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Hello. I'm Caroline West.
Welcome to this program,
Mental Health Assessment: The Primary Care Role,
coming to you on the Rural Health Channel.
I'd like to acknowledge that this program is being broadcast
from the land of the Wangal people of the Darug tribe -
traditional custodians of the land
and part of the wider Aboriginal nation commonly known as Eora,
and we acknowledge their Elders past and present.
Tonight, our program is all about mental health.
It's incredible to think that almost 45% of us
will suffer from a mental health condition like depression, anxiety
or a substance abuse disorder in our lifetime.
For those living in rural and remote areas,
access to special services can be really difficult.
While 30% of Australians live in rural and remote locations,
90% of psychiatrists have their practices in the city.
So the majority of care,
from mental health assessments through to treatment and support,
is coordinated from those in primary care -
the GPs, nurses, psychologists and allied health,
who are all part of the community, which is very important.
Tonight, we'll be exploring the key issues
from how to assess mental health issues
through to the practical aspects of management.
Now, this is not just a program for health professionals -
everyone out there is welcome to join in the conversation
and send through questions.
You can contact us throughout the show, get in touch,
and ask your questions via email, text, phone or even on Twitter.
The details will be on your screen throughout the program.
But first of all, let's meet our wonderful panel.
And I'd like to start with you, Tim.
Associate Professor Tim Carey is a clinical psychologist
and associate professor in mental health
at the Centre for Remote Health in Alice Springs.
- Welcome, Tim. - Thanks, Caroline.
Dr Bernadette Droulers is a GP from Bathurst in New South Wales
with a special interest in mental health.
- Welcome, Bernadette. - Thanks, Caroline.
Jody Eldridge is an Aboriginal mental health
drug and alcohol clinician
working in the Community Mental Health Program in Wagga Wagga.
- So, welcome, Jody. - Thank you.
Dr Catherine Hungerford is a credentialed mental health nurse
currently in an academic role at the University of Canberra, ACT.
Thank you for being here.
And Dr Jock McLaren is a psychiatrist
with extensive experience in remote-area psychiatry,
currently practising in Brisbane.
- So, welcome, Jock. JOCK: Thank you.
So, welcome to you all.
Perhaps if I can go to you first, Bernadette.
You're a GP - a very busy GP - in a rural area.
Just how common are mental health issues in your practice?
I find in my practice they're extremely common.
Statistics show that probably 30% of patients
presenting to general practices have a diagnosed mental disorder,
and probably at least another 30%
have some degree of psychological distress.
So, extremely common.
And on top of that, probably at least 50% of patients
with chronic medical conditions
also suffer from some degree of psychological distress,
if not a mental disorder.
- Mm. - So it's very common.
Extremely common.
And I guess when you're trying to build a connection with somebody
and discover whether they do have a mental health issue,
they may not present with that straight off.
- Is that your experience? - Yes.
Yes, quite often they'll come in...
They don't come in with a sign on their head
with the standard checklist of signs, symptoms of depression.
More often they'll come in saying, 'I'm tired, I'm run down,'
or 'Doc, I just need a tonic,'
and we have to sort through a myriad of symptoms
to work out what's really going on underneath all that.
And I guess to sort of work your way through those scenarios,
if I can turn to you, Jock,
I guess building trust, rapport, a relationship with the patient
is really critical.
- Can you tell us about that? - That's absolutely essential.
Psychiatry comes with a lot of baggage -
you know, we're the people who put people away -
and you've got to overcome that,
because one thing people in rural and remote areas don't want
is they do not want to be sent away.
Firstly, it's an awful long way, it's a different climate,
often nobody speaks their language.
And when they come back,
they have this terrible, terrible burden
of the stigma of having been sent to a mental hospital.
So it's very, very important to build trust and confidence
right from the beginning.
It's important to be seen around the community,
to be part of the community,
and even just something like going for your run in the evening
and being seen
is a very important way of building up a sense
that this person's somebody we could actually talk to.
Mm. So making yourself part of that community
and connecting with people.
So do you think there still is a large stigma
attached with mental illness?
Oh, there's a huge stigma, particularly in country areas.
People tend to say... when I was in the north, people would say to me,
'Oh, you live in the north -
you must have such a lovely, relaxed lifestyle.'
Grr!
I've never been so busy in all my life.
People in remote areas in particular
will hold back until things are out of control.
And so you don't see... People don't bother you with minor stuff.
When they come in, it's serious, it's gotta be taken very seriously.
'Cause they've taken the time out to come in.
You've mentioned that sort of staying as part of the community.
Jody, you work very much in a community setting
in Aboriginal health.
How important is it for the people that you see
to stay in their community setting?
Yeah, very important.
They need to see us out in the everyday life,
out in the community doing things, running programs
and very much being involved and caring about what's going on
for them in their world.
And you create programs
to specifically plug them into the grid, so to speak?
I do. I do. So I have a Mums and Bubs group which runs every week.
We run different programs,
from whether it be healthy eating to relaxation -
a number of things.
And those women rely on that every week,
so, yeah, it's a really good thing.
Fantastic.
There are so many services.
Catherine, if I can come to you on this one.
So I guess when people are in rural and remote locations,
they could be accessing mental health services
through a variety of channels.
There's a bit of confusion out there as to what everybody can provide?
Take us through it.
It's wonderful that there's now
so many different kinds of health professionals out there,
who have all got their own specialty area,
but that can be confusing for people.
'Who do I go to, when?'
And I think in rural areas in particular,
some more remote areas will only have a nurse.
Sometimes a doctor will fly in and out,
sometimes a psychiatrist will fly in and out.
There may be counsellors or Aboriginal health workers,
but many people will say, 'I don't know who to go to,
I don't know who to turn to,' or who even to refer to -
some health professionals may not know who to refer to.
