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Setting the Stage for Disclosure

Network, Winter 2004

For most people with a mental illness, confiding in their primary care practitioner will be the first step they take towards disclosure. Dr. Ron Book discusses how a family physician can create a practice that makes it easier for a patient with concerns about their mental health to talk about them with their doctor.

What are some of the things that a family physician can do to convey to patients that he or she is concerned for their mental health and not just their physical health?

RON BOOK: Statistically we know what is out there in terms of mental illness. We know how many people need help and what percentage of those people actually walk through our office during the course of a day. Although there is a certain degree of onus on the patient if they are concerned about something to raise that with their doctor, there is just as much responsibility on the part of the family physician to ask questions that cover more than just the physical issues. I think you can create your practice in a way that makes it friendly to bring up these sensitive issues. A lot of people have guilt, or they are embarrassed about the depression or anxiety they are feeling. As family physicians, as primary care givers, we have to convey the message that it is okay to talk about these things, because statistically the most likely person they will access is the family physician.

How does a family physician create a “friendly” practice?

RON BOOK: One thing is to have information readily available in the waiting room in terms of pamphlets and posters — things that clearly signal to the patient that the doctor is willing to discuss these topics and that if they have problems in these areas they can bring them up. You could also actively screen for mental illness during an annual physical or routine visit through the questions you ask. Another possibility is to screen indirectly with self-administered questionnaires which are filled in in the waiting room prior to their appointment. These are some of the things you can do, on a proactive basis, to let people know that you are willing and wanting to help them.

Once a patient has been diagnosed with a mental illness, how do they prepare to talk to family members, friends and their employer to ensure the most positive response?

RON BOOK: I feel strongly that if a patient’s family is involved in helping them they generally do much better than if they are on their own trying to deal with this. Many times I have had a patient come in with their spouse and other family members as a group, and I talk with them together to help them understand what the illness is, what they can expect, the treatment we are planning, and how they can help in this process. When a patient is surrounded by people who are willing to take time out of their lives to help a loved one through a difficult time, it paves the way for the patient to make not only a quicker recovery, but to have a more full recovery. Part of how you define recovery is not just the initial treatment phase, but the longitudinal results. Unfortunately, a lot of people do well at first but then go off the treatment course. When they have the support of family members they are more likely to keep on with the treatment, which leads to a better outcome.

Are there special difficulties experienced by other cultures within our communities when they are diagnosed with a mental illness?

RON BOOK: I have had some experience both here in Brantford and in Thunder Bay with Aboriginal communities. Certainly in Northern Ontario the whole structure of the Aboriginal society is in disarray. Substance abuse and unemployment is pretty horrific. When I’ve been involved with treating patients from Six Nations here in Brantford, in terms of the cases I’ve seen they have done well and have had the same outcome as anyone else. I do think, though, there may well be some differences in terms of acceptance, even in how we organize things from a western medical system. The spiritual issue definitely plays a role. One thing I try to explore with any patient is what has been important to them in the past — physical activities, social or spiritual activities — and try to help them re-establish those links. Often they have been abandoned and that’s part of what has contributed to the spiral of depression. Certainly with First Nations individuals, that can play a large role with their cultural belief of who they are as an individual and who they are as a nation.

When people disclose the fact that they have a mental illness, what kind of response are they hoping for?

RON BOOK: To find out that they are not alone. I think what mental illness does in real terms is to isolate. We are a social species and we need that human contact. I think if you can help people to understand that they are not going to go through this alone, that we as their family physician are here to help, that their family is there to love and support them, then that will often do more good than some of the treatment plans we come up with. When people are anxious or depressed their thinking and perceptions are often distorted, and that is very alienating and quite frightening. I think if we can respond by saying, “I hear what you are saying. I know this must be a horrible thing to go through but we are going to help you get through it,” then that would be the best response we could possibly make.

Dr. Ron Book, CCFP, a family practitioner who graduated in 1989, became involved in running the emergency department for psychiatry at Lakehead Psychiatric Hospital while his wife completed her residency in Thunder Bay. He has since been asked to design, set up and run an emergency psychiatric system in Brantford, Ontario. Dr. Book is currently completing his psychiatric residency in Hamilton at McMaster University.

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