Rationale

Mental health disorders are estimated to affect almost half (45%) of Australians aged 16–85 at some point during their lifetime, with one in five (20%) affected during a 12-month period.1

General practitioners (GPs) provided 2.7 million Medicare-subsidised mental health–related services in 2013–14.2 An estimated 13% of all general practice encounters reported in the Bettering the Evaluation and Care of Health (BEACH) survey for the same time period were mental health-related, which translates to more than 17 million (approximately 735 encounters per 1000 population) consultations. Despite these high numbers, available evidence demonstrates that people experiencing mental health issues regularly struggle to access appropriate healthcare, or to be treated with respect and dignity when they do enter the healthcare systems.3

An Australian national survey conducted between 1997 and 2007 found that while the proportion of people accessing mental health services increased in that time period, the proportion of those accessing GPs for mental health issues did not.4 As many as 60% of individuals with self-assessed mental health concerns sought no professional help at all, and it is of concern that 80% of these individuals had accessed general practice care about other health issues in the previous 12 months.4 Individuals at the highest level of risk were those over 60 years of age, 90% of whom had obtained no help for their concerns about mental health, despite seeing a GP in the same 12-month period.4

Recognised factors that can inhibit a patient from presenting with mental health issues in a general practice consultation include poor GP interview behaviours, perceived lack of time and the belief that the GP can do nothing to help.5

A trusting therapeutic relationship between an individual and their GP presents an ideal situation in which to identify a mental health issue and to offer education, support and management of its impacts. GPs are increasingly involved in the early intervention and prevention of mental health disorders and the optimisation of mental health.6,7 It is therefore imperative for all GPs to develop knowledge and skills in this area.

The core skills of general practice, particularly the importance of a therapeutic relationship where holistic, patient- centred continuity of care is provided and in which psycho-sociocultural aspects are routinely considered, are essential. It is important to note that individual improvement in depressive symptoms has been linked to the strength of the therapeutic relationship.8 Other core skills, such as understanding the importance of well-defined therapeutic boundaries, and practical implementation of legislation related to consent and relevant mental health Acts (regarding issues like guardianship, involuntary admission and treatment), are also vital for effective management of individuals experiencing mental health issues.

An understanding of the barriers individuals may face in talking about their psychological symptoms and in receiving care is important in improving access to quality care, particularly for individuals from vulnerable communities.

Individuals’ reluctance to disclose mental health symptoms can be related to a number of factors, but for many the primary concern is related to perceived risk of stigmatisation. Some may instead present in a healthcare consultation with somatic complaints attributed to, or caused by, psychological factors. A GP is well placed to engage a patient in conversation about these issues, assist in developing insight and to address some of the contributing factors, such as health anxiety and depressive symptoms, in order to improve their overall wellbeing.9 Experience in managing mental health issues and relevant postgraduate qualifications have been shown to help GPs better cope with complex presentations, including patients with persistently undifferentiated illness, somatisation and/or hypochondria.10

It is important for GPs to understand the role and appropriate use of evidence-based online education and therapeutic tools to assist individuals who may find it difficult to engage with their GP, and to help them recognise and access help for their mental health symptoms.11

Mental health issues were estimated to represent 13% of the total burden of disease in Australia in 2012, ranking fourth behind cancer, musculoskeletal disorders and cardiovascular disease,12 and depression was the fourth most common condition requiring treatment in 2013–14.13 GPs are reported to be the most common providers of mental health services and are often the first point of contact for patients experiencing these types of problems.2,14 While GPs commonly see high-prevalence disorders, such as depression, anxiety, substance abuse and personality disorders, most will also encounter a range of less common mental health problems, such as psychosis.

GPs commonly see individuals when they are vulnerable to secondary factors, such as being physically unwell or having a loved one who is unwell, coping with significant social stressors, or being given a serious diagnosis. Comorbidity of mental health conditions with other chronic medical conditions or drug and alcohol problems is common in general practice presentations, further complicating diagnosis and management of mental health disorders.15 Many chronic disorders have been found to be associated with increased depressive morbidity.16

In order to provide quality care, GPs require skills in distinguishing normal emotional reactions, such as grief, sadness, anger and anxiety, from more disordered responses that impact an individual’s ability to function and developing skills in assessing, supporting and managing the full psychological spectrum.

