Reflections on GP mental health care over 45 years: a father and son perspective
Medical Observer
THEN
I AM delighted to read about changes in GP mental health in the past 20 years. Forty-five years ago the concept did not even exist, not to mention the range of treatment options currently available.
Imagine for a moment a GP waiting room in 1965: a hot stuffy place occupied by the old and the young. Weekday appointments are seven minutes long and five minutes on Saturday.
Doctors work an exhausting 70 hours a week, usually running late because they have been delivering babies, making home visits, or assisting at the hospital. There is no Medicare and the fee is meager.
Both doctor and patient are under pressure when they meet in the consulting room. As the patient tells of their symptoms, the doctor localises the malady, examines the patient and prescribes the treatment.
Bearing in mind the pressure the patient sees the doctor is under, into this mix he or she may or may not mention in passing that they are depressed or anxious, have domestic strife, sexual problems or indeed that they are deluded, hallucinating or even suicidal.
Stressed and short on knowledge, having attended only half a dozen lectures and visited a psychiatric facility once or twice in the course of his six years of medical training, what is the doctor to do beyond scream for help?
He or she may choose to see the patient after hours when there is a little more time or prescribe anything from dill water, rose water, vitamins, or his or her own (or the pharmacy’s) special concoction.
Barbiturates, chloral hydrate, bromides, or one of the emerging class of antidepressants; MAOIs, tricyclics or the diazepines for anxiety are other options. The choice is usually based on what the drug rep says, for there is virtually no educational material.
If the patient is very disturbed, the doctor may choose to send him to a (rarely available) psychiatrist, an outpatient department or a psychiatric institution.
In general, there is no therapy as such, no cognitive behavioural therapy (CBT), perhaps just some good advice to ‘have a rest’, ‘get off the alcohol’, ‘look to one’s responsibilities’, ‘think about the better things in life’.
This is all well-meaning, and when given in a supportive environment where the doctor knows the patient well, it probably helps. This is not surprising, as a number of studies have shown that 50–60% of patients with mild to moderate depression get better with appropriate support and placebo alone.
Having said this, a significant group of doctors simply focus on the physical and avoid the psychological altogether. I would emphasise that these doctors are not bad doctors or bad people, they are simply trying to survive in their own particular way in an environment that is not conducive to helping people in a psychological sense.
Dr Tim Blashki
Dr Tim Blashki is a retired psychiatrist, former GP, and author of one of the world’s first trials of GP depression management (BMJ, 1971).
NOW
I’VE been a GP for almost 20 years, and over that time I’ve seen many changes in mental health, most of them positive. Perhaps the biggest change has been in the language of GP psychiatry. Terms like “psychiatric illness” have been traded in for phrases like “mental health problems”, reflecting a shift in values and the philosophical approach to people’s experiences of mental illnesses.
General practice now shares much of the responsibility and burden for mental health care with other primary health professionals. Psychiatry has also had to make room for a plethora of mental health specialists, in particular psychologists, who are now integral to team care. The expansion of responsibility for community care to allied health professional has greatly improved the access and affordability of care.
When I started general practice, referrals for mental health problems were often the most difficult. Telling an unemployed depressed patient that what they needed was a series of specialist consultations at $100–$200 a pop generally didn’t go down well.
Federal governments since early 2000 deserve credit for substantially funding programs, such as the current Better Access to Mental Health Care, which have put in-depth psychological care within financial reach for most Australians. Needless to say, I think recent cuts to these initiatives are shortsighted.
However, not all the reforms have been rosy. The bureaucracy of government funded mental health services can be intrusive to the normal flow and rhythm of quite intimate and sensitive GP consultations. Sometimes handing a patient a tissue will tell you more than handing them a K10. And the structured paperwork and various “plans” draw GPs’ attention away from listening and eye contact, to typing and printing forms from a computer.
Templates with boxes and headings such as “Problem 1” and “Action 1” compartmentalise the consultation and subtly infiltrate GPs’ notions of the nature of mental illness, and what ought to be done. Round pegs and square holes come to mind.
Community narratives about mental illness have also evolved and biological metaphors have flourished. Patients are often told: “Depression is just like diabetes; instead of a problem with insulin, there’s a deficiency in your serotonin level.” This oversimplified story has gained currency, and millions of scripts are written every year for antidepressants, particularly SSRIs, to “fix the serotonin levels”.
Concurrently, non-pharmacological and complementary approaches have also gained traction with patients, such as CBT, meditation and mindfulness.
Fortunately, the idea of mental illness as a weakness to be ashamed of has waned, thanks in large part to the sustained efforts of not-for-profits like beyondblue, the Black Dog Institute and Sane Australia.
A procession of high-profile personalities going public with their experience of mental illness has also helped shift community understanding. After all, if one can have a mental illness and still be a famous football player or inspiring parliamentarian, maybe it’s not such an intractable problem after all.
So after 20 years in practice, I do believe people get a much better GP mental health care than they used to. Opportunities for GPs to learn new mental health skills have also grown, and there’s a much broader range of specialist services available for GPs to refer to when needed.
Dr Grant Blashki
Associate Professor Grant Blashki is a GP and lead editor of General Practice Psychiatry.
