Saturday 6 April 2013

More GPs take on mental health cases

Partnership with IMH a success, with high levels of patient satisfaction reported
By Poon Chian Hui, The Straits Times, 5 Apr 2013

MORE doctors in neighbourhood clinics are now managing patients with mental health conditions. And patients have welcomed the arrangement.

A partnership with the Institute of Mental Health (IMH) to have stabilised patients cared for in the community has seen the network of general practitioners (GPs) grow from 34 in 2009 to 53 today. And more than 1,300 patients have been referred to their care from IMH since the partnership was forged in 2005.

Programme director and IMH consultant psychiatrist Goh Yen Li said the initiative has been a success so far.

In a survey of 114 patients early last year, more than 90 per cent reported high levels of satisfaction, citing reasons such as "the GP spends time listening to me" and "the GP was patient".

Said Dr Goh: "GPs are often the first point of contact for patients with mental illnesses. This places them at the forefront in detecting, treating and referring a patient with mental illness."

Any GP can assess a person for mental illness and, if required, refer him to a specialist at a public hospital. But GPs under the partnership will manage stable patients after they have received specialist care.

To help these doctors along, training is provided by the IMH.

A one-year graduate diploma programme was started in 2010 to train GPs on how to recognise and manage mental disorders. IMH plans to increase the number of clinical attachments under this diploma, so GPs can get more experience in handling mental patients.

The latest batch of 24 GPs graduated two weeks ago. Among them is Dr Low Kee Hwa, 55, who said he has recently been able to pick out more people with depression or anxiety disorders.

One example he gave was of a woman in her 60s who visited five months ago complaining of chest discomfort. But she was actually suffering from depression.

Sensing something amiss, he probed further. The patient broke down in tears and revealed how strained relationships with her children were causing her stress.

Said Dr Low: "I have observed that more patients are now more willing to talk about common mental issues. So it would be essential for GPs to be able to treat these conditions."

But seeing someone who is mentally ill can take three times as long as a consultation for simple ailments such as a cold, which can be done within 10 minutes.

Which is why Dr Low will sometimes ask the patient to return when the clinic is not so crowded.

Regular talks by health-care experts are also open to all GPs as some mental health conditions, such as dementia and depression, can be tricky to differentiate.

Dr Srinivasa Sastry Malladi of IMH's geriatric psychiatry department said these conditions commonly affect the elderly. But symptoms - problems with appetite, sleep, motivation and memory - can be very similar and may confuse doctors, he said. Dr Malladi, who recently gave a talk to 110 GPs on how to tell the two conditions apart, said it is vital that correct diagnoses are made even at the primary-care level.

On top of training, the GP partners are supported by a team of IMH case managers. They remind newly referred patients of their appointments with the GPs and contact the patients afterwards to find out about their experience.

Meanwhile, GPs can contact the case managers if they encounter problems, such as patients not keeping to their treatment. The doctors can also call a 24-hour hotline operated by IMH to consult its specialists.

Another safeguard for the patients is that they are referred to the care of GP partners only if they are stable, said Dr Goh. This means they have not been hospitalised for the past six months and require similar medication each time.

Bridge the mental health treatment gap
The Straits Times reported yesterday that more mental health patients are being cared for in the community by trained general practitioners, under a partnership with the Institute of Mental Health. A psychiatrist says that even more can be done to make sure people who are unwell mentally get the treatment they need.
By Chong Siow Ann, Published The Straits Times, 6 Apr 2013

WHEN my colleagues and I conducted the Singapore Mental Health Study which assessed the mental health status of the adult resident population, we had anticipated that mental illness would be prevalent in the local population and that most would have their onset early in life, as is common elsewhere. These turned out as we predicted. What caught us by surprise was the number of people with mental illness who had never sought help.

The proportion of people who have an illness that requires care but do not receive treatment is known as the treatment gap. Wide treatment gaps for mental illness are common worldwide. They are wider in developing than in developed countries, with the proportion of those receiving help corresponding with a country's overall spending on health care - in particular, mental health care.

However, even in the world's biggest economy and most powerful nation, this under-treatment is still considerable: 31 per cent of the United States population are estimated to be affected by mental illness every year, of which 67 per cent are not treated. In Europe where mental illness affects 27 per cent of people yearly, 74 per cent of them receive no treatment, which seems even more egregious when compared with diabetes where only 8 per cent of people in Europe are not treated.

In Singapore, we found that six out of 10 people with major depression have not sought help.

