General practitioners (GPs) play an important role in the detection and management of mental illness, especially with prevalent conditions such as depression and anxiety, and social conditions such as intimate partner violence.1 The prevalence of gender-based violence has been estimated at 27.4%.2 In the most recent (2007) Australian National Survey of Mental Health and Wellbeing, the prevalence of any lifetime mental disorder was 45.5%, with a 12-month prevalence of 14.4% for anxiety disorders, 6.2% for affective disorders and 5.1% for substance use disorders.3 Patients, especially women, who experience underlying intimate partner violence, often present with depression and anxiety.4
What are the key equity issues and who is at risk?
- Socioeconomic disadvantage – The National Survey of Mental Health and Wellbeing identified that ‘the proportion of people who reported having mental problems increased as levels of socioeconomic disadvantage increased’. In 2007–08, 16% of people living in the most disadvantaged areas had a mental or behavioural problem, compared with 11% of people living in the least disadvantaged areas. The likelihood of depression among low socioeconomic status (SES) persons is almost double that of SES persons (most marked for persistent depression). 3,5,7 Anxiety and affective disorders are more common in unemployed people. 8,9 In patients with chronic disease and disability, lower educational level and unemployment are predictive of depression. 10,11
- Practices in disadvantaged areas have a higher prevalence of depression to identify and manage. Mental health services overall are used at lower rates by the socioeconomically disadvantaged, possibly related to low health literacy and stigma.12–14
- Suicide and attempted suicide are consistently associated with markers of SES disadvantage including limited educational achievement and homelessness.15,16
- Aboriginal and Torres Strait Islander peoples – Aboriginal and Torres Strait Islander peoples are known to be at greater risk of morbidity and mortality from mental health–related conditions affecting social and emotional wellbeing. Aboriginal and Torres Strait Islander peoples are hospitalised for mental health problems at twice the rate of non-Indigenous Australians and experience twice the rate of suicide, rising to five times the rate in the 15–19 years age group.17 Very high psychological distress in Aboriginal and Torres Strait Islander communities may be related to the risk factors of chronic stress and exposure to violence, racism (including within the health system18 where all concerned have a role to ensure this does not happen), and marginalisation and dispossession.19
- Culturally and linguistically diverse patients (CALD) – Differences in the way depression is understood and presented may create barriers to accessing effective depression care for patients from non–English-speaking and culturally diverse backgrounds.20
- Age – Income-related inequalities in the prevalence of psychological distress and common mental health conditions are particularly common in midlife.21 With advancing age, socioeconomic inequities lead to an increase in anxiety and depression. Young people with a low level of education have the greatest likelihood of experiencing chronic depression and progression from anxiety to depression. Socioeconomic disadvantage is associated with both the incidence and chronic nature of depression and anxiety symptoms in older adults.22
- Childbirth – Postpartum depression and poor childbirth outcomes are associated with socioeconomic disadvantage.23 Postpartum depression is more common in women from CALD backgrounds and these women are less likely to receive help.24 Immigrant women experience many barriers to accessing high-quality, equitable care and are especially vulnerable to stress in the postpartum period, which may result in postnatal depression.25,26
What can GPs do?
- Refer to the general principles of providing patient education and supporting health literacy in disadvantaged groups (refer to preamble).
- Be aware of the associated stigma of mental illness if offering opportunistic screening for depression to disadvantaged groups.
- Refer to The Royal Australian College of General Practitioners’ (RACGP) National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people for important information on offering mental health care to Aboriginal and Torres Strait Islander patients.27
- Assist women to achieve optimal postpartum health by linking them into social and medical supports, improving their health literacy and self-efficacy, and promoting positive coping strategies and realistic expectations.28 Early screening and treatment of women with perinatal mental illness can alleviate symptoms and decrease comorbid disease risk.29 Culturally appropriate, individual-level interventions may be important.30
- The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice. East Melbourne, Vic: RACGP, 2014.
