An Innovative Five-Step Patient Interview Approach for Integrating Mental Healthcare into Primary Care Centre Services (AlKhathami Approach)

Abstract

Mental health problems are often inadequately diagnosed and managed in routine primary healthcare (PHC) services. The new Five-Step Patient Interview approach (the AlKhathami approach) is comparable to psychiatric interviews and is more accurate than current screening tools for identifying patients’ degrees of psychological stress. This will assist in integrating the screening and management of psychological stress and common mental health problems among patients seeking PHC services. It is a valid and reliable tool for integrating mental healthcare into PHC and family practice services. The Five-Step approach offers an opportunity to provide mental health services in busy clinics (5–8 min duration). It improves physician-patient communication by encouraging the exploration of patients’ perspectives. It plays a role in controlling chronic organ diseases and physical complaints. It also reduces the frequency of patient health services, enhances the satisfaction of patient healthcare providers, and reduces unnecessary investigations and medications, thereby safeguarding healthcare resources.

1. Introduction

Patient interview is a core skill for providing healthcare management in clinics. The problems underlying a patient’s complaint can be organic, mental, or comorbid. Patients usually present with physical complaints and mental health (MH) problems [1]. However, mental health (MH) problems are highly prevalent in approximately 60% of primary healthcare (PHC) patients, which is usually missed, particularly among patients with chronic illnesses who receive inappropriate management [1, 2]. Depression and anxiety disorders are widespread and considered disabling, leading to enormous human misery and loss of health and economic productivity [3]. Management of common mental disorders in health centres improves health outcomes and economic production [3]. Depression alone, which is mostly missed, negatively impacts the economic losses of governments, employers, and households and can cause a lack of energy, disturbances in sleeping and eating patterns, and substance abuse. It has led to a drop in worldwide productivity, costing the global economy more than $1 trillion and an annual rate of 800,000 deaths worldwide [4]. According to WHO (2016), the returns on investment in treatment far outweigh the costs based on the study, which covered 36 countries for 15 years from 2016 to 2030. The estimated cost of treating mental disorders is US$147 billion. Furthermore, the returns far outweigh the costs [5]. A 5% improvement in workforce participation and productivity is valued at $399 billion and improved health adds $310 billion in revenue. However, the current investment in mental health services falls far short of what is needed.

Clinical evidence showed similar results when comparing care delivery for patients with depression or anxiety disorders in hospital and primary care. However, patients who received services in primary care were serviced faster, had continuity of care, and were more satisfied with the service, which cost less [6]. Therefore, avoiding patients’ suffering and ‘doctors shopping’, a holistic approach is necessary for empowering the PHC physicians to serve the patients with integrated care in busy clinics [6].

Traditional patient interviews to identify mental health problems are not effective in busy clinics such as PHC centres [7, 8]. In traditional patient interviews, doctors control the consultation with less concern about dealing with patients’ perceptions because this prolongs the consultation [9]. Thus, physicians’ skills should be enhanced to empower them to detect and deal with such disorders to achieve desired outcomes [10]. Therefore, an efficient structural patient interview framework is mandatory to avoid missing mental health problems and provide high-quality care [11]. Improving the patient interview process is essential for discovering real problems or issues underlying patient complaints [12].

2. The five-step patient interview approach (AlKhathami approach)

The five-step approach can fill the healthcare gap by complementing the bio-psycho-social approach, as it covers psychosocial aspects more effectively and efficiently to discover the real cause of the patient’s suffering. This approach enables health centres and family physicians to detect mental disorders. Similarly, the ability to efficiently classify them as either mental illnesses referred directly to the specialist or anxiety and depression can be dealt with a high-quality at primary healthcare centres. Thus, these five steps bridge the gap in providing mental healthcare services at the primary health centre level. It also integrates mental healthcare with the daily work of doctors without requiring a specialist or specialised clinic in primary health centres. The five-step approach is a practical approach suitable for busy clinics due to its high predictability of mental health problems and takes only 4.1 minutes in average. It is an effective approach with high reliability in integrating mental healthcare into primary healthcare services and enhancing collaboration between primary care doctors and mental health specialists [13], as shown in Figure 1. The Five-step approach covers the psychological and social aspects of the biopsychosocial approach, as illustrated in Figure 2.

Figure 1.

The five-steps patient interview for mental health care in PHC & Family Practices (AlKhathami approach).

Figure 2.

Modified bio-psycho-social approach.

