Editorials
Making Psychotherapy Work in Primary Care Medicine
Ideally, psychotherapy and pharmacotherapy are complementary and synergistic.1,2 They are inseparable because all clinical encounters, even those limited to medication management, contain at least informal psychotherapeutic elements and opportunities. However, not all patients can or will participate in explicitly combined treatment. Some will not tolerate psychotropic drugs, either physiologically or as a matter of personal choice. Other patients cannot overcome a sense of stigma associated with mental health services, or they lack sufficient ability to trust, to introspect, to communicate, or to learn, all traits important for effective psychotherapy.
Given this complexity of individual presentation and response, what should a primary care physician do? In this issue of American Family Physician, Rupke and colleagues3 reasonably suggest that for mild to moderate depression, most patients may choose their treatment. Patients unfamiliar with psychological treatments may make more informed decisions if they understand from the beginning that psychotherapy is not "just talking" but involves becoming stronger and wiser through effortful change and learning.
As part of a balanced approach to treatment selection, it can be helpful to present medication in the same light (i.e., not as a stand-alone "cure" but as a tool to help patients actively examine and improve their lives). When discussing patient choices, it also is helpful to remember that sometimes treatment preferences can be part of the problem, such as when victims of domestic violence request medication with the dysfunctional expectation that they will no longer need to face their life problems, or when a patient's request for counseling stems from a desire to influence or have a special relationship with the physician.
Once a patient is interested in psychotherapy as a treatment option, or when clinical factors mandate its consideration, the physician must decide which patients may receive treatment from the physician and which patients need referral to a mental health subspecialist.
For physicians considering counseling in the office setting, the following are issues to consider:
• Does the patient have a sufficiently positive relationship with you, one that is characterized by warmth, trust, and willingness to openly disclose information? The most robust finding in psychotherapy research over one half century is that the quality of the therapeutic alliance is the best predictor of treatment outcome.
• Does the patient's insurance restrict mental health treatment or impose special managed-care requirements for patients with psychiatric diagnoses? Clarification of these issues is an essential element of treatment planning, because a plan that does not match available resources cannot be implemented.
• Does the patient have any concerns about relationships that you may have with other persons? Although a family physician's knowledge of and access to other family members is a potentially valuable clinical asset, it cannot always be therapeutically deployed without risk to the therapeutic alliance.
• Does the patient have a need for the enhanced confidentiality often available in mental health settings? The Health Insurance Portability and Accountability Act made special provisions for the separate physical and legal treatment of psychotherapy notes. Other laws in many jurisdictions, as well as in federal courts, provide a legal privilege for specialist mental health treatment that may not apply to counseling by a primary care physician. Any patient whose mental health and treatment may become an issue in litigation (including disability determination) may be better served by a subspecialist.
• Does the patient have complex comorbidities, a personality disorder, or a history of significant interpersonal difficulties or early trauma affecting his or her capacity for healthy attachment? In these cases, referral to a subspecialist may be more desirable because such patients are at greater risk of complicated treatment courses and of re-enacting their interpersonal difficulties in the physician-patient counseling relationship. Patients with a history of physical or sexual abuse are at particular risk and may have difficulty establishing a useful psychotherapeutic relationship with a physician who also performs invasive procedures or genital examinations.
For physicians considering referral to a psychotherapist, the following are issues to consider:
• Do you have adequate information about the therapist's track record? Unlike medications, which have highly controlled chemical compositions, psychotherapy varies greatly according to the skill of the individual practitioner. Paper credentials are a reasonable place to start, but the best way to find skilled therapists is to keep track of patient experiences. Therapists to recommend are those who successfully engage and retain even difficult patients; therapists to avoid are those who have high rates of patient drop-out, noncompliance, and hospitalization, or those who fail to collaborate with other health professionals. Listening to your patients' post-referral experiences will help you develop knowledge of the therapists in your community and also may allow you to assist patients in extricating themselves from an unfortunate experience.
• Is the patient willing or able to tolerate the possibility that he or she will need to meet more than one therapist before finding a good match? Some trial and error in finding the right therapist is inevitable.
• Are the patient and therapist willing to collaborate with you? Therapists who insist on overly rigid interprofessional boundaries, or patients who will not allow their therapists to talk with their physicians, are exhibiting signs of potential trouble. Monitoring referral outcomes is important because poor-quality psychotherapy may cause serious harm, exacerbate presenting symptoms, or produce new symptoms as a result of defining unrealistic goals or tasks (psychotic decompensation or suicide would be extreme examples). A patient may lose trust in the physician or may even become disillusioned to the point of not obtaining necessary treatment in the future.4
Following these few principles will help patients get the most benefit from brief office counseling and from formal psychotherapy.
The Author
THOMAS E. SCHACHT, PSY.D., A.B.P.P., is professor in the Department of Psychiatry and Behavioral Sciences at the James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn. He received his doctorate in clinical psychology from Rutgers University, Graduate School of Applied and Professional Psychology, Piscataway, N.J. Dr. Schacht completed a medical psychology internship and fellowship at the Oregon Health Sciences University School of Medicine, Portland, and a postdoctoral research fellowship in psychosocial treatments research at Vanderbilt University, Nashville, Tenn.
Address correspondence to Thomas E. Schacht, Psy.D., A.B.P.P., Dept. of Psychiatry and Behavioral Sciences, James H. Quillen College of Medicine, East Tennessee State University, P.O. Box 70567, Johnson City, TN 37614 (e-mail: schacht@etsu.edu). Reprints are not available from the author.
REFERENCES
1. Jarrett RB, Kraft D, Doyle J, Foster BM, Eaves GG, Silver PC. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch Gen Psychiatry 2001; 58:381-8.
