Introduction

Mental health problems present in between 30% and 60% of primary care consultations.¹ One in six men and one in four women will suffer from a mental illness at some point in their lives.^2,3 GPs, for example, find that at least 30% (or 1.5 days per week) of their working week concerns mental health consultations. For depression alone, prevalence amongst the adult population in the UK varies between 17–71 per thousand for men and 25–124 per thousand for women.

Unfortunately these patient presentations in primary care are frequently complex and do not always fit easily into diagnostic categories.⁴ The objectives of this chapter are listed in Box 15.1.

Box 15.1 Chapter objectives

The recognition of primary survey positive patients and those with complex but not immediately life-threatening presentations (primary survey negative patients)

The secondary survey, history taking and examination of the patient with signs or symptoms of mental illness

To describe mental health assessment and differential diagnoses with specific reference to depression and deliberate self harm

To discuss alternatives to admission, treatment and options for referral

To clarify definitions of mental disorder

To summarise the Mental Health Act (1983)

Assessment of valid consent and capacity

Primary survey

A mental illness may cause a patient to take an overdose or injure themselves in such a way that they develop immediately life-threatening ABCD problems. These problems are covered in Chapter 14.

An immediately life-threatening psychiatric situation is where the patient wants to kill themselves, or harm others (Box 15.2), but will not comply with treatment. Management will depend on a large number of factors – not only your assessment of the problem but also the extent and availability of local services.

Box 15.2 Indicators of life-threatening behavioral problems (a positive primary survey)

The patient is threatening to kill or seriously harm themselves

The patient is a risk or danger to themselves or to others

The patient, through lack of appreciation of the consequences, is likely to come to harm

The patient, through lack of capacity, is vulnerable to abuse from others

The patient has become acutely confused

Enlisting the support of family and carers is often the simplest and best way to resolve such conflicts. However if this does not work you will have to call for assistance. This may be the patient’s own primary care team or the mental health team. In extreme situations where you judge that there is an immediate threat to the wellbeing of the patient, or others, you should call the police.

The Mental Health Act (MHA), in Section 63, states that the detained (or ‘sectioned’) patient’s consent is not needed for medical treatment for mental disorder (when this is under the direction of the Responsible Medical Officer). This is detailed as being:

However, the MHA does not necessarily permit the compulsory treatment of a physical disorder in a patient who is not consenting.

Secondary survey

If it is obvious that the patient is going to have to be assessed by another professional then only a brief evaluation will be required. However the following steps need to be taken to ensure the patient is suffering from a mental illness and not a physical disorder. Acute infections, intoxications, drug withdrawal syndromes, diabetes and neurological conditions are common physical conditions that may present with symptoms of mental illness/disorder. An acute confusional state may present very rapidly, especially in older patients. In the elderly this frequently can result from chest or urinary tract infections, recent life change, or progressive dementia.

Medical assessment is indicated if:

fever

history of recent fit

impaired or depressed level of consciousness

known diabetic

loss of awareness of surroundings

recent onset of confusion, disorientation and memory impairment

signs of head injury/recent history of head injury (2 weeks)

suspected chest or urinary tract infection.

Mental health assessment

While it is difficult to completely separate the mental health assessment into ‘history’ and exam sections, it aids understanding to use the SOAPC system. Effective mental health assessment requires a very sensitive consultation style to gain the patient’s trust and showing the patient that you recognise their distress and experience. Some key principles for the mental health interview are identified in Box 15.3. Consultation skills that improve identification of emotional distress include frequent eye contact, relaxed posture, use of open questions at the beginning of the -consultation, use of minimal verbal prompts while actively listening and avoiding giving information too early in the consultation.

Box 15.3 Common signs and symptoms of mental illness

Changes in the nature of mood (affect)

Disorders of perception – hallucinations and illusions

Disorders of thinking (cognition) – delusions, negative thinking

Patient’s appearance and behaviour

Speech and communication

Subjective – history

History taking can be difficult and at times confusing but the use of the standard template for history will help give structure and avoid omission. Elicit the main presenting complaint(s) and the onset and progress of symptoms. Is this an acute problem or more long term? Are there factors that make the symptoms better or worse? Is there a previous history of similar problems and is the patient currently undergoing treatment for these symptoms? Note the drug history, including the patient’s compliance with any treatment. Is there any history of abuse of alcohol or illicit drugs? Note the past medical and psychiatric history.

Information from carers is often of great importance in the assessment. If carers are not present and you are having difficulty, you may have to trace them and discuss the issues (preferably with consent of the patient). Box 15.4 summarises the assessment of a patient with psychiatric symptoms.

Box 15.4 Mental health – history

Presenting problem

History of onset and progress of presenting problem

Previous medical history

Drug history/allergies/compliance with treatment

Past psychiatric history

Previous contact with services

Carer information

Objective information – mental state examination

Perform a brief physical exam, including noting the vital signs (especially pulse, temperature and Glasgow Coma Score). Listing the elements of a mental state examination is an excellent way to bring some structure to what can be a confusing and difficult task. These key elements are listed in Box 15.5. The assessment of social support is often of the greatest importance in deciding a management plan.

Box 15.5 Elements of a mental state examination

A – appearance

B – behaviour (normal, flat, manic, tremor)

C – cognition, concentration, memory, attention span, thought process (logical, flight, tangential)

D – Delusions and ideation (suicidal, homicidal), hallucinations

E – energy and motivation

Also assess risk to self and others, of deliberate self harm (DSH), impulsivity, signs of abuse of drugs or alcohol, current carer or family support, coping strategies

This process can be difficult but allow the patient to explain the problem in their own words. Be non-judgemental. Try to help the patient focus on the issues to enable them to gain self-control. Seek clarification by the use of paraphrasing, reflection and summarising. Share your impressions. Do not be afraid to use periods of silence.

TIP

Talk to the family and get their viewpoint

Analysis

At the end of the assessment you should be able to judge if the patient has:

a physical disorder

a disorder of mood (commonly depression)

acute anxiety or panic

acute confusion

a psychotic disorder

or is threat to themselves or others.

Depression

Depression is the most common mental disorder in primary care and covers a range of mental health diagnoses and problems. These are all distinguished by lowered mood and a loss or decrease of interest and pleasure in daily life and experiences. Additionally, there are disorders of thinking, problem-solving and behavioural and physiological symptoms.⁵ Box 15.6 lists the diagnostic criteria for severe depression but it is often difficult to discriminate between normal mood variations, dysthymia (Box 15.7) and cyclothymic (Box 15.7