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You can work it out: shrinks aren’t always the best option

Keeping a journal or confiding in a friend can help overcome emotional issues.

“When people get sick or injured or want advice about their health, they want to see a doctor” Dr Andrew Pesce, AMA President.

As a child psychiatrist, I work with general practitioners to enhance the well-being of children and adolescents. I think the role of the GP is and should remain central to the Australian health care system.

There are two groups of potential patients for psychiatrists:

  • 1% to 2% of Australians who are intermittently or permanently crippled by severe psychosis, mania, fear or melancholy; and

  • 20% to 25% of Australians who at some point in a year could attract a psychiatric diagnosis, including alcohol misuse.

The first group does require expert mental health intervention. Many in the second group don’t even acknowledge a problem and, if they do, it often resolves without medical intervention.

Many don’t want medical attention anyway, and there is no good evidence that psychiatrists produce better outcomes for these patients than our less expensive colleagues.

Unfortunately, in public pronouncements on psychiatry, the second group is often conflated with the first. This is illustrated in claims such as hundreds of thousands of young Australians are currently locked out of the mental health care that they desperately need.

These claims exaggerate the needs of the second group while deflecting attention from the unmet needs of the first.

So where do GPs come into it?

The truth is GPs treat the majority of mental health problems and have a great deal to offer their patients. Primary care mental health should not be seen as a second-rate form of psychiatric intervention.

General practitioners have extensive knowledge of a patient’s community and, often, prior knowledge of the patient and their family.

This information and their capacity to build a relationship with the patient over time mean that GPs are well placed to provide optimal assessment and management of many primary care presentations of depression in young people.

Doctors make potentially great therapists because medical training teaches them to maintain equanimity and good judgment in the context of trauma, cruelty, despair and death.

It equips them to help patients to develop coherent and cohesive stories about their complex and confusing experiences. But psychiatrists are not the only ones who can do this.

Counsellors, confidantes, and even keeping a journal can fulfil the same function for some individuals, without patients having to adopt a medical label.

Under the Better Access scheme, the public health system supports GPs referring on mental health problems to psychologists and other allied health professionals.

One of the problems with this scheme is it forces GPs to label their patients in a potentially stigmatising way in order to access the services.

But more importantly, it encourages referring away of mental health problems rather than having the GP work collaboratively with mental health professionals.

The net effect is that GPs overrate what specialist mental health services have to offer, and underrate their own contribution. General practitioners should not be reduced to being prescribers and referrers.

Outside of serious medical matters, it is not the best first step is to seek out a doctor. That’s why I don’t join my colleagues in condemning Tuesday’s budget cuts to Medicare rebates for GP-based psychological services.

There are other ways to deal with both physical and emotional problems - which is not to be taken as a promotion of crank remedies.

Evidence consistently shows that relationships contribute more to healing than any specific intervention, evidence based or otherwise.

This is why “watchful waiting” - providing a careful assessment, in the absence of anything dangerous, and monitoring the patient’s well-being without applying a specific intervention - is so effective. It is also very different from doing nothing, with which it is often confused.

So let’s restrict the use of scarce specialist resources to when we are confident they can make a difference, let GPs take the lead with most mental health presentations, and encourage people to consider ways of making sense of their distress that don’t involve giving it a medical label.

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