Consultation with an unhappy teenager
Does a depressed teenager present an even more challenging consultation than usual? Dr Lionel Jacobson outlines what to expect
GPs often see unhappy patients. As a registrar you will see adults with stress symptoms who report unhappiness, or who exhibit features of low mood. You may find these consultations challenging, but are there even more challenges if a teenager reports distress, or looks depressed?
Psychological issues are present in 25 per cent of consultations with adults, and research indicates a similar pattern for teenage patients. But certain background issues may make care of unhappy teenagers rather more difficult.
For instance, teenagers report difficulties in accessing care, and a large proportion report unfavourably on care that they do receive. Further, teenagers tend to have shorter consultations in comparison with other age groups, although reasons for this are unclear.
What to do
The following ideas are not intended as a 'recipe' for success, merely a 'list of suitable ingredients' to help with any consultation where a teenager may report unhappiness, or appear to be unhappy.
· The 'triple diagnosis'
Unhappy teenage patients may use a physical symptom as a 'ticket' to initiate a consultation, so you may need to be proactive and 'read between the lines' on occasions. An understanding of physical, social and psychological dimensions to consultations is helpful.
· Good communication
There is no substitute for good communication skills. Active listening, allowing the patient to continue uninterrupted, reflecting, and appearing to have the time, space and interest to listen are invaluable.
A common complaint made by teenagers about the care they receive from their GP is a perception of being rushed and largely ignored by an apparently uncaring GP.
· Differing agendas
Many teenagers are more worried about issues of appearance (spots and weight for instance), whereas doctors are concerned about smoking, alcohol or drug use, or risky sexual behaviour.
While it is true that these unhealthy behaviours have some associations with unhappiness, please remember not to be too 'preachy' if called upon to give health advice.
· Confidentiality issues
Remember to emphasise confidentiality, and that any discussion will not be revealed to third parties. This is difficult if the patient is brought by a family member or accompanied by a friend.
In these circumstances the doctor has the option to carry on in the presence of others if the patient requests this, although it is usually more appropriate to insist on seeing the patient alone.
· Assessment of risk
An acronym 'HEADSS' helps you to remember to cover relevant aspects of mental function. The letters refer to inquiries about Home, Education, Activities, Drugs, Sex and Suicide (this only applies if a risk is suggested from prior assessment).
It is important to consider if all the information is needed, or whether some questioning may be perceived as excessive prying. There is no foolproof assessment of suicide risk, but gentle inquiry may tease out how the patient is feeling.
· To break confidentiality?
It is possible that information is divulged which requires 'passing on' to other authorities without the patient's permission, although this is an extremely rare event. Under these circumstances it is better if the patient is asked if it is okay to pass on such information prior to revealing this.
If permission is not granted, please ponder if it is absolutely imperative that such information is divulged. A discussion with others, such as another GP or a medical defence organisation, without revealing specific patient details maybe necessary.
· Clinical picture
Diagnoses are not easy to ascribe on the first meeting. As a rule, clinicians should remember their initial role of support may be more helpful than reaching for the prescription pad.
But broadly speaking suitable medication for adults is also suitable for teenagers, although there is a question-mark against some of the newer antidepressants.
· Remember your own emotions
You may need to reflect on any emotions engendered by the consultation. You may have feelings of confusion, perplexity and difficulty of knowing how to proceed over the situation that has been revealed.
If so, this may mirror the experience for the patient, and it is useful to be aware of this during the consultation. You may need to debrief these feelings with a colleague at a later juncture, preferably during your 'hot review'.
· Observation and follow-up
Most management of unhappy patients needs a period of 'observation' and follow-up. This may be arranged with yourself if you feel confident, or alternatively with a colleague who you and the patient trust.
Usually, this may be another GP within the surgery but may take the form of a referral to another agency. On this latter point you may need to discover how to access these agencies locally, and you will need to take advice.
· Learning points
There may be much to find out before any follow-up consultation. Your first consultation with an unhappy teenager may act as an impetus to find out more, including regarding specific communication skills with teenagers.
The RCGP's adolescent task group has prepared many useful resources look at its website at www.rcgp.org.uk/clinspec/adolesgr.asp
At a follow-up appointment, clearly you will be better prepared. But it is not unusual for a teenager to fail to attend this appointment. Your natural inclination may be to feel that you were not as helpful as you first thought, but it is more likely the situation has resolved and the patient feels no need for follow-up.
This mirrors child psychiatry appointments where 'did not attend' rates are often 30 per cent or more.
However, there may be learning points if an untoward event occurs. For instance, it is natural to feel guilty if a teenager who has consulted you takes an overdose, and this 'significant event' should be debriefed with a colleague. These issues should be used as examples of object lessons in how to consult more appropriately on future occasions.
Teenagers represent 10 per cent of the population and deserve good health care in the form of GPs who are aware of their specific health needs considerate, caring, respectful, non-judgmental health care providers.
As registrars you can foster an improved atmosphere for teenagers to feel more comfortable when attending their GP.
Teenage health in primary care is largely about communication issues, and it is likely that
getting communication with teenagers right
will help communication with other age
· Give time, understanding, support and adopt good communication skills
· Emphasise confidentiality of the consultations
· Assess risk (use 'HEADSS' as reminder)
· Use follow-up, but be prepared for non-attendance at next appointment
· Use of good skills with teenagers may help communication with others
is an NSPCC site for teenagers
is a useful site for teenagers and parents
is a BBC site for all
is Oxford GP's Dr Ann Mcpherson's site
she is also author of the Diary of a Teenage Health Freak series
www.surgerydoor.co.uk (select teenage health)
is helpful too
is the RCGP's adolscent task group website
Lionel Jacobson is a half-time partner in Ely, Cardiff, an honorary lecturer at the University of Wales College of Medicine and a member of the RCGP adolescent task group