Dealing with mental health problems in primary care

The most important thing to do is listen. Appear kind and interested in them as a person. We know from patient feedback and research that the fact someone listened is the most important thing.

Listen actively: remain calm; pay close attention to what the patient is saying; ask questions and paraphrase to ensure you’ve understood them; use eye contact and body language to acknowledge you are listening. Then try to find out:

• How the person’s problem is affecting them (note their mood)
• What’s troubling them the most
• What helps them cope with this - offer brief advice if appropriate
• Offer empathic comment (to encourage hope)
• Ask about suicidal intent (this is covered in more detail later)

Give the person hope by reassuring them that help is available, and that you have seen people in similar situations get better. It’s helpful to find out how this works in your own practice; for example, is there a particular GP or healthcare professional you can refer the person to? You can learn about assessing someone, supporting them with self-help and the different agencies that can be accessed. The more you understand, the more confident you’ll feel when patients come to you with this sort of problem.

You should regard listening as a really important intervention.

The original purpose of the visit can usually be rescheduled to give you time to deal with the problem that’s really on the person’s mind. Imagine that you have an exam this afternoon and are really worried about it; then your practice manager decides to tell you about the new system for checking the emergency equipment. It’s unlikely you’ll be interested or take in the information – waiting until afterwards when you’ve done the exam will mean you’re more able to engage.

The patient might come in to see you with vague or unexplained physical symptoms such as headaches, bowel problems, indigestion, general aches and pains, or amenorrhoea.

Those with a long-term physical health problem are much more susceptible to depression. They may attend for a regular health check, for example, someone with diabetes may attend because their blood glucose readings are raised. The reason for this could be the fact that they’ve stopped eating healthily and exercising because they’re feeling low.

They might tell you about:

• Difficulty in managing usual day to day activities
• Increased tiredness and/or problems with sleep
• Problems with colleagues, family or friends
• Change in appetite and/or eating habits
• Increase in smoking
• Increased alcohol / drug consumption

In patients you’re familiar with, you might notice a change in their appearance, for example, usually smartly dressed and now looking unkempt. Or they may appear flat or less engaged.

In these situations, you can use the depression screening questions which are advocated by NICE.

An answer ‘no’ to the questions means the person is unlikely to have a problem. But let the patient know you have an open door and that they can always return if anything changes. It’s vital that they have the option to come back. An answer of 'yes' to any of the questions should trigger a more detailed diagnostic assessment using a diagnosis and response tool.

There are two tools which have been validated for primary care. They are also used by the IAPT service (Increasing Access to Psychological Therapy). This might be the next step for someone who requires treatment, so it’s useful to use the same measures.

1. Patient Health Questionnaire (PHQ-9). This comprises of nine questions to score the severity of a person’s depression.
2. The Generalised Anxiety Disorder assessment (GAD7) contains seven questions to score the severity of a person’s anxiety.

Using these tools helps you become familiar with the most common symptoms of anxiety and depression. It can also help you see how the mental health problem is affecting the person without asking lots of probing questions. You can then use the time in the consultation to work on what’s troubling them the most, for example sleep. The tools are only a guide but are really helpful to measure improvement.

If they have suicidal intent, then this needs to be dealt with immediately.

You should always ask about suicidal intent. It will not put the idea into a person’s head. Often, people are relieved to be asked and to be able to talk about it. It’s important to record their responses, especially if they deny any thoughts, in case there are investigations later. There’s a list of simple questions which can guide you through the process of asking about suicide. This can show when a person has thoughts but not intent and when they do have intent. It’s important that you know what to do in these circumstances and will be supported in your actions. If you’re concerned, then refer the patient to a duty GP, for example, immediately. There needs to be a process in place so that everyone knows what to do and who to talk to.