Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID:14841).
Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months answers are not published.
Case 1 – Josh
Josh, 25 years of age, is a carpenter’s apprentice. He presents to your inner city practice at the urging of his mother, who has been concerned about his mood over the past 6 months. You are able to assess Josh over a couple of appointments and determine that he has mild-to-moderate depression, which is starting to affect his work. You discuss management options with Josh but he does not feel comfortable attending sessions with a psychologist and is very reluctant to consider medication. He works long hours and is living at home with his parents, who are helping to support him financially while he completes his training.
Regarding the evidence for efficacy of e-mental health (eMH) programs in the treatment of depression, you are able to tell Josh that effect sizes have been found to be:
- smaller than for face-to-face psychological therapy
- larger than for face-to-face psychological therapy
- smaller than for antidepressant medications
- at least as large as for face-to-face psychological therapy
- uncertain, compared with those for face-to-face psychological therapy and antidepressant therapy.
On the basis of the case history, the potential barrier to engaging in face-to-face psychological therapy that is most likely to be relevant to Josh is:
- childcare logistics
- distance to care
- physical disability and impaired mobility
- unwillingness to disclose.
You educate Josh regarding the availability of eMH programs for the treatment of depression. An effective strategy to increase the likelihood of engagement would be:
- Emphasise the privacy risks around use of eMH programs.
- Explain to Josh you won’t need to see him again until he has completed the prescribed program.
- Log on to your preferred program within the consultation to help familiarise Josh with the program.
- Tell Josh to ‘google’ e-mental health and choose whichever program he thinks he would like.
- Write down the name of the website on a piece of paper and give it to Josh.
You review Josh 2 weeks after prescribing an eMH program and are pleased to hear that he has completed the first three modules. He has noticed a slight improvement in his symptoms, although he still feels down and is not sleeping well.
The most appropriate next steps in management would be:
- commence antidepressant medication
- encourage, regular follow-up, reassess and adjust the treatment plan
- explore, encourage, reassess and refer Josh to another eMH program or psychologist
- intensive follow-up, reassess adjust the treatment plan, refer and/or medicate
- occasional follow-up.
Your practice wishes to improve the efficiency and outcomes for its patients who have chronic diseases. The registrar has completed a practice audit, which indicates only 10% of the GP management plans the practice performs have been reviewed. The partners are wondering where this places them in relation to other general practices around Australia.
You are able to tell the partners that the percentage of regularly reviewed care plans is approximately:
One of the practitioners identifies communication difficulties as a key frustration when managing patients with chronic disease.
Which of the following digital technologies is likely to be the most effective at improving communication between care team members?
- e-referral systems
- electronically shared progress notes
- shared electronic health records
- structured care plans.
One of the partners is very keen on adopting newer digital technologies to support chronic disease management within the practice.
All of the following are likely benefits of adopting digital technologies EXCEPT:
- cost reductions
- decreased patient satisfaction
- improved Medicare compliance
- improved patient follow up
- reduced document scanning.
You are a GP working in a small rural community. Many of your elderly patients are finding it increasingly difficult to travel into the clinic for appointments and home visits are becoming more necessary. The local Royal District Nursing Services (RDNS) provide valuable support to help patients remain in their homes, but their resources are becoming stretched. You are keen to support new initiatives that use telehealth to provide patients with support to manage their medications.
You consider which of your patients would be eligible for this service as outlined in the broadband-enabled innovation plan (BEIP). From the list below, the patient most appropriate for referral is:
- Lucille, 72 years of age, social anxiety disorder, lives alone, no regular medicines
- John, 74 years of age, vascular dementia, requires the assistance of his wife Anne for personal care activities
- Alfonso, 84 years of age, cardiovascular disease, minimal English, lives with his wife Maria who is well
- Maud, 88 years of age, mild Alzheimer’s dementia, type II diabetes and cardiovascular disease
- Joan, 93 years of age, osteoarthritis, lives independently, president of the Rose Growers’ Society.
You are chatting to Maureen, one of the local RDNS nurses and she expresses that she has really enjoyed learning how to use the telehealth equipment but is concerned that some of her clients miss the face-to-face time with the nurses.
Maureen’s statement gives examples of a:
- negative outcome for clients and staff
- negative outcome for staff and a positive outcome for clients
- positive outcome for staff and clients
- positive outcome for staff and a negative outcome for clients.
The BEIP trial has shown all of the following outcomes EXCEPT:
- age as a barrier to the use of technology
- increased time spent directly on medication management
- reduced travel-associated expenses
- savings in travel time for clients.
Case 4 – Isabel
Isabel, 39-years of age, is a mother of two young children and works part-time as an accountant. She presents in distress and reports feeling sad and crying all the time over the past month. Isabel is finding that she is irritable with her children, can’t concentrate at work and is having difficulty getting to sleep at night. She has noticed that her jeans are becoming loose around the waist. Her PHQ2 score is 12.
Which of the following is the most appropriate first-line treatment plan for Isabel?
- Face-to-face cognitive behavioural therapy (CBT) or internet-delivered CBT (iCBT)
- Selective serotonin reuptake inhibitior (SSRI)
- SSRI and iCBT.
For which of the following patients is iCBT also most likely to be effective?
- George, 24 years of age, crystal methamphetamine dependence and depression
- Mary, 24 years of age, just been diagnosed with bipolar affective disorder
- Estelle, 36 years of age, accountant with recurrence of depressive symptoms
- Fred, 48 years of age, chronic schizophrenia with increasingly depressed mood over the past 2 months.