2.5 Recommendations for treatment in Ireland
Mimi Copty, from the Irish College of General Practitioners, is the main contributor
to the Irish Health Services Executive (HSE) guidelines on mental health. These
guidelines are based around a report that Copty completed in 2003 (Copty, M. 2003).
In this report patients and primary carers were involved. It was both quantitative and
qualitative including responses from GPs, Mental Health providers and Service users.
It was limited qualitatively (focus groups) in the number of GPs who participated and
notably there were none from a rural practice. There was also a low representation
from consultant Psychiatrists (1 in total). In its recommendations to the former South
Western Area Health Board (SWAHB) it concluded that mental health training is
lacking among GPs even though 95% of mental illness is being dealt with in primary
care. Training needs and deficits need to be identified and appropriate training should
be provided for GPs. Protocols must be developed for detection, assessment,
treatment, referral and interface between primary and secondary care, discharge, and
communication with the patient.
There also needs to be more collaboration between GPs and Mental Health Service
Providers. This can be helped by employing counsellors, psychologists and
community psychiatric nurses in the general practice. Mental health providers can
relocate to a primary care setting thus facilitating the communication between
psychiatric staff and GPs. If there is a regular interface between GPs and Psychiatrists
there could be case discussion before referral. Link workers, such as community
psychiatric nurses could provide a link from psychiatry to general practice in order to
facilitate communication and training needs (Copty 2003). This is calling for a
multidisciplinary approach to Mental Health care in the community. There is a lack of
knowledge among GPs of the psychological services available. The onus is on allied
mental health providers to make themselves known to GPs. It was also found that
there was a lack of knowledge concerning various psychological service providers,
GPs and the public did not understand the difference between different psychological
approaches. It is up to these service providers to educate the public and GPs about
licensing and accreditation and the various therapeutic approaches. Media such as
leaflets, tapes and posters on Mental Health should be available in GP practices
(Copty 2003). There is no specific mention of psychotherapy in this report.
The “Guidelines for the Management of Depression and Anxiety Disorders in primary
care” (HSE 2006) provide guidelines for screening, assessment, diagnosis and
management of depression and anxiety in primary care. It specifically states it is of
interest to GPs, pharmacists, psychiatric nurses, psychiatrists, clinical psychologists,
service users and all other people caring for depression and anxiety (again counselling
and psychotherapy are not mentioned by name).
For both depression and anxiety the format is the same. High risk groups are
identified. A brief psychiatric assessment guideline is provided for GPs. GPs are
asked to consider using one of the widely available psychological instruments to
assess depression. There is also a brief summary of the diagnostic criteria as set out in
the DSM-IV for diagnosis purposes. The two forms of treatment prescribed are
pharmacological
treatment
and
Psychological
recommendations made in relation to providing both.
treatment.
There
are
no
The Psychological section is brief and a little unclear. It does provide a distinction
between counselling and psychotherapy but also states that the two overlap. In this
section it addresses the lack of primary care psychological services provided by the
HSE. However there is a commitment to their development. It is significant that it is
believed that this service will be provided by counselling psychologists rather than by
any other discipline. Users of the guidelines are also provided with accreditation
information. It states that patients with mild to moderate mental health problems
should be referred to primary therapy services. More severe cases should be referred
to secondary and tertiary services. These are not clearly defined but it assumed Copty
means Psychiatric Institutions. The shortcomings of this document are offset by the
“Guidance document for the provision of counselling in a primary care setting” (HSE
2006).
This guideline document gives definitions of counselling and a brief summary of
different approaches. However it does not provide a clear distinction between
counselling and psychotherapy. It states that the preferred method of counselling is
CBT. The document briefly distinguishes between a counsellor/therapist, a clinical
psychologist, a counselling psychologist and an addiction counsellor, but again one
would be none the wiser as to what a counsellor/therapist is after reading it. It does
however
state
that
only
accredited
counsellors/psychotherapists
and
clinical/counselling psychologists would be qualified to provide counselling in
primary care. Only in the section entitled “Access to Counselling” do we get an
insight into the differences between counselling and psychotherapy. Mild stress
related problems, struggling with life events and losses are appropriate for primary
care. For severe and complex mental disorders or personality disorders “generic
counselling” is not recommended. Patients with trauma, unsuccessful treatment,
complex social problems, severe depression, severe anxiety or comorbidity should be
referred from a primary care counselling setting to a community mental health team
or psychotherapy service.