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One-day Conference on Clinical Psychology in Primary Care. A need and a right for individuals

The Catalan version of this chronicle, which was held in Madrid on Novembrer 19, 2013, has been published in PSIARA, College of Psychologists of Catalunya, on January 2013

http://www.psiara.cat/view_article.asp?id=4183

From the very title the day promised to be of great interest and of course it was. The attendance was remarkable, about 600 professionals present in the hall. The most glaring absence was of the representatives of the Ministry of Health, despite several invitations they had been sent. This absence reflects quite accurately the attitude of health authorities regarding psychological assistance in public care, not different from the one shown to related topics, such as the development of the Master in Health Psychology.

Dolores Gomez, Member of the Governing Board, General Council of Psychologists opened the day. She said there is consensus viewing  Clinical Psychology as the first level of approach in primary care, for without going further, 43% of medical consultations are related to mental health and 23% of the prescriptions are for psychopharmacological drugs, concluding that psychological care is what society is demanding.

Francisco Santaolalla, President of the General Council of Psychologists elaborated on what would be a recurring theme throughout the day, the effectiveness and efficiency of Clinical Psychology, especially for the attention of a vast panoply of minor mental pathology existing without diagnosis. Santaolalla also regretted the absence of a representative from the Ministry of Health.

Antonio Alemany, General Director of Primary Care, Community of Madrid, insisted on a basic fact for him, that primary care constitutes the first system of mental health care and thus Clinical Psychology can improve prevention and health promotion, focusing both on the individual and the community, even in health education, the goal being to avoid medication, which is already the case in some places. He referred to programmes in Murcia, and stated that the issue is being studied in Catalonia. Attention must be biopsychosocial he said, and ended up stating that consultations with the Mental Health Centres were included in the 2010-14 Strategic Plan for Madrid.

After the presentation, the conference consisted of two lectures and three tables for several communications, one in the morning and two in the afternoon, the latter also acting as the closure.

As the two lectures were the main events of the day, we’ll review them first.

Tor Levin Hofgaard, Chairman of the Norwegian Psychological Association, outlined firstly with some brushstrokes the health reality in his country. Norway has a population of 5,000,000 inhabitants, with a 3% unemployment, which is not really true unemployment; most are off work out of illness and disability. Primary care comes under the responsibility of the municipalities and secondary assistance under the responsibility of the state, distributed in 4 areas.

The health system has 4,700 general practitioners, 4292 specialists, 2069 nurses and 230 clinical psychologists. En passant, Tor Levin told us that six years of undergraduate and five years of special studies are required to obtain the clinical specialization. At present only 25% of the municipalities have a psychologist, but the system’s goal is that every municipality have one.

Coming to the topic of the day, the psychological attention in primary care, Tor Levin told us, with humour and a point of friendly irony, that we psychologists forget that we are when we talk to politicians. As clinicians we know too well that mere information does not cure or change anyone, so how is it that we persist overwhelming politicians with data they are the least interested in hearing?

Let’s stop complaining and talking about us and our problems, let’s talk instead about what society needs, including their own (the politicians) problems, not ours. In Norway psychologists are getting on successfully with this strategy, they have stopped uttering objective data; they just tell stories and bring patients to politicians’ offices.

We also have to change the primary care system. Roughly speaking, everyone may assume that a in a step-by-step system, the way to address mild depression or other conditions should be: 1) placebo, 2) self-help, 3) Cognitive Behavioural Therapy for 10 weeks, 4) clinical psychologist. If you look closely, added Tor Levin, this scheme is designed to focus on the patient with a medical problem, not at all a mental one. When the patient afflicted with a mental ailment comes to consultation he has spent months or years making the decision of asking for help. Receive him with this approach means rejecting him (Tor comments by the way that this scheme did not work with him). Let’s do it the other way around, he says, let’s put the clinical psychologist in the first place, and he will know what should be done, saving intermediate steps, or even appealing to community resources, the family or any other kind of context.

The speaker also spoke at length about what he called the “windows of opportunity”, namely taking advantage of every opportunity of political intervention, though sometimes it means a step back, but anyway following the path to the desired goal. As an example of the latter, he explained that in his country clinical psychologists engaged in a fierce struggle getting the right to prescribe coercive treatment with the same authority as psychiatrists did, something that might upset a lot of them but got the tactical purpose of not having less authority than them in the health system.

In the second lecture we listened to Rebecca Johnson, Clinical Psychologist. Primary Mental Health & Talking Therapies Service. Kingshill Centre. Wednesbury. UK.

She began by referring to the IAPT program (Improving Access to Psychological Therapies), located within the NICE (National Institute for Health and Clinical Excellence). Rebecca told us that in the UK 3600 psychologists were hired between 2008 and 2011 to carry through the program for primary care (aiming at hiring up to 8000 in six years), using only an aggressive approach of cognitive behavioural therapy.

