Although the profile of mental health issues has been greatly raised in the last few years, and with good reason, sadly it has often struggled to gain parity with physical illnesses, in terms of both funding as well as importance in the minds of some healthcare professionals as well as members of the general public.
Whereas previously advice was commonly along the lines of “pull yourself together”, we now recognise that the burden of mental health, especially that left untreated, is considerable. With one in four individuals suffering a psychiatric problem at some point in their lives, it is also very common. Although this may be as simple as transient low mood which does not interfere with functioning on a day to day basis, some will be affected by anxiety and/or depression to a level where they struggle to enjoy life, interact with those around them and maintain relationships. They may be dismissed from jobs and even lose their housing.
As frontline healthcare providers, we need to be vigilant to mental health issues, which may often not be the main reason for consulting. Nonverbal cues can include low affect, apparent lack of self-care and sometimes just a gut feeling that something is not quite right, especially if the person has previously been of a happy disposition. Rather than be ignored, these need to be addressed in a sympathetic way, as often patients are too shy or embarrassed to raise the issue.
When assessing mental health issues, contrary to a tick box culture, it is perhaps more pertinent to enquire as to the effect on the patient’s life, as opposed to how many symptoms they have in isolation. One pervasive complaint may cause greater disability than five low level features.
Always try to screen for risk of harm to self or others. It has long been established that asking about suicidal thoughts does not make the patient more likely to commit suicide. It may even help them to raise a topic that they are too fearful to discuss. I try to establish protective factors, for example a supportive partner, or young children, when asking about what would stop someone actively self-harming.
Once a mood problem has been raised, we should look to individualised care, rather than a one size-fits-all approach. The Royal College of Psychiatrists currently recommends talking therapies as first line, with medication as a second step. However if you have a patient to whom counselling does not appeal, or indeed is too low at this point to benefit from counselling, it is not unreasonable to offer medication from the outset, with regular follow up. A recommended trial of an individual antidepressant is three months, by which point it will be apparent if it is helping.
Discussing precipitating and maintaining factors is also important. If a patient is in an abusive relationship, has a financial worry, or alcohol/substance misuse, it is vital to tackle these, signposting to relevant organisations as needed.
I believe that patients benefit from a friendly face, an empathetic approach and presenting options in an unambiguous way, with the offer of regular follow up. If they can be seen by the same clinician for one issue, this often helps establish rapport as well as continuity of care.
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