2.1 Step 1: suspicion

Predicting a patient’s pathological condition is based on the physician’s knowledge and practical experience. For example, if a patient is presented with dysuria, the doctor expects inflammation in the urine; thus, each of the following is based on proving that the patient has a urinary tract infection. Organic diseases have symptoms and signs that the patient exhibits and may have pathognomonic symptoms or signs that make them easier to diagnose and manage quickly. While mental disorders do not have pathognomonic signs or symptoms, patients may exhibit symptoms indicative of organic diseases [14]. This allows doctors to anticipate and deal with a disease that is not the actual cause of a patient’s problem. This creates a gap in providing mental healthcare promptly, leading to doctors’ inability to make correct diagnoses and increasing patient suffering. Additionally, there is an increase in the consumption of health resources, such as unnecessary investigations and medications, which have nothing to do with the real problem behind patients’ suffering.

This is the reason behind ‘doctors shopping’. Patients with mental disorders, especially depression or anxiety, often complain of physical symptoms or lack of control of organic diseases; most cases are accompanied by sleep disturbances, including difficulty in initiating or interrupting sleep [2, 15, 16]. Therefore, patients with depression and anxiety do not meet their expectations of low satisfaction with their interviews with doctors who follow the usual interview approach in primary health centres [17].

The most crucial suspicion step lacks a link to patient-interview approaches. Due to this loss, many doctors cannot identify or consider mental disorders in their patients. Doctors usually focus on the symptoms mentioned by the patient and interpret them according to the symptoms of the disease that they have learned, without considering mental health disturbances.

Thus, three groups of patients were considered as suspected patients [13]: (i). patients with uncontrolled organic diseases or physical symptoms such as diabetes mellitus, hypertension, bronchial asthma, irritable bowel syndrome, low back pain, headache, fatigue, among others; (ii). the second group included patients with frequent healthcare visits; and (iii). the third group included patients with sleep difficulties, such as insomnia or sleep disturbance. AlKhathami (2022) proved that 87% of suspected groups had mental health problems compared to 8% of non-suspected groups. Before starting case management for suspected groups presenting with organic disease or physical symptoms, doctors should conduct the second step: screening [13].

2.2 Step 2: screening

2.2.1 Screening of hidden agenda and delusion among suspected patient

The Five-Step Patient Interview approach has higher credibility than the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder-7(GAD-7) as tools for screening and classifying psychological stress levels, with high sensitivity (66.1%) and specificity [99.1%] [13].

Many patients complain of symptoms and fear of the disease without exploring their perceptions. They usually expect doctors to identify or discuss this issue. Thus, when these ideas are not discussed, the patient is often not convinced of the diagnosis and treatment and frequently visits health clinics. This comes through the ‘Idea-Concern-Expectation (ICE) technique’ to explore the patient’s perception [18]. The formula of the questions is very important to reach the required results: What does the patient think is the cause of the symptoms he is complaining about, what is his fear of them, and what does he expect the doctor to address that complaint? For example, ‘What do you think is the cause of your headaches’ and ‘What do you think is the reason for not controlling your hypertension?’ It is very important not to ask the patient about the cause of the problem or the patient’s fear of the problem in general because the patient will often react with a defensive reaction, ‘You are the doctor, not me’, as if a patient was asked about a scientific subject.

Here, the doctor does not need to spend time discussing these ideas; only when the patient explores them do they know that the doctor is aware, and they will be included in the remainder of the interview. Typically, thoughts or fears of a serious illness indicate a ‘hidden agenda’. Thus, we ensure the patient does minimise ‘doctors’ shopping’. Furthermore, it strengthens the doctor-patient relationship, enhances patient confidence, and reduces drug prescriptions, leading to safe health resources [19, 20].

Simultaneously, the doctor determined whether the patient had delusional ideas. In such cases, the patient should be referred directly to a psychiatrist for interviews and treatment. Family doctors and general practitioners can identify psychotic symptoms and promptly refer patients. Perhaps, Moses’s story clarifies this situation.

Example-1: ‘Moses is suffering from uncontrolled hypertension.’

Moses, aged 53 years, is known to have frequent visits due to a lack of blood pressure control. Each visit raised the dose until it reached the maximum, after which another drug was added, and the usual investigations were repeated without achieving blood pressure control. While telling the patient, he did not commit to following the doctor’s advice or recommendations. Moses was administered three medications for hypertension with variable uncontrolled blood pressure readings.

The patient was re-dispensed with the medication. He met his family physician, who was trained using the Five-Step approach, and the following discussion took place:

Doctor-Patient Interview Session.

Step-1: The doctor asks, ‘Does the patient need mental health care?’

Answer: yes, because she has uncontrolled hypertension and frequent visits.

Step-2: The doctor asks, ‘Does he have a hidden agenda, delusion, or stress?’

ICE technique: (screening for hidden agenda or delusion).

Doctor: What do you think is the reason for not controlling your blood pressure?

Moses said, ‘I am the Minister of Platinum, a member of international organisations; they want to take the platinum from me, and they never will’.

The answer is illogical, indicating a possible delusional thought process.

