Young adults' perceptions of GPs as a help source for mental distress: a qualitative study

Abstract

Background

Few young adults with mental disorder seek help from a GP.

Aim

To explore young adults' perceptions of GPs as a source of help for mental distress.

Design of study

Qualitative interviews.

Setting

Bristol and surrounding areas, UK.

Method

Males and females aged 16–24 years screened as ‘cases’ with probable mental disorder (GHQ [General Health Questionnaire]-12 score≥4) or describing past episodes of mental disorder (n = 23) were sampled purposively according to help-seeking behaviour. Semi-structured interviews explored help-seeking choices. Transcripts were analysed using thematic, constant comparison and case study analysis.

Results

Most young adults did not value or recognise GPs as a source of help for mental disorder or distress. They thought that GPs deal exclusively with physical illness, lack training in mental health, are unable to provide ‘talking’ therapy, and may be dismissive of those consulting with mental distress. A prescription for antidepressants was seen as the most likely outcome of a consultation, but young adults wished to avoid this and so rarely consulted. Encounters with GPs could challenge or reinforce these perceptions.

Conclusion

Negative perceptions about the value of consulting a GP for mental distress may explain low rates of help-seeking among young adults, including those with severe distress. Young people require a better understanding of GPs' role. It is also necessary to address evidence reported elsewhere that some GPs also experience uncertainties about what they can offer within the constraints of primary care.

INTRODUCTION

Fewer than 40% of adults with a mental disorder seek help from a GP (UK national psychiatric morbidity survey).¹ Similar low rates of help-seeking are reported in other countries^2–4 and psychological-based autopsy studies of suicide cases also reveal low rates of GP attendance in the weeks before death.⁵ Survey data suggest people do not seek help because of barriers including stigma, stoicism, and the belief that treatment is unnecessary or will not help.^6,7 Young adults (aged 16–24 years) are among those least likely to consult when mentally distressed.^8–10 Compared with other adults they are least likely to endorse the GP as a help source for mental distress.^6,10,11 Non-consultation is of serious concern because of increased rates of suicide among young men¹² and its association with negative coping strategies, such as deliberate self-harm and alcohol use.¹³ However, little research has focused on young adults.

This study combined a survey to explore non-help-seeking among mentally-distressed young adults aged 16–24 years with qualitative interviewing to obtain in depth narratives of help-seeking behaviour. Here, we describe young adults' perceptions of GPs as a help-seeking option when experiencing mental distress.

METHOD

This qualitative research was conducted in 2001 alongside a questionnaire survey of 16–24 year olds (n = 3004) living in and around Bristol (South West England).¹⁴ Participants were sampled randomly from the local Health Authority population register, which included all those registered with a GP and covered inner city, suburban and rural areas.

The survey included the General Health Questionnaire (GHQ-12)¹⁵ to identify those with probable mental disorder. It also enquired about suicidal thoughts and whether or not help or advice had been sought about distress from a range of sources including friends, counsellors, GPs, and secondary care. Maximum variation sampling was used to select a diverse group of survey ‘cases’ (GHQ score ≥4) for qualitative interviews with a range of sociodemographic characteristics, varying severities of distress, and different help-seeking strategies (help-seeking and non-help-seeking). The survey was administered in five batches with sets of qualitative interviews attached to each batch. This ensured individuals were interviewed shortly after completing the questionnaire (mean delay 36 days) and allowed analysis of each set of interviews to be carried out while the next batch of questionnaires was administered. Analysis was thus incremental, with new data compared against existing codings. Emerging themes were identified and pursued in the next set of interviews, iteratively, according to the general principles of grounded theory.¹⁶ Sampling continued until diversity had been achieved and consistent data emerged.

Interviewees were encouraged to identify the issues that had been most important to their help-seeking decisions. A topic guide was used to ensure similar areas were covered, including: concepts of mental distress, lay diagnosis, meanings attached to help-seeking, reasons for non-help-seeking, and potential sources of help when distressed. The GHQ is a probabilistic tool and can be sensitive to false positives and transient disturbances.¹⁵ Therefore a diagnostic tool, the Clinical Interview Schedule–Revised (CIS-R),¹⁷ was also administered to gain a more accurate assessment of the existence of mental disorder.

