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Youth Mental Health

Mind the gap

Author: Amanda Lyons

GPs are crucial to achieving better outcomes in youth mental health throughout rural Australia. 

The Australian youth development index 2016 report contained positive news on the nation’s youth, finding improvement in youth development index (YDI) scores – which measure overall levels of education, health and wellbeing, employment and opportunity, political participation and civic participation for young people – for almost all states and territories since 2006.1

However, the report also revealed that YDI health and wellbeing scores have deteriorated, with significant development gaps between Australia’s rural and urban youth.1

The National Rural Health Alliance (NRHA) has identified a comparative lack of access to mental health services, combined with a lower likelihood to seek help, as factors in higher rates of mental health issues in rural and remote areas. These issues include a higher suicide rate among young men and Aboriginal and Torres Strait Islander peoples.2

Dr Shannon Nott, a general practice registrar and former finalist for New South Wales (NSW) Young Australian of the Year, is not surprised by these findings.

‘There are the same issues [for urban and rural youth] surrounding transition in life and personal identity that come with growing up and getting older,’ he told Good Practice. ‘But we don’t necessarily have services available to our rural youth that people in metropolitan areas would.’

Dr Nott has found that youth in rural areas can also face a number of pressures that are not routinely encountered by those in urban areas.

‘If you look at farming communities, there are stresses from environmental challenges – droughts, flooding, etc – with people losing huge amounts of their cropping, their potential income, for the year,’ he said.

‘Farms are mostly family-run businesses and I think the stresses parents feel from the loss of a crop, for example, will certainly be felt by the children as well.

‘Being able to provide young people capacity or ability to deal with those issues is key to addressing some of the mental health issues we see in rural Australia.’

Dr Mary Emeleus, GP and psychotherapist who works with young people in Townsville in north-eastern Queensland, emphasised that the GP’s role can be vital in this context.

‘In many small places, the GP is the primary place to go if young people do seek help,’ she told Good Practice.

Dr Claudio Villella, GP advisor for the national youth mental health foundation, headspace, believes this makes GPs particularly well placed to help young people in rural areas with issues of mental health.

‘Close to one in four young people will experience a mental health disorder, and three out of four of those people won’t seek help,’3 he told Good Practice. ‘But we know that those young people are often seeing GPs, so GPs are a really good inroad into providing an opportunity for them to open up about the problems they’re experiencing.’

Building relationships

As the most likely source of assistance for young people in rural areas, how can GPs best help this patient population? Dr Villella believes making young people feel welcome is the first thing GPs should consider.

‘Engagement is really the first port of call,’ he said. ‘Making practices youth-friendly and having materials in waiting rooms that specifically engage young people, so that when a young person is sitting in a waiting room they can see themselves in some of the material that’s presented.’

Dr Villella also emphasised the importance of building a strong therapeutic relationship with younger patients.

‘If young people establish a relationship with a GP who they can see is going to give them time and support them, then they’re more likely to back to that GP if there’s any subsequent issues,’ he said.

Part of establishing this relationship involves explaining confidentiality, which is identified by many young people as a key barrier to accessing help for mental health issues, especially in small rural communities.

‘They might be nervous about discussing their concerns with the same GP that other family members, especially parents, are seeing,’ Dr Villella said.

Dr Villella has a number of recommendations when discussing confidentiality with young people who present with mental health issues.

‘If they present with a parent, it is important to say you would really like to spend some time alone with the young person, and explain the limits of confidentiality while both are present,’ he said. ‘That way the parent can understand that if there is something serious going on they will find out about it.

‘In the more common scenario where you have, say, a 15-year-old who presents without a family member or parent, it’s really important to be clear about the limits of confidentiality. That is the first thing you should discuss with them.

‘You are setting the scene and if at some point you feel compelled to engage a family member or friend or carer, then you have provided the explanation up front.’

Dr Emeleus has found it is rare that family should be excluded from a young person’s care. Even in such cases, however, she believes it is vital to acknowledge the family’s role in the young patient’s life.

‘It’s important to keep them in mind even if you can’t practically involve them in consultations or the care plan,’ she said.

Taking time for relationship-building can present something of a difficult issue for time-pressured GPs, particularly in rural and remote areas. But, in Dr Emeleus’ experience, it can make a world of difference with younger patients.

