It takes, on average, about 10 seconds for a certain type of patient to come in blurt, ‘I don’t know where to start…’ and dissolve into tears. I pass the tissues, wait and listen.
Depending on whom you listen to GPs are not diagnosing mental health problems well enough, or overdiagnosing them and prescribing too many psychoactive medications. How is it is possible for both of these apparently opposite paradigms to co-exist?
As a GP who regularly diagnoses and intervenes to treat mental illness, I feel I am damned if I do, and damned if I don’t. It’s made all the more difficult due to the pressure of trying to assess someone’s mental health in a single appointment, especially if there is a waiting room full of people, some of them with similarly time-consuming problems.
The consequences of getting it wrong can be disastrous. Not picking up the early, perhaps non-specific signs, of mental illness that later lead to suicide attempts, hospitalisation and perhaps even deaths, has massive effects on the patient, their family and the practice. As with any missed or delayed diagnosis it can be difficult to handle for the doctor.
What I find most difficult, though, is the other end of the spectrum – the milder shorter-lived symptoms, usually in patients that have been labelled as ‘depressive’ or ‘anxious’ in the past. Patients who may well have been off and on antidepressants all their lives. Patients who have had a difficult childhood, unsatisfying and unpleasant work situations or who are simply very unhappy about where they live due to the quality of either the housing and/or the neighbours. These already difficult situations can be made worse by an acute crisis such as a relationship breakdown, bereavement, unemployment or financial hardship.
There are a group of patients who fervently don’t want to be medicalised and be ‘on tablets’. There are others, who after describing how they feel, say that they couldn’t possibly talk to a stranger about how they are feeling.
I have found myself saying to patients, ‘I would feel unhappy if I was going through what you are going through. But, what we have to decide here is whether your unhappiness is truly depression, or whether it is a natural reaction to the circumstances that you are going through.’
As I have written before on this blog, I have often explained to those wanting ‘something to make me feel better’, that a GP can’t change your job, your housing, your family, or your relationships.
And when they get better, as they usually do, I have no idea if it is the change in neurotransmitter levels, the natural passage of time or the fact that they simply had the chance to offload on me. Perhaps NHS-grade tissues have got powerful properties.
Dr Samir Dawlatly is a former secretary of the RCGP’s adolescent health group and a GP in Birmingham.