How appropriate are current primary care responses to poverty-related mental distress?

Talk Code: 
Prize Plenary 1
Presenter: 
Felicity Thomas
Co-authors: 
Lorraine Hansford, Joseph Ford, Rose McCabe, Katrina Wyatt, Richard Byng
Author institutions: 
University of Exeter, University of Plymouth, City University

Problem

Poverty and deprivation create and exacerbate mental distress, resulting in high use of primary health care within low-income communities. In addition to placing time and resource pressures on GPs, doctors increasingly face practical, social and moral responsibilities as gatekeepers to welfare support for this population group. This can create challenges for doctors and patients, and raises important questions over the medicalistion of poverty-related distress. The DeStress study aimed to understand how treatments for common mental health conditions are prescribed and used in low-income communities in response to poverty-related distress; whether such approaches are considered effective by the patients and the doctors concerned; and what alternatives could be put in place.

Approach

The ESRC funded DeStress project has undertaken sixteen focus groups with residents in low-income communities (n=97), interviewed family doctors (n=10) and low-income patients (n=80), and has undertaken conversational analysis of video recordings of primary care consultations for mental health (n=52). The research adopted a co-creative approach, in which residents from low-income communities (experts by experience) worked alongside health professionals and representatives from third sector groups to identify key research questions for investigation, analyse the data, joint-present at conferences and make recommendations on more effective consultations and other approaches for patients experiencing poverty-related distress.

Findings

Patients from low-income communities experience a range of challenges accessing mental health support, and when they do, they often feel that it is inappropriate to their needs. Use of conversational and narrative analysis identified widespread dissatisfaction with the medical model for mental health amongst GPs and low-income patients, yet GPs felt they had few options available to them that did not exacerbate the over-medicalisation of poverty-related distress. Despite high levels of prescribing, we found a low level of endorsement by GPs for antidepressants and IAPT, with negative implications for both patient wellbeing and GP stress and burnout. New community-based models such as peer-support and social prescribing to address causes of distress were mooted. There were differences in views as to how these should be supported.

Consequences

Current primary care responses to common mental health conditions over-medicalise poverty-related distress and can be unhelpful for GPs and patients. GPs need to be supported to adopt a role that recognises the bio-psycho-social and is aware of non-medical forms of support for patients experiencing poverty-related distress. Responsibility for poverty-related distress needs diluting away from GPs to other sectors, as well as to communities themselves. Engaging with low-income communities in a meaningful manner can help to ensure that patients feel better able to discuss their concerns and understand and contribute to the diverse forms of treatment and support that are available in primary care and beyond.

Submitted by: 
Felicity Thomas
Funding acknowledgement: 
The DeStress project was funded by the Economic and Social Research Council (ref. ES/N018281/1) and Health Education England. We are very grateful for this support.