Common mental health problems in primary care

Most people with a mental illness in England are dealt with in primary care, yet mental illness is unrecognised in two thirds of those attending. So what can general practice nurses do about it?

People may visit a healthcare professional in primary care and discuss other concerns that are impacting on, or are related to, their mental health. It is the responsibility of healthcare professionals working in primary care to identify common mental health problems, assess the severity, provide relevant information, and offer the correct treatment options. This article has been written to guide healthcare professionals through this process.

Common mental health problems cause distress and can influence the overall economy.¹ Conditions such as depression, generalised anxiety disorder (GAD), social anxiety disorder, panic disorder, obsessional compulsive disorder (OCD), and post-traumatic stress disorder (PTSD) are regarded as common mental health problems.²

The authors of the Adult Psychiatric Morbidity Survey (APMS)³ reported that 43% of adults in England thought that they had had a mental health condition at some point in their life (35% men vs 51% women); but only 19.5% of men and 34% of women had been given a professional diagnosis. A national survey of wellbeing indicated that 20% of people in the United Kingdom over the age of 16 had symptoms of anxiety or depression (females 22.5% vs males 17%).⁴

DEPRESSION

Depression has been described as one of the leading causes of disability globally.⁵ It has an adverse effect on the way a person feels, thinks, and acts. The symptoms can vary in each person and the ability to manage these symptoms is affected by their personality, resilience, family history, premorbid problems (such as trauma and sexual abuse), relationships and social problems.

There are nine criteria for diagnosis:⁶

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

3. Significant weight loss when not dieting, or weight gain.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day.

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation.

Types of depression

The different types of depression are:

• Subthreshold: fewer than five of the diagnostic criteria.
• Mild: five or more of the diagnostic criteria and the symptoms result in minor functional impairment.
• Moderate: five or more of the diagnostic criteria and between mild and severe functional impairment.
• Severe: most of the diagnostic criteria, and the symptoms significantly interfere with functioning (psychotic symptoms may also be present).
• Persistent depressive disorder: refers to low mood that has lasted for at least two years but may not reach the intensity of severe depression. The person can usually function day to day but feel miserable.
• Seasonal affective disorder (SAD): occurs when the days get shorter in the autumn and winter. It is thought that the lack of sunlight causes the hypothalamus to produce higher levels of melatonin (a hormone associated with sleep) and lower levels of serotonin (a hormone which affects mood, appetite, and sleep).
• Bipolar disorder: people with bipolar disorder have episodes of depression that often follow a period of mania. The symptoms of mania may include grandiose ideas, very high self-esteem, reduced need for sleep, racing thoughts and activity, and an enhanced pursuit for pleasure (such as sex, overspending and risk taking). Bipolar disorder is a severe mental illness.
• Perinatal depression: occurs during pregnancy or in the first 12 months after delivery.
• Premenstrual dysphoric disorder (PMDD): this is a severe form of premenstrual syndrome (PMS).

ANXIETY

When a person is in danger or is being threatened the normal response is fear. The fight or flight response is triggered, enabling the body to adapt psychologically and physically so they can either run away or fight. In the anxious person, the fight/flight response is triggered from an inappropriate stimulus. This stimulus maybe the thought of a threat or something going wrong in the future, or due to a particular situation. Anxiety can be a long-term disability with there being episodes of relapse and remission. Despite this, it is often unrecognised.⁶ Depression or substance misuse may also be present. The symptoms of anxiety are:

• A feeling of fear, worry, or unease that is persistent and interferes with daily activities.
• Avoidance behaviours (e.g., avoiding certain places or situations)
• Physical symptoms such as a racing heart, sweating or trembling.

