General practitioner management of mental health during the COVID-19 pandemic
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Clinical
General practitioner management
of mental health during the
COVID-19 pandemic
Ashvini Munindradasa, Grant Blashki, MENTAL HEALTH ISSUES are common in the consumption.4,5 In some parts of Australia,
Sally Hall Dykgraaf, Jane Desborough, Australian community, with approximately COVID-19 closely followed devastating
Michael Kidd 3.2 million Australians experiencing an bushfires, meaning some communities were
anxiety-related condition and 2.5 million already in a heightened state of anxiety and
Background
experiencing feelings of depression each stretched beyond their normal capacity.2,6
Psychological issues are common year.1 The COVID-19 pandemic has In high-income countries, GPs are
presentations in general practice. brought fears relating to the virus itself central to providing mental healthcare,7
The COVID-19 pandemic has created a (eg potential exposure of self and family), and are the first point of contact for mental
‘perfect storm’ for the deterioration of anxiety about physical distancing and health presentations and the facilitators of
mental health. General practitioners (GPs) concerns regarding unemployment and access to other therapists.8,9 Psychological
are ideally placed to provide supports for
economic loss.2 Since the start of the issues are the most common health issues
people with mental health issues.
pandemic, the Australian Government has managed by Australian GPs.10 GPs often
Objective announced that more than $500 million have longstanding relationships with their
The objective of this article is to provide will go towards boosting key mental health patients, and are well placed to understand
an overview of management approaches
services, supporting the National Mental their personal, family and community
for mental health issues, paying attention
Health and Wellbeing Pandemic Response contexts and appreciate the interaction
to fostering resilience and lifestyle
factors, particularly during the COVID-19 Plan.3 Unsurprisingly, general practitioners of concurrent physical and other mental
pandemic period. (GPs) have been called upon to provide health conditions and medication use.
increased mental health supports for their With increased demand for mental
Discussion
patients, further adding to their significant health services during the pandemic,
While feelings of fear and anxiety are
expected in these uncertain times, some
clinical workload. GPs need to provide increased mental
people may experience an exacerbation The COVID-19 pandemic, lockdowns, health supports while keeping up to date
of a mental illness or develop a mental associated loss of employment and with pandemic-specific guidelines and
health issue for the first time during the financial stresses, navigation of adapting to new methods of delivering
COVID-19 pandemic. A list of resources homeschooling for parents while working healthcare. Furthermore, GPs themselves
available to GPs is provided, and case from home and isolation of school-age are experiencing similar worries and
studies are used to demonstrate how
children from their peer groups created uncertainties related to potential infection
these resources can be used to support
assessment and management during the a ‘perfect storm’ for the exacerbation of self and family, conflicting home and
COVID-19 pandemic. of existing mental health conditions work commitments, as well as financial
and the development of depression or implications of the pandemic on practice
anxiety. Further consequences included viability. This article aims to offer guidance
a reported spike in domestic violence for GP management of depression and
and an increase in reported alcohol anxiety during the COVID-19 pandemic
472 Reprinted from AJGP Vol. 50, No. 7, July 2021 © The Royal Australian College of General Practitioners 2021General practitioner management of mental health during the COVID-19 pandemic Clinical
by providing an overview of management rules so that they are still applicable during then use metaphors and imagery to
approaches (Figure 1), a list of resources the pandemic can strengthen shared navigate challenges.19 Coherence is
(Table 1) and two case studies. family values.17 related to people’s desire to make sense
Other models developed to manage of the world.18 Encouraging a view that
emotional responses to natural disasters families are ‘in it together’, and that
Assessment focus on the three Cs: control, coherence their current plight is specific, not the
Apart from assessing presenting and connectedness.18 Control is reflected fault of anyone and time limited and
complaints and personal and family in the belief that people can access manageable, may reinforce beneficial
history of mental health conditions, a personal resources to achieve valued goals. belief systems.17 Despite the impact of
psychosocial history (ie coping methods, Strengths-based cognitive behavioural social distancing, isolation or quarantine
social supports and socio-occupational therapy (CBT) can also be used to facilitate requirements, connectedness can be
functioning) is essential to understand control, with patients encouraged to emphasised with fewer people with
the full impact of the pandemic on an construct personal models of resilience whom patients have more meaningful
individual’s mental health.11 Screening that identify personal strengths, and relationships, or by expanding social
for mental health issues is particularly
important for those with pre-existing
mental health problems, healthcare
workers, those in quarantine and the
unemployed and casualised workforce, Assessment
all of whom are known to be at increased
risk of mental illness during a public
health emergency.2 A mental health risk Physical Mental
assessment should be considered in
Suicide risk
vulnerable patients for early detection
Self-harm
of mental health problems or even Alcohol and other coping strategies
