Am I OK with #RUOK day? If rhetoric matched reality then maybe.

As a psychiatrist I am not so sure about public disclosures of mental illness.

Today is #RUOK day. It’s also a week where two of the top headlines in media have some sort of personal and professional significance to me. A famous AFL player asks for leave because of ‘mental health concerns’. And the Royal Australasian College of Surgeons (RACS) admits to widespread bullying and harassment of its members by members.

Why do both these topics hit a sweet spot? Well, both highlight the point that society functions better when we adopt the approach ‘do as I say not as I do’. In both instances, the message is the same. Don’t tolerate what is bad behaviour, don’t tolerate stigma, and practice open disclosure if you are struggling.

If only,

As a psychiatrist who works with patients with psychiatric illness every day, I know more than many the personal impact of mental illness on the lives of those experiencing it. That’s why I strive so hard to manage my patients and advocate for their rights and wellbeing. Why I focus on recovery. Why I care. Because I know that mental illness is common and treatable.

So what has got me feeling like I live in a parallel universe? It’s the imbalance of the strong public health messages such as asking ‘R U Ok?’, and the real life situation for many victims and patients who feel they have no voice or no audience. Because they have practical, tangible reasons to keep silent.

So, this week Lance Franklin has been given leave from his professional career as an AFL footballer as he is struggling with something. As he should. What I disagree with is the notion that one is brave only because they speak up and ask for help in a very public way.

I have seen many patients who have disclosed to their employers that they have a mental illness. Patients who need to see me and need a medical certificate to substantiate their whereabouts away from the office. Patients who are actively managing their mental illness and getting better. I have seen the same patients become victims to harassment in the workplace, and I have been placed in the untenable position of providing reports to validate that my patients are ‘safe’ to be at work. When I am not the employer but the treating doctor and confidante. Some of these patients actually work for organisations that donate large sums of money to organisations that work to reduce the stigma of mental illness. Hence the parallel universe.

In one tragic example, an organisation knew an employee was seeing me because my name and contact details were on a medical certificate I provided. They contacted me ‘as a courtesy’ prior to sacking the employee to ensure that they made attempts to keep the employee safe after breaking bad news. Without the employee, my patient, knowing anything about it. I knew the patient was to be sacked before they did. I was placed in an impossible situation, and was furious at the way the matter was handled. On numerous occasions I have been asked to be involved in workplace assessments if a patient of mine is recovering from an episode of mental illness and returning to work in a graduated manner. Very quickly, reports turn into assessments of competency and performance. My role shifts between keeping my patient from relapsing or suffering untoward as a result of these behaviours and explaining to employers why I will not compromise patient confidentiality. In some difficult cases, my notes are subpoenaed and confidentiality is broken anyway.

So, see why the public health message does not add up to the real life experience?  Although everybody knows what is the correct way to act. That is, ask for help if you need it.  Of course I agree because I know help is available and is lifesaving. I just really implore people to be careful who they are telling.

This year has also shone light on the impact of mandatory reporting of impaired doctors and doctors asking for help. New AHPRA guidelines outline that doctors must be reported to our regulatory body if one suspects they are practicing whilst impaired, thus placing the public at risk. Doctors are under intense scrutiny to prove they are competent to work, as they should be as health professionals. Yet they endure monitoring from both their employers and the regulatory body, AHPRA. There is data emerging that this will only serve to drive doctors who are suffering underground, away from care that will help them. As a doctor that treats doctors I know this is a defining factor in whether or not to tell anybody you are struggling.

And now RACS have been shown up to harbour bullies within their ranks, at a rate that would close down any other organisation overnight. We doctors are not surprised. We all have scars from the misuse of power whilst training whether it be from surgeons or senior members of other disciplines. Hopefully RACS will choose to ‘do what it does not what it says’ and out the bullies, rather than asking trainees to speak up. They have enough knowledge and information now after all, and can no longer pretend to be ignorant of these cases.

I know if had done the ‘right thing’ during my psychiatry training and spoken up about bullying, I would not be a psychiatrist today. The bullies do determine your fate.

So, how do I feel about campaigns such as #RUOK in the light of recent events? It would be lovely to believe that we exist in a world where stigma about mental illness can be overcome. That we can move from choosing celebrities as  role models to accepting that 1 in 5 people go through an episode of mental illness. That it is just as much of society as is the common cold. That bullies can be exposed and dealt with by organisations with more power than an individual. That people can speak up about having a mental illness or being bullied without retribution but instead complete compassion. I will continue to try and traverse both universes, yes I will continue to ask my patients, colleagues and friends if they’re OK beyond today.

But I will offer the sage advice based on experience and my own journey;

Ask for help because you deserve it and it is waiting for you. Ask because you only have one crack at a rich fulfilling life. Just seek out the right people to tell. They are waiting. And ask in a way so you feel empowered, safe and above all, cared for.

