Mental Health Assessment: The Primary Care Role

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 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. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs.

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