International Review of Psychiatry (1998), 10, 102± 105

Training general practitioners in mental health skills

DAVID GOLDBERG

Institute of Psychiatry, King’ s College, De Crespigny Park, London SE5 8AF, UK

General Practitioners vary between themselves both

in their ability to detect and their ability to manage

mental disorders. There is great variation between

both individual clinicians and between doctors in

different countries. In general terms, the skill

needed is that of any good communicatorÐ to allow

the patient to tell the story in his own way, and to be

curious about recent events in the patient’ s life that

may be subjecting him to stress.

This sounds very simple Ð but it is not. Patients

typically present with somatic symptoms, and often

have combinations of real physical disorders and

other symptoms for which no obvious cause has

been found. The doctor is under time pressure to

bring the interview to a satisfactory resolution, and

needs to exclude possible organic causes for the

patient’ s various symptoms. Small wonder that the

temptation is to interrupt the patient with an agenda

of the doctor’ s own, and systematically to exclude

possible physical causes before the patient has been

given a chance to describe his symptoms in his own

way.

This early stage of the interview can last anything

from 20 seconds to several minutesÐ but during it

the doctor encourages the patient to talk, and asks

directive questions, that allow the patient freedom

to describe his symptoms in his own way. Provided

that patients are encouraged to do this, the moment

will soon arise when the doctor becomes more direc-

tive, and to exert more control over the interview.

When symptoms are described that sound atypical,

or for which there are no obvious physical causes,

the doctor may need to supplement his knowledge

of the patient’ s home and family background, or to

discover whether there have been stressful life

events. When cues arise that suggest psychological

distress the doctor is alert to them, and follows them

up with directive questions.

Interviews in general practice tend not to follow

the rigid schemas taught in medical school, but may

oscillate between personal questions about the fam-

ily and allowing more of the description of the

somatic symptoms to emerge. From time to time it

may be necessary to make some supportive com-

ment to the patient (Goldberg & Huxley, 1980,

1992; Marks et al., 1979).

It is m istaken to suppose that this is some special

ability, quite different from other skills in clinical

medicine Ð so that those who are good physical

diagnosticians are likely to have little psychological

acumen. In fact, the reverse is the case Ð doctors

with high psychological sensitivity do better than

insensitive doctors on tests of factual knowledge of

medicine, and are more likely to possess post-

graduate quali ® cations (Goldberg & Huxley,

1992).

The above observations cam e about by analysing

many hundreds of interviews between general

practitioners and their patients, in the course of

which it becam e clear that doctors who are good at

detecting emotional disorders have patients who

make it easy for them, by exhibiting more cues

relating to distress than similarly distressed pa-

tients, being interviewed by less sensitive doctors

(Davenport et al., 1987; Goldberg et al., 1993).

W hat is happening is that the less sensitive doctors

discourage free communication, and that patients

become aware of this very early on. Some of the

behaviours that discourage patients are not making

eye contact and have more avoidant posture at the

beginning of the interview, interrupting the patient

before he has ® n ished speaking, and asking many

`closed’ questions, to which the patient must reply

`yes’ or `no’ . By contrast, patients interviewed by

doctors good at picking up distress are encouraged

by the doctor’ s attentive posture and tendency to

make eye contact with them; these doctors make

more facilitations while listening and ask questions

with a psychological content, and in a directive

rather than a closed style (Goldberg et al., 1993).

Patients picking up these cues from the doctor

speak with less distress in their voices, keep their

hands and arm s still, and are much less likely to

mention psychological sym ptoms (Davenport et al.,

1987). Some behaviours release cues when carried

out by sensitive doctors, but not when done by

insensitive doctorsÐ these are questions about the

patient’ s social life, having an empathic manner

and total number of questions dealing with the

patient’ s psychological adjustment (Goldberg et al.,

1993).

A subsequent paper showed that sensitive doctors

generally have superior communication skills, and

are better able to prescribe medication, communi-

cate information about treatment more effectively,

and give advice more clearly than less sensitive

doctors (Millar & Goldberg, 1991). Thus, doctors

with superior communication skills make detection

of distress easy for themselves, by behaving in such

a way that makes it easy for the patient to display

the distress that is being felt. Doctors who are less

good manage to make the patient’ s suppress all

0954± 0261/98/020102± 04 $7.00 Ó 1998, Institute of Psychiatry

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Training GPs in mental health skills 103

evidence of their distress, which is not manifest even

to a psychiatrist viewing a videotape of the consul-

tation.

Training family doctors in communication

skills

The use of video-feedback in changing professional

behaviour goes back 20 years, and the ® rst system-

atic studies of teaching the skills described above

came from several sources (Goldberg et a l.,

1980a,b; Verby et al., 1979; Whewell et al., 1988).

Audiotaped feedback had earlier been used by

Lesser (1985), who had called his method `prob-

lem based interviewing’ . Lesser came over to Eng-

land and helped to turn his method into a group

teaching course using video feedback, which was

evaluated with positive results (Gask et al., 1988).

Trainees were offered weekly sessions over 6

months, and those who were least able to interview

well showed the greatest improvement scores at the

end of the course. Teaching was then offered to

established GPs (Gask et al., 1987), where trainees

are shown a clear model for interviewing patients,

and then meet in groups to discuss one another’ s

techniques. The teacher offers his or her own views

if necessary , but most of the helpful comments

come from other trainees. Trainees are encouraged

to become aware of cues they might otherwise

ignore Ð such as the vocal quality of the patient’ s

voice, the patient’ s posture and any spontaneous

movements. The training has been shown to

achieve lasting effectsÐ scores of trained doctors

improve still further when tested a year later (Bow-

man et al., 1992).

