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Title: The interactive management of common mental health problems by general practitioners and patients in primary care consultations
Author: Wheat, Hannah
ISNI:       0000 0004 2741 975X
Awarding Body: University of Exeter
Current Institution: University of Exeter
Date of Award: 2012
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Background: The primary care consultation is the arena in which UK patients typically first formally present their mental health concerns. Despite the 'interactive' nature of the management of mental health, most consultation research has focused on the behaviour, perspectives, or characteristics of only one of the participants. There has been no sequential, real-time analytic work, despite GPs reporting that such interactions are difficult and related training is lacking. Objective: To analyse the interactive management of mental health in the primary care consultation, specifically, the way patients present their mental health-related problems and how GPs respond, and patient requests and GP offers for mental health-related sickness certification. Method: Conversation analysis (CA) was used to examine an existing set of 76 audio-recorded 'early' mental health consultations, from a wider corpus of 506 patient consultations, collected in 2004, from 5 practices in London, involving 13 GPs. Consultations were classified as 'early' mental health consultations if: (A) the patient scored 11 or more on the HADS depression questionnaire, (B) they scored between 8-10 and there was emotional content in the consultation or (C) the HADS depression score was under 8 but there was a GP diagnosis of depression, post-consultation. The first analytic section was on patients' problem presentations: From the 76, 15 consultations were examined. 7 of these consultations fell into classification A. These 7 also fell into category B, as they all contained emotional content. 6 fell into category B (but not A) and all 15 fell into category C. The second analytic section was on GPs' responses to patients' trouble talk surrounding an emotional issue. From the 76, 23 consultations were examined. 9 consultations fell into classification A. These 9 all also fell into category B. 8 fell into category B (but not A). While all 23 cases fell into classification C, 6 only fell into C (not A or B). Sickness certification: From the 76, 10 consultations were examined. 7 cases from the wider corpus (ongoing mental health consultations) were all selected. In total there were 17 consultations examined during analysis. Only the 10 consultations from the 'early' sample were classified. 6 of these fell into 2 classification A. 5 of these 6 consultations also fiited into B, one did not, as there was no emotional content. 2 of the A categorised consultations did not fit into C, as there was no diagnosis of depression. 2 consultations fell into classification B and also C (but not A) and 8 fell into classification C. Findings: Patients typically present first experiences of mental health problems as late-arisinq concerns, through indirect means, preferring a collaboratively built presentation. This delayed presentation format contrasts to physical health problems, which typically get presented after the GP's opening question. In 3 out of the 11 problem presentations of a previously un-experienced common mental health problem, the problem was not taken up by the GP. However, within these problem presentations the GP typically did not initially acknowledge the concern and the patients would have to re-do the presentation of the problem before it would be addressed. GPs claimed and demonstrated understanding of patients' emotional troubles through various means. The impact of these understanding displays on the interaction was influenced by their lexical content, their spoken delivery and where they were positioned with regard to the progression of problem presentation. The responses resulted in either the expansion of the problem presentation or its curtailment. Building and successfully demonstrating understanding, resulted from a series of turns of talk which employed 'interpretive talk' from the GP and in which both GP and patient were fully engaged i.e. they were both contributing more than one word responses before the topics conclusion and through their responses they both expanded and progressed the discussion of the problem. In consultations in which sickness certification was mentioned, patients displayed an awareness of the constraints on the issuing of a first certificate through their request formats and their indirect efforts to induce an offer. GPs often indexed the patients' interactional work to secure a sick certificate through the offer format 'do you want', which oriented to the certificate being a desire rather than a need. Both GPs and patients treated repeat certification as non- problematic. Conclusion: Patients used a variety of strategies to cautiously 'manage' the introduction, elaboration of, and decision-making regarding their mental health concerns. This cautiousness suggests that patients are uncertain of how legitimate their common mental health problems are and of how they will be received by the GP. Cautiousness was less apparent when the problem was a 3 4 repeat occurrence. Throughout the analysis a 'collaborative' approach to talking about and 'managing' the common mental health issues led to a more productive discussion.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available