{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T10:55:56Z","timestamp":1782903356464,"version":"3.54.5"},"reference-count":41,"publisher":"Royal College of General Practitioners","issue":"762","license":[{"start":{"date-parts":[[2019,2,12]],"date-time":"2019-02-12T00:00:00Z","timestamp":1549929600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Br J Gen Pract"],"accepted":{"date-parts":[[2025,5,22]]},"published-print":{"date-parts":[[2026,1,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The term \u2018complex mental health difficulties\u2019 describes long-term difficulties with emotional regulation and relationships, including personality disorders, complex trauma, and dysthymia. People with complex mental health difficulties often experience episodic and crisis-related care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>To understand how general practices can better recognise people with complex mental health difficulties and provide the best care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design and setting<\/jats:title>\n                    <jats:p>A concurrent mixed-methods study was conducted with three components: two qualitative studies and a database study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>People with lived experience of complex mental health difficulties were consulted throughout the study. Qualitative interviews with GPs and people with complex mental health difficulties were conducted and transcripts analysed using thematic analysis. For the database element a retrospective case\u2013control analysis was conducted using the Connected Bradford database. Integration of results was conducted using \u2018following the thread\u2019 and triangulation methods.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In the GP interviews, four overarching themes were identified: the challenges of complex mental health difficulties; role expectations; fragmented communication, fragmented care; and treatment in the primary care context. In the lived experience interviews, four main themes were identified: 'How I got here'; varied care experiences; traversing mental health services; and 'being seen'. In the database study element, approximately 3040 (0.3% of the database population of approximately 1.2 million) records met our criteria for complex mental health difficulties, suggesting significant undercoding. The most informative feature was the count of unique psychiatric diagnoses. From the triangulation process, five meta-themes were identified: complexity of mental health difficulties; experience of trauma; diagnosis; specialist services; and GP services.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The current organisation of care and lack of an acceptable language for complex mental health difficulties means that patients\u2019 needs continue to go unrecognised and 'unseen'.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3399\/bjgp.2024.0818","type":"journal-article","created":{"date-parts":[[2025,6,5]],"date-time":"2025-06-05T09:30:11Z","timestamp":1749115811000},"page":"e10-e20","source":"Crossref","is-referenced-by-count":1,"title":["Complex mental health difficulties: a mixed-methods study in primary care"],"prefix":"10.3399","volume":"76","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9665-0635","authenticated-orcid":false,"given":"Phillip","family":"Oliver","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0567-8166","authenticated-orcid":false,"given":"Vyv","family":"Huddy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7620-7110","authenticated-orcid":false,"given":"Ciar\u00e1n","family":"McInerney","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2652-0624","authenticated-orcid":false,"given":"Ada","family":"Achinanya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3069-6091","authenticated-orcid":false,"given":"Michelle","family":"Horspool","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0915-7250","authenticated-orcid":false,"given":"Kritica","family":"Dwivedi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0233-2431","authenticated-orcid":false,"given":"Chris","family":"Burton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1987","published-online":{"date-parts":[[2025,6,5]]},"reference":[{"key":"2026012707354409000_76.762.e10.1","unstructured":"National Institute for Health and Care Excellence (2009) Quality and Outcomes Framework (QOF) indicator development programme: briefing paper. QOF indicator area: Serious mental illness. accessed. https:\/\/www.nice.org.uk\/Media\/Default\/standards-and-indicators\/qof%20indicator%20key%20documents\/NM15-%20NM20%20Briefing%20paper%20to%20the%20committee%20on%20mental%20health.pdf. 17 Sep 2025."