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With over 15 years’ experience as a GP with a special interest in mental health, Dr Erin Waters is well placed to offer registrars a bevy of consulting tips in the space.

Mental health can be daunting but it’s also immensely rewarding

According to the 2018 RACGP Health of a Nation survey (conducted pre-pandemic), psychological complaints are the most common GP presentation. As Erin quite rightly puts it, “You can’t be a GP that doesn’t do mental health. It’s a core skill.”

Erin says that while some registrars will have experience in psychiatry from medical school and their hospital years, the type of patient presentations vary greatly to those seen in the community.

“In hospitals, you’re usually dealing with acute psychosis. In general practice, we’re mainly dealing with depression and anxiety, alongside the full spectrum of mental health conditions,” she explains.

As a registrar, you may view mental health presentations as scary or challenging, but Erin says you should not discount your role in supporting patients struggling with these conditions.

“Throughout your career, you’ll probably save more lives through your mental health and counselling skills, than you will with your advanced life support skills,” she says.

To help you hone them, here are Erin’s top ten tips.

  1. It’s all about communication

Erin believes the secret to a mental health consultation lies in developing your communication skills.

“I think being a good listener is the most important part of being a good GP. Recognise the therapeutic impact of doing just that alone; sitting there, taking notice and validating the patient’s story and concerns without judgment. It shows them they can feel comfortable sharing their experience, and is a key step in building that vital doctor-patient relationship,” she says.

In Erin’s experience, she feels the patient is usually the one who holds the answers.

“As doctors, we want to fix things. But it’s actually really important we take a step to the patient’s side and take on a coaching role. Let them set the agenda by identifying their most pressing issue, and then support them in setting very specific and measurable goals you can work on together.”

  1. Never assume – particularly when it comes to possible risk to self or others

Erin’s next key mental health care tip is to never assume anything.

“You’ve got to explicitly ask about risk and whether the patient is having suicidal or self-harm thoughts, have hurt themselves or attempted to take their life. Often you’ll be surprised with the answer,” she explains.

“If the answer is yes, you need to assess that further. If you don’t know what to do in this situation, seek help on the spot from your supervisor, or via referral with the local acute care team.”

  1. Don’t underestimate the value of thorough history taking

Over time, Erin says she’s realised the things that can make the most impact in anxious or depressed patients are the most basic, and these can sometimes be overlooked during a consultation.

“Diet, exercise, sleep and social connections all contribute to the presentation. I know I’ve changed my own practise over the last few years to explicitly ask my patients things like ‘how many times a day do you eat?’” she says.

“When I started doing that, I was so shocked at how many patients would say, ‘Oh, one meal a day’. And I’d reply ‘Do you think that that could be contributing to your lack of energy or constant anxiety?’”

  1. Adopt a trauma-informed approach

Many patients suffering with anxiety or depression have experienced some form of trauma. It might be grief at the loss of someone close, bullying at school or work, or even serious physical, sexual and/or emotional abuse.

“You’ve got to let the patient decide how much of their problem they want to tackle at any one time. They might have a very small window of tolerance for distress, so might not be able to disclose everything at once. You need to be mindful and respectful of this,” she explains.

“‘Asking to ask’ is a useful strategy, particularly for sensitive questions. This reassures patients that they’re in control of how, when and to whom they tell their story.”

Erin says this is why creating that safe therapeutic relationship is so vital – as is maintaining an open and non-judgemental stance – as it allows your patient to feel free to share the burden of their distressing thoughts, if not at the present consult, then perhaps at a future one.

She adds it’s also paramount you check your own attitudes and expectations.

“Patients suffering with mental health issues may push boundaries and have trouble following the rules of social and professional etiquette. This can often be a consequence of their underlying illness – perhaps they’re too depressed to remember their appointment, or they may not even be able to bring themselves to get out of bed, or be too anxious to leave the house.”

  1. Invest time in building a strong referral network

For Erin, the right referral network is essential for success.

“You need to believe in the people you’re referring to. As a doctor, if you believe this person will be helpful for your patient and can demonstrate that to them, it’s more likely they’ll get on board and have a positive experience,” she explains.

Erin had developed an excellent referral network of mental health professionals, but when the pandemic hit, many of these practitioners couldn’t keep up with the demand and closed their books. She’s now had to look a little harder.

“I’ve had to find new and up and coming psychologists and other mental health workers in the local community. For example, a psychologist recently opened her practice locally and sent out her flyer. I’m going to phone her to see if she’s someone that aligns with my values and is somebody I’d like to refer to. Establishing these professional relationships is really important so that you can all work together as a team,” she explains.

  1. Know your limits

As a new registrar, Erin says you’ll often feel out of depth when dealing with mental health patients.

“Even those of us who are very experienced in the space feel this way. A lot of the time, it’s uncomfortable and the only way to address that is to do more of it.”

If you find yourself with knowledge gaps, Erin encourages you to be proactive in filling them. It might be through additional professional development or seeking out supplementary supervision with those working with mental health conditions. The GPTQ mental health module is a good place to start as it contains an extensive list of resources.

Erin says: “It’s imperative that you don’t practise outside your expertise. If you’re ever uncomfortable managing a patient, speak to your supervisor. Just because our tertiary mental health services are overwhelmed, doesn’t mean that you – as a registrar – have to take on all the risk and responsibility.”

  1. Patient follow-up is vital

Erin finds many registrars are reluctant to ask patients to return for a review.

“They refrain from asking patients to come back because they don’t want to inconvenience them, but it’s actually very important as it shows them you care. Give them explicit follow-up instructions, so ‘Please make another appointment for one or two weeks’ time. And in the meantime, if you have any problems, these are some numbers to call for help.”

  1. Mobilise your patients’ social supports – especially the younger ones

During her three years working with Headspace, the national youth mental health foundation, Erin learnt much about dealing with this vulnerable section of mental health care patients.

“A big part of my work is building enough trust with the patient that you can get their consent to involve their support people, be it family, other caregivers or their school. If you don’t mobilise these supports, you’re not going to be able to really help them,” she explains.

“As a registrar, it’s likely you’ll see a lot of young patients dealing with mental health issues as they tend to gravitate to the younger and newer doctors in the practice. So it’s an area in which you need to develop your skills.”

  1. Medication should not be your primary management plan

While it can be tempting to reach for the prescription pad when faced with a desperate and mentally unwell patient, Erin feels medication is never the single solution to a mental health presentation.

“You’ve got to work through all those other things, like lifestyle factors, social factors, and psychological therapy. Medication should never be mono-therapy as although it has an effect, it’s not a cure for what is often a much more complex bio-psycho-social problem.”

  1. Practise self-care

While rewarding, supporting patients with mental health conditions can be taxing, so Erin says self-care is essential. Follow your own good advice and make the time for proper nutrition, sleep and regular exercise. Having your own GP is crucial, as is making time to talk with your peers, family and friends regularly.

“We’re really supportive of registrars asking for help and practising self-care. You should never feel embarrassed or ashamed to seek out our help. That’s what we’re here for,” she smiles.

If you’d like to learn more about mental health, Dr Peter Byrnes previously shared his experience working in the mental health space as well as offering some suggestions that may assist you in supporting patients struggling with their mental wellbeing.