The duration of the interview was only 1 minute and 20 seconds.

Plan: The decision was to refer Moses to a psychiatrist as an urgent case with a ‘psychotic disorder’. There was no requirement to complete the interviews.

In the psychiatrist’s clinic: the diagnosis was schizophrenia and a mania case.

After that, he was followed up under the cooperative care of a psychiatrist and a family doctor. The patient’s condition was controlled, and better results were obtained.

The lesson learned from Moses’s story:

• Throughout this period, schizophrenia was not detected until he was 53 years old.

• Every time Moses arrived at the health centre, the BP was measured and was often uncontrolled. More tests were requested, and the dose of the drug was increased, or another drug was added.

• When a doctor was trained using a modern approach (the Alkhathami approach), the case was discovered easily and quickly.

• Previously, doctors focused on measuring the blood pressure to reach a normal reading without noticing that it could be a mental or psychological illness; thus, the condition was not controlled.

• This increased the suffering of the patient and his family

• Frequent visits and consumption of healthcare resources such as investigations and medicines.

• All these could have been avoided if a doctor had a modern and effective patient interview approach.

2.2.2 Screening of psychological stress among suspected patient

Stress screening through sleep, concentration, performance, and relationships (the SCPR technique). The Five-Step Patient Interview approach has a higher credibility than the PHQ-9 and GAD-7 as a tool for screening and classifying psychological stress levels with a high sensitivity (85.3%) and specificity (99.1%) [13].

All tools for detecting psychological stress are completed questionnaires analysed later, which are usually impractical or time-consuming [21]. Appling the Five-step approach it is possible through the three questions asked by the doctor during the interviews. The first indicator of stress is sleeping difficulty. Early insomnia: Insomnia is the most common symptom of mental disorders [22]. People with insomnia are twice as likely to develop depression than others; therefore, early detection of stress in a person reduces their risk of depression [23]. When a person does not have a sleep disorder, mental disorders can be ruled out in 98.9%, while 97% of patients with depression and anxiety experience sleep difficulties [2]. Therefore, sleep difficulty indicates mild stress, while interrupted sleep indicates moderate to severe stress, with high sensitivity (85·3%) and specificity (74·2%) for defining stress [13].

The second stress indicator is a decline in concentration or performance. There is an inverse relationship between stress, concentration, and performance [23]. AlKhathami (2022) proved a decline in the level of a person’s concentration or performance is an indicator of the presence of moderate to severe psychological stress, with high sensitivity (84·8%) and specificity (86·4%) [13].

The third stress indicator was a decline in social relationships, either a tendency to spend more time with oneself or easy anger and intolerance of discussions. Patients with depression tend to be socially isolated, and irritability (which makes one easily angry) is a major predictor of psychological distress [24]. Thus, when there is a decline in social relations, such as tendencies towards isolation or quick anger, this is an indication of the presence of psychological stress [24] to a moderate to severe degree, with high sensitivity of 90% and specificity of 80% [13].

2.3 Step 3: service scoping

This step is important for setting a framework for the work of healthcare centre and family doctors with a clear scope. The Five-Step approach works with high sensitivity (96%) and specificity of 100.0% compared to expert psychiatrists’ assessments [13]. Thus, this approach enables identifying the scope of the mental healthcare services, whether in the primary healthcare centres or referred to a specialist, knowing that only 3.4% of mentally ill patients require to be referred to a specialist [13], as illustrated in Figure 3.

Figure 3.

Doctors’ responsibilities before (A) and after (B) the five-step approach.

Primary healthcare doctors are not required to diagnose a specific psychotic disease; however, when a psychotic disease is suspected, they should refer the patient directly to a mental health specialist for collaborative work.

Primary healthcare doctors and family medical doctors should manage patients with depression and anxiety. Other mental health disorders should be referred to by mental health specialists as part of collaborative work.

2.4 Step 4: diagnosis of depression and anxiety

The Five-Step approach has a high efficiency in diagnosing depression and anxiety disorders, with a high sensitivity of up to 96.3% and specificity (92%) compared with expert psychiatrists’ assessments and has a high predictive value (96·4%) [13].

According to the WHO mhGAP Guide (WHO, 2016, pp19), ‘individuals with depression experience a range of symptoms, including persistent depressed mood or loss of interest and pleasure, for at least two weeks’ [25]. This step applies the PHQ-2 to diagnose depression, the GAD-2 to diagnose anxiety, and the entire presentation from Steps 1 to 3 of the five-step approach. Thus, this step is not only based on the main criteria of anxiety and depression (PHQ-2) and anxiety (GAD-2) [26, 27]. Diagnosis is also based on the symptoms of psychological stress included in Step-2 (screening for psychological stress). These criteria are highly compatible with the diagnostic and statistical manual of mental disorders, fifth edition (DSM-V) criteria.

