General practitioner management of mental health during the COVID-19 pandemic

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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
                                                      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
                                                      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 2021
General 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
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
health issues can deteriorate over time.                                       interventions

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
                                                                                                                                                  Acute mental health
patients keep perspective and encourage                                                    Limit media
positive behaviours, such as keeping up
connections with friends and family, even
in the presence of worry, pessimism and                                                                                                                               Pharmacological
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   473
Clinical                                                                          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                            

                                Suicide Call Back Service                     1300 659 467

Information on general          Head to Health                      

Online mental health            e-Mental Health in Practice         

                                Black Dog Institute                 


                                Beyond Blue                         



Resilience in children          Beyond Blue                         

Alcohol and drug                Alcohol and Drug Foundation         

Financial/debt                  National Debt Hotline               

Domestic and family             1800RESPECT                         

Management                      Beyond Blue: A guide to what works for
guides for general              depression
                                Beyond Blue: A guide to what works for
                                anxiety disorders                             topic5/GuideToWhatWorksForAnxiety.pdf

                                RACGP e-mental health – A guide for GPs

474   Reprinted from AJGP Vol. 50, No. 7, July 2021                                                            © The Royal Australian College of General Practitioners 2021
General 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   475
Clinical                                                                                General practitioner management of mental health during the COVID-19 pandemic

Conclusion                                            Response Group (seconded), Primary Care Division,            put all hands to the pumps. Front Public Health
                                                      Australian Government Department of Health, ACT;             2014;2:33. doi: 10.3389/fpubh.2014.00033.
Despite the various disruptions of the                Research Manager, Rural Clinical School, ANU              8. Farrer LM, Walker J, Harrison C, Banfield M.
COVID-19 pandemic, most Australians                   Medical School, College of Health and Medicine,              Primary care access for mental illness in Australia:
                                                      Australian National University, ACT                          Patterns of access to general practice from
are resilient and will not experience a
                                                      Jane Desborough RN, RM, MPH, PhD, Action                     2006 to 2016. PLoS One 2018;13(6):e0198400-e.
diagnosable mental health condition.                  Research, COVID-19 Primary Care Response Group               doi: 10.1371/journal.pone.0198400.
Feelings of fear and anxiety should not               (seconded), Primary Care Division, Australian             9. Australian Institute of Health and Welfare. Mental
                                                      Government Department of Health, ACT; Senior                 health services in Australia. Canberra, ACT: AIHW,
necessarily be considered pathological or             Research Fellow, Research School of Population               2021.
require intervention; however, many others            Health, Australian National University, ACT
                                                                                                                10. The Royal Australian College of General
will have experienced an exacerbation of              Michael Kidd AM, MD, FAHMS, Deputy Chief                      Practitioners. General practice: Health of the
                                                      Medical Officer and Principal Medical Advisor,                Nation 2020. East Melbourne, Vic: RACGP 2020.
mental health concerns or developed a                 Primary Care Division, Australian Government
                                                                                                                11. World Health Organization. mhGAP intervention
mental health condition for the first time.           Department of Health, ACT; Professor of Primary
                                                                                                                    guide for mental, neurological and substance
                                                      Care Reform, Australian National University,
The management approach outlined in this                                                                            use disorders in non-specialized health settings.
                                                      ACT; Adjunct Professor, Department of Family a
                                                                                                                    Geneva, CH: WHO, 2016.
article focuses on fostering resilience and           Community Medicine, University of Toronto, ON;
                                                      Emeritus Director, World Health Organization              12. Su W, Stone L, Blashki G. Improving mental
promoting healthful lifestyle behaviours,                                                                           health and reducing suicide risk: How GPs can
                                                      Collaborating Centre on Family Medicine and Primary
psychological interventions and appropriate           Care, GVA; Professorial Fellow, Murdoch Children’s            help during the COVID-19 pandemic. Med Today
pharmacotherapy and referral. While this              Research Institute, The Royal Children’s Hospital
                                                      Melbourne, Vic; Honorary Professor of Global Primary      13. Beyond Blue. Anxiety checklist. Melbourne, Vic:
overview draws on online and application-             Care, Southgate Institute for Health, Society and             Beyond Blue, 2020. Available at www.beyondblue.
based resources, the list of resources is             Equity, Flinders University, SA                     
                                                                                                                    [Accessed 14 April 2021].
not exhaustive, and clinicians have many              Competing interests: None.
                                                      Funding: None.                                            14. Beyond Blue. Anxiety and depression checklist
options available to them to manage their                                                                           (K10). Melbourne, Vic: Beyond Blue, 2020.
                                                      Provenance and peer review: Not commissioned,
patients’ mental health in the context of             externally peer reviewed.
                                                                                                                    Available at
                                                                                                                    anxiety-and-depression-checklist-k10 [Accessed
the COVID-19 pandemic.                                Correspondence to:                                            14 April 2021].
                                                                        15. Black Dog Institute. Online clinic. Sydney, NSW:
                                                                                                                    Black Dog Institute, 2019. Available at https://
Key points                                            Acknowledgements                                     [Accessed
                                                                                                                    14 April 2021].
•   GPs are well placed to manage
                                                      The authors would like to acknowledge the input
                                                      of Tobias James and Alice Wetherell from the              16. PeConga EK, Gauthier GM, Holloway A, et al.
    mental health issues in the context               PHXchange, Research School of Population Health at            Resilience is spreading: Mental health within
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© The Royal Australian College of General Practitioners 2021                                                                  Reprinted from AJGP Vol. 50, No. 7, July 2021   477
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