Mohammad Razai and colleagues argue that GPs are in a unique position to provide psychological support and treatment during the current pandemic, as continuity of care is associated with lower mortality rates and better patient outcomes. They outline a strategy for identifying and managing adults struggling with the psychological impact of social isolation.
The guidance recommends the use of existing tools to identify patients at risk of loneliness, depression and anxiety, including those with pre-existing physical or mental health conditions, older people living alone or in institutions, disabled individuals and the recently bereaved. Validated tools include the Patient Health Questionnaire-4 for anxiety and depression, the Columbia Suicide Severity Rating Scale and the UCLA Loneliness Scale, which has been shown to be reliable when completed via telephone consultation and is applicable in different cultural settings.
The authors point out that patients struggling with mental health impacts of social isolation can present for any reason and may or may not divulge distressing psychological symptoms. If psychological distress is not mentioned outright by patients, the decision to screen should be based on clinical judgment, prior knowledge of the patient, and individual risk factors.
In addition to routine reassurance, safety-netting, self-care advice and online self-guided CBT, the guidance recommends two evidence-based treatment strategies: remote telephone or video consultations and social prescribing.
Telephone consulting is well-established in primary care but is limited by the lack of non-verbal cues, say the authors. Video consultations can be used for both initial consultation and subsequent therapy such as befriending, problem solving, counselling, and coaching (by clinicians or trained social prescribers), and may be particularly helpful for anxious patients, according to the guidance. The authors offer a framework for remote consultations although they note that the usefulness of video consultations may be limited in deprived or rural settings, in people with low health literacy, and in older adults who do not use the internet.
Social prescribing is recommended in the guidance as a means to improve the social and psychological wellbeing of patients by way of non-medical interventions such as singing in a virtual choir, online exercise or art classes, mindfulness and meditation. This can be facilitated by trained non-clinical staff who can introduce patients to community support networks and contact them for regular reviews. Practices can also refer patients for support from community volunteers, such as NHS Volunteer Responders, who can help with social prescribing, shopping, regular telephone conversations, and physically distanced home visits.
The authors suggest focusing on patients most at serious risk of psychological harm and asking what matters to them. Where online tools are not accessible, the clinician or social prescriber could advise the patient on simple exercise routines, recommend appropriate radio or television programmes, or signpost them to accessible health and wellbeing activities. Physical activity is particularly recommended as it has benefits for both physical and mental health.
Dr Razai said: 'While social distancing is inevitable to prevent spread of coronavirus, these restrictions are likely having a huge negative impact on people’s mental health. Our guidance is intended to support the primary care community, so that the best evidence-based interventions can be used to help those most in need.
'Social prescribing, ranging from one-to-one coaching to online yoga classes and choirs, can make a big difference. The benefits of social distancing are clear, but it’s important to consider the consequences of these measures and respond proactively to protect people’s mental health.'