So given that we've heard that mental health conditions
occupy such a great space
in terms of the number of conditions that we see,
how important is it for all of those allied health professionals
to be upskilling, if you like, in mental health?
It's very important to be upskilling,
and there's some great programs now
offered by the Commonwealth Government online
that they can upskill through.
But I think just as important as upskilling
is being able to work together as one, if we can,
and communicate with one another, work together.
Who knows what information, when -
it's very important to pass the information on.
CAROLINE: Mm-hmm. Yeah.
Tim, you're a clinical psychologist, working very much in a team setting.
How important is it for you to have all of that background information
coming from other health professionals?
Very important, Caroline.
It's a great point that Catherine made.
I'm lucky at the moment -
I work in the public mental health service in Alice Springs
with a really great team of psychiatrists,
and we work very closely together.
Previously I've worked in primary health
in a co-located practice with GPs
and there, again, worked very closely with the GPs.
And I think that is really important
because by the time I get to see people,
I assume that I'm seeing someone with a mental health problem,
meaning that physical health problems
have been kind of ruled out
or that the psychiatrist or the GPs have already assessed those
and taken care of those, essentially.
So I'm lucky in that sense that I get to work in a practice
where the continuity of care and communications is very, very open.
CAROLINE: Mm-hmm.
And are we seeing the same sort of conditions that crop up
for the populations living in rural and remote areas?
Or is there a slightly different shift there
in terms of presentations
and the sort of issues that people are up against?
I think a lot of the problems are similar.
I don't kind of try and fit people into diagnostic boxes
so much as concentrate on problems in the lives that they're living.
And because people in rural and remote communities
have different circumstances in their lives,
those circumstances are gonna be different
from people in metropolitan centres.
But the underlying mental health problems
and psychological distress is going to be very similar.
So the things that you might link them into
in terms of social supports and community groups and programs
will necessarily differ.
But, yeah, I think the underlying distress
is still similar and prevalent and important.
CAROLINE: Mm-hmm.
What about the access pathways -
you know, what sort of services are available?
What are we up against in certain areas?
Jock, what's your experience?
You've travelled around a lot in remote parts of Australia.
Well, that was a little bit different
because I was totally integrated into the health service
in the Kimberley region.
And so I just travelled around, I just travelled nonstop,
just throughout the year.
So... people knew me,
people were very familiar and it was very much easier.
And the medical practitioners, in particular,
but also the remote nurses,
knew that they could ring me anywhere, any time of day and talk.
And that was terribly important.
This high level of communication between the different practitioners,
it's very important.
A lot of my work was simply supporting the remote nurses.
Sometimes I didn't even see the patient.
But I'd be talking to the nurses about them all the time.
A lot of wisdom comes from community nurses?
They do a fantastic job
at getting to know people in the community, and it's fantastic.
- There isn't much they haven't seen. - (Laughs) Yes. Very wise, yes.
If I can butt in, I think some important differences
between the rural, remote and certainly the urban services,
so far as access and pathways goes,
would come down to distance and perhaps accessibility,
and of course in Australia we're big on pushing
that we have services that are accessible.
And that can be difficult in rural and remote areas
where - Jock mentioned this earlier -
where people have to travel large distances often
to access specialist services,
away from their families, away from their supports,
away from their friends.
And that takes them out of their communities,
which Jody's speaking to,
and they're in a very artificial environment,
then discharged back into the place they left,
in a different space,
but it's difficult for them, if they're feeling better, to go back.
So you might want to talk to that,
about Alice Springs, how it is out there.
Well, yeah, just exactly that.
And I think it speaks to the importance
of a continuity of service between psychiatry,
allied health, psychology and the GPs in primary care,
so that people aren't kind of lost to the service.
Yeah. Perhaps what we can do is bring in one of our case studies here,
because it may be interesting
to explore some of the issues that it raises.
Let's take a look at this story of Jean,
who's a 50-year-old farmer's wife and she's got an appointment today.
She's presented to your waiting room.
She's dishevelled, she seems pretty agitated in the waiting room,
and, on examination, responds in a pressured, anxious way.
She begins to talk in a very rapid manner
about a workman from a neighbouring property.
He's been harassing her, coming around at night, calling her
and, last night, made lewd suggestions through the window.
Her husband is currently away.
Jock, what's going through your mind
with what we need to think about here?
My first thought is, this is potentially quite dangerous
and something serious is happening.
And there may be a factual basis to what she's saying,
there may not be - so there's gonna be some detective work straightaway.
I would be in touch with her husband immediately.
He's entitled to know that this is happening.
It's quite serious.
And you would immediately be asking him for any information
that he can give.
You'd have to try and contact the neighbours to see what's going on.
You have to be very careful about that,
'cause it could lead to trouble.
You want to have some independent information
about whether she's drinking or using drugs.
One other thing you have to bear in mind these days
is presence of firearms in the house -
and this is where I'd be talking to the husband.
If necessary, they'd have to be removed.
So this is quite a serious case. It would have to be taken seriously.
It could not be put off. She would have to be seen.
Other people with coughs and colds
would have to be put off to see this case.
- They'd have to wait. - Yeah.
So perhaps if she came to you, Bernadette,
what would you be thinking when she presented in that state?
You've known her for a while and she's not normally like this.
Well, I'd agree with Jock, and I'd be most concerned
she's not evolving a serious psychotic illness.
She's exhibiting some serious symptoms
of delusions, hallucinations and paranoia.
And I would be expediting a referral as fast as I could
after I've done my initial assessment.
At least getting on the telephone
and chatting to my local psychiatrist
or the local mental health team,
which I'm lucky enough to have access to where I live.
So if she was in an extremely agitated state
and it was possibly a psychosis,
is this the sort of place where medication could play a role,
as well as the counselling?
Yes, I think this is a very important role.
