Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Primary care counseling improves psychological symptoms in patients with psychological and psychosocial problems

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ACP J Club. 2002 May-Jun;136:108. doi:10.7326/ACPJC-2002-136-3-108


Source Citation

Rowland N, Bower P, Mellor Clark J, Heywood P, Godfrey C. Effectiveness and cost effectiveness of counselling in primary care. Cochrane Database Syst Rev. 2001;(3):CD001025 (latest version 11 May 2001). [PubMed ID: 11686973] (All 2002 articles were reviewed for relevancy, and abstracts were last revised in 2008.)


Abstract

Question

In patients with psychological and psychosocial problems, is counseling in primary care effective and cost-effective?

Data sources

Studies were identified by searching databases including MEDLINE; EMBASE/Excerpta Medica; PsycLIT; CINAHL; the Cochrane Library; and the Cochrane Collaboration Depression, Anxiety, and Neurosis Register of Randomized Controlled Trials (RCTs) and controlled clinical trials (for trials completed by April 1998). Search terms included primary health care, counseling, psychotherapy, general practice, and clinical psychology. A specialist journal was hand searched, bibliographies of relevant studies were scanned, and experts were contacted.

Study selection

Published and unpublished studies in all languages were selected if they were RCTs; examined patients with psychological or psychosocial problems who were suitable for counseling; used a clear definition of counseling compatible with that of the British Association of Counselling; used counseling offered by trained practitioners; included outcomes of clinical effectiveness, patient satisfaction, and health service utilization; and compared counseling with a control therapy. Trials of patients on psychotropic drugs in addition to counseling were included if a direct comparison could be made between therapies. Exclusion criteria were specialist counseling or structured therapies (e.g., cognitive behavioral therapy, behavioral therapy, and problem-solving therapy).

Data extraction

Data were extracted on methodologic quality, participants, type and duration of interventions, and outcomes and cost-effectiveness.

Main results

4 English-language RCTs (678 patients) using up to 12 sessions of face-to-face counseling of individual patients offered by a range of trained practitioners met the selection criteria. Follow-up ranged from 6 weeks to 9 months. Results focused on post-treatment follow-up (6 to 12 wk). Data on psychological symptom levels were pooled from the 4 RCTs; patients receiving counseling had better psychological symptom levels than did those receiving usual care (standardized mean difference −0.30, 95% CI −0.49 to −0.11). 3 RCTs reported generally high patient-satisfaction levels with counseling. No clear difference was shown between counseling and usual care for health service utilization (4 RCTs) or cost-effectiveness (1 RCT).

Conclusions

In patients with psychological and psychosocial problems, counseling in primary care improves psychological symptom levels. Patient satisfaction with counseling seems to be high. Data are lacking on the cost-effectiveness of counseling.

Sources of funding: University of Leeds and Manchester University.

For correspondence: Ms. N. Rowland, Bootham Park Hospital, York, England, UK. E-mail Nancy.Rowland@excha.yhs-tr.northy.nhs.uk.


Commentary

Because up to one third of patients in primary care have psychological conditions requiring care (1), the review of primary care counseling for psychological and psychosocial problems by Rowland and colleagues is welcome. The review examined studies of counseling in primary care done by trained counselors. On the surface, it seems that the use of counselors in primary care is appropriate; however, there are a few caveats. Because the studies had differing inclusion criteria, data for patients with major depression, dysthymia, or anxiety disorders were pooled together in the analyses. In addition, the type of counseling varied from study to study. The review would have been strengthened if specific psychological symptoms had been analyzed separately to determine whether certain ones are more amenable to counseling. The results may not apply to all psychological symptoms. Finally, because counseling was not compared with psychotropic drugs, it is unclear whether 5 minutes of counseling and the additional use of drugs would be as beneficial as the reliance on multiple sessions of counseling.

Even with these cautions, a counselor in primary care practice seems to be beneficial and should be a service that is covered by health insurance. This review clearly shows that patients prefer counseling.

Philip J. Baty, MD
Grand Rapids Family Practice Residency
Grand Rapids, Michigan, USA


Reference

1. Pringle M, Laverty J. A counsellor in every practice? BMJ. 1993;306:2-3. [PubMed ID: 8435570]