The results to date have shown that the program is profitable, having fulfilled its goals in an acceptable manner, for instance among other achievements, having brought back to their jobs thousands of workers off work. Going into more detail Johnson told us that not all recruits were qualified psychologists but professionals who had also other qualifications, such as social workers or mental health nurses. These had been given intensive training in CBT. Although it is considered that the results are good, it was found that 40% of patients who completed treatment showed no clinical improvement, and thus a second line was also required. In our service says Rebecca we have eleven trained nurses working in CBT and as a complementary line for patients who do not respond to CBT we have several other professionals doing psychotherapy: Schema Therapy, Attachment Psychotherapy, Systemic, Rational emotive, Cognitive Analytic Therapy and EMDR. As a curiosity Rebecca informs us that Asperger’s patients love CBT, because it coincides very much with their way of thinking.

Invited to speak more personally about the overall outcome of the program IAPT, the speaker confessed that her valuation fluctuated by seasons. She said that it is true that on one side IAPTR has actually increased people’s access to psychotherapy in general, but it is also true that they have that 40% unresponsive to CBT and so other approaches are needed. As one of the programme’s impacts on the profession of clinical psychologist Rebecca told us about the possibility of allowing other professionals into psychotherapeutic tasks but with lower salaries, and about the severe increase in university fees for students of psychology which has resulted in the decline in the number of psychology professionals.

Comparing both lectures, we clearly see that the first is political, while the second is clinical. Both, for their specific messages and the difference between the two levels are most useful for us. The first lecture allowed us to see a “politician” psychologist, used to dealing with those responsible for health, addressing them in their own language, while in the second we had the opportunity to listen to a professional with an ostensible clinical approach, sensitive to the diversity and the fact of psychopathological human suffering.

Following is  a panoramic overview on the three roundtables.

FIRST TABLE

Monica Cavagna, Sociologist. Master in Health Economics and Pharmacoeconomics, presented the outcome of the OCU study on access to mental health from primary care. She began emphasizing something that is already accepted in the NHS and NICE guidance, as well as from the London School of Economics: “The empirical and scientifically validated psychotherapy is the first line of intervention in primary care as well as a right of the patient. ”

The OCU study synthesized the results of a survey conducted in Madrid and Catalonia:
1) Just using a medical approach weathers the storm,  although everybody agrees that drugs are only useful in the short term
2) Doctors are aware that their work is only a contention wall.
3) 90% of the consultations in Mental Health Centers are of primary care.
4) There are several clinical psychological models, the OCU considered necessary not only more psychological attention, but also with greater control and based on scientific evidence.

Esperanza Dongil Collado, Professor at the Faculty of Psychology at the Catholic University of Valencia presented the results of their investigation of drugs consumption in Spain.
1) Between 2000 and 2007 anxiolytic consumption increased by 160% (considered European Average 100)
2) Women double men in psychopharmacological drugs use.
3) In primary care each patient with generalized anxiety disorder annual costs € 5,730 more than the same patient if the consultation is only medical.
4) In primary care, 28% of patients develop psychiatric drugs addiction.

Javier García Campayo. Psychiatrist and Associate Professor. Miguel Servet Hospital and University of Zaragoza, presented his findings on the cost-effectiveness of psychotherapy in primary care. He said that “we have to show the cost effectiveness of including Clinical Psychology in Primary Care.” He found that 25 to 33% of primary care patients suffer from psychological distress, only 5% of them being referred to the Mental Health Centres, which are already collapsed.

NICE guidelines recommend not administering drugs for mild depression. But as psychotherapy is more expensive than psychopharmacological attention, with the opportunities offered by new technologies, we aim to online better care for depression. There are already programs like “Beating the Blues” or ” Blues bygone “, in Spanish we have another program “Sonreir es divertido” (Smiling is fun) and  psychologists must accept that in the future there will only exist what comes in a Smartphone.

Antonio Cano, Professor of Basic Psychology, School of Psychology at the Complutense University of Madrid, presented his paper “Prevalence of emotional disorders in primary care: PSICAP Project”. He agreed that mental pathology extends from 30 to 50% of the primary consultations, but only 1 out of 3 patients is properly treated, i.e., by methods of scientific evidence. He mentioned that in the UK 3000 hired psychologists and their results have proved profitable, also in the U.S. they have hired psychologists, with good results too.

Antonio Cano presented his psychotherapy project, sponsored by COP Madrid. The PSICAP consists in administering CBT to a population of 1126 patients in two groups, 563 each, an experimental and a control one along 9 sessions. Assessments are performed pre-treatment, post treatment and again, several months later. This project is based on a pilot one, carried out for 43 patients (23 treated and 20 in the control group), with improvements in all clinical variables considered.

TABLES IN THE AFTERNOON

Miguel Costa Cabanillas. Clinical Psychologist,  Mental Health Centre.  He talked about psychological experiences in Primary Health Services, Madrid. It was a very interesting communication, the only one in the course of the day with a clear vocation to transcend the strictly clinical care to align with overall psychological care, striving for contextual changes and community care as an essential task of the psychologist.