Many psychological disorders in general practice are self-limiting illnesses and the GP’s role in these situations is to explain, ease distress and act to speed recovery.17 The spectrum, impacts and complexity of psychological presentations in general practice is broad, ranging from emotionally charged encounters with patients or their relatives, recognition of impacts of personality traits on health and wellness, grief, stress and trauma reactions; to varying severities of depression and anxiety, post-traumatic stress disorder (PTSD), eating and body image disorders; to psychotic and personality disorders.

The skills and knowledge required to manage this spectrum of psychological distress are also broad, and include:

  • use of mental health screening tools
  • ability to recognise red flags and identify risk of self-harm or suicide
  • use of de-escalation and mental health first-aid techniques
  • provision of education regarding relaxation and sleep hygiene strategies
  • supportive counselling
  • motivational interviewing
  • structured problem solving
  • cognitive and dialectical behavioural therapy
  • development of relapse prevention plans.

Effective and empathic management of psychological symptoms requires background knowledge of normal and adaptive psychological reactions to life stressors, commencing from undergraduate education and updated over a GP’s lifetime.

Individuals commonly prefer to be assessed for mental health problems by their GPs, rather than a mental health specialist.18

Medication can be a useful therapeutic adjunct. It is important that GPs’ knowledge and skills include understanding when to consider the use of psychotropic medications, as well as their potential benefits, acute and chronic side effects and possible dangers, including the cardiovascular risks of some medications. It is also essential that GPs develop an ability to determine when to refer to specialised mental health services and when to continue management in general practice. Establishing effective communication and links between GPs and mental health services facilitates high-quality patient care.

Intentional self-harm (including suicide) accounted for 20.9% of injury-related deaths in Australia in 2010 and is a major cause of death for people experiencing mental health issues.19 The rate of youth suicide in Australia peaked in the 1990s and is now decreasing. However, intentional self-harm remains the second-leading cause of death for young people aged 15–24 (after transport accidents), accounting for 20%.19 It is thus imperative for GPs to have a low threshold to sensitively ask patients about thoughts of self-harm or suicide and to develop strategies to assist them if a risk is identified.

People with a mental health diagnosis have an elevated risk of preventable natural and unnatural death,20 with psychiatric outpatients twice as likely to die from diseases such as ischaemic heart disease, which has often gone undetected in such patients.21 Despite a steady decline in cardiovascular mortality for most Australians, people with a mental health diagnosis have received little or no benefit from this progress.22,23 Clinical depression predicts increased mortality,24 particularly in the case of comorbid clinical depression and coronary heart disease.25

Some mental health conditions can impact an individual’s capacity to care for themselves in regards to modifiable lifestyle factors, including the use of alcohol, cigarettes and other drugs as a contributing factor or a consequence of psychological symptoms, exercising regularly, and maintaining good nutrition. Patients whose primary issue is a mental health disorder deserve the full range of care, including preventive services, offered in general practice.

