Complex mental health difficulties: Learning from the UNSEEN study with recommendations for GPs

Complex mental health difficulties is a transdiagnostic term used to describe patients with mental ill-health who experience repeated episodes of anxiety and depression, with long-term, frequently unpredictable, changes in mood and difficulties in relationships. These patients often fall between services such as IAPT/Talking Therapies and specialist secondary care mental health teams. The care of patients with complex mental health difficulties represents one of the biggest challenges for general practice and the wider healthcare system.

The UNSEEN study (Understanding services for people with Complex Mental Health Difficulties) was a two year research study conducted to examine how general practice can better identify people with complex mental health difficulties and provide high quality care. We carried out interviews with patients and GPs and conducted a database study looking for features within electronic healthcare records which might help us identify patients with complex mental health difficulties. In this document we describe what was learnt from UNSEEN and how this might be helpful for GPs in their day to day practice.

Complex mental health difficulties include conditions such as personality disorders, dysthymia and complex PTSD. However, rates of coding in electronic health records or formal diagnosis of these conditions are much lower than the actual prevalence rates and therefore many patients go under-recognised. Following the UNSEEN study, we found 7 key areas to think about when considering complex mental health difficulties: (i) early life and antecedents; (ii) emotional regulation difficulties; (iii) social adversity and vulnerabilities; (iv) overlapping mental health-related problems; (iv) comorbid drug and alcohol use/dependence; (v) patterns of prescribing; and (vii) service use patterns.

In interviews, GPs recognised this group of patients and highlighted the significant workload and management challenges. GPs expressed frustrations with services and being left holding patients but also described positive experiences of working with newer primary care transformation teams. Continuity of care, allowing time and space for patients, and promoting an empathic culture within the wider practice team were all considered important. Patients with lived experience of complex mental health difficulties described their experiences of trauma and adverse childhood experiences being central to how they made sense of their diagnoses. Their experiences of trying to obtain help from their GP mirrored what we heard in clinician interviews.

The challenges experienced on both sides often result in GPs and patients being left frustrated with unsatisfactory consultations and a perception of little progress despite significant efforts. It can be easy to overlook the importance of good general practice in such situations. However, patients in UNSEEN expressed a great deal of positivity towards their relationships with their GPs despite the difficulties experienced.

Bringing together what we have learned from UNSEEN, we provide some suggestions to be in consultations. Ultimately, every patient will be different and have their own story and challenges, but we hope that this document will raise awareness and provide a few practical tips in managing complex mental health difficulties.