Mental Health for Doctors

Dr Charlotte Middleton (00:00:15)
Mental health issues are driving Australians to visit their GP more than any other health concern. Almost half of Australians will experience a mental health illness in their lifetime, yet only 54% of these will ever access treatment. The mental health agenda has come a long way, but still has a long way to go. In the lead up to World Mental Health Day in October, today’s panel will look at the current state of mental health care treatment in Australia. Is a system set up to support this growing issue? What role does technology play? And how can we look after the mental health of our all important health care workers? Joining me today is Dr. Louise Stone, GP and clinical associate professor at ANU Medical School.

Dr Louise Stone (00:00:58)
Hey Charlotte, how are you?

Dr Charlotte Middleton (00:01:02)
Dr. Geoff Toogood, Cardiologist, founder of CrazySocks4Docs and Beyond Blue speaker.

Dr Geoff Toogood (00:01:10)
Hi Charlotte, thanks for having me.

Dr Charlotte Middleton (00:01:13)
Dr. Samineh Sanatkar, post-doctoral fellow with Black Dog Institute and University of Newcastle.

Dr. Samineh Sanatkar (00:01:20)
Hi Charlotte, nice to be with you today.

Dr Charlotte Middleton (00:01:23)
And Jason Threthowan, CEO of Headspace.

Jason Threthowan (00:01:27)
Hey Charlotte.

Dr Charlotte Middleton (00:01:28)
And Dr. Grant Blashki, GP and lead clinical advisor at Beyond Blue.

Dr Grant Blashki (00:01:34)
Hi Charlotte?

Dr Charlotte Middleton (00:01:36)
All right guys, let’s get started. Thank you so much for joining me today in today’s panel on this really, really serious and all important topic. Look, it comes as no surprise that Australians’ resilience has been severely tested recently what, with the Bush fires, then the floods, and now of course, the nationwide pandemic. It’s all putting a significant strain on people’s mental well-being. What effect do you think these events have had on the nation’s mental health? Louise, I might start with you.

Dr Louise Stone (00:02:09)
Thanks Charlotte. It’s been a really difficult time for everybody. And I guess I’m in Canberra and I’ve got a few panelists here in Melbourne, so there’s probably feeling it much more than I am, but I think the interesting thing about a pandemic is that pandemics drive people apart, natural disasters tend to bring people together. The hardest thing about pandemics is that people have difficulty connecting with others and that makes life incredibly challenging. There are particular groups, of course, that are vulnerable, we’ve got parents of newborns, we’ve got the elderly, we have people in palliative care, but we’ve also had people who have normally managed life very well and even lived perhaps a life of generous privilege and now that’s all turned on its head very, very quickly. And for those people, having mental health concerns is very unfamiliar, so they struggle to come into our door and to talk. And some of those people of course are doctors and that can make life very difficult because it’s difficult for them to step into that space.

Dr Charlotte Middleton (00:03:12)
We’ll certainly talk about doctors and other healthcare workers in a moment, but Geoff and Grant, you are both in the epicenter at the moment, living in Melbourne. What have you been witnessing there?

Dr Geoff Toogood (00:03:25)
Where do you want to start? From a personal point of view, we’ve been locked down obviously to stage four, only allowed to go five kilometers from our house. I’m in the fortunate position of being able to go to work, but then you go to work and expose yourself to risk. Unfortunately, my hospital had a significant outbreak in health care workers. We had close to 700 furloughed from our hospital for a period of time. That added stress on our hospital. Not all were sick, they were just isolating.

Dr Geoff Toogood (00:04:05)
And that also, I might add, created extra isolation for us as a hospital, because we felt cut off a little bit from the other parts of Melbourne. So not only we’re isolated from country Victoria, we’re isolated from the rest of the country, but our hospital was put under added stress. So for us there’s added anxiety, uncertainty, we were concerned obviously about contracting the virus and getting adequate PPE. I’m divorced, so I share custody of my children and they decided to not come one of the weeks because they’re too scared of getting COVID from me. And I thought it was probably a reasonable decision.

Dr Charlotte Middleton (00:04:50)
But it’s all those extra ramifications that this has resulted in. Something like that, you wouldn’t be alone in that.

Dr Louise Stone (00:04:58)
No, I don’t think we’re alone. And I think we’re coming out of it, there’s hardly anyone furloughed now, hardly anyone positive in the hospital, getting back to normal capacity. But then there’s the issue of that is that you’re expected to have bounced back to normal capacity after you’ve been working under a stressful environment or psychologically stressful environment before. And that’s everyone in the hospital was affected. It’s not just the doctors, it’s everyone from-

Dr Charlotte Middleton (00:05:28)
Every level.

Dr Louise Stone (00:05:29)
… everyone that’s in the footprint of that hospital was affected by it.

Dr Charlotte Middleton (00:05:34)
Wow, I can only imagine. And Grant, you’re in general practice, what’s your experience been?

Dr Grant Blashki (00:05:40)
Well, also being in Victoria, it really has been quite a parallel universe to the rest of Australia. I don’t think people have fully followed what the lockdowns been working out [inaudible 00:05:51]. And certainly my patients who live on their own or single and have been sticking to the rules, they’ve lost their sense of humor after six months of mocking about, and it’s a triple whammy because you’ve got the loss of jobs and economic things, you’ve got worries about infections and there’s been quite significant numbers in Victoria.

Dr Grant Blashki (00:06:13)
And then I think also there’s the family life’s been turned upside down. Most of us go along like last week is going to be pretty similar to next week, and I think there’s been that overall sense of, “What the hell just happened to my life?” It really has been turned upside down. Having said that, we’re optimistic that we’re getting some loosening of lockdowns and getting things under control, but it’s been a pretty tough gig for people in Victoria, to be honest.

Dr Charlotte Middleton (00:06:44)
I can only imagine, but I guess just looking at the broader picture of mental health in Australia, we know now, as I said in my introduction, that it’s driving people to their GPs now more than ever. It’s now the major health concern that people are actually seeing their GP for. Medicare tends, though, not to support us GPs in terms of doing more complex and longer consultations. Louisa, again I might ask you in this situation, how can we… GPs are struggling to keep up with the demand, so how could we perhaps better support GPs to provide those needs of our patients?