I suppose, in my role,
I'd be a bit hesitant to be the initiator of that medication,
but certainly I have done so under the supervision of a psychiatrist.
We really have to assess risk in this patient
and it may well be that this lady is going to require hospitalisation
and close supervision over the next 24, 48 hours,
just at least to relieve her distress.
If what we're witnessing is quite bizarre,
she is obviously experiencing
quite significant anxiety and distress herself.
Because sometimes it's quite difficult to actually get a diagnosis
in these early stages, isn't it?
There's a provisional diagnosis, but it could be a few things.
Tim, is that your experience when people are very unwell?
Oh, definitely.
One of the positive things with this lady
is that she's actually presented herself for help -
she hasn't been brought in.
So that's kind of a good thing.
And I think part of the assessment would maybe explore a little bit
about what brought her along, what her concerns and worries were,
along with the kinds of things that she's reporting.
So, yeah, definitely - taking people seriously
and spending time to understand the problem from their perspective
and the context in which that problem is occurring
in terms of their day-to-day living is really important.
Mm-hmm.
And I guess if you're a nurse in a community situation,
how would this situation unfold
if somebody presented in a really agitated way?
I think it would be very difficult.
I've found that the difference between working in a rural location
and an urban location
comes down to confidentiality issues in a small rural location.
And someone who presents with psychotic symptoms
may seem scary and will have the label of 'mad',
and it's very difficult for that person
to be then taken to a mental health unit,
often in a police paddy wagon or under some sort of 'guard'.
Then they're put in there and then, again, they have to go home.
So working with that person and working against the stigma
that still seems to surround certainly psychotic illness...
I would say it's far more stigmatised than a mood disorder.
Mm.
So working with that is very complex.
As you say, it's really scary, isn't it?
When somebody's really unwell,
they're moving into a foreign world rapidly.
When it becomes a medical problem suddenly
and, as you say, they're introduced to things
that they may be confused about or may feel that they don't warrant,
it's tricky.
It's scary for them if they're taken to an acute mental health unit.
It's scary for their family, it's scary for their friends.
And then, again, working with that whole family, friends, partner,
her husband, who may not know what's happening,
may not have ever experienced psychosis, psychotic illness,
and then, again, when she's discharged.
So there's a lot of work and a lot of background work needs to go in
before we can send her home again.
Mm. Jody, what's your experience
if you have somebody who presents in this kind of way?
Have you had people with, say, postnatal depression
who've been severely unwell come to you?
Yeah, definitely, definitely.
So we sort of look at exactly what the issues are at hand,
and, in this case, we'd definitely look at
to see whether or not this is actually real,
this is actually happening -
so, yeah, is it actually occurring at the time,
is this a delusion or is it not,
is there any other health reasons or anything like that?
So just sort looking at the whole story.
In terms of confidentiality, which has been mentioned a little bit,
how much information can people access?
So does somebody's husband have the right to know about them
when they're unwell?
What's the story there with...?
'Cause people are naturally fearful
that perhaps their personal information will be disclosed
to somebody that they know as a friend
who works in a capacity in the health field -
what are the boundaries there?
I find the whole conversation quite interesting
because if someone's wife had a cardiac event, a heart attack,
and was raced to hospital, would people sit there and think,
'Hmm... should we inform the husband?'
But if someone has an acute psychotic episode
and they're rushed to hospital,
they do tend to wonder what should happen,
and I find that whole conversation quite interesting.
- Why is it so different... JOCK: Mm.
..when there's an acute illness happening?
Well, except that I don't think...
There's not an acute illness happening yet in this case.
We don't know.
We don't know, for example, that the woman's not intoxicated
or under the effects of some substances
or she's started some dementing illness.
You know, again, so ruling out physical illnesses
would be important.
In my work, again,
with working in the public mental health service,
I certainly share information with people
and would involve family as well if necessary.
But I always put the patient at the centre of that,
so they're in control of whether that happens or not.
And even in the mental health service,
where notes are shared between psychiatry
and psychology and allied health and mental health nurses, and so on,
I still make patients aware of that
and let them know what the limits to confidentiality are.
And you'd move into tricky turf if in fact there were allegations
against the partner, for example,
who then wanted access to the information.
So it's a difficult one.
So perhaps if we can move onto our next case study,
because this illustrates an example that I think will resonate
with many of us.
Our next case study is Sam, who's been encouraged to see his GP
by the local financial counsellor.
Sam is 47 and has suffered a great deal of financial pressure
in the last five years because of the drought.
Things are improving financially,
but Sam has recently confided in the counsellor
about the effect of the stress.
He reports insomnia, he's waking early,
he's very anxious, he's had increased alcohol use
and various strains on his family life.
Sam reluctantly agreed to the referral.
So what do you think of this scenario,
Catherine, with Sam's financial counsellor sending him along?
Is that something that we see quite a lot of in the community?
Not necessarily a financial planner sending somebody in,
but somebody who's outside traditional medical or allied health.
I think so, because there's so many different workers these days,
and certainly the awareness of mental health
and mental health issues has increased over the last few years,
with the Commonwealth Government putting a lot of money that way.
So there's certainly much more raised awareness,
and people will refer.
And I think it's great that the financial counsellor
feels comfortable enough to have done that,
and the GPs take a great role in being the first point of call.
Yeah, so Bernadette, you are the first point of call.
Are you worried about Sam? What's going through your mind?
My initial... Looking at these symptoms, yes.
I'm quite concerned about Sam.
He ticks a lot of the boxes for being a person at risk -
purely because of his age, his socio-economic standing
and probably loss of face in that area.
He's exhibiting some quite serious symptoms of depression,
with sleep disturbance and early morning awakening,
and there's the co-added problem of the alcohol intake.
So I would be spending a lot of time with this man,
and really exploring what's going on for him
at this time in his life.
