Integrating self-help materials into mental health practice

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Integrating self-help materials into mental health practice

Elizabeth Church

PhD

Peter Cornish

PhD

Terrence Callanan

MD FRCPC

Cheri Bethune

MD CCFP

This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

Can Fam Physician 2008;54:1413-7

ABSTRACT

PROBLEM ADDRESSED

Patients’ mental health issues have become an increasing focus of Canadian family physicians’ practices. A self-help approach can help meet this demand, but there are few guidelines for professionals about how to use mental health self-help resources effectively.

OBJECTIVE OF PROGRAM

To aid health professionals in integrating self-help materials into their mental health practices.

PROGRAM DESCRIPTION

A resource library of print, audiotape, and videotape self-help materials about common mental health issues was developed for a rural community. The materials were prescreened in order to ensure high quality, and health professionals were given training on how to integrate self-help into their practices. The library was actively used by both health professionals and community members, and most resources were borrowed, particularly the nonprint materials. Health professionals viewed the resources as a way to supplement their mental health practice and reduce demands on their time, as patients generally worked through the resources independently. Some improvements are planned for future implementations of the program, such as providing health professionals with a “prescription pad” of resources and implementing Stages of Change and stepped-care models to maximize the program’s effectiveness.

CONCLUSION

Although more evidence is needed regarding the effectiveness of self-help within a family practice context, this program offers a promising way for family physicians to address mild to moderate mental health problems.

RÉSUMÉ

PROBLÈME À L’ÉTUDE

Les problèmes de santé mentale sont un centre d’intérêt de plus en plus important dans la pratique du médecin de famille canadien. Une approche basée sur des outils d’aide personnelle peut aider à répondre aux besoins, mais il existe peu de lignes directrices pour orienter le professionnel dans l’utilisation efficace de tels outils pour la santé mentale.

OBJECTIF DU PROGRAMME

Aider le professionnel de la santé à intégrer des outils d’aide personnelle dans sa pratique en santé mentale.

DESCRIPTION DU PROGRAMME

Une banque d’outils d’aide personnelle constituée d’imprimés, de bandes magnétiques et de vidéocassettes portant sur des problèmes courants de santé mentale a été mise sur pied à l’intention d’une collectivité rurale. Ces outils ont été présélectionnés afin de s’assurer de leur qualité, et les professionnels de la santé ont reçu une formation pour intégrer ces outils dans leur pratique. La banque a été abondamment utilisée tant par les professionnels de la santé que par les membres de la collectivité; la plupart des ressources ont été empruntées, particulièrement le matériel non imprimé. Les professionnels de la santé considéraient ces ressources comme une façon de complémenter leur pratique en santé mentale tout en réduisant leurs contraintes de temps, puisque les patients utilisaient les ressources de façon autonome. Dans le futur, on prévoit améliorer l’implantation du programme, par exemple en fournissant aux professionnels de la santé un « bloc de prescription » des ressources, et en implantant des modèles d’étapes de changement et de soins par étapes pour maximiser l’efficacité du programme.

CONCLUSION

Bien qu’il faille davantage de données probantes sur l’efficacité de l’aide personnelle dans le contexte de la pratique de la médecine familiale, le programme suggéré offre au médecin de famille une façon prometteuse de prendre en charge des problèmes de santé mentale de légers à modérés.

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C

anadian family physicians are often the only providers of mental health services for most of their patients.¹ Surveys have found that about a third of the problems that patients bring to their family physicians have mental health components,² and this trend seems to be increasing.³ Because addressing mental health issues is demanding more of family physicians’

time and energy, it is important to have programs that support their efforts.

Self-help approaches can be valuable supplements to family physicians’ practices because patients can use them independently to address mental health issues. Self- help usually refers both to bibliotherapy, in which patients use materials to gain understanding or to solve problems, and self-administered treatments, in which patients follow a plan of treatment without professional supervision.

