Challenges in Getting a GP Diagnosis for Mood Disorders in the U.K.
In this discussion, we aim to highlight the challenges faced by your local health practitioners in the diagnosis and management of mood disorders in adults.
Specifically depression, anxiety and bipolar disorder in a primary care setting, while highlighting areas or gaps in the mental healthcare system where changes might be made.
Challenge 1
Primary care is made up of different health services, including general practitioners (GPs) or medical doctors based in the community. Ethics and protocols covering patient clinical safety and data protection (confidentiality and consent) are owned by NHS England. It is the Department of Health (DoH) that funds NHS England, which in turn is responsible for funding Primary Care Services. This includes specialised facilities like Children and Adolescent Mental Health Services (CAMHS) and improving access to psychotherapy (IAPT). Referral from a GP is needed in most cases to get access to these specialised services, known as secondary care.
These services have been underpinned by the commissioned ‘NHS England Mental Health Taskforce’, reporting a ‘five-year forward plan for mental health’ that nine years on, the goal of working with local groups, including the government, to implement a care economy that assures health equity or fairness across the country is struggling due to various reasons, including a pandemic and sheer economics. This task force provided ‘evidence-based treatment pathways’ and best practices for GPs, working with ‘arm’s length bodies’, such as the National Institute for Health and Care Excellence (NICE). NICE is an executive non-departmental public body, that the Department of Health and Social Care sponsors.
GPs meantime have various points of oversight, including the Quality and Outcomes Framework (QOF) for patient care, and the Clinical Commissioning Groups (CCG). The role of CCGs is to encourage benchmarking between medical colleagues across surgeries in different communities, enabling a collection of population-level data that includes consulting with service users and patients.
This overview of health services sets the scene for one of the first key challenges for primary care settings, and that is, the complex structure in which they operate. Notwithstanding, the NHS task force goal was improving the availability of the augmented services, that prior, saw GPs struggling with referrals for secondary care. Particularly for gaining access to psychotherapeutic oversight with a lead time of 6 to 12+ months. This has more than doubled since the COVID-19 pandemic.
Challenge 2
The second challenge is that according to a survey by Hobbs and colleagues (2016), GP workload is reaching a ‘saturation point’, quoting consultation times with patients of 9.22 minutes. It alludes to the concept of ‘opportunity costs’, whereby a GP may have to spend longer with one patient dealing with a depression questionnaire, alongside discussing complex treatment options, for instance, which will invariably have an impact on others waiting to be seen that day. Potentially reducing their consultation time or risking GP burnout over time.
The recent COVID-19 pandemic has meant GPs are choosing a hybrid model of working between home and surgery, which can add a level of complexity. This arrangement could introduce challenges related to communication, coordination of patient care, and the logistics of providing medical services effectively in both settings. It may also involve adapting to different technological tools for remote work and face-to-face interactions, potentially impacting workflow, patient management and the dynamics of the patient-doctor relationship.
Challenge 3
With this in mind, a third challenge is establishing a patient-doctor relationship or trusting therapeutic setting in that narrow window of 9.22 minutes and potentially over a digital link or telephone. Dr. Daniel Dietch, GP Partner and Mental Health Lead for the General Medical Council (GMC) indicated that around 5% of his total patients presented with anxiety disorders. This 5% accounts for only those who are aware they have an issue and/or are prepared to discuss it.
In this context, the doctor-patient relationship is pivotal, extending beyond the clinical examination. Observations of the patient, coupled with an understanding of their preferences and beliefs through open and non-judgemental dialogue, become integral components in proposing a tailored treatment plan.
Treatment plans while addressing immediate concerns must also consider continuity of care. This might involve relevant signposting to information about the illness, self-care strategies, and guidance on when or where to seek further appointments and support. This approach ensures that patients not only receive the necessary medical attention but are also equipped with the knowledge and resources to actively participate in their well-being beyond the confines of the consultation.
Challenge 4
Complex assessment is a fourth key challenge, in needing to unpack and understand what pathology or symptoms are underlying the presenting disorder. The ‘type’ of disorder, the ‘level’ (e.g. severity), and the ‘duration’ of symptoms, plus any other symptoms (sleep issues, fatigue, chronic pain, or self-harm).