},{"issue":"1","key":"2026012707354409000_76.762.e10.2","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/cbm.2068","article-title":"Shining lights in dark corners of people\u2019s lives: reaching consensus for people with complex mental health difficulties who are given a diagnosis of personality disorder","volume":"28","author":"Lamb","year":"2018","journal-title":"Crim Behav Ment Health"},{"key":"2026012707354409000_76.762.e10.3","unstructured":"MIND (2018) \u201cShining lights in dark corners of people\u2019s lives\u201d: the consensus statement for people with complex mental health difficulties who are diagnosed with a personality disorder. accessed. https:\/\/www.mind.org.uk\/media-a\/4408\/consensus-statement-final.pdf. 17 Sep 2025."},{"key":"2026012707354409000_76.762.e10.4","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/j.mhp.2018.10.003","article-title":"Personality disorder and substance use disorder \u2013 an update","volume":"12","author":"K\u00f6ck","year":"2018","journal-title":"Ment Health Prev"},{"issue":"3","key":"2026012707354409000_76.762.e10.5","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1192\/bjp.2024.80","article-title":"The interface of autism and (borderline) personality disorder","volume":"225","author":"Zavlis","year":"2024","journal-title":"Br J Psychiatry"},{"key":"2026012707354409000_76.762.e10.6","doi-asserted-by":"publisher","DOI":"10.1017\/S095457940800031X"},{"key":"2026012707354409000_76.762.e10.7","doi-asserted-by":"publisher","DOI":"10.1080\/13651501.2021.1904998"},{"issue":"2","key":"2026012707354409000_76.762.e10.8","doi-asserted-by":"crossref","DOI":"10.1192\/bjo.2022.1","article-title":"Experiences of crisis care among service users with complex emotional needs or a diagnosis of \u201cpersonality disorder\u201d, and other stakeholders: systematic review and meta-synthesis of the qualitative literature","volume":"8","author":"DeLeo","year":"2022","journal-title":"BJPsych Open"},{"key":"2026012707354409000_76.762.e10.9","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph15122763"},{"key":"2026012707354409000_76.762.e10.10","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.188.5.423"},{"key":"2026012707354409000_76.762.e10.11","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2021-053943"},{"issue":"3","key":"2026012707354409000_76.762.e10.12","article-title":"Detecting and addressing trauma-related sequelae in primary care","volume":"23","author":"Coon","year":"2021","journal-title":"Prim Care Companion CNS Disord"},{"key":"2026012707354409000_76.762.e10.13","doi-asserted-by":"publisher","DOI":"10.1034\/j.1600-0447.2000.102001052.x"},{"key":"2026012707354409000_76.762.e10.14","doi-asserted-by":"publisher","DOI":"10.1016\/j.brat.2015.07.006"},{"issue":"4","key":"2026012707354409000_76.762.e10.15","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1177\/2150131917714929","article-title":"Personality disorders in primary care: impact on depression outcomes within collaborative care","volume":"8","author":"Angstman","year":"2017","journal-title":"J Prim Care Community Health"},{"key":"2026012707354409000_76.762.e10.16","doi-asserted-by":"publisher","DOI":"10.1177\/2150131916638329"},{"issue":"2","key":"2026012707354409000_76.762.e10.17","doi-asserted-by":"crossref","first-page":"46","DOI":"10.35680\/2372-0247.1139","article-title":"Beyond patient-centered care: enhancing the patient experience in mental health services through patient-perspective care","volume":"3","author":"Carey","year":"2016","journal-title":"Patient Exp J"},{"key":"2026012707354409000_76.762.e10.18","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0248316"},{"key":"2026012707354409000_76.762.e10.19","doi-asserted-by":"publisher","DOI":"10.3399\/BJGPO.2024.0223"},{"key":"2026012707354409000_76.762.e10.20","doi-asserted-by":"publisher","DOI":"10.1080\/14780887.2020.1769238"},{"key":"2026012707354409000_76.762.e10.21","doi-asserted-by":"crossref","first-page":"26","DOI":"10.12688\/wellcomeopenres.17526.2","article-title":"Connected Bradford: a whole system data linkage accelerator","volume":"7","author":"Sohal","year":"2022","journal-title":"Wellcome Open