I’m not usually lost for words, but offering a GP’s perspective on mental health has proved challenging. When thinking about treating patients who come seeking help with mental health issues I find myself falling into a pattern of thinking that I advise GPs in training to avoid – it’s usually not that people have unrealistic expectations of doctors, but more that doctors wrongly assume people have unrealistic expectations of them. These clashing assumptions can then adversely affect how doctors and patients communicate and may lead to some feeling like their needs aren’t being satisfactorily met.
I’m heartened by the positive experiences of care I hear about, but there are too many occasions when services could do better. After 32 years as a doctor, initially in mental health, then general practice and neurology, I have learned (amongst other things) that we don’t know enough about the brain. It is far easier to do a good job with conditions where we fully understand what’s going on, and have tests to make a definitive diagnosis.
However there is a lot of information out there to support best practice in mental health. Since 2015, the Dept of Health has produced a series of “forward view” documents for mental health and general practice. The required funding has not yet been realized for all of these and there are significant shortages in most staff groupings, but it is movement in the right direction.
NICE is currently refreshing its Depression Guidelines (out to consultation), and along with the Royal College of Psychiatrists as NCCMH (National Collaborating Centre for Mental Health), is part way through a 4 year program to describe what good mental health services look like. These will set challenging standards for commissioners and providers of services that are likely to become mandatory over time. So will these things make a difference? I think so, if the recommendations are adopted and – crucially – adequately funded.
A strong theme throughout is that of parity of esteem – meaning that mental health services must be given equal priority to physical health services. Quite rightly, as there has been historical under-funding of mental health services, there is a focus on access to services in terms of capacity to see more people, and time targets – as we have for physical health. This is important as outcomes are better if there is early intervention.
Parity of esteem is also about knowledge and attitudes. People sometimes apologize for not getting better quickly enough from depression. In fact this is quite common, and yet we would be surprised if people apologized for being physically ill.
To support people into recovery, it is important to discuss all relevant factors together, in partnership, and manage all long-term conditions holistically. At different times people may need different interventions. If someone chooses not to accept an intervention it can be interpreted as not wanting help, but it may be the wrong time for that intervention for that person. There are more choices available these days, but sometimes there are longer waits for certain therapies. Interventions can be discussed, and informed choices made that aren’t mutually exclusive and may be reconsidered at a future date.
The Sheffield Mental Health Guide to local and national services is an excellent resource which can be accessed via links from the Sheffield Flourish website or the CCG MH protocols for primary care. The guide has links to important websites such as IAPT’s. These outline interventions that people can be referred for, or often self refer.
Recovery from mental ill-health is often described as a journey, and in this a GP can be a good guide. Medication is helpful when prescribing is appropriate, and informed by best evidence and patient preference, but many people will also need the psychological interventions and recovery activities offered by IAPT, as well as the third sector and secondary care.
A final note about recovery; the joy of being a doctor for a number of years is that people who were my patients are now my valued colleagues. Recovery may take time and is a hard road to travel. But being a part of that journey with your patient is a worthwhile and rewarding experience.