Common Mental Disorders Depression - New Zealand Doctor

2
Principles of intervention
in the primary care setting
2.1 Rationale for intervention
The high prevalence and morbidity of common mental disorders such as depression
and the potential for effective treatment provide a strong rationale for identification,
active management and follow-up in primary care. 65,101 Likely benefits include ease
of access for patients, early intervention and a holistic and integrated approach. 129
2.2 Recognising potential mental disorders
A routine check of psychosocial health is the first step in recognising potential
mental disorders and the most vital assessment tools are the communication and
observational skills of the practitioner. A structured approach to assessment ensures
that the relevant domains are addressed and enables the practitioner to identify risks,
protective factors and any issues of cultural context and identity.
Functional disability should be considered carefully, as many patients with modest
or subthreshold symptoms have significantly impaired occupational or social
functioning. 4,73,130 Substance use disorder can be difficult to recognise because
it is relatively less disabling than some other disorders. 131
Formal assessment tools may have a supplementary role in diagnosis, but can be
time-consuming and are less versatile than global clinical assessment. Tools may
also be useful to help assess severity and monitor response to treatment.
Although many people with mental disorders present with physical complaints, the
majority will divulge psychological problems if asked directly. 132,133 A nonjudgmental
manner and assurance of confidentiality increase the likelihood of disclosure. 134 The
involvement of family/whänau in the assessment process may also encourage disclosure.
Sometimes problems take several sessions to ‘unravel’ in the clinical setting and
may involve an assessment process of ‘trial and error’. 135 For all patients with mental
distress it is therefore vital to negotiate active follow-up.
There may only be sufficient time to address urgent concerns within the course of a
15-minute primary care appointment. In the opinion of the Guideline Development
Team (GDT), many patients would benefit from an extended consultation to allow
time to explore their personal perspectives and promote self-management goals, 136
though it may be difficult to provide this within current resource constraints.
Identification of Common Mental Disorders and Management of Depression in Primary Care 17