Accordingly, doctors should be aware of the cultural dimensions of society when presenting with depression and anxiety, i.e., in Arabic countries, these metaphors could be used: ‘Sadri dayeq alayya’ (my chest feels tight), ‘Tabana’ (I am tired, fatigued), ‘Jesmi metkasser’ (broken body), ‘The heart is poisoning me’, ‘As if there is hot water over my back’, and ‘Something blocking my throat” [28]. In India, ‘sinking heart’, ‘feeling hot’, and ‘gas’ [29]. In Nigeria, ‘heat in the head’, ‘biting sensation all over body’, and ‘heaviness sensation in the head’ [30]. For Mexican Americans, ‘nervous’, ‘brain ache’, ‘brain exploding’, or ‘uncontrollable’ [31]. In addition, most patients with depression have coexisting anxiety and medically unexplained somatic symptoms [16, 25]. However, 70% of mental disorders begin before the age of 18 years and often continue into adulthood [32], with anxiety and depression being the most prevalent [33].

Primary healthcare providers should deal with various anxiety types (Barton et al., 2014, pp3): General anxiety disorder: ‘constant worries and fears’; obsessive-compulsive disorder: unwanted persistent or repetitive thoughts or behaviours that seem impossible to stop or control; social phobia: ‘a debilitating fear of being seen negatively by others and humiliated in public’; specific phobia: ‘excessive or irrational fear of a specific object or situation’; posttraumatic stress disorder: ‘extreme anxiety disorder that can occur in the aftermath of a traumatic or life-threatening event’; and panic disorder: ‘repeated, unexpected panic attacks as well as fear of experiencing another episode’ [34]. The formula of the suggested questions about the types of anxiety that doctors can use is demonstrated in Table 1.

Generalised anxiety disorder: ‘Do you experience persistent stress, anxiety, or fear?’; Obsessive-compulsive disorder: Do you experience persistent or repetitive thoughts or behaviours you cannot stop or control?; Social phobia: ‘When meeting people, do you feel fear that others will look at you negatively and humiliate you? Specific phobia: ‘Do you have an irrational fear of a certain thing?’; Post-traumatic stress disorder: ‘Do you experience attacks of anxiety that could be associated with physical symptoms, such as increased heartbeat, that occur after a traumatic event and persist after?’; Panic disorder: ‘Do you experience frequent and unexpected attacks of fear of shortness of breath as if you are dying, and are you afraid of them recurring?’

Table 1.

Doctor’s question scenarios exploring types of anxiety.

It is important that bipolar disorder, which was included in Step 3, be excluded. Doctors ask about the period of hypomania or mania; if yes, you need to refer the case to a psychiatrist.

2.5 Step 5: management

The Five-Step approach is consistent with the decision of a psychiatric expert in terms of whether the patient requires to be started on non-pharmacological therapy, reaching 99.9% with a high sensitivity of 92% and specificity of 95% to determine the requirement for antidepressant therapy [13]. The Management plan for depression and anxiety depends on the level of psychological stress (Step 2), summarised in Table 2.

Depression – Anxiety	Stress level (classification)	Non-pharmacological	Narrative therapy	Antidepressant
Mild cases	Early insomnia	Yes	No	No
Moderate–severe cases; Occurs with a post-recent social event	Interrupted sleep or decline in concentration, performance, or affect the social relationship	Yes	Yes	No (if does not respond, then Yes)
Moderate–severe cases; Occurs due to medications, e.g., B-blocker, contraceptives and steroid		No	No	Modify medication first, then re-assess
Moderate–severe cases; Occurs with no recent social event or medication side effect		yes	No	Yes

Table 2.

An outline of the management plan for anxiety and depression.

Narrative therapy is a method used to solve problems and help make decisions impartially without emotional influence. Often, a person takes the initiative to solve others’ problems while limiting psychological stress when it comes to himself (Appendix 2).

Antidepressants, selective serotonin reuptake inhibitors (SSRIs) as the first line, should be considered for moderate-to-severe cases of depression and anxiety. However, in two situations: first, when symptoms initially occur after social events such as divorce, separation, failure, conflict, or crisis, narrative therapy should be attempted to help patients cope with the situation and be re-assessed before considering antidepressant therapy. Second, medications that affect mood, such as β-blockers, chemical contraceptives, or steroids, should be modified and re-assessed before initiating antidepressant therapy. Several studies demonstrated the safety of SSRIs during pregnancy and lactation [35].

When treating depression and anxiety with chronic organic diseases, such as diabetes and high blood pressure, a therapist must also follow up on the organic diseases. In most cases, medications can be dispensed, or drug doses can be reduced—specifically, controlling depression and anxiety results in decreased adrenaline and cortisone levels, which ultimately support the control of chronic diseases [36, 37] as demonstrated in Figure 4. Understanding management procedures should include understanding psychological capacity.

