WHERE does your mind fly when you hear the term “mental illness”? Do you think about chronic enduring illnesses such as schizophrenia, bipolar disorder or schizoaffective disorder? Would you include personality disorder in that list, or eating disorders?
If that’s the sort of list you come up with, you are missing most of the people in the population who are experiencing the kind of psychological distress and mental illness that is occurring all around you, in your patients and in the community at large.
I do not need to say to this readership that one in five Australians experience mental health difficulties every year. And the lifetime prevalence of mental health disorders in Australia is 47%. One per cent of the population has schizophrenia. Between 3% and 9% have bipolar disorder (depending on your sources). But no matter how many of the severe and enduring illnesses you include, you will still fall short of that 47%.
So, what’s going on? The truth is that the commonest mental health disorders in the community are not the severe and enduring kind, but anxiety, stress and depression – conditions that are potentially very serious, but which are not necessarily what we think of when we are asked to think about “mental illness”.
The tragedy is that, as medical practitioners, we are not all well equipped to recognise and manage these common mental health conditions – either in ourselves or in others. The Royal Australian College of General Practitioners’ (RACGP) 2018 Health of the Nation Report recognises, for example, that about two-thirds of general practice consultations contain a mental health element, and two-thirds of GPs say patients talk about mental health more than any other health issue. GPs identified patients’ mental health as being the most concerning health issue for the future.
But it doesn’t matter whether your specialty is general practice or something else, many people are coming through your door with mental health concerns. Their distress may be directly related to whatever physical symptoms or condition has brought them to see you, it may be exacerbating their physical condition, or it may even be the basis of their inability to manage their physical condition. In all these situations, their mental health is very much your business – whether psychiatry is your specialty or not.
Much of the psychological distress we see in medical practice is in the mild to moderate range. Much of that distress can be managed without medications and without referral to face-to-face care if practitioners can point their patients to appropriate, low intensity interventions and know how to use them.
What do I mean by a low intensity intervention? I mean something that provides support and teaches psychological survival skills using brief therapy techniques; techniques that use therapists’ time efficiently and which match the severity of that person’s distress.
Low intensity interventions include GP-delivered counselling, community-based counselling, guided self-help, group therapy and online self-help.
Do you know that Australia is a world leader in the development of evidence-based online therapy programs? The first one was MoodGYM. Launched in 2001, MoodGYM is an online interactive self-help book which has been used extensively all over the world in research and clinical environments and has been proven to be effective in resilience building in vulnerable adolescents (for whom it was originally developed), as well as in the treatment of mild to moderate anxiety, depression and stress across the age range.
Several meta-analyses have confirmed that in mild to moderate anxiety, online cognitive behavioural therapy (eCBT or i-CBT) is as effective as manualised face-to-face therapy. Studies have also shown effectiveness in depression and other common conditions.
The Australian program with the most evidence to support its use is THISWAYUP from St Vincent’s Hospital in Sydney, the University of NSW and the Clinical Research Unit for Anxiety and Depression (CRUfAD). This is a suite of diagnosis-specific courses that, like all the other eCBT programs, can be used as stand-alone self-help or can be integrated into face-to-face therapy. There are 11 courses for various disorders and one online pain management course that is an invaluable resource when pain clinic accessibility is difficult. Five of the courses are available as apps for mobile devices. Unlike the other Australian programs that are completely free of charge to the user, THISWAYUP courses cost the user just under $60 but have the advantage of keeping the nominated practitioner in the loop of care with regular email updates about their patient’s progress. THISWAYUP also has three short courses that are available free of charge – for insomnia, for mindfulness and for stress management. It may be useful for you to go to these free courses to see what THISWAYUP is all about, and for patients, looking at these courses is a useful way to help them decide whether they want to pay the money to join a more intensive paid course.
Other reliable Australian options providing eCBT for specific conditions that are available free of charge include a suite of programs from Swinburne University of Technology called Mental Health Online, and an excellent motivational interviewing program for people with alcohol-related problems (along with one for alcohol use combined with depression) called OnTrack from Queensland University of Technology.
On the other hand, Black Dog Institute’s myCompass program is a transdiagnostic option suitable for everyone, whether the diagnosis is stress, anxiety or depression. It provides 14 separate symptom-focused modules, each about 30 minutes long, that provide interactive mental health skills training that has the advantage of being able to be done in any order that the user prefers.
There is something else you might want to know about as well, and that’s the MindSpot Virtual Clinic at Macquarie University. MindSpot includes four transdiagnostic wellbeing courses (including the only one available for Indigenous users) and three diagnosis-specific programs, including one for chronic pain management. Mindspot’s point of difference is that on enrolment in a MindSpot course your patient will be contacted by phone or email (the patient’s choice) by one of the mental health practitioners at the MindSpot Clinic, and the same practitioner will contact them to provide support after each of the five lessons in the course. All this is federal government-funded and available completely free of charge to the user.
While not everyone you see with a mental health problem is going to want to go online for help, some people will go if they know there are reliable programs available, and some people will even prefer the online option to face-to-face therapy. Maybe using these low intensity options appropriately will take some of the pressure off the mental health sector by leaving practitioners time and space to concentrate on the more severe end of the mental illness spectrum. It is also just possible that some of the people who are currently not receiving any treatment will then be able to access some of the treatment they need.
Do you need to know more? You can find guidelines for the use of eMH on the RACGP website, information about reliable resources on the federal government’s Head to Health website, and a resource book on the eMHPrac website. There is also a range of educational material for health professionals on the eMHPrac page of the Black Dog Institute website, as well as a multidisciplinary online Community of Practice where we can help each other manage the mental health problems that we see.
It’s time that we as medical practitioners took common mental health conditions seriously and better understood their impact on our patients’ physical health. It’s also time we made ourselves familiar with the reliable, evidence-based, low intensity interventions that we can recommend to patients to help manage their mental health and improve their psychological resilience.
Who knows, we might even benefit from these programs ourselves!
Dr Jan Orman, MBBS MPsychMed, is a GP with a special interest in mental health. She works in Black Dog’s Institute’s Professional Education team developing and delivering educational programs for the e-Mental Health in Practice Project.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.