Mental health and international primary care – interview with Prof Chris Dowrick

This week, I had the pleasure of interviewing Professor Chris Dowrick who I met whilst translating for a mental health workshop held in WONCA Asia Pacific in Kyoto earlier this year.

He’s the Professor of Primary Medical Care at University of Liverpool but also the Chair of the WONCA working group on mental health and has given multiple talks about mental health in the primary care setting. He’s so super down-to-earth and easy to talk to that I was super keen to interview him for this blog.

“I’m the Chair of the WONCA Working Party for mental health and I’ve been that for three years. I was elected a few years ago but I’ve been involved with the Working Party for about ten years and I’ve been involved with WONCA for about 20 years. I’ve always been interested in in mental health and particularly in relation to primary care.”

WONCA has Working Parties and special interest groups for pretty much everything. If you are interested in mental health, there’s a working group; if you’re interested in occupational health, great, there’s another working group. Not that I’m jealous but the emergency medicine working group have met up this month in Kathmandu for their first international meet-up. It’s great meeting like-minded primary care physicians from across the world but imagine like-minded primary care physicians with the same specialist interest!

“People tend to start by setting up a Special Interest Group and, then, if that really gets going, then it can be turned into a Working Party. You have to have a reasonable number of people from different parts of the world with a very clear plan for what you want to do and then you propose that to WONCA Executive group, and they say ‘yes that’s fine’ or ,’no, it’s not” and away you go, “

“Our particular one, there’s more than 200 people in it. We set up a core officers’ group of about a dozen people and we’ve also got representatives from each of the seven WONCA regions. We’ve also got a couple of representatives from psychiatry. And we are currently, looking for a representative from WONCA young doctors so there’s an opportunity there if somebody’s interested!!”

“We meet virtually every two or three months and we just tell each other the good things we’re doing. I’ve started a monthly e-bulletin where I share news about what everybody else is doing across the whole Working Party and that works well. It becomes quite a useful way of transferring and sharing information and picking up ideas. In addition to that, there can be ad hoc meetings of people who happen to be at a particular conference like, the WONCA Europe conference.”

Mental health has obviously been a hot topic in recent past and is something that is so relevant to our work as GPs. Working in London with its young transient international population means I often come across stress at work, mild depression and anxiety and the occasional unstable personality disorder. So I ask him does he think that there is more prevalence of mental health issues or just a better awareness?

 “It may well be increasing more because if you look across the world, there’s more wars going on, there’s climate change, all sorts of things so the world is perhaps a less stable place than it was 20 years ago. But as well as that, there is a much greater interest and willingness to discuss and accept psychological problems as real things.”

“I think it’s a greater awareness. I wouldn’t necessarily use the word ‘better’. Problems like depression and anxiety and PTSD are very much multi- cause but also very much situational. People in stressful situations are more likely to have those experiences so a transient population in central London is quite likely to have much higher levels of those things, whereas a more established population in a leafy suburb of London or Cheshire are less likely to.”

“That [a greater willingness to talk about mental health] is great in lots of ways but there’s the risk of overdiagnosis and over-medicalisation of things which are situational life stresses rather than illnesses. You have to be very careful that it doesn’t tip over into saying that this is a medical problem and it needs a medical or pharmacological intervention because, occasionally, it does but, most times, not actually.”

We’re full of hot topics in this conversation – overdiagnosis! Why is overdiagnosis such an issue in mental health?

“If you’re making the diagnosis of depression or anxiety, the positive thing is you’re saying to the patient. ‘Yes, I believe you. You’ve got a problem, and I, as a doctor, I’m going to help and I’m going to do something about it’ so it can be an expression of care, and expression of caring. And that’s great.” 

“The downside of it [overdiagnosis] is that you’re saying ‘yes, you’re ill there’s something wrong with you as a person’. The danger is to is to say that the problem resides inside the individual rather than saying this particular individual is in a very problematic situation, or life circumstances – whether it’s economic insecurity or an asylum seeker or that are in a situation of domestic violence.”

“It is the context that we should be helping them to work on – whether getting through an asylum process, working out ways of living, or moving on from a difficult interpersonal relationship.