Dr Louise Stone (00:07:25)
It’s tricky, isn’t it? Because there’s a few things going on. One of the biggest things is we have no data. The mental health work that GPs do is counted according to the way they bill, not actually about what they do. And so we actually know very little. I remember working in policy and someone saying, “The biggest mystery in healthcare is what happens inside in 1923, because we actually don’t know.” And of course we had BEACH, but BEACH has been defunct for a while. So I don’t think we have a clue what GPs actually do. So in the absence of data, one of the other difficulties we have is that a number of other pieces of the healthcare mosaic, it doesn’t always work as a system, have their own segments that they look after and quite distinct triaged elements. They’ll pick the patients that work for their model, that produce the outcomes, that fit their criteria, which leaves the patients they don’t want in general practice.

Dr Louise Stone (00:08:26)
And one of the difficulties we have is it’s not a matter of complexity. Of course the simple patients, it sounds like a terrible way to put it, but the patients who have a straightforward mental health disorder and who don’t have co-morbidities, don’t have intellectual disability, don’t have autism, don’t live homeless, aren’t in their nineties, all those conflicting elements are well served by a number of places in the system. And acute mental health services will usually take the severe people providing they fit certain diagnostic criteria, but then there’s a whole group, which is often called the missing middle. I don’t think they are the middle, I think they’re often quite severe, that are outside the remit of everyone else, but us. And it’s that group that are the most vulnerable.

Dr Louise Stone (00:09:17)
We know that the people with the highest income have five times less mental health problems and five times more services. We are not meeting the needs of that bottom quintile who have the most mental health services, the most mental health issues, the most risk, and by far the least access to anything. And that’s where general practice is working, which is a terribly difficult space because we know they need caseworkers, we know they need accommodation, we know they need support and we can’t get it. And that’s the part that causes the quite significant moral distress in GPs, that idea of wanting to do their best and being unable to do so because of a lack of resources available to them.

Dr Charlotte Middleton (00:10:05)
Grant, in your general practice, same things?

Dr Grant Blashki (00:10:09)
Yeah. I’m in a big bulk billing practice on a mole, which has become a bit of a sink for people who are homeless or not doing very well. And I really respect always the way [inaudible 00:10:26] systems, issues. And it’s true, general practice, particularly bulk-billing general practice ends up as a catch-all for a lot of people that don’t fit necessarily neatly somewhere else. I think some of the role that the GPs are playing, apart from specific mental health assessments and referral, is a bit of an anchoring role at the minute because people’s worlds has been turned upside down, not like anything I’ve seen in my lifetime.

Dr Grant Blashki (00:10:57)
And the GP just being there with continuity, some of my patients with chronic mental health issues have got them booked in quite regularly, and we’re not necessarily, as Luis says, the mystery of what happens. A fair bit of that will be pastoral care and how you’re going, and if you caught up with your parents yet. There’s a fair bit of that as well, which isn’t cognitive behavioral therapy or any clever psychological technique, it’s just a bit of containment and anchoring and feeling like there’s some order in the world.

Dr Charlotte Middleton (00:11:32)
Absolutely. Look, Samineh and Jason, I might bring you into this conversation, because obviously, Louise mentioned statistics and data, and it’s obviously hard to know exact numbers, but I guess you do have numbers in terms of what you see coming through your organizations. Jason, you deal obviously mainly with the adolescent population. What have you seen in terms of numbers, particularly, I guess, during this pandemic, but in general?

Dr Grant Blashki (00:11:59)
I think, Charlotte, across the primary health system, and probably across the acute system too, we had a drop-off in people accessing services in that wave one. And then we were waiting for the exile and it came, and then wave two in Victoria, in particular came and put a lot of limitations in… Despite actually, and we’ll get to it later I’m sure, the benefits of them, telehealth, which has predominantly been phone-based services as well as video, but predominantly been phone-based. That telehealth initiative was absolutely gold at the right time in order for the COVID cases [inaudible 00:12:35] that are different to that. Hopefully now we’re getting on top of the virus in Victoria and we’re obviously going to be maintaining this scenario for some time, we’re now seeing an increasing number of people coming out to see their doctor and young people as well seeking more support now than they were prior. But there was a gap in between.

Dr Grant Blashki (00:13:03)
And actually what we’ve been trying to do is just bought the benefits of telehealth, actually the system was turned upside down. For instance, in Victoria, there was less than 5% of services provided in headspace over the last number of weeks in person. Now, obviously, we’re not quite the same as general practice, and for a lot of reasons, but at the same time, the health care workers, the doctors, the health clinicians have done a marvelous job in not only living through the pandemic themselves, their own family situations, but they’ve also been there and responsive, not just in-house, but also out of house.

Dr Grant Blashki (00:13:44)
We’ve seen an increase in the number of young people seeking support from our online services, more from the web chat. None of us nature of actually reaching out online and having a web chat with someone that they’ve never spoken to before, but in fact, 50% of them have never spoken to anyone before about their mental health challenges. And so that’s been a really positive thing, but actually linking them back into a GP or headspace center for followup care has been really important.

Dr Charlotte Middleton (00:14:15)
Fantastic. That’s interesting. Samineh, what’s your experience at Black Dog Institute?

Dr. Samineh Sanatkar
(00:14:20)
I’m not directly involved with the clinical services at the Black Dog Institute, but just from what my colleagues are telling me who do work in the clinic, they say very similar things to other panelists in that a lot of the time before psychotherapy actually takes place, some more fundamental issues need to be addressed such as unemployment and housing and so on before therapy can begin and continue. And what is difficult with that is to being restricted to 10 or now maybe 20 sessions.

Dr. Samineh Sanatkar
(00:15:08)
In reality, these things take a lot longer to sort out and to begin to establish this rapport with someone who might have had difficult experiences before also within the healthcare system. So to reestablish this trust and encouragement to go forward can sometimes be really challenging and requires a lot of, like the other panelists say, a lot of courage movement and engagement to change someone’s past experience to a more positive world view. And that of course also influences people’s mental health, how they’re doing if they feel supported and guided through the process. So, it’s something that it’s really tremendously important and all healthcare workers play such a vital part in what is going on in this country at the moment.

