Evaluation of the short-term impact of counseling in general practice

Effect of a social media-based counselling intervention in countering fake news on COVID-19 vaccine in Nigeria

The aim of this study was to understand the impact of counselling in countering fake news-related COVID-19 vaccine. We conducted two separate experiments. In the first experiment, we exposed the treatment group to fake news on COVID-19 vaccine through a WhatsApp group chat while the control group was not. We then tested the effectiveness of such fake news on their perception. In our second experiment, we exposed the treatment group to a social media-based counselling intervention wherein we attempted to counter the earlier fake news on COVID-19 vaccine which they were exposed to. We found that respondents who were exposed to fake news reported greater negative perception about COVID-19 vaccine than their counterparts in the control group. We also we found that as a result of the counselling intervention, the respondents in the treatment group reported more positive perception regarding COVID-19 vaccine while their counterparts in the control group who were earlier exposed to fake news on COVID-19 did not significantly change their perception. This study has highlighted the importance of counselling in countering fake news within the context of health promotion. This approach is yet to receive significant attention in literature, especially from developing countries.

Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review

OBJECTIVES

Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. We reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.

DESIGN

Systematic literature review.

DATA SOURCES

We searched the Medline, Embase, PsycINFO, Healthcare Management Information Consortium (HMIC) and Global Health databases.

ELIGIBILITY CRITERIA

All quantitative studies published before July 2019 were eligible for the review; participants of any age and gender were included. Studies did not need to report a certain outcome measure or comparator in order to be eligible.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a standardised table; however, pooled analysis proved unfeasible. Studies were assessed for risk of bias using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane collaboration's tool for assessing risk of bias in randomised trials.

RESULTS

Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. Furthermore, the interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.

CONCLUSIONS

While there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.

Impact of counsellors in primary care on referrals to secondary mental health services

Aims and Method

A questionnaire survey of all general practices in one health authority plus an assessment of a random sample of referrals were used to evaluate the impact of counsellors in primary care on referrals to mental health services.

Results

A total of 91.1% of practices responded to the survey. A counsellor was present in 20.3% of these practices. A random sample of 180 referrals to community mental health teams was reviewed. There was a significantly higher referral rate from practices that employed a counsellor (P = 0.003). There was no evidence of a difference in rates of caseness of referrals between practices that employed a counsellor and those that did not.

Clinical Implications

Practices employing counsellors had significantly higher referral rates to mental health services, with no difference in the level of caseness between the two groups of referrals.

Counselling for mental health and psychosocial problems in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care.

SEARCH STRATEGY

To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011).

SELECTION CRITERIA

Randomised controlled trials of counselling for mental health and psychosocial problems in primary care.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events.

MAIN RESULTS

Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions.

AUTHORS' CONCLUSIONS

Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression

BACKGROUND

Psychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders.

METHODS

Meta-analysis and meta-regression of randomized controlled trials of brief psychological therapies of adult patients with anxiety, depression or mixed common mental health problems treated in primary care compared to primary care treatment as usual.

RESULTS

Thirty-four studies, involving 3962 patients, were included. Most were of brief cognitive behaviour therapy (CBT; n = 13), counselling (n = 8) or problem solving therapy (PST; n = 12). There was differential effectiveness between studies of CBT, with studies of CBT for anxiety disorders having a pooled effect size [d -1.06, 95% confidence interval (CI) -1.31 to -0.80] greater than that of studies of CBT for depression (d -0.33, 95% CI -0.60 to -0.06) or studies of CBT for mixed anxiety and depression (d -0.26, 95% CI -0.44 to -0.08). Counselling for depression and mixed anxiety and depression (d -0.32, 95% CI -0.52 to -0.11) and problem solving therapy (PST) for depression and mixed anxiety and depression (d -0.21, 95% CI -0.37 to -0.05) were also effective. Controlling for diagnosis, meta-regression found no difference between CBT, counselling and PST.

CONCLUSIONS

Brief CBT, counselling and PST are all effective treatments in primary care, but effect sizes are low compared to longer length treatments. The exception is brief CBT for anxiety, which has comparable effect sizes.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Effectiveness and cost effectiveness of counselling in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling.

SEARCH STRATEGY

To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers.

SELECTION CRITERIA

All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form.

MAIN RESULTS

Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar.

AUTHORS' CONCLUSIONS

Counselling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.

Thirty-six month outcome data from a trial of counselling with chronically depressed patients in a general practice setting

Counsellors have been employed in general practice with little evidence of effectiveness in this setting. This randomized controlled trial examined long-term effectiveness of short-term counselling in general practice for patients with chronic depression, either alone or combined with anxiety. Participants were 181 patients recruited from nine general practitioners' (GP) practices in Derbyshire by screening consecutive attenders using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression and social adjustment were measured at baseline, 6, 12, and 36 months. There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6, 12, or 36 months. Although fewer experimental group patients were still 'cases' on the BDI than controls at 6 and 12 months, this difference disappeared at 36 months. There was no evidence to demonstrate a long-term effect of improved outcomes in those referred to counselling.

