New report shows GPs’ role in mental health care is increasing

The latest Australian Institute of Health and Welfare (AIHW) data on mental health services in Australia (MHSA), released on 13 October, provides a picture of the national response and shows the role of GPs in mental health care is growing.
 
According to figures from the BEACH survey, around 12.4% of all general practice encounters were mental health-related in 2015–16, up from 10.8% in 2007–08.
 
Depression, anxiety and sleep disturbance were the most commonly managed problems, accounting for 60.8% of all mental health-related consultations.
 
GPs prescribing, suppling or recommending medication was the most common management approach (61.6 per 100 encounters), followed by counselling, advice or other clinical treatments provided by a GP (49.6 per 100 encounters).
 
Referrals were given at a rate of 18.8 per 100 encounters, most often to psychologists and psychiatrists.
 
People aged 65 and over had the highest rate of mental health-related encounters, with 1198.2 per 1000 population, far more than the national rate of 749.9.
 
Dr Louise Stone is a GP and Clinical Associate Professor at the Australian National University and has a special interest in mental health.
 
While she agrees that the GPs’ role in mental health is increasing, she believes the data grossly underestimates the reality.
 
‘Generally speaking, BEACH data is fine, but BEACH data is now old so we’ve got out-of-date figures,’ she told newsGP.
 
‘The rest of the data that comes from the AIHW tends to come from the mental health billings.
 
‘So if I see a patient for a mental health condition and I just bill a normal consultation, they don’t get counted.’
 
As it stands, the data-collection process does not account for patients with long-term sequelae and multimorbidity common in general practice, leaving many mental health consultations unaccounted for.
 
‘For instance, when I treat a patient with autism who also has cardiac disease, their autism is part of that presentation but it doesn’t get counted as mental health,’ Associate Professor Stone said.
 
‘Neither does grief counselling, breaking bad news, divorce, sexual assault, harassment, bullying at work, issues with kids who are anxious or kids who have got abnormal behaviours, behaviour disorders in dementia.’
 
Almost $10 billion was spent on mental health in Australia in 2017–18; however, Associate Professor Stone says many mental health organisations have models based on a ‘single-illness fallacy’, which often sees patients with complex needs fall through the cracks.
 
‘It’s always good to build a service on which there is evidence and the people for which there is evidence have a single diagnosis; first presentation of depression or anxiety, nothing else going on,’ she said.
 
‘All the non-government organisations tend to take the least complex, more easily managed, better-outcome patients, which means that general practice tends to get the patients who are more complex, more multimorbid, less fixable, and have no evidence.
 
‘They tend to be the patients who can’t afford anything. We know that the greater your disadvantage, the more mental health problems you have, and the less services you get.
 
‘There’s an assumption that GPs only treat mild-to-moderate depression and anxiety. It’s not true.’


Dr Louise Stone believes GPs’ mental health encounters are complex and disagrees with the ‘assumption that GPs only treat mild-to-moderate depression and anxiety’.

In 2018, there were 3441 psychiatrists (13.3 full-time equivalent [FTE] per 100,000 population), 23,083 mental health nurses (87.8 FTE per 100,000 population) and 27,027 psychologists (92.3 FTE per 100,000 population) employed in Australia.
 
The data highlights a shortage of psychiatrists, and with mental health expected to worsen as a result of the COVID-19 pandemic, Associate Professor Stone says that shortage is only ‘going to get worse’.
 
The recent 2020-21 Federal Budget committed $5.7 billion in mental health and suicide-prevention funding.
 
But with GPs already projected as being central to dealing with the long-term sequelae of the pandemic, and often the first point of contact for people concerned about their mental health, Associate Professor Stone says this is not evidenced in the distribution of funds.
 
‘We’re always told politically that we are the cornerstone of the health system, but we were not in the budget,’ she said.
 
‘I haven’t seen the words “general practitioners” in the health budget, at all. So how does that work?’
 
‘We also don’t tend to turn up in health plans, except for referrals in and referrals out, and our patients don’t get counted; they’re silent in policy.
 
‘We actually need to look at the patients who don’t turn up to services and start to look at their suffering to understand what GPs actually do.’
 
To gain that understanding, Associate Professor Stone believes GPs need a seat at the table.
 
‘Someone needs to talk to us. We’re not in on the policy conversations – they’re not happening,’ she said.
 
‘Someone said the greatest mystery in health is what happens in an item 23. We do a lot of this and no one’s got a clue. So until we know what GPs are doing, I don’t think there’s any way of getting around this.’
 
While better directing of services requires up-to-date, in-depth data, the last mental health survey in Australia was conducted in 2007.
 
‘We know what people turn up to services, but we don’t know what’s out there, we don’t know how patients travel through the system,’ Associate Professor Stone said.
 
‘Now, in my experience it’s a little bit like a pinball machine. I click patients into the system, they bounce around a whole lot of services, they get rejected after triage, and they come back to me if they’re complex, which most of them are.
 
‘But every hour we spend assessing someone and deciding that they’re not right for our service is an hour of wasted money – and I’m seeing a lot of waste.
 
‘The Department of Health’s mission is health for all Australians. Well, we’re failing.
 
‘The people with the most need get the least services, and we can’t fix that without data. Chucking more [money] at it is the easy part, but it is not good policy.’
 
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