‘We’re all doing different things’ — exploring primary care practitioners' perspectives of managing distress: a qualitative study

Hannah Bowers; Carolyn A Chew-Graham; Miriam Santer; Harm Van Marwijk; Berend Terluin; Tony Kendrick; Paul Little; Michael Moore; Manoj Mistry; Debs Smith; Al Richards; Bronwyn Evans; Nikki Lester; Roya Kolahy; Adam W A Geraghty

doi:10.3399/BJGP.2024.0820

Abstract

Background Distinguishing emotional distress from mental health problems such as anxiety and depression can be difficult for clinicians. Both commonly present and are managed in primary care. There are likely to be important differences in the management of emotional distress compared with anxiety and/or depression, but the current nature of assessment and management is unclear.

Aim To explore how emotional distress is understood and how people are managed by a range of practitioners in primary care settings in the UK.

Design and setting A qualitative study using semi-structured interviews with primary care practitioners in the UK.

Method Online interviews were conducted with practitioners who directly assess patients with mental health symptoms, including GPs, nurse practitioners, social prescribers, and mental health practitioners. Recruitment was via a digital poster circulated by research delivery networks. Interviews covered how practitioners understood and identified distress, the support provided to patients, and challenges assessing and managing emotional distress. Verbatim transcriptions were analysed using an inductive thematic approach.

Results In total, 29 interviews were conducted and four themes were developed in collaboration with the wider team, including public contributors: the multifaceted nature of distress; ‘We’re all doing very different things’; managing and understanding distress is challenging; and demedicalising distress in the face of increasing societal pressures. Complexity was driven by the wide-ranging professionals involved, complex patient circumstances, systemic challenges, and societal contexts.

Conclusion Identifying and managing emotional distress is complex, variable, and challenging. Complexity appears to be increasing through the systemic challenges and range of professionals involved.

How this fits in

Previous research with patients and GPs has highlighted that ‘emotional distress’ and anxiety and/or depression are commonly seen in primary care and are difficult to distinguish. In this study, we illustrate how distress is conceptualised and managed by a broad range of practitioners in primary care, including those in newer roles introduced as part of the Additional Roles Reimbursement Scheme. Our findings highlight significant challenges, complexity, and variability in both identifying distress and supporting patients experiencing distress. These challenges were seen to be driven by current contextual factors such as overmedicalisation of mental health, increasing social pressures, and systemic challenges within primary care settings.

Introduction

GPs estimate around 40% of their consultations involve mental health.¹ They are responsible for detecting and treating ‘common mental health problems’.^2,3 Ninety per cent of people with mental health problems are being supported entirely within primary care.⁴

Common mental health problems such as depression and anxiety are defined in diagnostic manuals with guidelines to inform management.^5,6 However, there is long-standing criticism of a disease-model approach to depression, which is focused on diagnostic criteria and symptom duration and severity.⁷ There is debate about the distinction between a depressive and/or anxiety disorder and a (potentially severe) emotional response with functional impairment that may not represent psychopathology. The latter has been conceptualised as ‘distress’^8,9 and is very common in primary care.^10,11

There are evidence-based guidelines for the management of depressive and anxiety disorders,⁵ whereas there are no such guidelines for supporting people experiencing distress. Clinicians and patients may agree that their symptoms do not reflect psychopathology, rather they may be driven primarily by difficult life circumstance.^12,13 Nonetheless, diagnostic labels may be used in order to enable access to some form of treatment (such as antidepressant medication), where options for those experiencing distress might be limited.¹⁴

Thus, this is an area where clinicians face complexities regarding appropriate identification^13,15 and related complexities regarding appropriate management.¹⁶ Further compounding factors include increasing levels of distress nationally following the COVID-19 pandemic and the cost of living crisis, alongside rising antidepressant prescriptions, and urgent calls to address this rise.^17–19

Patients experiencing the full range of symptoms including depression and/or anxiety and distress are now managed by a varied and growing number of practitioners in primary care. NHS England’s introduction and roll-out of the Additional Roles Reimbursement Scheme (ARRS) in 2019 expanded the recruitment of a wide range of practitioners including clinical pharmacists, mental health practitioners, and social prescribing link workers.²⁰ These practitioners play key roles in supporting mental health, including both identification and management. It is critical to understand how the increasingly broad array of practitioners understand and work in this area to ensure appropriate and effective care is provided.

Our aim in this qualitative study was to explore how distress (as opposed to mental illness) is understood and managed by a range of practitioners in primary care settings in the UK.

Method

Study design

We conducted a qualitative study using semi-structured interviews to explore UK primary care practitioners' perceptions and experiences regarding the management of people with distress.

Participants

Three research delivery networks shared information about the study with primary care practices. Practices then shared this with staff via email. Practitioners were also recruited via team networks and snowball sampling.

Primary care practitioners who directly assess patients with mental health symptoms were eligible to take part. Practitioners were purposively sampled to ensure diverse recruitment with regards to gender, ethnicity, age, role, and years’ experience.

Data collection

Semi-structured interviews (up to 60 min) took place via video call or telephone (using Microsoft Teams). Interviews were conducted by the first author, a female senior research fellow with a PhD in psychology who co-led the project with the senior author. Interviews took place between November 2023 and April 2024. The interviewer had no relationship with participants prior to interviews. Interviews were audio-recorded and transcribed verbatim. The interview schedule (see Supplementary Box S1) explored how practitioners conceptualise distress compared with depression and anxiety and their approach to management.