suicidal thoughts.12 It should be noted
that some people may present having
already assessed their mental health by
using tools available online.13–15 Regular Management
follow-up to reassess symptoms and
ensure that diagnoses and interventions
are appropriate is important, as mental
Non-pharmacological
health issues can deteriorate over time. interventions
Management
Psychological
Fostering
Fostering resilience resilience
Lifestyle interventions Referral
(online/face to face)
The presence of increased anxiety,
Encourage positive Optimise physical Cognitive behavioural Better Access initiative
loneliness and sadness are expected adaptive behaviours activity and nutrition therapies
NewAccess program
in the context of a pandemic, and is Social prescribing Offer strategies to Interpersonal therapy
Private mental health
lower alcohol/
not necessarily diagnostic of a mental Engage family belief
cigarettes/drug use
Acceptance and services
systems commitment therapy
health condition.2,16 GPs can help Maintain routine
Others
Acute mental health
services
patients keep perspective and encourage Limit media
consumption
positive behaviours, such as keeping up
connections with friends and family, even
in the presence of worry, pessimism and Pharmacological
interventions
negative emotions about the pandemic. (if required)
While family resilience frameworks
emphasise communication, organisation
and belief systems, these are likely to be Regular follow-up
disrupted during a pandemic.17 GPs can
help their patients reinforce such processes
by focusing on the three Rs: routines, Figure 1. Overview of management approaches for mental illness during the
rituals and rules.17 Maintaining routines, COVID-19 pandemic
developing new rituals and renegotiating
© The Royal Australian College of General Practitioners 2021 Reprinted from AJGP Vol. 50, No. 7, July 2021 473Clinical General practitioner management of mental health during the COVID-19 pandemic
contacts in ways that are not dependent on for at least 10 minutes have been found commitment therapy, even when delivered
face-to-face engagement.18 Finally, ‘social to predict greater resilience during remotely and in multiple contexts,28–30 as is
prescribing’, where people are referred COVID-19.25 Coping mechanisms and often necessary during the pandemic. CBT
to non-clinical services, support groups strategies to minimise cigarette and alcohol aims to modify maladaptive, automatic,
and social structures, can be helpful for use should be addressed. The Australian negative thoughts and can reframe fears
people experiencing mental health issues, Government’s Head to Health website relating to hopelessness about social
chronic physical health conditions or social provides helpful resources on physical connection or fear of infection, whereas
isolation.20,21 activity, nutrition and sleep.26 Media IPT allows the pandemic to be framed
reports can be a source of stress, and as a role transition.31 Promisingly, CBT,
Lifestyle patients should be encouraged to monitor IPT and computer-assisted therapies
Tobacco smoking, inadequate nutrition, and limit their media consumption and have good evidence of effectiveness for
harmful alcohol consumption and physical rely on official and trusted sources of common mental health conditions such
inactivity are behaviours that contribute to information.2,23,27 as depression and anxiety.32,33
greater chronic disease burden, including
for those with mental health issues.22 Psychological interventions Referral
Optimising aspects of physical health, by Several psychological interventions Most GPs are familiar with the Better
focusing on healthy eating and regular can assist people with mental health Access to Psychiatrists, Psychologists
exercise, should be discussed.23,24 More conditions. Favourable results have and General Practitioners Initiative
minutes of daily exercise and more days been reported for CBT, interpersonal (Better Access), funded through the
per week spent outside in the sunshine psychotherapy (IPT) and acceptance and Australian Government’s Medicare
Table 1. Useful resources for Australian general practitioners
Suicide helplines Lifeline www.lifeline.org.au
Suicide Call Back Service 1300 659 467
Information on general Head to Health https://headtohealth.gov.au
health/wellbeing
Online mental health e-Mental Health in Practice www.emhprac.org.au
supports
WellMob https://wellmob.org.au
Black Dog Institute www.blackdoginstitute.org.au
myCompass www.mycompass.org.au
Beyond Blue www.beyondblue.org.au
eheadspace https://headspace.org.au/eheadspace
MoodGym https://moodgym.com.au
Resilience in children Beyond Blue https://resources.beyondblue.org.au/prism/file?token=BL/1810_A
Alcohol and drug Alcohol and Drug Foundation https://adf.org.au
resources
Financial/debt National Debt Hotline https://ndh.org.au
resources
Domestic and family 1800RESPECT www.1800respect.org.au
violence
Management Beyond Blue: A guide to what works for https://resources.beyondblue.org.au/prism/file?token=BL/0556
guides for general depression
practitioners
Beyond Blue: A guide to what works for https://learn.beyondblue-elearning.org.au/workplace/resources/pdf/
anxiety disorders topic5/GuideToWhatWorksForAnxiety.pdf
RACGP e-mental health – A guide for GPs www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-
guidelines/view-all-racgp-guidelines/e-mental-health
474 Reprinted from AJGP Vol. 50, No. 7, July 2021 © The Royal Australian College of General Practitioners 2021General practitioner management of mental health during the COVID-19 pandemic Clinical
Benefits Schedule. During the pandemic, point?’ His investigations reveal glycated • consideration of whether Bob’s dose
recognising the immense value of these haemoglobin of 9.8%. of antidepressant requires adjustment
psychology sessions, the Australian Bob has a pre-existing mental health • follow-up options, including the use
Government extended the program condition, is socially isolated and has a of telehealth.