Res"},{"issue":"5","key":"2026012707354409000_76.762.e10.22","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0322771","article-title":"Identifying primary-care features associated with complex mental health difficulties","volume":"20","author":"McInerney","year":"2024","journal-title":"PLoS One"},{"key":"2026012707354409000_76.762.e10.23","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.c4587"},{"key":"2026012707354409000_76.762.e10.24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1440-1584.2007.00866.x"},{"key":"2026012707354409000_76.762.e10.25","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2018-026616"},{"key":"2026012707354409000_76.762.e10.26","doi-asserted-by":"publisher","DOI":"10.1177\/1363459319874100"},{"issue":"9","key":"2026012707354409000_76.762.e10.27","first-page":"791","article-title":"Small groups for supporting GPs\u2019 professional development in mental health disease - an evaluation","volume":"34","author":"Whilhelm","year":"2005","journal-title":"Aust Fam Physician"},{"issue":"1","key":"2026012707354409000_76.762.e10.28","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1080\/02650533.2011.579695","article-title":"\u2018There\u2019s always this sense of failure\u2019: an interpretative phenomenological analysis of primary care counsellors\u2019 experiences of working with the borderline client","volume":"26","author":"Rizq","year":"2012","journal-title":"J Soc Work Pract"},{"key":"2026012707354409000_76.762.e10.29","doi-asserted-by":"publisher","DOI":"10.1111\/j.1440-1614.2006.01798.x"},{"key":"2026012707354409000_76.762.e10.30","unstructured":"NHS (2019) NHS Mental Health Implementation Plan 2019\/20 \u2013 2023\/24. accessed. https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2022\/07\/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf. 17 Sep 2025."},{"key":"2026012707354409000_76.762.e10.31","doi-asserted-by":"publisher","DOI":"10.1080\/09638237.2019.1608923"},{"key":"2026012707354409000_76.762.e10.32","doi-asserted-by":"publisher","DOI":"10.1136\/fmch-2020-000458"},{"key":"2026012707354409000_76.762.e10.33","doi-asserted-by":"publisher","DOI":"10.1186\/s12888-021-03605-4"},{"key":"2026012707354409000_76.762.e10.34","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp11X588457"},{"key":"2026012707354409000_76.762.e10.35","doi-asserted-by":"publisher","DOI":"10.1186\/s12875-016-0479-y"},{"key":"2026012707354409000_76.762.e10.36","doi-asserted-by":"publisher","DOI":"10.1016\/j.gaceta.2011.12.006"},{"key":"2026012707354409000_76.762.e10.37","doi-asserted-by":"publisher","DOI":"10.1186\/s12888-017-1381-4"},{"key":"2026012707354409000_76.762.e10.38","unstructured":"NHS England NHS Improvement National Collaborating Centre for Mental Health (2019) The community mental health framework for adults and older adults. accessed. https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2019\/09\/community-mental-health-framework-for-adults-and-older-adults.pdf. 17 Sep 2025."},{"key":"2026012707354409000_76.762.e10.39","doi-asserted-by":"publisher","DOI":"10.1017\/S1463423620000304"},{"key":"2026012707354409000_76.762.e10.40","unstructured":"Health Services Safety Investigations Body (2023) Continuity of care: delayed diagnosis in GP practices. accessed. https:\/\/www.hssib.org.uk\/patient-safety-investigations\/continuity-of-care-delayed-diagnosis-in-gp-practices. 17 Sep 2025."},{"key":"2026012707354409000_76.762.e10.41","unstructured":"Oliver P Burton C Achinanya A (2024) Complex mental health difficulties: learning from the UNSEEN study with recommendations for GPs. accessed. https:\/\/orda.shef.ac.uk\/ndownloader\/files\/44420219. 17 Sep 2025."}],"container-title":["British Journal of General Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.3399\/BJGP.2024.0818","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,27]],"date-time":"2026-01-27T15:35:59Z","timestamp":1769528159000},"score":1,"resource":{"primary":{"URL":"http:\/\/bjgp.org\/lookup\/doi\/10.3399\/BJGP.2024.0818"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,5]]},"references-count":41,"journal-issue":{"issue":"762","published-online":{"date-parts":[[2026,1,1]]},"published-print":{"date-parts":[[2026,1,1]]}},"alternative-id":["10.3399\/BJGP.2024.0818"],"URL":"https:\/\/doi.org\/10.3399\/bjgp.2024.0818","relation":{},"ISSN":["0960-1643","1478-5242"],"issn-type":[{"value":"0960-1643","type":"print"},{"value":"1478-5242","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,5]]}}}