Data analysis

Data were analysed thematically, informed by the steps of reflexive thematic analysis,²¹ combined with a ‘codebook approach’ that facilitates collaboration in applied research.^22,23 Familiarisation and coding were completed by the first author using NVivo (version 14). Data extracts were discussed at regular team meetings. This informed iterative development of codes and themes. The team comprised behavioural scientists, academic GPs, a mental health nurse, and three public contributors. Information power was considered during discussions and recruitment finished when the team agreed there was sufficient information power.²⁴

Public involvement

A diverse group of public contributors with lived experience of distress and/or depression participated in regular team meetings to discuss the data, coding, and theme development. They informed the study aims and the interview schedule, and contributed to this article.

Results

Participants

In total, 29 participants were recruited from 74 expressions of interest across 36 practices (see Table 1). The mean age was 42.6 years (range 22–69) and they had been in their role for 5.8 years on average (range 5 months to 24 years).

View this table:

Table 1. Demographic characteristics of the recruited sample (N = 29)

Thematic analysis

Four themes (see Supplementary Box S2 for example codes) were developed that encapsulated how distress was conceptualised and managed in primary care: the multifaceted nature of distress, ‘We’re all doing very different things’, managing and understanding distress is challenging, and demedicalising distress in the face of increasing societal pressures. Figure 1 illustrates the findings.

Figure 1. Diagram of thematic findings.

The multifaceted nature of distress

Distress was considered to be highly complex and multifaceted. Wide-ranging contributing factors were highlighted (such as bereavement, finances, housing, employment, health conditions, neurodivergence, and abuse). Participants emphasised a need for individualised support to suit patients’ complex circumstances:

'It’s very person-centred in terms of it’s not just, okay, you're distressed, so this is what we do with distressed people. It’s very personalised to their exact issues at that time.' (Mental health occupational therapist [MHOT]07001)

This complexity was compounded by cultural factors (such as some cultures being less likely to speak to non-medical practitioners), language (such as difficulties using interpreters), and refugee status (particularly regarding isolation in rural areas). Relative social deprivation was reported to be a common characteristic of patients experiencing distress. For some participants this created additional challenges regarding the patient’s ability to manage their distress, their ability to make lifestyle changes (for example, time off work or changing jobs), and their use of drugs and alcohol:

'They're people that generally speaking would be the poorer members of society who just don't have the agency, the networks, the social networks to be able to change what’s going on for them at the moment. I'd say almost all of them have experienced childhood trauma, and almost all of them experiencing pain and some physical health problems alongside everything else, lots of housing issues and often experiences of loss and bereavement.' (Social prescriber [SP]09001)

‘We’re all doing very different things’

There were a wide range of practitioners involved in supporting people experiencing distress. They were providing different support because of a need for individualised care, varied skillsets, and uncertainty around novel roles. They often worked collaboratively drawing on their specific skill set and expertise:

'I feel like it’s so new in our area. We're all just doing our own thing and fumbling our way through … I feel like we're all doing very different things.' (MHOT10005)

Support largely fell into five broad categories: supportive listening, practical support (such as problem-solving and supporting lifestyle changes), signposting and referring, techniques for managing distress, and medication.

Supportive listening was considered an important way to show empathy, validate and normalise emotions, and offer reassurance by a range of practitioners. Normalisation also served to counter patients’ medicalised view of distress:

'I think, sometimes, people just need to talk to the GP; and [for] some, the doctor is medicine. I'm sure that sometimes helps — and just being able to tell people that it’s normal to feel awful, when someone’s just died — that sort of thing. Try not to medicalise the symptoms.' (GP09001)

Mental health practitioners and mental health occupational therapists described providing strategies for coping with distress (for example, distress tolerance techniques from dialectical behavioural therapy). They sometimes had workbooks or handouts they provided to patients. Many also addressed lifestyle factors that may exacerbate distress such as alcohol use and sleep hygiene:

'I think people come in saying, I'm feeling like this, and I shouldn't be feeling like this, and you've got to make this stop. So I think a lot of the work that we try to do is say, no, actually, it’s okay to sit with that distress, but here’s how you can cope with it.' (MHOT10002)

Mental health occupational therapists and mental health practitioners sometimes worked alongside social prescribing link workers who offered more practical support, signposting and empowering patients to help themselves.

Social prescribing link workers recognised their role was not specifically in mental health, but despite this, mental health (particularly distress) was something they see regularly. Signposting to services to address the specific stressor (such as bereavement support groups or Citizen’s Advice) was discussed by the vast majority of participants. There was variability in services known to be offered that were dependent on local availability. Social prescribing link workers were seen by participants as having expertise in signposting to community support, and many of the participants said that they referred patients to social prescribing link workers:

'Our role as social prescribers is to give people time … Although they may have mental health problems, ultimately there are many other things that would also be affecting them ... So we obviously try and listen to them, we try and hear what they're saying, and then we try and link them up with services that will help them with those worries.' (SP06004)

Many participants talked about signposting patients to NHS Talking Therapies for support – however one practitioner with experience assessing patients for NHS Talking Therapies recognised that this is not always appropriate for people experiencing distress caused by an external stressor:

'It’s hard to then say, "Oh, try to be more motivated", because they are motivated to try and get themselves better, but they just weren't getting the support from other services, like the council, for example, so it didn't necessarily fit with what our therapy could do.' (Mental health practitioner [MHP]13002)

Participants shared contrasting views about medication. Some participants described prescribing antidepressants for patients experiencing distress if that distress was having an impact on their ability to function, if it was of a longer duration, or getting worse. Many of the interviewed GPs reported avoiding prescribing antidepressants for distress in favour of NHS Talking Therapies or social prescribing. Some non-GP participants reported working with GPs who often prescribe antidepressants for people experiencing distress. These participants felt GPs’ time-limited consultations make exploration of patients’ circumstances difficult. They felt this increased the likelihood of a depression diagnosis and antidepressant prescription:

'They're on antidepressants and things like that, and again, they'll be on 50 milligrams or whatever, and then it’s like, it’s not working so I'm going to go back and speak to my GP about upping it, and it goes up, and then it changes medication, and then it goes up. It never seems to be coming down … You speak to people, and they've not actually had a conversation with the GP. The GP doesn't know that relationship problems have happened or something’s happening at work.' (MHP10007)

Some participants also talked about short-term medication use to manage distress (such as benzodiazepines, beta blockers, and medication to improve sleep).

