Psychological therapies - types of

Article about types of psychological therapies - technical - UK primary care based.

Types of psychological therapies

Low intensity treatments are brief interventions that can be offered to patients with mild to moderate:

  • Depression - computer based cognitive behavioural therapy, guided self help, and behavioural activation exercises
  • Panic disorder - computer based cognitive behavioural therapy, guided self help, and pure self help
  • Generalised anxiety disorder - computer based cognitive behavioural therapy, guided self help, pure self help, and psychoeducational groups
  • Obsessive compulsive disorder - guided self help only.

High intensity treatments are usually face to face sessions. They can be offered to patients with:

  • Depression (mild, moderate, or severe) - cognitive behavioural therapy, interpersonal therapy, behavioural activation
  • Depression (mild or moderate) - counselling, couples therapy
  • Panic disorder (mild, moderate, or severe) - cognitive behavioural therapy
  • Generalised anxiety disorder - cognitive behavioural therapy
  • Social phobia - cognitive behavioural therapy
  • Post traumatic stress disorder - cognitive behavioural therapy, eye movement desensitisation, and reprocessing
  • Obsessive compulsive disorder - cognitive behavioural therapy.

You can also offer high intensity treatment to patients who do not respond to low intensity treatment even if they have a moderate condition.

Low intensity therapy delivered by psychological wellbeing practitioners

  • Computerised cognitive behavioural therapy
    • This is an interactive computer programme that helps patients challenge negative patterns of thought
  • Pure self help
    • Patients are given written materials to help them work through their problems
  • Guided self help
    • Patients are given written materials and support from a therapist, usually at the beginning, middle, and end of the programme
  • Behavioural activation
    • Behavioural activation focuses on activity scheduling
    • Patients are encouraged to try activities they are avoiding and analyse why they are avoiding these activities. For example, due to a lack of motivation
    • Patients with depression who have this treatment become focused on achieving their goals, while improving their symptoms of depression
  • Structured exercise
    • Patients attend a structured exercise programme of up to three sessions a week for 10-12 weeks
  • Psychoeducational groups
    • Psychoeducation is a form of education for patients and families or carers of patients with mental health problems
    • Patients are given education about their problem and how to manage their condition

High intensity therapy

Other than cognitive behavioural therapy, other types of high intensity treatment include:

  • Interpersonal therapy
    • Interpersonal therapy is a type of face to face psychotherapy. It is based on the concept that mood is connected to interpersonal events and relationships with people. The therapist helps the patient learn new ways of relating to people, which can improve the symptoms of depression
  • Counselling
    • Counselling is a form of psychotherapy. The counsellor does not give answers but listens and encourages the patient to find solutions to a particular problem or challenge
  • Couples therapy
    • This therapy helps people who are in a relationship to work through their difficulties.

Clinical tips

The patient health questionnaire 9 is a depression assessment tool that is validated for use in primary care.

The tool is short so patients can be assessed during a GP consultation. You should ask the patient "Over the last two weeks, how often have you been bothered by any of the following problems?"

  1. Little interest or pleasure in doing things
  2. Feeling down, depressed, or hopeless
  3. Trouble falling or staying asleep, or sleeping too much
  4. Feeling tired or having little energy
  5. Poor appetite or overeating
  6. Feeling bad about yourself; or that you are a failure or have let yourself or your family down
  7. Trouble concentrating on things, such as reading the newspaper or watching television
  8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
  9. Thoughts that you would be better off dead, or of hurting yourself in some way

You should ask them to score each of these criteria with one of the following:

  • Not at all - 0 points
  • Several days - 1 point
  • More than half the days - 2 points
  • Nearly every day - 3 points

The severity of the patient's symptoms is based on the PHQ-9 score:

  • 0-4 none
  • 5-9 mild
  • 10-14 moderate
  • 15-19 moderately severe
  • 20-27 severe.

The maximum total score is 27 points. You should add up the total score and read code this in the patient's medical records - for example, 20/27. You should ask patients to complete the assessment tool at their first consultation and at subsequent consultations to monitor their progress.

The generalised anxiety disorder questionnaire (GAD-7) is used as a screening tool to measure the severity of anxiety for generalised anxiety disorder.

You should ask the patient "Over the last two weeks, how often have you been bothered by any of the following problems?"