Meta-analysis of data on costs from trials of counselling in primary care: using individual patient data to overcome sample size limitations in economic analyses

OBJECTIVE

To assess the feasibility of overcoming sample size limitations in economic analyses of clinical trials through meta-analysis of data on individual patients from multiple trials.

DESIGN

Meta-analysis of individual patient data from trials of counselling in primary care compared with usual care by a general practitioner.

SETTING

Primary care.

PATIENTS

People with mental health problems.

MAIN OUTCOME MEASURES

Direct treatment costs, depressive symptoms, and cost effectiveness.

RESULTS

Meta-analysis of individual patient data proved feasible. The results showed that the previous analyses of individual trials were underpowered to provide useful conclusions about the cost comparisons. The results are sensitive to assumptions made about the costs of sessions with a counsellor and the management of patients by a general practitioner.

CONCLUSIONS

Meta-analysis of individual patient data may assist in overcoming sample size limitations in economic analyses. Although feasible, such analysis has shortcomings that may limit the validity of the results. The relative costs and benefits of this method, as opposed to further collection of primary data, are as yet unclear.

The role of bibliotherapy in health anxiety: an experimental study

Despite its high prevalence and implications for health care resources, health anxiety is generally considered difficult and expensive to manage. Structured self-help materials (bibliotherapy) using a cognitive behaviour therapy (CBT) treatment approach have been shown to be clinically effective. This experimental study investigated the effects of bibliotherapy on patients who had been identified as demonstrating health concerns. The 40 participants (patients drawn from GP surgeries) were randomly allocated to two groups, one receiving bibliotherapy and the other not. Half the patients had a medically diagnosed problem. Anxiety was assessed before and after the bibliotherapy intervention, which took the form of a cognitive-behavioural self-help booklet for health anxiety sufferers. Patients in the bibliotherapy group showed reduced levels of anxiety at post-test, even when they also had an identifiable physical problem. These results are consistent with the idea that self-help materials can be an effective and accessible intervention in CBT, although further research is recommended.

Effectiveness and cost effectiveness of counselling in primary care

BACKGROUND

Counsellors are prevalent in primary care settings. However, there are concerns about the clinical and cost-effectiveness of the treatments they provide, compared with alternatives such as usual care from the general practitioner, medication or other psychological therapies.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials, controlled clinical trials and controlled patient preference trials of counselling interventions in primary care, for patients with psychological and psychosocial problems considered suitable for counselling.

SEARCH STRATEGY

The original search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned to uncover further controlled trials. Contact was made with subject experts and CCDAN members in order to uncover further trials. For the updated review, searches were restricted to those databases judged to be high yield in the first version of the review: MEDLINE, EMBASE, PSYCLIT and CINAHL, the Cochrane Controlled Trials register and the CCDAN trials register.

SELECTION CRITERIA

All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2001 were included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet. The relevant data were entered into the Review Manager software. Trials were quality rated, using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. In view of the diversity of counselling services in primary care (the range of treatments, patients and practitioners) tests of heterogeneity were done to assess the feasibility of aggregating measures of outcome from trials. Sensitivity analyses were undertaken to test the robustness of the results.

MAIN RESULTS

Seven trials were included in the review. The main analyses showed significantly greater clinical effectiveness in the counselling group compared with 'usual care' in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n=772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n=475, 4 trials). Levels of satisfaction with counselling were high. Four studies reported similar total costs associated with counselling and usual care over the long-term. However, the economic analyses were likely to be underpowered.

REVIEWER'S CONCLUSIONS

Counselling is associated with modest improvement in short-term outcome compared to 'usual care', but provides no additional advantages in the long-term. Patients are satisfied with counselling, and it may not be associated with increased costs.

Counselling and interpersonal therapies for depression: towards securing an evidence-base

Both generic counselling (delivered by BACP level counsellors in primary care settings) and the interpersonal therapies place a central value on the role and function of relationships--both within and outside the practice setting - as a vehicle for understanding and treating people presenting with depression. Recent studies have compared generic counselling with antidepressant medication, usual GP care, cognitive-behaviour therapy (CBT), and as an adjunct to GP care (i.e. in combination with GP care). Findings suggest either that there is no difference between generic counselling and other treatment conditions, or that there are small advantages to counselling over usual GP care but only in the short-term with such differences disappearing at 1-year. Studies investigating the interpersonal therapies (IPT) have established that the content of such therapies differ in their content from behavioural and cognitive therapies despite the outcomes being broadly similar. Considerable research effort has focused on the process of change in IP therapies. Important factors include the level of prior commitment by the patient to psychological therapy and their confidence in the therapist. Patients with well assimilated problems tend to do better in CBT than psychodynamic-interpersonal therapy. Therapists need to be flexible and responsive to patient needs particularly concerning interpersonal and attachment issues. Future research in counselling needs to identify the effective components of generic counselling and relate these to a theoretical base. In the IP therapies, there needs to be a greater focus on the change outside the therapy session and on the effectiveness of such therapies in non-research settings.

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness

OBJECTIVE

To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.

DESIGN

Prospective, controlled trial with randomised and patient preference allocation arms.

SETTING

General practices in London and greater Manchester.