If you were worried about suicide - over to you, Jock -
what are some of the questions that we should be asking
when we're trying to tease that out, 'cause it's very difficult sometimes.
You don't go straight to that question,
'Are you going to kill yourself?' because people will just say no.
You have to come in...
It's a bit like you're circling and coming in slowly
and you're trying to convey the impression to this person,
'You can trust me. I understand what you're talking about.'
So asking questions relating...
I start with the general vegetative questions -
sleep, appetite, energy, etc -
and slowly come around through cognitive functions,
and then to mood.
And even then, you say, 'How have you been feeling?'
'Have you been feeling very low and miserable?
How much of the time? How bad is it?
Have you got to the stage where you're sick of things?
Are you sick of living? Any suicidal ideas?
And any urge to act on those ideas?'
So you've come right down through the stages to this point.
And they know where it's heading, and people will be quite honest.
They don't tend to hide things.
They'll say, 'Yeah, I've got these ideas.
I see a tree when I'm driving and I think I could jerk the wheel,
but then I think of my children and I don't want to do it.'
That says a lot.
I see an awful lot of people who are suicidal.
Perhaps half of the people I see are suicidal at the time of referral.
So we have to deal with that.
You can't put them all in hospital. You'd wreck their lives.
But the numbers of suicides in Australia's a national tragedy.
There are 2,000-plus suicides a year in Australia,
and my understanding is 80% of those are in men,
so about five males a day die from suicide.
And it's been said that if five whales a day died,
that would be a hue and cry in the media,
and we'd be down there with our placards.
'No way, this is not acceptable.'
But, for some reason, suicide's slipped into a little blind spot
in terms of consciousness.
- Is that a fair appraisal? - Yes, it is.
It's a very... it's a problematic area.
People don't want to talk about it. They don't want to know about it.
And then there's this thing,
'Well, he committed suicide so there was something wrong with him.
He was morally defective, so perhaps we'd better pretend he didn't exist.'
Whereas in fact a lot of them are preventable.
Some aren't, but a lot are.
So you have to have a very high index of suspicion.
You've just got to keep this in your mind all the time.
Let's add up the factors.
This man's living alone, he's in pain,
he's had some major losses, unemployed, cut off from his family,
past history of drug and alcohol abuse,
he's been in jail, personality disorder, etc, etc.
This is a high risk. This man's not going to last long.
You've got to act.
I guess if you were trying to assess him in a clinical setting,
and you were trying to refine some of the feedback you were getting,
what are some of the assessment tools that we could be using
in clinical practice to help really review depression and anxiety?
In just routine clinical practice,
I think there's some really useful standard tools.
The DASS - the depression, anxiety and stress scale -
is a really useful tool to use just generally.
I know it's something that can be used...
Bernadette, I think you use it periodically,
use it at the beginning of when you start seeing someone
and then to recheck after a few months.
I also use the outcome rating scale,
which is a scale that assesses people over four areas of functioning.
It's really useful to use every session,
so it's been designed as a way of tracking progress
for someone every time they come into session.
So there's certainly a variety of assessment tools out there.
It's really important just to pick one or more than one
that suits the purposes that you're wanting to assess for.
So not all of them are necessarily great for assessing suicide,
but some are very good for assessing suicide and risk.
And, as I said, the DASS is very good to use in primary care
because it covers depression, anxiety and stress,
which are common presentations.
Sure. If we decided that Sam was very depressed,
where would you take it from there?
What would your management involve, your strategies involve?
This is a very complex case - I think I would certainly spend
a significant amount of time with Sam in the first instance,
exploring what's actually going on in his life, his presenting problem,
and get a really good history about
has he had past history of mental illness,
has he had any past admissions,
and looking at his whole social and emotional background.
But moving on from there and after I've done an assessment,
if the assessment came back with quite a severe depression,
I would certainly be talking to Sam about management of his problem,
and talk to him about the options that are available.
And I agree with Tim -
putting him at the centre of his care,
exploring what he's prepared to accept.
And that recommendation would be to do psychological intervention.
But I think in the more moderate to severe cases of depression
that we would certainly have a discussion about medication as well.
So, basically, there is a range of steps we could take Sam through,
so it's really identifying his particular risk
and then assisting him with moving
into some sort of collaborative process for management.
And sometimes with the outcome measures, like the DASS 21,
they can actually be useful in prompting a conversation.
So there can be...
Some of the particular questions on something like the DASS 21
the patient might score particularly high on,
so that could be a place to actually focus your assessments on.
So the outcome tools can have a range of different uses.
We've talked about the stigma with mental illness,
but depression is one area where we've seen
a lot of prominent Australians come forward
with their stories of depression.
How useful is it that people are coming forward
and talking about their situations?
Jody, what do you think is the impact
on some of the patients that you see,
knowing that they're not alone, for example?
Yeah, that's exactly right.
I think just - yeah, exactly that - letting them know they're not alone,
that there are services out there that can help them...
Yeah, and places that they can go to and things like that, definitely.
Yeah, and lots of resources that we can touch on later.
But perhaps we can now discuss another case
of someone very interesting.
A 25-year-old woman called Yvonne, and she's living in a rural town.
She's the wife of the local schoolteacher,
and she's recently arrived,
which is not an uncommon story, I understand, in rural communities.
She's been a frequent visitor to the local pharmacist,
inquiring about natural remedies for insomnia, headaches,
irritability and general emotional upset.
The pharmacist suggested that she make an appointment
with the psychologist in a nearby town.
They're lucky to have one.
Bernadette, is this an appropriate referral?
Look, a direct referral from a pharmacist to a psychologist
I don't think is an entirely appropriate referral.
On a base level, she would need to see the general practitioner
to get rebates for the psychological services in the first place.
But, really, the most appropriate person for Yvonne
is to really have a full and thorough assessment
with a general practitioner.
There are so many issues going on for a patient like Yvonne.