  1. Feeling nervous, anxious, or on edge
  2. Not being able to stop or control worrying
  3. Worrying too much about different things
  4. Trouble relaxing
  5. Being so restless that it is hard to sit still
  6. Becoming easily annoyed or irritable
  7. Feeling afraid as if something awful might happen

You should ask them to score each of these criteria with one of the following:

  • Not at all - 0 points
  • Several days - 1 point
  • More than half the days - 2 points
  • Nearly every day - 3 points

The severity of the patient's symptoms is based on the GAD-7 score:

  • 5-9 mild
  • 10-14 moderate
  • 15 or more severe

Clinical tip

If patients do not respond to treatment with medication and high intensity psychological therapy, you should:

  • Check the patient is taking the drug and if they are having side effects
  • Gradually increase the dose of the drug in line with British National Formulary guidelines
  • Consider changing the drug
  • Offer referral to specialist mental health services.

Note: The improving access to psychological therapies (IAPT) programme is specifically about implementing NICE guidelines for common mental health problems and making the psychological therapies that are recommended more accessible. There was a commitment made by the Secretary of State for Health that within three years this programme would deliver 3600 new therapists, treat 900 000 people of whom half would be expected to recover, and ensure that GPs had access to the service for their patients.

The characteristics of the service are:

  • The delivery of stepped care
  • A service aimed at adults of working age
  • A commissioner led service
  • Self referral for patients
  • Measuring outcomes

Patients from black and ethnic minority groups

Patients from ehnic minority groups can have specific physical health and mental health problems. It has been shown that these populations have high rates of chronic diseases, such as diabetes and cardiovascular disease, and poorer general health. It has also been shown that women born in India and East Africa have a 40% higher rate of suicide than the general population. The Count me in Census has shown that these groups are also three times more likely to be admitted as inpatients to mental health units. Barriers to access to psychological therapies include:

  • Communication difficulties
    • For example, if therapists only speak English, patients may not be able to effectively communicate
  • Cultural understanding of mental health problems
    • For example, in Punjabi, Urdu, and Hindi there is no direct translation of the word depression
    • Patients may not understand what psychological therapies are
  • Stigma surrounding mental health problems
  • Lack of availability of therapists of a particular sex.

Patients who are from minority ethnic groups should be able to access psychological therapies. GP practices, practice based commissioning groups, and PCTs can improve access for these groups by:

  • Working with faith and community groups - such as churches and youth groups
    • You can increase knowledge about services by engaging with these groups
    • Patients from black and minority ethnic populations often contact their faith group first, when they are depressed
  • Providing an interpreter service or qualified translators
  • Providing a telephone answering service in multiple languages
  • Translating leaflets about psychological therapies into languages that are relevant for your community and translating self help materials into other languages
  • Offering self referral to psychological therapies
    • When offered self referral, patients from black and minority ethnic populations were more likely to attend the service
    • This may be because self referral is more culturally acceptable for these patients.

Patients with disabilities

It has been shown that up to 15% of adults with severe learning disabilities have a behavioural disorder either as a result of their disability or because of an underlying mental health problem. You should be aware that:

  • There are assessment tools that are adapted to assess the mental health of patients with learning disabilities
  • Patients with disabilities may present with behavioural problems when they have anxiety and depression
  • It has been shown that patients with mild learning disabilities may benefit from psychological therapy.

Clinical tip

There needs to be a flexible service when providing psychological therapies for individuals with children. Parents may need to:

  • Bring their child to the appointment
    • Parents may need a longer sessions if they bring their child to the appointment
  • Have home visits if the baby is young
  • Arrange appointments around childcare
  • Arrange appointments when the parent is attending for the baby's health checks
  • Have close contact with other appropriate services such as the health visitor
  • Be given recommendations for local mother and toddler groups.

Key points

  • Psychological therapies can be either low intensity or high intensity such as counselling
  • Improving access to psychological therapies can be a cost effective way to improve patients' health
  • Patients who self refer for psychological therapies often have the same severity of depression or anxiety as patients who are referred by their GP
  • By working with faith groups, schools, and community organisations you can promote access to psychological therapies for patients who may not want to see their GP

Clinical tip

You should ask about symptoms of anxiety and depression in patients with physical illness and assess them using the PHQ-9 or GAD-7 questionnaire. This is because anxiety and depression can be a cause of physical illness or due to physical illness.

You should always remember that when treating patients you should tailor the treatment to the individual. You may also have access to other services outside of the NHS, such as university counselling services, which may be appropriate for some patients.

In this article we have highlighted those treatments with the best evidence and which are approved by NICE. Treatments with less evidence include:

  • Hypnotherapy
  • Relaxation therapy
  • Problem solving therapy
  • Social skills training.

Note: Depression and anxiety often coexist with other physical illnesses. Medical problems that are associated with mental health problems include:

  • Cardiovascular disease
  • Diabetes
  • Chronic obstructive pulmonary disease
  • Chronic pain
  • Sickle cell disease
  • Rheumatoid arthritis
  • Stroke.

Psychological therapies have been shown to improve the health of patients with long term conditions, such as diabetes, and improve their ability to manage their condition.