Interviews lasted 1–2 hours. All were tape-recorded and transcribed verbatim. The computer programme Atlas-ti was used to store data and assist with analysis. Data were coded to identify themes and conceptual categories. Descriptive accounts of each code were produced to explore themes within and across interviewees. Tabulations and analytical grids indicated the prominence of themes, patterns in their occurrence, and relationships between codes. Case summaries were compiled of each interviewee's narrative, which tracked sequences of events, behaviours, and beliefs. These helped to make sense of shifts in perception over time and to examine instances where individuals expressed views opposing the common trend. The transcripts of help-seekers and non-help-seekers were compared to identify reasons for differing responses.

How this fits in

Less than a third of young adults (aged 16–24 years) with a mental disorder consult a GP about their symptoms. There is a lack of qualitative research exploring the reasons for these low rates of help-seeking. Young adults have a limited understanding of GPs' role in relation to mental health. They perceive GPs as physical specialists with little or no skills and knowledge to address mental health problems, so may not disclose symptoms even if these are severe.

RESULTS

In total, 1276 young adults were surveyed¹⁴ and 35.4% (n = 449) were GHQ ‘cases’. Of these, only 8.3% (n = 37) had recently consulted a GP about emotional problems or symptoms of distress. Help-seeking was similarly low (14.2%) among those reporting recent suicidal thoughts (n = 135). Interviews were conducted with ‘cases’ to explore these findings. In total, 106 cases were invited to interview and 29 agreed to participate, but six could not be contacted or did not attend. A total of 23 interviews were conducted. This cannot be interpreted as a response rate in the conventional sense as ‘hard to contact’ groups were over sampled until participants had been recruited. Response between groups varied from 13% (females 16–19 years, males 20–24 years) to 80% (females 20–24 years).

Interviewees covered a range of sociodemographic characteristics and severity of mental distress (Table 1). Several had experienced high levels of distress (recently or in the past). CIS-R scores indicated that two were ‘non-cases’ so general beliefs about mental distress and help-seeking were obtained from these individuals. Twelve interviewees (4 males, 8 females) had consulted a GP about mental distress on at least one occasion and six were consulting at the time of interview. Several had withdrawn from treatment or chosen not to consult for subsequent episodes. Most consultations occurred after considerable delay, prompted by a crisis, such as a suicide attempt, and instigated by friends or family. Only three interviewees attended promptly and freely. Eleven had not consulted at all. All discussed their views on the extent to which GPs are an appropriate and helpful resource for those with mental distress, and help-seekers described their experiences.

Table 1.

Characteristics of interviewees.

Characteristic	n = 23a
Sex
Male	10
Female	13
Age
16–19 years	12
20–24 years	11
Parental social class
Non-manual	16
Manual	6
Not reported	1
Residency
With family	17
With friends/partner	6
Alone	2
Occupation
Work full/part-time	10
Study full/part-time	12
Unemployed	3
House and family	1
Mental distressb
Current cases	14
Past cases	8
Non-cases	2
Indicators of severe distress
Suicidal thoughtsc	14
Self-cutting	5
Overdosing	4
CIS-R score >20	5

^aNumbers out of 23. Missing data indicate that, in some cases, options were not mutually exclusive.

^bA ‘current case’ is defined as someone scoring 12 or more on the Clinical Interview Schedule-Revised (CIS-R) and/or currently receiving medical treatment for mental disorder and includes chronic cases. A score of 12 or more provides clinical evidence for neurotic mental disorder. Past cases were identified by evidence of past diagnosis and treatment.

^cReported in questionnaire or at interview.

The appropriateness of consulting

Three-quarters of those interviewed (n = 17) believed that GPs are not an appropriate source of help for mental distress. Interviewees tended to dichotomise physical and mental aspects of health. They associated GPs with the treatment of physical complaints such as sore throats, asthma, and injuries, and more than half believed GPs have no role in the treatment of mental disorders or distress:

‘They're there for your bad ankle and cuts and bruises not for your mind games aren't they?’ (Interviewee 6: male, 17 years.)

‘I just associate my doctor with if I had a bad stomach or … yeah, I wouldn't go to my doctor no, no, not if I was depressed.’ (Interviewee 22: female, 23 years.)

