Counselling for mental health and psychosocial problems in primary care

Many patients in primary care suffer from mental health and psychosocial problems. These problems often involve feelings of sadness, nerves or stress. Many of these problems may be due to personal and social problems or reactions to life events such as physical illness or unemployment.

‘Counselling’ is a recognised psychological therapy that is often provided to such patients. In the United Kingdom, counsellors have often been employed to deliver psychological therapy to patients in primary care settings. Providing counselling alongside other treatments such as cognitive behaviour therapy means that patients have greater choice, and that alternatives can be found for patients who either do not benefit from standard treatments or who do not find them acceptable.

However, recent clinical guidelines in the United Kingdom have highlighted the lack of evidence for counselling compared to other treatments such as cognitive behaviour therapy, and have not been able to clearly recommend the use of counselling in primary care.

In this review we found nine studies involving counselling in primary care for 1384 participants. There were some problems with the methods in some studies. The evidence suggested that counselling is better than usual general practitioner care in improving mental health outcomes in the short term, although the advantages are modest. People who receive counselling in primary care from a trained counsellor are more likely to feel better immediately after treatment and be more satisfied than those who receive care from their general practitioner. However, in the long term, counselling does not seem to be any better than GP care. Although some types of healthcare utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. There is very limited evidence comparing counselling with other psychological therapies (2 studies with 272 participants) or with antidepressant medication (1 study with 83 participants).

Authors' conclusions: 

Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

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Background: 

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care.

Objectives: 

To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care.

Search strategy: 

To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011).

Selection criteria: 

Randomised controlled trials of counselling for mental health and psychosocial problems in primary care.

Data collection and analysis: 

Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events.

Main results: 

Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions.

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