Dr Helen Schultz is a psychiatrist in Richmond, Melbourne, Australia, and author of “How Shrinks Think”.

 

 

 

The delicate balance between quantity and quality – my view on the increase in prevalence of mental illness in children and adolescents

iStock_000014067068SmallGreetings all,

It’s official. What we at the coal face see has been confirmed by a recent study, “Young Minds Matter” that concludes thousands of children and teenagers suffer from mental illness. And, as we know at the coal face, they largely suffer in silence.

What a sad state of affairs in a time when we know so much more about prevention and mental illness, what a tragedy for the next generation, what a social disaster. Continual erosion to the basics must play a part. Financial distress, the epidemic of drug and alcohol misuse, and the loss of the family structure due to poverty and violence. Incalculable factors, specific to some families but generalised as a whole. In essence, we have lost our way when it comes to remembering that in fact the family is an integral protective structure for children’s mental health and resilience, and attempts to threaten this will inevitably be felt by the next generation.

As a psychiatrist, I have seen a large number of adolescents over the years, and I know in many cases the problems expressed within the child generate from their environment. When that environment consists of those whom the children fear they will suffer in silence rather than speak up. Children learn from a young age whether or not their parents or other adults can cope with their ‘stuff’. In many cases children become parentified and learn to conceal their angst and be available for adult’s problems. They present later in life struggling to understand how to relate to others, unable to show kindness to themselves, or identify their purpose in life. And so the cycle continues.

This new study reports that 7% of Australia’s children and adolescents have anxiety to the point where it is a recognisable mental illness. One in 20 children have chosen a place to commit suicide. I am sure the rates are higher and there would be large spikes in incidence in sectors of society. I can’t imagine how prevalent anxiety disorders are for those children held in immigration detention centres. Or children with marked social disadvantage.  Of course they don’t tell parents. Their parents are often emotionally and physically unavailable.

When I underwent child psychiatry training I learnt all about the child within a system. I still operate within this approach when I see my patients; that is to recognise the ‘big picture’ and try and provide interventions that address these other crucial factors, such as parental conflict or school place bullying. I learnt that this work takes time and takes a team. Often the child that presents is not the patient. They can be the harbinger for a family in crisis.

So why then the gross dismantling of multidisciplinary services? Why at a time when family structure is crumbling under the weight of societal forces are we allowing mental health services to crumble too? The federal health minister, Ms Sussan Ley stated that she sees the results from this recent study as positive in that children are coming forward to ask for help. Her press release stated

“It’s also a credit to young Australians, and society as a whole, that so many are not only bravely opening up about their emotions and behaviours, they’re actively seeking out help and taking positive actions to manage them”

A credit? A tragedy that they have to ask at all. And more importantly, who are they telling and what happens when they do so?

At the same time as this news is breaking, so are the warnings about an alarming rise in the use of antipsychotic and antidepressant medications in this same age group. In particular is the distressing trend for young adolescents and children to be commenced on major antipsychotic medications such as quetiapine for off-label indications such as insomnia. Doctors are exposing children and adolescents to the harmful short and long term effects of antipsychotic medications, including weight gain, diabetes and potential cardiovascular disease without any evidence. Numerous reports identify this rise in prescribing of these agents has nothing to do with a rise in psychosis, but simply that such medications are seen as a benign broad brush stoke approach to any emotional distress and child could present with. It is not just happening in psychiatry but in primary care. We will regret exposing our children and adolescents to these medications in the future, I am sure, but right now, it seems to be the only approach to mental illness and emotional distress in a society where most psychosocial services are no longer funded or regarded as valuable.

So yes, the quantity is there – we do need to remember that our children and adolescents are vulnerable and experience distress borne from a modern society and new stresses and strains – but we fall short from providing quality care. And I am sure we will reflect on this time as a failed opportunity to use our knowledge and wisdom, advocate for a better mental health system based on evidence, where children and adolescents can feel safe, and go on to lead the lives they deserve.

 

Sleep and psychiatry – time for a tweet chat!

Greetings all,

I have been involved in the area of sleep psychiatry and have been running medical education workshops, known as SleepSchool since 2008.

I have been running these in conjunction with Dr David Cunnington, director at Melbourne Sleep Disorders Centre, and creator of Sleep Hub.

We have run quite a number of workshops around Australia since 2008, but haven’t done so for a while. We used to have great support from pharma but for many reasons this is no longer the future of medical education.

Anyway, not to worry, as now that both David and myself are actively engaged on social media, and I am guesting at @WePublicHealth this week, we have decided to trial a tweet chat that highlights the intricate relationship between sleep and mental illness. This will occur on Friday 22nd May 2015 at 1430 AEST.

We will be using the hashtag #sleepschool although popular around mums and babes with sleep issues, it carries on our workshop name as it moves into the Twittersphere!

Find out more about #SleepSchool here