Figure 4.

Relationship between stress & mental health & body function.

3. Psychological capacity

Gruber et al. (2023 pp-1) asked an important question: ‘Why might some people fail to regulate their emotions despite having the ability to do so?’ [38] Gross et al. explained that psychological discomfort is a disorder involving the inability to regulate emotions, which results in a decrease in a person’s moral and functional performance and quality of life [39]. Patients often experience psychological disabilities, work performance problems, illnesses and physical symptoms [40, 41]. These physical and psychological diseases sometimes negatively affect psychological capacity and ability [42]. Muschalla and Jöbges stated that 50–70% of patients with comorbid mental disorders have psychological capacity impairments [43]. Therefore, psychological capacity is becoming increasingly important for maintaining productivity in daily life [44] and should be considered in mental health management.

Thus, the psychological capacity of the container can be considered. A person who suffers from stress, anxiety or depression has a lower psychological capacity than expected. Exposure to life stressors, such as negative social or financial factors, is likened to something that occupies space within the psychological capacity. Genetic factors or a lack of happiness hormones, such as serotonin which are usually associated with high levels of stress hormones, adrenaline, and cortisol, lead to a lack of psychological capacity. Proposed image of the effects.

The effects of psychological stress and happiness hormones on psychological capacity are shown in Figure 5.

Figure 5.

A proposed image of the effects of psychological stress and happiness hormones on the psychological capacity.

In managing moderate-to-severe anxiety and depression, it is necessary to focus on raising happiness hormones and decreasing stress hormones, adrenaline, and cortisol using antidepressants, regular exercise, especially walking, for psychological recreation, and not only sports. Additionally, psychological stress hormones can be reduced by not engaging in discussions and arguments, self-motivation, and not self-blaming, relaxation therapy, particularly deep breathing, which reduces stress hormones, and narrative therapy to manage personal problems or decision-making. Moreover, regular follow-up with a signed doctor helps support management outcomes.

4. The proposct interview approach

Integration of mental healthcare into the services of primary healthcare centres using the five-step approach to interview patients could have a higher rate of control of chronic diseases and physical symptoms, relieve patients’ suffering, raise the satisfaction rate of recipients and providers of healthcare services, reduce unnecessary frequency of visits to health centres, and reduce unnecessary medications, laboratory or radiological investigations, and referrals. Accordingly, the health resources were preserved, as demonstrated in Figure 6.

Figure 6.

Proposed outcomes of the five-step patient interview approach application.

Example-2: ‘Sami’s battle with uncontrolled diabetes mellitus.’

Sami is a 60-year-old man with uncontrolled diabetes mellitus. He received the highest dose of two types of medications (Sulfonylurea and Glucophage), yet the Hb1Ac reached 13% despite the patient’s commitment to health and drug instructions. Therefore, the family doctor decided to switch to insulin as the approved treatment guide stipulated. The patient refused to receive insulin due to his old age. The same decision was made when the patient was referred to the hospital. However, despite the patient’s persistent decision, the specialist decided to refer the patient to a family doctor. When the patient returned, he met with a family physician trained in the Five-Step approach to interview the patient, and the following discussion was held:

Doctor-Patient Interview:

Step-1: The doctor thinks, ‘Does Sami need mental health care?’

Answer: yes, because he has an uncontrolled organic disease.

Step-2: Screening.

‘Does he have hidden agenda, delusion’ ICE technique, doctors’ questions:

• ‘What do you think is the reason for not controlling your diabetes?’

• ‘What makes you afraid of not controlling your diabetes?’

• ‘What do you expect me to do regarding your uncontrolled diabetes.’

All answers were within a logical thought process and no delusion.

b. Stress Screening:

1. Sleep indicator

Doctor: Do you have difficulty sleeping when you place your head on a pillow?

Sami: Yes, I have difficulty sleeping > > (mild stress).

Doctor: Do you experience sleep interruptions without apparent reasons? Answer: Yes > > (moderate to severe stress)

1. Concentration and performance indicator

Doctor: Have you noticed a decrease in your concentration and performance?

Sami: Yes, clearly > > (moderate–severe stress)

1. Relationship indicator

Doctor: Have you become more inclined to sit alone than before?

Sami: Yes, although I was social and loved hanging out with others.

Doctor: Have you become more provoked? I mean, you quickly become angry.

Sami: Yes > > (moderate–severe stress).

In conclusion, from Step-1 and Step-2, Sami has moderate–severe stress.

Step-3: ‘Does the patient need to be referral to a Psychiatric clinic or stay under the Family doctor’s care?’ (Scoping Step).

Sami has no suicidal or psychotic or dementia symptoms, or drug abuse.

