Improving the mental health skills of the primary care team Improving the skills of general practitioners

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About half of GP trainees have a 6-month psychiatry hospital attachment, many of which are considered to be unhelpful for a future generalist career. (74) Many GPs have had no higher professional training in mental health and are not required to do so. Historically, continuing medical education for GPs has been based on traditional didactic educational methods which are unsuitable for learning psychiatric interviewing skills. (74,75) GPs are likely to select training by perceived rather than real need. A survey of 190 randomly selected GPs from 95 health authorities in England and Wales (74) found that 35 per cent of respondents had received mental health training in the previous 3 years and that 83 per cent of this group had found the courses useful. Respondents rated their competence in a range of mental health skills as generally average, but felt particularly confident in depression recognition with every respondent rating themselves as average or above; 42.5 per cent rated themselves as being above average at communication skills, whilst nearly two-thirds rated themselves below average at 'psychodynamic counselling' and 52.5 per cent rated themselves as below average at cognitive techniques. Respondents 'personally and definitely' would like further training in psychodynamic counselling (25 per cent), stress management techniques (20.8 per ent), cognitive techniques (15 per cent), management of addictions (13.3 per cent), how to help the long-term mentally ill (10 per cent), when to prescribe psychotropic drugs and what to prescribe (9.2 per cent), and assessment of suicide risk (7.5 per cent). It is notable that most respondents who want training prefer management skills to assessment. Perhaps GPs are not going to recognize a condition until they are confident in how to manage it or who should be referred.

Another survey of the perceived training need of 380 GPs in Southeast London asked respondents to select preferred training from 26 mental health topics and indicate their preferred educational format.(76) Nearly two-thirds of the GPs responded, with some wanting no training, some wanting all the training, and most being intermediate (mode, five topics requested). Preferred formats were small-group work alone or with an accompanying lecture. Educational programmes responsive to the GPs wishes are being produced using an iterative process involving some of the GPs from the original survey. (76)

There is widely cited but limited evidence that a fairly didactic depression training changed the behaviour of 18 GPs in Gotland (7778) and possibly improved patient outcome,(79) although 3 years later the educational effect faded when half the GPs had left the area. (80) However, it has not been possible to reproduce these results in the United Kingdom (Hampshire Depression Project). An educational intervention for GPs about anxiety disorders (81) over two seminars with a mixture of didactic input, case discussion, role play, and use of computers and distance learning materials showed increased recognition, improved attitudes, changes in referrals, and more patients treated in primary care.

Reviewing actual consultations with learners is an important educational method which was shown to change behaviour in medical students, (82) psychiatrists/83' and primary care residents in Charleston, North Carolina.(84) Adding the technique of problem-based interviewing (85> in a group setting(86) improved the accuracy in assessing emotional distress of both GP trainees(87) and experienced GPs,(88) and these changes persist.(89) GP trainers can transmit these skills to trainees.(90) This approach uses real consultations presented in a facilitated peer group with the opportunity for skill rehearsal. (86) An alternative method, which allows skill rehearsal, is to use prepared videos in which actors and GPs actually demonstrate microskills. Videos have been produced on a variety of subjects, such as somatization disorder, alcohol problems, child and adolescent problems, depression in old age, talking treatments in depression, dementia, psychosis, anxiety, and chronic fatigue. Some of these packages have been evaluated.(3,91> Most continuing medical education for British GPs is arranged by district-based tutors who generally have limited time for and expertise in educational provision.(92)

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