On World Mental Health Day, Eamonn's extensive article examines a variety of alternative approaches at a local level, to helping those with mental health challenges

An alternative approach to helping mental health problems at a local level

Medication or hospital treatment is not always the best choice for mental health difficulties

Medication such as anti-depressants has and will continue to play an important role in the treatment of mental health difficulties such as depression. The National Institute for Clinical Evidence (NICE) is the main advisory body to the NHS in the UK. NICE determines health and clinical policy in the UK and is an internationally renowned organisation. NICE does not advise the routine use of medication for milder mental health difficulties such as mild to moderate depression or anxiety. According to Dr Michael Byrne and Conol Twomey (consultant psychologists who help advise on HSE policy), the reasoning behind the NICE guidelines relation to medication probably lies in the fact that psychiatric medication have possible side effects, a high cost and questionable evidence of their effectiveness in the treatment of mild to moderate mental health problems over placebosablets containing no active ingredients).

Stepped care model

What are low intensity interventions?

Low intensity interventions are brief therapies (excluding medication) given to patients in primary care settings (e.g., their local doctor’s surgery). Evidence shows that people who present to their doctor with mild or moderate mental health difficulties often only need “brief” or “low intensity” treatment options to get them through a difficult period in their life. The idea of low intensity therapy is to provide quick and cost effective therapy to patients in a convenient manner that suits people’s needs. Examples of low intensity therapy include brief cognitive behavioural therapy (CBT) sessions for patients; group CBT-based psycho-education; bibliotherapy, internet therapies and guided self-help.

Some specific examples of low intensity interventions

Computerised CBT

Cognitive Behavioural Therapy (CBT) is based on the theory that peoples’ emotions and behaviour are influenced by their perception of events. It is not the situation in itself that determines what people feel but rather the way in which they react and feel about the situation. More detailed information on CBT can be obtained in Whelehans Pharmacy including details of CBT therapists locally. Traditionally CBT was always done one to one with a therapist. However, a number of interactive software programmes are now available that replicate some functions of a CBT therapist, especially in the UK. These internet based CBT therapies are called computerised CBT. A computerised CBT self-help programme recommended by NICE in the UK is Beating the Blues (for people with mild to moderate depression, www.beatingtheblues.co.uk) which consists of eight 50-minute sessions completed online and is available to the general public in the UK through the NHS primary care services. It can also be accessed by people in Ireland for a fee of around €165.38. Some people prefer using a computer rather than talking to a therapist about their personal feelings. The software can also be used as an introduction to CBT, helping develop knowledge and skills that will facilitate more effective one-to-one therapy.  Evidence suggests that using computerised CBT packages can help treat anxiety and depressive disorders, particularly when used in conjunction with a therapist.

Bibliotherapy

Many local libraries in Ireland now operate a Healthy Reading Scheme were they offer access to books on all areas of mental help including depression, anxiety, self-esteem, Alzheimer’s disease, stress, schizophrenia etc. For those feeling overwhelmed and isolated, a book can offer a first step in a way that offers no judgement. In the Westmeath area, you can contact Westmeath County Library at 04493 32162 or mgarlib@westmeathcoco.ie for more information.

Internet therapies

Internet therapies can also be undertaken solely by the individual (i.e. self-help). These ‘e-therapies’ are easily accessible and have been shown to be effective for a range of psychological difficulties including depression, anxiety, eating disorders and insomnia.

It is important to distinguish internet therapies from cCBT. For example, internet-based therapies could refer to, or include, those therapies that are delivered in 'real-time' (i.e., via instant messaging) whereas cCBT is more like a self-help course (that may or may not have intermittent therapist assistance)

Studies indicate that internet therapies can be as effective as face-to-face therapies. Internet therapies are still in their infancy, but there is growing evidence that they can help people through mental health difficulties including mild to moderate anxiety and depression. Unlike the UK, Internet therapies are not yet widely available in Ireland. However, in addition to computerised CBT options I mentioned earlier, there are an increasing number of internet-based therapies available in Ireland. For example, the online mental health promotion project, HeadsUp (www.headsup.ie) that is run by the Rehab Group is a website aimed to provide support to 15 to 24 year olds experiencing mental health difficulties. Headsup provides online CBT skills programme for free for adolescents and young adults.  In addition, many voluntary listening services such as Aware (for depression, www.aware.ie) and Bodywhys (for eating disorders) have recently added online support (e.g., Via email and online support groups) to their range of services.

