Complex mental health difficulties in primary care: scoping review with thematic synthesis

Background Complex Mental Health Difficulties (CMHD) is an umbrella term for long-term problems with emotions and relationships, including personality disorders, persistent depression and consequences of trauma. People with CMHD often fall between NHS services that focus on either common mental disorders (anxiety, depression) or psychosis, leaving GPs as their main source of support.

Aim To understand what is known about primary care for CMHD, from both GP and patient perspectives.

Design & setting We conducted a scoping review of GP and patient experiences of CMHD in primary care in UK, Europe, Australasia and North America.

Method We searched Medline, PsycInfo and Embase for eligible studies between January 2002-October 2023. Titles and full texts were screened by two reviewers. Thematic synthesis of qualitative studies and narrative synthesis of quantitative studies were undertaken.

Results We screened 2209 papers and 33 met inclusion criteria. Three key themes were found: the challenge of recognising CMHD, its impact on primary care workload, and patient priorities. GPs recognised CMHD through complexity of diagnoses, of psychosocial issues and of healthcare use. However, they were ambivalent about diagnosis and lacked the resources to make or discuss diagnoses. Working with people with CMHD involved responsibility work, relationship work, and emotional work, under pressured conditions. Patient priorities included addressing stigma, reducing fragmentation and receiving relationship-focused care.

Conclusion This scoping review delineates the very real challenges people with CMHD and their GPs face in providing care. It helps set an agenda for work to address gaps in provision and improve outcomes.