Exploring how patients respond to GP recommendations for mental health treatment: an analysis of communication in primary care consultations

Healthcare providers and patients: an essay on the importance of professional assertiveness in healthcare today

Professional assertiveness can enable the healthcare provider to confidently share their expertise without seeming authoritarian to the patient. Professional assertiveness is an interpersonal communication skill that helps express opinions or knowledge while respecting similar competencies in others. For healthcare providers, this compares to sharing scientific or professional knowledge with their patients while respecting their person, ideas, and autonomy. Professional assertiveness also connects the patient's beliefs and values with actual scientific evidence and healthcare system constraints. The definition of professional assertiveness might be easy to understand, but it remains challenging to apply in clinical practice. In this essay, we hypothesize that the practical difficulties healthcare providers encounter with assertive communication stem from their misunderstanding of this style.

Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework

OBJECTIVES

This study aimed to (1) examine barriers and enablers to General Practitioners' (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self-harm and (2) recommend potential intervention strategies to improve implementation of them in primary care.

DESIGN

Qualitative interview study.

METHODS

Twenty-one telephone interviews, semi-structured around the capabilities, opportunities and motivations model of behaviour change (COM-B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified.

RESULTS

GPs valued additional knowledge about self-harm risk assessments (knowledge), and communication skills were considered to be fundamental to high-pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities).

CONCLUSIONS

Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.

An evaluation of Anxiety UK's psychological therapy service outcomes

BACKGROUND

Anxiety and depression are highly prevalent. The aim was to examine the effectiveness of Anxiety UK's national psychological therapy service; benchmarking against NHS IAPT data.

METHODS

We examined psychological therapy outcome data for Anxiety UK clients who completed therapy between April 2019 - March 2020 and benchmarked this against NHS Improving Access to Psychological Therapies (IAPT) outcome data for the same period. Anxiety UK clients completed validated measures of anxiety and depression at two time points: the first and last therapy session. Caseness, recovery, reliable improvement and reliable recovery rates were based on IAPT definitions.

RESULTS

957 clients completed at least two psychological therapy sessions with an Anxiety UK Approved Therapist. Recovery, reliable improvement, and reliably recovered rates exceeded IAPT targets. Depression and anxiety reduced from first to last session. Cognitive behavioural therapy produced the greatest change in anxiety over time compared to counselling and hypnotherapy. The more therapy sessions attended, the greater the change in anxiety and depression scores from the first to last session.

LIMITATIONS

For some clients, anxiety and depression levels may have alleviated without therapy. No outcome data were collected following therapy cessation. Therefore, conclusions regarding maintenance and long-term effects of therapy cannot be made.

CONCLUSION

Anxiety UK provide highly effective psychological therapies for anxiety and depression. Flexibility in the number of therapy sessions provided is recommended for NHS services and those of external organisations.

When patients and clinician (dis)agree about the nature of the problem: The role of displays of shared understanding in acceptance of treatment

Globally, 4.4% of the world's population suffer from depressive disorder, and 3.6% from anxiety disorder. Previous work found considerable negotiation between providers and patients about the nature of mental health problems and frequent patient resistance to treatment. However, how doctor-patient shared understanding of the problem is reflected in treatment recommendations and whether this is consequential for patient acceptance of treatment is poorly understood. This study explored shared understanding of the problem and patient acceptance of treatment using conversation analysis. In 52 U.K. video recorded primary care consultations (collected July 2014-April 2015), 33 treatment recommendations for medication or talking therapy were identified. Shared understanding was explored focusing on: whether the patient presented the mental health problem as their primary initial concern and how they characterised the concern; whether the mental health concern was raised by the patient; and how the doctor aligned with the patient's earlier characterisation of the problem in the treatment recommendation itself. These phenomena were coded for each treatment recommendation and the impact on treatment acceptance was explored. Patients accepted the recommendation immediately in 38% cases and actively resisted in 62% cases. However, two communication behaviors were associated with patient acceptance: recommending treatment for the patient's initial focal concern and doctors' turn design in the recommendation itself, i.e., using the patient's earlier words from the initial problem presentation to describe and characterise the problem. Given the global burden of mental health problems and frequent patient resistance to treatment, understanding how professionals can engage more closely with the patient's perspective is important. When doctors use the patient's precise words from the initial problem presentation in the treatment recommendation, this displays an understanding of the patient's perspective and personalisation of treatment based on the underlying biomedical or social causes, which then impacts on patient acceptance of treatment.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

Use of the Patient Health Questionnaire (PHQ-9) in Practice: Interactions between patients and physicians

We analyze the use of nine-item Patient Health Questionnaire (PHQ-9), an instrument that is widely used in diagnosing and determining the severity of depression. Using conversation analysis, we show how the doctor deploys the PHQ-9 in response to the patient's doubts about whether she is depressed. Rather than relaying the PHQ-9 verbatim, the doctor deviates from the wording so that the response options are selectively offered to upgrade the severity of the patient's symptoms. This works in favor of a positive diagnosis and is used to justify a treatment recommendation that the patient previously resisted. This contrasted with the rest of the data set, where diagnosis was either not delivered (as patients are presenting with ongoing problems) or delivered without using the PHQ-9. When clinician-administered, the PHQ-9 can be influenced by how response items are presented. This can lead to either downgrading or upgrading the severity of depression.

General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal

BACKGROUND

There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects.

AIMS

To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms.

METHOD

Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert.

RESULTS

Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned.

CONCLUSIONS

Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.