2. Scott J, Palmer S, Paykel E, Teasdale J, Hayhurst H. Use of cognitive therapy for relapse prevention in chronic depression. Cost-effectiveness study. Br J Psychiatry 2003;182:221-7.
3. Rupke SJ, Blecke D, Renfrow M. Cognitive therapy of depression. Am Fam Physician 2006;73:83-6,90.
4. Strupp HH, Hadley SW, Gomes-Schwartz B. Psychotherapy for better or worse: the problem of negative effects. New York: J. Aronson, 1977.
The 2006 Childhood and Adolescent Immunization Schedule: Reflections at the 50th Anniversary of the Polio Vaccine
See Practice Guideline on page
167.
The 2006 Recommended Childhood and Adolescent Immunization Schedule, published in this issue of American Family Physician,1 is a joint product of the Centers for Disease Control and Prevention's (CDC's) National Immunization Program, the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics. Its unveiling, during the 50th anniversary of the licensure of the Salk poliovirus vaccine, allows reflection on two basic premises of childhood and adolescent immunization. First, children are vaccinated to reduce serious illness and death. Second, any vaccine that comes into widespread use in the United States tends to diffuse into the developing world, usually at greatly reduced cost.
I have had the pleasure to serve the AAFP on vaccine policy issues and am one of two AAFP liaisons to the Advisory Committee on Immunization Practices (ACIP). My involvement with immunization issues has provided three profound experiences that I would like to share.
In March 2000, I represented the AAFP at the CDC's Measles Elimination Meeting. Like many family physicians entering practice in the early 1990s, I knew very little about measles and even less about disease elimination. I walked away with a newfound respect for measles and, after reviewing the extensive evidence, voted that measles had been eliminated from the United States. Accordingly, the United States has attained a level of vaccination at which sustained transmission of measles is no longer possible.2 That said, measles remains a leading cause of childhood death worldwide, accounting for an estimated 530,000 preventable deaths in 2003.3 The cost to immunize a child against measles in a developing country amounts to less than $1.
In October 2004, 36 years after licensure of the rubella vaccine, rubella received elimination status in the United States.4 Congenital rubella syndrome, with its attendant blindness, deafness, and heart defects, has been relegated to the past.
As a new liaison to ACIP in June 2004, I was invited to join the Meningococcal Working Group. With input from the AAFP Commission on Clinical Policy and Research and the AAFP Immunization Cooperative Advisory Group, I helped shape the recommendations for the recently licensed tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4; Menactra). Though relatively rare, meningococcal disease may result in significant sequelae for its victims and their families, communities, and health care professionals.5 In making the final recommendations, the working group and ACIP demonstrated interest in and response to the sensibilities and sensitivities of family physicians. Three target groups-children 11 and 12 years of age, adolescents at high school entry, and college freshmen planning to live in dormitories-were determined based on sound epidemiology, vaccine properties, and an interest in creating a "preadolescent platform" for appropriate vaccine delivery and discussion of other important preventive health issues. However, most cases of meningococcal disease occur in the developing world; U.S. cases account for only 0.1 percent of the estimated 171,000 meningococcal-related deaths each year.6
The past year brought a notable reemergence of pertussis. Waning immunity from the birth-to-five-years diphtheria-tetanus-pertussis/diphtheria, tetanus toxoids, and acellular pertussis vaccine series likely contributed to epidemic spread, especially in adolescents. The pre-adolescent visit provides an excellent opportunity to boost pertussis immunity. Two recently licensed tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis adsorbed (Tdap) vaccines, Adacel and Boostrix, contain antigens for tetanus, diphtheria, and pertussis and are approved for use in adolescents. Tdap vaccine can be administered safely with MCV4.
Fifty years ago, family physicians could only dream of the elimination of polio, measles, and rubella. Through the combined and cooperative efforts of researchers, manufacturers, public health practitioners, legislators, parents, pediatricians, and family physicians, these diseases are mostly memories. We are witnessing dramatic declines in varicella and hepatitis A infections and in invasive disease from Haemophilus influenzae type B and pneumococcus. Continued cooperative efforts to ensure high levels of childhood vaccine coverage are essential to protect our children and children throughout the world. To this end, the AAFP has approved the 2006 Recommended Childhood and Adolescent Immunization Schedule.
The Author
JONATHAN L. TEMTE, M.D., PH.D., is associate professor of family medicine at the University of Wisconsin Medical School, Madison. He also serves as the American Academy of Family Physicians' liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.
Address correspondence to Jonathan L. Temte, M.D., PH.D., University of Wisconsin Medical School, Department of Family Medicine, 777 S. Mills St., Madison, WI 53715 (e-mail: jon.temte@fammed.wisc.edu). Reprints are not available from the author.
REFERENCES
1. Advisory Committee on Immunization Practices, American Academy of Family Physicians, American Academy of Pediatrics. Recommended childhood and adolescent immunization schedule, United States, 2006. Am Fam Physician 2006;73:167-8.
2. Orenstein WA, Papania MJ, Wharton ME. Measles elimination in the United States. J Infect Dis 2004;189(suppl 1):S1-3.
3. World Health Organization. Measles. Accessed online December 9, 2005, at: http://www.who.int/mediacentre/factsheets/fs286/en/.
4. Centers for Disease Control and Prevention. Achievements in public health: elimination of rubella and congenital rubella syndrome-United States, 1969-2004. MMWR Weekly Rep 2005;54(RR-11):279-82.
5. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2005;54 (RR-7):1-21.
6. Atkinson W. Meningococcal disease. In: Epidemiology and prevention of vaccine-preventable diseases. 8th ed. Atlanta: Centers for Disease Control and Prevention, 2005.
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Academy of Family Physicians. |