Then, the decision was patient should stay under his Family doctor’s care.

Step-4: ‘Does he has depression and or anxiety.’

Doctor: Inside you, do you feel happy, relaxed, or do you feel uncomfortable or unhappy? Sami: I feel not as happy as I used to be.

Doctor: The things used to make you happy; do they still make you happy, as before, or no longer?

Doctor: Do you feel relaxed or tense most of the time? Sami: Most of the time, I feel anxious.

Doctor: Do you fear the future, your health, or fear for your family members? Sami: Yes.

Conclusion Sami has Anxious-Depression. What is its classification?

As the patient has moderate stress, the final diagnosis was ‘Moderate–Severe Anxious-Depression’.

Step-5: Doctor, ‘What is the Management Strategy?’

• As the case is moderate-to-severe, no drug use affects mood and no precipitated social event.

Decision: To start on an antidepressant (escitalopram 5 mg once daily for six nights and then continue on 10 mg), Plus Non-pharmacological Strategies:

1. Sleep hygiene

2. Exercise, particularly regular walking

3. Relaxation therapy such as deep breathing

4. Support self-steam

5. Avoid arguments or stressful discussions

6. Regular follow-up

After 10 days patient had a hypoglycemic symptom.

Plan a decreased dose of sulfonylureas with regular follow-ups and monitoring of blood sugar levels. Sami continued to have hypoglycaemic attacks by reducing the number of hypoglycaemic medications until all medications for diabetes mellitus were discontinued.

Sami was happy that he started depression management, and all depression symptoms disappeared after 2 months—blood sugar readings were normal, and HB1Ac retention to 7%.

Sami said:

‘The last time I laughed heartily like now was when I was 15 years old. Unfortunately, throughout my suffering from diabetes and before that, it never occurred to me that I had a psychological disorder. I used to think that life was like this and that the obligations of this world were the reasons for my psychological discomfort. The great mistake doctors blamed was that the length of my diabetes treatment did not occur to a doctor if he asked me about my sleep, performance, and psychological comfort. I start all doctors focusing on diabetes and its symptoms and blame me for not adhering to their advice despite my full commitment’.

In the present time:

Sami lives kindly and spends most of his time comfortably with his family. He went out to shop with them, visited his friends and received visitors. Further, he did not experience sleep disturbance or psychological distress. Additionally, he had not received any diabetes treatment and showed normal levels. Sami continued on the management plan for anxious depression, consisting of non-pharmacological advice and escitalopram 10 mg, with regular visits to his doctor every 8 weeks after his condition stabilised and he reached remission status.]

Example 3: ‘Sara is suffering from uncontrol Hypertension and Irritable bowel syndrome.’

Sara was 45 years old and had suffered from irritable bowel syndrome (IBS) and high blood pressure for several years. The disease was uncontrolled. Sara was taking lisinopril (10 mg daily) and other medications for bowel disturbance.

She met her family physician, who was trained in a Five-Step approach to interviewing patients, and the following discussion was held:

Step-1: ‘Does the patient need mental health care?’

Answer: yes, because she has an uncontrolled organic disease.

Step-2: ‘Does she have (hidden agenda or delusion) or (Stress)?’

1. ICE technique: The answers were normal (no hidden agenda or delusion)

Doctors’ questions were:

• What do you think is the reason for not controlling your blood pressure?

• What makes you afraid of not controlling your blood pressure?

• What do you expect me to do regarding your uncontrolled blood pressure?

All answers were within logical thought.

1. Stress Screening: There was moderate to severe stress in the forms:

   1. Sleep indicator:

Doctor: When you put your head on a pillow, do you sleep or have difficulty sleeping? (mild stress).

Sara: Yes, in difficulty.

Doctor: If you sleep, does sleep break for no apparent reason?

1. Concentration and performance (moderate–severe stress)

Doctor: Have you noticed a decrease in your concentration or performance? Sara: Yes, clearly

1. Relationship indicator (moderate–severe stress)

Doctor: Have you become inclined to sit alone? Sara: Yes.

Doctor: Have you become easy to annoy as compared with previously?

Sara even causes more family conflict with my husband and children. Later, I started to blame myself for why I got so eagerly like that.

N/B: anyone was yes mean there is a positive for stress screening

• In conclusion from Step-1 and Step-2

Sara needs mental healthcare and has moderate–severe stress.

Step-3: ‘Does the patient need to be referral to a psychiatric clinic or stay under the family doctor’s care?’ (Scoping Step).

Sara had no suicidal, psychotic, or dementia symptoms or drug abuse. The decision was that the patient should remain under the care of their family doctor.

Step-4: ‘Does he has depression and or anxiety’.

Doctor: Inside you, do you feel happy and relaxed or uncomfortable or unhappy?

