How do you decide which management approach to use with an individual patient?
Choosing an evidence-based treatment is important and patient preference is paramount. If a patient isn’t interested in a particular treatment, it won’t work.
Find out what the patient has tried in the past and what they thought of that treatment. Ask which treatments they are interested in trying and which they object to. If the patient has no special preference, I’d recommend CBT.
Also, consider the severity of the patient’s illness. People who are severely depressed and anxious may have difficulty with cognitive exercises involving a lot of thinking, processing and verbal information. Consider starting with more behavioural strategies – getting them active and participating in exercise.
Financial constraints are very important to consider as is access to treatment.
Access becomes particularly important in regional or remote areas where face-to-face psychological treatments may not always be available. Internet-based treatments are an option for people with access to the internet. Telehealth options may also be available where psychologists offer remote treatments using patient workbooks (possibly online) and regular remote treatment sessions (using the phone). Some telehealth services can be rebated through Medicare.
The eMHprac website is a valuable site with information on the available e-mental health resources
What are transdiagnostic treatments and when do you recommend them?
Transdiagnostic treatments are effective across anxiety disorders and some other mental health conditions. Like always, the patient needs to be interested in engaging with the program and it needs to be an evidence-based program. These programs not only treat the primary disorder, but also treat the comorbid disorders.
There is even some evidence that they are better at treating the comorbid disorders than diagnostic-specific programs. So, if the patient had a number of anxiety disorders, with or without a depressive disorder as well, a transdiagnostic program could be suitable.
If I was a GP with only 15 minutes to see the patient, I may struggle to diagnose a specific anxiety disorder, but I would probably be able to see if the patient was experiencing clinically significant anxiety. I would feel comfortable referring them to a transdiagnostic treatment as the specific disorder is less important. It doesn’t really matter if they have social phobia or GAD or PD; the processes underlying an effective CBT intervention are the same across all the anxiety disorders.
What are the essential elements that should be included in a mental health care plan?
A preliminary diagnosis is helpful. Is there an anxiety disorder? Is there secondary depression? Is there self-harm? Is the patient showing suicidal, homicidal or psychotic behaviours? A treatment history if possible, and some psychosocial history is useful as well. Is the patient working? Have they got family around?
Some GPs may have a preferred outcome assessment tool – for example the K10. The psychologist can administer this after the sessions with the patient and the GP can get a sense of whether the patient is moving forward.
Have you got tips for a GP who would like to deliver relaxation, problem-solving, graded exposure and mindfulness techniques?
It is always important to explain the rationale behind a treatment – why should the patient consider doing this treatment and how does it work?
Look at concrete ways of implementing the treatment and how to customise it to the patient’s needs. For example, with relaxation, the patient could download audio, buy a relaxation CD or download an app. Does the patient prefer a male or female voice?
Explore the barriers the patient may have in following the treatment.
- Do they have any fears about the treatment?
- Are their expectations realistic? For instance, do they think psychological treatments or meditation exercises will turn them into a hippy or change their personality in some way?
- Do they fear a medication will be addictive or make them psychotic?
If patients don’t hold realistic ideas about treatment, ask them to tell you more. Perhaps, they know someone who has had a bad experience. Talking to the patient and problem-solving the barriers is key.
Problem-solving therapy can help if the person has a problem for which they are responsible, and which can be addressed by changing behaviour. A problem with debt is the patient’s responsibility and can have a practical solution. Being worried about getting dementia decades into the future may be the patient’s responsibility but is not addressable directly in the present.
Learning how and when to act on problems is valuable. Knowing a problem is not the patient’s responsibility or there is nothing they can do about it can help with letting go.
For graded exposure, I would expect most GPs to refer the patient to a specialist – not because they can’t do it, but because they may not have enough time in the consultation. When you ask a patient to do something intimidating and frightening, it needs to be done within a trusting and safe relationship. Many GPs establish that with their patients, but you need to give the patient the time to desensitise and habituate, and this doesn’t usually happen in 15 minutes.
If the GP would like to manage the graded exposure themselves, I would recommend using external resources to support the process. There are excellent online resources (online programs and workbooks) that go through the principles of overcoming fears. These are usually embedded in a CBT package.
For all treatments, the GP plays an important role in holding the patient accountable. Regularly ask how the patient is coming along with the treatment.
For example, someone with arachnophobia, you may ask ‘Last week you were going to look at pictures of cartoon spiders. How did you go with that?’ If you never ask, the patient is more likely to stop doing it.
Is there anything else you would like to say to GPs treating patients with anxiety?
GPs really do a great job. They are the gateway, helping people to realise and say that they are struggling with anxiety, and helping them to have the courage to consider treatment and seek a specialist.
I think hope is a really important thing. Anxiety disorders are chronic, and not everything will work for everybody. Specialists may come in and come out of a journey, but if the GP can be there for the patient in an ongoing way, it is so important.
You can’t underestimate the power of being hopeful and consistently being willing to help and saying, ‘let’s do it together!’.