Even more startling are disorders like obsessive compulsive disorder and alcohol misuse disorders, where nine out of 10 did not have any sort of treatment.

When mental illnesses remain untreated, they tend to worsen, develop more complications and become less responsive to any subsequent treatments. Research has found that untreated mental illness is associated with school failure, teenage pregnancy, unemployment, spousal violence, substance abuse, chronic medical conditions and poor quality of life.

There are a number of steps in the help-seeking process for the mentally ill person - becoming aware of the illness, perceiving the need for treatment, and then actively seeking treatment. All these are influenced by a myriad of factors like age, gender, race, education, religion, the beliefs and attitude of family and friends, the prevailing culture, the availability and accessibility of mental health services, financial resources and insurance coverage.

It has often been suggested - almost to the point of stereotyping - that Asians have a tendency to focus more on physical features than on emotional or psychological ones, leading to this remissive attitude about seeking help from mental health professionals. There is also a deep and pervasive fear of discrimination and stigma.

My colleagues and I in the mental health treatment field thus tried the usual conventional ways of reaching out to the public - with awareness-raising campaigns and public talks.

As is often the case, after such a public talk, some members of the audience would approach me and ask help for a family member who is manifestly unwell mentally but vehemently refuses to seek help. Most times, what would emerge from the account is similar: A family member or loved one has suffered years of a smouldering mental illness but refuses treatment because he does not consider himself unwell. The distress of these family members is often palpable, as is their helplessness. There is usually nothing very helpful that I can offer, which leaves me feeling wretched.

This lack of awareness of the presence of an illness is called anosognosia and is commonly found in a serious mental illness like schizophrenia.

It can be baffling to any observer as the person is so obviously unwell. Writer Oliver Sacks, in his clinical tale The Man Who Mistook His Wife For A Hat, described it as such: "It is not only difficult, it is impossible... to know their own problems... And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the 'situation' of such patients, for this is almost unimaginably remote from anything he himself has ever known."

This enigma presents a particular challenge in providing help to these individuals as they would refuse needed treatment since they do not perceive that they are ill in the first place.

Still, much can be done to narrow these treatment gaps.

There is already a raft of initiatives under way as part of Singapore's National Mental Health Blueprint and Policy.

Early detection systems for certain mental illnesses have been implemented in the community and general hospitals. Training in the recognition and management of mental disorders is being provided to care providers in the various social sectors and grassroots organisations. The Straits Times reported yesterday that more general practitioners are being trained to care for patients with mental health conditions.

Further public awareness campaigns have been mounted. Medisave and MediShield have been extended to include coverage for mental illnesses.

While these measures are certainly good and overdue, more needs to be done.

Schools, for example, are important settings for mental health promotion and implementing preventive measures since many mental illnesses have an early onset, in adolescence or early adulthood.

School-based screening programmes and lessons to teach children stress management and some basic aspects of mental illness may help. Teachers and parents should also be educated in recognising features of mental illnesses that are common in children, since children are most unlikely to seek help on their own and depend on adults looking after them. Often and unfortunately, these adults - parents in particular - tend to normalise signs and symptoms of mental illness as part of the to-be-expected turmoil of growing up and adolescence angst. This is, of course, understandable as few parents would like to think their child mentally ill.

In the workplace, there should be programmes on early screening and recognition, and processes in place to ensure that workers with mental disorders are not discriminated against but are given the necessary assistance to preserve their skills and re-enter the workforce.

There is scope too for bold and innovative thinking. Technology allows for Internet- and telephone-delivered psychotherapy to increase access to care. There can also be collaboration with spiritual and traditional healers who, from our research, are often consulted by those with emotional and psychological woes.

But for the average Singaporean, the best way to reduce the treatment gap is vigilance. If you think a family member is unwell mentally, speak to someone you know who has experience in mental health like your family doctor or even a mental health professional like a clinical psychologist or psychiatrist.

Even if the unwell person is unwilling to seek help on his own, advice can still be sought on his behalf from these care providers. There are also helplines available (see below). If there is any danger to the person or others, police assistance can be asked for to have the person escorted to the emergency room of a hospital.

But the most important hurdle to overcome is that inevitable initial reluctance to even approach anyone for help.

The writer, Associate Professor Chong Siow Ann, is a senior consultant psychiatrist and the vice-chairman, medical board (research) of the Institute of Mental Health.


- Singapore Association for Mental Health: 1800-283-7019
- Silver Ribbon: 6386-1928
- Institute of Mental Health's Mobile Crisis Service: 6389-2222

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