Managing Mental Health

Mental disorders are the leading cause of years of life lost due to disability in Australia. The predominant disorders in males are substance abuse disorders (primarily alcohol abuse), suicide / self harm and depression. Affective disorders (predominantly depression) are the leading cause of mental heath disorders in women.1

The likelihood of co-morbidities is also high, with one in three people suffering from an anxiety disorder also suffering from an affective disorder, and one in five a substance abuse disorder.

An increase in the early diagnosis and treatment of mental disorders in the last 15 years is likely to have played a large role in the reduction in suicide rates in Australia.²

The has lead to the Australian Government introducing the Better Outcomes in Mental Health Care program, followed by the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule.³

A GP is the most accessible person for patients to approach regarding mental health problems.⁴ Approximately 75% of patients with a mental illness will approach their GPs for help.⁵

However, a substantial number of patients still find it difficult to disclose their psychological problems to their GP.⁴ In these patients, it is common for mental illness to masquerade as a medical condition with non-specific symptoms such as insomnia, prolonged fatigue, headache, nausea and musculoskeletal pain.²

The 12 item Somatic and Psychological Health Report (SPHERE-12) is one of many screening instruments available to assist in identifying these hidden mental disorders.⁶ It has two components of 6 items each; the first measures aspects of depression and anxiety, and the other measures fatigue.⁶

Studies have been conducted into its sensitivity and specificity. Some studies report sensitivities of up to 93% and specificities between 20% and 72%.^2,6 The SPHERE-12 has the potential to identify less severe cases likely to benefit from early mental health interventions.²

Alternatives include the 30-item General Health Questionnaire (of which part of the SPHERE-12 is derived) and the Composite International Diagnostic Interview (CIDI), which generates a diagnoses based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).^2,6

Alternatively, if the patient is willing to discuss their psychological problems, Carlatt has suggested some useful screening questions for some common disorders:⁷

Depression:

• "How has your mood been recently?…Have you ever felt very down or depressed, so depressed that your whole life was affected by it for at least 2 weeks?"⁸

Anxiety:

• "Are you a worrier?…What do you worry about?"⁹ 
• "Have you ever had a panic or anxiety attack?"¹⁰

Suicide / self harm:

• Direct approach may be useful
• "Have you ever felt suicidal? Have you had thoughts of wanting to hurt yourself?"¹¹

Substance abuse:

• "Do you enjoy a drink now and then?"¹² 
• Followed by CAGE:¹³
  • Cut down ("have you ever felt you should cut down?")
  • Annoyed ("have people annoyed you by getting on your case about drinking?")
  • Guilty ("have you ever felt bad or guilty about your drinking?")
  • Eye-opener ("have you ever needed to take a drink first thing in the morning to steady your nerves or get rid of a hangover?") 
• Lastly: "Do you think you have a drinking problem?"¹²

Psychosis:

• "Have you had any experiences like dreaming when you’re awake? Have you had any strange or odd experiences lately that you can’t explain?…Do you ever hear or see things that other people can’t hear or see?"¹⁴

Caring for yourself

Mental health isn’t just for patients. Doctors are rarely taught how to reduce their stress and improve their own wellbeing while dealing with human suffering.¹⁵

Hilton Koppe, a Senior Medical Educator and General Practitioner in New South Wales, has published several papers providing tools and strategies for doctors to improve their self care.^15-18 The end result is that you have to make a focused effort to look after yourself physically, mentally and spiritually, and to look after your relationships, activities and the environment where you live and work.

Tips for looking after yourself:

• Eat well, exercise and reduce the amount of toxins you consume (such as alcohol).¹⁸
• Interrupt negative self talk and replace it with positive messages.
• Take 20 minutes of mental quiet time each day. This can be in small portions. ¹⁸
• Try to see the humanness in those around you, ponder the mystery of life and incorporate a spiritual ritual into your week (such as giving thanks). ¹⁸
• Put time aside for your relationships (e.g. have at least one night a week together). ¹⁸
• Try to have at least one activity to look forward to each week. ¹⁸
• Finally, you probably spend more waking hours in your surgery than you do elsewhere, so take a good look around your surgery and see if there is any way you can make your consulting room more pleasant. ¹⁸
  

References

1. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Health and Welfare; 1999.
2. Wihelm K, Finch A, T D, Hickie I. What can alert the general practioner to people whose common mental health problems are unrecognised? Medical  Journal of Australia. 2008;188(12):S114-S9.
3. Fletcher J, B B, Kohn F, Naccarella L, Blashki G, Burgess P, et al. Meeting demand for psychological services for people with depression and anxiety: recent developments in primary mental health care. Medical Journal of Australia. 2008;188(12):S107-10.
4. The MaGPIe Research Group including, Bushnell J, McLeod D, Dowell A, Salmond C, Ramage S, et al. Do patients want to disclose psychological problems to GPs? Family Practice. 2005;22:631-7.
5. Australian General Practice Network. Primary Mental Health Care [online]. 2008 [cited 2008 October 1] Available from: URL: www.primarymentalhealth.com.au.
6. Clarke D, D M. An examination of the efficiency of the 12-item SPHERE questionnaire as a screening instrument for comon mental disorders in primary care. Australian and New Zealand Journal of Psychiatry. 2003;37:236-9.
7. Carlatt D. The Psychiatric Interview. 2 ed. Philidelphia: Lippincott Williams and Wilkins; 2005.
8. ibid. p. 154
9. ibid. p. 175
10. ibid. p. 172
11. ibid. p. 146
12. ibid. p. 183
13. ibid. pp. 182-3
14. ibid. p. 191
15. Koppe H. Wellbeing Part 1 – what is it? Australian Family Physician. 2002;31(4):374-5.
16. Koppe H. A road to humanity. Australian Family Physician. 2008;37(7):563-5.
17. Koppe H. Self care strategies for doctors: Assessing our wellbeing. Australian Family Physician. 2002;31(5):475-7.
18. Koppe H. Self care strategies for doctors: Making changes. Australian Family Physician. 2002;31(6):569-72.