Responding to experiences of young people with common mental health problems attending Australian general practice

Although the onset of 75% of the major mental disorders and alcohol or other substance misuse is before the age of 25 years,1,2 most young people with common anxiety or depressive disorders report 5–15-year delays before they receive care.2 This is despite the growing evidence that there is great potential for achieving better functional outcomes during the earlier phases of illness.3,4 Additionally, development of early intervention services is the highest community priority for major mental health service reform.5 These imperatives have been recognised by the Australian Government through its new youth mental health initiative.5,6 Within this national and international context, the roles to be played and the interventions to be provided by various forms of primary health care are actively debated.3,4 The debate reflects the lack of a clear evidence base for best practice when treating young people, as well as the persistence of quite divergent models of current practice.7,8

Possible types of services cover a wide range, including: novel e-health forms, which are typically clinician-independent (eg, MoodGym: http://moodgym.anu.edu.au);9,10 more conventional telephony-based contacts;11,12 targeted youth health services (although these often employ only minor or covert mental health components); and conventional general practice-based services. However, only some of the latter have specific youth-appropriate service links or provide the style of psychological services most appropriate to the earliest phases of common anxiety or depressive disorders.13,14

Here, we focus on data reflecting young people’s experiences of primary care in Australia over the past decade. We also consider the likely effectiveness of enhanced general practice-based service models (“collaborative” or “stepped” care) for young people.

Data presented here were obtained from two distinct nationwide general practice clinical audits conducted during 1998–1999 and 2000–2002.

Clinical audit data from the management of young people in Australian general practice over the past decade provide us with the basis for promoting the development of better quality services. While the data have limitations related to the periods of collection, as well as the fundamental nature of cross-sectional audits, they demonstrate the size and scope of the reforms that are likely to be necessary. Major service adjustments and related changes in professional priorities are required to lift identification and intervention rates to acceptable levels. Use of pharmacological therapies alone, or in combination with psychological approaches, does not appear to be excessive. Increased access of young people to psychological therapies should remain a high priority, particularly as a first-line therapy for those in the early stages of illness. It is not yet apparent, however, that recent Medicare enhancements for psychological services will actually increase access for young people.8

Even in the later SPHERE data set (with GPs recruited through the Compass Strategy who were strongly committed to improving young people’s access to services), young people with disabling disorders (and those at high risk of progression to illness) were still receiving relatively low levels of care. In our view, this reflects a lack of a systematic approach to identifying and providing appropriate and evidence-based interventions rather than any individual doctor-based failure. New programs should aim to incorporate a wide range of population and practice-based strategies that promote early identification and key elements of the collaborative care model (Box 4).

Community surveys indicate that young people are already very aware of the high prevalence of mental disorders (eg, depression), frequently recognise these disorders in themselves or in family members, and are familiar with the potential benefits of the major interventions available.17,27 What is clearly missing is a willingness to use professional services.29 A strong trend is to rely on peer, family and other non-professional support. In our view, this reflects two factors, namely the community’s broader lack of experience with the potential benefits of professional services, as well as the more general disconnection between younger people and medical services. By contrast, older people who visited GPs for general medical services were more likely to use the same practitioners for their mental health needs14 and receive better mental health care.13,14

Unfortunately, the data reported here indicate that detection and treatment of common mental disorders, even in those who do actually decide to seek general medical care, remain the exception rather than the rule. Additionally, there was surprisingly little evidence of medical practitioners making use of other highly skilled practitioners or providing integrated, effective care for which there is a clear evidence-base.8,19 However, as these data were collected before the more recent incentives for more integrated styles of general practice,8,37 it is possible that some improvements will now occur.

Some have argued that one-off comparisons of patient self-report and concurrent rates of diagnosis or treatment by doctors are poor indicators of the overall quality of mental health care in general practice.40,41 However, this view assumes that most patients with mental disorders will be in contact with the practice on multiple occasions. Unfortunately, general practice utilisation data in Australia indicate that young people are infrequent attendees and are also less likely than middle-aged or older people to seek mental health assistance from their doctor.8,27 Therefore, in young people, the cross-sectional method is more representative of the genuine “missed opportunity” rate than other longitudinal strategies. Additionally, some other particular sociodemographic, educational and geographical factors (eg, being male, having a lower income, living a greater distance from a general practice) have strong effects on reducing the frequency of attendance by certain at-risk groups.7,26

Another common criticism is that more severe cases are detected and treated and that high under-recognition rates are largely limited to brief or non-disabling disorders.41,42 However, as the SPHERE diagnostic system utilises three levels of case-determination (and is, therefore, quasi-dimensional) and is non-specific rather than specific in nature (ie, does not distinguish anxiety from depression or other narrow clinical categories), we can examine the relationship to severity. The data presented here clearly indicate that, even among young people with more severe disorders, identification and treatment rates are unacceptably low. We suggest that our quasi-dimensional approach is particularly important when considering the non-specific diagnostic status of young people, and that it actually promotes the use of safe and simple information or web-based psychological strategies for early intervention in those with less severe forms of illness or those in the earlier phases of their illness. Thus, it is consistent with an illness-stage model, where earlier phases of illness are identified but treated with the least harmful interventions available.3 While it may be reasonable to limit medical therapies to those with well established or chronically disabling disorders, not providing any informational or psychological interventions to young people at high risk, those with emerging disorders, or those in the early phases of illness, risks both lost opportunity and, potentially, great harm.4,43

While community awareness initiatives17,32,33 are important for increasing general community knowledge about mental disorders and their treatments, as well as shaping more positive attitudes,27,29 it is clear that what is now needed is increased access to active treatments, and particularly psychological, informational, behavioural, e-health and other non-pharmacological options to match the stage of illness.3 What is also needed is reporting of actual experiences of care, including the fact that most services provided in the past by GPs were largely non-pharmacological and that we can now expect the absolute number and proportion of these services to grow in the future.

Importantly, such notions of enhanced primary care are now possible in Australia as a result of major recent changes in the national finance mechanisms available to GPs, allied health professionals and psychiatrists. Further, the development of communities of youth services within the framework of the National Youth Mental Health Foundation (headspace) provides considerable opportunity for systematic research and evaluation of new systems of care.

The challenges involved in developing new youth-appropriate primary care services are numerous, but include:

• increasing young people’s access to such services, by meeting the challenges of cost, distribution, stigma, privacy, and linking to other relevant medical, alcohol and drug services;

• providing the style of services that young people most seek, by attending to the issues of youth preferences for first use of counselling rather than medication-based interventions;

• focusing workforce training and development largely on early-intervention models and the provision of brief but concurrent alcohol and drug interventions; and

• providing evidence-based psychological and medical services (despite young people’s strong preferences for non-professional and non-evidence-based lifestyle and social adjustments).

Major resource, structural and professional challenges may continue to impede the movement towards the rapid development of such new systems.8,34,38 Our previous audit of primary care practice showed that those GPs who saw a large number of patients per day and worked in solo practitioner-style environments delivered the poorest quality mental health care.7,13,14 Even though a range of other mechanisms (such as group-based psychological therapies and new Medicare Benefits Schedule (MBS) item numbers for integrated psychiatrist–GP care) were supported under previous primary care-based mental health reforms,37 they were not widely used. At the top of community concerns has been the lack of access to affordable psychological services.6 By supporting new MBS items for GPs, psychologists and other allied health professionals who provide these services (either to individual patients or in groups), one of the major structural barriers to improved quality of practice has been removed. The challenge now is whether the relevant health professionals, with the support of their representative professional bodies, actually begin to restructure practice to deliver evidence-based collaborative care and, thereby, actually meet community expectations and public health needs.8