She needs her medical history sorted out,
have a full physical check-up.
We need to find out about her drug and alcohol intake,
we need to find out about her social history.
She may have a whole range of issues that are going on in her life,
and it may be even as simple as domestic violence.
And I think all those issues need to be sorted
through a proper evaluation - an assessment done.
A full physical examination just to make sure
she has no underlying physical disorder, which is entirely feasible.
And then a management plan or a formulation
can be worked out for this person.
What tests might you run on her to exclude some of the common causes
of, say, an anxiety disorder?
I routinely, for all my new mental health patients...
I think it's really important for them to know...
As I said before, they often come in with physical symptoms,
and they honestly believe they have a physical illness.
So I think, in my part, if I do a full physical examination
and send them off for blood tests,
checking biochemistry, haematology, hormone levels, thyroid disorders,
biochemical profile,
both the patient and myself can be really satisfied
that there's no underlying medical disorder,
which every now and again we do get surprised with.
And certainly thyroid disorders pop up in anxiety disorders.
OK, so she's decided to come along and see you,
so she's bypassed the psychologist, she's come to the GP
or perhaps the community nurse,
so she's come into a port of call, which is allied health,
but you've got a really busy clinic.
You've got people stacked up waiting to see you, Catherine,
in your clinic, and she's presented and she's got a lot on her mind.
There's a lot to get through.
How are you going to manage that in a really busy practice
where somebody's obviously in need?
Well, of course, counsellors, psychologists, allied health
work a little differently from GPs in that we have more time,
so generally we'll have at least an hour.
So it's great that she's come to see you. (Laughs)
And I think I would reiterate
what Jock said and the others have said - listen.
I think the first port of call for anyone that comes through the door
is just hear what they have to say.
Because often just the telling of the story,
unburdening, will help.
Jock, I know you've worked in some very interesting parts of Australia,
and you're a very good listener.
How important is it to have that skill of listening
as a health professional?
I think it's critical.
But my intake assessment is very, very highly structured,
so I go through a huge amount...
I think I ask something like 400 questions.
Oh, my goodness. How long does that take you?
Over an hour, and pushing things through.
But it covers everything, and the last question is,
'Is there anything we haven't covered?'
(Laughs) Have you ever had somebody say...
Yes! Sometimes they say yes.
You know. 'I forgot to mention...'
But just taking the history in such a structured way -
it can be a revelation to a lot of people.
The other thing that shocks me is the number of people I've seen
with complex psychiatric histories who say,
'Nobody's ever asked me that.
Nobody's ever asked me what church we were brought up in.'
This is terrible!
I've had people...
I've just done an assessment for a chap in the US.
He said, 'I've seen three of the most senior professors,
in this state,' and it's a big state.
He said, 'They didn't ask any of those questions.'
You've got to ask.
People generally won't volunteer, men in particular,
and rural men even more extreme.
They won't volunteer unless you ask.
They're not holding it back -
they just don't think it's appropriate.
OK, so they keep it to themselves.
What's the story, Jody, with women -
say, younger women - who may also be reluctant for various reasons
to talk about where they're at.
What's your experience there?
I found, a lot of the time,
it's not actually the issue at hand that they've come to see you with.
What might they come to see you with?
What's an example of the sort of story someone would give
when they come to see you?
In my case, it's more focused on the children.
And then you actually get to talk to them,
and it's more about what's actually happening at home.
The whole story, so yeah.
It is a matter of listening
and sitting down and seeing what's going on in the home,
and everything else, and then it cuts back
on what's really happening, and a lot of the time...
That's fascinating. So they'll often bring their child for something,
a physical matter, for example?
Or even just with behaviours and things like that.
Yeah, so it's focusing not on them, on someone else.
And then you get to chat with them,
and it's not just about the children,
it's also about them.
So I guess you're building that rapport
which gives them permission to then talk to you
about what's really on their mind.
Exactly.
What are the issues they're up against?
Are they fairly engaged or are they isolated?
These younger women? How young are we talking?
Some of these mothers are what sort of age that you see?
Probably 15 is around the youngest,
but it ranges from 15 to, you know, 37.
And these women are all feeling very, very similar.
They're at home, they're isolated.
A lot of them aren't living in the towns
in which they've grown up, so they don't have many friends.
They don't work, a lot of the time, or they have worked in the past
and don't feel that they can maintain a job
whilst raising children and things like that.
Because it is difficult. Obviously, it's very difficult.
So, yeah.
Yeah, very interesting.
We've got a question from Bob from Armidale,
which is really carrying this seam through nicely, and he asks,
'What can be done if you think a friend is going through tough times?'
I bet we've all been asked this question.
'Is it my place to butt in? What can I do to help?'
So, Tim, can I ask you to respond?
Yeah, sure. Just taking up Catherine's point earlier,
I think it's great that a lot more people
are now aware of mental health problems
and can kind of spot them and pick them.
If you've got a friend who's going through tough times,
of course I would butt in. That's what being a friend is.
That's what friends are for, isn't it?
In fact, it's a comment on where we've got to as a modern society
that we would even need to ask that.
I think part of mental health problems involves being disconnected
from family and friends and social groups,
so of course butt in and check things out.
But it's also important...
The last thing someone who's going through tough times needs
is to be pushed around or directed.
So they still have to have some kind of control and empowerment
over what happens to them, but certainly being there,
supporting them, checking things out, listening to them,
offering to help is incredibly important,
and it's what being a friend is, I think.
I would go further and say, depending on the age...
If Bob's friend is younger,
a younger male will often need someone to go with them.
So, as a friend, you can offer to go with them somewhere.
And that may give them the impetus they need rather than saying,
'What you need to do, Bob or Bob's friend...'
That's a critically important point,
because studies have repeatedly shown
that the worst thing is critical relatives and friends.
