Evaluation of out-patient counselling compared with general practitioner care following overdoses

In a randomized prospective treatment study, 80 overdose patients (not requiring intensive psychiatric intervention) received either brief out-patient counselling or were returned to the care of their general practitioners with advice on management. There was little difference in outcome between the two groups. However, two sub-groups of patients benefited more from out-patient counselling than from general practitioner care, these were: (a) women, and (b) patients with dyadic problems. Counselling following overdoses should be focused on groups of patients such as these who are most likely to benefit from it. Further work is needed to identify treatment approaches that will help other groups who take overdoses, especially men.     

Counselling in the European Economic Community

Counselling is becoming increasingly important in modern general practice and the relationship between counsellors and general practitioners varies in different places and in different countries. Through a Stanning Overseas Fellowship I had the opportunity of examining this relationship in several countries in Europe in order to compare and contrast arrangements.     

The clinical effectiveness of counselling in primary care: a systematic review and meta-analysis

BACKGROUND: Counselling is frequently used in the management of common mental disorders (such as anxiety and depression) in primary care. However, there are concerns over the clinical effectiveness of counselling, both in comparison with usual general practitioner care, and with other treatments such as alternative psychological therapies and antidepressant treatment. This study used systematic review methodology to assess the current evidence-base. METHOD: A systematic literature review located seven trials of relevance, comparing counselling with usual general practitioner care, cognitive-behaviour therapy and antidepressant medication. Data on internal and external validity were examined using a standardized quality rating scheme. Data concerning the impact of counselling on symptoms of anxiety and depression were pooled using meta-analytical procedures. RESULTS: The main analyses showed significantly greater clinical effectiveness of counselling compared with usual general practitioner care in the short-term (standardized mean difference -0.28, 95% CI -0.43 to -0.13, N=741, six trials) but not the long-term (standardized mean difference -0.07, 95% CI -0.26 to 0.12, N=447, four trials). Sensitivity analyses were undertaken to test the robustness of the results. CONCLUSION: Counselling is associated with modest improvement in short-term outcome compared with usual general practitioner care, and thus may be a useful addition to mental health services in primary care.     

Treating depression in general practice: factors affecting patients'' treatment preferences.

We performed a cross-sectional survey of general practice attenders to determine their preferences regarding treatment for depression and characteristics associated with such preferences. Counselling was more popular than drug therapy (antidepressants), particularly among women, those who believed antidepressants are addictive, and those who had received such treatment in the past.     

THE STATUTORY REGISTRATION OF PSYCHOTHERAPISTS

ABSTRACT In order to begin the process that might lead eventually to the statutory regulation of psychotherapists, agreement will have to be reached between the mentalhealth disciplines and the psychotherapy institutions on a structure that can contain and govern the profession. To establish whether statutory registration is possible for the profession, talks should be held between the appropriate representatives of the Royal College of Psychiatrists, the British Psychological Society, the Central Council for Education and Training in Social Work, the Royal College of Nursing, the Tavistock Clinic, the Association of Child Psychotherapists, the British Confederation of Psychotherapists, the United Kingdom Council for Psychotherapy and the British Association for Counselling among others. If the nature of the profession is found to be such that a single containing structure cannot be created for it, then the protection of the public will have to be provided, as it is at the moment, by well-governed voluntary registers.     

''Inside-out'', back-to-front: a model for clinical population genetic screening.

Developments in DNA technology have resulted in a dramatic increase in the number of genes identified. With the localisation of a gene it is possible to devise procedures suitable for mass carrier screening programmes. Until recently mass carrier screening was only possible for a limited number of disorders, for example, Tay-Sachs disease and haemoglobinopathies. Counselling possible carriers was based on estimations of risk. The momentum towards mass carrier screening is likely to be increased by gene therapy. Carrier screening for cystic fibrosis alone will have dramatic implications for genetic service provision as 4 to 5% of the UK population carry the CF gene. The potential for genetic screening of multifactorial diseases, for example, cancers, should also be considered. The existing organisation of genetic services is likely to be inadequate. A new specialty of clinical population genetics is required. A model is proposed of clinical population genetic screening programmes, organised under a 'common umbrella' led by a public health physician, while screening and follow up will remain the responsibility of the appropriate clinician.     

Training and disillusion in Counselling Psychology: A psychoanalytic perspective

In this paper, I argue * that Counselling Psychology's professional identification with pluralism poses significant emotional problems for trainees. An important factor in such problems may be the trainee's sense of disappointment and disillusion that the route to professional and personal self‐transformation will not be achieved via a set of universal theoretical principles and established clinical ‘rules’. I draw on recent psychoanalytic theory to suggest that the task facing trainees involves balancing pluralism, characterized as an ‘external’ third position, with an ‘internal’ third space indexing an awareness of subjectivity and intersubjectivity. Maintaining a dialogical‐dialectical perspective on these two positions allows for a creative space in which the trainee may be transformed from lay helper into professional counselling psychologist via a personal engagement with theoretical, clinical and academic material presented during training.     

