Identifying mental health symptoms

The qualitative findings show that, among the GPs, there are heterogeneous concepts and precepts regarding the nature of mental illness. In the International Classification of Diseases (ICD 10), a mental health diagnosis is achieved by assessing a clinically recognisable set of signs and symptoms associated with personal functional impairment.27 The GPs interviewed reported difficulties in the recognition and detection of mental health signs and symptoms in young people. From a GP's perspective, a child or adolescent mental illness could be seen as clinically, or socially, defined. Such perspectives were clear from the comments made to the researcher (box 1). Whereas in the case of adult mental health, GPs have at their disposal a checklist that helps decide on the need for a referral, no such mental health tool was known to exist for UK GPs to use with children and adolescents.

Interestingly, all seven GPs interviewed reported that they seldom see emotional and behavioural problems in the under-18-year-old population (ranging from one to up to eight referrals a year per GP). Furthermore, when asked whether they remembered a case when a family or teenager came in for one complaint but other symptoms were noticed that were indicative of mental health, all admitted to never having had such a case. Yet, so-called atypical or masked presentations are relatively common for psychiatric disorders in adults.28 There may be a reluctance to undertake mental health assessment if a younger patient or their parent comes in with another complaint (eg, a sore throat) as suggested by one GP who considered that, in this case, asking deeper questions would be ‘inappropriate’ (GP3).

Many of the comments reflect a lack of consensus between GPs in evaluating complex presentations of mental illness. One GP commented that it was easier to detect children as they are ‘pretty straightforward’ (GP3), since their problems are mostly behavioural problems, although another stated ‘they don't come to light so easily… it's usually some kind of behavioural problem… they don't come and tell you’ (GP6). Although there are standardised diagnostic criteria for detecting clinical syndromes that involve antisocial behaviour,27 GPs differed markedly in their understanding of these. A similar observation was noted for mental illnesses that present with mood changes. While one GP commented on how body language can give the signal ‘I'm miserable’ (GP4), and therefore needs some consultation to find out the source of the issues, another commented that they would not refer a ‘slightly gloomy and grumpy teenager’ (GP1). In fact, irritability occurring most days, showing little diurnal variation and lasting more than 2 weeks, and out of context and culture for that teenager, may be a mood signal for unipolar depression.29 ,30 This same GP stated he would not refer if the teenager presented ‘a little bit of cutting just to enjoy ourselves… that could just be a way of getting attention!’ (GP1). Recent studies have shown that non-suicidal self-injury (NSSI) is indeed relatively common, occurring in some 10–15% or so teenagers.31 Furthermore, NSSI is associated with a 5–10-fold increase in suicidal thoughts and behaviours in depressed teenagers.32 These recent research findings highlight the key importance and responsibilities of CAMHS research into practise communications to GPs when new facts of high clinical relevance are published.

Choosing whether to refer

Even when mental health symptoms have been identified, a second group of challenges exist in deciding when and whether to refer. All of the GPs interviewed stated they refer when there are significant overt mental illness risks, such as physical signs of recurrent self-harm and report of suicidal attempts. However, even among this small sample of interviewed GPs, there was significant variation in the other, subtler, types of triggers that would warrant a referral. These themes were mainly around more generic ‘risky’ issues, within the following domains:

• Evidence of child abuse (GP1, GP3)

• Need for medication/therapy that I cannot prescribe (GP1, GP2)

• Huge temper/anger management signs (GP 3, GP 6)

• Panic and anxiety symptoms (GP 2)

• ADHD symptoms (GP 2)

• If child had been in local authority care (GP 2)

• Behaviour problems (GP 1, GP2, GP3)

