It may seem strange to recommend psycho-education as an independent intervention when education is part of all good clinical care where you engage the patient and begin to build a therapeutic partnership. The principles of adult education tell us that reinforcement is a key to effective outcome so expect to have to repeat this information. Psycho-education involves explaining the disorder to the patient and answering the patient's questions about the disorder. Typically, you would provide information at an appropriate level and this would include education about how common their disorder is, what symptoms people have, any complications or other problems, what causes it, what will happen in the longer term, what treatments work and what are the pros and cons of those treatments. It may also be useful to supplement this with a handout that the patient can take away with them, read and refer to as needed.

Does it work?

The hard outcome data on patient education is scanty but it is a major component of all good clinical care. There is good evidence that the more people understand about their illness and it's treatment the better they adhere to treatment plans. Psycho-education is a major component of all self-help programs (e.g., Lampe, 1996). Knowledge about the symptoms, the natural history of a disorder and the effective treatments has been shown to improve outcome (Craighead, et. al., 1998)

How do you do it?

1. Remember to use words that the patient can understand. List the symptoms and signs that the patient has. List the diagnostic criteria for the disorder. Say that you think that the patient meets criteria for the disorder and relate it back to their symptoms.
2. Say it is a common the disorder (i.e. you are not alone), describe the natural history of the disorder and what improvements can be expected from treatment. Instill hope "many other people have benefited from this treatment"
3. List the treatments that work and outline the treatment plan you would recommend for this patient.
4. Invite questions and discuss.
5. Reinforce at subsequent consultations.

Psychoeducation, or what the doctor might say:

Below is an example the minimum that a GP might say when beginning a psycho-education session with a patient with the specified mental disorder.

F10: Alcohol abuse/dependence:

The recommendations for healthy drinking are less than14 drinks per week for women, or 28 drinks for men. It seems that you are drinking more than this. The problem with drinking at your level is that it can damage your liver, heart and result in depression or dementia. The first thing we must do is reduce the harm your drinking is doing. The best way to do cut down is to limit the number of drinks you have and write the total in a diary. Drink light beer or space your drinking with soft drinks. Try to have two alcohol free days each week and limit your drinking to two drinks on other days. Come back and see me in a fortnight and show me the diary. I expect you to have good and bad days, this can be hard and scary at first but stick with it and come and see me in two weeks. Once we get started there are other ways that I can help (motivational interviewing).

F11: Drug abuse/dependence:

Your drug use is a serious problem (codeine, sedatives or marijuana; if other drugs refer patient to drug and alcohol service) and we have already discussed that it is making problems at work and with the family. You need to decide to quit. The best way to do this is to keep a diary of your drug use and try to gradually reduce it. Why don't you come back in a week with the diary and we can then review when you used and why you used at that time. Once you have decided to quit I can help further (motivational interviewing).

F20: Chronic Psychosis in relapse.

We've talked about how difficult it is for you to concentrate or to motivate yourself to do things, and that you are still hearing voices and have ideas that are different to those of other people. Regular medication can help control your symptoms. New drugs like risperidone are easier to take than the older medications. I will begin you on a low dose of risperidone and I want you to come back and see me in a week. At that time I'd like to see you with your family or others you live with when we can discuss other strategies for managing your symptoms like the problem solving technique and social skills training.

F23: Acute Psychotic Disorder

You've said that you can't think clearly, that you are having strange experiences and that all this is very frightening. There are a number of possible reasons for this change in you and they will need to be investigated. I will refer you to a specialist who will advise about the diagnosis and treatment. We could arrange for you to go to hospital but it would be better if we can manage this with you staying at home. In the meantime I would like you to take some medication that will lessen the strange experiences and the fear. Until you see the specialist I'd like to see you most days to make sure you are progressing properly. [make an appointment with a private psychiatrist or with the community mental health centre, or discuss the case with the registrar on duty at the inpatient unit]

F31: Bipolar Disorder

You've said that you are very energetic and active, very elated and irritable, not your usual self at all. I think you have an illness called hypomania and that if not treated you are likely to spend all your money, and upset your family and friends, and generally do yourself no good. (If recurrent episode) I think you should go back on your medication and hopefully will not need to go back to hospital. I'd like to organize an appointment with the specialist that looked after you last time. (If first episode) I'd like to get a specialist opinion and while we wait for that I'd like you to take medication that should help your mood and energy become more normal. I'd like to speak to your family about your condition. Later I'd like to teach you and the family problem solving techniques to lessen difficulties. (If in depressive phase treat for Depression).