Guidelines for counselling in infertility: outline version

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented in six sections. The first section describes how infertility consultations differ from other medical consultations in obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems). Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation, surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the complete text of the Guidelines for Counselling in Infertility.     

Recurrent miscarriage: principles of management

Recurrent miscarriage is a heterogeneous condition which has many possible underlying causes. Ideally, couples with the problem should be managed in a dedicated miscarriage clinic, with thorough investigations according to a protocol, with structured history and investigation sheets. Counselling is an important feature and may be provided by a specially trained counsellor, or specialized nurse appropriately trained in counselling. Counselling should include an explanation of the possible underlying causes of the condition, and of the prognosis of each of the conditions. There is no definite cause of miscarriage in approximately half of the patients. No treatment is needed in this group, apart from reassurance and tender loving care. Treatment of unproven value, for example progesterone support in early pregnancy, should not be offered. Treatment offered empirically or as part of a research project should have a sound scientific and statistical basis, and should include careful counselling with informed consent of the patient. There are many controversial issues in the management of recurrent miscarriage; consequently, there is a need for locally agreed guidelines for management. Women who conceive again should be offered regular monitoring, including serial ultrasonography in the first trimester of pregnancy. An active audit programme to review regularly the various outcome measures set against defined targets should be established in the clinic.      

Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy.

BACKGROUND: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue. AIM: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue. DESIGN OF STUDY: A randomised controlled trial incorporating a cost-consequences analysis. SETTING: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months. METHOD: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale. RESULTS: Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score). CONCLUSIONS: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.     

How disabling is depression? Evidence from a primary care sample. The Counselling Versus Antidepressants In Primary Care Study Group.

BACKGROUND: Major depression is an illness with a high prevalence and is most commonly seen and treated by general practitioners (GPs). AIM: To determine the level of disability in depressed patients seen in a primary care setting, and to investigate whether the level of disability was associated with the severity of the depression. METHOD: Prospective data collection, using the 36-item Shortened Form (SF-36), from the Medical Outcomes Study, as a measure of disability, and from the Beck Depression Inventory (BDI) in a sample of depressed patients recruited from a Counselling versus Antidepressant in Primary Care (CAPC) study in the Trent Region. All patients met the research diagnostic criteria for major depression. RESULTS: Two hundred and fifty patients were assessed. These patients reported high levels of disability compared both with published norms and with other chronic physical illnesses. Increases in disability were especially noticeable in the domains of the SF-36 that were specific to mental illness. There was a significant correlation between scores on the SF-36 and the BDI. CONCLUSION: This study confirms that depressed patients in primary care report high levels of disability on the SF-36, and that the instrument is both specific to the domains expected to be affected by mental disorder and is sensitive to the severity of mood disturbance.     

The economics of employing a counsellor in general practice: analysis of data from a randomised controlled trial.

BACKGROUND: Counselling is currently adopted in many general practices, despite limited evidence of clinical and cost effectiveness. AIM: To compare direct and indirect costs of counsellors and general practitioners (GPs) in providing care to people with emotional problems. METHOD: We carried out a prospective, randomized controlled trial of non-directive counselling and routine general practice care in 14 general practices in north London. Counsellors adhered to a Rogerian model of counselling. The counselling sessions ranged from one to 12 sessions over 12 weeks. As reported elsewhere, there were no differences in clinical outcomes between the two groups. Therefore, we conducted a cost minimisation analysis. We present only the economic outcomes in this paper. Main outcome measures were cost data (service utilisation, travel, and work absence) at baseline, three months, and nine months. RESULTS: One hundred and thirty-six patients with emotional problems, mainly depression, took part. Seventy patients were randomised to the counsellors and 66 to the GPs. The average direct and indirect costs for the counsellor was 162.09 Pounds more per patient after three months compared with costs for the GP group; however, over the following six months the counsellor group was 87.00 Pounds less per patient than the GP group. Over the total nine-month period, the counsellor group remained more expensive per patient. CONCLUSIONS: Referral to counselling is no more clinically effective or expensive than GP care over a nine-month period in terms of direct plus indirect costs. However, further research is needed to establish indirect costs of introducing a counsellor into general practice.     

A systematic review of computer-based softwares for educating patients with coronary heart disease

OBJECTIVE: To evaluate the use of computer-based softwares for educating patients with coronary heart disease. METHODS: A systematic electronic search for randomised controlled trials and comparison studies published from 1999 to the end of 2005 using the MEDLINE (1999-2005), EMBASE (1999-2005) and CINAHL (1999-2005) was carried out. Articles including the reference lists in the following journals were hand-searched: Patient Education and Counselling and Patient Counselling and Health Education. RESULTS: A total of 487 articles were identified. Based on a review of abstracts, five studies fulfilled the inclusion criteria of the review. A scoring sheet was used to assess the papers' quality. All studies reported significantly increased knowledge in patients using the educational software when compared to standard education. The difference in knowledge between the intervention and control groups remained high even at 6 months follow up. Furthermore, patients reported high satisfaction with the educational programs. CONCLUSION: Despite there only being five studies that met the inclusion criteria, this review supports the successful use of computer software to increase knowledge in patients with coronary heart disease. The reviewed articles reveal that computer-based education has an important role in increasing patients' knowledge about their condition. PRACTICAL IMPLICATIONS: It is commonly reported that patients want more information about their illness. This study shows that computer-based education can be a useful, acceptable to patients and effective way to deliver education about coronary heart disease.     