For the disorder to be diagnosed, these symptoms should be present for at least six months and should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.⁶

Types of anxiety

The different types of anxiety are:

• Generalised anxiety disorder is characterised by excessive worry about different events, associated with heightened tension.
• Social anxiety disorder is a persistent fear of, or anxiety about, one or more social situations that is out of proportion to the actual threat from them.
• Panic disorder is categorised by recurring unforeseen panic attacks followed by at least one month of persistent worry about having another panic attack.
• Obsessive-compulsive disorder (OCD) is characterised by the presence of obsessions and/or compulsions.
• Post-traumatic stress disorder (PTSD) can develop after a stressful event or situation of an exceptionally threatening or catastrophic nature that is likely to cause pervasive distress in almost anyone.

ASSESSMENT

To determine whether someone has depression and/or anxiety there are screening questions available. The person simply answers ‘yes’ or ‘no’; if they answer yes to either question the healthcare professional should explore whether this is something they want help with and consider further assessment of the mood symptoms they are experiencing (see Box 2). An answer of ‘No’ to the first four questions indicates that the person is unlikely to have depression or anxiety. If the person answers yes to one of the screening questions and then declines help, this is usually because they do not have an underlying depression or anxiety. They should be given the option of coming back to see a healthcare professional should they change their mind.

An answer of ‘Yes’ to any of the questions should trigger a more detailed assessment, using the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder assessment (GAD-7). When a person presents with a possible common mental health problem, they should always be asked directly about suicidal ideation and intent.

TREATMENT

People with mild to moderate problems are usually treated in primary care. Those with moderate to severe problems will receive treatment from other agencies including Increasing Access to Psychological Therapies (IAPT) and mental health specialist services.

Primary care

The responsibilities of healthcare professionals working in primary care regarding common mental health problems are outlined in national guidance:⁷

• Active monitoring or watchful waiting, this is a decision between the clinician and the person to not treat the condition, and to intermittently reassess its status along some rational time course in follow-up.⁸
• Offering recommendations to promote physical wellbeing, such as sleep hygiene, the benefits of following a regular exercise programme and eating a healthy diet, reducing caffeine and alcohol intake if appropriate, taking medication as prescribed and adequate rest and relaxation.
• Advising on ways to improve psychological wellbeing, for example, structured problem solving, sharing worries with others, self-help books, making lists, assigning worry time, activity planning, distraction techniques, mindfulness, relaxation, and self-monitoring diaries.
• Suggesting ways to enhance social wellbeing, such as adult education, meeting up with friends, visiting the library, catching up with relatives, and walks in the park.
• Identifying the correct treatment options taking into account the person’s past experience, previous treatment, symptoms, severity, functional impairment, physical health problems, and personal and social factors.
• Providing relevant information, including the nature, content and duration of the proposed treatment, acceptability and tolerability of the proposed treatment, possible interactions with any current treatments and implications for the continuing provision of any current treatments. Suggesting helpful websites (See Resources).
• Offering treatment. Discussing with the person the symptoms to treat first and the choice of intervention, suggesting the least intrusive, most effective intervention first.
• Making an appropriate referral by taking account of the person’s preference when choosing from a range of evidence-based treatments (listed below). If the person also presents with harmful drinking or alcohol dependence, they should be referred for treatment of this first.
• Considering special needs by providing or referring for the usual treatments when a mild learning disability or mild cognitive impairment is present and adjusting the method of delivery or duration accordingly; and consulting a specialist when there is a moderate to severe learning disability or a moderate to severe cognitive impairment.
• Antidepressant medications are an effective treatment for people with moderate to severe depression. Those who have had a newly prescribed antidepressant or have a change in dose or type, should be reviewed two weeks later to assess the effect.

