Oireachtas Joint and Select Committees
Wednesday, 7 February 2018
Joint Oireachtas Committee on Future of Mental Health Care
Medication and Talk Therapy: Discussion
Dr. Brian Osborne:
I am a GP in Galway and assistant director of the PRC.
General practice teams deliver continuing personal medical care, provided by generalist health care professionals, including GPs, practice nurses, and a growing strand of practice based allied health professionals in the fields of psychology, counselling and family therapy. When well supported and adequately resourced, GP teams can engage systematically in activities known to prevent and care for a range of mental health issues and medical conditions. This is achieved through the use of brief interventions in respect of alcohol and tobacco, lifestyle interventions in the context of exercise and stress management as well as delivering ongoing community based care.
Elsewhere in the primary care domain, the counselling in primary care service, CIPC, provides off-site counselling for people who are significantly stressed, but this only applies for people who are eligible under the primary care reimbursement scheme, PCRS, or medical card scheme. General practitioners' ability to refer to voluntary and-or private counselling services or specific services such as local addiction counselling varies depending on local circumstances and, crucially, on the ability of the individual to pay. The ICGP is of the view that there is a major lack of capacity in this area of service provision. On a system-wide basis, the volume of service provided by the CIPC is inadequate, and a majority of the population are ineligible for CIPC services. The contribution of voluntary agencies is increasingly evident and important to GPs and people who use these services.
When a person attends general practice with a mental health issue, several approaches are explored. The GP will engage in initial evaluation and diagnosis. People mostly present with mild to moderate anxiety and depression. In many instances, an opportunity for reflection, shared formulation of the issues, lifestyle advice, a cognitive approach grounded in a pre-existing understanding of the individual and their particular circumstances, signposting to relevant additional resources, and follow up at the practice level will enable many people to resolve the problems they experience. This is particularly the case when the reflection is undertaken with a GP who has a deep and long-term knowledge of the individual, their circumstances and their past medical history.
Prevention, earlier diagnosis and management of problem use of alcohol and recreational drugs, or the presence of signs and symptoms of a range of psychiatric conditions including postpartum depression, self-harming, addictions, adjustment reaction to life events, abnormal grief reactions, obsessive compulsive disorder, OCD, borderline personality disorder, chronic anxiety disorder, or clinically significant depression will result in a more formal practice-based approach, the management of which will reflect the circumstances of the practice, and the needs of the individual.
The earliest diagnosis of severe spectrum or complex psychiatric diagnoses is also undertaken by GPs, including psychoses, bipolar affective disorder and high-risk suicidality. These activities are undertaken across the full spectrum of people who attend, including those from deprived and affluent backgrounds, the young and the old. At the severe or persistent end of the spectrum of clinical presentations, treatment will extend to pharmacotherapy and-or referral to psychiatry.
When practices are operating in a dearth of resourcing, opportunities and time to engage with the people and families concerned are fewer. Less can be done in terms of prevention and earlier intervention, with increased pressure on GPs to treat people pharmacologically and to refer, regarding which many GPs are unhappy. Payment is a known additional barrier to optimal treatment for many citizens. It is a major cause of dissatisfaction where pressure of work is such that GPs are unable to spend adequate time with patients who have significant mental health issues. Onward referral to secondary care is challenging for people.
The impact of financial emergency measures in the public interest, FEMPI, cuts and sustained failure to deliver a contract for general practice has caused many professionally important activities in general practice to come under pressure as a result of competing and conflicting pressures of higher professional values set against relentless business pressures. This conflict is a major deterrent to younger general practitioners establishing in practice and a cause of burnout among older colleagues, contributing directly to medical emigration and leaving people without essential services. Our health system would appear to value machines, hospitals, and drugs over talk therapy, time to care and social support.
Being able to manage problems in the general practice setting has the added advantage of markedly reduced or an absence of stigma. GPs and the people who attend them for care of mental health issues both prefer to avoid the use of pharmacotherapy where possible; while it is quicker and easier to prescribe medication, in many instances it is neither the best nor the first thing to do.
I will hand over to my colleague, Dr. O'Brien.