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 Self-help 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 anti-depressants. 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 anti-depressants, 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.