A hypercritical attitude is counterproductive.
You just say to them, 'I don't know what the problem is,
but I will stay with you. We'll go together.'
CAROLINE: 'Cause often, yeah...
That's a really important point, isn't it?
Because often there's a bit of misunderstanding.
It's great that this friend's being supportive,
but isn't it the case that some friends and family,
when somebody expresses they've got a mental health condition,
they expect them to pull up their socks,
or get over it, or it's mind over matter...
Do you find that?
That expression, 'Let go, move on.'
(Growls) That's terrible.
Yeah, it's not particularly compassionate, is it?
It's not compassionate, it's not helpful.
We don't know what goes on in another person.
All you can say is, 'I will be with you.'
Mm. We've got another question now from Brendan, and he's called in.
He works in allied health and thinks he is in a position
to identify changed behaviours and moods in patients
he sees on a regular basis. What can he do?
TIM: (Whispers) Refer!
So he's not a general practitioner,
but he's working in part of the extensive team.
What can he do here, Bernadette?
I think someone in this position is quite well-equipped
to do a basic assessment scale, like a K10 or a DASS score.
My concern is what do you do with the information once you get it?
So I think as long as there's been some training
and you have a really good back-up of what to do with the results
once you get them, who do you refer to?
I feel the general practitioner's probably their next port of call,
and I would be delighted to get a referral from someone to say,
they've already done an assessment scale,
there's a concern about a particular patient.
And often that allied health worker, as you were saying, Catherine,
has spent a lot of time with that patient.
'Cause I think as GPs, we often get a little time poor,
and we're scurrying through things,
and often when it's a less pressured environment, there's time to listen.
That you get some real gems in terms of what's troubling someone.
Mm. We've got one more question that's coming through.
Stephanie from Casino wants to know,
'What happens in remote communities if a patient needs urgent psych care?
Where does the patient go?'
That's a very important question, isn't it?
Who's in a position... Jock?
It depends on which part of the country you're in,
and whether they can be treated at the site,
or whether they have to be removed, taken elsewhere.
There's a lot of legal complications.
A lot of consideration.
General practitioner again is the right person to go straight to -
to the GP.
Particularly somebody who knows the patient.
All GPs are aware of...
They'll get a call in the middle of the night,
'We've got a patient out here
who's just taken to his car with an axe, what are we going to do?'
And those people...
Maybe you do have to go straight to the police.
But the general practitioner is the correct person to approach.
They've got the legal background.
They've got a lot more experience too.
If it's a very remote community and there's no GP,
and even no nurse, that can get tricky.
So I'm uncertain about how remote that person meant.
But if there's no GP, there's generally a nurse
or a nurse practitioner or community nurse somewhere.
But, as Jock said, sometimes worst case scenario is the police.
Or, sometimes, I guess you could also pick up the phone.
There's that resource of picking up the phone and calling somebody,
or if you have a little bit more time doing a teleconference with someone.
RHEF, for those interested out there,
have done some terrific programs on teleconferencing
and how that's moving in very positive directions
for people living in rural communities,
allowing them to have access to mental health services,
but to remain in their community.
So there are lots of resources that people can possibly tap into
via the internet, teleconferencing, the phone.
So perhaps we could move on to our next case study.
This is a very interesting one
because it involves a young man, Charlie, who's a 13-year-old,
and his teachers noted an increasing withdrawal
from the classroom participation and his interaction with other students.
The teachers contacted the father
and suggested Charlie might need some help.
The father somewhat reluctantly brings Charlie to the GP
and relates that his wife died about 18 months ago from cancer.
However, he's not concerned about Charlie
and he thinks he just needs time to get over it.
He himself is a busy man, as he runs a large property now on his own.
Charlie seems reticent to talk about anything, like many 13-year-old boys.
If you were the GP, Bernadette,
where would you start with Charlie and his father?
This is a tricky one, isn't it?
Yes, I find these cases particularly challenging,
and, as a more mature GP, I know these particular patients,
I feel I don't... I find it very difficult
to develop a rapport with them
and I very quickly sort of refer or call in people
who I may be able to discuss the case with,
but I think mostly just developing that rapport and listening.
I do a lot of diarising with the younger patients
and getting them to write stories or do drawings.
I find that's useful.
I'd be concerned in this case about the father.
I actually would love to talk to him and get him in on a consultation,
at the same time, doing a covert mental health assessment on Dad,
because the child may well be exhibiting
the father's depressive illness.
So, in this situation, he has lost his wife
and may well be struggling himself.
Yeah. What do you think about that, Tim?
The father perhaps being part of this picture?
Yeah, I mean, if the wife has died through something like cancer,
that suggests quite a long period of illness,
so there's undoubtedly been some upheaval and distress in the home
for a while.
So I'd like to definitely spend some time with the dad.
I also don't think you should rule out problems at school.
If Charlie is withdrawn in class and withdrawing from classmates,
he might be getting bullied at school.
You know, it could be something like that going on as well.
So all sorts of things need to be considered in a case like this
where there are family dynamics as well.
Mm. Jody, you're a bit of an expert at communicating with younger people.
Some of us may...
It's such an important thing to make that connection,
but some allied health struggle with teenagers.
You work a lot with teenagers.
How do you find you go with that,
and what are some of the tips you could share with us?
I'd probably say it comes back to...
If you're wanting to do a complete assessment with this adolescent,
I'd probably take him out of an environment of...
Somewhere where he's comfortable.
So... you know, outside, play some handball with him,
have a bit of a chat about what's going on.
So, once again, it's getting the whole picture.
Like you were saying, it might not be anything to do with his mum.
It could have... He could be bullied.
There could be many things that are going on.
So I think it's just having a look and having a chat
and sitting down and listening to what's going on for this young boy.
Mm-hmm. Catherine, what would you be thinking here?
Well, I have a different thought.