These kinds of resources are popular both with mental health professionals, such as psychiatrists, psychothera- pists, and psychologists, who routinely recommend these kinds of resources to their patients,^4-8 and Canadian con- sumers who are increasingly consulting such resources for health information. There is considerable evidence that many self-help approaches can be effective for mild to moderate mental health problems, such as depression, anxiety, and mild alcohol abuse.^9-11 It is hypothesized that self-help approaches might foster a greater sense of self- efficacy than more directive care, because patients work through problems on their own.^12,13 At the same time, professionals have to be cautious about recommending self-help resources: not all patients have the capacity to use this kind of approach (for example, patients who are actively suicidal), and many of the most popular self-help materials (in bookstores, etc) have no empirical support for their effectiveness.⁶

Objective of program

There are few guidelines for professionals on how to use mental health self-help resources effectively.^14,15 This article describes a program that was developed to aid health professionals in integrating self-help materials into their mental health practices.

Description of program

The program was initiated as part of a larger demonstration project, the Rural Mental Health Project, in a rural Newfoundland community. The aim of the program was to increase rural health care providers’ capacity to respond to mental health needs.¹⁶The community had a population of about 3000 people, with a catchment of 10 000. Two social workers served the catchment area,

but there were no psychiatrists or psychologists.

In order to address the most commonly seen mental health issues, local health professionals, including family physicians, nurses, social workers, and guidance counselors, were asked to identify the most pressing mental health needs in their community. The issues

they identified, such as depression, parenting issues, marital or relationship problems, and addictions, were similar to those generally brought to family physicians’

offices. A resource library of about 100 print, audiotape, and videotape materials on these topics was purchased for the community. Funding for the resources was pro- vided by the provincial government’s Department of Community Services. All the materials were prescreened in order to ensure high quality: print materials were either evidence-based or recommended by experts,⁶ while audiotape and videotape materials were evaluated using the DISCERN criteria.¹⁷ (A catalogue of the library may be obtained from the corresponding author.)

The resource library was housed at the local health centre, which had a part-time librarian who was also the community librarian. Health professionals who had par- ticipated in the Rural Mental Health Project were invited to a videoconference where they were introduced to the materials and given guidelines on how to integrate self- help into their practices most effectively. Some participants also engaged in an informal journal club, in which they gave brief synopses of the materials they thought would be useful in their practices.

Evaluation

The librarian tracked the use of the library over a 14- month period, noting which resources were borrowed, by whom, and for how long. Fifty-nine percent of the materials were checked out during this period. Parenting resources were the most popular, including materials on child discipline, living in a stepfamily, and helping shy children. Next were resources for depression, followed by materials on addictions, death and dying, learning disabilities, attention deficit hyperactivity disorder, and anxiety. Although there were fewer videotapes and audiotapes in the resource library, proportionally they were borrowed more often than print resources.

Health professionals, including physicians, social workers, nurses, nurse practitioners, and guidance counselors, used the library most frequently, accounting for 61% of the borrowed resources. Those who attended the initial training session were the most likely to recommend resources to their patients. A quarter of the resources were checked out by community members, and 14% were borrowed by staff and administrators in the health centre and teachers and principals from local schools. By the end of the 14 months, a kind of snowball effect had developed, with the most popular materials circulating among community members.

The primary author conducted follow-up interviews with 4 participants: the resource librarian and 3 health professionals who had accessed the resources frequently—a family physician, a guidance counselor, and a nurse. The interviews were about half an hour in length;

they were audiotaped and transcribed, and a thematic analysis of the transcripts was carried out.

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Participants believed that the anonymity of a self-help library was an asset for a rural community, as there is still a stigma in rural communities about mental health issues and they had to be cautious about raising “touchy subjects” when “everyone knows everything about everything.” The librarian noted that, while resources about topics such as sexual problems and divorce were not checked out, they were often taken off the shelves, presumably having been read in the library. The librarian played a pivotal role in publicizing and recommending the resources; often people would ask for guidance regarding a particular problem, such as grief, and she would suggest appropriate materials.