Interviewer: ‘Where can you go for help if you're ill?’

‘I think the doctor is always going to be there. That's always top of the list as far as physical health goes. Mental health? I dunno.’ (Interviewee 1: male, 20 years.)

‘I don't think for the situation that was going on that the doctor would have been the right person.’ (Interviewee 20: female, 18 years.)

Interviewer: ‘In what situation is the doctor the right person to see?’

‘Um, colds, asthma.’ (Interviewee 20: female, 18 years.)

Interviewer: ‘So physical things?’

‘Yeah, yeah, it can be emotional but I generally don't think that doctors can help much in that way. They're more helpful for, you know, someone who's broken a leg or who feels that they can't really breathe.’ (Interviewee 20: female, 18 years.)

GPs were also associated with the treatment of ‘illness’ only and mental distress was rarely categorised as ‘illness’, with symptoms being normalised as ‘stress’ or ‘personal problems’ and dismissed as ‘non-medical feelings’ or ‘emotions’:

‘If I've given it a name, like my job or family, then there's almost no point in going [to GP] 'cos like could a doctor help me with my job or could he help me with my family? I mean I see that as something I'd have to sort out.’ (Interviewee 1: male, 20 years.)

‘I've always seen illnesses as like ill people and I don't think I'mill 'cos like today I feel physically fine so as far as I'm concerned I'm not ill and that's why I think its so hard for people to get like help with something like depression or stress or whatever … I see that I don't need to go to the doctors for that. I haven't got a leg falling off, it's just I happen to feel a bit down.’ (Interviewee 3: female, 20 years.)

GPs were generally rejected as a possible source of help, even where no alternative presented itself. Most interviewees were left with no apparent avenue for help, even in several cases where they considered themselves to have a mental disorder or were so distressed as to consider suicide:

‘First of all I just wanted to die. I didn't want to have to go through it.’ (Interviewee 15: female, 18 years.)

Interviewer: ‘Did you think of speaking to your doctor?’

No. I don't think doctors take mental health very seriously and I don't know whether I look to a doctor for that either … If I've got a physical problem then I go to the doctor. If I've got a psychological problem then there's no-one really to go to.’ (Interviewee 15: female, 18 years.)

GPs' knowledge and training

Almost half of the interviewees believed GPs lack sufficient knowledge and training to respond to patients who are distressed or have a mental disorder. Some questioned whether GPs receive any mental health training at all. GPs were regarded as physical specialists whose area of expertise is the body rather than the mind. They were thought to lack both a general knowledge of mental health and specific knowledge about how to treat mental illness or help with personal problems:

‘I'm sure they [doctors] don't exactly know what the pills do to you … I'm not trying to undermine them or anything but they don't know what they're doing because they don't know how the brain works. I mean they don't know how to access it or change it in proper ways … I don't personally think they can do much because it's all still guesswork. I don't mind going there [to GP] for physical problems but I wouldn't go there for mental problems.’ (Interviewee 10: male, 16 years.)

‘I do get on with my doctor, it's just that I think he would be a bit like “mmm, it's not my area” … I mean, I know you have to go and see them (GP) to see someone else but really I don't think they know a lot about it [depression]. (Interviewee 3: female, 20 years.)

Interviewer: ‘Do you think doctors know much about stress and depression and what to do about it?

‘They could probably just advise you. I suppose they would just refer you to somebody that did know … I just imagine the doctor would say, “oh here's some tablets”. But nah, I don't think doctors. I think they've probably got like a … they could just skim the water with it but not go in depth about it.’ (Interviewee 22: female, 23 years.)

While some interviewees believed no specialist could access or understand ‘the mind’, others considered counsellors and psychiatrists to be knowledgeable and equipped with therapeutic skills they believed that GPs do not have:

Interviewer: ‘Who could help someone in that situation [depression]?’

‘Someone professional who actually knows what they're talking about, like a psychologist or a psychiatrist. Not your GP 'cos they're not trained to do it. They're just trained to look at you and give out medicines.’ (Interviewee 16: male, 19 years.)

Therefore, GPs were perceived as unqualified, which fosters a lack of confidence in their capacity to help, and an unwillingness to consult with mental symptoms or emotional problems.

