I graduated from medical school in Sydney in 1964, having had only about 12 lectures in psychiatry in total. My first real contact with psychiatry was as a second-year resident at Royal Melbourne Hospital, where I worked as a medical officer under Professor Brian Davies. Psychiatry interested me and came easily to me, and this sparked an interest which has continued for the rest of my life.

As a result of this experience, I went to a typical psychiatric hospital of the time. There were some very good and dedicated people working there, but, for the most part, treatments at that time were only partially effective, and there was a large custodial component in the function of the institution. My first job was unsupervised, and involved looking after a ward for young women (adolescents and those in their early 20s), many of whom had psychosis with poorly controlled symptoms. I left after 6 months and began working in general practice, as I wanted to help people experiencing mental illnesses in the community.

The general practice I joined practised in a traditional manner for that time. The focus was on patients’ somatic symptoms and on somatic treatments. Patients had great faith in the doctors, whom they had known for many years in what was a rather tight-knit community. Psychological problems were generally ignored or ascribed to some somatic problem or social difficulty. Treatment consisted of support, advice, and a variety of what were essentially placebo treatments, ranging from rose-coloured water (dill water), vitamins, Waterbury’s compound, the pharmacist’s special concoction (often a bromide-containing medication), and night sedation with drugs such as chloral hydrate and barbiturates. The use of tricyclic antidepressants, monoamine oxidase inhibitors and minor tranquilisers, often in minute doses, was just beginning. Depression was just starting to be acknowledged as an illness; most depressions were perceived as reactions to events or a failure of will. Anxiety more or less went with the depression, with the exception of phobias and “panic” states.

It became clear to me that much of what I was seeing in general practice — I thought about 70% — was psychologically based, and so I returned to psychiatry at Royal Melbourne Hospital, where I again worked under Professor Brian Davies. It was in this dual setting of psychiatry and of general practice that I began to think about psychological disorder in the community, and depression and anxiety in particular.

In the late 1960s, I decided to do a doctorate in medicine. I chose to do this with a focus on general practice for a number of reasons.

• First, as I’ve already mentioned, many of the problems that I’d seen in general practice were of a psychological nature.

• Second, while most mental health problems were being seen in general practice, most of the research was done in hospitals on inpatients and the results were being extrapolated to general practice patients. The assumption was that these patients were part of the same cohort, but, having worked in both places, I believed this to be incorrect.

• Third, I was interested in the notion of placebo as an effective treatment, and I had wondered whether some of the “antidepressant effect” seen in patients treated in general practice for depression was possibly the result of such a placebo effect.

• Fourth, I thought that some of the response to antidepressants in this mildly to moderately affected group might be occurring because of reduced anxiety, rather than to a specific antidepressant effect.

• Finally, I could find very little published research on what was essentially a large group of people in the community who had some type of mental disorder.

Initially, I had two problems. The first was that GPs were said to be not particularly interested in psychiatry.4 However, I felt that given half a chance, many GPs would respond to an offer of some help and of an opportunity to be involved in a research project. This indeed proved to be the case. It involved me visiting GPs in their practices and talking about the sorts of issues that they faced, which facilitated the study and was central to its successful completion over 9 months in late 1969 and early 1970. The Research Committee of the Victorian branch of the Royal Australian College of General Practitioners were well acquainted with the project and approved it.

The second problem was that of constructing a study that had the same scientific rigour as previous studies that had been conducted in institutions, and to apply this rigour in a general practice setting. To accomplish this, it was necessary to ensure randomisation, placebo control, double blinding, and for the patients to be rated both subjectively and objectively with the use of rating scales such as the Hamilton Rating Scale for Depression5 and the Taylor Manifest Anxiety Scale.6 To confirm whether the patients did actually take the tablets that were prescribed, riboflavine was included in the formulation, and patients’ urine was tested for compliance with treatment. The coauthors of the study, Robert Mowbray and Brian Davies, made important contributions to the planning of the study.

For me, the most fascinating and important finding was that clinical improvements occurred in 55% of patients who had received placebo after 7 days, and in 61% at 28 days. Indeed, there was a handful of patients who wanted to continue taking the placebo even after they were told it was a placebo, and we managed to obtain more placebo from the pharmaceutical company, so that they might continue taking their “medication”.

With respect to the specific treatments, I was not surprised that the higher dose of amitriptyline (150 mg per day) was the most effective in relieving depression and anxiety. Anecdotally, I thought that the smaller dose of 75 mg might also be effective in relieving symptoms, but this proved not to be the case. I was interested to read a recent study by Furukawa et al, published in the British Medical Journal in 2002, in which they found a good response to low-dose tricyclic antidepressants.7

With respect to side effects, there was no difference between the groups. This was very surprising, but I think it might be attributed to a problem in the study design. Participants were given a list of possible side effects before starting the medication — something I thought to be important because some might well have been troubled with the higher doses — and this may have created a bias that was reflected in the side-effect profile across all groups.

I have already alluded to the apparent lack of interest in psychiatry among GPs in those days, to the stigma associated with psychiatric illness, to the notion that depression was induced by life circumstances or was a failure of will; certainly, “madness” was something to be avoided at all costs. While there was some acknowledgement of a biological tendency or disposition often reflected in a family history, when this was discerned, patients were generally sent off to the psychiatrist and the case considered exceptional.

The other social factor was that while women came to their doctors for treatment, men generally did not. Men saw it as a weakness, unmanly, and indicative of failure; their way of expressing their distress was often through aggression, excessive alcohol consumption or, at worst, carefully planned or violent suicide. So, I saw mainly depressed women who seemed more ready to say something about how they felt and express something of their vulnerability. Hence, the idea of studying only women in this project came to mind.

The management of mental health in general practice is far removed from that of 40 years ago. GPs are more educated in mental illness, and mental illness is less stigmatised. Research has provided a greater understanding of mental disorders and the treatments available, whether they be biological, social or psychological, and much therapy is now evidence-based. It is important that mental health research continue in the setting of general practice, and there are at least three important lessons for future researchers that I’d like to share (Box 2).

Fortunately, mental health is now seen as a community responsibility, and there is commensurate financial commitment. Powerful support structures now exist — community, psychiatric, psychological and social. GPs have rightly become an integral part of this process.