The role of the GP in the care of people with mental health conditions
As a GP, your role is to:
- develop trusting relationships by giving the patient time to talk about their concerns
- communicate effectively, professionally and sensitively with patients, relatives and carers, recognising potential difficulties in communicating with people with mental health conditions and the importance of generating and maintaining rapport, supported through continuity of care
- consider potential complexities in presentation and range of mental health needs and concerns
- take account of psychosocial factors, including cultural background, bereavement, unemployment, relationship problems, alcohol and substance misuse, and gambling
- consider life-course factors – adverse childhood experiences (ACEs), interactions between work and mental health, the impact of being a carer, older adults with cognitive impairment who initially present with anxiety and depression
- assess risk to make the patient’s safety and the safety of yourself and others a priority. Be aware that risk assessment is important but that there are no validated scales that predict suicide
- use history and examination to come to a diagnosis of a mental health condition and be comfortable in discussing this diagnosis with the patient
- distinguish a mental health condition and its management from distress and advice about promoting mental wellbeing
- be proactive, offer continuity of care, negotiate a shared management plan, arrange follow-up and give advice on when and who to call for help (‘safety-netting’)
- ensure early intervention with appropriate referral
- consider evidence-based prescribing and deprescribing of medication for people with mental health problems, including antidepressants, antipsychotics and anxiolytics, as well as monitoring requirements
- have a basic understanding of indications for, and principles of, psychological therapies such as cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and family therapies. Be aware that these therapies may need to be specifically tailored for neurodivergent individuals
- be aware of the physical health needs of people with severe mental illness (SMI) (including side effects of antipsychotics) and the mental health needs of people with long-term physical conditions
- avoid diagnostic overshadowing. Offer advice and support to patients, relatives and carers regarding prevention, prescribing, monitoring and self-management of both mental and physical multimorbidity
- coordinate care with other organisations and professionals (for example, ambulance service, community mental health teams, social workers, secondary care, voluntary and community sectors, social prescribers and police)
- follow agreed protocols, including as part of the Mental Health Act and the Mental Capacity Act where appropriate
- be aware of differences in legislation across the UK.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations of common mental health conditions
- recognition of normal variations through the life course
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management including initial and continuing care, chronic disease support and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
Below is a list of common presentations or symptoms that may represent mental illness. The role of the GP is to differentiate between stress, distress, mood disorder and diagnosable mental illness, working with the patient to agree what the problem is and management options.
- Fatigue and feeling tired all the time
- Poor concentration and motivation
- Reports of feeling stressed or anxious
- Behaviour change, such as irritability, anger, hypervigilance and self-harm
- Sleep disturbance, including insomnia and hypersomnia, night terrors and early morning awakening
- Feelings of worthlessness, self-harm or suicidal thoughts
- Persistent physical symptoms that are not explainable after investigation
- Psychomotor agitation or retardation
- Hallucinations
- Unusual ideas or beliefs, which may be delusions
- Thought disorders
- Acute confusional state, such as delirium
- Memory disturbance
Some of these symptoms can represent physical ill health or are comorbid with physical health problems.
Common and important conditions
- Mood (affective) problems such as depression, including features of a major depression such as psychotic and biological symptoms; cyclothymia and bipolar disorder
- Self-harm, including putting themselves in dangerous situations as well as self-poisoning and cutting; suicidal ideation and behaviour
- Anxiety, including generalised anxiety and panic disorders, phobias and situational anxiety
- Obsessive disorders, including obsessive compulsive disorder (OCD), skin picking disorder, body dysmorphic disorders and rarer conditions, including trichotillomania
- Acute adjustment reactions
- Eating disorders, including in those living with obesity, binge eating disorder, anorexia and bulimia nervosa
- Severe behavioural disturbance, including psychotic disorders such as schizophrenia, acute paranoia and acute mania
- Personality disorders, including borderline, antisocial, narcissistic
- Bereavement reactions and persistent grief
- Sleep disorders, including insomnia, sleepwalking
- Trauma, including post-traumatic stress disorder (PTSD), dissociative identity disorder
- Pregnancy-associated disorders such as antenatal, perinatal and postnatal anxiety and depression, puerperal psychosis
- Mental health disorders associated with physical health disorders:
- anxiety and depression comorbid with physical long-term conditions such as diabetes, cardiovascular disease, inflammatory arthritis, chronic obstructive pulmonary disease (COPD) and neurological disorders
- anxiety, depression and psychosis associated with learning disabilities and neurodiversity
- anxiety, depression and/or psychosis associated with treatment prescribed for physical health disorders, such as steroids
- Organic reactions such as delirium
- Addictive and dependent behaviour such as alcohol and substance misuse and gambling. This is common in those experiencing mental health problems (termed ‘dual diagnosis’) and is often unrecognised
- Mental health disorders associated with substance misuse
- Adjustment reactions associated with life stages such as childhood, adolescence and ageing
- Impact of ACEs on development of mental health problems in adolescence and adulthood
- Abuse, including child, sexual, elder, domestic violence and emotional
- Behavioural problems such as enuresis, encopresis and school refusal
It is important to consider the cultural context of patients and presentation of their symptoms, which may represent mental health problems, including spiritual and religious beliefs and practices. It is also essential to consider the possibility of unrecognised neurodivergence in patients presenting with mental health disorders.