Dr Charlotte Middleton (00:16:11)
Fantastic. Thanks for that. And I guess that ends into my next question of how we can better direct people, I guess, to the right places for information. We all know good old Dr. Google, people are jumping on and looking up their own symptoms, self-diagnosing themselves, which we know obviously there’s a myriad of reasons why they shouldn’t be doing that. Grant, I might ask this question of you, I guess with both your experience in general practice and Beyond Blue of how we can better guide people to the right places for the information and perhaps ways of then seeking treatment.

Dr Grant Blashki (00:16:49)
At Beyond Blue, we found that since March and April, we’ve had a 40% to 60% jump each month compared to the month last year on contacts with our support service. And the online chat, which is our forums, have had 1.3 million people on it. So we were actually asked to set up a dedicated mental health phone line for COVID and also a dedicated website, which has got some great articles on it, guides, ways of getting services. Deals with all the sorts of issues we’ve been talking about, social isolation, losing your job. We’ve got a good partnership with the financial counselors, Australia. So there’s lots of supports out there. And I think the GPs can recommend some of these to people. The Beyond Blue corona phone line is 1-800-512-348, and there’re free mental health professionals, 24 hours confidential. So it’s not a bad start for people and they can also help direct them if they need help. We certainly found a heavy weighting towards Victoria. During the second lockdown, 75% of the contacts to our support service coming from Victoria.

Dr Charlotte Middleton (00:18:20)
Not surprising, I guess.

Dr Grant Blashki (00:18:21)
Yeah.

Dr Charlotte Middleton (00:18:23)
All right, guys, let’s move into I guess talking about the mental health of our healthcare workers. Obviously, there’s been a significant strain on them throughout this, adapting to new processes, fear of infection, Geoff you mentioned, adapting to new technologies and basically almost overnight having to deliver healthcare in a completely different way. So been enormous challenges across the board. What overall toll do you think this pandemic has taken on the mental health care of our workers, Louise?

Dr Louise Stone (00:19:02)
I’m in Canberra. And one of the interesting things in Canberra, I think, which many of my colleagues will share, is that Christmas in 2019, is usually a time when people go down the coast and relax and recharge. And I think it’s not just about the pandemic. We didn’t have that either. We forget the Bush fires. We feel like we’ve been on duty for two years without a break. And most of us have been on duty for two years without a break. I think that takes an extraordinary toll.

Dr Louise Stone (00:19:32)
I also think that we need to start being a little bit honest about our services. Often, the policies that we write down are not the ones we actually use. And we give the impression to particularly junior doctors that they’re not allowed to take time off, that it’s not appropriate for them to have sick leave, that it’s not okay to struggle. And we know from the Beyond Blue survey that a lot of doctors carry around this idea that we would judge them, our colleagues would judge us if we said we had a mental health problem, would think we were less competent, would report us to the medical board.

Dr Louise Stone (00:20:07)
All those things create a wall of shame that is very difficult to break. And I often say I want general practice to be a place where shame goes to die, but what you really need to do is to get that person in the room and have an actual person actually talking to them and actually accepting them the way they are. Often, these people have no stigma at all about anybody else, including their doctor colleagues. If my friend had depression, no problem. I’d tell them, “It’s fine. I don’t think any worse of you.” And then you say, “How do you feel in the waiting room?” Suddenly there’s silence. So I do think it’s this hidden trauma that we build in medicine that really inappropriate, and it’s not what we have in our policies. It’s not what we say, it’s the way we behave. We got to break that down.

Dr Charlotte Middleton (00:20:56)
And I guess the concern there is that we know that amongst doctors, they have much higher levels of psychological stress, higher than the general community. They have burnout rates that are huge, their alcohol and drug abuse, suicide rates are higher. Geoff, this is a nice segue, I guess, into your organization, CrazySocks4Docs. I’d love to get a little bit of background of how that came about and what you’re hoping to achieve when it comes to the mental health of doctors.

Dr Geoff Toogood (00:21:29)
Like a lot of things, it came about a little bit by chance, I guess, but also by my experience. I think I just chatted about the stigma and issues as a doctor with mental health, I felt that very much. I think there’s certainly lots of good policies at places I work, but I don’t think the policies are often adhered to by certain people, not everybody. And so I faced significant stigma, both from outside, I thought, but a lot from inside. The waiting room stories kind of view, but I remember going to the way to waiting room in my general practice, petrified that someone would recognize me in the waiting room.

Dr Geoff Toogood (00:22:17)
And then you think, “Well, how am I going to know I’ve got a mental health issue? I might just have a sore knee, or I might have hurt the shoulder,” and I was petrified other doctors would find out and other people would find out because of the effect on my career and other issues around that. Major [inaudible 00:22:39], but I got to the level of a specialist, so I was only going okay. And the stigma is around, I bought a dog just to keep company. The dog had decimated most of my socks. There’s two odd-colored socks, I’ve been buying happy socks deliberately, which I brought to cheer myself up when I was unwell. So I went to work and then the comments from a few people behind my back was that he’s going crazy again, inappropriate word. And no one actually came up to see if I was okay.

Dr Geoff Toogood (00:23:13)
In fact, I was like, “Okay.” I just rushed out the door one day with a couple pair of mismatched socks and thought, “This is just ludicrous. Someone could have talked to me, someone could have spoken to me, someone could have asked me if I was okay,” I was actually okay, “and not use the word crazy.” And I’ve heard a bit of pushback about using it with the socks, but it’s about the socks, the socks are crazy. It’s not me that’s crazy. So you can use the word in the right context, but not in… Some of it was about awareness, but a lot of it is about breaking the stigma around mental health in our healthcare professionals. One of the things, I hope, with this pandemic is some people realize it’s that they may get anxious going to work, and they may struggle a little bit with what’s going on, particularly in Victoria where we’ve been hammered. And they may have a bit more empathy for their colleagues now if they’re feeling the same way. So that’s where that came from.

