Introduction

In the UK, around 4 in 10 people presenting in primary care consultations — regardless of their presenting complaint — are experiencing some form of mental illness^​1​.  Some may find it hard to speak openly about their problems, while others may not even recognise that mental ill-health is the cause of their difficulties.

Most people experiencing poor mental health do not have an active diagnosis of mental illness in their clinical records. They may access healthcare for other reasons; for instance, medically unexplained symptoms and chronic conditions are associated with lower levels of wellbeing and an increased risk of mental illness. People with chronic conditions are twice as likely to experience a mental health issue, while clusters of nine or more symptoms confer a very high risk of depression (80%) for medically unexplained symptoms^​1–4​. Similarly, the majority of people in the UK (≈75%) who die of suicide do not have a documented history of mental illness. This is unlikely to improve without increasing active enquiry by healthcare professionals, removing stigma around mental health and moving towards parity of esteem between physical and mental health^​5,6​.

One of the barriers to supporting patients with poor mental health can be a lack of confidence or knowledge around management of common presentations, or what action to take in the event of a new disclosure. This knowledge gap can contribute to delayed diagnosis or inappropriate use of specialist resource, reducing access to support for the people who need it most. It is equally important to assess mental health and wellbeing in high-risk groups as early intervention can help to improve prognosis and overall health outcomes.

For more information on various aspects of mental health, please visit The Pharmaceutical Journal‘s dedicated mental health content collection.

This article will explore risk factors for mental illness and provide information and tips about simple screening tools and other approaches that can help in early intervention, so that patients with comorbid mental illness — from first presentation to those with established mental health conditions showing signs of relapse — are actively supported to seek help and access treatment.  

The components of the psychiatric history are discussed in detail and the mental state examination and risk assessment framework are covered in brief. While some elements of mental health assessment may fall outside the scope of practice for many prescribers, having an appreciation of mental health assessment and terminology is likely to improve referral quality and communication with specialists, helping to promote access to timely treatment^​7​. 

Impact of mental illness on physical health and wellbeing

Over 15 million people, around 30% of the UK population, are currently living with at least one long-term condition and, of these, more than 4 million will be experiencing mental health issues^​4​. For example, people with cancer, diabetes, asthma or hypertension have been shown to be at higher risk of experiencing depression, anxiety or post-traumatic stress disorder^​4,8​.

The most common mental health disorders seen in primary care are mixed depression and anxiety states^​9​. People typically access services when they are no longer able to cope with the status quo, either because of high levels of anxiety or other debilitating physical symptoms, which may be psychosomatic in nature (e.g. upset stomach, chest pains)^​1​. Occasionally, depression and anxiety may be symptoms of an underlying physical or neurological condition, such as thyroid disease, heart disease, cancer or Parkinson’s disease^​10​.

There are many ways that poor mental health can act as a barrier to achieving optimal physical health. These barriers to treatment can lead to people suffering serious health inequalities over the course of their lifetime, with patients with severe mental illness (SMI) living fewer years in good health and dying 15–20 years earlier on average than the general population^​11​.  

Some examples of ways mental health problems impact physical health are summarised below. Please note this is not an exhaustive list:

• Reduced capacity for self-care or failure to prioritise own needs may lead to poor sleep, exercise, nutrition and difficulties with medicines adherence;
• Distractibility, anxiety or cognitive issues may impact medicines adherence and clinic attendance;
• Self-management of symptoms, such as stress or poor self-esteem, contributes to unhealthy behaviours, such as smoking, excessive alcohol consumption, use of non-prescribed medication, or disordered eating;
• Feeling stigmatised or developing social anxiety leading to avoidance of social interaction, becoming isolated, missing routine physical health screening interventions (resulting in delayed diagnosis of physical health issues). Social isolation has been linked to an increased risk of cardiovascular disease;
• Psychiatric medication side effects may cause or contribute to physical health conditions including cardiometabolic syndrome, akathisia and sleep disorders (e.g. antidepressants, antipsychotics) and renal disease (e.g. lithium);
• Diagnostic overshadowing — this is a phenomenon where symptoms are attributed to mental illness rather than the actual underlying condition culminating in delayed diagnosis of serious disease. Adherence may also be compromised if the patient’s concerns about side effects are dismissed.