Managing and understanding distress is challenging

Participants recognised that it can be difficult to differentiate between distress and depression and anxiety. GP participants described differences more readily than other practitioners who took longer to reflect before responding. Ultimately, participants were largely in agreement about what the differences are: distress has an external cause that is often time limited, whereas depression and anxiety have other characteristic symptoms and may have a greater impact on functioning.

Most practitioners felt it was useful to distinguish between distress and disorder. For GPs (who described their role as diagnosing and prescribing) the distinction was important for determining treatment, particularly medication:

'I'm sure it must be useful to work out whether they're suffering with depression or anxiety, or some other mental health issue, because that I'm sure would influence how you manage them. It could add to how you manage them. In terms of managing the distress, if they're distressed because of, they can't feed their family that week, but they're otherwise not normally suffering with mental health problems, then we might have ways to access food banks and get support from the social prescribers, things like that. So there might be lots of things there, but if they also suffered with depression, then you might also look at talking therapies, or medication, or other things as well.' (GP09001)

Some practitioners (particularly mental health occupational therapists, mental health practitioners, and social prescribing link workers) felt that the label of distress, depression, and/or anxiety was less relevant and instead focused on the patient’s complex individual circumstances to determine management, regardless of diagnostic label:

'My job is to hear what that person says, the meaning that person gives to everything in their lives and then together we co-create a plan to change, so it doesn't matter if that person has a diagnosis or not. It doesn't change anything.' (SP09001)

Participants frequently highlighted the need to have an in-depth conversation with the patient in order to identify distress and determine management. Short appointments were seen as a barrier to this, particularly for GPs, whose shorter appointments were seen to increase the likelihood of a depression diagnosis:

'... the GP was saying, "I think he’s really low in mood". So I had an appointment with him and that’s where we explored in a bit more depth about all of the changes that had happened because of the loss of the job … the GP had prescribed antidepressants, actually, but he hadn't taken them … So we did a lot of work about, at that point in time, rebuilding that resilience … He didn't pick up the prescription. Said he just felt better.' (MHOT10002)

This distinction was also guided by the patient’s medical records and some participants reported supplementing conversations with screening tools (for example, the Patient Health Questionnaire²⁵ [PHQ]) to support decisions about providing a diagnostic label:

'I mean, we're quite lucky because a lot of our patients come pre-triaged on our eConsult, and so they will have done PHQs and GAD [Generalised Anxiety Disorder screening tool], and all the rest of it. So that will also help sway the decisions, especially if they're scoring really high on a PHQ or really high on a GAD-7. You'd be like, oh gosh, maybe we should be thinking about giving them a diagnosis.' (GP01001)

Some practitioners used questionnaires less frequently or only to evidence a perceived need for medication. One mental health occupational therapist described her reluctance to use questionnaires as they fail to capture the complexity of the patient’s situation:

'From my experience of working in mental health, I don't find that they [questionnaires] often give a true representation of what the patient’s actually going through.' (MHOT10002)

Five practitioners expressed less confidence in managing distress because of perceived limited expertise in mental health:

'No, I can't say I do feel confident because it’s — again, mental health isn't my field. I'm an adult-trained nurse. So it’s not my comfort zone in any way, shape or form, but I can't turn that individual away so try to manage it in a safe a way as possible, but I'm not confident or comfortable with it on most occasions.' (Nurse practitioner 08001)

Other practitioners were more confident in their approach, sometimes drawing on their experiences from previous employment outside of primary care.

Participants identified many systemic challenges to managing distress such as long waiting times for services, inappropriate referrals (within primary care), and a lack of service provision:

'So I think a lot of patients that end up with us should never get as far as us. I think they should go straight to the talking therapies, but there’s such a long wait on that they don't have access. I think they often re-present to us because they're not getting anywhere. I think we prescribe more because we have no other option.' (GP06001)

This resulted in some participants feeling frustrated or like a failure. For some participants managing distress affected their own wellbeing. Some reported experiencing distress and vicarious trauma.

Some participants took a ‘scattergun’ approach to referrals that they felt exacerbated long waiting times:

'Then you feel a bit guilty because it’s a bit of a scattergun effect to which service will pick you up first, and then you know you're causing a problem because you're bottlenecking all the services, but you just want to get some help as soon as possible for them.' (MHOT10005)

Some practitioners, particularly ARRS practitioners, had guidance about the duration they should see a patient (for example, no longer than 6 months). This contradicted the benefits seen in practice by supporting people for longer periods. Practitioners talked about prioritising the patients’ needs over the guidance from management (often external to the practice):

'We're managing patients that maybe no one else in the surgery — not hasn't been able to, but it hasn't been appropriate for anyone else. I will carry on and do what is right for the surgery, but then I have guidelines from my employers saying you only have up to six months to see this person.' (SP13001)

Demedicalising distress in the face of increasing societal pressures

Participants highlighted the changing context of mental health as a challenge in managing distress. Society’s destigmatisation of common mental health problems was viewed as creating a medicalised view of distress:

'In my view, there’s been a lot of emphasis on destigmatising mental health … they come in and say, I'm depressed … I find a lot of what I end up doing is talking to them about actually, it’s not a depression, it’s not a mental illness. What you're experiencing is a really normal reaction to a life event.' (MHOT10002)

