Mental health in primary care
Working at first base: psychiatrist David Codyre and GP Tane Taylor say primary care is working to improve the nation’s mental health
by Susie Hill
“We know that in the month before someone attempts suicide most have visited a GP,” says David Codyre. "We know that if people with a mental health problem present anywhere, it is usually in primary care.”
Dr Codyre is an Auckland psychiatrist who – unusually – works in primary care. He is primary health organisation ProCare's clinical director of primary mental health, and he says a sharper focus on mental health within primary care is quite capable of reducing suicide rates.
Interestingly, he says, suicide rates have fallen around the country during this time. ProCare has been focusing on mental health care for the last 10 years, he says, ahead of the nation as a whole, which has only been doing so for the past five.
As a result, GPs are getting more proficient in recognising when physical symptoms might indicate emotional problems, and they are being given tools to address this.
Dr Codyre cites three ways in which primary care practice has recently improved mental health care:
- Training and workforce development – where GPs better understand mental health in the context of their everyday work
- Funding for longer consultation times when GPs recognise mental health as an issue
- Upskilling nurses to access self-management tools for patients
- Funding brief access to talking therapies (counselling) where necessary.
“If we do all that better, we will reduce suicide rates,” Dr Codyre says.
Talking about suicide
He believes another contributing factor to lowering suicide rates may include a greater national awareness of depression, largely due to the successful national depression initiative TV and web campaign, fronted by former All Black John Kirwan.
Anecdotal evidence from GPs suggest that more people, particularly men, are coming to primary care with depression since the campaign. The flipside of that is that primary care needs a wider range of services to address the upsurge.
The medical profession and others should be able to talk about suicide safely in public, Dr Codyre says.
He cites initiatives like The Nutters Club, a radio and TV show supported by the Mental Health Foundation that he co-hosts with comedian Mike King (pictured above with Dr Codyre). The show encourages open discussion about mental health and addiction issues, led by guests and callers who have had personal experience.
Secondary and primary sectors should collaborate
People deemed to have more serious mental illness are elevated to a secondary level of mental health care, but Dr Codyre believes collaboration between frontline services and secondary mental health care could reduce the number of people needing such services.
Secondary mental health care is part of what Dr Codyre calls New Zealand’s “institutionalized mentality”, where more money goes to fewer people and there is a mutual lack of trust between sectors. He says it is important for specialists and primary care to find ways to work together.
“DHBs have to work with PHOs, for example, to get more collaboration and to shift people’s habits of thinking. There is good research to inform this and show that when specialists work with primary care fewer people need to get into specialist services.”
This, he says, is all underpinned by the fact that with better access to mental health care and better standards of care, we will further reduce the suicide rate.
Mainstreaming for Maori: building bridges, not islands
For Maori, there are some GPs who believe the best way to improve the care of people experiencing mental health disorders associated with suicide attempts is to go mainstream – a view which some may find controversial.
Dr Tane Taylor is an Auckland GP and chair of Te Akoranga a Maui, the Royal New Zealand College of General Practitioners (RNZCGP) Maori Faculty and acting chair of the RNZCGP’s Auckland Faculty Board.
“I do not subscribe to the notion of ‘by Maori for Maori’, but the best for Maori - whatever is best for Maori, and wherever it comes from. The average is not cutting it, we need the best,” he says.
Dr Taylor believes the RNZCGP’s Cornerstone Practice Accreditation Programme will go a long way to address unmet Maori health needs, including mental health care. And he says using accreditation modules makes it possible to measure outcomes to prove what works and what doesn’t.
“International evidence supports that if we go after small groups it becomes costly and non-effective, but if we screen for all populations we will capture a lot of Maori.”
Dr Taylor says 98% or more of the Kiwi population is seen in mainstream general practice, so it makes sense to require outcomes for every GP through their accreditation quality processes.
“They are required to look after all Maori on their books, as opposed to those ‘in the community at large’; they need to make sure Maori are being served and managed appropriately with clear outcomes [in order to] reduce disparities.”
The Cornerstone Practice Accreditation Programme ensures GPs identify gaps in their practice. Funded by the Government in the first cycle, general practices go through accreditation every three years, and the accreditation tools used by the RNZCGP are continuously modified.
Under this system, every practice now has to have a Maori health plan; their practice has to show they have engaged with local Maori and that they are making a difference.
“They have to show Maori in their practice have at least the same healthcare as non-Maori, for example, are they getting free chronic diabetes care? This is all measureable.”
But there’s currently no module for mental health. Dr Taylor says this is a priority area.
“My understanding is that in the not too distant future specific modules addressing mental health issues will be made available to the sector.”
He says improving all aspects of Maori health should be about building bridges, not creating islands.
“Maori want and must participate in finding solutions [and we should], but this is not a Maori only issue, it is a New Zealand issue; we all need to be involved.
“We are encouraging initiatives based on family, but they need closer evaluation and outcomes that can be generalised, rather than occurring only in pockets.”
He is very happy with the way accreditation is progressing because instead of looking at islands, general practice is looking for bridges – in alignment with the collaborative approach needed for effective suicide prevention work for all populations.