The advantages of low intensity intervention

Is best practice being implemented in Ireland?

In the UK, the NHS has invested heavily in providing easier access to psychological services at a local setting so patients who present to their GP with mental health difficulties have immediate access to psychological services in their area such as CBT and counselling. The service also aims to reduce the reliance on medication as the main treatment option for mental health problems. As of March 2011, the NHS had recruited nearly 4000 new cognitive behavioural therapists. Half of the UK population now have access to these services and this figure is continually improving.

The NHS programme is called IAPT which stands for “improving access to psychological therapies”. The aim of IAPT is to improve services for people suffering from depression and anxiety disorders. The NHS also launched a website to support the role out of increased psychological services called www.iapt.nhs.uk.

The report commissioned by the Irish Department of Health in 2006 called “A vision for change” recommended a similar service in Ireland which would give GPs alternative psychological treatment options in their locality. One the aims of “A vision for change” is to take the pressure of GPs and provide psychological services that they can refer patients to without waiting lists.

While the intentions of our health service is admirable in relation to mental health, unfortunately the advent of the economic crash means that the funding required to implement new psychological services has not been there and progress is slow. The irony is that investment in this area would largely pay for itself, as early interventions with mental health difficulties leads to less need for long term mental health care, less days off work (thus a more productive workforce), less drug costs as the need for expensive psychiatric medication is reduced and less social issues such as drug abuse, homelessness and crime which are sometimes linked to mental health problems.

Initiatives that have been implemented in Ireland

Despite the slow role out of psychological services nationwide, there have been successful pilot initiatives in some areas in Ireland. An example of this is an initiative in the North-East where the HSE National Counselling Service (NCS) provides counselling to adults at a local level. Since this initiative was started in 2005, nearly 3000 adults have been provided with counselling services by 15 counsellors employed by the HSE. 64% of these service users showed clinical recovery in their condition due to the counselling provided.

MoodGym is a UK based website aimed to teach cognitive behaviour therapy skills
for preventing and coping with depression. In Roscommon and other areas around Ireland, MoodGym is being trialled with the ultimate aim of parts of it being incorporated into the HSE’s programme.

Another initiative which is based on NICE best practice is being provided in Roscommon. The Roscommon initiative is being provided psychology graduates all based in the HSE Psychology Department in Roscommon. Five mental health professionals Roscommon are involved in providing interventions to adults in the area based on a “stepped care” model. Service provided in Roscommon include brief CBT sessions for patients; group CBT-based psycho-education; bibliotherapy  (The use of self-help books, described above); a walk-in clinic (where an individual can walk in for support/advice/ counselling at short notice); internet therapies and a call-back service (where therapists give psychological support and advice over the phone). GPs in Roscommon have the option of referring patients to these services. 

Reference: the information and reference for this article has been kindly provided by Dr Michael Byrne, who is a Mullingar-based Clinical Psychologist. A member of the national Vision for Change Implementation Group, the Mental Health Clinical Care Programmes Working Group and the Mental Health Commission, Dr Byrne has contributed to the formulation and implementation of national mental health policy.  He has written many papers on various topics, including mental health issues.  He provides CBT through his private clinic in Mullingar.

For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591.

Some useful websites:

Adult Mental Health

www.aware.ie

www.grow.ie

www.bodywhys.ie

www.sirl.ie

www.drugsinfo.ie

www.samaritans.org

www.alzheimer.ie

www.headwayireland.ie

www.mentalhealthireland.ie

www.yourmentalhealth.ie

www.irishadvocacynetwork.com

www.rcpsych.ac.uk

www.mind.org.uk

www.ias.ie

www.mhcirl.ie

www.nsue.ie – National Service Users Executive

Children & Families

www.barnardos.ie

www.childrensrights.ie

www.parentlineplus.org.uk

www.endchildpoverty.ie

www.ispcc.ie

www.irishhealth.com

www.youth.ie