I actually thought it was great that the teacher referred, um...
- What was his name? Charlie. Yeah. CAROLINE: Charlie.
And I think that's an added dimension.
It shows the raised awareness across all the services,
and it's not just about health professionals.
It's great that teachers are now keeping an eye out
for mental health issues in adolescents and kids.
And the important point about the teacher
is that the teacher picked up a change in Charlie's behaviour,
and I think that's the real key.
A teacher's someone who knows Charlie over a long period of time,
and to see a change in what's going on for him is a key
that there might be something going on.
CAROLINE: Mm. Mm.
I think it's important too, and I'll probably get into trouble for this,
but don't go straight to drugs in these cases.
There is so much pressure now to put children on drugs,
and I think that pressure has to be resisted.
A boy like this, it might be he is grieving his mother.
It could well be a protracted grief reaction,
in which case drugs are probably going to be the wrong thing.
He needs to develop that rapport with somebody
and be allowed to explore this.
It will take time. There's nothing gonna be lost.
Maybe he does need drugs, but that's down the track.
At the moment, let's start with building a rapport,
proper assessment, talk to the family,
talk to the other brothers, there may be aunties and uncles,
where are the grandparents?
All of this footwork that has to be done,
but don't run straight to drugs,
because the minute that kid goes on drugs, he's labelled.
In terms of the bigger picture too with management,
and this may be relevant for his father as well as for Charlie,
what are some of the other things apart from counselling
and apart from possible medication
that we could be using as part of management?
Say he did have some sort of depression
or some sort of adjustment condition...
I'm thinking of lifestyle factors here
that we could use to promote wellness.
What are some of the things that you use, Bernadette?
Yes, I'm very big on lifestyle issues,
and in my history-taking,
just getting a good fix on what the diet's like,
what the sleeping patterns are like,
and how much exercise the patient does.
In this situation, I'd be certainly trying
to get Charlie hooked into an exercise program.
There's good evidence to show that that improves mood and wellbeing.
Just making sure he's eating three meals a day,
having breakfast before he goes to school,
and having a nutritious diet,
yeah, and just adequate sleep, good sleep routines.
I was going to say sleep,
because so many teenagers cut corners, don't they?
And they're staying up late...
JOCK: They're staying up all night doing this.
..and they're doing all this all night.
Limiting electronic media after a certain hour at night
is very important.
It's a huge issue.
I'm sure you do find that, Tim -
adolescents with sleep disorders and anxiety,
and they're on their phones at three o'clock in the morning.
- Till all hours. Yeah. CAROLINE: Sorry. Jock?
A boy like this, he may have pulled out of sport,
so you'll have to speak to the sportsmaster
or whoever's coordinating the sport
and get them to give him extra attention.
Quite often... my experience from many years ago
was that if you stumbled at sport, you were out.
What we're trying to do is get them to bring the stumblers back in.
We don't want elitism in sport at this age.
We want it to be all-inclusive.
Are there any... Does he belong to a church? Does he belong to Scouts?
Are there other support groups?
All of these things to improve his socialisation
and reduce his withdrawal.
- Mm, yeah. - They're important.
Getting really connected into his community,
if he has retreated in other areas.
Yeah, very important.
We've got another question. Caller asks if a referral...
I think we touched a little bit on this before,
about if a referral from a pharmacist
about a customer is appropriate, especially in a small town?
- Hmm. - I think it's entirely appropriate.
CAROLINE: OK.
Certainly if it's a patient of mine that has medications
that the pharmacist has developed a rapport,
often they might be the first point of contact.
In a busy general practice in a rural community,
it may be 6 to 12 months before you see patients.
You're often doing repeat prescriptions
and I'd be quite happy to take a call from a pharmacist
with some concerns.
And I guess the way of managing chronic diseases
is very much a team-based approach,
and very often a pharmacist will be included in a formal way
on that team, and they'll be doing a medication review, possibly,
for that patient,
and they're very much part of the collaboration, aren't they?
I think in the old days
we were far more separate in our silos, weren't we?
And, these days, we've come together.
TIM: It's more of an issue of where the referral goes.
So a referral from a pharmacist to the GP is definitely appropriate -
a referral from a pharmacist somewhere else
might not be so appropriate.
And would the same go for whether you're an Indigenous patient
or an Indigenous community member, do you think, Jody?
I think, 'Why not?'
They may only be accessing a pharmacist,
so, I mean, that'll give them the opportunity
to then get that referral,
otherwise if the referral's not made, then...
CATHERINE: They're missed. - Yeah, that's exactly right.
Mm-hmm. Mm-hmm.
So, from all backgrounds,
having that network of referral is really important...
I think so.
CAROLINE: ..whether teacher, pharmacist, financial counsellor -
everyone has a role to play
in encouraging someone to get assistance.
JODY: Definitely.
Because, really, we're dealing with...
Early diagnosis, early attention
is really gonna make a difference to outcomes, isn't it?
This is what we're really here for,
is that sense of, 'How are we going to improve the situation for people?'
The buzzword is 'accessibility',
and the professionals have got to be accessible.
The worst thing is where they're hiding behind big walls
with iron bars, even with broken glass on the top.
The first mental hospital I worked in
still had broken glass on the top of the walls,
and you've got to get away from that siege mentality,
because it takes over the professionals.
This is why when I was in the Kimberly,
my office was actually my four-wheel drive.
I didn't actually have an office,
and that was fine because people knew where I was,
and there was no sense of,
'You can't stop me, you can't talk to me.'
There was always a sense of moving through the community.
I always used to use the analogy that Mao Zedong said,
that the Red Army moves through the community
like a fish moves through the rice plants in a rice paddy -
it never does any damage, it's always there.
And that's how we have to be - have to be accessible.
Fantastic.
