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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