This medical view was related to challenges in supporting patients owing to patient expectations of a ‘quick fix’ or medication to treat their distress. This had an impact on the patient’s motivation and sense of responsibility (where some patients felt it was the clinician’s responsibility to treat the distress):

'Some of them are disappointed that I don't immediately offer them medication — maybe they want a quick fix.' (GP09001)

This was compounded by reports of increasing distress, particularly in relation to the current cost of living crisis. Some practitioners suggested that people have less tolerance for distress in this context:

'I feel there’s a lot less ability to cope now and I think partly that’s because of the pressures of life, that most people are so stressed that there’s no room for dealing with anything else.' (GP12001)

Short appointment length and long waiting times for psychological therapy were seen to contribute to medicalising distress through increasing antidepressant prescriptions. One social prescribing link worker described how demedicalising distress could relieve some of the pressure on services by directing people away from GPs towards support from other practitioners and the community:

'[social prescribing] is an empowering strengths-based model for people that increases confidence, and that is what we need if we're not going to burden the NHS with endless things. If we have a paternalistic view of things where we feel something is wrong with us that we can't possibly change, we need a doctor … That’s just going to increase the burden on the NHS.' (SP09001)

Discussion

Summary

These findings highlight the variability in managing distress in primary care. Variability in management was seen as crucial to address the wide-ranging patient circumstances, which often intersected with deprivation.

Distinguishing between distress and disorder was challenging and a demedicalised view of distress was favoured by many participants. Practitioners supported patients by normalising emotions and offering support for the external stressor, often provided by non-medical practitioners. Some of these practitioners also supported patients to self-manage the feelings of distress. Practitioners’ short appointment times and a paucity of timely and appropriate support impeded management.

Strengths and limitations

This study recruited a wide range of practitioners in primary care, including those from newer ARRS roles. This has enabled the exploration of distress management from a wider and more novel perspective in primary care. Recruiting and interviewing many practitioners without a specific interest in mental health allowed for exploration of a broad range of practitioners’ views, highlighting that many lack confidence in supporting people with mental health difficulties.

Participants were recruited from three CRNs in England. Although many practices covered deprived regions, allowing for consideration of how deprivation has an impact on distress, there is likely additional variability across other regions. The gender split of participants across the roles was somewhat reflective of the workforce. Although we deliberately sought views of men in roles predominantly held by women, recruitment of more women GPs may have enhanced the data. The ethnicity of participants is approximately reflective of the population; however, many of the practices recruited in this study had predominantly white patient populations. Further research should explore the impact of ethnicity on the presentation and management of distress, particularly as our findings suggest some groups may seek support from particular practitioners over others.

Comparison with existing literature

The predominant understanding of distress was that it was caused by an external stressor, but some felt that distress was a milder precursor to depression. These views, reported by a broad range of practitioners, are similar to those of GPs reported in a previous qualitative study.¹³ Some practitioners used screening tools to aid decision-making about depression diagnosis and prescribing antidepressants. However, in a primary care cross-sectional study, almost half of the participants who scored as possibly depressed using the PHQ-9 were categorised as distressed but not depressed by the Four-Dimensional Symptom Questionnaire¹⁰ (4DSQ, measuring distress, depression, anxiety, and somatisation as separate constructs).²⁶ Practitioners’ use of the PHQ-9 with patients experiencing distress may therefore result in overdiagnosis of depression and overprescription of antidepressants.

Some GPs described how distress is better managed by non-medical professionals in primary care to address the social causes of distress. Support was frequently signposted by a social prescribing link worker and required significant tailoring to address the wide-ranging causes of distress, often (but not always) related to deprivation. A systematic review of uncontrolled evaluations demonstrated that social prescribing for mental health can improve outcomes, reduce GP consultations, and reduce prescriptions.²⁷ Although practitioners have previously acknowledged there is a greater need for social prescribing in areas of deprivation,²⁸ there are accessibility barriers (such as affordability and transport issues).²⁹ This may be addressed through coproduction to improve accessiblity.³⁰ Practitioners mentioned signposting to community and voluntary sector services, but discussions of this issue in the data were limited. Further qualitative work should explore the patients’ and practitioners’ experiences of these services in supporting people experiencing distress.

Some practices had mental health occupational therapists or mental health practitioners who conducted psychotherapeutic work to help patients self-manage distress. However, there are concerns about shortages of these practitioners.³¹

To counter the disease-model of depression in UK primary care, Dowrick proposed a shift from reporting symptom severity to instead exploring the physical, psychological, and social circumstances of the patient, which does not require a diagnostic label.³² In the current study, distinguishing between distress and depression was considered useful to determine management, particularly where medication is concerned. However, some practitioners (particularly social prescribing link workers and mental health occupational therapists) argued that the label is less important and instead focused on providing empathy, empowerment, and individualised support for people experiencing distress.

Short consultations were reported to make it challenging to distinguish between distress and depression and/or anxiety, which may sometimes result in prescription of antidepressants (particularly for GPs). Most practitioners felt that antidepressants were useful for depression and not distress. However, previous qualitative work with GPs demonstrates how antidepressants are sometimes offered (particularly in areas of deprivation) because of limited access to alternative interventions.¹⁴ In the current study, longer appointments were said to facilitate better understanding of distress, thereby directing people to appropriate care; however, those responsible for diagnosing and prescribing (that is, GPs) had the shortest appointment times.

