Consultation Skills - Effective mental health consultations

As demand continues to grow, Dr Martin Lindsay explains how to achieve more in consultations.

Mental health: guide the conversation through active listening (Photograph: JH Lancy)
Mental health: guide the conversation through active listening (Photograph: JH Lancy)

Surgeries are reporting that 30% of all appointments are being used by patients seeking help for mental health conditions such as anxiety and depression, and the demand continues to grow.

The root causes are well documented in major urban areas with transient populations, high unemployment, social and economic deprivation and erosion of the traditional family unit all playing a contributing part.

It is easy to feel overwhelmed as a GP, especially when support services such as Improved Access to Psychological Therapies (IAPT) are at full capacity. NICE gives little practical advice on issues GPs face regarding mental health, such as family disharmony, homelessness, overcrowding and stress in and outside the workplace.

Talking therapies

NICE cites the use of talking therapies, such as CBT, but gives no steer on how GPs can use brief interventional therapy to help patients while they wait for weeks and sometime months for IAPT assistance.

A large amount of research shows how poor mental health affects physical wellbeing and the QOF now encourages GPs to carry out annual health checks, because of the effects mental health has on life expectancy and morbidity.

Patients with chronic long-term illnesses can become depressed for many reasons, such as the limitations their condition puts on what they can do. This can hinder physical recovery and highlights the importance of finding a solution to aid the patient's physical and mental recovery. Mental and physical wellbeing exert a powerful influence over one another, of which the public needs to be made more aware.

Active listening

A trap some GPs fall into is feeling that they have to provide a depressed patient with a ready-made remedy and being unduly pressured by the confines of their appointment slots. In my experience, patients can get a huge amount off their mind in that time if you just let them talk and guide the conversation through active listening.

There is something about verbalising and writing down what is troubling you that can be cathartic. GPs can help by allowing the patient to talk then reflect on how to solve the problem.

I find it useful to ask patients to look at their condition in terms of cause and effect. This applies to almost everything we do. Most of us focus on the outcome or effect without realising that real change takes place at the 'cause' end of the equation.

This is a useful technique to apply because people can stand back and see what is really troubling them instead of just focusing on their emotional state.

Key consultation skills

Patients with depression

  • Listen. Ask the patient to vocalise what is bothering them.
  • Respect and empathise with the patient's condition.
  • Interaction is about transfer of emotions. Ensure you are focused on what the patient is feeling, not yourself.
  • Do not attempt to obtain a whole picture of the patient's condition. Get an outline and a feel for the issues.
  • Suggest forms of non-clinical pathway support, such as local voluntary groups.
  • Keep the patient informed about the progress of referrals.
  • Be aware that some groups, such as Kurdish and south Asian communities, may refer to a physical rather than a mental pain and be sensitive to their approach to expressing themselves.
  • Be flexible with your 10-minute appointment slots.
  • Encourage patients to self-refer to IAPT.
  • Remind patients their emotions do not define them as individuals.

Pieces of the puzzle

I often tell students to think of a patient as a million-piece jigsaw. You are never going to put all the pieces in place in the allotted time, so establish an outline and a feel for what is happening to them.

It is detective work, but the patient presents all the clues if you have the acuity to pick up on them. For example, if a patient says they felt a certain way and you can reflect and identify with what they describe, or understand how they could feel that way, you probably have enough information to understand their situation.

Focus on the patient

My advice is to focus on the patient's emotional experience, not yours. All social interaction is based on the transfer of emotions, but you have to listen without bias or personal feeling.

I often find when speaking to patients that the little things you do are as important as the big things, including making sure the patient feels they have been listened to and asked clarifying and pertinent questions.

This means sitting down and really listening to the patient's problems, giving them extra time, suggesting non-clinical pathway support and, most importantly, keeping them informed of what is happening with regard to referral.

It is also important to recognise that it takes most patients a long time to work up the courage to see their GP about a mental health problem and they are often anxious their request for help may be inappropriate.

Reassurance, patience and empathy can be as effective as medication in depression, as long as you can engage with the patient. Many GPs would appreciate more support and training from their mental health trusts and this is a major area that clinical commissioning groups will need to address.

I personally favour talking therapies, which are proving effective in IAPT, but we need to give patients a choice, to see what works for them.

This will mean liaising with local consortia and mental health trusts to provide broader access to the various therapies.

  • Dr Lindsay is LMC chairman of Haringey in north London and the borough's GP representative for Barnet, Enfield and Haringey Mental Health NHS Trust

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

 Further learning

These action points will provide further learning opportunities in this area:

  • Update your knowledge of talking therapies. Make a comparison based on the latest evidence.
  • Ask a mental health lead or representative in your area to update you and your colleagues about any new developments at your next practice meeting.
  • Find out which local support groups are available in your area and ensure you have their details, such as website addresses or leaflets, to hand in your consulting room, and that you circulate the information to your colleagues.

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