Pathways of recovery: preventing further episodes of mental illness (monograph)

The role of primary care including general practice

Page last updated: 2006

The role of primary care, particularly general practice, in mental health care is now well recognised. Most mental health care is delivered through general practice and other primary care services, with GPs providing mental health care to 75% of those seeking such help (AIHW 2002). Many people who have been seriously affected by mental illness manage their illness with only the support of a GP; for other people the GP will form an essential part of a wider team of mental health service providers. GPs can provide ongoing mental health care in several different ways: through direct care, shared care, and referral to specialist services. An established and ongoing relationship with a health practitioner is a vital tool for continuing care, and the place of primary care and general practice in relapse prevention needs to be more fully explored and supported.

There seems to be growing evidence of GP clinics being engaged with by the mental health team and growing levels of secondary consultation and improving understanding and knowledge. It's probably not relapse prevention – it's more about information and understanding and being able to identify premorbid or prodromal conditions. But, primary care are fearful of being equipped with the knowledge of being able to identify prodromal syndromes. If you identify, what's your duty of care, that's what they're fearful of, where are the services to provide the follow-up response. —Clinician
General practice has a role in the continuing care of all people who have experienced mental ill health, irrespective of the severity and chronicity of the mental illness. For those people who have experienced an acute episode that has required hospitalisation, effective discharge planning involves engaging the GP in the person's ongoing mental health care. The GP, case manager and psychiatrist comprise a health support team that can provide a high level of support to people within the community.

The GP's role is also critical for the many people who are discharged from acute settings into the community without a case manager and only infrequent, if any, contact with a psychiatrist. A case manager may not be assigned, either because this function is not deemed to be necessary, or because there is no capacity to provide one. In these situations, the GP (with the family and carers) may need to provide a case management-type function by ensuring that the necessary support services are put in place.

There are also many people who have been seriously affected by mental illness who have never been hospitalised and have managed their condition within the community, often without the support of specialist mental health services. For such people, the GP may be the only point of contact for health care and is, therefore, an essential ongoing source of health support, information, and referral. Top of page

To effectively engage general practice in relapse prevention, there are many supports that need to be in place. Firstly, GPs need to be available and easily accessible to people who have experienced mental illness, and this is not always the case. GP services are insufficient in many areas, particularly rural and remote areas, but even some urban areas are underserviced. Even when GP services are available, they are not accessible in a timely manner because of the high level of demand on their services.

I have to book in 3 weeks ahead to get to see my doctor. By then it's too late. Sometimes I just book in ahead anyway, so there's an appointment if I need it. —Consumer

My son has moved to a new area and he can't get onto the doctor's books. They are all full and won't take any more patients onto their books. I keep trying and keep phoning and asking but I've got nowhere. Our only option is the emergency room. —Carer

GPs also need to be skilled in providing mental health care, and they vary in their ability, training and interest to do so. Two major initiatives have recognised the role of general practice in mental health care: the National Primary Mental Health Care Initiative which came into effect in June 1999, and the Better Outcomes in Mental Health Care Initiative in 2001. These initiatives aim to promote and encourage quality primary mental health care through education and training and other capacity building strategies and responding to the barriers to providing mental health care that are commonly expressed by GPs. It is essential that these initiatives continue to support GPs in providing mental health care, and that special emphasis is placed on the training and support needs of GPs providing services in rural and remote communities, Aboriginal and Torres Strait Islander communities, multicultural communities, and to younger and older Australians with mental health care needs.

A major strength of general practice in relation to relapse prevention is the importance of an established and ongoing relationship between health care provider and consumer. If such a relationship is in place, relapse prevention can be implemented much more effectively. Where such a relationship is not in place, it is an important first step to attempt to develop it. The ability to discuss the factors that affect relapse and put a relapse prevention plan in place is optimised when a consumer has a GP who knows them and their circumstances and with whom they have developed a trusting relationship. This can be especially important for young people who do not like to talk about their personal issues to people with whom they have not established a relationship (Rickwood, Deane, Wilson & Ciarrochi, in press).

