Mental Illness Stigma – A Reflection
“His hallucinations are as real to him, as my senses are to me”
The burden of mental health is often overlooked. Every year, one in every five people Australians will experience a mental health illness; this includes anxiety, depression, bipolar and eating disorders. The problem with mental illness is that people still experience a lot of stigma. As a result, young adults are afraid to seek help, men are embarrassed to talk about their personal issues, older adults with mental illness often have poor support and most importantly people often feel no one understands them; that no one can help. All these factors make mental health disorders difficult to identify, assess and treat.
During my general practice rotation, I saw a lot of people with mental health issues. The majority of these patients were returning for their regular check up. Each patient had a mental health plan, a support network and a goal to reach. Despite the stigma that still lurks with mental illness, it was good to see that people were reaching out and seeking help for what could be a very debilitating problem.
This reflection is about my encounter with a patient who presented with mental health issues. This experience came from my first day of my general practice rotation.
I met Ian who was a 31 year old male who presented to the clinic for the first time. Initially he seemed calm and blasé, but when I began asking him questions his persona changed completely. It was as if I had opened a jig-saw puzzle, that hadn’t been completed. Each jig saw piece represented a problem and each piece- each problem – untouched, ignored and nearly broken. With limited understanding in taking a mental health history, I felt as though I was thrown into the deep end.
“What brings you to the clinic today?” I asked. He then slowly took his hat off and began moving his head from side to side, unsteadily clenching his hands and swinging his shoulders and arms around. It was as though he was trying to get something off his back. He became very anxious and fidgety. I kept silent as I observed.
“This is going to be serious”, I thought to myself.
He then told me his story.
He presented with depression, anxiety and psychosis. All this started after a break up with his girlfriend which sent him into a major depressive episode and from there the ball kept tumbling, problems kept coming and no one was there to stop the ball from crashing.
I should add that I was alone with him in a room when I was taking this history. I was asked to take the history of the new patients and later present it to the consultant. I have never been confronted with a person who had psychosis, one on one, in the same room, bounded by four walls with the door closer to him then it was to me.
While taking his history I was actually planning my escape route. I was trying to recall where the emergency button was just in case things turned sour. Admittedly, I did not remember where the button was because I was not paying attention during my orientation that same morning. He did not make me feel safe.
However, I quickly realized the important role general practitioners have in mental heath care. I began to appreciate the opportunity I was given with Ian and we continued talking.
In hindsight, what I initially thought, the fear that erupted for a second, was the sort of stigma that accompanies mental illness. No one fully understands what the other person is going through, especially in psychosis. I learnt that Ian’s perception of what was real, may not be real to us, but it was very real to him. We cannot biologically or physically comprehend his state of mind. We can only recognize changes in mental health, empathize with the individual, listen and take appropriate steps in helping them to manage and recover where and when possible.
I decided to research some articles to get a better understanding on how to approach a patient with psychosis in a general practice setting and to learn more on the role general practitioners and psychiatrists have in the management of psychosis.
Acute psychosis is a common psychiatric emergency that may present to health services other than mental health practitioners. RACGP highlights the importance of providing treatment without causing further trauma. Involuntary orders or involvement of police may be required in situations where the risk is acute and cannot be attenuated (Lee & Jureidini, 2013). Tranquilizing medication may be needed in the interest of safety. Further, investigations need to be considered to rule out other differentials of psychosis including medications, illicit drugs and thyroid problems.
In practice, general practitioners rarely make a diagnosis in isolation from specialist services. The role of the GP is in early recognition, to provide support and prompt referral to mental health clinics and services and psychiatrist, and subsequently be involved in the follow-up and long-term management of the patient.
It is well known that the suicide risk is high among patients with schizophrenia spectrum disorders and psychosis (Donker et al., 2013). Early management is therefore critical, and includes setting up a multidisciplinary team, a team of allied professionals and starting psychosocial interventions at the earliest opportunity (Byrne, 2007). Treatment achieves complete remission, without relapse in 25% of patients (Byrne, 2007).
Oud and colleagues (2007) study mentions that the outcome of care of psychotic patients depends very much on personal characteristic of the general practitioner and the quality of local collaboration with Mental Health Service. There is no systematic approach to psychotic patients. Therefore the doctors level of experience, patients access and support to other health professionals, facilities and treatments, and family support are key principles in holistic management of these patients (Byrne, 2007; Lee & Jureidini, 2013).
Establishing good rapport is critical. It is important that the patient can discuss difficulties with compliance openly and be able to speak frankly on their thoughts about treatment.
After my talk with Ian, we were able to organise a follow up appointment with him to create a mental health plan. For Ian to make the journey to the surgery, tell his story and ask for help must have been very challenging. I hope by taking this first big step, Ian can improve and manage his ongoing battle.
Byrne, P. (2007). Managing the acute psychotic episode. BMJ Clinical Review, 334, 686-692.
Donker, T., Calear, A., Grant, JB., Spijker, BV., Fenton, K., Hehi, KK., Cuijpers, P., & Chistensen, H. (2013). Suicide prevent in schizophrenia spectrum disorders and psychosis: a systematic review. BMJ Psychology, 1, 2-10.
Lee, Hsu-en., & Jureidini, J. (2013), General practice psychiatry: Emerging psychosis in adolescents A practical guide. Australian Family Physician, 42, 624-627.
Oud, MJT., Shuling, J., Slooff, CJ., & Jong, BM. (2007). How do General Practitioners experience providing care for their psychotic patients?. BMC Family Practice, DOI: 10.1186/1471-2296-8-37.