From the interviews with the health professionals, it was apparent that they viewed the resources as a way to supplement their mental health practice and reduce demands on their time. They usually either referred patients to the library or recommended relevant resources:

“I usually suggest books to parents .... If it is very accessible, they’ll take it and read it, but who has time to go and search.” Occasionally the health professionals had follow- up discussions with patients regarding the resources, but generally left their patients to work independently and did not attempt to integrate self-help into treatment plans.

They stated that it was critical that the materials had been prescreened, because they did not have time to review materials themselves: “Sometimes I feel bad recommending books I haven’t read, but if they come from [the] Rural Mental Health Project, I figure that someone has looked at them, that they must be okay.” The health professionals also used the resources for themselves in order to increase their knowledge in a particular area, to provide training for paraprofessionals, and for personal reasons.

Discussion

Two “Book Prescription Schemes,” which are some- what similar to our program, have been launched in the

United Kingdom. In one, family physicians are pro- vided with “prescription pads” that list 35 self-help books addressing common mental health problems, such as depression and anxiety. Patients take their “prescriptions” to the public library where the books are housed.¹⁹ The other scheme is similar, except that patients are offered a maximum of 3 brief “supportive” sessions with a nonprofessional.¹⁸ While there is not yet evidence of the effectiveness of these schemes, they have rapidly become very popular: it is estimated that there are now more than 40 across the United Kingdom.²⁰

Our program and the programs in the United Kingdom have strengths and limitations. One advantage of our program is that videotapes and audiotapes are included. This is important because literacy can be a stumbling block in self-help programs.^13,19 We also provide training to health professionals and to the librarian on how to use the self-help resources most effectively.

One benefit of the UK programs is that the “prescription pad” given to every family physician can streamline the process of recommending resources. Offering supportive coaching to patients might also increase a program’s effectiveness: a study that assessed patients’ experience with a self-help clinic found that the participants rated contact with a paraprofessional as the most helpful aspect of the clinic.¹²

One limitation of self-help programs in general is that they frequently do not provide sufficient support for patients who have serious mental health problems.

As well, neither our program nor the UK programs addressed motivation and adherence. Self-help programs require that patients be ready for change.^9,12,13 Finally, none of the programs has evaluated effectiveness, so we do not know whether the resources have lasting positive effects on patients’ mental health.

Improving the program

Based on our experience and the successes of the UK programs, we plan to implement some changes to our program:

• Each health professional will be given a “prescription pad” with a list of the resources, as well as an anno- tated bibliography that briefly describes each resource and for whom it would be most helpful.

• As lack of motivation can affect success, we will provide training for the professionals in how to use the Stages of Change model, which helps to identify patients’ readiness to change.²¹ This assessment can be done fairly easily by either the professionals or the patients.²²

• In order to ensure that patients are receiving the appropriate level of support, a stepped-care model will be adopted.²³ With this approach, the professional starts with the simplest, least intrusive intervention and only progresses to more intensive treatment if necessary. This model has been used in the treatment

Project components

•

Resource library of print, audiotape, and videotape mental health self-help materials, prescreened to ensure high quality.

•

Resource person to coordinate and recommend materials.

•

Videoconference to introduce materials to health professionals and give guidelines on using self-help in mental health practice.

•

Informal journal club for participants to share useful resources.

For additional information,

please visit www.mun.ca/rmhitp/index.php

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of depression, panic disorder, alcohol abuse, hyper- tension, and anxiety. The steps will be as follows:

- The professional will first assess the severity of the mental health problem.

- If the problem is mild to moderate and the patient appears ready to make changes, relevant self-help resources will be recommended.

- The professional will follow up with the patient after about 4 weeks to assess the effectiveness of the resources.

- If the problem has not been alleviated, the professional will assess whether this is related to motivation or environmental factors, such as lack of time, whether other self-help materials might be more appropriate, and whether more intensive treatment, such as psychotherapy or medication, is appropriate.