Perceptions of help from GPs

Most interviewees thought only traditional methods of practice (observing and testing for disease) and types of treatment (medicine or surgical procedures) were available to GPs. These were associated with physical malfunction but were incompatible with interviewees' beliefs about the nature of mental distress as intrinsic to the self or life situations, and therefore not observable or amenable to medical treatments. Interviewees regarded person-centred interventions, such as talking therapy and problem solving, as the main ways of resolving mental distress but did not think these were provided by a GP. Only four interviewees (three help-seekers, one non-help-seeker) recognised that GPs could fulfil a listening role:

‘If that's what doctors are for … I would [consult], but that's not what they're for. They're there to give tablets to people and you know, I can't imagine sitting down to my doctors saying 'oh my foot hurts and also I'm feeling a bit pissed off.’ (Interviewee 22: female, 23 years.)

‘A doctor's not gonna sit down with you and let all your feelings and the rest of it out, because that's not what doctors are for. They're there to sort out your physical problems, give you a few tablets … I don't think you'd be able to go for your 10.30 appointment with your doctor and they'd be able to sort your life out for you.’ (Interviewee 6: male, 17 years.)

This perception was explained by the limited remit, methods of practice, and training interviewees assigned to GPs and also the structure of primary care, which they believed imposed time constraints and required ‘instant cures’:

Interviewer: ‘Do you think [GPs] are good people to go to for emotional problems?’

‘Personally, no I don't think they are … They're sort of like “oh you've got 3 minutes.” They just want your problem and an instant sort of cure for it … I don't think they'd be the right person to go to.’ (Interviewee 13: female, 20 years.)

It was thought likely that a GP would prescribe antidepressants, which for over two-thirds of interviewees was given as a reason for not consulting, as they believed this could result in addiction and dependency:

‘I wouldn't mind going for help as long as they [doctors] could come up with a better solution than pills … If I knew I could go along and get something sorted in my head without having to be on Prozac® [Lilly] then possibly I would go along now, but I can't see that happening.’ (Interviewee 9: female, 23 years.)

Although a few interviewees (n = 6) suggested ways a GP might help (motivational exercises, information-giving), most were sceptical about whether a GP could help at all:

Interviewer: ‘Is it ever worth telling your doctor if you feel that way [suicidal]?’

‘Um probably, yeah but then they might just say that it's not a wise idea. I just don’t think they would be that helpful … I think they would just say well I think you should just go and see a counsellor if you're thinking of committing suicide, or just write a song or write a poem.’ (Interviewee 20: female, 18 years.)

GPs were seen to facilitate referral but interviewees' discussion of this further illustrated their belief that GPs did not have the skills to act as a source of help for mental distress:

‘I wouldn't go to the doctor for help with it [depression]. I'd expect to be referred. I'd expect him or her to sort of tell me I needed to go to see someone and refer me to someone else … its [GP] more of a middle man than someone who could solve the problem.’ (Interviewee 1: male, 20 years.)

Beliefs about GPs' attitudes

Half of those interviewed thought that GPs have negative attitudes towards mental distress. Possibly projecting their own beliefs about the inappropriateness of consulting, interviewees suggested that GPs ‘can't be bothered with mental health,’ ‘do not take mental problems seriously’, and would be ‘unsympathetic’ towards those consulting with ‘personal problems.’ They feared various negative responses including being laughed at, stigmatised, offered no help, or labelled as a ‘time-waster’. Several believed that GPs would adopt a particularly dismissive stance towards young people. These concerns were further reasons for delaying or not seeking help.

Positive perceptions and experiences of consulting

Transcripts of those who had attended a GP (n = 12) were examined further. A small number (n = 3) held entirely positive perceptions about seeking help from a GP for mental distress. In contrast to other interviewees, these were help-seekers whose pathways to their GP had been relatively direct and voluntary. Notions of inappropriateness were absent from their accounts and they valued the ‘medical’ management of symptoms:

‘I knew there was something wrong and if there's something wrong, you go to the doctors. You know, that's common sense innit. They're paid to see people who aren't very well. So that's what I went to do. I did have an inkling that I probably was depressed.’ (Interviewee 14: male, 18 years.)