“But you can have a sense that you [the doctor] have checked the box, you’ve done the job, you’ve done something which may be helpful. But the risk of both of those things, whether it’s antidepressants or psychological therapies is that you’re saying to the person ‘you are a person with the problem. It’s you rather than you in your context.’ I think that’s what medicine does in general, so I’m not blaming anybody – it’s just, that’s the orientation that we [the medical profession] come from.”

This is really interesting!! So what can we do??

“First of all, we need to listen carefully and to acknowledge the suffering of people who are coming to see us, and that’s not as easy as it sounds, And then the second thing is offering hope that things can be even just a little bit different from what they are now. Those are two things to always come back to, as the basic tenets of why I’m in medicine – why I’m in family medicine.“

“We have to not just talk but we have to listen. To what people are saying, very respectfully and very carefully, just to sort of hear the nuances and tease it out a bit.”

“Even just by acknowledging it and taking it seriously and listening with respect and compassion to what that person is saying- that in itself will be a thing that will help them – knowing that there’s this person, this other human being who is a human being in a position of authority in the community who is taking me seriously, who is hearing what I’m saying. This is expressing compassion. And that’s a pretty big thing.”

Not wanting to fix things or jump in too early to manage my own uncertainty and my own discomfort is admittedly really hard but I’ve been practicing since this discussion. I also wonder what my patients think. Are they seeking a diagnosis or a label? Are they seeking a transaction (i.e. me giving them something in return)? Are my patients ready to sit with their own difficult feelings? I guess this is what people call “doctor as a drug”.

As I mentioned, Chris and I met in Japan, the country famous for its karoshi (death by overwork), hikkikomori (withdrawing from society) and high suicide rates. Has Chris noticed any differences between the West and the East?

“I think people in Japan are much more – again, this is just my superficial outsider’s view – cautious and more reserved about talking about mental health issues and about expressing emotional feelings on anything really. Whereas in Europe, in the States – in the Westernized countries – there’s a greater willingness to discuss things in terms of how you feel, about psychological manifestations of whatever’s going on.”

“It reminds me of my parents’ generation who went through the Second World War when stoicism is absolutely crucial because life was just, objectively, very stressful and there was a high chance of death or people you know you dying. There wasn’t really much you can do so you had to just get on with it and just find ways of coping.”

Can you give any other examples of the cultural differences in mental health?

“If I take medically unexplained symptoms, which is something that in this country [UK]we see a lot of and, maybe particularly tired-all-the-time or fatigue and that’s probably to say there’s a mental health thing underlying that. I was doing some work in Bahrain in the Middle East a few years ago and they were saying, ‘No, see here our first thought is that they’re dehydrated’. Really. ‘And so we’ve got them on an IV drip to give them some saline and then more often than not they feel better.’ So that’s just one very concrete example of how a phrase has some very different meanings depending on where you are.”

So how does the WONCA working party on mental health fit into this?

“Over the last couple of years we’ve produced a series of guidance documents for family doctors on a variety of things that family doctors themselves have said.”

“The first one we produced was on the first depression consultation. And then we’ve got a series on non-drug treatments for common mental health problems; one on medically unexplained symptoms; physical health care of patients with severe, mental illness; and then we’ll proceed by producing other ones on dementia, mental health of asylum seekers and refugees, and so on. We’re pulling those all together into a book which will be published early next year on global mental health for family doctors” 

“We’ve run a series, at WONCA level, of a ‘Train the Trainer’ programme in depression and common mental health problem. We did one three years ago, in Moldova in Eastern Europe in conjunction with EACH – so it’s the  InternationalAssociation for Communication in Healthcare – looking at communication skills and mental health management. And then we’ve we ran one again with EACH last year in Japan with Professor Ryuki Kassai and colleagues and that was training up a half a dozen family doctors in primary mental healthcare and then encouraging them to train others.”

“And then just this year, we’re doing a big ‘Training the Trainer’ program for family doctors across Asia Pacific region, which involves   family doctors in Japan but also in the Philippines and Korea and in Vietnam, in Pakistan, in Nepal, and elsewhere, where we’re giving people a lot of  knowledge and skills but also giving them some confidence in their own teaching and presentation skills so that they can teach other people.”

Are there any other good resources for teaching?