Practitioners reported that patients often experienced distress with complex multimorbidity as well as challenging social circumstances. Multimorbidity may complicate consultations through increased appointment length to cover multiple topics and further difficulty identifying distress within a complex presentation of multiple psychological and physical symptoms.³³ Many participants viewed distress as non-medical and highlighted a need to demedicalise distress to reduce the pressures in primary care and better support people experiencing distress. This may be achieved through normalising patients’ experiences, reducing prescriptions for antidepressants, and increasing provision of psychological and social support provided by ARRS roles. Further research is needed to explore patients’ experiences of these new roles in primary care and their impact on patient outcomes.

Implications for research and practice

Current pressures make it difficult to help people manage their distress in primary care. There is a need to improve how patients are directed to services within and outside of primary care to reduce inappropriate referrals and waiting times. This is increasingly vital as broader contexts continue that are likely to increase distress (such as the cost of living crisis, geopolitical instability, and the climate crisis).^18,19,34,35 This may be achieved through training practitioners in identifying and supporting distress (for example, through improved social prescribing).²⁸ Research should develop processes that facilitate more rapid delineation between distress and disorder, particularly for GPs. For example, this could include exploring the utility and feasibility of tools that may support this distinction (such as the 4DSQ), supporting consultation approaches that more readily allow for this distinction, and/or increasing consultation length.³⁶ This may reduce antidepressant prescribing, normalise patients’ experiences, and direct patients to more suitable support. This demedicalised approach to distress would direct patients to support that addresses the (often social) causes of distress, which may alleviate some of the pressures in primary care, particularly for GPs.

Mental health occupational therapists and mental health practitioners appear to play an essential role in helping patients to self-manage distress, while social prescribing link workers vitally support patients to address the external stressor. Expansion of these roles may benefit patients and practices but may not be feasible because of workforce shortages. Other methods to support patients to self-manage symptoms of distress, such as guided online support or workbooks, may therefore prove useful.

The conceptualisation and management of distress in primary care is complex and highly variable. Improvements are needed to support practitioners to identify and manage people experiencing distress to address systemic challenges, overmedicalisation, and increasing societal pressures driving distress.

Notes

Funding

This study is funded by the National Institute for Health and Care Research (NIHR) School for Primary Care Research (project reference: 668). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Carolyn A Chew-Graham is part-funded by NIHR West Midlands Applied Research Collaboration.

Ethical approval

This study was approved by the NHS Research Ethics Committee (reference: 23/HRA/4080).

Provenance

Freely submitted; externally peer reviewed.

Acknowledgements

We would like to acknowledge the practitioners who took part as research participants, as well as the practices and research delivery networks who supported recruitment. We would also like to acknowledge our public contributors for their contribution to the research and to this publication.

Disclosure

The authors report no conflicts of interest in this work

Received December 20, 2024.
Revision received February 13, 2025.
Accepted May 22, 2025.

http://creativecommons.org/licenses/by/4.0/

This article is Open Access: CC BY 4.0 licence (http://creativecommons.org/licenses/by/4.0/).