Conclusion

Mental health issues are an increasing focus of family physicians’ practices. A self-help approach, where family physicians refer patients to a library of high- quality mental health resources, can help meet the demand for such care. This strategy is an efficient way for family physicians to address mild to moderate mental health problems, particularly if care is framed within a stepped-care model of practice. Although we need

EDITOR’S KEY POINTS

•

Self-help approaches can be valuable supplements to family physicians’ practices because patients can use them independently to address mental health issues. For some, self-help approaches might also foster a greater sense of self-efficacy than more directive care, because patients work through prob- lems on their own.

•

This article describes a program designed to help health professionals in a rural community integrate self-help materials into their care of patients with mild to moderate mental health concerns by making a library of prescreened self-help resources avail- able to the community and offering guidance to health professionals on how to integrate self-help into their practices most effectively.

•

Almost 60% of the resources were checked out during a 14-month period, and other resources appeared to be used on-site.

Parenting resources were the most popular, followed by resources for depression, addictions, death and dying, learning disabilities, attention deficit hyperactivity disorder, and anxiety. Nonprint materials were borrowed pro- portionally more often than print resources.

POINTS DE REPÈRE DU RÉDACTEUR

•

L’utilisation d’outils d’aide personnelle peut com- plémenter avantageusement le travail du médecin de famille puisque le patient peut utiliser lui-même ces ressources pour résoudre des problèmes de santé mentale. Pour certains patients, l’utilisation de tels outils pourrait être plus valorisante que des soins plus directifs, puisqu’ils travaillent eux-mêmes à résoudre leurs problèmes.

•

Cet article décrit un programme destiné à aider les professionnels de la santé d’une collectivité rurale à intégrer des outils d’aide personnelle aux soins des patients qui présentent des problèmes de santé mentale de légers à modérés en met- tant à la disposition de la collectivité une banque d’outils d’aide pré-sélectionnés et en offrant aux professionnels de la santé des orientations sur la façon d’intégrer le plus efficacement possible ces outils dans leur pratique.

•

Près de 60% des ressources ont été empruntées sur une période de 14 mois, alors que d’autres docu- ments auraient été utilisés sur place. Les ressources parentales étaient les plus populaires, suivies de celles sur la dépression, les dépendances, la mort et la fin de vie, les déficits d’apprentissage, le l’hype- ractivité avec déficit de l’attention et l’anxiété. Les outils non imprimés ont été empruntés proportion- nellement plus souvent que les imprimés.

What we learned from the project

Although this was a pilot project and we cannot draw any conclusions about its effect on patients’ mental health, we gained some insight into how to establish this kind of program:

•

Identify one person, preferably a librarian or a health professional, who will be knowledgeable about the resources so that he or she can recommend resources to users.

•

House resources in a space that is easily accessible for health professionals and community members and that offers some privacy for those who want to consult the resources on-site.

•

Prescreen the materials. Guides, such as the Authoritative Guide to Self-Help Resources in Mental Health,

⁶

are useful here.

•

Accommodate literacy issues by including nonprint resources such as videotapes and audiotapes.

•

Provide training to professionals on how to use self-

help materials effectively in mental health practice,

including information about the types of prob-

lems that are amenable to self-help, an overview of

evidence-based programs, and guidelines on how to

integrate self-help into mental health practice.

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more evidence to support the effectiveness of self-help in a family medicine context, this method offers a great deal of promise.

Dr Church is a Professor and a Program Head in the School Psychology Program in the Faculty of Education at Mount Saint Vincent University in Halifax, NS. Dr Cornish is an Associate Professor and Director in the Counselling Centre at Memorial University in St John’s, Nfld. Dr Callanan is an Associate Professor and Discipline Chair in Psychiatry in the Faculty of Medicine at Memorial University. Dr Bethune is a Professor in the Discipline of Family Medicine at Memorial University.

Acknowledgment

We would like to thank Ms Kim Osmond for her work in facilitating the project.

competing interests None declared correspondence

Dr Elizabeth Church, Faculty of Education, Mount Saint Vincent University, 166 Bedford Hwy, Halifax, NS B3M 2J6; telephone 902 457-6721;

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