the figure of the clinical psychologist plays a fundamental role in the day-to-day life of the family doctor, being at the same time support and a therapeutic tool. Many times, due to the still existing taboo in relation to mental illnesses, it is difficult for the patient himself to ask for help in this regard; On numerous occasions, patients repeatedly make seemingly banal consultations, without finding a way to express their feelings about what is really happening to them.
With the current functioning of the PC, it is very common that when the patient goes to see their doctor they find a substitute, which can lead to a loss of confidence in the system if this is recurrent. This also increases the risk of not detecting moderate or severe mental pathologies that require EC. A comprehensive PC model has been proposed in which psychological intervention is accessible as one more community resource. The psychoeducational groups carried out have been a very positively valued therapeutic tool by patients and their reference professionals, demanding greater access to them.
Within the framework of community nursing, the mental health approach has a broad development in the follow-up of the patient who suffers from a chronic process and who therefore attends the consultation period and on a scheduled basis. The purpose of this visit is to advise, assess and promote follow-up in the management of the pathology that has been diagnosed and to prevent possible complications. It tries to work from a holistic approach. It is about being a reference and support in their process, to accompany the assimilation of the disease and establish behaviors that generate health, through the bond and the development of autonomy. Working together with mental health enriches this process, through coordinated practices and advice during the care process.
The concept of quaternary prevention is highlighted, which is the professional activity that avoids or mitigates the consequences of unnecessary or excessive activity in the health system. The consideration that mental suffering is part of life without necessarily having to be pathological, being sometimes functional and a driving force for changes that bring benefits in the medium or long term. The indication of treatment focused on the empowerment of the user, enhancing their coping skills and problem solving, become key pieces of a new way of addressing mild system pathologies. The professional’s capacity for containment in the face of human suffering, without having to give specific answers, is a central therapeutic facet. It’s hard not to have answers.