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GPs play a vital role in mental health care, but their place is often overlooked, writes Canberra GP Associate Professor Louise Stone …
When I first moved to Canberra, I was asked to speak at a mental health event. I assumed the organisers had access to my profile and knew that I was teaching into my fifth Masters degree of mental health at the time.
When I rang the convenor to ask about the brief, however, they told me they wanted me to describe a presentation of simple depression and anxiety.
Before I could respond that I believed that encountering “simple depression and anxiety” was quite rare in general practice, they continued that, after I spoke, the convenors would explain how I could have managed the presentation better using Health Pathways — a health platform used in the Australian Capital Territory and in New South Wales to help clinicians make the right decisions together.
I would like to say I was surprised, but unfortunately we often face the mistaken belief that general practitioners do “simple” mental health work and need support with “simple” techniques to improve our clinical performance.
Some see us as “glorified referrers”, assessing patients before sending them to more expert colleagues.
In Victoria’s mental health and wellbeing workforce strategy, GPs appear to be completely absent from the discussion, apart from a brief mention of our high rates of burnout.
Yet 70% of GP consultations involve a mental health issue, and more people receive mental health treatment from their GP than from psychologists and psychiatrists combined.
Mental health generalism is different to psychiatry, psychology or social work.
It needs different strategies, skills, metrics and support. Generalism is challenging to describe, quantify and, therefore, value.
Mental health generalism cannot be separated from the breadth of work GPs do, and it is hidden within general consultation item numbers.
With the defunding of the Bettering the Evaluation and Care of Health (BEACH) study, we have stopped looking for the work GPs do, and quantifying it.
What is mental health generalism?
Mental health generalism involves primary, secondary and tertiary health promotion. It is integrated with physical health and social care.
It reaches beyond mental disorders, such as depression and anxiety, to conditions that can profoundly affect mental health but may not be specifically identified as a mental health problem.
Here is how mental health generalism can work:
Opportunistic primary and secondary health promotion
Mental health promotion starts in utero. The birth of a baby is a profound change in the relational complexity of a family. Those first few years of immunisations, toddler behavioural issues, childcare infections and bumps and bruises give us ample opportunity to support the mental health of the whole family.
The same is true in adolescence, retirement and even nursing homes. During that time, chronic illnesses emerge, and the mental health impacts can be severe. Early intervention makes a difference.
Pre-contemplation
Many people do not recognise or accept that there is a mental health component to their illness.
This is understandable, especially in communities where stigma is significant.
As with pre-contemplators who smoke, we need to spend time to work with them and shape their illness narrative to introduce the possibility of mental illness. It can take some time before the patient is ready to see a psychologist, psychiatrist or social worker or contemplate treatment with us.
Multimorbidity
Multimorbidity is the norm in general practice.
Separating the head from the body (or the brain from the mind in neurological conditions) is unhelpful and potentially harmful.
One GP I spoke to commented that all their patients have at least three conditions involving trauma, substance misuse, neurodiversity, mental illness, complex post-traumatic stress disorder, poverty, homelessness, marginalisation or chronic disease.
The alternative to general practice with complex multimorbidity can be a career of health care navigation, a full-time job for the consumer and carer, with a complex web of intersecting teams.
Care of vulnerable populations
Vulnerable patients have higher mental health needs, but much lower access to services.
Without generalist care by GPs, many of these patients have no access to health services at all.
Low literacy in English, low health literacy, poverty and previous experiences of invalidation, discrimination or culturally unsafe environments in health care institutions impedes care.
Refugees, those living with homelessness, people in the LGBTIQ+ community and patients who live in nursing homes, group homes and correctional facilities are supported by GPs.
Medical trauma
Birth trauma, intensive care unit experiences, and other traumatic events cause deep psychological wounds.
Debriefing often occurs in primary care, because often it is the hospital that has become a psychologically unsafe space.
Although processing this trauma can involve psychologists, it is often the GPs who do the early work of hearing the story.
Crisis management
Sexual assault, childhood trauma, grief and the diagnosis of serious illness causes acute trauma.
Since there are often physical health implications as well as mental health consequences, GPs often manage these symptoms in their initial stages.
Death, disablement, infertility and other deep losses profoundly affect the sense of who a person is, and their place in the world.