Dr Geoff Toogood (00:24:12)
It is gradually changing. On another side, I think Grant knows, I just done a video with seven out of Australians about suicide prevention. That’s not something we would have done five or six years ago, and I’m sort of thinking, “Goodness, I’m speaking about a dark time in my life on a national website as a doctor.” I still think that’s not a common thing to do and should be, eventually.

Dr Charlotte Middleton (00:24:42)
Absolutely. Fantastic.

Dr Louise Stone (00:24:44)
Glad to say how grateful I am for your leadership, Geoff. It makes a huge difference for the junior doctors that I see. I look after a number of doctors and to have a senior colleague, especially a non-GP specialist who’s able to be someone that these young doctors look up to in a hospital setting to be able to be open and honest, that story is just so important. And I’m so grateful to people like Beyond Blue and Black Dog who give us space for those voices to be heard. I think it really makes such a big difference to break down that bizarre culture that we have that somehow we’re bulletproof, it just doesn’t make any sense.

Dr Charlotte Middleton (00:25:27)
Couldn’t agree more.

Jason Threthowan (00:25:28)
I was going to say the same there Louise too. My recent experience with bushfire-affected communities was when we went in there to support the headspace centers and local providers, it was about supporting them to support their communities. And actually what’s happened is that there’s been a delayed response in health care workers actually seeking supports themselves because they’ve been about everyone else. And we’re actually seeing a delayed in the recovery process generally because COVID came in between.

Jason Threthowan (00:26:01)
So it’s actually now more important than ever that we actually do put in place really dedicated support or realize what’s already out there to support clinicians on the frontline who perhaps have put themselves aside and whilst they’re being dealing with their own circumstances, they’ve been focused on others, which I think is just a trait of doctors to put themselves aside for other people. And I think COVID is a really good reminder that actually we’re all vulnerable at some stage and we’re all vulnerable now. There’s never been a time now to chicken on ourselves and be a little bit selfish, being a bit about you, as opposed to just always being about others.

Dr Charlotte Middleton (00:26:40)
Couldn’t agree more.

Dr Grant Blashki (00:26:44)
Charlotte, if I could comment as well?

Dr Charlotte Middleton (00:26:46)
Yeah.

Dr Grant Blashki (00:26:47)
I think that we need to start thinking about mental health in workplaces as very much a workplace safety issue. And I think that COVID has emphasized that, that it’s not a nice, “Maybe we’re feeling compassionate that day and we’re going to be kind to our staff.” It is about governance and leadership and setting up the processes so we’re not setting up our colleagues and our young doctors for trouble. Just as an example, we did a survey of 20,000 first responders, MOs, fire risk, and we’re looking at their mental health rights. And the biggest protective factor was a supportive workplace, which had quite a dramatic effect.

Dr Grant Blashki (00:27:39)
Just as one example, it’s odd that the medical profession has abandoned the clinical supervision that so many of our fellow professional colleges just would never dream of. So you don’t have young doctors coming to see me and they’ve had people with COVID or someone dying on them, or someone suiciding who they were looking after, and they’re somehow supposed to just go, “Okay, got to work tomorrow.” It’s really not good practice. And I think that’s a real problem still in our profession.

Dr Charlotte Middleton (00:28:14)
Like Louise said, it’s almost like we’re supposed to be… We’re not normal. We’re supposed to just get on with it and keep going. We’re going to react the same way everyone else does in these situations. [crosstalk 00:28:28] Yeah. Samineh, I might bring you in here actually, because I’d love you to talk about what the Black Dog Institute has been doing in supporting in particular junior doctors in the hospital environment.

Dr. Samineh Sanatkar (00:28:42)
Just to speak a little bit about what the other panelists have been addressing, our team has conducted qualitative interviews with doctors in training, and a lot of these stories actually came up in our conversation. Doctors in training do pick up on the workplace culture that exists in our hospitals and our clinical practices, so when they feel that they struggle with their mental health, oftentimes, I might add, induced by sleep problems. Nowhere else are you scheduled to work 13 hours then be seven hours off and then start another 12-hour workday and be expected to function the same way the next day and the next weeks and the next month as in the medical profession, I believe so. This induced insomnia in the workplace is really tremendously difficult. It affects our cognition, our metabolism, our physical health, and you guys know this so much better than I do, but from a mental health perspective, of course this is a catastrophe.

Dr. Samineh Sanatkar (00:30:06)
And when I look at this as a psychologist, it’s really quite questionable as to how these systems prevail for so long and in such a pervasive manner as to not to see the straightforward implications that these kind of work schedules have. And it’s something that junior doctors, all of them, everyone we spoke to, communicated to us, it’s immensely difficult to keep up in a fast-paced work environment like this, not get enough rest, not get enough sleep to just basically work through your experiences of the day or of the night and then be expected to come back again and learn something that you’re actually quite unfamiliar with still, because even though you spend 10 years at university maybe, and you have a tremendous amount of knowledge, still, the work structure, the ways of working are incredibly difficult to learn.

Dr. Samineh Sanatkar
(00:31:19)
It’s a big task to have this amount of responsibility, and I feel junior doctors say this a lot, that this responsibility coupled with their crazy workload really becomes something that even the tremendous people, they’re perfectionist, they can work so, so well, it will affect most people at some point because, like you all were pointing out, there are no superheroes on this planet, and we need to make work work for us. At the end of the day, we’re people and we’re providing services to other people and we got to make it work on both sides of the equation.

Dr Louise Stone (00:32:08)
Can I just add something in there, just because I just think Grant and Samineh, thank you so much for raising the issue of workplaces. It’s just an analogy that I like to use, we often think of resilience as being how bouncy a ball is, and we tell junior doctors that they need to be bouncy or they need to be super balls and bounce anywhere they like. I have a daughter who’s a historian who came up with this great analogy. And she said, “You know what? The bounciness of a ball is about the ball and the surface on which it has to bounce. There’s no ball that’s going to bounce in a toxic swamp.” And I think one of the hardest things for junior doctors is they always think it’s them. And what’s more, we tell them that it’s them, “You need to be more resilient.”