Mental health problems are more common in people from lower socio-economic groups – another example of health inequalities. Deprivation means that problems can occur at an earlier age and patients are less likely to be able to access a range of treatments.
Examinations and procedures
- Perform a relevant physical and mental state examination
- Understand and discuss the role of common drugs (antidepressants, antipsychotics, anxiolytics), their side effects and monitoring requirements with patients and carers and collaboratively plan the length of treatment and how to stop medication
- Understand and explain the role and content of psychological therapies with patients and carers, including CBT, eye movement desensitisation and reprogramming (EMDR), counselling, psychotherapy, psychoanalysis, aversion, flooding and desensitisation therapies, family therapies
- Understand and discuss suicide prevention strategies
- Understand the role of the GP in detaining patients, including the Mental Health Act and the Mental Capacity Act (or equivalent legislation)
- Electroconvulsive therapy indications and side effects
Investigations
- Screening for metabolic and cardiovascular risk factors in people with SMI, ensuring that such risks are minimised through appropriate lifestyle advice and management, including facilitating behaviour change and making changes to medication where appropriate
- Appropriate use and interpretation of assessment tools for mental health conditions such as depression, anxiety, postnatal depression screening scales, dementia screening, suicide risk assessment and risk of self-harm
- Monitoring of people on medication such as anxiolytics and antipsychotic medication (for example lithium)
- Physical investigations such as blood tests, electrocardiogram (ECG) and relevant neurological investigations, when indicated
Service delivery
- The prevalence of mental health conditions and needs among your own practice population
- Practice registers for specific mental health conditions and recording the required data
- The role of urgent care services, including emergency departments, liaison psychiatry, crisis services and telephone support, and their local availability
- Availability of and referral to voluntary and community services and charities that promote mental health and wellbeing
- The range of psychological therapies available, including CBT, mindfulness, counselling, psychodynamic, psychosexual and family therapy
- Increasing equity of access to primary care and mental health services, including potential access issues for those who are vulnerable or have different cultural backgrounds
- Safe prescribing, including duration of prescriptions, drug interactions and side effects, required monitoring, consequences of overdose and prescribing in children, pregnant women and older adults
- Supporting patients in making choices about which treatment options may work best for them. The ability to choose improves the likely effectiveness of the intervention
- Supporting children in difficulty, and accessing support and advice from specialist child and adolescent mental health services (CAMHS) and CAMHS workers in primary care
- The needs of and services for veterans, including the psychological effects of trauma and war (such as PTSD)
Case example
Bushra Habib is 51 years old and works as a teaching assistant. Her husband has just been made redundant from his job in a national information technology (IT) company. She phones your surgery complaining that she feels stressed all the time and finds it difficult to sleep. She is tearful over the phone but does not feel that her mood is low. She admits that she worries much of the time and her sleep is poor. She says she is ‘just about coping’ with her job, but feels she is getting frustrated with her pupils and her own children. She tells you she is worried because her brother is on some very strong tablets for a ‘serious mental problem’ that the family are ashamed to talk about.
With the help of a GAD-7 scoring on the generalised anxiety disorder questionnaire (GAD), you discuss with her the possibility that she has ‘anxiety’ and might benefit from treatment. You also suggest she has a blood test to ‘check her thyroid’. She agrees to have the blood test but says she does not want tablets – she feels that she should be able to sort things out for herself. She says she feels that tablets are only for weak people.