Sara Gonzalez, Clinical Psychologist, University Hospital Marqués de Valdecilla. Cantabria. In her communication, “Early intervention for depression in primary care centres in Asturias”, she presented a comparative study focused on three approaches: 1) CBT, 2) Brief systemic solution-focused treatment, 3) Placebo group support and discussion group, all compared with 4) Waiting List.
In general the results 1 and 2 are higher than 3 and 3 higher than 4. In the short term there is no difference between 1, 2 and 3. As long-term results, 1 and 2 are higher than 3. Not surprisingly, data shows that the better the patient’s social adjustment and the lower their psychopathological background the better the outcome in each case.

Olga Pérez Ibáñez, Clinical Psychologist, Mental Health Centre, Castelldefels, Parc Sanitari de Sant Joan de Deu, Barcelona. She presented her descriptive study of psychological interventions in the Support Programme for Primary Health Care in the Province of Barcelona. She described, without analyzed results, a program of support from Mental Health Centres to Primary Care Centres, developed in several centres in Catalonia, (Granollers, Cerdanyola, Castelldefels). In Catalonia it is estimated that 30% of Primary Care consultations are related to mental health.

Luis Javier Sanz, Clinical Psychologist, CEDT Azuqueca de Henares, Guadalajara. He presented “Experiences in alternative treatment settings for coordination between primary care and mental health assistance: The pilot experience of Azuqueca de Henares”. He described the implementation of a plan of coordination and referral between primary care and mental health care. In a very illustrative and suggestive way he described the reciprocal images primary care physicians and mental health professionals have of each other. The latter believe that primary care physicians are patients poor holders, become quickly distressed if the patient cries and so they refer them without enough motives. For his part the primary physician thinks that the mental health professional is not available, gives confusing information and often discharge patients too soon.

Julio Martin, Clinical Psychologist, Head of welfare programs, Mental Health Branch, Murcia Health Service, and Ascension Garriga, Clinical Psychologist. Responsible for the training multiprofessional unit, Murcia, talked on “Adaptation of shifting of clinical psychologists as residents in primary care”. Alluding to the “windows of opportunity” mentioned by Tor Levin, they mentioned ironically that they had had one. The Lorca earthquake had led to the hiring of two psychologists (now  just one of these two contracts still remaining). They elaborated on the advantages of the Program of Internal Residents, describing rotations in primary care, first just a month and then extended. Julio insisted that the clinical psychologist is fully prepared to enjoy greater flexibility competence and not bound to give the same medicine to all patients.

CLOSING TABLE

Maria Paz Garcia Vera, Clinical Psychologist and Vice-president of SEPCyS and Wenceslao Castro, Clinical Psychologist, Vice-president of AEPC elaborated on the “Profession and Social Commitment, the need of clinical psychology in primary care”. They concentrated mainly on the precautions to take in the implementation of psychological care in primary assistance. According to the speakers, psychologists have a responsibility to keep their own characteristics, protecting the scientific training model (Boulder model) and never back away from scientific evidence. Under these conditions, primary care is an important area for scientific practice of Clinical Psychology. There´s no reason either to lose something that “we take care of so carefully, the therapeutic relationship, and we dread hearing about the asepsis in the rapport, and we must never forget that we always need the cooperation of the patient.” They also warned us about the dangers of tailgating the medical model. We don’t need to swallow just like that that “psychotherapy is expensive” we need to review more carefully the figures to support this claim.

César González Blanch, Clinical Psychologis, President of ANPIR. He talked about “The Pursuit of specialized psychological care in primary assistance”. The speaker explained his reluctance to be tempted  adapt uncritically the British experience. He also stated that it would be unrealistic to think that Clinical Psychology could only cope with mild disease. We have a lot to do with the great diversity of prodromic states, subclinical and chronic pluripathology.

The current situation may be summarised in the form of SWOT as follows:

S: effective treatments available, possibility of group treatment, brief treatments.
O: Decrease of drug expenditures, PIR Program includes rotation in Primary Care
W: Shortage of Clinical Psychologists
T: Conflict between professionals and the prevailing biologicist viewpoint.

Finally conclusions on the need of at least one clinical psychologist in each training unit, of which there are 126 in Spain

In his final speech, closing the one-day conference, the coordinator and member of the COP, Dolores Gomez, wondered why psychological care is not already in primary care. How can that be? What is the share of responsibility that is up to the COP?

She developed some personal reflections, including comments from several communications heard, and concluded that a little more pragmatism and common sense suggest what we need to do to get to work together, and that we need to involve other associations, find partners in other groups.

Let’s remember two things, Dolores emphatically ended: nobody knows what is not asked and, as the OCU states, up to 79% of patients treated recommend psychotherapy.

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