Later, the methods were taught to G P trainers in

both London and M anchester (Gask et a l., 1991).

It was found that the critical thing to offer a

potential teacher was feedback of his or her own

interviewing techniquesÐ so that they in effect ex-

perienced the teaching they were just about to offer

to trainees themselves. Further feedback of their

own teaching sessions, or earnest discussions and

advice on their teaching methods, added little to

this.

Teaching the management of somatization

It has already been mentioned that psychologically

distressed patients are likely to present with somatic

symptoms: this ® nding is true across the world in

the WHO’ s study in 15 cities (Ustun & Sartorius,

1995), and even in the UK, where psychological

presenting problems occur more frequently than

they do in developing countriesÐ physical presenta-

tions are the rule. To make matters still more com-

plicated, patients may have co-existent real physical

disease, but the physical disease may not be the

explanation of the patient’ s complaints. Less sensi-

tive GPs con® ne their activities to excluding serious

physical causes for the patient’ s symptoms in the

former situation, and will often allow the physical

disease to appear as the explanation in the latter.

During Lesser’ s visit to Manchester, we adapted his

teaching on the management of somatization and

persuaded GPs to role play the various components

of his model on videotape, after which we asked

viewing trainees to practice each separate behaviour

using a `micro-skills’ teaching approach. In this GPs

divide themselves into groups of three, in which one

plays the part of the doctor, another the patient, and

a third the observerÐ the conventional role-playing

method. After they have tried each micro-skill, the

tape demonstrated another example of a doctor

displaying this skill (Gask & Goldberg, 1993).

This teaching was evaluated by Kaaya and

others (Goldberg et al., 1989; Kaaya et al., 1992)

and found to be effective, and has since been

further adapted by M orriss and others (M orriss et

al., 1998). The latter workers found that such

training decreased the cost of referrals of such

patients by 23%, with no corresponding increase

in primary care costs. The train ing produced better

clinical outcomes in the patients: it has been

shown to be an extremely cost-effective form of

treatment.

The effect of teaching problem based interviews

on the mental disorders treated by the doctors has

been studied by Gask & Goldberg (1993), with

somewhat inconclusive results. However,

signi® cantly better outcomes were seen for patients

who were both depressed and anxious, due to de-

creased anxiety in the patients. Trained doctors

were also signi® cantly better at detecting disorders,

gave more information to patients and the patients

felt that their problems had been understood. How-

ever, the assessor was not completely blind to the

group to which the patient had been assigned, but as

far as possible the study relied upon objective mea-

sures provided by the patients.

A classi® cation of mental disorders seen in

primary care based upon management

Another approach altogether is to produce a sim-

pli® ed classi® cation of mental disorders for use in

primary care which is user-friendly, and leads di-

rectly to managementÐ with detailed advice on

counselling and advice to the patient and his family.

In their original form these consisted of a set of 24

cards (Ustun et al., 1995) which was subjected to a

® eld trial in 15 countries. The British trial (Gold-

berg et al., 1995) showed that use of the depression

card caused doctors to require more depressive

symptoms before prescribing anti-depressants, and

added to their management strategies when dealing

with a depressive episode. This system now forms

part of a training pack obtainable from WHO, which

includes a range of materials that may be found

useful in teaching mental health skills.

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104 David Goldberg

Good practice guidelines

The Royal Colleges of General Practitioners and

Psychiatrists got together to enunciate their `Beat

Depression’ Campaign, which produced good prac-

tice guidelines (Paktel & Priest, 1992) and led to a

major evaluation called the Hampshire Depression

Project. Detailed results of this project are still

awaited, but preliminary analyses suggests that de-

spite the intensity of the training experience offered

to GPs, the clarity of the treatment guidelines, and

the reasonableness of the teaching methods

adopted, that the project did not produce a lasting

effect upon the treatment behaviour of the GPs who

collaborated in the study. This echoes similar

® ndings from the United States, where Lin et al.

(1997) have shown that extensive physician edu-

cation over a period of one yearÐ that included

didactic advice on prescribing, role plays of good

practices, good practice guidelines about treatment

and use of a reference handbookÐ all failed to pro-

duce a measurable effect upon patient outcomes.

The authors conclude that `on site personnel and

monitoring of patient progress and treatment adher-

ence seem to be necessary. Katon et al. (1996) have

shown that the attendance of a psychiatrist in pri-

mary care did indeed improve treatment outcomes,

but this is hardly a practical solution for routine

care.

The contribution of other primary care staff to

patient care

The possib le role of the practice nurse in mental

health care has been discussed by Mead et al.

(1997), and their role in improving compliance by

elderly patients being treated for depression has

been successfully demonstrated (Blanchard et al.,

1995). Nurses have also been trained to administer

problem-solving treatment by Mynors-Wallace et al.

(1995). This was shown to be as effective as an

anti-depressant in the treatment of major de-

pression, and that both active treatments are more

effective than a placebo drug. General practitioners

can also be trained to give his form of treatment

themselves (Gath & Mynors-W allace, 1991).

Other approaches to training

Gask et al. (1998) carried out an intensive training

programme focused upon depression in primary

care, which involved their general practitioners in

attending 10 hours of training, including training

videotapes, role plays and viewing tapes of their own

consultations. They received training in both prob-

lem-solving and cognitive techniques relevant to

depression. The doctors were rated by their role

played `patients’ as better communicators as a result

of this training, and they felt more con® dent about

managing their depressed patients.

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