References

1.↵
1. Mind
(2018) GP mental health training survey summary. accessed. https://www.mind.org.uk/media-a/4414/gp-mh-2018-survey-summary.pdf. 17 Sep 2025.
2.↵
1. Ramanuj P,
2. Ferenchick EK,
3. Pincus HA
(2019) Depression in primary care: part 2 - management. BMJ 365, pmid:30962249. l835.
OpenUrl Abstract/FREE Full Text
3.↵
1. Mitchell AJ,
2. Vaze A,
3. Rao S
(2009) Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374(9690):609–619.
OpenUrl CrossRef PubMed
4.↵
1. Ferenchick EK,
2. Ramanuj P,
3. Pincus HA
(2019) Depression in primary care: part 1—screening and diagnosis. BMJ 365, pmid:30962184. l794.
OpenUrl Abstract/FREE Full Text
5.↵
1. National Institute for Health and Clinical Excellence
(2022) Depression in adults: treatment and management. NG222. accessed. https://www.nice.org.uk/guidance/ng222. 17 Sep 2025.
6.↵
1. American Psychiatric Association
(2013) Diagnostic and statistical manual of mental disorders. (American Psychiatric Association, Washington, DC), 5th edn.
7.↵
1. Dowrick C
(2009) Depression: beyond the disease era. London J Prim Care (Abingdon) 2(1):24–27, pmid:26042162.
OpenUrl PubMed
8.↵
1. Horwitz AV
(2007) Distinguishing distress from disorder as psychological outcomes of stressful social arrangements. Health (London) 11(3):273–289, pmid:17606693.
OpenUrl PubMed
9.↵
1. Horwitz AV,
2. Wakefield JC
(2007) The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder (Oxford University Press, New York, NY).
10.↵
1. Geraghty AWA,
2. Stuart B,
3. Terluin B,
4. et al.
(2015) Distinguishing between emotional distress and psychiatric disorder in primary care attenders: a cross sectional study of the Four-Dimensional Symptom Questionnaire (4DSQ). J Affect Disord 184:198–204, pmid:26099254.
OpenUrl PubMed
11.↵
1. Mitchell AJ,
2. Rao S,
3. Vaze A
(2011) Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy. J Affect Disord 130(1–2):26–36, pmid:20708274.
OpenUrl CrossRef PubMed
12.↵
1. Geraghty AW,
2. Santer M,
3. Williams S,
4. et al.
(2017) “You feel like your whole world is caving in”: a qualitative study of primary care patients’ conceptualisations of emotional distress. Health (London) 21(3):295–315, pmid:28177273.
OpenUrl CrossRef PubMed
13.↵
1. Geraghty AWA,
2. Santer M,
3. Beavis C,
4. et al.
(2019) ‘I mean what is depression?’ A qualitative exploration of UK general practitioners’ perceptions of distinctions between emotional distress and depressive disorder. BMJ Open 9(12), pmid:31843841. e032644.
OpenUrl Abstract/FREE Full Text
14.↵
1. Chew-Graham CA,
2. Mullin S,
3. May CR,
4. et al.
(2002) Managing depression in primary care: another example of the inverse care law? Fam Pract 19(6):632–637, pmid:12429666.
OpenUrl CrossRef PubMed
15.↵
1. Johnston O,
2. Kumar S,
3. Kendall K,
4. et al.
(2007) Qualitative study of depression management in primary care: GP and patient goals, and the value of listening. Br J Gen Pract doi:10.3399/096016407782318026, pmid:17976282.
OpenUrl Abstract/FREE Full Text
16.↵
1. Hyde J,
2. Calnan M,
3. Prior L,
4. et al.
(2005) A qualitative study exploring how GPs decide to prescribe antidepressants. Br J Gen Pract 55(519):755–762, pmid:16212850.
OpenUrl Abstract/FREE Full Text
17.↵
1. Davies J,
2. Read J,
3. Kruger D,
4. et al.
(2023) Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. BMJ 383:2730, pmid:38052460.
OpenUrl PubMed
18.↵
1. Broadbent P,
2. Thomson R,
3. Kopasker D,
4. et al.
(2023) The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences. Lancet Reg Health Eur 27, pmid:37035237. 100585.
OpenUrl CrossRef PubMed
19.↵
1. Smith LE,
2. Amlȏt R,
3. Fear NT,
4. et al.
(2022) Psychological wellbeing in the English population during the COVID-19 pandemic: a series of cross-sectional surveys. J Psychiatr Res 153:254–259, pmid:35843066.
OpenUrl PubMed
20.↵
1. NHS England,
2. NHS Improvement
(2019) Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme guidance. accessed. https://www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf. 17 Sep 2025.
21.↵
1. Braun V,
2. Clarke V
(2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):77–101.
OpenUrl CrossRef
22.↵
1. Marks DF,
2. Yardley L
1. Joffe H,
2. Yardley L
(2004) in Research methods for clinical and health psychology, eds Marks DF, Yardley L (SAGE Publications, London) In, pp 56–68. Content and thematic analysis.
23.↵
1. Braun V,
2. Clarke V
(2021) Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Couns and Psychother Res 21(1):37–47.
OpenUrl
24.↵
1. Malterud K,
2. Siersma VD,
3. Guassora AD
(2016) Sample size in qualitative interview studies. Qual Health Res 26(13):1753–1760.
OpenUrl CrossRef PubMed
25.↵
1. Kroenke K,
2. Spitzer RL,
3. Williams JB
(2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613, pmid:11556941.
OpenUrl CrossRef PubMed
26.↵
1. Terluin B,
2. van Marwijk HW,
3. Adèr HJ,
4. et al.
(2006) The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 6. 34.
27.↵
1. Cooper M,
2. Avery L,
3. Scott J,
4. et al.
(2022) Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review. BMJ Open 12(7), pmid:35879011. e060214.
OpenUrl Abstract/FREE Full Text
28.↵
1. Aughterson H,
2. Baxter L,
3. Fancourt D
(2020) Social prescribing for individuals with mental health problems: a qualitative study of barriers and enablers experienced by general practitioners. BMC Fam Pract 21(1), pmid:32957923. 194.
OpenUrl PubMed
29.↵
1. Bernard K,
2. Wildman JM,
3. Tanner LM,
4. et al.
(2023) Experiences of non-pharmaceutical primary care interventions for common mental health disorders in socioeconomically disadvantaged groups: a systematic review of qualitative studies. Int J Environ Res Public Health 20(7), pmid:37047854. 5237.
OpenUrl PubMed
30.↵
1. Hassan SM,
2. Giebel C,
3. Morasae EK,
4. et al.
(2020) Social prescribing for people with mental health needs living in disadvantaged communities: the life rooms model. BMC Health Serv Res 20(1), pmid:31906933. 19.
OpenUrl CrossRef PubMed
31.↵
1. MacConnachie V
(2024) Assessing the impact and success of the Additional Roles Reimbursement Scheme. accessed. https://www.nhsconfed.org/system/files/2024-02/Assessing-impact-success-ARRS-FNL.pdf. 18 Sep 2025.
32.↵
1. Dowrick C
(2013) Depression as a culture-bound syndrome: implications for primary care. Br J Gen Pract doi:10.3399/bjgp13X665189, pmid:23643203.
OpenUrl FREE Full Text
33.↵
1. Kappelin C,
2. Sandlund C,
3. Westman J,
4. Wachtler C
(2023) Dancing with the patient: a qualitative study of general practitioners’ experiences of managing patients with multimorbidity and common mental health problems. BMC Prim Care 24(1), pmid:37081385. 104.
OpenUrl CrossRef PubMed
34.↵
1. Ventriglio A,
2. Ricci F,
3. Torales J,
4. et al.
(2024) Navigating a world in conflict: the mental health implications of contemporary geopolitical crises. Ind Psychiatry J 33(Suppl 1):S268–S271, pmid:39534168.
OpenUrl PubMed
35.↵
1. Cianconi P,
2. Betrò S,
3. Janiri L
(2020) The impact of climate change on mental health: a systematic descriptive review. Front Psychiatry 11, pmid:32210846. 74.
OpenUrl CrossRef PubMed
36.↵
1. Mercer SW,
2. Fitzpatrick B,
3. Gourlay G,
4. et al.
(2007) More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract doi:10.3399/096016407782604910, pmid:18252071.
OpenUrl CrossRef PubMed

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[1] 1.↵
Mind
(2018) GP mental health training survey summary. accessed. https://www.mind.org.uk/media-a/4414/gp-mh-2018-survey-summary.pdf. 17 Sep 2025.