Relationships with patients can be, however, quite complicated for family GPs who also provide health care to family members and carers. At times, the family or carer's need for information or intervention may conflict with the health needs or requests of the consumer. In such situations, active relapse prevention plans are a vital tool to enable the GP to provide support to all parties without crossing confidentiality boundaries. For example, if it has been previously agreed by the consumer that the role of the family member in terms of early warning signs is to inform the GP who is then expected to provide some form of early intervention, the conflicts at such a time may be minimised. Monitoring early warning signs and early intervention responses can raise complex issues regarding privacy and communication. Effective and explicit communication strategies between the consumer, family and carers, and the GP, as well as careful and respectful planning are imperative to avoid conflict.

Another strength of primary care for relapse prevention is a focus on providing holistic care, addressing both physical and mental health. People with mental illness often have compromised physical health and it is essential that their physical health needs are recognised and met. Physical and mental health are inseparable and affect each other in complex ways; good physical health is conducive to good mental health, and vice versa. The holistic approach to health care provided by services provided within a primary health care network, with ongoing monitoring of physical as well as mental wellbeing, is essential to prevent relapse.

Particular emphasis is placed on the role of medication in relapse prevention and GPs have an important function in prescribing and monitoring psychiatric medication and encouraging people to appropriately maintain their treatment programs. To do this, GPs need training and support, particularly around dosages and the side effects of psychiatric medications and ways to minimise these. The ability to consult with prescribing psychiatrists and to have easily accessible information about medications is essential. GPs also need skills to encourage effective use of medicines, and techniques such as behavioural tailoring and motivational interviewing may be relevant (Miller & Rollnick 1991). Top of page

In relation to medication, an important part of the recovery process for many consumers is minimising their medication or coming off it completely. GPs have a highly relevant role in this process, by seeing the person frequently throughout this process and monitoring progress. After the psychiatric medication has ceased, it is critical for the GP to continue to work with the person to monitor wellbeing to ensure a timely response if the need for medication reemerges. Coming off medication is a fearful time for many family members and carers, and a period of heightened risk for relapse. The support of the GP to the family and carer, as well as the consumer, is essential to allay fears by ensuring that appropriate supports and early interventions are in place.

I came off my meds a couple of months ago. My doc helped me to come off them slowly and now I'm off them completely. Yeah, my family doctor, not the psychiatrist. She'll keep an eye on things, so if I need to have something to help keep me stable, then I'll have to have something. But I'm going really well and if I keep up the hard work I hope I'll be able to stay off the medications. —Consumer
Psychological, as well as pharmacological, treatments are recognised as being important for relapse prevention. Effective cognitive behavioural skills are particularly emphasised as an important component of relapse prevention for many people, and some GPs have developed the skills and interest to provide CBT themselves. However, all GPs need to understand the usefulness of cognitive behavioural skills for their mental health patients and encourage the learning of these skills by referring to allied health services that can provide CBT. This requires partnerships with allied health professionals to ensure that such referral pathways are in place.

The holistic approach of general practice also enables the GP to incorporate a broader view of the psychosocial and environmental impacts that may affect relapse. An understanding of a patient's personal and family situation is essential to ensuring that supports are in place to prevent relapse and sustain wellness. This may include referral and liaison with many other community agencies and it is important that the GP is effectively integrated within their community through a primary health care network to be aware of and able to ensure access to psychosocial and psychiatric rehabilitation support.

Of special relevance is the need for GPs to be able to meet the needs of consumers across the lifespan. This requires an understanding of the different impacts on mental health across the lifespan as well as the diverse service sectors that need to be engaged depending on the lifestage of the consumer. For example, for young people who are at risk of further episodes of mental illness, working effectively with the school and family is essential. MindMatters Plus GP Initiative aims to bring schools and general practice together to develop better referral pathways and networks of care for young people with high support needs for mental health and wellbeing.

Older adults who have experienced mental illness also have unique needs where GPs require special skills and understanding. Older adults often have complex physical health needs, as well as their mental health needs, and partnerships with the aged care sector and home and community care may be required. Furthermore, older people who have had a lifetime of experience with mental illness are a particularly vulnerable group who require a high level of ongoing support in the community.