A referral was also made if the GP felt they needed to prescribe medication, access to further therapy, and a further diagnosis or specialists’ opinion. The selected comments in box 2 show how the GPs interviewed all expressed the need for specialist knowledge for detecting, treating and managing mental health disorders in young people, and that this knowledge is not necessarily one that they possess. Despite this overall recognition of the importance of specialist knowledge of others in the care pathway, each GP had a differing view on their own capability in delivering treatment for mentally ill young people. Of the seven interviewed GPs, only two reported having prescribed antidepressants to young people or children, but the other five said they would not, under the current guidance from NICE.29 Only one of the GPs felt comfortable to see the patient again and try methods such as cognitive behavioural therapy (CBT) and prescribe medication if necessary (box 2). A key part of the lack of referral even for a full assessment was because of the time restrictions on GP appointments in giving justified time required for a diagnosis and formulation (box 2). In some GP practices, there are monthly multidisciplinary meetings with specialist agencies that are child and family focused, at which school nurses and social services may participate, which may buffer the non-specialist knowledge base of the medical practitioner.

The findings suggested clearly that an overt risk factor is never ignored as seen in the second comment in box 2. However, it seems that the decision to refer is not always clearcut, nor dependent solely on the GP's judgement. As with many other conditions, this does also depend on what is likely to be acceptable to the parent (one GP commented on often having ‘a lot of pressure from parents to refer’ GP2), as well as whether the service will accept the referral. A few GPs noted that estimating the likely success of their referral is part of the tricky process they need to go through. The paperwork and process can take a while and GPs do not wish to raise the patients’ or families’ expectations when it is likely to be an unsuccessful referral. One GP even called the CAMH referral criteria a ‘mystery’. Another GP stated that she would not refer if ‘it's unlikely CAMH will take them’ (GP3).

It can be concluded that the decision to refer very much depends on the overt nature of the presenting clinical conditions (ie, the risk of harm, signs of inability to function normally, parents’ influence). However, these clinical decisions appear mediated by the GPs’ judgement regarding the likelihood of acceptance from CAMHS. The implication is that the entry criteria for CAMHS are simply not being delivered in a clear and concise way to GP services, and that CAMHS has to consider the value that may accrue to GP both from a specialist consultation as well as a referral for potential treatment.

Communicating with referral agencies

Once the decision for referral has been made, the next step for a GP is determining the most appropriate referral route. Where they are sent very much depends on the presenting conditions. Figure 1 shows, collectively, what the GPs either drew or stated as being their referral routes. The figure only represents the possible routes taken in the referral decision-making process. This includes those agencies that refer to the GP, and those the GP refers onwards. The information collected and represented in figure 1 shows the agencies which the GPs themselves have provided in the interviews about their possible, and/or previously used, referral routes.

The GPs unanimously stated that no feedback is ever received from voluntary or social services despite this information being very important in future and ongoing diagnosis and treatment (see example comments in box 3), due mostly to their different confidentiality requirements. For many of the GPs, a good relationship was established with their local CAMHS, especially if they had access to a voice on the phone to help them with a referral query. Having only one referral route for all mental health services was also seen favourably, although retaining the option to consult other available expertise was also apparent from the interviews. Alternative expertise, however, is limited, given that liaison psychiatry nurses, commonplace for adults, do not exist for children in the UK. Despite the overall satisfaction with CAMHS, there were comments made about their ‘non-communicative style’ (GP2), especially in terms of their criteria and thresholds for accepting referrals. Incidentally, the key informants at CAMHS during this study noted a similar challenge in reaching GPs to participate in care management and the care pathway development process, but the reasons for these challenges have not been investigated for this region.

Finally, when presented with the latest care pathways developed locally by the Trust, only two out of the seven GPs recognised the document (it is unknown whether or not they all received it previously), and one of them called it ‘nonsense’. The care pathway measure called the Child Global Assessment Scale, indexing the level of overall personal impairment of the patient while unwell and used for every CAMHS assessment, was a particular source of difficulty. None of the GPs interviewed was familiar with this scale despite its prominence in the CAMHS document. It should be noted, however, that this document may not have been intended for primary care workers, although it contains information which could be used both for education and communication of the referral process.