Generalist mental health skills 2

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Unit 615

September 2024

Generalist mental health skills 2

Here we present cases 15 years on from the cases presented in unit 614 to help you refine your skills in ‘noticing over time’ and tuning in to changes that happen in families and individuals as they live their lives. You may choose to review each case in unit 614 as though reviewing your patient’s records before they come to see you.

As outlined in unit 614, Generalist mental health skills 1, general practitioners have a way of assessing that takes in the breadth of the whole person, the depth of seeing beyond the presenting complaint and a length that offers continuity of care over time. This continuity of care is not simply about deepening the human trust relationship; it also facilitates honest disclosure and a growing understanding of the person as the clinician and patient journey through many of the ups and downs of life together.

It is also about a way of assessing knowledge over time. Unlike episodic hospital care, generalist care continually takes into account the past (when we search for aetiology or wonder whether we have missed something) and the future (when we are initiating care that is preventive and know we will have to be part of this person’s future healthcare team).

This awareness of time in every consultation is a key element of the diagnostic appraisal that is unique to the primary care setting. As part of this assessment, we are privileged to be able to see the pathophysiological processes we learn in medical school played out in an individual or family over time. It also allows us the gift of seeing the outcome of our own interventions in their lives. Sometimes these insights lead to generalist innovations aimed at increasing early intervention and prevention, such as the Sense of Safety framework discussed in this activity.

Learning outcomes

At the end of this activity, participants will be able to:
  • describe the unique role that generalist mental healthcare plays in a family’s life over time
  • develop a plan for managing the impact of domestic violence on patient confidentiality
  • identify links between childhood trauma and adult mental and physical distress
  • assess the impact of general practice on the practitioner’s wellbeing.

Case studies

Below is a list of the case studies found in this month's edition of check. To see how these case studies unfold and gain valuable insights into this month's topic, log into gplearning to complete the course.

Priya, aged 55 years, is now single, with ageing parents, three young adult children at various stages of independence, a full-time job in graphic design and a host of midlife worries.

You have now been Priya’s general practitioner for many years, and you supported her 10 years ago when she decided to leave her husband, initially moving into a domestic violence shelter and then on to private rental accommodation. You have not seen her since her last cervical screen five years ago.

When Priya returns, you notice she looks nervous as she glances around the room. You are reminded of her presentation 15 years ago when you correctly identified that she was experiencing family violence. Priya starts by telling you that there have been many changes over the years and she does not quite know where to begin.

Your next patient is Lena, aged 30 years, who presents requesting blood tests as she is experiencing fatigue and is concerned about her family history of type 2 diabetes. You have known Lena since she presented to you with atypical anorexia aged 15 years. You were intensively involved in her care at that stage for three years. You have seen her infrequently throughout her 20s, and she has presented as quite well in that time.

Over the course of the consultation, you elicit that she is ‘not eating well’, is often ‘losing control’ over what she is eating, is unhappy with her weight (she has been at a consistent higher weight since her teens) and is very unhappy in her workplace. She mentions feeling ‘empty’ and ‘worthless’ at times, and that she is unable to advocate for herself at work with her boss, who she describes as ‘dominating’.

Paul, aged 61 years, who last came to see you 15 years ago, presents to your clinic. On reviewing your notes from his last visit, you notice a history of domestic violence that has affected Paul and his family. In the intervening years, Paul and Priya, who is also a patient of yours (Case 1), have divorced, and Paul has ceased work. He is now on a disability pension for his back pain. He uses most of his pension on the rent for his one-bedroom flat, painkillers and ordering food delivery online. He has gained 15 kilograms since you last saw him, his body mass index is 30 kilograms/m2 and his blood pressure today is 160/100 mmHg. Paul does not do any regular exercise and describes experiencing broken sleep and waking up gasping for air – he also mentions some ‘freaky nightmares’. He does not smoke.

Paul’s main reason for presenting seems to be to tell you how much he regrets losing Priya and how much he misses his children. At times he seems very resentful of Priya and speaks angrily of everything he lost as though she were to blame. At other times he appears crushed and aware of how his behaviour in the past has influenced his present.

He has occasional contact with his younger brother, who sometimes comes over for a drink.

Jai is now aged 19 years and studying commerce at university. He did quite well at high school, which he attended with a small group of friends from his local primary school. With all his friends around him, he did not find it too difficult to concentrate when studying for his exams, but he has found university much harder. He failed a few subjects in his first year, and he presents with anxiety about the impending start of the new university year. He has started to have panic attacks and wonders if he should drop out.

You have known Jai for most of his life and have watched his family dynamics change over that time. You were proud to see his mother, Priya, rise to the challenge of parenting Jai in his early childhood and through her marital breakup when Jai was aged nine years.

You observed Jai develop good friendships, settle well and succeed at high school as you met regularly with his mother throughout that time and supported her in her parenting. You feel that Jai’s school performance was helped by his mother’s consistent presence as a trusted and reliable parent. You note, with curiosity, the fact that Priya has also been struggling since Jai left home and wonder about the parallel presentations.

Your next patient, Dee, is a general practitioner and colleague, aged 47 years. She works at another practice, and you have not seen her since before the COVID-19 pandemic. She looks exhausted and wrung out, and she says she forgot to book her cervical screening test and mammogram (annual surveillance has been recommended for her because of a family history of breast cancer), both of which were due 18 months ago. Dee declares that she has had enough of this job; she does not enjoy it anymore, and despite always having planned to stay in general practice long term, she is thinking of leaving clinical work altogether.

Dee describes feeling somewhat isolated within her practice, partly because of differences in the care needs of her cohort of patients. During the pandemic there were many times when Dee felt she was unable to offer the care she wanted to provide her patients, given the constraints of the system and the systemic limitations of telehealth and personal protective equipment.

CPD

This unit of check is approved for 10 hours of CPD activity (two hours per case). The 10 hours, when completed, including the online questions, comprise five hours’ Educational Activities and five hours’ Reviewing Performance.


 
Educational
Activities
5
hours
Measuring
Outcomes
0
hours
Reviewing
Performance
5
hours

Complete check online

To enroll in this check unit online: 

  1. Log into myCPD home page
  2. Select 'Browse' and search for 902855
  3. Select the course and register

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TOPICS

Abuse and violenceDoctors healthMental health

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