Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page.

Objective: To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice.

Method: Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases.

Results: GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment.

Conclusion: GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.