Sara: I feel not as happy as I used to be.

Doctor: The things used to make you happy; do they still make you happy, as before, or no longer? Sara: no more.

Doctor: Do you feel relaxed or tense most of the time? Sara: Most of the time, I feel tense.

Doctor: Do you fear the future, your health, or your family members? Sara: Yes.

Conclusion Sara has Anxious-Depression; What is its classification?

As the patient has moderate stress, the final diagnosis was ‘Moderate–Severe Anxious-Depression’.

Step-5: Doctor, ‘What is the Management Strategy’

• As the case is moderate to severe, no drug use affects mood and no precipitated events.

Decision: To start on antidepressants (escitalopram 5 mg, then raised to 10 mg once daily).

Plus, Non-pharmacological Strategy.

After 2 weeks of instruction to keep looking at blood sugar levels:

In follow-up visits 2 weeks later:

• Sara had improved mood and sleep as compared with previous weeks

• BP had improved in lower readings 110/70 mmHg.

• No more attacks of irritable bowel symptoms

• She said, ‘When I stand up like I am losing consciousness.’

Plan: Continue on Escitalopram 10 mg/day. The Lisinopril dose was reduced to 5 mg daily. No medication for IBS.

Visit 3 (3 weeks later):

Sara was satisfied, felt comfortable and happy, much better than before.

Sleep, performance and focus are improved.

BP 125/75 mmHg.

They were continued on a management plan for 9 months, with regular visits every 6–8 weeks. After 9 months, the dose of escitalopram was reduced to 5 mg for 2 months and then to 5 mg every other day for 1 month. The medications were gradually discontinued. They continued to adhere to non-pharmacological advice, especially regular walking and deep breathing relaxation, and not stopping escitalopram suddenly. Follow-up BP readings were performed to ensure the need to continue on the same dose or stop if needed, according to regular evaluation and follow-up.

5. Conclusion

The Five-Step Patient Interview is a modern and effective approach for integrating mental healthcare into primary healthcare services. Therefore, doctors can identify patients who may require mental healthcare before starting the interview, determine if the person suffers from psychological stress in a brief time commensurate with the nature of work in crowded clinics and define the scope of mental healthcare services. It also illustrates the framework for collaboration between primary care doctors and mental health specialists.

Acknowledgments

Thanks and appreciation to my teachers, whom I learned, and to patients who benefited from applying this approach, who enormously impacted the results’ success. I thank the Saudi Ministry of Health, where I work and provide educational services to postgraduate students and health services in its health centres.

Thanks and gratitude to my family members who tolerated my preoccupation with my research. I thank everyone for trying to change their approach towards interviewing patients accustomed to applying it to the modern, brief and useful five-step approach, God willing.

Conflict of interest

The authors declare no conflict of interest.

Appendix-1

An innovative Five-Step Patient Interview approach for providing mental healthcare in primary healthcare centres (AlKhathami AD approach) [published by AlKhathami AD. General Psychiatry 2022; 35:e100693. doi: 10.1136/gpsych-2021-100,693.]

Step 1: Suspect mental health problems.

Primary care physicians should suspect mental health problems in patients who present with any of the following:

Frequent clinic consultations; uncontrolled chronic diseases or physical symptoms; or sleep disturbances.

If the above indicators are absent, the patient will likely not have a hidden mental health problem, and the physician can proceed with the traditional patient interview.

Step 2: Screen for suspected stress-related mental health problems.

Two screening measures are included in the patient interview:

a. Screening for hidden agendas, concerns, or impaired thinking/judgement * using ICE interview questions.

I (idea): What do you think is the cause of your present symptoms, uncontrolled sugar levels, or blood pressure?? C (concern): Why do you worry about your present symptoms, uncontrolled sugar levels, or blood pressure?? E (expectation): What do you expect me to do for your symptoms, uncontrolled blood sugar levels and blood pressure?

These actions augment the doctor-patient relationship by discovering the patient’s feelings and worries.

*Thinking or judgement: If delusions or hallucinations occur, the patient must be immediately referred to a psychiatrist.

b. Screen for psychological stress:

Psychological stress and its severity must have existed for at least 2 weeks or longer to qualify as a mental health problem.

Sleep: enquire about three different situations:

‘When you put your head on the pillow, do you sleep easily or have difficulty sleeping?’ Early insomnia occurs in patients experiencing mild stress.

‘When you sleep, do you often wake up?’ Interrupted sleep occurs in moderate to severe cases of stress.

Performance and concentration: the present performance and concentration were compared with those before the occurrence of symptoms. A marked decline indicated moderate-to-severe stress.

Relationship: ‘How are your relationships with people close to you? Do you like to be alone? Easy anger?’ A positive response indicated moderate-to-severe stress.

