To think this GP comment was a bit daft

[Juno999]

I had a GP telephone appointment wrt to mental health issues, then a couple of months later I had an in-person appointment for a UTI.
Whilst in the GP's office, I saw my patient file was open on his pc. He left the room to get something and I had a quick scan with my eyes from where I was sitting.
He'd referred to my previous telephone appointment in which I said I'd felt depressed and he'd written 'She actually sounded bright and cheery over the phone.'
I just thought it was a strange comment really, someone can sound bright and cheery yet be going through mental health problems, or maybe that's just how I sound on the phone, or maybe I'm trying to mask it. All sorts of reasons, it just felt like he was minimising it almost.

Mental health is minimised. You're right.

It's a strange thing to write. I struggle with my MH but I've worked in customer services for over 10 years so I automatically put on a false persona on the phone which probably comes across as bright and cheerful but I definitely don't feel that way,

Yes, I probably did put on a voice which I do when I'm speaking in a formal setting over the phone. I wouldn't speak to my GP like I would to my partner or family.

Do you think a gp doesn't know that depressed people often mask?

However, he will also have telephone consultations with patients who can't form a coherent sentence or who cry throughout. He has made a note that is useful for him and other medical professionals, that's all.

He made a note on how you were presenting. I don’t see what is wrong with that.

I agree, its about presentation. When someone is depressed, red flags like expressing suicidal ideation need to be recorded, it doesnt mean he thinks you are not depressed.

I think it is normal to write about how someone presents. They will know how you sound and how you feel may not match but it is usual to note this I would say.

Think of it the other way round OP had you been on the phone saying everything was fine but sounding depressed would you be concerned.

I worked on a psych ward, how someone presents is important, it paints a picture of how their mental health is affecting them on a daily basis. Eg, do they have active plans to end their life? are they tearful/expressing feelings of hopelessness? how is their personal hygiene? are they able to function or are they too depressed to work etc etc Its not about "oh she seemed bright on the phone therefore she cant possibly be depressed", its about assessing the level of how much its affecting someone's daily life which can tell you a lot about how severe it is and what the potential risks might be. Doctors have a duty of care to assess risk and how someone presents can tell a lot about that. Obviously, people can mask and doctors cant be mind readers or predict with 100% accuracy whether someone will end up harming themselves but documenting how someone presents is an important part of building up a picture.

Its a reference note about how you presented along with your diagnosis. For instance if you phoned up in future and were not chatty or cheerful they would know that there's a change. I hope that makes sense.

I make full notes for the phone calls I make at work on clients. You just put down the FACTS of what was said (and how it was said, etc., if appropriate). It's not a judgement or an opinion.

it Seems normal to note how you presented as this could very different. Doesn’t mean they won’t take it seriously. Make sure to take probiotics if you’re taking antibiotics, gut health is so important for mental health

It's information about you. Imagine if you ring and sound really down, it will help him to glance at his notes and realise that this is a significant sign for you

I’m not a medical professional but I read a lot of doctors notes and occupational health reports as part of my role. It’s common when reporting on mental health issues to record how someone presents / their general demeanour. They also frequently comment on how someone looks - i.e. do they look like they’re taking care of themselves. I don’t think it’s minimising, it’s just recording information that’s relevant to the overall picture.

He has minimised it, that's why he's used the word 'actually' as if it's unusual or surprising you would act like that on the phone.

I wouldn't be crying on the phone to the doctor, imminent suicide or not. If you were comparing me against someone who would do that, you would be missing potential huge problems in the state of my mental health by assuming I probably wasn't as bad as them.

It's part of what is called the "mental state exam" and it's a helpful part of assessing mental health issues, including risk. As others have said, your GP probably didn't mean to imply you weren't really depressed or were lying - just that you were, despite your low mood, able to compose yourself for the call. The management plan and risk profile might be different if you had said very little and spoken in a flat tone of voice, or if you had been speaking very quickly and mixing up different trains of thought.

During a phone consultation, your GP has less to go on - they can't see how you look - so tone and content of speech is a helpful part of the assessment.

I am a doctor myself and I find it odd and jarring to see my own medical records when shown - the specific language and phrases can sound quite judgemental (e.g. "patient denies headache" rather than "patient reports she doesn't have a headache"). The language and content of medical records can read oddly and can be quite archaic.

