Self-portrait of a person with schizophrenia, representing that individual's perception of the distorted experience of reality in the disorder.

For some time there has been talk of Northern NSW Local Health District Community Health (CMH) sharing the care of patients who require depot antipsychotic medication with GPs. This was to be aimed at the more mentally stable mental health patients. Some guidelines were discussed but never implemented.

Meanwhile, GPs have reported numerous instances of patients saying they no longer attend CMH and were therefore presenting for depot injections or for ongoing care including oral antipsychotic drug prescriptions.

Along with this service provision including a mental health assessment, appropriate mental and physical care is needed. Handover of responsibility has frequently occurred without a formal case history and management plan for their ongoing care being sent.

The potential list of risks with this process is long and GPs have increasingly been expressing concern about the lack of communication between CMH, GPs/practices. GPs within a practice can at times find themselves responsible for an unstable mental health patient’s welfare, leaving the clinician vulnerable and at times unable to get local advice.

Public psychiatry access is not available in our region. Private psychiatrists may not be appropriate or available for GPs to access while the Acute Care Service is only for managing acute situations. The Mental Health Access line is far from ideal in advising GPs. Vital patient care can therefore be compromised when professional help is not available.

GPs are already seeing many mental health patients some of whom require regular oral or depot antipsychotic or other psychotropic medication. These in turn may have significant side effects including weight gain and the metabolic syndrome. This can lead to significant cardiovascular risk, often made worse by smoking, drug and alcohol use, poor diet and physical inactivity, many if not most of which are relatively common amongst people with significant mental health disorders.

In response to this in September 2017 NSW Health put out some guidelines for the physical care of mental health consumers.

In the forward, the Secretary Elizabeth Koff, stated:

‘There is international recognition that the gap in life expectancy between people with a serious mental illness and the general population must be acted upon.

The cause of this life expectancy gap is complex.

Whilst death from suicide contributes to this life expectancy gap, the predominant causes are physical health conditions such as cardiovascular disease, respiratory disease and cancer.

Recognition of the importance of bringing mental health and physical health care together is at the core of providing holistic care for people with a mental illness. This requires action in the way that health services treat and support people with a mental illness and all those who assist them.’

Section 3.1.3, ‘Strengthening relationships with GPs’, states:

“GPs should be considered an integral part of the mental health care team, particularly in terms of improving the physical health of mental health consumers. Developing shared care arrangements with a consumer’s GP, or linking consumers with a GP in the area, should be a priority for mental health services. To support this, a strategy should be developed, at either a local or Local Health District level, to strengthen relationships with local GPs.”

The guidelines go on to suggest ways of improving communication with GPs. The North Coast Primary Health Network’s GP Clinical Council representatives are well suited to lead the negotiations with the LHD’s Mental Health team in order to develop a strategy, and plans are afoot for this to happen.

An educational process for LHD mental health staff and GPs would also be needed to implement such a strategy.  Also appropriate joint funding would need to be sought to develop the strategy. 

Developing a shared care model for GP based antipsychotic depot services as well as for other case managed patients is a highly complex but important issue for mental health consumers. With appropriate guidelines and pathways there is hope that current practice can be significantly improved.

Aside from the cost shift from State to Federal government – the former funds community and acute mental health services, the latter is responsible for GP services - a shared care model could well better serve a patient’s mental and physical health needs.