Feature
Expert calls for GP psychiatrist sub-specialty
A prominent GP and researcher has suggested the sub-specialty to help provide better treatment to patients with mental health conditions.
Associate Professor Louise Stone is calling for a new GP sub-specialty in mental health.
Mental health is now the single most common reason patients see their GP, and the health issue that causes GPs most concern for their patients’ future.
GP and Australian National University (ANU) Associate Professor Louise Stone recently raised the idea of a GP psychiatry sub-specialty as a way to treat ‘the patients lost in the middle’ – those who are too well for acute mental health and too sick for primary health networks and headspace.
Associate Professor Stone told
newsGP the patients seen by GPs are often not seen by other mental health professionals.
‘The patients we see are often those who don’t go to psychologists or psychiatrists, particularly those who can’t afford long-term care and who have a history of long-term trauma. The system doesn’t offer public care for those patients,’ she said.
‘We see a lot of patients with mental health problems that we wouldn’t call disorders. Grief, breaking bad news, workplace bullying and harassment, patients coping with the birth of a child with a disability, the transition to palliative care, becoming a carer and struggling with the emotional impact of it.
‘Those patients belong in our space as GPs.’
Associate Professor Stone believes a possible structure for GP psychiatry might be to add a third level of accredited training to the existing two levels set by the
General Practice Mental Health Standards Collaboration (GPMHSC).
‘You would be able to demonstrate to the [GPMHSC] that you have the experience, not only the qualifications,’ she said.
According to Associate Professor Stone, however, better funding for GP mental health would have to accompany the sub-specialty.
‘It’s $2 a minute to see a suicidal patient, and $6 a minute for six-minute medicine. You take a cut when you see a longer patient,’ she said.
‘I love the work, but I’d go broke if I did it all day.’
Associate Professor Stone said that, as generalists, GPs are well placed to look after these patients.
‘GP psychiatry would be about finding GPs who have made this their interest within general practice,’ she said.
‘We take the patients everyone else rejects. We talk about stepped care, but we’re the closet under the stairs.
‘My vision of it is not about becoming a psychiatrist, but about doing the work we already do in general practice and going deeper in what we actually we do.’
Associate Professor Stone outlined a possible structure for a GP psychiatry sub-specialty
‘If we’re able to recognise this, we might be able to get VMO [visiting medical officer] status in rural communities so we can admit patients,’ she said.
‘It’s about time we had an MBS item for an extra level of care for 50 minutes for trauma or suicidality. At the moment, I do ridiculous amounts of pro bono work because I can’t charge adolescents sleeping in cars. You just can’t.
‘Because of that, we need to make sure GPs who do this work don’t burn out. Their income is so much lower than if they only did procedural work, and the emotional impact is high.
‘Mental health in general practice is really different. I spent my first 10 years as the only female GP within three hours, so I was flooded with trauma. I delivered lots of babies to women who had been sexually assaulted. The work finds you.
‘One of the things we do that psychologists and psychiatrists don’t have the chance to is get people really early, before they form their ideas [about their condition]. They don’t know they have depression or anxiety. They just know they feel wrong.
‘It’s up to us to shape the story, to give people ideas to hold on to and to help them seek care.
‘You might have a patient coming in with chest pain, irritable bowel syndrome and intergenerational trauma, and you’re trying to give them a sense of where their psychological history fits, and then do matchmaking for them to find the right psychologist or psychiatrist to take them forwards.’
Associate Professor Stone said the current primary care mental health system – such as mental health care plans – might be a good first step for many patients, but leaves the complex and challenging issues untouched.
‘Mental health care is now very commodified and is seen much more procedurally,’ she said.
‘You make a diagnosis, follow the protocol, give an aliquot of care, the patient gets better. But that just doesn’t work in my world. It just doesn’t work.
‘If I take a patient with intergenerational trauma, somatisation, sexual abuse and four chronic diseases, calling it depression and giving cognitive behavioural therapy [CBT], it’s not what it is. A little bit of CBT is a drop in the ocean.
‘It doesn’t touch childhood trauma, which affects one in four women and one in six men, and which we know does awful things to a person’s sense of self. What we need is trauma-informed care and a longstanding relationship with someone who treats them with respect.
‘For those who are really unwell, I’d prefer them to be seeing a psychologist or psychiatrist every fortnight over years. But we’ve chosen not to fund that, and so instead I’m the surrogate.’
mental health stepped care sub-specialty
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