Brief behaviour change strategies for distressed patients in primary care

Encourage patients to talk about distress

Patients may be uncomfortable discussing distress openly with their physician, owing to stigma or a notion that primary care appointments should be focused on physical concerns.20 Consider explicitly inviting patients to report distress and concerns using a short waiting room survey, questions or topics patients may want to ask about, exam room poster, handouts, and reminders to write down concerns before they meet with you.21

Preliminary evidence suggests that by explicitly inviting patients to identify their priorities before the visit, patients may be more likely to disclose distress earlier in a visit, rather than raising a distressing issue at the end of a visit or not at all. In a randomised controlled trial in primary care (60 patients), patients who used a computer based tool to help them identify priorities to discuss with their physician were more likely to disclose stressors (85.7% v 48.1%, 6.16 times greater odds, P=0.011) compared with usual care. Study patients also disclosed stressors marginally earlier in the visit (comparing line numbers in transcripts of the visits, average of 188.0 v 341.2, a 45% reduction in number of text lines before disclosing stressor, P=0.059), in visits of comparable lengths (24.2 v 22.9 minutes on average, not significantly different).22

Some practices routinely use a screening tool like the Patient Health Questionnaire-9 (PHQ-9), which can provide helpful information about a patient’s distress, thoughts of suicide, and response to treatment. An over-reliance on screening scores may result in overestimating the severity of a patient’s distress, however23—or underestimating distress, if the patient denies distress but identifies troubling life situations. We encourage using screening tools to initiate a conversation that ultimately engages the patient in a brief discussion about his or her concerns and priorities.

Acknowledge distress

On observing that your patient is distressed based on self-disclosure of distress or stressors, non-verbal cues, and/or screening results, communicate to them that you perceive their distress and you would like to help. In the words of a patient contributor whose spouse died by suicide, “None of his doctors ever asked about depression. I just wish they would have asked.”

Agenda setting

Estimate how long the visit will be and review matters to be discussed, including seeking patient input on topics.568 For distressed patients in particular, this is likely to help the patient decide how detailed (or succinct) to be when discussing topics of concern, and can avoid the need to interrupt or end a conversation abruptly.

Identify patient priorities

Inquire about the patient’s perceptions of his or her concerns. We would ask one or more questions like: “What are one or two of the most important concerns that may be causing you to feel [use patient’s own words for distress]?” or “How have you noticed [patient’s words for distress] affecting you?” You may add your own observations, inquiring in a tentative manner, such as, “You mentioned staying up late watching TV; not getting enough sleep can lead to feeling depressed. Could that be part of the issue?”

You may choose to conduct screening at this point, if feasible, for depression, anxiety, pain, or social concerns such as housing. Attempt to identify a small number of priorities. This can help patients focus on one problem at a time, so they feel less overwhelmed and more motivated to develop and carry out an action plan.

To transition the conversation towards next steps, briefly summarise this discussion, such as: “It sounds like your main concerns today are sleep difficulty due to pain, and disagreements with your husband. How about we spend a few minutes talking about the pain and strategies that might help you sleep a little better, and then see what ideas we can come up with for your relationship with your husband?”

Problem solving and goal setting

In brief problem solving or goal setting interventions, providers discuss patients’ concerns and help them develop personalised, concrete action plans. Helping a patient establish a personally relevant goal and action plan to address the goal can reduce distress, as reported in systematic reviews and meta-analyses of cognitive behavioural therapies.567 Problem solving therapy can be effective when delivered or supervised by primary care physicians, as indicated in a meta-analysis6 (table 1).

If you identified a specific issue while setting the agenda, you could ask about it, such as, “You mentioned stress due to arguing more with your husband—what are one or two small changes you could make that might help your relationship?” Help the patient develop a very specific plan of what behaviours she will do and when she will do them.

Behaviour change

Instead of (or in addition to) a personalised behaviour plan for a specific problem, you can propose several types of behaviour changes that benefit patients’ moods. CBT incorporates a variety of brief interventions that have an impact on mood and functioning, such as relaxation strategies9 and doing more valued, enjoyable activities daily, including positive social interactions.8 CBT based interventions have been successfully delivered in primary care by mental health providers, physicians, and nurses. Face-to-face, remote, or self-led formats are all effective for primary care patients with depression, according to meta-analysis.5 Additional behavioural changes include increasing physical activity,10 improving sleep,11 improving nutrition,12 and reducing alcohol intake13 (table 1; box ‘Additional educational resources’).

How to help patients navigate challenges?

Behaviour change can be difficult, especially when patients feel discouraged, overwhelmed, or worried. It is important to strike a balance between believing in and empowering your patient, and empathising with challenges and setbacks that can occur. Basic CBT strategies to help empower patients to change behaviour include:

• Providing a rationale regarding why the chosen behaviour helps to improve patients’ moods

• Asking the patient to choose one small change he or she feels ready to start right away and set a specific goal (eg, walk for 15 minutes during lunch break Monday/Wednesday/Friday, spend 10 minutes reading to child before bedtime). Describe the rationale for this too, such as, “All of us are more successful when we choose behaviours we feel ready to try, with a detailed plan we feel fairly confident about implementing”

• Encouraging patients to track their progress by documenting what they do. Patients are more likely to change behaviour when they monitor progress towards their goal7

• Telling your patient that you believe they can make the change and that you will ask about this goal at your next visit (create a reminder system). This will likely strengthen your healing relationship and motivate your patient to follow through.1

Acknowledge that unexpected barriers sometimes come up and that it is acceptable for the patient to adjust their plan or even start over if this happens. For example, “There may be times when you can't meet your goal of walking at lunch three days a week, like if you need to work through lunch or if it rains; don't let that get you down, remember each new week is a chance to succeed.”

Underscore that you want your patient to return and tell you how it went, even if she or he did not complete the plan. A key point in problem solving is that, even when an action plan does not go as planned, you and the patient will learn new information about the problem and how to address it.

After you have developed a plan, succinctly review the process of focusing on one priority and developing an action plan. Note that the patient can follow a similar process on his or her own for other problems or goals. By helping your patient understand why and how to change behaviour, you help empower him or her to continue to make improvements independently, beyond what you can discuss during your encounters. This practice of learning the rationale and process for behaviour change is an integral part of CBT interventions.

What to cover at follow-up visits?

Review the patient’s goal and plan,7 again setting an agenda. Celebrate successes, even partial ones—we have observed that distressed patients sometimes report that they “failed” when they in fact made partial progress. Empathise with challenges that arose. Some patients may return having not attempted or completed their action plans. As in the initial conversation, it may be helpful to empathise in a non-judgmental way with concerns or barriers that might be causing the patient to feel ambivalent about changing the behaviour. The action plan may need to be adjusted if it was too ambitious or if the patient is not ready to make the change yet. Such adjustments and review of progress are characteristic of CBT, including problem solving interventions.