Interviewer: ‘Are doctors good people to go to then?’

‘Well, I don't stay there for like 10 minutes talking about myself, no. But I just tell them how I've been feeling like, the appointment could last about 3 minutes, then I just walk out the door really.’ (Interviewee 21: male, 18 years.)

Interviewer: ‘So do you think you get the sort of help you'd like or need?’

‘Well as long as the doctor supplies the tablets I'm pretty sure I could help myself.’ (Interviewee 21: male, 18 years.)

GPs were positively evaluated for providing referral elsewhere (n = 6), prescribing medication (n = 4), listening (n = 3), and being caring and supportive (n = 2).

‘She [responder's GP] actually gave me a tissue because I was crying and said that perhaps she'd put me on some anti-depressants … but she's been brilliant actually, my doctor, excellent. Definitely a big part of helping me regain my confidence. Never rushes me or anything.’ (Interviewee 14: male, 18 years.)

A difference in perception was evident among four interviewees who had been coerced to attend a GP. They acknowledged GPs as a potential resource for mental distress where previously they had not. Others described negative experiences where GPs had appeared dismissive, uncertain, or unable to respond. These experiences reinforced negative perceptions and compromised further help-seeking:

‘It seemed almost as though he [GP] didn't know what to do about it [depression]. He was asking me what I wanted him to do and really I just wanted him to tell me what he was going to do you know. I just wanted someone to take control and help me.’ (Interviewee 23: female, 24 years.)

Interviewer: ‘So you wouldn't consider going back to your doctor?’

‘No, definitely not, no. I've sat in front of him before and sobbed because I was upset and he just did another blood test.’ (Interviewee 15: female, 18 years.)

‘I don't think it [depression] is noticed as much as it should be by GPs. I don't feel you get the help that you need. No, I don't feel they take it seriously enough actually. I went to my GP for 10 months telling him how I felt. Ten months and in the end, on the last occasion, I went in and didn't see my GP. I seen a locum and I just broke down and I walked straight out of there and I was given some antidepressants and every time I go to my GP now he doesn't really ask what's happening.’ (Interviewee 5: female, 22 years.)

DISCUSSION

Summary of main findings

Most young adults in this study did not value or even recognise GPs as a help source for mental disorder or distress. They thought it would be inappropriate and unhelpful to consult, believing that GPs deal exclusively with physical illness, lack training in mental health, cannot provide ‘talking’ therapy, and will only prescribe unwanted medication. At best, the GP was cast as a ‘middle man’ (sic) who would simply refer the patient to a more appropriate source of help. These beliefs were cited as reasons for not consulting a GP for symptoms of mental distress currently or in the past. Notably, those whose pathway to the GP had been relatively unproblematic did not share such perceptions and valued the use of medication to manage symptoms.

Strengths and limitations of the study

There has been little exploration of help-seeking among mentally-distressed young adults. This study provides new insights into their views and decisions about the GP as a potential help source. It is likely that the negative perceptions identified here contribute to low rates of help-seeking observed in psychiatric morbidity surveys and prior to suicide. They may also explain other behaviours that impede management of mental distress in primary care, such as somatic presentation and non-attendance at follow-up appointments.¹⁸ Additional factors such as stigma, difficulties surrounding lay diagnosis,^19,20 and the cognitive disturbances associated with mental disorder²¹ may also interfere with help-seeking.

While the sample is small and it is possible that those interviewed were atypical, efforts were made to ensure diversity by including those who had chosen to consult a GP (‘negative’ cases) and usually poor-responding and hard-to-contact groups. The survey conducted as part of this study provided a large and detailed sampling frame to improve the generalisability of findings. The interviewer was close in age to some responders, which appeared to reduce the power differential and increase rapport. The interviewer is a social scientist and presented herself in this way. Open discussion may have been impeded had she been a healthcare professional. The research team included a clinical epidemiologist and a GP, so a diversity of perspectives were brought to data interpretation.

In general, young people infrequently access primary care services for any reason, including physical health complaints; the findings of this study should be considered within this context. Young people's perceptions may derive from limited contact, and therefore fewer opportunities to establish relationships with GPs. Where consultation has occurred, this is likely to have been instigated by parents and confined to physical problems. Shifts in perception evident in the accounts of some interviewees following mental health consultations reinforce this view. Also, responders who viewed the GP as an inappropriate source of help discussed this explicitly, while those not sharing this view tended to take GPs' appropriateness for granted, so did not discuss this at length.

