Common mental illnesses, such as depression and anxiety, account for a substantial burden of disease in the Australian community.1 To date, however, most people with these disorders will not receive any mental healthcare.2 The provision of some psychological treatments by general practitioners is one response to addressing this vast, unmet need.3 Since November 2002, a new Medicare Benefits Schedule (MBS) item for "Focussed Psychological Strategies"4 has been available to suitably trained GPs who are currently participating in the Better Outcomes in Mental Health Care (BOiMHC) initiative funded by the Australian Government.5 This initiative is one of several strategies that aim to improve community access to psychological treatments and facilitate better access to specialist mental healthcare providers.5 We argue that ongoing training and support are essential for GPs to provide high quality psychological treatments.
Incorporating specific psychological treatments into general practice is based on a sound public health rationale. Although expanding access to specialist mental healthcare providers6 is essential, the need for psychological treatments could never, and should not, be met entirely by these professionals. GPs see most patients with common mental health problems,7 particularly those who are actively seeking medical or psychological care.8 Unfortunately, few patients receive the counselling that is likely to benefit their condition,9 or that they feel they need, from their GP.10
Of course, GPs already provide support, listening and commonsense as part of usual clinical care.9 When combined with other specific treatments, such as appropriate antidepressant medication, this alone may have substantial population benefits.11 For many GPs, there is no desire to go beyond this level of care, and many choose to refer patients requiring specific psychological treatments to specialist providers.
However, GPs who are willing to learn about and provide psychological treatments will require evidence-based approaches12 that can be integrated into general practice.13 Currently, several psychological techniques described as Focussed Psychological Strategies (including psycho-education, cognitive-behavioural therapy, relaxation strategies, skills training and interpersonal therapy4) (Box 1) are included as treatments within the MBS.
Traditionally, GP training in mental health at both undergraduate and postgraduate levels has been poorly focused on managing typical primary-care problems (eg, depression, anxiety, somatisation, common substance misuse and risk-taking behaviour). Continuing professional development in mental health, which is relevant and practical to primary care, is now essential to ensure high quality care, and, at the very least, to ensure training is not counterproductive or harmful.
Although very few general education courses are effective,14 more specific skills training is beneficial. Such skills include rehearsal of microcounselling skills, which, when supplemented by feedback from video or audio-taped consultations,15 results in improved clinical outcomes for patients.16 Training programs that are supported by enhanced access to specialist support, structured follow-up of patients and provision of patient education materials have also been shown to improve patient outcomes.17 Brief educational programs incorporating behavioural principles also result in sustained improvements in the quality of practice.18
Ongoing mental health training is a prerequisite for accessing the Focussed Psychological Strategies component of the BOiMHC initiative.5 Providers of such training must meet detailed requirements set by the General Practice Mental Health Standards Collaboration (Box 2).19 We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond these minimum training requirements) for refinement of psychological skills.
Currently, hard evidence for the value of clinical super-vision and peer support of GPs is lacking.20 However, most mental health clinicians, including specialist psychiatrists and psychologists, embrace a system of ongoing clinical supervision. Such an approach is consistent with educational principles that encourage not only skills acquisition but also ongoing monitoring of use of those skills in real clinical situations. In our opinion, GPs are likely to benefit from a similar professional system.
Currently, in Australia, there is no formalised provision of peer support or supervision for GPs working in mental healthcare. However, some Divisions of General Practice have developed support programs, including peer-support groups, case-conferencing, teleconferencing and videoconferencing models.20
From a practical perspective, engaging groups who have the experience to supervise and support GPs on a large scale will require substantial organisational reform. For example, state-based mental health services could provide much needed support and training for GPs. This would require a shift in focus towards high-prevalence disorders such as depression and anxiety, and better integration between state and federally funded services. Such reform is already occurring in Victoria with the introduction of Primary Mental Health and Early Intervention Teams,21 but in most other states it is not given high priority.
Private psychiatrists are another source of expertise, and could better support GPs in a supervisory role if there were financial incentives to do so. Allied health professionals, including psychologists participating in the Allied Health Pilots component of the BOiMHC initiative, are another resource if their expertise is not entirely consumed by service provision. From a long-term perspective, all these professional groups might benefit from spending more of their training time in general practice settings, to increase their understanding of the general practice context.
Research into provision of psychological treatments by GPs is urgently required,22 and should specifically focus on GP training and how GPs interact with, and are supported by, specialist mental health services. Although the BOiMHC initiative has precipitated mental health training of GPs on a scale not seen before, the evidence base is lagging behind. Priorities for evaluating GP-delivered psychological care include training and support, as well as measurement of improvements in practice that deliver genuine benefits to patients and population health (such as decreasing suicide rates).11
1: Focussed Psychological Strategies*
Focussed Psychological Strategies are derived from evidence-based psychological therapies integrated with general practice expertise. They comprise:
Psycho-education (including motivational interviewing)
Cognitive-behavioural therapy, including:
Behavioural interventions: behaviour modification; exposure techniques; and activity scheduling
Cognitive interventions: cognitive analyses, challenging and restructuring; self-instructional training; and attention regulation
Relaxation strategies
Progressive muscle relaxation
Controlled breathing
Skills training
Problem-solving skills training
Anger management
Social skills training
Communication training
Stress management
Parent management training
Interpersonal therapy
These strategies must be provided to patients by a credentialled medical practitioner and are time-limited, being deliverable, in general, in up to six planned sessions of at least 30 minutes each. In some instances, up to a further six sessions to an individual patient may be approved in any 12-month period.
The Health Insurance Commission must be notified by the Mental Health Standards Collaboration that a general practitioner has met the required standards for higher-level mental health skills.
* This is an abbreviated version of the Medicare Benefits Schedule item descriptor for items 2721–2727.4
2: Key requirements for education and training providers of Focussed Psychological Strategies general practitioner programs19
To ensure GPs can competently deliver Focussed Psychological Strategies, training programs must meet the following requirements before they can be approved.
The program must be for a minimum of 20 hours face-to-face duration (excluding meal and other breaks).
The program must have been developed in consultation with GPs, consumers, carers and other mental health professionals (eg, psychologists, psychiatrists).
The program must be delivered by suitably qualified trainers and clearly state their qualifications.
The program must have clear, stated and measurable learning outcomes.
The content of the program must include:
at least four Focussed Psychological Strategies (as stated in the Medicare Benefits Schedule);
relevant case studies;
demonstration of techniques;
guidance in scripting and rehearsal (including opportunities for GPs to practise and receive feedback from presenters);
discussion of closure issues; and
discussion of the relevant Medicare Benefits Schedule item descriptors and Medicare documentation.
Abstract
Provision of "Focussed Psychological Strategies" by general practitioners is one component of the recent Better Outcomes in Mental Health Care (BOiMHC) initiative.
The BOiMHC initiative requires GPs to undertake minimum training requirements before they may provide services under the new Medicare Benefits Schedule item number.
We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond the minimum training requirements) for refinement of psychological skills.
Research focusing on GP training and how GPs interact with specialist services in the provision of psychological treatments is urgently required.