You suggest that she might seek support from the local NHS Talking Therapies service. She is not too sure, but you give her details of the service and explain that it is a self-referral service she can contact herself. You also give her some written materials about anxiety and panic, with some links to useful websites – you check she has access to a computer or tablet – and ask her to make an appointment for review in two weeks.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are the boundaries of my involvement and responsibilities in Bushra’s case? How do I maintain my own health as a GP? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | How do I feel about patients consulting me with complex psychosocial and mental health problems? How do I deal with my feelings about working with patients who are distressed? What are the relevant sections of the General Medical Council (GMC) Good medical practice guidance? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How might mental health problems affect communication between doctor and patient? How do I demonstrate empathy with people with mental health problems? How do my own feelings and situation affect my interactions? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What is the differential diagnosis in this patient? What elements of the patient’s narrative and biographical data might point to depression? How do I sensitively explore alcohol and substance use? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | Which clinical assessment tools for depression and anxiety are appropriate for use in primary care? What are the essential ‘red flag’ symptoms and signs for depression and anxiety? How would I assess suicide risk in this patient (being aware that there are no validated tools for predicting risk of suicide)? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How do I prioritise my management of different biological and psychological symptoms? Am I familiar with variations and patterns of presentations of common mental health conditions? How might time and continuity influence my decisions? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are the important evidence-based guidelines for management of mental health problems in primary care? When and how should I refer to specialist services? How can I try to maintain some continuity of care when I have no appointments or am on annual leave? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How could comorbid long-term conditions affect the presentation of mental health conditions? What mental and physical health problems have the most potential for significant interactions with medication? What are the priorities for ensuring patient safety? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What interventions and therapies are available in primary care to manage anxiety? How do we create seamless multidisciplinary services in mental health care? How do we define areas of responsibility and leadership in mental health services? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What are the best sources of updated information in mental health? What is the role of peer group support (such as Balint and First5 groups)? How can I audit the standard of care I provide? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What additional risk factors should we screen for in patients with mental health conditions? What systems need to be in place to ensure safe and consistent monitoring? How do we develop services to improve access to care for marginalised and stigmatised members of society? What are the advantages and disadvantages of self-referral systems? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What are the important determinants of and influences on mental health? How does my role extend beyond the medical model? How well equipped am I to explore cultural and spiritual factors in patients’ lives? Why might patients be reluctant to access psychological services? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How can I ensure equity of access to mental health services? What community resources are available for patients with mental health conditions, including voluntary and charitable services? How do I ensure that I understand and recognise the cultural issues in my practice population? Are there any support groups specifically for patients from certain cultural groups? What support for Bushra could be sought from advocacy services? |
How to learn this area of practice
Work-based learning
A significant proportion of primary care consultations involve discussion of mental health concerns. By observing and participating in consultations, you can learn to communicate sensitively, build trust and respond to cues from patients, their relatives and carers. You will have the opportunity to learn to take a holistic approach to understanding and co-developing an explanation for a patient’s illness presentation. You will learn how to differentiate distress from a diagnosable mental illness, how to develop a shared management plan and how to review and revise plans at follow-up.
You will have the opportunity to gain a better understanding of the role of the primary care mental health teams, specialist teams, referral criteria and care pathways. Shadowing other allied healthcare professionals in general practice, such as mental health practitioners and link workers, will help you understand how different team members can support patients with mental health problems, while exploring third sector providers could help you to create a local practice resource directory.
Some GP registrars have psychiatry placements. Where possible, it is valuable to spend time in different mental health care settings to provide insight into patient journeys, from community mental health teams to inpatient wards and crisis teams. You can learn about how referrals to psychiatry are assessed, which patients are cared for by both primary and specialist care, shared care approaches and how the physical health of patients with SMI is monitored and supported.
Learning with other healthcare professionals
Supporting patients with mental health problems often requires teamwork across health and social care and the third sector. Discussion of the roles of individuals representing the many professional and non-professional groups should help you understand the variety of services available. Shadowing people in these different roles, and attending joint learning sessions with psychiatry GP registrars and mental health practitioners, could help you to gain a greater understanding of the services provided locally and the need for cross-agency communication and partnership working.
Examples of how this area of practice may be used in the MRCGP
Applied Knowledge Test (AKT)
- Diagnosis and management of depression, including psychological and pharmacological options
- Drug treatments for mental health problems, including interactions, side effects and monitoring
- Assessment of physical symptoms in a person with a chronic mental health condition
Simulated Consultation Assessment (SCA)
- A woman has ongoing abdominal pain, and the gastroenterology letter (provided) indicates no organic cause
- A young mother is worried by thoughts that TV and radio presenters are talking about her, despite acknowledging that this cannot logically be the case
- A teenager asks for help with compulsive tidying, which takes hours at a time and is interfering with his schoolwork
Workplace-based Assessment (WPBA)
- Log entry reflecting on the implications of a rejected referral to mental health services when there are serious concerns about the patient’s mental state
- History-taking with a patient requesting more sleeping pills