Early intervention is crucial. Prescribers should keep mental health in mind when taking a patient history or performing a clinical assessment, particularly when reviewing patients at high risk of mental illness. Other than chronic physical health issues, social determinants of health, family history of mental illness, age and sex may all interact to increase an individual’s risk of developing mental illness.

Social determinants of health 

The World Health Organization recognises that health is “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”, acknowledging the complex interplay between physical health, mental health and social determinants of health on an individual’s wellbeing^​12​.  

Social influences and mental health may interact to significantly reduce quality of life. For example, adverse childhood experiences have been linked to a higher risk of developing obesity and cancer and a higher risk of mental illness^​13​. Risk of developing mental illness is further increased by other social factors, including poverty, social isolation, unemployment and substance use (e.g. tobacco, marijuana etc.)^​14​. 

Social determinants of health such as living conditions, literacy, cultural stigma, access to transport, employment status and carer burden should be considered as part of the assessment as they may impact on the patient’s ability to access treatment. 

Incorporating mental health and wellbeing into assessments therefore requires an extensive psychiatric history covering social influences. 

Conducting an effective psychiatric history

The purpose of the psychiatric history is to guide initial assessment and help tailor treatment to the individual. Crucially, it also helps with rapport building, which is essential for the patient to feel comfortable sharing their internal experience, and is therefore a valuable exercise for all consultations, not just those where mental illness is suspected (consider the missed opportunity of addressing medication concerns for instance). Key components of the psychiatric history are outlined in Figure 1^​1​ with some of the domains and components explored in further detail below.

Systematic enquiry

Systematic enquiry is an important component of the psychiatric history used by specialists to fully assess mental state. In the generalist setting, depending on the presenting complaint, this part of the history might entail a brief physical examination or use screening questions to identify possible risk factors for mental illness. Screening questions can help to make the most of limited consultation time in the event that mental illness is disclosed or suspected. 

When screening for risk factors and suspected mental illness you should draw on the psychiatric history and presenting complaint to pursue a line of enquiry. For example, if the patient is struggling with sleep and low mood, it would make sense to screen for depression and suicidality, while if their presentation or behaviour seems odd, you may wish to screen for psychosis. The general screening questions below may be helpful:

Anxiety disorders

• What physical symptoms have you been experiencing?
• How calm have you been feeling recently?
• Have you had any concerns or worries of late? If so, can you please tell me about them?

Depressive disorders

• How has your mood been recently?
• Are you still enjoying things the way you used to?
• How do you view the future just now?

Psychosis

• Have you had any beliefs that you think people might find odd?
• Have you had any unusual experiences recently?
• Have you had any difficulty controlling your thinking?
• Have you heard people’s voices when there’s no one around?
• If so, where do you think the voices are coming from and what are they saying?

If the patient’s responses support the suspected diagnosis, a rating scale can be used to ensure all possible symptoms are detected and the severity of symptoms assessed. The relevant National Institute for Health and Care Excellence (NICE) guidance should also be consulted or a comprehensive overview of screening and management for each condition^{​15–18​}. Links to examples of rating scales and screening tools are provided at the end of the article (see ‘Expanding your scope of practice)’

The following sections provide advice on next steps where there is established or suspected mental illness. Although it is not expected that prescribing pharmacists should conduct a lengthy mental state exam and risk assessment, an overview of the assessment process is provided below to support communication with specialist services. Understanding what information the specialist is looking for in an initial referral will help to avoid delays in accessing support for your patients. 

Assessing mental state

The mental state examination (MSE) is used by specialists conducting a psychiatric history to provide a snapshot of the patient’s current mental state at the time of review. A mental state examination requires advanced assessment skills; the assessor needs to gain insight into the patient’s inner thoughts, feelings and perceptions whilst simultaneously drawing inference from the psychiatric history and their outward observations of the patient to form a subjective impression including level of risk.

Exploring the domains of the mental state examination in depth is outside the scope of this article but additional resources are available at the end of this article.

It is important that prescribers have an appreciation of how the mental state examination is structured as this can provide improved insight when reviewing clinic letters from specialists and when working within the multidisciplinary team. The mnemonic ‘ASEPTIC’ provides an example structure for the MSE (see Box 1)^​1,19​. 