Any comorbidities, including substance addictions, eating disorders, and existing diagnoses like high blood pressure and even pregnancy, as well as factoring the very young or the very old. Bipolar disorder diagnosis adds further complexity, in that symptoms of mania or hypomania do not typically present in GP practice, directly implicating treatment options.
Stigmatisation can hinder open communication between GPs and patients, leading to underreported symptoms and reluctance to discuss medication concerns. This barrier may deter the disclosure of psychiatric symptoms and sensitive topics due to societal taboos.
Stigmatisation affects medication adherence, as individuals may withhold information about non-compliance. Patients may also fear workplace discrimination or being labelled with a specific diagnosis. Considering all these factors during a standard appointment poses a significant challenge for GPs.
Challenge 5
A fifth challenge involves acknowledging and understanding each patient’s individual differences, crucial for GPs to provide personalised and effective healthcare, ensuring that treatment plans are tailored to the specific needs and circumstances of each patient. Individual differences refer to unique and varied factors, including the following:
Environmental Factors: The environment in which a person lives can impact their health. This includes exposure to pollutants, allergens, climate conditions, and lifestyle factors such as diet and physical activity,
Lifestyle Choices: Personal habits and lifestyle choices, such as diet, exercise, smoking, and alcohol consumption, can have a profound impact on health and may contribute to the presentation of symptoms.
Psychosocial Factors: Mental health, stress levels, social support, and socioeconomic status all influence how individuals experience and cope with symptoms. These factors can also affect their adherence to treatment plans.
Cultural and Ethnic Differences: Cultural backgrounds and ethnicities can influence health beliefs, attitudes toward medical care, and the prevalence of certain health conditions. This can affect how individuals express symptoms and their willingness to seek or adhere to medical advice.
Age and Gender: Different age groups and genders may experience symptoms differently. For example, certain health conditions may be more prevalent in specific age groups or genders, and the presentation of symptoms may vary accordingly.
Pre-existing Health Conditions: Individuals may have pre-existing health conditions or comorbidities that can complicate the presentation and management of new symptoms along with any prescribed medications.
Access to Healthcare: Disparities in access to healthcare services, including geographical location, financial constraints, and cultural barriers, can impact when and how individuals seek medical attention and follow through with recommended treatments.
A GP may heed the concept of ‘watchful waiting’ in the case of ‘uncertainty’, which points to a process of elimination across appointments. This might include recommending exercise, specific blood tests, or referring to a dietitian for expert advice as part of the treatment plan.
Challenge 6
With all this in mind, the sixth and final challenge is the potential for under or over-diagnosis. This might stand to reason the latest reports in the news about 'antidepressant overuse’ in the NHS. This has since been disputed. GPs can turn to various resources, including the British Association for Psychopharmacology (BAP) guidelines as well as input from colleagues, and other specialists, as well as NICE guidelines.
Nice guidelines provide proven healthcare pathways that support the assessment of symptoms for depression, anxiety and bipolar disorder, including key principles for treatment and guidelines on related psychotropic drug recommendations.
This includes the NICE ‘stepped care model of depression’ guidelines for 18+ adults with a focus on primary care and joining up patient family-carer-healthcare professionals to streamline services and better support the patient’s holistic needs.
In Summary
The six key challenges faced by GPs in primary care when it comes to the diagnosis of specific mood disorders are:
· Overly complex structure in which primary care or PC operates
· GPs overextended to ‘saturation’ point (9.22 minutes consultation time per patient)
· Lacking time to establish a trusted and compassionate therapeutic relationship
· Assessment complexity, including psychotropic and psychotherapy recommendations
· Complexity of gene-environment interactions, including demographical differences
· The potential for under or over-diagnosing in the complex mix of mental and physical symptoms to be assessed within a narrow window for consultation
The content presented in this blog incorporates factual information along with perspectives and opinions. It is designed to stimulate discussions and exploration of ideas. However, it does not represent official advice or exhaustive factual claims. Readers of course consider multiple sources when forming a viewpoint. Alternative viewpoints are highly encouraged and welcomed at Blindspot.