F32 Depression:

You've said that your mood is low, you've lost interest in things and there have been other changes as well. These symptoms have lasted for some time now and are not really explained by what has happened to you, even though you think that you are in some way to blame. I think you are suffering from Major Depressive Disorder. Untreated, it is likely to last for months, during which time you might damage your job prospects and your friendships. (If depression is moderate or severe say) I think you need treatment with an antidepressant medication. Once you are started on the medication I will teach you psychological ways (activity scheduling, problem solving, cognitive therapy) to hasten your recovery and help you remain well. I'd like to see you in a few days and it would be best if your wife/husband/friend came with you so that we can all work together to get you well. Alternatively I could refer you to a specialist. Which would you prefer?

F40 Social Phobia:

For years you've become very anxious when in company, in case others notice that you're anxious, or you say or do the wrong thing. The risk in your mind is that that they will think you are weak or incompetent and this is the reason you avoid such situations. This condition is called social phobia and without treatment it tends to persist, because each time you avoid a situation, the relief you feel strengthens the fear of that and similar situations. Antidepressant medication will lessen your anxiety and make it easier to enter situations and this might suit you. I could teach you to reduce your anxiety using the controlled breathing technique, how to view your reactions to situations more clearly (cognitive therapy), and how to master feared situations by confronting them in a planned way (graded exposure). Alternatively I could refer you to a specialist for treatment. Which would you prefer?

F41 Panic Disorder/Agoraphobia

You have sudden attacks of fear in which your heart beats fast, you can't breathe and you have other physical symptoms of anxiety. In consequence you fear you might have a heart attack, collapse and die during one of the attacks. You have begun to avoid situations in which escape wouldn't be possible or help couldn't get to you if an attack occurred. The condition is called panic disorder with agoraphobia. Without treatment it tends to persist, because each time you avoid a situation the relief you feel strengthens the fear of that and similar situations. I could teach you how to control some of your anxiety using the slow breathing technique, how to challenge worrying thoughts using cognitive therapy and how to master feared situations by confronting them in a planned way (graded exposure). Antidepressant medication will also lessen your panics and make it easier to enter situations Alternatively I could refer you to a specialist for treatment. Which would you prefer?

F40.2 Specific Phobia

Many people have excessive fears of snakes, poisonous insects, heights, closed places, dogs and still water. Mostly these fears have been present since childhood and mostly people learn to avoid such situations. This avoidance reinforces the phobia. If your phobia is interfering with your life and activities too much I could teach you how to confront and master your fear using graded exposure.

F41.1 Generalized Anxiety Disorder

You're worried about a physical symptom that as far as I can see is not evidence of a serious illness. You've mentioned that you've had persistent and uncontrollable worry over everyday things for months. Being on edge and physically tense is wearing you out. You said that you've been like this, on and off, for much of your life, but that this spell has gone on too long. Your condition is called Generalized Anxiety Disorder and tends to persist. You might choose to learn some psychological strategies like slow breathing and problem solving and relaxation to control your worry and tension. I could treat you with an antidepressant drug that would reduce your worry. We could do both, so that after you stop the medication you will still have strategies to manage. Alternatively I could refer you to a specialist. Which would you prefer?

F41.2 Mixed Anxiety and Depression

You've said that your mood is low, you've lost interest in things and that you are worried and anxious all the time. These symptoms have lasted for some time now and are not really explained by what has happened to you even though you think that you are in some way to blame. I think you are suffering from Mixed Anxiety and Depression. Untreated, it is likely to last for months, during which time you might damage your job prospects and your friendships. I think you need treatment with an antidepressant medication and with psychological strategies. Once you are started on the medication I will teach you psychological ways (activity scheduling, problem solving, cognitive therapy) to hasten your recovery and help you remain well. I'd like to see you in a few days and it would be best if your wife/husband/friend came with you so that we can all work together to get you well. Alternatively I could refer you to a specialist. Which would you prefer?

F42.2 Obsessive Compulsive Disorder

You've told me that fearful thoughts of harm to you or your loved ones keep entering your mind no matter how hard you try and resist. To control your fears, you have been checking or washing repeatedly to the point that the obsessions and the compulsions interfere with your life to the point that your life seems dominated by the disorder. Antidepressant medication will lessen the power of the obsessions so that they are easier to resist. Additionally I could show you how to manage the compulsions in a planned way (graded exposure and response prevention) so that the strength of the obsessions lessens and you become well. Alternatively I could refer you to a specialist for treatment. Which would you prefer?.

F43.2 Adjustment Disorder

You've been through a tough time. You are overwhelmed by what's happened to you. It's been difficult to cope and you've been feeling sad and anxious. Unfortunately medication that calms your nerves takes away your ability to manage. If we do nothing, your distress will pass, but I'd like to use this opportunity to teach you ways of coping that hasten recovery and make you more able to cope in the future. They are Stress Management/ Structured Problem Solving . Here is a handout. Read this and come back tomorrow when we can go through it.