- Rees S, Silove D, Chey T, et al. Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function. JAMA 2011;306(5):513–21.
- Slade T, Johnston A, Oakley Browne MA, Andrews G, Whiteford H. 2007 National Survey of Mental Health and Wellbeing: Methods and key findings. Aust N Z J Psychiatry 2009;43(7):594–605.
- Campbell J, Laughon K, Woods A. Impact of intimate partner abuse on physical and mental health: How does it present in clinical practice? In: Roberts G, Hegarty K, Feder G, editors. Intimate partner abuse and health professionals: New approaches to domestic violence. Edinburgh: Churchill Livingstone, 2006; p. 43–60.
- O’Toole TP, Johnson EE, Redihan S, Borgia M, Rose J. Needing primary care but not getting it: The role of trust, stigma and organizational obstacles reported by homeless veterans. J Health Care Poor Underserved 2015;26(3):1019–31.
- Patel V, Lund C, Hatherill S, et al. Mental disorders: Equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Geneva: WHO, 2010.
- Richardson R, Westley T, Gariepy G, Austin N, Nandi A. Neighborhood socioeconomic conditions and depression: A systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 2015;50(11):1641–56.
- Denney JT, Wadsworth T, Rogers RG, Pampel FC. Suicide in the city: Do characteristics of place really influence risk? Soc Sci Q 2015;96(2):313–29.
- Milner AJ, Niven H, LaMontagne AD. Occupational class differences in suicide: Evidence of changes over time and during the global financial crisis in Australia. BMC Psychiatry 2015;15(1):223.
- Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2015. Canberra: AIHW, 2015.
- Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: The mental health impacts for Victorian Aboriginal communities. Med J Aust 2014;201(1):44–47.
- Cunningham J, Paradies YC. Socio-demographic factors and psychological distress in Indigenous and non-Indigenous Australian adults aged 18–64 years: Analysis of national survey data. BMC Public Health 2012;12:95.
- Furler J, Kokanovic R, Dowrick C, Newton D, Gunn J, May C. Managing depression among ethnic communities: A qualitative study. Ann Fam Med 2010;8(3):231–36.
- Lang IA, Llewellyn DJ, Hubbard RE, Langa KM, Melzer D. Income and the midlife peak in common mental disorder prevalence. Psychol Med 2011;41(7):1365–72.
- Green MJ, Benzeval M. The development of socioeconomic inequalities in anxiety and depression symptoms over the lifecourse. Soc Psychiatry and Psychiatr Epidemiol 2013;48(12):1951–61.
- Collado MAO, Saez M, Favrod J, Hatem M. Antenatal psychosomatic programming to reduce postpartum depression risk and improve childbirth outcomes: A randomized controlled trial in Spain and France. BMC Pregnancy Childbirth 2014 Jan;14:22.
- Lansakara N, Brown SJ, Gartland D. Birth outcomes, postpartum health and primary care contacts of immigrant mothers in an Australian nulliparous pregnancy cohort study. Matern Child Health J 2010;14(5):807–16.
- O’Mahony JM, Donnelly TT. How does gender influence immigrant and refugee women’s postpartum depression help-seeking experiences? J Psychiatr Ment Health Nurs 2013;20(8):714–25.
- O’Mahony JM, Donnelly TT, Bouchal SR, Este D. Cultural background and socioeconomic influence of immigrant and refugee women coping with postpartum depression. J Immigr Minor Health 2013;15(2):300–14.
- National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 2nd edn. Melbourne: RACGP, 2012.
- Fahey JO, Shenassa E. Understanding and meeting the needs of women in the postpartum period: The perinatal maternal health promotion model. J Midwifery Womens Health 2013;58(6):613–21.
- Meltzer-Brody S, Stuebe A. The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol 2014;28(1):49–60.
- Fung K, Dennis CL. Postpartum depression among immigrant women. Curr Opin Psychiatry 2010;23(4):342–48.