[2] Mind

[3] 2.↵
Ramanuj P,
Ferenchick EK,
Pincus HA
(2019) Depression in primary care: part 2 - management. BMJ 365, pmid:30962249. l835.
OpenUrl Abstract/FREE Full Text

[4] Ramanuj P,

[5] Ferenchick EK,

[6] Pincus HA

[7] 3.↵
Mitchell AJ,
Vaze A,
Rao S
(2009) Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374(9690):609–619.
OpenUrl CrossRef PubMed

[8] Mitchell AJ,

[9] Vaze A,

[10] Rao S

[11] 4.↵
Ferenchick EK,
Ramanuj P,
Pincus HA
(2019) Depression in primary care: part 1—screening and diagnosis. BMJ 365, pmid:30962184. l794.
OpenUrl Abstract/FREE Full Text

[12] Ferenchick EK,

[13] Ramanuj P,

[14] Pincus HA

[15] 5.↵
National Institute for Health and Clinical Excellence
(2022) Depression in adults: treatment and management. NG222. accessed. https://www.nice.org.uk/guidance/ng222. 17 Sep 2025.

[16] National Institute for Health and Clinical Excellence

[17] 6.↵
American Psychiatric Association
(2013) Diagnostic and statistical manual of mental disorders. (American Psychiatric Association, Washington, DC), 5th edn.

[18] American Psychiatric Association

[19] 7.↵
Dowrick C
(2009) Depression: beyond the disease era. London J Prim Care (Abingdon) 2(1):24–27, pmid:26042162.
OpenUrl PubMed

[20] Dowrick C

[21] 8.↵
Horwitz AV
(2007) Distinguishing distress from disorder as psychological outcomes of stressful social arrangements. Health (London) 11(3):273–289, pmid:17606693.
OpenUrl PubMed

[22] Horwitz AV

[23] 9.↵
Horwitz AV,
Wakefield JC
(2007) The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder (Oxford University Press, New York, NY).

[24] Horwitz AV,

[25] Wakefield JC

[26] 10.↵
Geraghty AWA,
Stuart B,
Terluin B,
et al.
(2015) Distinguishing between emotional distress and psychiatric disorder in primary care attenders: a cross sectional study of the Four-Dimensional Symptom Questionnaire (4DSQ). J Affect Disord 184:198–204, pmid:26099254.
OpenUrl PubMed

[27] Geraghty AWA,

[28] Stuart B,

[29] Terluin B,

[30] et al.

[31] 11.↵
Mitchell AJ,
Rao S,
Vaze A
(2011) Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy. J Affect Disord 130(1–2):26–36, pmid:20708274.
OpenUrl CrossRef PubMed

[32] Mitchell AJ,

[33] Rao S,

[34] Vaze A

[35] 12.↵
Geraghty AW,
Santer M,
Williams S,
et al.
(2017) “You feel like your whole world is caving in”: a qualitative study of primary care patients’ conceptualisations of emotional distress. Health (London) 21(3):295–315, pmid:28177273.
OpenUrl CrossRef PubMed

[36] Geraghty AW,

[37] Santer M,

[38] Williams S,

[39] et al.

[40] 13.↵
Geraghty AWA,
Santer M,
Beavis C,
et al.
(2019) ‘I mean what is depression?’ A qualitative exploration of UK general practitioners’ perceptions of distinctions between emotional distress and depressive disorder. BMJ Open 9(12), pmid:31843841. e032644.
OpenUrl Abstract/FREE Full Text

[41] Geraghty AWA,

[42] Santer M,

[43] Beavis C,

[44] et al.

[45] 14.↵
Chew-Graham CA,
Mullin S,
May CR,
et al.
(2002) Managing depression in primary care: another example of the inverse care law? Fam Pract 19(6):632–637, pmid:12429666.
OpenUrl CrossRef PubMed

[46] Chew-Graham CA,

[47] Mullin S,

[48] May CR,

[49] et al.

[50] 15.↵
Johnston O,
Kumar S,
Kendall K,
et al.
(2007) Qualitative study of depression management in primary care: GP and patient goals, and the value of listening. Br J Gen Pract doi:10.3399/096016407782318026, pmid:17976282.
OpenUrl Abstract/FREE Full Text

[51] Johnston O,

[52] Kumar S,

[53] Kendall K,

[54] et al.

[55] 16.↵
Hyde J,
Calnan M,
Prior L,
et al.
(2005) A qualitative study exploring how GPs decide to prescribe antidepressants. Br J Gen Pract 55(519):755–762, pmid:16212850.
OpenUrl Abstract/FREE Full Text

[56] Hyde J,

[57] Calnan M,

[58] Prior L,

[59] et al.

[60] 17.↵
Davies J,
Read J,
Kruger D,
et al.
(2023) Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. BMJ 383:2730, pmid:38052460.
OpenUrl PubMed

[61] Davies J,

[62] Read J,

[63] Kruger D,

[64] et al.

[65] 18.↵
Broadbent P,
Thomson R,
Kopasker D,
et al.
(2023) The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences. Lancet Reg Health Eur 27, pmid:37035237. 100585.
OpenUrl CrossRef PubMed

[66] Broadbent P,

[67] Thomson R,

[68] Kopasker D,

[69] et al.

[70] 19.↵
Smith LE,
Amlȏt R,
Fear NT,
et al.
(2022) Psychological wellbeing in the English population during the COVID-19 pandemic: a series of cross-sectional surveys. J Psychiatr Res 153:254–259, pmid:35843066.
OpenUrl PubMed

[71] Smith LE,

[72] Amlȏt R,

[73] Fear NT,

[74] et al.