I agree with PP that he is just writing an observation because if you were monosyllabic or very distressed he would note that. It doesn’t mean he doesn’t think you are not depressed but is just noting that you are probably not on the point of complete shut down where he needs to get particularly worried. Or at least it will inform his assessment.

I think it's phrased badly but meant well.

Oh I had exactly this worry a few months ago. Called about my debilitating anxiety, and I can see the consultation notes on my app. The first sentence said I was bright, chatty, alert and focussed. I have the sort of job where you have to pretend to be cheerful and enthusiastic however you feel, so I think I automatically mask it.

I worried that it meant they maybe didn't believe me, but I eventually just told myself it was a safeguarding check to record that I wasn't sounding suicidal. Try not to think about it too much.

I have all sorts of MH issues and I definitely mask by being bright and cheery! It was okay to make the comment I think but he should’ve followed it up by saying you were potentially masking.

Mental state examination is pretty important. I work in sexual health, but I have a lot of regular patients who have known mental health issues. I often make a note of how they present on the day so as a team we can identify any subtle changes in their mental health which might indicate that we should offer any additional support or have a discussion re onward referral to GP or psychosexual therapy.

It’s not a dig at you OP, don’t worry!

Completely normal.

Sometimes it sounds odd, but more often than not you have to document an absence of abnormality. When you document the normal bit it always sounds odd.

For example. Appeared appropriately dressed, appeared appropriately kempt

This seems odd but it tells you there's an absence of some things

Take someone on an antidepressant for example.

Some people when they are deeply depressed, are unable to dress appropriately. They might wear winter clothes in the summer as a cover all. It might be really clear that they haven't washed in some days.

If the next appointment they come in looking more kempt, it might be an early sign that the antidepressant is working.

Some antidepressants can tip people into mania. People in mania can completely change the way they are dressed (usually inappropriately for the weather, or bright colours for example). Your documenting this didn't happen by documenting things that don't seem note worthy

It can be really helpful to document a baseline. I have a patient who dresses in a way that's a bit eye catching, she also speaks quickly. It's helpful to document wearing striking makeup is normal for her, and her speech is usually fast, otherwise it can be mistaken for the first signs of mania.

Make up on women can be a really good indicator to. If you think of some women in your life, it's likely you could guess how they are feeling via make up. For some women, if they are wearing no make up (when they usually always wear make up) it can be a sign things are really a struggle. For me, I never wear make up so my baseline is make up less, I'm also usually fairly unkempt (lots of animals!) So my baseline would be a sign someone else was struggling.

It's often hard in depression in particular to get objective views about things. When I'm deep in it, I can find it hard to see progress or decline, I feel like I've always felt like this but others can usually see me lifting or lowering before I can.

Obvious we should always be asking people how they feel first of all and taking their answer straight out, but it's not uncommon for people to consistently mark themselves as a 3 each week, when they look like they've taken a massive dive for example.

Masking happens in depression all the time. People will tell you they feel better than they do (and this is a real worry) so it's helpful to have outside markers.

Of course they are very subjective, just like the rating scales. Sometimes people will deliberately dress up for Dr's appointments, some people will wear make up even though things are completely awful. However it usually does confirm they aren't catatonic, or so low in energy they can't even do that. We shouldn't base everything of any one measure. Everything in mental health is a "might be", its usually a collection of signs that point you in a direction

In your case think of as you answering the phone as you recording high pulse. If you answer the phone in a tone that's only slightly normal for everyone else, it might be a sign that you've dipped significantly. If you normally record a high pulse, and your pulse is lower than average at next check, the gp will know its a significant drop for you even if its in normal parameters for other people .

Thanks for your answers

Don't take this the wrong way because I'm sure you know how you feel and it's absolutely valid how you and others feel. Depression isn't straight cut... but there are so people who perhaps have a more extreme level of depression to the point where they simply cannot hold down paid employment.

Agree with others Dr has to go off of how OP presents. This is why medical notes are not left in the open for free to all because a simply misunderstanding leads to something like what OP is thinking.

Yes perhaps he shouldn't have left the screen open like that