Chapter 12
Psychosocial Interventions in the Community for Anxiety and Depression

Linda Gask¹ and Carolyn Chew-Graham²

¹ University of Manchester, Manchester, UK

² Research Institute, Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, UK

The context

In England, the Social Exclusion Unit's report on mental health confirms that people from a number of groups find it particularly difficult to access help for anxiety and depression (see Chapter 4 on older people and Chapter 8 on ethnic minorities). In recognition of this, The Big Society was the flagship policy idea of the 2010 UK Conservative Party general election manifesto. The stated aim was to create a climate that empowers local people and communities, building a ‘big society’ that will take power away from politicians and give it to people, and supporting the development of local resources to support people in their community.

This chapter illustrates that collaboration between other organisations in the community outside healthcare (social care providers, public health, housing, local government and the ‘third’ or voluntary sector) is essential to ensure that people with anxiety and depression get access to appropriate help that meets their particular needs, many of which may have a large social component.

Problems with accessing care for anxiety and depression

People who are experiencing anxiety and depression may not access care for a number of different reasons. Firstly, they may not recognise that they have a mental health problem, or do not wish to use the term ‘anxiety’ or ‘depression’. Stigma remains a powerful problem in the community and militates against people recognising and seeking help for depression. Secondly, they may have difficulty in making sense of how the healthcare system operates (i.e., they lack health literacy), and understanding how it can help them. Thirdly, they may or may not actually seek help for symptoms, and fourthly their presenting symptoms and problems may or may not be accurately identified by a health professional (this is usually from a doctor or nurse in primary care). Finally, they may or may not be offered appropriate or acceptable treatment for their problems. Effective treatment for depression and anxiety is still lacking across the world according to the World Health Organization, and even where the evidence exists, such services or interventions may not be available for patients and their clinicians. Many people also have social difficulties, which are inextricably linked with their mental health problems.

‘Social problems’

As we saw in Chapter 1, life events, chronic social stresses and lack of social support play a key part in the aetiology of anxiety and depression. This sometimes leads health professionals to assume that the mental health problems a person is experiencing and describing are simply a ‘reaction’ to social problems, are understandable, and not something that they (the health professional) can do anything to alleviate. This is because they do not think that the person can feel any better until their life situation improves (which may be wrong – they may still benefit from treatment that will help them to manage circumstances and stress more effectively and assist in their recovery). Additionally, they may think that there is nothing they can do to assist a person in actually managing their social problems – which is not entirely true. A key issue in medicine, and in particular in primary care, is the extent of wider social causes of health inequalities, which commonly accompany anxiety and depression and are a legitimate focus for health professionals. Many people with anxiety and depression have complex and sometimes enduring social needs (see Box 12.1). However, research has shown that GPs in the UK often have very limited knowledge of, and poor links with, resources in the community. GPs are most likely to refer people to counselling and specialist advice focusing on financial and housing problems, but much less likely to signpost people to community groups or to agencies that might specifically address other types of problem. Counselling in itself may be unhelpful if the problems that caused, or result from, the anxiety and depression are not in themselves addressed in a practical way.

Social prescribing

Social prescribing may be beneficial to people with anxiety and depression. This means signposting people to non-health-service resources. At a time when budgets are being cut in social care provision across many countries, associated with high unemployment, GPs find themselves increasingly facing complex social problems associated with chronic physical and mental ill health. Medical and nursing professionals can play a role not only in providing information about resources (which requires up-to-date information locally available – preferably user friendly and easily available on the web) but also in supporting patients to make use of such resources (see below). Examples of such resources can be found in Boxes 12.2 and 12.3.

Box 12.3 Arts on Prescription service for people with anxiety and depression

The ‘Time Out’ project at START in Salford, UK

Start ‘Time Out’ Arts on Prescription service offers up to two sessions weekly, each lasting 2 hours with all materials and equipment provided. Professional artists are there to help as much as members need and will guide them through a series of activities, which could include: drawing and painting, pottery, gardening, photography and more. They can try a variety of activities and choose what they like best. Beginners are especially welcome.

The project is flexible and can last up to 6 months. Members can explore opportunities in volunteering, leisure interests, employment and education. Or, having enjoyed their 6 months of art sessions they may then decide to join the member-led art group.

A mental health worker carries out the initial assessment, and is available for one-to-one counselling and support when needed. She also runs workshops to promote mental wellbeing such as relaxation sessions.Additional outreach art sessions are also organised in local primary care settings, which have also welcomed exhibitions of members’ work.