Dr Louise Stone (00:32:56)
And that ties in also with this idea of privilege, “I’m very lucky. I’m a white, middle class woman born in Australia. I don’t have those layers of disadvantage of my overseas-trained colleagues or my colleagues who have gender or sexual diversity.” They experienced layer on layer on layer. And then we tell them that they need to be more resilient. They wouldn’t be here if they weren’t resilient. So I think we have to watch our language really importantly, because it gives them the impression that they’re failing. And that’s really dangerous.

Dr Grant Blashki (00:33:27)
Just to add to Louise’s point there, I think within the medical culture, we assume that most of the dysfunction, particularly with mental health issues, lives inside your head, between your ears, but one thing that I’ve learned working with Beyond Blue in our big workplace group, called Heads Up, is often the dysfunction lives in the structures of the system, poor governance, unrealistic workloads, lack of support, not managing bullying or discrimination properly. It actually lives there. It manifests in the person when they come to your general practice, but it’s really sometimes in very dysfunctional workplaces.

Dr Geoff Toogood (00:34:10)
I might add, with the preference of not labeling any workplace, if that’s okay, but I completely agree. In Japan, they brought in workplace regulation around Karoshi, which is death by the work. And it was around 55 hours. And I think Black Dog has some research suggesting that junior doctors start to struggle with hours over 55, 56, which is where Japanese people were starting to take their own lives because of overwork. I use the analogy resilience is about bouncing. You can bounce on a trampoline, you can’t bounce on concrete. A lot of workplaces places are really like concrete and they don’t allow you that ability to bounce.

Dr Geoff Toogood (00:34:55)
I looked at my own self. It was me as a failing for a long time, and then I realized quite after a lot of treatment to get better, that some of it was me and just my susceptibility, but once you worked on that, you have to take out the workplace that had been toxic and coarse and then work your way around it. It’s great to change and it still doesn’t… I don’t know if it needs changing, the hours won’t change because there’s still senior doctors wander around claiming that they get up at 7:00 and work till 11:00. And if they’re doing that, well, what does the resident think? If the senior doctor says… It’s not leaving work, but if the senior doctor is going home on time to spend time with their family, do other issues, then that’s the standard you got to set. But-

Dr Louise Stone (00:35:44)
The theory of beneficial mistreatment, Geoff, the idea that it does us good, all this, “I worked 36 hours yesterday and I ate hot gravel,” it’s the idea… It turns up in the military and law and all these… The theory of beneficial mistreatment, “It does us good, it makes us stronger like calluses on your hands.” It’s wrong, basically.

Dr Charlotte Middleton (00:36:07)
It’s the dismissive, I guess, nature of when you do bring up something or, “Well, in my day, we worked even longer hours than this and coped, so what’s wrong with you?” They can be very dismissive. But Samineh, I’m really interested in the Black Dog Institute app though that you’ve put up for junior doctors, if you’d like to tell us a little bit about that.

Dr. Samineh Sanatkar
(00:36:31)
Yes. What we intended to do was to provide an inconspicuous way of helping doctors in training with their mental health, if they are looking for information on how to maybe better manage their sleep so they get at least as much sleep out of the hours that they have for sleeping as they possibly can. And also to address some of the mental health issues that can come up, or to address some of the complications that can arise with speaking to superiors or other colleagues and issues that their doctors in training put forward that is really bothering them. So we collected this information from doctors in training from their own personal accounts and created an app where they are able to self-direct which topics they are interested in, what they would like to look into, how to seek help if they would like to seek help for any mental health problem or bullying at the workplace or what it may be, and offer workplace and non-workplace options of addressing these issues depending on what people feel more comfortable with.

Dr. Samineh Sanatkar
(00:37:58)
And of course, that always depends on who you’re talking to. So we try to really address a variety of issues and provide a variety of points of contact that hopefully provide a stepping stone, so to speak, some help in getting this process started. And also what some junior doctors said that they’re in this blur, they never sleep properly, they work all these hours, they don’t know how they felt a week ago. They sometimes barely can keep track of how they’re doing. So we try to embed a little function in the app so that junior doctors can lock their mood, their work life balance, just really simple metrics and then visualize them within the app so they can get a visual representation of how they were doing the past few weeks and so on.

Dr. Samineh Sanatkar
(00:39:05)
So we try to really collect what doctors in training were saying about what they’d like to see in an app like this, and work with the experienced specialists and learning specialists to integrate those topics and recommendations in this app that is purpose built for them. And as such, it forms part of the New South Wales’ JMO Wellbeing and Support Plan. So we try to contribute to doctors mental health that way, but it’s a very unguided… it’s a self-guided tool and it’s very much also in the testing stage still, so we’re still trying to make it better. New South Wales doctors have been testing the app and using it and giving recommendations. So I feel just this process of trying to just uncover what junior doctors would like to see, what they need, has been a tremendous experience and we can only go from here.

Dr Charlotte Middleton (00:40:29)
Well, it sounds a wonderful initiative. Fantastic. Can’t wait for it to be rolled out across Australia. All right, guys, let’s move into e-mental health. Obviously got to a lot of wealth of experience on that on this panel. Obviously, traditionally the treatment of mental health has been more of a person-to-person interaction. That’s all obviously changed drastically even just in these last six months. We have advocates for it, we have people that have some concerns for it, where does the panel sit in relation to online treatment of mental health? Do we really need to physically be face-to-face with people to provide quality mental health? I might start with you, Jason.

Jason Threthowan (00:41:14)
Look, I think e-mental health is such a generic term. A lot of people will just think about all that’s telehealth, which is like face-to-face, good screen to screen or telephone to telephone, e-mental health should be broader than that, it offers a range of options that a patient can actually engage it 24 by seven online, participate in online communities. So if they’ve got a particular diagnosis, they’d like to know who else has got the same, who else is going through what I’m going through and be joined up, have peer-moderated online activities, they like to participate perhaps in online forums, group chats, community spaces like Beyond Blue and Red Chat and headspace and others. Black Dog will do that because we’re trying to increase the reach.