MSEs differ depending on the line of enquiry pursued. For example, an older patient presenting with cognitive difficulties and insomnia may be offered further cognitive evaluation, while a younger person presenting with the same symptoms might be evaluated further for depression or psychosis, depending on information provided by their unique history, appearance and behaviours combined with their response to active enquiry. 

Some domains should be straightforward for the generalist to complete, time permitting. Insight (the patient’s understanding of their mental state) is arguably the most crucial line of enquiry as the impact of untreated mental illness on chronic condition management can be significant. Some key questions to ask when establishing patient insight into mental illness include:

• Do you think anything is wrong with you?
• What do you think is the matter with you?
• If you are ill, what do you think needs to happen to make you better?

For cognition, the assessor will check orientation to person, place and time (see Box 2). A commonly used tool is the abbreviated mental test score (AMTS) — a 10-point assessment that was introduced by Hodkinson in 1972 to rapidly assess elderly patients for the possibility of dementia.

The remaining domains of the MSE are based on a combination of observation, history and active questioning and require practice to refine. Prescribers who are interested in expanding their practitioner remit to include the mental state examination could consider requesting supervision from a specialist mental health practitioner (many primary care networks have opted to develop these roles owing to unmet need in primary care).

Risk assessment

A crucial part of the assessment, the risk assessment dictates onward management of the patient, based on risk to self and/or others at the time of assessment. 

Each mental health condition is commonly associated with specific symptoms or behaviours, which may be detrimental to overall health and wellbeing and increase personal risk. In some cases, this harm may extend to others. For example, onset or worsening command hallucinations involving harm to others, coupled with an overwhelming urge to act on these commands or evidence of planning, would require urgent psychiatric assessment. Ensure you enquire about the following symptoms to help you establish the level of risk^​20​: 

Depression 

• Self-harm or suicide;
• Hopelessness;
• Worthlessness;
• Ability to care for others (with dependents).

Psychosis 

• Command hallucinations (enquire about content and compulsion to act).

Mania/hypomania 

• Self-neglect (sleep, eating, hygiene);
• Risky behaviours (spending, drug use, risky sexual behaviours, emotional lability [hostility]).

Substance misuse

• Impact on physical health (accidents, seizures, overdoses, abscesses, BBV);
• Financial cost;
• Harm to others (e.g. driving under the influence).

Eliciting suicidal intent or history is extremely important and forms part of the risk assessment. It is important not to shy away from this line of questioning. More advice on how this can be done sensitively and effectively, can be found in: ‘Suicide: how to recognise the warning signs and deal with disclosure’.  

There are additional risk factors for specific patient groups; for example, for older adults, consider falls risk, confusion and wandering. You should additionally consider risk from others; for example, vulnerable adults or children, sex workers and migrants may be subject to abuse or exploitation.  

Compiling the psychiatric formulation

Once information-gathering is complete, the final step is to compile the psychiatric formulation. This will act as the management plan for the patient and will support prompt and appropriate treatment where specialist referral is required. The formulation should be clearly structured and begin with the overall impression of the patient based on the psychiatric history and their response to screening questions. For example: 

“Impression: new onset depressive episode”

Or, for an existing mental health condition (e.g. during an annual review for a patient with SMI or a patient with a long-term condition and comorbid mental illness): 

“Impression: stable — symptoms remain manageable”.

Examples of the patient’s behaviour, thoughts, appearance, speech or perceptions or elements of the history which support the statement should be recorded. It is important to check with the patient, and in the care plan where available, what is meant by terms such as “manageable” or “stable”. These will be individualised for the patient and it should not be assumed to mean a complete absence of symptoms. 

One method for arranging the information contained in the formulation is to group relevant findings under the ‘Five Ps’ (see Box 3).

The Five Ps approach acknowledges that most acute mental health crises are brought on by psychosocial stressors and that, by supporting the patient through stressors and maintaining protective factors, it is possible to mitigate or even prevent future mental health crises and avoid unnecessary hospital admissions^​1​. 

Finally, risk (or absence of risk) to self and to others will need to be documented. This reflects risk at the time of the assessment, not past or future risk. It is important to capture the patient’s current symptoms and how these compare to previous presentations.  