‘We need to remember that some young people come from quite chaotic, disadvantaged or dysfunctional circumstances and may not actually have any other reliable, safe adults in their life who they can run things past,’ she said. ‘Doctors sometimes find themselves in that role, and I think we need not feel bad about that.

‘I think that can be a very important role.’   

Treating young people

Once a younger patient has disclosed mental health issues, it is important for GPs to keep in mind that they may need a different treatment approach than an adult would require.4 According to Dr Emeleus, this is partly related to the young person’s biology.

‘[A young person’s] brain is still developing and their social development still needs to occur,’ she said. ‘You need to consider what would normally be expected for somebody of this age and what developmental tasks should be happening.’

Dr Emeleus has also found that treatment of young people is more effective if they are engaged and included in the decision-making process.

‘Young people have told me [they value] the feeling of being respected and making collaborative decisions, so that the doctor educates them and provides advice,’ she said.

‘And then you work out the plan together, rather than them being told what to do.’

This shared planning includes decisions about prescribing selective serotonin reuptake inhibitors (SSRIs), or antidepressants, a treatment option that Dr Villella has found often doesn’t appeal to these patients.

‘Young people often really don’t want to be on medication,’ he said. ‘So if they are prescribed medication without having been engaged around their values in terms of the treatment, then that will disengage them.

‘It’s really important that GPs take a shared-decision approach.’

Medication is also less likely to be a definitively appropriate treatment path for younger patients.

‘The evidence for SSRIs in young people is not as strong as it is for adults,’ Dr Villella said. ‘Also, young people present some risks. If SSRIs are not taken regularly, with a very high level of compliance, they can actually make people feel worse. And young people can be not as compliant [as adults] when taking medication.’

For these reasons, a ‘stepped’ approach has been found to be effective when treating young people for mental health issues, with an emphasis on attempting psychological treatments before prescribing. e-Mental health services can also be especially helpful in a rural setting.

‘We need to be skilful in non-drug options,’ Dr Emeleus said. ‘This includes psychological interventions, knowing about e-mental health, and also how to help young people negotiate the social aspects of their world, which is where the family and carer inclusion comes in.’

Raising awareness

In August 2016, Dr Nott jumped at a rather unique opportunity to increase awareness of the issue of youth mental health when he participated in the infamous Mongol Derby.

The Guinness World Record holder for the world’s longest and toughest horse race, the Mongol Derby is designed to replicate Genghis Khan’s postal route system during the height of his 13th-century empire, with a course that extends more than 1000 km across the Mongolian Steppe.

Participating in the race also offered Dr Nott the chance to raise funds for batyr, a NSW-based organisation that runs mental health education programs for students in schools and universities.

The Mongol Derby incorporates 25 horse stations, or rest stops, across its length. Riders can end each day in one of these stations, or ride further on and stay with a local family on the vast Mongolian landscape.

Given its stringent conditions, Dr Nott feels fortunate to have been included in the 2016 line-up for the race.

‘They only accepted 44 riders from around the world to race,’ he said. ‘Some of the people that raced with me are incredible horse-people – professional dressage riders, professional jockeys and people who have been their country’s endurance horse-riding champions.

‘So it was quite an honour to be able to race alongside these people in Mongolia.’

Dr Nott was also very pleased to have been able to raise money for an organisation like batyr and help in what is an extremely important area of Australian healthcare.

‘I was lucky to be able to raise over $5000 in total, but I’m also continuing to raise more money,’ Dr Nott said. ‘Hopefully I’ll be able to get more money in the future for batyr and will work with them into 2017 to look at how can we utilise some of those funds to provide some mental wellbeing and education programs for young people.’

 References

  1. Australian Youth Development Technical Advisory Committee. Australian youth development index: 2016 report. Woolloomooloo, NSW: Youth Action New South Wales, 2016. Available at www.youthaction.org.au/australian_ydi [accessed 28 November 2016].
  2. The National Rural Health Alliance. Mental health in rural and remote Australia, fact sheet October 2016. Canberra, ACT: NRHA, 2016. Available at http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-mental-health-2016.pdf [Accessed 28 November 2016].
  3. Position Paper – Young people’s mental health. North Melbourne, Vic: headspace, 2011. Available at www.headspace.org.au/assets/Uploads/Corporate/Young-Peoples-Mental-Health.pdf [Accessed 28 November 2016].
  4. James AM. Principles of youth participation in mental health services. Med J Aust 2007;187(7):57.