“The MH gap programme which is run by the World Health Organization is very helpful and that’s focused on low- and middle-income countries – so it’s for first contact, health workers who may or may not have qualified medics who have been through graduate training to be GPs – but is also very relevant to high-income countries like ours.” 

“The place to start is the MH Implementation Guide MH IG 2.0 which was produced in 2016 and is web-based so you can download or you can just access it. It also links into a very effective training programme for a variety of common mental health problem. They also include epilepsy in their remit. It’s algorithm-based, which I have some anxieties about, but actually works reasonably well.”

“It’s all based on best available evidence from meta-analyses and should be applicable anywhere in the world so, for example, they focus on amitriptyline and fluoxetine, not because they’re the most fabulous drugs at the moment, but because they are drugs that are available practically anywhere.”

“They’re freely accessible, I mean of course, you will want to modify these depending on your circumstances and your culture. They’re done and good enough but you can then adapt them to whatever circumstances you use.”

We also touch on the mental health of doctors. There’s been plenty of news of doctors’ suicides and burnout in the past few years and what can we say to support all doctors to not tread down that path….

“If you’re not able to look after yourself then you certainly will not be able to look after anybody on so it’s about acknowledging that it is not a self-centered nor a sort of luxury but that it is essential.”

“Being aware of who to go to for help and advice and that is anybody whether you’re a young doctor or a senior GP. I mean all of us, at some time or other, quite frequently will come up against things that we don’t know what to do with or we’re actually feeling challenged by and that’s okay. That’s true, that’s how I’m feeling that’s not a sign of failure, in some way, but I need some help. We should be thinking about ourselves as human beings rather than just us as doctors and we should think about where we find our sources of comfort or sources of joy.”

“I used to write a wellbeing blog and one of the things I was writing about was creating your own personal well-being recipe, where you write down up to ten ingredients of things that make you feel good.”

“And so, mine includes various things including spending time with my family, or walking in mountains, swimming in the sea, watching test cricket. And the one that always makes people giggle is that I like ironing when I’m a bit stressed. I like ironing shirts and that just gives me a sense of self-control – making things tidy.  Getting people to write down a list of things that actually make them feel good may make them feel better. And then when times are tough, coming back and digging out your list and finding at least one or two of those things that you can actually do straight away may make you feel better. Because obviously I can’t always get in the car and go walk up a mountain but I can always find a shirt to iron and I can almost always find some cricket to watch on telly somewhere!”

There’s one final question I wanted to ask. I belong to a group of’ yes men’ and, typical to this group, we end up saying yes to a few too many things and ending up getting super stressed. I’m getting better at balancing my life, in general, but did Chris have any tips on how to manage a better work-life balance.

“Yes, I think the implication is learning how to say no to things which is difficult. I guess, for most doctors, we want to say yes because we want to make a difference so we would have to say yes. But, and it’s really difficult for young doctors because they think, ‘Maybe that was the opportunity that would make the difference.”

“It’s easy to say no to things that you don’t really want to do but what gets more difficult, and, I don’t quite know the answer to this even yet, is to say no to things that you would like to do and to say no to things that you know you could do quite well so that’s harder. I acknowledge how complicated that is!! My wife keeps telling me that I keep on saying this and stop doing things but then I  start doing other things instead!!”

“But yes to acknowledge that saying ‘no’ is actually a very healthy and wise and sensible thing to do. That’s as far as I could go on that I think!”

So finally, before we sign off, what can young doctors interested in mental health do to get involved?

I’m very happy to just have a talk to people online if that’s helpful. In terms of WONCA Europe there is the Young Doctors’ Movement called the Vasco da Gama Movement and there are people within that who have an interest in mental health. I think a bit of additional training, whether it’s face-to-face or online is helpful and I think, beyond these various resources that we’ve talked about, there is King’s College, London,  and their global mental health masters and also short courses  It’s  always the balance between being enthusiastic and doing stuff but actually having enough knowledge and skill and a structure behind you to be able to actually do something that will be genuinely helpful to other people  rather than just exhausting yourself running around in circles and getting  a bit stressed about things when you’re not quite sure what to do.” 

“But I think we absolutely need young and enthusiastic people getting involved!”

Watch this video here of Chris talking about suffering and hope, the 3rd Helen Lester Memorial Lecture at Society for Academic Primary Care (SAPC) in 2016

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