Many patients present to primary care complaining of feeling blue, sad, or depressed. GPs generally work from a biomedical standpoint using the concept of depression, with medicalisation being the logical result. We believe that GPs are able to adopt a more person-focused approach in which they prioritise the psychosocial above the biological. Here we provide two examples of how GPs could start with this approach in a consultation with a patient who is feeling blue, sad, or depressed. An important element of the proposed approach is only applying a psychiatric diagnosis in selected patients with a high prior chance of serious psychiatric disorder.
THE BIOMEDICAL APPROACH
The high prescription rates for antidepressants1 suggest that GPs work from a biomedical point of view and start questioning the patient about the symptoms of depression listed in the guidelines. GPs commonly report having ‘no other option’ than to prescribe given that patients are unable to access talking therapies quickly, and/or because of insufficient time for alternative approaches. Do GPs have other options? Yes!
THE PERSON-FOCUSED APPROACH
GPs can turn the biopsychosocial consultation model around — replace a disease-focused with a person-focused approach — and prioritise the psychosocial above the biological (flipped consultation).
The person-focused approach considers the presentation of distress as an invitation for a conversation about the individual’s capacity to find solutions and resources from within their own context, empowering rather than medicalising an individual in distress. The person-focused approach follows a flipped order: it starts with psychosocial and only if necessary adds the biological.2 How to start with the psychosocial? There are two possibilities.
TALK TO YOUR PATIENT
The first is co-constructing an explanation of illness with your patient. You say to your sad patient that such feelings are often the consequence of something happening in their life, and invite them to reflect with you on that idea. Mr Tomes (pseudonym) complained of feeling sad. While discussing some minor problems he suddenly said: ‘Doc, how is it possible that I’m so sad?’ I replied that many people feel sad because of things that happen in their life, currently or in the past, and asked him what he thought about this. He started to cry and told me a story about a significant life event that he had been keeping to himself. After that he seemed relieved.
The second is inviting the patient to tell their story. Barbara Hunter (pseudonym), who has recently moved into the area, consulted me, saying ‘I’m depressed, I need medication.’ I said that I couldn’t prescribe her antidepressants immediately as I would first like to know her better and get an idea about what was going on. I invited her for some consultations. We talked about her personal circumstances and what bothered her, about problems in the relationship with her husband emerging after they had discovered that their son had an alcohol addiction, and finally about their daughter who had revealed that her brother had sexually abused her.
Barbara said that she used to walk a lot, but lost the energy to do so. I said that I understood her feeling of being depressed. Together we decided that instead of starting antidepressants she would make another appointment, try to walk for an hour each day, think about how she and her husband used to discuss problems in the past, and consider if there were other problems contributing to the situation.
SYMPTOMS OF A PROBLEM NOT A DISEASE
What we do here is approach symptoms as potential indications of something being wrong rather than a sign of disease.3 By helping patients understand their symptoms, the focus is on enhancing the autonomy and potential of the patient to recover. We think that exploring this should lead to a common description of the problem and that the patient feels that the GP shares their goals.4 When a more structured approach is needed, working according to the Strengths model can help.5
The ‘bio’ part of the person-focused approach is safety netting. Here, the biological/psychiatric elements come in. This step should only have priority if there is a high risk of serious psychiatric disease (psychosis, endogenous depression) or if the psychosocial approach is not working. Withholding or postponing a psychiatric diagnosis is justified in most patients against the background of the low prevalence of serious psychiatric morbidity in primary care.6
- © British Journal of General Practice 2018