PI Brief Update

What Do GPs Know About Mental Health? - Dr Mark Burgin

29/01/25. Dr Mark Burgin discusses some of the reasons why GPs continue to insist that they do have expertise in mental health. 

Mental health is a lifelong progression from childhood experience and attachment through identity crises and bereavement. It can include serious mental illness such as depression or psychosis or mental health adjustments to life events. Prevalence figures suggest that about 1 in 6 people have mental health symptoms. 90% of all mental health consultations in the NHS are with GPs.

The treatments available to psychiatrists and GPs have few differences. There are no expensive and complicated tests for mental illness and the medications are similar apart from a few medications such as Lithium. The psychiatrists have access to hospital admission and ECT but rarely use either. It is plausible that GPs might be able to manage mental health in the community if they have the right skills.

There is evidence that GPs are doing something, the difference between high and low referring practices can be tenfold. In the last two decades since primary care has been less effective the numbers of people referred each year to mental health services has doubled. Although the prevalence of mental health problems has increased, they have not doubled. These facts would suggest that at least some GPs could manage mental illness without referral.

Skills

Psychiatrists have extensive training in many areas of psychiatric practice and often have specialist training in psychological treatments as well. Their CVs on expert reports can stretch to several pages although a few produce a booklet to provide a more comprehensive account. Psychologists are similarly impressive and have often undertaken extensive training in specialised treatments such as EMDR.

The humble GP by contrast may have half a page on their CV dealing with psychological experience. They may struggle to explain how 80 mental health consultations a week for 10 years can translate into ‘expertise’. Even the basis of a GP’s mental health experience can be difficult to explain. What is the biopsychosocial model (BPSM) and how does it work?

GPs are often puzzled by the response of mental health services that a patient is ‘too complex’. To a GP all patients are complex, they all have multiple issues and the aim of treatment is to help the bits that can be made better. If a patient is complex then surely there is something that the mental health services can offer? This apparent difference in approaches suggests that GPs have something special to offer in mental health.

Outcomes

GPs often outperform specialists in terms of outcomes. This is not surprising as the GP will see a patient at the start of their problems whereas the specialist will only see them when they become ill. This has been studied in high and low referring GP practices. In the former the patients they refer are paradoxically sicker than the low referrals. This might suggest that GPs can prevent mental illness from developing.

The limited research on GPs treating mental health suggests that early intervention is a key part of the process. Some GPs can alter the pathway of the illness and in many cases prevent the illness from taking hold. How they achieve this is unclear although they seem to have some ‘psychological understanding’. This has been replicated in early psychosis but it does not explain everything.

GPs also appear to have better outcomes with those who have chronic long term mental health conditions. Using a step wise ‘psychosocial progress’ the patients become more independent and have better relationships. Although this has not been well studied it suggests that GPs may know (or can do) something that other mental health professionals do not.

Gatekeeping

GPs have long been seen as the gatekeepers in the NHS whose job is to refer to a ‘proper doctor’ if a person is unwell. This rather discouraging caricature of a complex and challenging job has not been dispelled by medical leaders. There appear to be three key elements to gatekeeping that have therapeutic potential. The first element is having a chat to the GP, this helps the person describe their problem. Often the solution is straightforward such as take an anti-depressant or be nicer to your partner.

The second element is problem solving, often the patient complains of being overloaded with thoughts. They cannot use these thoughts to solve their problem so go round in circles. The GP can phrase their options as a list to choose from, making it easier to make progress. The third element is collaborating with the patient to face their difficulties and work together to find a way through the difficulties.

These three elements sound simple but they are in effect all that the specialists do. GPs have the advantage of being able to see their patients every week if necessary and also that the patients can come back if they do not get better. This access and continuity of care mean that GPs can deliver rapid and effective interventions in a relatively unconstrained way.

Conclusions

GPs expertise comes from working on the coalface of the NHS. They see the patients who need to see them and learn what works to make them better. They may not have as many letters after their name or have been to as many courses but they have real experience. Those GPs who develop some ‘psychological understanding’ can claim to know something about mental health.

Outcomes in mental health are often patient completed questionnaires at the end of the therapy. This can overestimate short term benefits over long term improvement. Often the best outcome is a return to work or stabilising of a relationship rather than a reduced score. GPs underuse psychometrics and specialists underuse long term follow up to measure their performance.

If all general practices referred patients like the lowest quartile of GPs then there would be a 75% reduction in referrals. If those patients had a similar severity to those GP referrals then there would a 50% reduction in scores. It seems likely that some GPs know something about mental health. It is however certain that when they stop doing whatever they are doing, secondary care becomes overloaded. 

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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