Jason Threthowan (00:42:03)
But then there’s also, I’d like to say, a lot more focus on a combined effort between the face-to-face primary care services and actually you joined up digital services. So often we talk about services that are either face-to-face and in some weird way, in a parallel universe, there’s always online services. And as Grant pointed out before, huge increase in people reaching out to the tele web sector. And the integration back into the primary care GPs is always a little bit mixed in terms of…

Jason Threthowan (00:42:36)
We make an effort on our online services to try and get back to the usual GP the next day to say, “Look, someone’s reached out. This is secure messaging. Make it easy for the GP to always know that the patient has reached out to services. Doesn’t always happen, doesn’t always join up, data linkages can be in times a problem. So I would like to say a joined up effort so that if you are a patient who is going to a GP around three or four common problems that they’re presenting, that you’re also backed by an online presence that is equally supporting you, particularly in the after hours and weekend periods.

Dr Charlotte Middleton (00:43:11)
Sounds great. You’ve preempted my next question about how can we move the two. Grant, I might get your opinion on this with your experience in Beyond Blue.

Dr Grant Blashki (00:43:22)
I think e-mental health has got huge potential, and we’re seeing an absolute explosion of different apps and websites, ranging from diagnosis to management to helping find prognosis to monitoring, things that have got simple algorithms to some AI examples now. And I think what’s happened with COVID is the whole community’s being shepherded into what was niche, and it’s gone mainstream because people have to be online now. It’s the only way I can speak to my grandchildren or I can do my university course. And so it’s gone from this thing that your early adopters were into the same thing everyone’s into. I really support Jason’s idea that there’s a lot of moving parts and it’s a bit incoherent at the moment and we’re probably not working together nearly as well as we should.

Dr Grant Blashki (00:44:22)
Head to Health is a great resource if you’re looking for a platform that lists a lot of the different online resources, such as Mood Gym, and My compass, and a bunch of Beyond Blue things and headspace and that sort of thing. One area that we’ve worked in is Beyond Blue’s got an app called Beyond Now, which is quite a useful suicide prevention planning app. And we’ve had 80,000 downloads. I use it in my general practice because it’s a small app, but for those… When you’re doing your suicide risk assessments and making some planning with the patient, I actually use it in the practice and they’ve got a plan in their phone. So I think that we’ve only just scratching the surface of what’s going to be possible, but it’s very exciting in terms of accessibility, scale, 24-hour availability, all those things.

Dr Charlotte Middleton (00:45:16)
I think there’s a lot of groups now that can access this help that perhaps might’ve not accessed this before face-to-face, men in particular, I guess are able to access this kind of help more easily, adolescents as well. Louise, what’s your experience in general practice in terms of merging the two?

Dr Louise Stone (00:45:37)
Look, I think, as Grant says, there’s a great deal of potential. I often think back to the little country town I used to work in in Victoria, we’ve all got Victorian roots somewhere, and I often thought at the time how difficult it would be to be a young person questioning sexuality in a small community and how good it would be to be able to reach out to someone who’s not in your town. So I think there is a lot of capacity there. I think the benefits of recording and also being in a community that has shared lived experience is amazing. But I think like any therapy, there’s benefits and risks and side effects and co-morbidities, and that interacts with other things. In order to access a lot of these programs, you have to have reasonably good literacy, you have to have access to a device that’s preferably private, you have to have some Wi-Fi accessibility.

Dr Louise Stone (00:46:37)
A lot of the apps are normed against city-dwelling people, they’re normed against people who are predominantly fluent in English. So I do have a problem with this being the default go-to. I get a lot of referrals back from various services saying they’re unable to help my patients that would happen several times a day, that my patients would get rejected from the service. And it always stays on. An opportunity that they have, they do have e-mental health as though it’s this universal safety net, but just because it’s there, doesn’t make it accessible. There are gates to get into e-mental health that people don’t often acknowledge. And particularly when you’ve got quite a significant mental illness, there’s two things I’d say, one is that you’re cognitively slowed. You’re reading age drops by a couple of years, and I’ve been unable to find an e-mental health service that has a lower literacy than great expectations. So for a lot of my patients, it is inaccessible.

Dr Louise Stone (00:47:39)
The second thing about that is, I do think that there is healing, there’s more evidence for the therapeutic relationship than there is for any individual techniques. So I think we are treading on dangerous ground removing a therapeutic relationship from the equation. So my feeling is that it’s incredibly good addendum. I encourage people to pursue their own recovery in any way that they can. It’s wonderful that there’s a democracy of information now, that I don’t hold all the cards as a doctor, that people can go and learn on the run. But a lot of these programs only take them through the first episode and they don’t provide ongoing care and we’ve got to join that up because otherwise, if they “fail” e-mental health, the shame just gets worse and they feel that they’re not even able to manage this interaction with this app, they don’t understand it, they can’t make sense of it.

Dr Louise Stone (00:48:36)
I have mixed feelings because I think the group that is most disadvantaged that we fail most significantly are exactly the ones who don’t have access to this service that is absorbing an incredible amount of grant government and philanthropic money. So, I do have concerns, not to say that I don’t use e-mental health for appropriate patients.

Dr Grant Blashki (00:49:01)
I think, if I can just add to Louise’s point, that to have it as siloed between the two is no good. E-mental health or online opportunities should be as integrated as possible, in the same way that we’ve been trying to integrate face-to-face services between hospitals and GP clinics forever. A greater emphasis now would be try to look at the integration of general practice and the availability and accessibility of e-mental health. And that might be crisis lines, it might be distressed lines, but also too, it offers… Many people are seeking online support for their mental health in the evening. And that’s not always the easiest time to get access to face-to-face primary care services. So it would be good in partnership with general practice for patients that the GP knows to say, “Look, I think this would be good.”

Dr Grant Blashki (00:49:55)
And to be able to link in and for the two to be able to communicate more effectively so that the patient goes. Actually, they’re on the same page. Isn’t that good? I feel like I’ve got a team, but one’s a virtual team, one’s my primary care and that’s the GP. So that’s why I think into the future, better efforts because people are going online, lock it or not, but are going on for support and they’re trying stuff out. We just want to make sure it’s obviously evidence-based, it’s got some rigor, but that word integration should not be lost because I think at the moment there’s quite a bit of disconnect.

Dr Charlotte Middleton (00:50:29)
Does anyone else have anything to add about that?