[75] 20.↵
NHS England,
NHS Improvement
(2019) Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme guidance. accessed. https://www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf. 17 Sep 2025.

[76] NHS England,

[77] NHS Improvement

[78] 21.↵
Braun V,
Clarke V
(2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):77–101.
OpenUrl CrossRef

[79] Braun V,

[80] Clarke V

[81] 22.↵
Marks DF,
Yardley L
Joffe H,
Yardley L
(2004) in Research methods for clinical and health psychology, eds Marks DF, Yardley L (SAGE Publications, London) In, pp 56–68. Content and thematic analysis.

[82] Marks DF,

[83] Yardley L

[84] Joffe H,

[85] Yardley L

[86] 23.↵
Braun V,
Clarke V
(2021) Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Couns and Psychother Res 21(1):37–47.
OpenUrl

[87] Braun V,

[88] Clarke V

[89] 24.↵
Malterud K,
Siersma VD,
Guassora AD
(2016) Sample size in qualitative interview studies. Qual Health Res 26(13):1753–1760.
OpenUrl CrossRef PubMed

[90] Malterud K,

[91] Siersma VD,

[92] Guassora AD

[93] 25.↵
Kroenke K,
Spitzer RL,
Williams JB
(2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613, pmid:11556941.
OpenUrl CrossRef PubMed

[94] Kroenke K,

[95] Spitzer RL,

[96] Williams JB

[97] 26.↵
Terluin B,
van Marwijk HW,
Adèr HJ,
et al.
(2006) The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 6. 34.

[98] Terluin B,

[99] van Marwijk HW,

[100] Adèr HJ,

[101] et al.

[102] 27.↵
Cooper M,
Avery L,
Scott J,
et al.
(2022) Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review. BMJ Open 12(7), pmid:35879011. e060214.
OpenUrl Abstract/FREE Full Text

[103] Cooper M,

[104] Avery L,

[105] Scott J,

[106] et al.

[107] 28.↵
Aughterson H,
Baxter L,
Fancourt D
(2020) Social prescribing for individuals with mental health problems: a qualitative study of barriers and enablers experienced by general practitioners. BMC Fam Pract 21(1), pmid:32957923. 194.
OpenUrl PubMed

[108] Aughterson H,

[109] Baxter L,

[110] Fancourt D

[111] 29.↵
Bernard K,
Wildman JM,
Tanner LM,
et al.
(2023) Experiences of non-pharmaceutical primary care interventions for common mental health disorders in socioeconomically disadvantaged groups: a systematic review of qualitative studies. Int J Environ Res Public Health 20(7), pmid:37047854. 5237.
OpenUrl PubMed

[112] Bernard K,

[113] Wildman JM,

[114] Tanner LM,

[115] et al.

[116] 30.↵
Hassan SM,
Giebel C,
Morasae EK,
et al.
(2020) Social prescribing for people with mental health needs living in disadvantaged communities: the life rooms model. BMC Health Serv Res 20(1), pmid:31906933. 19.
OpenUrl CrossRef PubMed

[117] Hassan SM,

[118] Giebel C,

[119] Morasae EK,

[120] et al.

[121] 31.↵
MacConnachie V
(2024) Assessing the impact and success of the Additional Roles Reimbursement Scheme. accessed. https://www.nhsconfed.org/system/files/2024-02/Assessing-impact-success-ARRS-FNL.pdf. 18 Sep 2025.

[122] MacConnachie V

[123] 32.↵
Dowrick C
(2013) Depression as a culture-bound syndrome: implications for primary care. Br J Gen Pract doi:10.3399/bjgp13X665189, pmid:23643203.
OpenUrl FREE Full Text

[124] Dowrick C

[125] 33.↵
Kappelin C,
Sandlund C,
Westman J,
Wachtler C
(2023) Dancing with the patient: a qualitative study of general practitioners’ experiences of managing patients with multimorbidity and common mental health problems. BMC Prim Care 24(1), pmid:37081385. 104.
OpenUrl CrossRef PubMed

[126] Kappelin C,

[127] Sandlund C,

[128] Westman J,

[129] Wachtler C

[130] 34.↵
Ventriglio A,
Ricci F,
Torales J,
et al.
(2024) Navigating a world in conflict: the mental health implications of contemporary geopolitical crises. Ind Psychiatry J 33(Suppl 1):S268–S271, pmid:39534168.
OpenUrl PubMed

[131] Ventriglio A,

[132] Ricci F,

[133] Torales J,

[134] et al.

[135] 35.↵
Cianconi P,
Betrò S,
Janiri L
(2020) The impact of climate change on mental health: a systematic descriptive review. Front Psychiatry 11, pmid:32210846. 74.
OpenUrl CrossRef PubMed

[136] Cianconi P,

[137] Betrò S,

[138] Janiri L

[139] 36.↵
Mercer SW,
Fitzpatrick B,
Gourlay G,
et al.
(2007) More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract doi:10.3399/096016407782604910, pmid:18252071.
OpenUrl CrossRef PubMed

[140] Mercer SW,

[141] Fitzpatrick B,

[142] Gourlay G,

[143] et al.

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‘We’re all doing different things’ — exploring primary care practitioners' perspectives of managing distress: a qualitative study

Abstract

How this fits in

Introduction

Method

Study design

Participants

Data collection

Data analysis

Public involvement

Results

Participants

Thematic analysis

The multifaceted nature of distress

‘We’re all doing very different things’

Managing and understanding distress is challenging

Demedicalising distress in the face of increasing societal pressures

Discussion

Summary

Strengths and limitations

Comparison with existing literature

Implications for research and practice

Notes

Funding

Ethical approval

Provenance

Acknowledgements

Disclosure

References

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