Psychotherapy: Indications and contraindications
Indications for psychotherapy for mood and anxiety disorders
- Patient preference (as an adjunct to, or alternative to, pharmacotherapy)
- Mild to moderate major depression (PHQ-9 score of 5–14)
- Dysthymic disorder
- Mild to moderate anxiety disorder
- Somatic complaints that appear to have a significant psychological component and the patient appears to have some insight
Pharmacotherapy and psychotherapy
Medication adherence often improves when patients receive psychotherapy. Patients who are sensitive to medication side-effects or concerned with the long-term safety of antidepressants may prefer psychotherapy to medication. Psychotherapy may also be a good option for patients who are pregnant or planning a pregnancy and want to taper off medication.
The efficacy of psychotherapy for severe depression is controversial and appears to depend highly on the skill of the psychotherapist. Therefore, patients with severe depression should receive psychotherapy only as an adjunct to primary treatment. Psychotherapy should never compromise or delay optimal pharmacotherapy.
Ongoing close evaluation of the patient's clinical status and referral to a psychologist or psychiatrist is indicated when the patient fails to improve or suicidal potential escalates.
Chronic depression, bipolar disorder and somatoform disorders
Simple psychotherapy strategies can be integrated into the treatment of bipolar disorder. Chronic depression is difficult to treat with psychotherapy alone, but it can benefit from combined antidepressant medication and psychotherapy. Common conditions seen by primary care providers such as somatoform disorders (e.g., pain disorder associated with psychological factors or hypochondriasis) sometimes respond to cognitive-behavioural therapy (CBT).
Contraindications for psychotherapy in primary care
- Psychosis (e.g., psychotic depression, mania, schizophrenia)
- Organic mental disorder (e.g., dementia)
- Antisocial personality disorder and severe borderline personality disorder
- Severe substance use problems
- Poor psychological insight
Schizophrenia and bipolar disorder
Although promising evidence-based psychotherapy interventions based on specific manuals have been developed for schizophrenia and bipolar disorder, these approaches are too sub-specialized for most primary care providers.
Comorbid psychiatric disorders such as depression often occur in people with personality disorders. Personality disorders are not a contraindication for psychotherapy in primary care given that personality disorders do not worsen the outcome of treatments like CBT for depression. However, disruptive personality disorders like antisocial personality disorder or borderline personality disorder are far more difficult to treat, and qualified expertise is strongly advised in order to avert boundary violations.
Eating disorders, obsesssive compulsive disorder and posttraumatic stress disorder
Patients with eating disorders, obsessive-compulsive disorder and posttraumatic stress disorder can be effectively treated with CBT. However, the treatment approach is quite sub-specialized and requires extensive expertise that is beyond the scope of family medicine. In these situations, the primary care provider can offer supportive psychotherapy and refer the patient to a specialized mental health practitioner.
Severe substance use disorders
Although moderate substance use is not an absolute contraindication for adjunctive psychotherapy, psychotherapy provided by a primary care provider should never compromise or delay treatment for severe substance use disorders.
Cognitive impairment and poor insight
Any significant impairment in cognition, regardless of the cause, will make psychotherapy very difficult. Careful assessment of the patient's capacity to read and comprehend is extremely important.
Somatoform disorders, especially when the patient has very poor insight, are extremely difficult to treat with psychotherapy and are usually beyond the scope of a primary care provider.