funding up to 20 sessions per calendar serious chronic physical health condition.
year.34 For people with milder symptoms, Options for management include:
another option is referral to coaches in • assessment of symptoms using tools, CASE 2
the NewAccess program, developed by such as Patient Health Questionnaire-9 Linda, aged 20 years, presents to you
Beyond Blue and available in a number (PHQ9), General Anxiety Disorder-7 requesting sleeping tablets for insomnia,
of regions of Australia (Queensland, New (GAD7) or Depression, Anxiety and which she has experienced for the past
South Wales, Victoria and the Australian Stress Scales-21 (DASS-21) few months. She was made redundant
Capital Territory at the time of writing).35 • reiterating Bob’s suicide safety plan from her job at a local cinema where
People can self-refer to NewAccess for • emphasising the role of the 3Rs. she was working to support herself
a total of six sessions and do not need a Encourage Bob to stick to a regular as a musician, but all her shows were
mental healthcare plan.35 routine (eg getting dressed at the same cancelled. She has a supportive family
time every day and taking medication who are helping her apply for other
Pharmacological interventions at the same time). Bob can develop new jobs. She denies any suicidal ideation
While specific pharmacological therapies rituals, such as having dinner ‘virtually’ or thoughts of self-harm. Options for
are outside the scope of this article, a few with his siblings a few times a week. management include:
basic principles are worth reiterating. New rules, such as having an hour of • discussion about the importance of
Knowing a few medications well (ie the ‘digital detox’ or a 10-minute walk sleep hygiene and routine in sleep.
short- and long-term side effect profiles, every day, can be trialled Linda can be referred to the Head to
medication interactions and medication– • consideration of social prescribing of Health website to access the ‘Managing
disease interactions) enables prescribers to an activity that interests Bob. Examples insomnia course’ or the ‘Recharge app’,
be more confident in starting medications of potential activities include walking, which is a six-week wellbeing course
when needed. Once medications are gardening, speaking to his siblings over that focuses on improving sleep habits
started, patients should be followed up to the telephone, doing a shared project • trialling the 3Cs approach. Control
monitor their progress and potential side with his siblings (eg genealogy, cooking can be fostered by encouraging Linda
effects. Special groups of people that should using television cooking shows/online to focus on things she can do now to
be treated with increased caution include recipes as a guide, painting or drawing help with her short- and long-term
older people, people with chronic disease, that he can be encouraged to bring goals. Linda can be directed to
pregnant/breastfeeding women, children to appointments or taking courses/ mindfulness apps, which may help her
and adolescents.11 A detailed discussion volunteering with the local men’s shed find coherence by acceptance-based
of the various pharmacotherapies is • discussion about lifestyle practice of observing and engaging
outlined in the Psychotropic section interventions, such as physical activity in the present in a non-judgemental
of the Therapeutic Guidelines.36 and Bob’s current diet, that are likely and non-reactive manner. Linda can
contributing to poor diabetes control. even start a virtual concert with fellow
It may be worth discussing that musicians to facilitate connectedness
CASE 1 improving Bob’s diet and exercise may among her peers
Bob, aged 54 years, is a patient you help improve his mental health as well • consideration of social prescribing
know well. He presents three months • making sure Bob’s vaccinations are (eg focusing on her music, walking
after the date for his scheduled review up to date, especially influenza and groups with friends or volunteering
of diabetes management. He has a COVID-19 vaccinations to help with elderly residents in the
history of metabolic syndrome and major • encourage mindful engagement in community)
depressive disorder. He lives alone. His activities and referring Bob to the • discussion about the importance of
main supports are his siblings, but they Head to Health website for further healthy lifestyle interventions and
live in another state. Bob reports that information encouraging mindful engagement in
he has been feeling down, and although • discussion about current coping activities
he denies any active suicidal plans, mechanisms (eg alcohol consumption, • referral to the Beyond Blue website for
admits that ‘getting Corona might be a smoking) and providing relevant more information and resources
blessing’. He remains on the same dose supports • discussion and supports around any
of antidepressant medication and did • reassuring Bob that psychological negative coping strategies
not attend his last scheduled session interventions conducted remotely are • referral to the NewAccess program for
with his psychologist, as it was over still effective, and encouraging Bob to mental health coaching.
the telephone and ‘what would be the re-engage with psychology
© The Royal Australian College of General Practitioners 2021 Reprinted from AJGP Vol. 50, No. 7, July 2021 475Clinical General practitioner management of mental health during the COVID-19 pandemic
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