Now, for those of you out there who would like some more information,
there are a number of organisations
who have a range of very useful information
and support on this topic.
Some of those resources that are available include
the list that will be on our website.
I guess younger people too are accessing lots of resources
on their smartphones, aren't they, Jody?
JODY: Yeah, definitely.
CAROLINE: What are your clients doing
in terms of apps
and that sort of thing?
JODY: So, yeah, just downloading,
like, Relaxation/Mindfulness.
There's lots and lots.
So if you've got anxiety or depression or anything like that,
all you need to do is type it into your phone
and it'll take you on there, pretty much.
CAROLINE: Mm. Fantastic.
I think you need to be a little bit careful about...
Well, we need to be careful about some of those sites,
because a lot of them are actually maintained by drug companies.
They are heavily biased in favour of drugs,
and they don't go through the proper assessment
and they don't utilise other options
anywhere near to the extent that they should.
So patients will come in and say,
'I've done this and I've done that. I found this on the internet.'
You have to be very careful of that.
One bloke came in and said,
'I've accessed 25 sites and I've got 25 diagnoses.'
- (All laugh) - He was a very sensible man.
That's what happens with Dr Google,
but perhaps that's what we're here for, to be the filter.
Yes.
So I'd like to wrap up
because we've had some wonderful conversations tonight.
Perhaps take-home messages, because we've covered a lot of ground here.
Jock, what would be your take-home message for this evening?
For the health practitioners, be accessible and listen.
Really, that is the name of the game.
The worst thing is to be judgemental
or to treat the person as a lump of meat or a biological specimen.
You sit down, assess this person.
I mean, you're doing it professionally,
but at the same time you're being human.
So there's two levels - always these two levels going.
And you need a detailed assessment,
you need as much information as you can,
you share the information back with the patient
and then you discuss the options.
I don't use a lot of medication.
I never have, and I think it's not necessary to jump straight to drugs.
There's a lot of fear in general practitioners,
'If I don't put this person on antidepressants,
he could kill himself.'
The evidence is that he's just as likely to
if you put him on antidepressants.
There's a lot of figures to support that now.
So, basically, I guess you're saying,
'Listen, take the entire history into context, and be available.'
Yes.
You must be a wonderful psychiatrist.
You're one of the ones that are truly available.
- A very tired psychiatrist. - A very tired psychiatrist.
Catherine, what are the take-home messages from tonight?
I think as well as being available and accessible,
I think it's important to be inclusive.
So as well as including the person, include their families,
include their carers, friends, their support networks.
Make sure everyone's involved, and that person will do much better.
And in terms of encouraging health literacy
and for everybody to be understanding of the issues at hand,
is that really important as well when you bring everybody in?
So as well as including the families,
we should also include other health professionals,
so that's communication, I guess, in a nutshell.
Communicate with everyone. (Laughs)
Yeah, well, that's a really important point.
Jody, from your perspective,
you've got a tremendous amount of experience
working with younger women in particular.
What would you like to say
to perhaps some of the younger women watching tonight?
Yeah, that you're not alone,
that there are other people out there,
other women that are going through the same types of things,
so, yeah, get in contact with your local services,
talk to your midwife, talk to your doctor, those types of things.
- Fantastic. So, stay connected. - Definitely.
And I guess you've also talked tonight
about creating some sort of structure in your day
so you've got some purpose, something to go and do.
That's exactly right, exactly right.
Yep.
So, Bernadette, from your perspective?
Yes, I'd certainly like to second what Jock said
about listening to the patient, developing a rapport.
But mental health disorders are extremely common in the community,
and, really, the general practitioner stands at the coalface
and is the point of often first or second contact,
and is ideally placed to be the coordinator of that care,
to be the referral pathway,
of certainly assessment and then referral
and getting the best management for patients.
And I think it's really important
with the incidence of mental health disorders
that GPs constantly have their antennae up
for underlying psychological disorders.
It can make your life a lot easier if you detect them earlier.
Mm-hmm, and would that also go for detecting distress in other people -
not just community members, but perhaps colleagues?
- Oh, yes. - Perhaps ourselves?
Yes, yes. Certainly. Yes.
So keeping the radar up at all times?
Yes, I think it's really important.
Tim. What would you like to leave us with tonight?
Well...
We've heard some very interesting perspectives
and you certainly have a very interesting role as a psychologist.
Yeah, I do.
I think I'm lucky to work as a psychologist, and it's a role I love.
I think mental health problems
need to be considered as problems of living -
that there's nothing wrong with the person
when they've got a mental health problem,
there are problems in the life they're having
and the life they'd like to live.
So I think we need to spend time understanding the person
in the context of the life they're wanting to live
or the life that they value.
There's a range of terrific, effective options out there.
Not every treatment option is going to be effective for every person.
So it's a matter of helping people get good information
about the range of treatments that are available,
and then putting them at the centre of the decisions that are made.
- Wise words to finish with, Tim. Thank you, Caroline. (Laughs)
So I hope you've found this program on Mental Health Assessment useful.
The Primary Care Role - it's such an interesting topic, isn't it?
We could talk about it all night.
But if you're interested in obtaining more information
about the issues raised in the program
or you'd like to watch this program again,
please visit the Rural Health
Education Foundation website
at rhef.com.au
and click on the program page
'Mental Health Assessment -
The Primary Care Role'.
If you're a health professional,
don't forget to complete your CPD evaluation form,
which can be completed online.
You'll receive a certificate of attendance
and, if eligible, CPD points.
Our thanks go to the Department of Health and Ageing
for making this program possible,
and a special thanks to you
for taking the time to watch and contributing to our discussion today.
We'd appreciate any feedback on the program.
Your comments are very important to us.
So let us know you watched the program
by sending us an email or text,
and feel free to share your views - we'd love to hear them.
I'm Caroline West. Goodbye. And join us again on the Rural Health Channel.
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