For example, for a patient with SMI, risk might be recorded as “low” if they continue to experience command hallucinations, but current medication and social support means they no longer feel compelled to act on them, while an assessment of medium risk should prompt adjustment of medication where relevant and an offer of increased psychosocial support. Patients should then receive more frequent follow up until this risk has subsided. This may include support from a link worker or talking therapies depending on the nature of the stressors. For patients with SMI, further advice on management should be sought from their community mental health team. 

Referral, signposting and requesting input from mental health services

Specialist input is based on level of risk and it is expected that patients deemed at low risk who are not prescribed medication under a shared care arrangement will be managed primarily in primary care. A good understanding of local service provision will be helpful both for accessing specialist advice but also ensuring the patient is able to access all relevant psychosocial support to promote recovery. Advice on management may be sought from e-consult/ advice and guidance/ single point of access pathways for complex cases or where the patient has exhausted second or third-line management options. 

Patients who are showing signs of psychosis should be referred without delay to the local Early Intervention in Psychosis team (EIP). The current target for review is two weeks.

For patients with SMI with ongoing psychosocial stressors that increase their risk, you should seek advice from their psychiatrist and formulate a plan with the patient to manage these stressors.  This should include more frequent follow-ups until the risk has subsided.

High-risk patients (those deemed a danger to others or likely to come to harm without intervention) will require intensive support from the local crisis team. Try to encourage the patient to remain in the waiting room if possible or ask their permission to contact their next of kin or a trusted friend for support while awaiting assessment. 

A disclosure of untreated overdose requires urgent medical attention and psychiatric evaluation and the patient should be supported to attend their local accident and emergency department. Most acute trusts now have a psychiatric liaison team who can be contacted to assess the patient following admission. It is worth calling ahead or writing a brief referral letter for the patient or their carer to bring with them to the A&E reception to ensure the transition is well managed and the psychiatric liaison team are informed.

In all cases, being able to compile an effective psychiatric formulation and communicate this onwards will greatly improve the chances of your patient being able to access required supported.  

The following case scenario explores many of the principles introduced by this article. 

Case in practice

Patient profile:

Margaret is a 45-year-old female with a primary presenting complaint of sleep disturbance, reporting difficulty falling and staying asleep. The triage notes indicate that she is requesting a short course of sleeping tablets. On entering the consultation room, it is evident that she has been crying.

History of presenting complaint

On enquiry, it transpires that Margaret has had a recent bereavement. Her husband died unexpectedly from a heart attack last month and she has been struggling to cope since then. She tells you that she has been drinking more wine as it lifts her mood in the evening and helps her get off to sleep; however, she experiences middle insomnia and extreme anxiety each morning. She would like something that helps her to fall asleep and stay asleep as she is no longer coping.

Diagnostic work-up

Psychiatric evaluation: A comprehensive psychiatric history was obtained, exploring the patient’s family history, recent stressors, coping mechanisms and mental health symptoms.

Screening tools: 

The patient was screened for depression using a standardised questionnaire (PHQ-9) considering the duration of insomnia and potential mood-related symptoms. An alcohol use disorders identification test (AUDIT) was administered to determine the extent of her drinking.

Management

Bereavement counselling was recommended to address emotional distress and promote healing.

A fit note was arranged and Margaret was encouraged to seek an occupational health assessment via her employer, considering the potential impact of her symptoms on occupational functioning.

The prescriber provided tailored lifestyle advice. Margaret was found to have a low AUDIT score but was counselled on the effects of alcohol on sleep quality and mental health. She was also provided with sleep hygiene materials to support better sleeping habits.

Following positive depression screening, Margaret was referred for further evaluation based on the intervention of her choice.  

Margaret was encouraged to reach out to her friends and family for support. 

Follow-up

A review was arranged for six months time, at which Margaret reported significant improvements in sleep quality, emotional wellbeing and overall functioning. She has developed better insight into her mental health and developed healthier coping strategies, which in turn have helped her to reduce her reliance on alcohol.

Outcome

This case emphasises the importance of conducting a thorough psychiatric history in patients presenting with sleep disturbances. By identifying predisposing, precipitating and perpetuating factors for the presenting complaint, clinicians can identify underlying mental health concerns and offer targeted interventions that address the root cause and promote better overall health and wellbeing.

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