THEN
I AM delighted to read about changes in GP mental health in the past 20 years. Forty-five years ago the concept did not even exist, not to mention the range of treatment options currently available.
Imagine for a moment a GP waiting room in 1965: a hot stuffy place occupied by the old and the young. Weekday appointments are seven minutes long and five minutes on Saturday.
Doctors work an exhausting 70 hours a week, usually running late because they have been delivering babies, making home visits, or assisting at the hospital. There is no Medicare and the fee is meager.
Both doctor and patient are under pressure when they meet in the consulting room. As the patient tells of their symptoms, the doctor localises the malady, examines the patient and prescribes the treatment.
Bearing in mind the pressure the patient sees the doctor is under, into this mix he or she may or may not mention in passing that they are depressed or anxious, have domestic strife, sexual problems or indeed that they are deluded, hallucinating or even suicidal.
Stressed and short on knowledge, having attended only half a dozen lectures and visited a psychiatric facility once or twice in the course of his six years of medical training, what is the doctor to do beyond scream for help?
He or she may choose to see the patient after hours when there is a little more time or prescribe anything from dill water, rose water, vitamins, or his or her own (or the pharmacy’s) special concoction.
Barbiturates, chloral hydrate, bromides, or one of the emerging class of antidepressants; MAOIs, tricyclics or the diazepines for anxiety are other options. The choice is usually based on what the drug rep says, for there is virtually no educational material.
If the patient is very disturbed, the doctor may choose to send him to a (rarely available) psychiatrist, an outpatient department or a psychiatric institution.
In general, there is no therapy as such, no cognitive behavioural therapy (CBT), perhaps just some good advice to ‘have a rest’, ‘get off the alcohol’, ‘look to one’s responsibilities’, ‘think about the better things in life’.
This is all well-meaning, and when given in a supportive environment where the doctor knows the patient well, it probably helps. This is not surprising, as a number of studies have shown that 50–60% of patients with mild to moderate depression get better with appropriate support and placebo alone.
Having said this, a significant group of doctors simply focus on the physical and avoid the psychological altogether. I would emphasise that these doctors are not bad doctors or bad people, they are simply trying to survive in their own particular way in an environment that is not conducive to helping people in a psychological sense.
Dr Tim Blashki
Dr Tim Blashki is a retired psychiatrist, former GP, and author of one of the world’s first trials of GP depression management (BMJ, 1971).
NOW
I’VE been a GP for almost 20 years, and over that time I’ve seen many changes in mental health, most of them positive. Perhaps the biggest change has been in the language of GP psychiatry. Terms like “psychiatric illness” have been traded in for phrases like “mental health problems”, reflecting a shift in values and the philosophical approach to people’s experiences of mental illnesses.
General practice now shares much of the responsibility and burden for mental health care with other primary health professionals. Psychiatry has also had to make room for a plethora of mental health specialists, in particular psychologists, who are now integral to team care. The expansion of responsibility for community care to allied health professional has greatly improved the access and affordability of care.
When I started general practice, referrals for mental health problems were often the most difficult. Telling an unemployed depressed patient that what they needed was a series of specialist consultations at $100–$200 a pop generally didn’t go down well.
Federal governments since early 2000 deserve credit for substantially funding programs, such as the current Better Access to Mental Health Care, which have put in-depth psychological care within financial reach for most Australians. Needless to say, I think recent cuts to these initiatives are shortsighted.
However, not all the reforms have been rosy. The bureaucracy of government funded mental health services can be intrusive to the normal flow and rhythm of quite intimate and sensitive GP consultations. Sometimes handing a patient a tissue will tell you more than handing them a K10. And the structured paperwork and various “plans” draw GPs’ attention away from listening and eye contact, to typing and printing forms from a computer.
Templates with boxes and headings such as “Problem 1” and “Action 1” compartmentalise the consultation and subtly infiltrate GPs’ notions of the nature of mental illness, and what ought to be done. Round pegs and square holes come to mind.
Community narratives about mental illness have also evolved and biological metaphors have flourished. Patients are often told: “Depression is just like diabetes; instead of a problem with insulin, there’s a deficiency in your serotonin level.” This oversimplified story has gained currency, and millions of scripts are written every year for antidepressants, particularly SSRIs, to “fix the serotonin levels”.
Concurrently, non-pharmacological and complementary approaches have also gained traction with patients, such as CBT, meditation and mindfulness.
Fortunately, the idea of mental illness as a weakness to be ashamed of has waned, thanks in large part to the sustained efforts of not-for-profits like beyondblue, the Black Dog Institute and Sane Australia.
A procession of high-profile personalities going public with their experience of mental illness has also helped shift community understanding. After all, if one can have a mental illness and still be a famous football player or inspiring parliamentarian, maybe it’s not such an intractable problem after all.
So after 20 years in practice, I do believe people get a much better GP mental health care than they used to. Opportunities for GPs to learn new mental health skills have also grown, and there’s a much broader range of specialist services available for GPs to refer to when needed.
Dr Grant Blashki
Associate Professor Grant Blashki is a GP and lead editor of General Practice Psychiatry.
