Young people’s mental health: Why early engagement matters

Caroline West

3/08/2022 1:16:06 PM

Increasing numbers of young Australians are battling mental health disorders. Dr Caroline West looks at how GPs can help.

Young woman talking to GP
Many young people initially do not feel comfortable speaking to health professionals about their mental health.

Rebecca Langman remembers her time in high school, when her struggles with mental health began.
At 15 she found herself losing interest in activities, sleeping a lot and not wanting to go to school. Once at university, ‘everything got a lot worse,’ she told me in a recent NPS MedicineWise podcast.
‘I was experiencing a lot of really depressed, sad feelings, some suicidal ideation, substance use, lots of different things.
‘I didn’t have a regular GP. I didn’t have a psychologist.’
Rates of mental health disorders in young people on the rise
Rebecca is not alone. According to the latest National Study of Mental Health and Wellbeing
almost 40% of young people aged 16–24 had a mental health issue in the previous 12 months. And the long-term picture is equally concerning. A staggering 75% of those with mental health issues develop them prior to the age of 25.
Rates of antidepressant prescribing have also been on the rise. According to a 2021 study using the GP dataset ‘MedicineInsight’, antidepressant prescribing for young Australians aged between 18 and 24 years almost doubled between 2011 and 2020. COVID has of course complicated the picture further, with disruptions to work, study, travel and social connections.
The GP’s role and building engagement
Often the first point of professional contact for young people in distress, GPs know about this alarming trend all too well. 
Coffs Harbour GP Dr Nicola Holmes, who specialises in young people’s mental health, says it can still be ‘a difficult topic for young people to broach’ and that engagement early on makes a huge difference to outcomes.
The results of an NPS MedicineWise survey released this week suggested that almost half of young people initially do not feel comfortable speaking to doctors about their mental health issues – but, more positively, that the process gets easier.
Dr Holmes has adopted a proactive approach.
‘I think every opportunity you see a young person is an opportunity to screen around their mental health,’ she said.
‘You’ll find they’ll come in with an infected toenail or they’ll come in looking for help for their painful periods, or whatever is the medical issue presenting, but behind that, if you explore, often you’ll find the path into addressing psychological issues.’
Dr Holmes is a fan of the HEADSS assessment to start the conversation and build engagement, and she is always mindful of addressing the question of risk.
Keeping young people safe
It is a national tragedy that suicide is the leading cause of death in young people. And for every death, there are 100 to 200 estimated attempts. For those who belong to the LGBTQI or Aboriginal or Torres Strait Islander community, the risk is substantially higher.
Safety planning is one intervention that can make a real difference, yet a recent NPS MedicineWise survey has revealed that only 43% of respondents aged 16 to 24 with mental illness had used a safety plan, suggesting underutilisation.
Dr Michael Millard, Psychiatrist and Clinical Director of the Clinical Research Unit for Anxiety and Depression at St Vincent’s Hospital and the University of NSW says we need to bust some of the myths around talking to our young patients about suicidal thoughts.
Contrary to some concerns, he points to meta-analysis in the British Journal of Psychiatry from 2021, which shows that safety planning can reduce suicide risk by 43%.
Dr Millard says it is like a fire drill.
‘We all get the need to practice for a crisis event and be prepared,’ he said. ‘Safety plans help save lives and I recommend that they are updated regularly.’
Dr Holmes thinks GPs need to ask about suicidal thoughts.
‘[Not talking about suicidal thoughts is] a bit like saying, don’t ask anyone if they get chest pain on exercise, just wait ‘til they have their heart attack,’ she said.
‘We have strong evidence that asking about suicidal thinking does not increase action on those thoughts. In fact, it decreases it.’
Both Dr Holmes and Dr Millard have found the Beyond Now suicide safety plan app (free on the app store) a very useful practical safety plan that can be put on someone’s phone, unlike a paper version which can get lost.

Dr Caroline West believes that GPs have a crucial role in early intervention for mental health issues among young people.

Are we prescribing too many antidepressants?
The last couple of years with COVID have been especially tough for young people.
Many GPs who manage young people with mental health conditions are feeling the pressure of managing complex conditions with extreme time pressures and limited resources.
There can be pressure from a variety of sources including the patient, their family or carers to ‘do something’ to alleviate the distress by prescribing an antidepressant.
Concerns have been raised over the increase in prescribing. GPs currently prescribe about 86% of antidepressants.
As a former GP, Dr Millard acknowledges the urge to ‘do something’ and prescribe, but he is concerned that messages around clinical guidelines and the lack of evidence for SSRIs for mild-to-moderate depression are not always getting through.
SSRI side effects, like impacts on sexual function, agitation, suicidal thoughts and discontinuation symptoms, need to be carefully discussed to ensure a young person is sharing the decision and is giving their informed consent. And antidepressants cannot remedy many of the drivers of distress including unemployment, poverty, trauma or loneliness.
The exact reasons for the uptick in prescribing of antidepressants to young people may be complicated, but many GPs cite the lack of psychological service options as a key driver.
While the number of yearly psychological sessions currently covered by Medicare has increased from 10 per year to 20, this has not tackled the double whammy to young consumers of availability and, very importantly, affordability.
‘The vast majority of psychologists in my area won’t bulk bill,’ Dr Holmes says.
With the out-of-pocket gap often being more than $100, it is completely unsustainable or impossible for many.
Digital mental health treatments on the up
The rise of digital mental health treatments like This Way Up and Mindspot is going some of the way to filling this void.
Already 27,000 clinicians and about 160,000 Australians have used This Way Up programs. In addition to psychological therapies, Dr Holmes also stresses the importance of finding lifestyle interventions that a young person is interested in, including nutrition, exercise, hobbies and social groups that add to the management tools.
NPS MedicineWise has created a range of professional and consumer resources including videos, podcasts, decision aids and fact sheets, which can be found on the NPS MedicineWise website.
Maintaining mental wellness
Dr Millard feels that the management of mental health in young people is evolving.
‘The whole narrative of mental health would benefit from a reframe to the idea that we should be empowering our patients, helping them know that there are things they can do now that will make a difference,’ he said. 
‘As clinicians, we have a responsibility often when people don’t have that hope or that belief, firstly, to let them know that recovery is possible … And the aim really is to be building out their life as much as possible in terms of the things that keep them well.’
These days Rebecca is focusing on those aspects of life that help keep her well, while also being a passionate advocate for young people with lived experience. She is supported by her partner, friends and her health professionals, and along the way has cultivated a deep connection to nature.
‘Empowering young people and educating them is probably the most helpful thing we can do,’ Dr Millard said.
NPS MedicineWise has a range of consumer and health professional resources on engaging and empowering young people with mental health. See the NPS MedicineWise website.
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