Dr Geoff Toogood (00:50:31)
[inaudible 00:50:31] I’m a consumer in all this, I’ve grown up seeing my psychiatrist and psychologist face-to-face and tomorrow I’ve got a routine review with my psychiatrist, Zooming him in another place, which is okay. I don’t find a great deal of trouble with that. I saw my psychologist when I had some issues a few months back, with everything that’s going on. And that was much easier to book an appointment with her on tele-health than it was driving to see her from both points of view. So I think it’s got a positive. I was just trying to think, as Jason said, I’ll just touch on two points. One was, I wouldn’t regard myself as reasonably smart. When I was really unwell with my mental health issues, I was struggling to even do the most simple mental task. And I would look at something that I was taking like half an hour to an hour to fill in a form for the council, which when I actually recovered took me two or three minutes, it’s dah, dah, dah, dah, dah gone. I think there’s that.

Dr Geoff Toogood (00:51:44)
And I think what Jason says, I think my worst time was the late night, early morning time when the house is quiet, there’s nothing else going on and my brain is just not in a good place. That was a dangerous time for me. So that’s where e-health and access is better because thinking of driving to an emergency department or something at that time is probably not appropriate, or not easy to do. I’ve evolved, my most serious problems were before this rolled out and it was more basic apps and those things, but young children…

Dr Geoff Toogood (00:52:27)
My kids are seven, eight, and nine. I don’t know, [inaudible 00:52:29] I said, “Do you know about this?” “Yeah.” “Do you know about this?” “Yeah.” They’ve downloaded or looked at it, so they know a lot of that stuff, so they will engage with it really well. But I still agree, you still need the face-to-face personal contact of the person. I’m not sure how it would go with speaking to a psychologist or psychiatrist unseen before on Zoom. It might be a bit harder, but that’s just my preference. I already got an established relationship with them and I’m in recovery maintenance phase, not in a crisis phase.

Dr Charlotte Middleton (00:53:05)
Can I ask, and this is really for-

Dr Grant Blashki (00:53:07)
Hoping just to add something in there.

Dr Charlotte Middleton (00:53:09)
Sure.

Dr Grant Blashki (00:53:10)
It seems like when we’re talking about e-mental health [inaudible 00:53:16] telehealth, and I think it’s worth commenting at this time about the mental and physical strain on the practitioners of going to screen. Certainly, myself and my colleagues who are doing a lot of telehealth we do a whole day of general practice on it so they’re totally exhausted. Visually, they’ve got eye strain. I’m no expert on telehealth, but there’s something about just having that face-to-face intensity of contact for hour after hour that I think is very tiring for people.

Dr Grant Blashki (00:53:56)
There’s also a boundaries issue, which is, there’s something very sacred about you go to your clinic, you shut the door and you emotionally, whatever you’re hearing stays in the clinic, does to me. Whereas if you’re doing telehealth from home, there’s always risks about having a laptop in your home with the patient stories, it’s a bit harder to keep those boundaries. So I think we’re just working out how all that works, but I don’t think it’s the same. I wear a stethoscope in my house when I’m doing telehealth. It’s my little symbolic, “Right, I’m being a doctor now.”

Dr Geoff Toogood (00:54:38)
Like my scrubs.

Dr Grant Blashki (00:54:39)
Yeah, yeah. Whatever works.

Dr Charlotte Middleton (00:54:44)
Look, I guess with so much more being available, and we’re talking about all these different ways that we can deliver mental health treatment or that people have access to different types of mental health treatment, why do we think it is that still only around half of the population are seeking help? What are the issues here? What’s the barriers?

Dr Louise Stone (00:55:06)
Oh dear, there’s a lot, isn’t there? But I think Geoff had it with stigma, I think. But also remember that not everybody has a fabulous view of their internal world. A lot of people feel generally uncomfortable or unwell, but they can’t make sense of what’s going on enough to try and describe what they feel. We’re not all good at what we call mentalizing, having that capacity to look at the way we think and feel. And I used to see that a lot when I was working with farmers and miners, I’ve worked in Broken Hill and I’ve worked in a dairy community and it’s very difficult. And in fact, many of the men I looked after I don’t think had a great emotional vocabulary to describe what it was that was going on for them. I think that’s a huge barrier.

Dr Louise Stone (00:55:56)
I think the stigma is enormous. I always say to my patients that depression metastasizes guilt and shame, the nature of the illness makes you feel ashamed, makes you feel that you’re not worthy, that you’re not good enough. And that is a huge impediment to just getting in that door. It’s why it’s so terribly important that we do have helplines, that we do have places people can go in the middle of the night, but we also are able to look people in the eye and just say, “Are you okay? Because you don’t look right.” That’s the great benefit of a continuous relationship. And I’m also with Grant on trying to project empathy down a phone line or across a screen and trying to be present with a person through this medium is very hard.

Dr Louise Stone (00:56:51)
I’ve been teaching over Zoom or its equivalent for at least 20 years and it’s not new to me. I find it incredibly challenging to be present in the way that I can be in the room. So I think there’s a number of reasons. The other big thing that we haven’t talked about, though, is trauma. We’re looking at at least one in four people who are survivors of childhood trauma who have not been believed. And if they haven’t been believed in the past, then it’s a very big ask to expect them to assume that we will believe them when they come and talk about their feelings to us, they’ve learned that that’s not safe. And that is a huge proportion of the patients that I see struggling to come to terms with this idea that they’re safe now in the present.

Dr Louise Stone (00:57:44)
And of course they also may have had bad experiences with other environments. They may have talked to someone and had the crazy conversation that Geoff was mentioning earlier, which is completely inappropriate, or watched some movies that have treated people with mental illness very badly, or even gone to see a health professional and had their experiences invalidated. Those people to come to us, it requires a lot of courage and I really recognize how hard it is, how courageous it is to actually get into a waiting room and be prepared to share something with me and treat me as though I’m trustworthy. It’s not an easy thing.

Dr Charlotte Middleton (00:58:32)
Very eloquently put, Louise. Great. Did anyone have anything to add to that?