心理咨询门诊首诊189例的临床分析

目的 了解心理咨询门诊就诊对象一般情况、起病诱因、既往疾病史、诊断、治疗及男女间差异等,为心理咨询门诊工作提供指导.方法 整群抽取2002年5月21日～11月28日安徽省精神卫生中心心理咨询门诊所建的189份病历,对其首诊记录进行回顾性分析.结果 受教育程度为高中中专以上文化的被咨询者占65.54%,多于初中以下者(P＜0.01),差异有高度显著性.学生占相当的比例,占已知身份者中38.96%.男性以工作问题为疾病诱因的比例高于女性(P＜0.01),差异有高度显著性;男性恋爱问题为疾病诱因的比例高于女性(P＜0.05),差异有显著性,男性婚姻问题为诱因的比例低于女性(P＜0.01),差异有高度显著性;男性家庭问题为诱因的比例低于女性(P＜0.05),差异有显著性.被咨询者首诊时病程在10年以内的占96.76%;共有25.93%被咨询者既往经过治疗;既往慢性或严重疾病的患病率,男性高于女性(P＜0.01),差异有高度显著性;依据CCMD-3诊断为神经症者占被咨询者中38.10%,心境障碍占被咨询者中19.46%(P＜0.01),差异有高度显著性;分裂症、分裂样精神病、心境障碍、神经症总例数占建门诊病历的被咨询者中70.90%;治疗方案:138例(73.02%)皆心理治疗配合药物治疗.心理治疗用单纯心理疏导占121例(占138例中的87.68%).结论 心理工作者应更多关注学生心理健康,对男女心理咨询、干预应有不同侧重点,治疗中注意提高心理治疗质量.     

Microcephaly: genetic counselling and antenatal diagnosis after the birth of an affected child

We describe the clinical and genetic details of a series of microcephalic patients who were referred to the Genetic Counselling Service for the West of Scotland. There were 29 isolated cases of microcephaly and 9 families with recurrent microcephaly. The sib recurrence risk was 19%, which reflects the high incidence of autosomal recessive microcephaly in this series. There was evidence for several varieties of recessive microcephaly. The most frequent, affecting 5 sib pairs, was associated with spastic quadriplegia, seizures, and profound mental handicap. In 15 families with one microcephalic child, prenatal diagnosis by serial ultrasound scans was undertaken in 21 subsequent pregnancies. Four recurrences of microcephaly were detected in the third trimester and one recurrence was missed because no scans were performed after 24 wk gestation when the ultrasound measurements indicated satisfactory head growth. The main reason for late diagnosis of affected fetuses was that head growth did not slow appreciably until the last trimester. The high recurrence risk in this prospective series emphasizes the contribution of autosomal recessive inheritance of microcephaly amongst patients of our Genetic Counselling Service.     

An experiment in training in child care for general practitioners

The educational objectives for training general practitioners are widely agreed. However, there is a shortage of paediatric posts in hospital, especially in Scotland. As there are obvious advantages in training clinicians who will work in general practice in the setting of general practice, we have initiated 10 posts in training each of six months' duration and each in addition to the trainee year. Three months will be spent in general practice itself and systematic teaching will also be provided for three months by the Edinburgh School of Community Paediatrics. Pre-course and post-course assessments will be carried out and the learning achieved will be evaluated.     

Why do infertile males use psychological couple counselling?

The purpose of the present study was to identify characteristics of male patients that could be relevant for the uptake of psychological couple counselling for infertility. Therefore, 94 male patients who participated in psychological couple counselling were compared to 134 unselected infertility patients who attended an andrological clinic. Counselling users showed higher scores for depression and anxiety as well as a higher number of impaired sperm parameters. Multivariate analysis revealed that beyond the level of depression the number of impaired sperm parameters delivered additional information about the probability of a patient using counselling. For interpretation of these results the former research was broadly reviewed. It is suggested that an increased level of distress, the feeling of being responsible for infertility and few marital difficulties are relevant for the usage of couple counselling by male infertility patients. Practical consequences are discussed.     

Book Reviews

Book reviewed in this article
Freud and the Non-European by Edward Said
Counselling Older Clients by Ann Orbach . Published by Sage Publications, London, 2003     

DNA testing in familial hypertrophic cardiomyopathy: clinical and laboratory implications

Counselling and clinical assessment in familial hypertrophic cardiomyopathy (FHC) is difficult, particularly in the young, since echocardiographic and ECG changes may not be diagnostic and clinical severity can vary. From 1990, when the β-cardiac myosin heavy chain gene was implicated in the aetiology of FHC, considerable information about the molecular genetics of this disorder has emerged. However, an important question facing health professionals is the practical significance of DNA testing in FHC. The present study describes a DNA-based approach to screening for five commonly reported mutations involving the-cardiac myosin heavy chain gene. Approximately 11% of randomly selected families had an abnormality detected.