When we break bad news, debrief individuals and community after the loss of a loved one to suicide, work in palliative care, manage the pain of infertility and care for the parents of a sick child, we do mental health work.
Disaster management
After all the acute disaster response teams have left, GPs remain at the centre of the community recovering from its losses at the same time as they deal with their own personal grief.
This work can go on for years as the community recovers, not only from the disaster itself, but also the sense of betrayal when help is not forthcoming. Mental health impacts can be severe and long-standing.
Medically unexplained symptoms
No-one wants to care for someone with an anonymous illness.
Patients need care, advocacy, and diagnostic acumen, including mental health support.
Understandably, many develop mental health conditions during the long course of these challenging illnesses.
Complex psychiatry in isolated communities
In remote communities, the GP is the only option for people with serious mental illness.
Transport for remote patients is risky, as they may need sedation or even intubation to fly, so often the only option for care is the remote GP. In these communities, GPs provide psychiatry services, because there are no psychiatrists in place.
Similarly, many provide psychology and social work services, integrated with rural generalist care.
Doctors’ health
Doctors experience medical trauma and they need a safe place to debrief outside of the institution that employs them and in some cases caused significant harm.
It is the GPs who are the frontline workers caring for colleagues.
Why does mental health generalism matter?
All GPs are trained to provide mental health care, with mental health deeply represented across the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine curricula and Fellowship examinations.
However, mental health generalism has become unsustainable and is rapidly becoming extinct.
The Strengthening Medicare Taskforce has suggested that mental health generalism may be replaced with specialised multidisciplinary mental health teams, with each health professional working to the “top of their scope”.
This is a different service with different capabilities and cost. In the United States, the shift to subspecialised practice has led to an expensive health service with poorer outcomes and greater inequity.
In Part 2 of this series, we will examine the value that Medicare currently assigns to patients with complex mental health needs and consider the implications of removing Mental Health Generalism from the health care landscape.
Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health.
She is Associate Professor in the Social Foundations of Medicine group, Australian National University Medical School.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Excellent article Dr. Stone. Gp+25, I concur with everything you said. It’s time to value General Practice.
Well said. Most of our consultations contain an element of mental distress. After hearing a prominent psychiatrist say we don’t do much mental health in General Practice, if there a significant part of the consultation related to mental health I bill a mental health item number as this is the only way data can be collected on what GPS do.
It is also surprising to me how many patients have had major trauma in their lives which significantly affects their mental health. There is a paucity of services to send them to so the GP as said in the article is their sole support.
This is a brilliant article. As a former GP, psychiatrist and now Balint group leader with many GP participants, I concur with everything you’ve written so eloquently. Michael Balint in his classic “The Doctor, the Patient and His Illness” touched on many of these issues in 1964 in his recognition of the vital importance and specialised skills involved with being a generalist. What a sophisticated, comprehensive and contemporary account you have provided.
The remarkable series of victories secured by the first AIF in late 1918 were built on the insights of the British Army and the perceptive thinking of John Monash that war had to be fought differently and infantry alone could not except at an enormous unacceptable cost achieve the desired result.
General Practice in Australia is called on to fill in all the health gaps.
Like World War One infantry unsupported it will fail. Many players such as politicians, the health bureaucracy, university medical schools and some segments of the medical profession show it no respect.
Most of these critics have had no experience on what actually happens in the consulting room. The mental health I saw as a medical student or in hospital practice are not the mental health problems of general practice. I was often the only practitioner patients could access in a timely fashion and who at least understood their world. Their problems were hard and challenging. Life is not kind to many people.
As Louise points out general practice medicine and mental health are not simple.
There is now uncontestable evidence that good general practice care prolongs life by 2 years, reduces hospital admissions by 10% and patients feel cared for.
Is it not time general practice was shown some respect and given the resources to solve its own problems?
Yes , as Dr. Stone points out , as M.H .Generalists – we are apparently invisible , even though MH issues are pervasive and multimorbidity is the norm .
This particular mythology was also promulgated by an NPS campaign. I recall sitting in a group of 5 GPs with a collective experience of sixty clinical years listening to a “paint by numbers” presentation on the diagnosis and treatment of depression delivered by a Pharmacist .
And yes , I had to ask the question ” How many cases have you diagnosed “?
The problem is that the mythology informs health policy , including funding.