Note: If there are no hidden agendas or stress, the patient usually does not require mental healthcare; traditional care should be appropriate to help the patient.

Step 3: Scope best service options to address more severe mental health problems.

Primary healthcare professionals and family medical doctors should manage patients with depression and anxiety. Other mental health disorders should be referred to by mental health specialists as part of collaborative work.

Step 4: Diagnose depression and anxiety.

The diagnosis was based on the WHO mhGAP Guide (version 2.0; 2016) [25]. After excluding cases that needed a specialist referral (Step 3), two disorders were diagnosed and managed at the primary healthcare level (depression and anxiety disorders with >2-week duration).

Depression. One of the following criteria of PHQ-2 is needed to diagnose depression:

Sad mood: ‘Do you feel happy or sad?’

Loss of interest: ‘Are you still interested in things that made you happy in the past, or have you lost interest?’

Anxiety. One of the following criteria of GAD-2 is needed to diagnose anxiety:

Anxious and tense mood: ‘Do you feel anxious or tense most of the time?’

Excessive fear or worry (fear of the future, avoiding meeting people, increased heart rate and sweating); asking about panic attacks and post-traumatic symptoms.

Define the severity of depression and anxiety based on Step 2 findings and stress screening (mild or moderate to severe cases).

NB diagnosis was based on The PHQ-2 and GAD-2 plus the symptom findings in Steps 1 and 2 throughout>2 weeks.

Step 5: Manage mild mental health problems.

There are two rules:

Rule 1: For mild cases (only the presence of early insomnia), start with sleep hygiene, relaxation and regular exercise before taking antidepressants.

Rule 2: Moderate-to-severe cases (interrupted sleep, declined performance and concentration, and isolation or easy anger): consider antidepressant medication, except in the following two situations:

1. Patients experience mood changes due to the side effects of medications such as beta-blockers, steroids or hormonal contraceptives. The physician should modify the medication and re-assess the patient at the 1-week follow-up.

2. The patient reported an inability to cope with life events such as loss, responsibilities or conflict with others. Management actions involve applying narrative therapy as the first step before starting medication. Subsequently, the patient was re-assessed. If a patient does not respond well to narrative therapy, full mental health management should be initiated with regular follow-ups.

The entire management plan includes the following:

1. Non-pharmacological management comprises all of the next:

   • Regular walking or exercise

   • Avoid arguments and self-blaming, particularly in the first 2 weeks

   • Relaxation technique using deep breathing

   • Regular follow-up with attention on the improved symptoms, then discuss the none.

2. SSRIs, such as escitalopram 10 mg and fluoxetine 20 mg, are the first choice. Treatment was started with a half-dose for 6 days, then a full dose. Fully recovered, continue for 9 months on remission status, then taper the dose and stop it 1 year from the start.

Follow-up management visits.

Assess areas of improvement, that is, stress indicators (Step 2) and depressive and anxiety symptoms, focusing on positive progress. The second visit should be scheduled 1 week after the first for support and reassurance; the third visit could be scheduled 2–3 weeks later, depending on the patient’s needs.

Appendix-2

Narrative therapy used in the Five-Step Patient Interview approach (AlKhathami approach) [published by AlKhathami AD. General Psychiatry 2022; 35:e100693. doi: 10.1136/gpsych-2021-100,693.]

Narrative therapy:

Principles to be considered:

• Persistent stress overwhelms a patient until they can no longer tolerate it.

• Subsequently, they felt tense or depressed because they could not cope with their problems.

• Each person has a psychological capacity.

• Narrative therapy supports and helps patients to cope with their problems.

Narrative therapy steps:

• Let the patient identify their friend’s name. Let the patient imagine that their friends have the same problems. (The physician should re-tell the story to the patient as if the friend is suffering).

• Ask the patient to help their friend solve the problem.

• Logically, what would the patient advise that friend?

• Ask the patient to apply what they say personally. Sometimes, patients suggest an escape approach; let the patient think about the disadvantages of such a solution, hoping that the patient will change the approach to a more logical one.

On the follow-up visits:

• Encourage any progress, even if it is minimal.

• Do not assume the problem will be solved in one session; weekly follow-up must be performed until the situation improves.

• When it is difficult for the patient to progress, the narrative therapy should be stopped and he moves to SSRI therapy.

Videos available from (can be viewed at https://www.youtube.com/@user-ne2cn9yx4z):

• https://www.youtube.com/watch?v=yKK7a7sMBjI

• English Language: https://www.youtube.com/watch?v=IAg9tV4uGKI

• Arabic Language: https://www.youtube.com/watch?v=3FXDvLrzEsI&t=31s

• Role-play sessions:

• https://www.youtube.com/watch?v=SaNV0km8Fbg

• https://www.youtube.com/watch?v=S6sJFBRrn84