Using CBT in General Practice

The 10 Minute Consultation

Lee David

• Publisher: Scion Publishing
• Year: 2013
• Print ISBN: 9781904842934
• eBook ISBN: 9781907904622
• Edition: 2
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

How to use CBT within a typical 10 minute consultation Using CBT in General Practice, second edition provides GPs with an overview of the basic principles of CBT and shows how these principles can be applied within a typical 10 minute consultation. The book is written in a user-friendly, interactive and practical style and focuses on realistic ways to make CBT work by helping patients to make positive changes to their lives. Key features of this second edition include:

• case examples to highlight how the techniques can be applied in practice for patients with particular problems or clinical conditions, such as coping with negative thoughts
• problem-solving sections describe how to manage time constraints
• a new consultation model that can be used to implement CBT in general practice
• detailed overviews of the major clinical psychological conditions that can be treated using CBT, such as panic, low self-esteem, and insomnia.

Using CBT in General Practice uniquely provides the practical advice needed to implement CBT within the time constraints of a busy practice – it is therefore essential reading for all GPs, who must now offer CBT as a treatment option. As this is a practical manual and not just a book of theory, it will also appeal to other professionals involved in the management of patients with psychological problems such as practice nurses, health visitors, community psychiatric nurses, practice counsellors and palliative care doctors.

SECTION C – CLINICAL APPLICATIONS

Chapter 12

Depression

Understanding depression

Depression is common. Between 5 and 10% of people seen in primary care suffer from major depression, and as many as 2–3 times more people experience depressive symptoms but do not meet diagnostic criteria (see Box 12.1) for major depressive disorder (Katon & Schulberg, 1992).

Box 12.1

Diagnosis of major depression (DSM-IV Criteria: APA, 1994)

Five of the following criteria (including at least one of the first two criteria) must have been present almost every day for more than two weeks, and must cause significant impairment in social, occupational or other areas of functioning.

• Depressed mood for most of the day

• Reduced pleasure or interest in usual activities for most of the day

• Fatigue or loss of energy

• Substantial change in appetite or unintentional weight loss or gain

• Insomnia or hypersomnia

• Psychomotor agitation or retardation

• Diminished ability to think or concentrate, or indecisiveness

• Feelings of excessive guilt or worthlessness

• Recurrent thoughts of death or suicide

Cognitive-behavioural therapy for depression

CBT is the psychological treatment of choice for depression (NICE, 2009a). It is as effective as antidepressant drug therapy for major depression in primary care (Scott et al., 1997). It also has a lower rate of long-term relapse than antidepressants (Paykel et al., 1999), because patients develop lasting skills to help them cope with difficulties in life. In severe depression, a combination of CBT and antidepressants is more effective than either treatment alone.

A combined approach to depression for primary care

NICE advocates a stepped care approach to depression management, which includes psychological approaches and medication as potential treatment options in the primary care setting (Box 12.2).

Brief CBT approaches by primary care health professionals are particularly useful for patients with mild depression, for whom there is little evidence that antidepressant medication is effective. This can be carried out alongside self-help strategies, graded exercise programmes or medication if appropriate.

Box 12.2

Stepped care model (NICE, 2009a)

Focus of the intervention	Nature of the intervention
Step 1 All known and suspected presentations of depression	Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions
Step 2 Persistent sub-threshold depressive symptoms; mild to moderate depression	Low-intensity psychological and psychosocial interventions, medication and referral for further assessment and interventions
Step 3 Persistent sub-threshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression	Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions
Step 4 Severe and complex depression; risk to life; severe self-neglect	Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Understanding depression

Typical thoughts and thinking styles in depression

Depressed people characteristically develop negative thinking patterns, which are often examples of unhelpful thinking styles (Box 12.3).

Box 12.3

Common unhelpful thinking styles in depression

• Black and white thinking (“I am completely useless”)

• Negative, self-critical view of self (“I am such an idiot”)

• Ignoring positives (“Nothing went well this week”)

• Mind-reading (“He thought I was boring”)

• Negative view of the future (“Nothing will ever get any better”) and predicting catastrophes

• Taking excessive personal responsibility/self-blame (“I ruined the party for everyone”)

Depressed people tend to have self-critical and self-blaming thoughts, which lower confidence, self-esteem and cause problems in relationships with others:

“I’m a terrible parent; I’m a burden to others; I’m useless”

These thoughts are usually self-fulfilling because thinking so negatively tends to prevent people from behaving in constructive or positive ways.

Depressed people also take a negative and pessimistic view of the world. They jump to the worst conclusions and perceive others as critical, uncaring or hurtful. For example, they may focus on one minor criticism whilst ignoring a barrage of compliments.

“The world is so full of terrible events; Nothing ever goes right for me”

Negative thinking or hopelessness about the future is common in depression, and at its most severe, can be linked with suicidal thoughts and behaviour.

“I’ll never get a job – what’s the point in trying?”

“I will never get over this depression. Nothing will get any better”

From theory to practice…

Notice the negative thoughts displayed by depressed people. Look for negative thoughts about the self, world and future. Which unhelpful thinking styles are most common?

At this stage, do not attempt to challenge these thoughts. When you notice a negative thought, try pointing it out to the patient and empathise with the distress that the thought might cause (“It must be very difficult to think that way…”) Then discuss the impact of thinking so negatively (“I wonder how it affects your mood to think that way…?”).

Case Example 12.1: Negative thoughts in depression

Cathy is a 26 year old bank clerk who suffers from mild depression. Here, she describes a barbecue that she attended at the weekend.

“I went to Alison’s barbecue at the weekend. I didn’t want to go, because I knew that I wouldn’t enjoy it. I never have anything interesting to say. While I was there I made a terrible mistake – I forgot the name of Alison’s sister, Joanne. I’ve only met her once before and my mind went blank. I looked like a complete fool. I tried to make it up to her by apologising and asking abo...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Preface
• Introduction
• SECTION A – INTRODUCTION
• SECTION B – SKILLS
• SECTION C – CLINICAL APPLICATIONS
• References and further reading
• Training resources for health professionals
• Index