1. Introduction to AMP trainingplus

2. Key elements 1. Perspectives from hard-to-reach groups 2. Local issues 3. How does your practice respond?

3. Problems and Solutions

4. Hard-to-reach groups Problems with access Problems with care Black and minority ethnic communities Asylum seekers Homeless people Adolescents with eating disorders Older people with depression People with advanced cancers People with medically unexplained symptoms People with work-related problems

5. Evidence Published research Patient voices 20 qualitative papers carefully selected common themes 33 interview transcripts from seven existing studies common themes

8. Main findings Mental health problems often seen as rooted in physical or social problems Self-management strategies are common, but may be counter-productive Material and social disadvantage (including stigma) adversely affect help seeking

9. Mental and physical It’s not all in my ‘bloody head’ – I am not imagining it - it’s real and important. Patient with MUS Well, I think a lot of my depression can be put down to my physical health. This diverticulitis…..I know the doctors keep saying that anxiety makes it worse but I think it’s the other way round. The diverticulitis causes me to feel anxious. Older patient diagnosed with depression

10. Mental as social I cried because I felt that my life in Britain was not good. Chinese nurse It was the war, when we were fleeing...we suffered a lot. Because I didn't have pain like this before...And then there were members of my family that were killed as well. There's an underlying nervousness that....yes, I have stomach pains and my body trembles and I'm exhausted... Asylum seeker

11. Self-management Concealment I don’t tell my secrets to anyone, even my mum... No! South Asian woman Dysfunctional identification I went on the Internet and was reading about all these people who were making themselves sick and they were eating what they wanted and losing weight... Adolescent with eating disorders

12. Social withdrawal to core identities and roles - family or work It’s like hiding a thing you know. If you can’t see it – I’m ok. I’ve got no problems. And that keeps me strong. I’ve always been a strong person. I always have you know. [...] And you know – you keep going. Patient with advanced cancer

13. Social withdrawal Coping mechanism but also reduces likelihood of receiving help so you’re trying to hold everything in, whereas what you really want is somebody to say, how are you feeling, and then wow, the floodgates would open. Patient with work-related problems

14. Engagement with services Requires considerable personal investment: o time, material, emotional and social resources Poses threats to wider social identities: o friends, co-workers, neighbours Particular problems in deprived communities: o resources low and stigma high

15. Stigma I think there’s a stigma …about failure and not being able to cope. The whole word ‘depression’ …it’s got such negative connotations…so perhaps that actually keeps us from actually going to ask for help. Black Caribbean woman Interpreters take time and then maybe he doesn’t say exactly what you feel. For example he might say that I feel mad when I feel depressed. It’s not good for confidentiality as they talk too much in the community. Asylum seeker

16. Engagement with services o Dissonance on treatment options o People do say don’t take it [anti-depressants], it’s not good....I don’t know about the English but all the Asian people they do say they’re not good. o South Asian woman

17. improving access improving understanding improving care

18. Improving access Pluralistic multiple routes into care though traditional GP role is valued Adaptive Holistic Resonant importance of ‘right fit’ between patient and professional Socially conscious awareness of social dimensions of problems, and solutions

19. Improving understanding Demonstrate willingness to find out how patient sees themselves being on the ‘same wavelength’ concept of ‘embodied suffering’ may be helpful Respect for differing cultures more important than understanding NB broader than ethnicity

20. Improving care Provide effective information about mental health about available, appropriate support address unrealistic expectations Focus of interventions beyond the individual (and beyond primary care) re-engagement with wider world build on strengths encourage new roles

21. Community voices in [locality]

22. Understanding mental health [add slide(s) summarising key findings from information gathering]......

23. Role of primary care What works What could be better...........

24. what we already know what we already do opportunities for change

25. What we already know 1....... 2....... 3....... 4....... 5.......

26. What we already do 1...... 2...... 3...... 4...... 5......

27. Creating an action plan

28. Knowledge Need How to meet it 1...... 2...... 3...... 4...... 5...... 1...... 2...... 3...... 4...... 5......

29. Practice systems Need How to meet it 1. [amend appointment systems] 2. [improve interpretation services] 3...... 4...... 5...... 1...... 2...... 3...... 4...... 5......

30. Active linking Need How to meet it 1. [Contact with community voices] 2. Greater access to psycho- social interventions 3...... 4...... 5...... 1. [AMP Consultative Focus Group] 2. AMP PSI 3..... 4...... 5......