Comparison with existing literature

A perception that it is inappropriate to consult a GP as distress is thought to be ‘non-medical’ has been reported in studies of other age groups.^7,20 Low expectations about GPs' capacity to help and devote time to patients with mental distress have also been noted.²⁰ However, persistence of a notion of inappropriateness, even where symptoms are considered indicative of mental disturbance, does not appear to have been reported elsewhere. Indeed, studies of all adults suggest high endorsement of the GP as the main help-source in such instances.^20,22 Such views were almost entirely absent among young adults in the current study who generally perceived no role for a GP in the treatment of any mental distress. Our study's findings may have emerged because of the inclusion of non-help-seekers and because data were collected in the context of actual help-seeking decision-making. Other studies have been limited to hypothetical scenarios or consulting patients. Also, young adults' perceptions of the GP as a resource for mental distress may be more limited than older adults, who have greater experience of consulting. This may contribute towards explaining why young adults are a group least likely to seek help when distressed. Only 8% of the young adults surveyed as part of this study and found to be suffering from mental distress had consulted a GP.¹⁴

Implications for further research and clinical practice

Many ‘cases’ of mental disorder defined by current research and clinical criteria are mild or self-remitting. In such instances, the appropriateness of medical help-seeking may be disputable. However, the current study identified young people with severe distress who did not seek help but repeatedly accommodated worsening symptoms. There was a common belief that GPs are unable to help with mental health problems in any circumstance. Such negative perceptions about GPs as a help resource are discordant with the key role assigned to GPs in the delivery of mental health services by the National Service Framework (NSF) for Mental Health.²³

GP intervention may prevent distress escalating to crises, and can provide a gateway to specialist services. Consultation skills, such as active listening and empathy, may alone have a therapeutic effect.²⁴ In a recent study,¹⁸ GPs considered themselves to have a role in assessment, treatment, information-giving and referral of young people presenting with distress. Some indicated a willingness to allow extra time for counselling and support-giving, initiate therapeutic interventions, and provide interim support while patients were awaiting other services.

The current study highlights a need to provide young people with information about the role of the GP in mental health. It also indicates the type of help that young people favour and that will engage them (non-pharmacological) and identifies negative perceptions which require challenging. Research is required to establish effective ways of making GPs and primary care services appear more approachable and relevant to young people. Involving GPs in school-based outreach work may be possible approach to intervention. Young adults are an important group to focus on, as the illness behaviours formed during this time can persist.²⁵

The concerns of the young adults' reported here mirror those discussed elsewhere. Policy literature questions the extent to which GPs have the time and capacity to meet the demands placed on them by the NSF, and suggest that GPs require greater training and knowledge in mental health.²⁶ Similarly, GPs report a number of barriers that compromise their delivery of mental health care, including time constraints and a lack of resources that leave them feeling poorly equipped to offer alternatives to drug therapy.^18,24,27 They also experience uncertainty about the overlap between social problems and mental health problems and transient versus pathological disturbance.^18,27 These issues appear more challenging in relation to young adults' distress because at this age emotions are labile and turmoil and risk-taking behaviour is not uncommon.^18,24 The appropriateness of GPs treating life problems and minor distress has been contested,²⁸ and the extent to which GPs should support and deliver non-medical interventions unclear. Such difficulties led GPs in one study to avoid or discourage mental health consultations.²⁷ In this context, educating young people about the circumstances in which it is appropriate to consult is clearly problematic and needs to be coupled with a better understanding of the point at which medical help-seeking becomes beneficial. Increased attention towards developing better strategies is also required for GPs in managing mental distress.

Funding body

University of Bristol PhD Studentship (Lucy Biddle) NHS Executive South West Region (RS/15/04.00/Gunnell)

Ethics committee

United Bristol Healthcare Trust Research Ethics Committee (E4659); North Bristol Research Ethics Committee (054/00 & 2000/43); Weston Local Research Ethics Committee (E226)

Competing interests

The authors have stated that there are none