PARTICIPANTS

464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.

INTERVENTIONS

Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.

MAIN OUTCOME MEASURES

Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production.

RESULTS

197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis.

CONCLUSIONS

Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12 months.

Systematic review of the effect of on-site mental health professionals on the clinical behaviour of general practitioners

OBJECTIVES

To review the published literature concerning the effects of on-site mental health professionals on general practitioners' management of mental health.

DESIGN

Systematic review of controlled trials.

SETTING

Primary care.

PARTICIPANTS

General practitioners and mental health professionals.

MAIN OUTCOME MEASURES

Consultation rates, prescribing of psychotropics, and referrals to secondary care mental health services by general practitioners.

RESULTS

The effect of on-site mental health professionals on consultation rates was inconsistent. Referral to a mental health professional reduced the likelihood of a patient receiving a prescription for psychotropics or being referred to secondary care, although the effects were not consistent. An on-site mental health professional did not alter prescribing and referral behaviour towards patients in the wider practice population.

CONCLUSIONS

The secondary effects of mental health professionals on the clinical behaviour of general practitioners are comparatively modest and inconsistent and seem to be restricted to patients directly under the care of the mental health professional.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.

On-site mental health workers in primary care: effects on professional practice

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (18-22 June 1998), the Cochrane Controlled Trials Register (18-22 June 1998), MEDLINE (1966 to 1998), EMBASE (1980 to 1998), PsychInfo (1984 to 1998), CounselLit (18-22 June 1998), NPCRDC skill-mix in primary care bibliography, and reference lists of articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of MHWs either replacing PCPs as providers of mental health care ('replacement' models) or providing collaborative care/support to PCPs in managing patients' mental health problems ('consultation-liaison' models). The participants were primary care providers. The outcomes included objective PCP behaviours such as diagnosis, prescribing and referral.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-eight studies were included involving more than 460 PCPs and more than 3880 patients. There was some evidence that 'replacement' model MHWs achieved significant short-term reductions in PCP psychotropic prescribing and mental health referral, but the effects were not reliable. Consultation rates were also reduced, but with even less evidence of a consistent effect. There were no indirect effects in prescribing behaviour on the wider population and no consistent pattern to the impact on referrals. 'Indirect' effects on PCP consultation rates were not assessed. There was some evidence that 'consultation-liaison' model MHWs had a direct effect on PCP prescribing behaviour when used as part of complex, multifaceted interventions. Few studies examined the 'indirect' effects of such interventions, and those that did failed to provide evidence that 'direct' effects were generalisable to the wider population or endured once the 'consultation-liaison' intervention was removed.

REVIEWER'S CONCLUSIONS

This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.

Counselling in primary care: a randomised controlled trial

A randomised controlled trial of the effectiveness of counselling (In-House Counselled (IHC) group) compared to routine advice from General Practitioners (Routine Treatment (RT) group) was conducted with three practices and a total of 188 patients in East Sussex. Changes in interpersonal problems using the 32 item Inventory of Interpersonal Problems, symptoms of psychological distress using the Symptom Index and self esteem using Repertory Grids were compared between groups at four months and after a further four month follow-up. A questionnaire monitoring patient service satisfaction was given to those who had received In-House counselling. The number of counselling sessions, early withdrawals and refusers was also monitored. In order to facilitate interprofessional communication, the three counsellors and a GP representative from each practice met monthly for an Action Learning group, led by an external facilitator to provide a forum to discuss working practices. The group met six times for two and a half hours. An audit of the participants' medical notes was carried out at the end of the study to establish any changes in subsequent use of medical services and prescribing patterns. The results show that patients within both groups improved considerably, in line with similar studies. The IHC group was significantly less likely to be referred out to mental health services. However, there was no statistical difference between the groups on any of the measures or in changes in subsequent service use or prescribing patterns. This may have been a result of Action Learning Group producing more psychologically minded GPs. Patients in the IHC group were overwhelmingly in favour of counselling and stated that it had helped them with a variety of psychological problems.

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice

OBJECTIVE

This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices.

METHOD

Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments.

RESULTS

Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls.

CONCLUSIONS

The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.

Family practice physicians' firearm safety counseling beliefs and behaviors

The purpose of this study was to identify family physicians' firearm safety counseling beliefs and behaviors. A survey was mailed to a random sample of 600 members of the American Academy of Family Physicians. A three wave mailing technique was used to maximize the response rate and yielded 271 usable surveys (55% response rate). Outcome measures included training experience in firearm safety counseling, the prevalence of firearm safety counseling by family physicians, and their perceptions regarding such counseling. The majority (78%) of family physicians lacked formal training on how to counsel patients about firearm safety and 49% believed more time should be spent in residency programs on firearm safety counseling. The majority (84%) of respondents never or rarely counseled patients on firearm safety and 50% believed firearm safety counseling should be a low priority in their delivery of primary care. The majority of respondents did not regularly counsel patients about firearm safety, did not believe firearm safety counseling should be a priority, and did not believe firearm safety counseling would be effective in reducing firearm-related trauma.

The rise of counselling and the return of alienism

Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with "severe mental illness," largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of "the mad." Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.