Research into the Arts on Prescription initiative described in Box 12.3 revealed it provided ‘added value’ over and above being in receipt of psychological therapy alone. People attending perceived themselves as ‘returning to normality’ through enjoying life again, returning to previous activities, setting goals and stopping dwelling on the past, which for many had been a negative experience of more ‘talking’ approaches to therapy.

Finding evidence of ‘hard’ outcomes, in terms of cost-effectiveness, for social prescribing is difficult, although it has been shown to have an impact on anxiety, general health and quality of life in a large randomised controlled trial conducted some years ago in the UK by Grant and colleagues. Such interventions may be more acceptable to some groups – e.g., older people and people from British Minority Ethnic (BME) communities. There is also evidence that ‘befriending’ interventions are effective in reducing depression in older people, possibly by reducing loneliness that many older people experience.

Improving access

We think that improving access to care in the community for anxiety and depression requires a multifaceted approach (Figure 12.1) with three linked components: community engagement; addressing the quality of primary care; and providing psychosocial interventions that are tailored to the needs of people with complex reasons why they may have difficulty in accessing care.

Community engagement: means working in partnership with existing third-sector agencies, such a local black and ethnic minority organisations, services for older people, teenagers, asylum seekers and homeless people. Many of the people working in these organisations have a great deal of experience in trying to help people with anxiety and depression to access care. They may, however, have difficulty making links with traditional health providers such as primary care. They also may sometimes lack resources and expertise to be able to provide evidence-based and well-supervised psychological interventions, and again would benefit from closer links with mental health care providers. Third-sector workers are able to help identify areas of unmet need and, in our experience, are keen to improve their links with primary care to enable this.
Addressing the quality of primary care: needs to consider the experiences of people with anxiety and depression from the moment they approach the medical practice to register as a patient through contacting the reception for an appointment and visiting the doctor or nurse. What are the particular barriers to access in the practice? How does the receptionist manage a person who is in crisis, irritable and very anxious, at the front counter, and who does not seem to understand English? Are self-help materials for patients available in a range of languages? What about people who are illiterate? Is the practice team culturally competent? How much does the team know about the broad range of services available in the community (see ‘Social prescribing‘ above).
Providing tailored psychosocial interventions: there is evidence for the effectiveness of tailored psychosocial interventions for some groups, particularly older people and ethnic minorities (see Chapters 4 and 8). Tailoring needs to be based on an understanding of the factors that influence people’s response to an intervention and usually involves addressing social aspects of the format, content and delivery of, for example, a group without interfering with key aspects of the psychological content that are necessary for the effectiveness of the intervention. The term ‘mental health’ may, for example, be unacceptable to some groups. In an intervention for people from the Jewish community in Manchester, the groups that we set up for people to support self-help for anxiety and depression were called ’personal development’ groups – which was a far more acceptable term. Sometimes ‘wellbeing’ is used, but we have found that people still equate this to ‘mental health’, and do not find it an acceptable term. Community organisations should be both involved in designing and be partners in providing these interventions.

c12-fig-0001 — **Figure 12.1** Multifaceted model to improve access to mental health care.

In Box 12.4 we can see how Anthony, Bridie’s husband, is engaged in accessing help for his anxiety and depression through a combination of effective collaboration between the third sector and healthcare (local advertising of an outreach resource in the community in a healthcare waiting room, encouragement from a healthcare practitioner who recognises Anthony’s problem and knows about what is available in the community) and the availability of a tailored resource in the community (a service that will, if necessary visit at home, which for some older people is essential, though not for Anthony, and that runs groups that are not stigmatising – ‘craft and chat’). Elements of the AMP (Improving Access to Mental Health in Primary Care) model (quality of primary care, tailored psychosocial interventions) can be identified here. The important groundwork involved in commissioning the elements of the intervention and ensuring that key stakeholders (including primary care) were involved in designing and setting up the pathways that enable this to work constitutes the ‘community engagement’.

Summary

Primary care clinicians play an important role in the diagnosis and support of people with anxiety and depression, but need to harness the resources of their local community, signposting people to appropriate and acceptable services, tailored to meet the needs of specific patient groups.

Resource

Information about the AMP project (Improving Access to Mental Health in Primary Care) can be found at www.amproject.org.uk