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References

  1. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of results, 2007. ABS cat. no. 4326.0. Canberra: ABS, 2008. [Accessed 19 August 2011].
  2. Australian Institute of Health and Welfare. Mental health-related services provided by general practitioners. [Accessed 29 October 2015].
  3. Mental Health Council of Australia. Not for service: Experiences of injustice and despair in mental health care in Australia. Canberra: Mental Health Council of Australia, 2011.
  4. Parslow RA, Lewis V, Marsh G. The general practitioner’s role in providing mental health services to Australians, 1997 and 2007: Findings from the national surveys of mental health and wellbeing. Med J Aust 2011;195(4):205–09.
  5. Cape J, McCulloch Y. Patients’ reasons for not presenting emotional problems in general practice consultations. Br J Gen Pract 1999;49(448):875–79.
  6. Council of Australian Governments. National Action Plan on Mental Health 2006–2011. Canberra: COAG, 2006. [Accessed 19 August 2011].
  7. Powell Davies G, Harris M, Perkins D, et al. Coordination of care within primary health care and with other sectors: A systematic review. Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine: Sydney, 2006.
  8. Castonguay LG, Goldfried MR, Wiser S, Raue PJ, Hayes AM. Predicting the effect of cognitive therapy for depression: A study of unique and common factors. J Consult Clin Psychol 1996;64(3):497–504.
  9. Clarke DM, Piterman L, Byrne CJ, Austin DW. Somatic symptoms, hypochondriasis and psychological distress: A study of somatisation in Australian general practice. Med J Aust. 2008;189(10):560–64.
  10. Stone L. Explaining the unexplainable – Crafting explanatory frameworks for medically unexplained symptoms. Aust Fam Physician 2011;40(6):440–44.
  11. The Royal Australian College of General Practitioners. e-Mental health: A guide for GPs. East Melbourne, Vic: RACGP, 2015. [Accessed 3 February 2016].
  12. Australian Institute of Health and Welfare. Leading types of ill health. Bruce, ACT: AIHW, 2014. [Accessed 3 February 2016].
  13. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 2013–14. General practice series no. 36. University of Sydney: Sydney, 2014.
  14. Department of Health. The role of primary care including general practice. Canberra: DoH, 2006. [Accessed 3 February 2016].
  15. Teeson M, Proudfoot H, editors. Comorbid mental disorders and substance use disorders: Epidemiology, prevention and treatment. Sydney: National Drug and Alcohol Research Centre, 2003.
  16. Ohayon MM, Schatzberg AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry 2003;60(1):39–47.
  17. Cape J, Barker C, Buszewicz M, Pistrang N. General practitioner psychological management of common emotional problems (I): Definitions and literature review. Br J Gen Pract 2000;50(453):313–18.
  18. Lester H, Tritter JQ, Sorohan H. Patients’ and health professionals’ views on primary care for people with serious mental illness: Focus group study. BMJ 2005;330(7500):1122.
  19. Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014. [Accessed 3 February 2016].
  20. Walker E, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: A systematic review and meta- analysis.  JAMA  Psychiatry 2015;72(4):334–41.
  21. Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness. BMJ 2001;322(7284):443–44.
  22. Correll CU, Bobes J, Cetkovich-Bakmas M, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011;10(1):52–77.
  23. De Hert M, Cohen D, Bobes J, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011;10(2):138–51.
  24. Herrmann-Lingen C, Klemme H, Meyer T. Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients. J Psychosom Res 2001;50(6):295–301.
  25. Barefoot JC, Helms MJ, Mark DB, et al. Depression and long-term mortality risk in patients with coronary artery disease. Am J Cardiol 1996;78(6):613–17.

Useful psychological health resources and tools

  1. American Psychiatric Association, Diagnostic and statistical manual of mental disorders
  2. Australian National University, ‘Beacon’, ratings and descriptions of health applications and websites approved by health experts
  3. Black Dog Institute, ‘E-mental health in practice’ 
  4. Black  Dog  Institute, ‘The  psychological  toolkit’ 
  5. Mindhealthconnect, a variety of online information and therapeutic mental health resources for health professionals and the public
  6. The Royal Australian College of General Practioners, e-Mental health: A guide for GPs
  7. The Royal Australian College of General Practitioners, ‘General practice mental health standards collaboration
  8. The Royal Australian College of General Practitioners, gplearning online learning platform featuring several resources dedicated to psychological health, including ‘Common reactions and recovery following disaster or trauma’, ‘Depression in the male patient’, ‘Depression in the elderly patient’, ‘Depression with somatic symptoms’, ‘Managing insomnia in general practice’ and ‘Managing perinatal mental health issues in general practice’
  9. SleepHub, resources for health professionals
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