Treatment options delivered by other agencies

There is a wide range of treatment options which can be used for the different conditions:⁷

• Psychoeducation.The aim is to teach the person about their condition and its treatment and allow them express how they feel about it.
• Educational and employment support services aim to increase awareness of mental health at work and providing support for businesses in recruiting and retaining staff. They are led and supported by employers; more information is available at www.mindfulemployer.net
• Individual or group cognitive behavioural therapy. Cognitive (thoughts) behavioural (actions) therapy (CBT) is a psychological intervention where the person works collaboratively with the therapist to learn how their thoughts, beliefs and attitudes affect their feelings and behaviour. They are also taught coping skills for dealing with different problems.
• Individual self-help. This can be facilitated or done alone. It involves the person using a range of books, manuals and electronic materials based on the principles of CBT.
• Computerised cognitive behavioural therapy (cCBT) is a form of cognitive behavioural therapy that is delivered through a stand-alone computer-based or web-based programme over a period of nine to 12 weeks.
• Structured physical activity. These programmes are defined as structured and group-based (with support from a competent practitioner) and usually comprise of three sessions (24-60 minutes) per week for 12 weeks.
• Group-based peer support (self-help) programmes involve giving and receiving non-professional, non-clinical assistance from individuals with similar conditions or circumstances.
• Exposure and response prevention (ERP) is a psychological intervention used for OCD. The person is exposed to the feared situation with the support of a practitioner and taught ways of coping with their anxiety, distress or fear.
• Trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) is a psychological intervention for PTSD. The person is asked to concentrate on an image connected to the traumatic event and the related negative emotions, sensations and thoughts while watching the therapist's fingers moving from side to side in front of their eyes. They then discuss these with the therapist. This procedure is repeated, emphasising the difficult and enduring memories. When the distress about the image has lessened, they are asked to concentrate on it while having a positive thought relating to it.
• Interpersonal therapy (IPT) focuses on the person’s interactions. They work with the therapist to identify social conflicts, role transitions, grief and loss, and social skills, and their effects on existing symptoms, feelings, and problems. They are taught how to cope with or resolve such problems or conflicts.
• Behavioural activation (BA) is a psychological treatment that aims to reduce symptoms and problematic behaviours through behavioural tasks related to reducing avoidance, activity scheduling, and enhancing positively reinforced behaviours.
• Behavioural couples therapy aims to help people understand the effects of their interactions with each other as influences in the development and maintenance of symptoms and problems. The therapy involves working to change the nature of the interactions so that the mental health problems improve.
• Counselling is a supportive approach which helps patients to explore their feelings and problems and make appropriate changes in their lives and relationships.
• Short-term psychodynamic psychotherapy. The therapist and the person explore and gain understanding into conflicts and how these are represented in current situations and relationships.
• Combined interventions are the use of more than one treatment.
• Applied relaxation is the application of muscular relaxation in situations and occasions where the person is or might be anxious.

SUMMARY

Healthcare professionals in primary care have a responsibility to assess people for a common mental health problem. If identified, they should provide them with suggestions to aid physical, psychological, and social wellbeing, give them information about the treatment options and make referrals as appropriate.

• Now read the featured module, Depression for general practice nurses for a more detailed guide to the treatment of depression.

REFERENCES

1. McManus S, Meltzer H, Brugha T, et al. Adult psychiatric morbidity in England, 2007: results of a household survey; 2009 NHS Information Centre for Health and Social Care: Leeds.

2. NICE CG123. Common mental health disorders: Guidance and guidelines; 2011. https://www.nice.org.uk/guidance/cg123

3. Stansfeld S, Clark C, Bebbington P, et al. (2016) Chapter 2: Common mental disorders. In S. McManus, P. Bebbington, R. Jenkins, & T. Brugha (Eds.), Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

4. Evans J, Macrory I and Randall C. Measuring national well-being: Life in the UK, 2016. ONS. https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/2016#how-good-is-our-health

5. Vos T, Barber RM, Bell B, et al. (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2015;386(9995):743-800.

6. American Psychiatric Association (APA) (2013). The Diagnostic and Statistical Manual of Mental Disorders. 5th edition. 2015; Arlington (VA): APA.

7. NICE QS53. Anxiety disorders Quality standard; 2014. https://www.nice.org.uk/guidance/qs53

8. Hegel M, Oxman T, Hull J, et al. Watchful waiting for minor depression in primary care: remission rates and predictors of improvement. Gen Hosp Psychiatry. 2006;28:205–12.