F44 Dissociative or conversion disorder

Sometimes stress or shock can result in physical symptoms. I do not think that your symptoms are due to a serious physical illness. They could be the result of stress. I want you to go home, go to bed and rest, then come back and see me. I'll review your symptoms and then teach you some ways to cope with stress that are less likely to result in symptoms (Structured problem solving, progressive muscular relaxation, communication training).

F45 Unexplained somatic complaints

You've told me that your symptoms trouble you a lot but that no one can find a cause. I can find no evidence of serious illness but your symptoms are real to you and do interfere with your life. While your condition is not common we can help you manage better. We have seen others do well. Given that we don't understand the cause I suggest that you learn better ways of coping with stress (structured problem solving), ways to relax (progressive muscle relaxation) and ways to begin to enjoy life again, despite the symptoms (activity scheduling). Alternatively I could refer you to a specialist who could teach you these things.

F48 Neurasthenia

You've been tired and easily fatigued for some time now. Investigations have not shown a specific medical cause that we can treat. However, many people with this problem have had great benefit from straight forward things like getting your pain under control, sleeping properly and then gradually beginning to exercise (activity scheduling). Make an appointment for tomorrow when I can spend time with you and we can plan it out.

F50 Eating Disorders

You've described problems with dieting, binge eating and vomiting. None of it makes you happy with yourself, nor are these effective ways of managing your weight. Unless we do something it will just go on and there is a real risk that you'll get physically sick and depressed. Lets look at healthy ways of eating without weight gain. I'll need you to keep a food diary and note the events that test your resolve. Then I'll teach you some psychological strategies to help you feel better about yourself and be in charge of your problems. (structured problem solving, cognitive therapy, communication training).

F51 Sleep Problems

You have told me that you are having trouble sleeping. I do not think that it is because of some disease or condition, only that your sleep habits have got out of order. Sleeping pills do work, but only for a few weeks and you are likely to become dependent on them. So we need to put your sleep habits right. Here is a handout about sleep. I want you to fill in the sleep chart every day, read all about sleep and follow the rules for good sleep on the last page of the handout. I'd like to see you in a week to check progress.

F52 Sexual Disorders in Men

You've described sexual difficulties that occur when you are with a partner. They don't occur when you are on your own. We will need to make sure there is no physical cause. There are a number of things I can do. Firstly there is medication to improve your erection but we will also need to work on your confidence and your relationship (communication training, graded exposure). Alternatively I could refer you to a specialist.

F52 Sexual Disorders in Women

You've described sexual difficulties that occur when you are with a partner. We will need to make sure there is no physical cause. There are a number of psychological strategies that might help. We will need to work on your confidence and your relationship (communication training, progressive muscle relaxation, graded exposure). Alternatively I could refer you to a specialist.

F90 Hyperkinetic (Attention deficit) disorder

You have said that your child can't sit still, is easily distracted and is impulsive and disrupts others. From what we have seen in the consulting room I agree. He could have attention deficit disorder. This behaviour is likely to result in him having difficulty at school and in some cases becoming identified as bad or uncontrollable. There are two arms to treatment, the use of medication to increase his attention span, and the development of a settled home environment that lessens the triggers to his disruptive behaviour. Medication can only be prescribed by a specialist but you and I could work in partnership with specialist on how to change things at home (parent management training) and at school. You might choose to see a specialist alone.

F91 Conduct Disorder

You have told me how worried you are about your child's aggressiveness, bullying, cruelty, stealing and lying. You're worried that he might get into trouble with the law. Some children outgrow this phase but many do not and continue to have trouble as young adults. I will teach you two strategies, parent management training and structured problem solving, to help you manage your child better. Alternatively I could refer you to a specialist. Which would you prefer?

F98 Enuresis

Your child, even though now in school, is still wetting the bed most nights. This is called enuresis. It is time to do something about it. I will prescribe a low dose of an antidepressant drug and this will help the child to be dry. Your child should take responsibility for managing his bedding when it is wet, and should keep a list of dry nights on a calendar. You should reward progression towards being dry. If necessary we can get an alarm system to wake him the moment he begins to urinate. He should do well.

Z63 Bereavement and other stressors

You have told me how difficult it is since your (spouse/child/parent died)(since the trauma occurred). While recovery is the rule, there are some ways of coping with such events. Here is an information sheet (Management of Mental Disorders: managing loss or bereavement / Management of Mental Disorders: psychological responses to stress: what to expect and what to do), read it and discuss it with friends or family. Come back in a few days to tell me how you are going to put the advice into action.

References and recommended reading:

1. Craighead, W. E., Miklowitz, D. J., Vajk, D. J., & Frank, E. (1998). Psychosocial Treatments for Bipolar Disorder. In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press.
2. Lampe, L. (1996). A Management Approach to Anxiety. Australian Family Physician, 25(10), 1561-1567.