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Tackling mild mental health concerns with short, sharp interventions


Doug Hendrie


30/11/2020 3:49:24 PM

Not all mental health consultations require referral or medication, experts said in a recent GP20 presentation.

A person closing their eyes and breathing deeply.
Breathing deep, grounding yourself and calming techniques can address some mild mental health concerns.

With the past 12 months of natural disasters and a global pandemic, GPs are seeing an increasing number of mental health presentations.
 
But some can be tackled very quickly with clear, direct interventions and exercises, according to Townsville GP and Chair of RACGP Rural Dr Michael Clements. 
 
One of Dr Clements’ patients this year was a woman whose grown children did not want her to visit them in a different city due to COVID concerns, even after Queensland had eased restrictions.
 
‘I was the only person she was allowed to see, and she was so broken from that lack of connection with her kids,’ he said. ‘I asked if she’d mind if I called her kids and asked. She said, yes please.
 
‘I did and, within a week, she was there with her kids.
 
‘Good holistic GPs know that short, sharp interventions in consultations are sometimes all that patient might need.’
 
These techniques were discussed alongside invented case studies during last week’s GP20 clinical session, ‘Short and sharp mental health interventions for the busy GP’, in which Dr Clements spoke alongside Dr Mary Emelus, a GP and psychiatric registrar, and Dr Cathy Andronis, Chair of the RACGP Specific Interests Psychological Medicine network. 
 
The panel discussed the example of ‘Jason’, a 22-year-old man who lost his job due to COVID restrictions and was living off JobKeeper. He had become withdrawn and spent his days playing videogames.
 
For patients like Jason, Dr Emelus suggested the use of the Healthy Mind Platter, a concept created by Dr Dan Siegel to describe what inputs keep our minds healthy.
 
‘I use this every day,’ she said. ‘It’s really useful for behavioural activation and as an evidence-based response to mild depression.’
 
The platter of essential mental activities lists sleep time, physical time, focus time, time in (reflection), down time, play time, and connecting time.
 
‘These are the things we need every day or at least regularly,’ Dr Emelus said.
 
‘Your mind is embodied and relational. It lives in your body, and lives in relationships with the world and people outside ourselves.
 
‘Sometimes you find people have grown up with the idea that play time or down time are wicked or a waste of time, so education that [this is] part of your mental wellbeing is really important.’
 
The panel discussed the example of ‘Malik’, a nine-year-old boy who refused to go to school due to bullying. Even after this had been addressed, he was still scared to go.
 
‘There’s been recent research showing an increased mental health burden on children and teens from COVID, and COVID stress,’ Dr Clements said.
 
Dr Andronis said calming techniques could be taught quickly to patients like Malik.
 
‘If Malik is stressed in [the] playground, we can give him a simple breathing technique, which is a good tool because his breath is always with him,’ she said.
 
‘You can model this in the consulting room as a simple and invisible relaxation technique you can take and do anywhere, anytime. Frame it in positive language appropriate for the age of the patient.’
 
For children such as Malik, Dr Andronis recommended a square breathing technique, in which patients visualise a square and as their eyes move mentally along each side, they count to four.

Michael-Clements-article.jpg
RACGP Rural Chair Dr Michael Clements believes short, sharp interventions are sometimes all a patient needs.
 
Another example given was ‘Lucy’, who lived in a rural town alone after her husband died. Though she has close friends, Lucy is acutely missing her adult children who live in another city cut off by travel restrictions.
 
Dr Emelus said for patients like this, she recommends the PERMA+ approach devised by positive-psychology pioneer Dr Martin Seligman and added to by the Wellbeing and Resilience Centre at the South Australian Health and Medical Research Institute.
 
Dr Seligman’s original framework PERMA stands for positive emotions, engagement, relationships, meaning and accomplishment, and represent five domains of human needs. To this, the Wellbeing and Resilience Centre has added optimism, physical activity, nutrition and sleep.
 
‘I would ask Lucy to notice when she was feeling happy, peaceful and content. It could be gardening, walking the dog, her favourite thing on TV,’ Dr Emelus said. ‘This is a lovely conversation to have with people.
 
‘I use this every day in all age groups. I use it at the beginning to build rapport and revisit it from time to time. Next time you see them you can ask how that Jack Russell of theirs is. People light up when they talk about things that matter to them.
 
‘In COVID, it’s been about what you can access. You could also acknowledge the difficulty of what you can’t access – a common conversation these last six months has been, “No wonder you’re struggling, you can’t access the things that normally give you wellbeing”.’ 
 
Another example given was of 55-year-old ‘John’, a veteran who served in Afghanistan and lives with PTSD and depression. His marriage has broken up and he does not see his children often. In a consultation, John goes vacant and stops responding, which could suggest a PTSD flashback. 
 
Dr Clement said that while this was hypothetical, he has noticed precisely the same response in some of his patients.
 
‘People find themselves in the dark place and you don’t know why, they don’t know why,’ he said. ‘I even had an experience with a patient with a support dog. The dog noticed right away and went straight up and nuzzled him when he went into the dark place.’
 
Dr Andronis said entering a frozen state could happen any time and seemingly out of the blue.
 
In these situations, a quick intervention would be speaking to him calmly and slowly, using a very gentle, even voice, as if singing a lullaby.
 
‘In a split second, he’s not in the room. He’s not understanding what’s happening around him. He may be incredibly stressed,’ she said.
 
‘You might say, “It seems very difficult for you to be here now. Can you feel your bottom on the chair, your feet on the ground?”
 
‘Encourage slow breathing, or stretching a little bit. You could ask him to tell you five things you see in the room. This is a technique to bring people mindfully back into the room and help people to de-stress from a frozen state to a normal active mode.’
 
For their last hypothetical, the GPs discussed ‘Mr Emerson’, a highly community-minded retired school principal. COVID ends all of his activities and Mr Emerson finds himself ruminating at night about living alone and his lack of meaningful activities. His only bright spot is taking his dog for a walk daily.
 
For these situations, Dr Andronis recommends drawing on mindfulness techniques and weaving them into his daily walks.
 
‘Ask him when he’s walking to consider what he’s seeing in the world around him, not his worries, not his ruminating thoughts,’ she said. ‘You can say, “When you walk, try to have stretches where all you notice is the footsteps on the ground. Left, right, left, right”.
 
‘Or you could try a five-senses exercise: “What can you see, hear, feel, smell, taste?”
 
‘Or you could give an activity that’s very useful for people who are highly anxious, which is to look at your surroundings and look at each letterbox and notice them – big, little, wooden, metal ones.’
 
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