Jason Threthowan (00:58:39)
I think the stigma is definitely one thing. We concentrated a lot of the young people and within the cohort of even young people, there’s various cohorts of young people, young men, rural, LGBTIQ populations, they’re all having added, I guess, more context around stigma. There’s also then the experience of when I first sought help, what was that experience like? And if it’s not good, then it’s another big barrier as to why I might go back again. That’s a really important point when you’re at a vulnerable help-seeking journey if you have mental health, particularly when you could be a proud bloke in the mid forties, weight loss has been going great and you’re all of a sudden through COVID just lost the whole sense of being because your employment’s gone and you just didn’t expect this. And I’d go and seek help and it’s not good. What am I going to do? How do I bounce back?

Jason Threthowan (00:59:35)
That experience of the system is really important. And I do agree with the points that telehealth is awesome, but building a rapport with patients is actually, for the first time particularly, the relationship is always best in person.

Dr Charlotte Middleton (00:59:46)
Can we make-

Dr Grant Blashki (00:59:47)
If I could throw a…

Dr Charlotte Middleton (00:59:47)
Yeah.

Dr Grant Blashki (00:59:47)
Sorry, did I talk ahead of someone else?

Dr Charlotte Middleton (00:59:48)
No, no, no, Grant, go ahead. Go ahead.

Dr Grant Blashki (01:00:00)
I was just going to say, obviously in Australia, large multicultural population, and there’s a wide and varied views about mental illness from different cultures in Australia, many see weakness as the main thing about mental health, why can’t you just toughen up and get over it? Or family shame, or also lack of clarity about what is the role of the doctor. It’s not immediately obvious to a lot of people from different cultures that the GP is someone who would be of any use regarding a mental health issue. So there’s all these factors that come into play.

Dr Charlotte Middleton (01:00:45)
True, true. I’ve got a lot of people who are very surprised when I say to them, “I can do a mental health care plan for you that gives you Medicare rebated visits to a psychologist.” They just did not know that that was possible. So I think we have a way to go to educate people out there of what is available.

Dr Geoff Toogood (01:01:06)
I want to say one thing just for junior doctors, bringing the junior doctors, I think one of the things is time and access. They’re working like 8:00 till 7:00 maybe, 8:00 till 6:00, when can they pop into the local doctor to see them? And they’re not maybe getting the doctor that they’re comfortable with, so they often have to take time off work, then it’s question why for their afternoon off, they’re getting long-term treatment, it has to be at different times, they want… Other things, particularly in health professionals, is confidentiality about their illness initially in the early stages. So someone’s working and working long hours, getting access to care and time off work to go and get that appointment is not easy.

Dr Charlotte Middleton (01:01:54)
Geoff, do you think to the mandatory reporting laws would be a deterrent in a lot of situations as well?

Dr Geoff Toogood (01:02:00)
Yeah, I think it probably is the greatly changed. We aspire to the Western Australian model, but I think these issues in the sense that I think some doctors don’t understand the true mandatory reporting laws and unfortunately report doctors when they shouldn’t, and that just creates this enormous issue. And there is a fear you’re going to be watched. My own health being’s questioned more because I’ve been into mental healthiness than anyone else. That said, any other illness I can tell you when they’ve come back to work. So I’m not quite sure why, because they potentially could be impaired if they’ve had a major illness and they’re getting back to work. The mandatory reporting does, and some of it’s around the understanding of what is and what isn’t mandatory reporting, but secondly is the Western Australian models aspirational for most of us, I think.

Dr Charlotte Middleton (01:03:03)
Absolutely.

Dr Louise Stone (01:03:06)
Can I just say what I do with doctors? Is to mention that in about the first few sentences when I’m introducing myself and we’re talking about things and I set up the consultation talking about things that doctors care about. Canberra’s a small town, if I run into you in the street, I’m not going to say hello and ask you how your mental health is going in the supermarket, or if you talk to me, I’ll talk to you, those sorts of what’s going to happen with whether they pay me or whether… I mean, I’m happy to bulk bill doctors, but whether they feel comfortable about that. And the third thing I always mention is I want to talk right upfront before we get going about where the medical board stands. The medical board does not need to know if the practitioner’s work is not impaired. If you’ve got a mental health condition and you’re seeking help and you’ve got treatment and you’re looking after yourself and pursuing your recovery, then the medical board does not have to know.

Dr Louise Stone (01:04:09)
I’d like to be very upfront about that, because otherwise they’re busy tossing it around in their head and we’re not having a pleasant conversation because they’re worried whether they should tell me that they’re depressed or tell me that they’re worried about their anxiety or whatever it is. But I agree with Geoff absolutely that there is this perception that we should tell the medical board about illness. And the answer is the medical board is not concerned about somebody who is seeking treatment and is not impaired at work.

Dr Grant Blashki (01:04:43)
If I could add to that, I think the other tricky thing with the doctors that I look after is that you need to be clear that you’re treating them as a patient. Sounds really obvious, but you can get into this situation where they might have more knowledge than you, and I’ve looked it up, then but in a sense, that’s not really your role. You don’t have to be the smartest person in the room, you’re still being their doctor and going to make the calls on what we’re doing together. But you want to make sure that people can be a patient still, even though they’ve got all this medical knowledge.

Dr Charlotte Middleton (01:05:22)
That’s a great point, Grant.

Dr Geoff Toogood (01:05:26)
I’d just say for a doctor, the most important thing is to realize when you’re a patient, you might be a highly informed patient, but you need to still be the patient and listen to your doctor and take the advice and work with them. They’re going to help you on the journey, it’s not for you to tell them what to do.

Dr Charlotte Middleton (01:05:49)
Fantastic, Geoff, thanks for that. And I think that’s pretty much all that we have time for tonight guys, unless there was something that anyone wanted to add on that topic.

Dr Grant Blashki (01:06:00)
We’ve talked a lot about the difficulties, and there are a lot, but meanwhile, there’s an awful lot of GPs with tremendous common sense, compassion, juggling all the various complexity of general practice, helping a lot of people, so power to them. I think they’re awesome.

Dr Charlotte Middleton (01:06:21)
That’s great. Thanks for pointing that out. Well, I really appreciate your time this evening all of you for joining us. As I said, such an important issue that we need to be discussing. We have come a long way. Obviously, still have a long way to go, but thank you so much for your time this evening.