Supervisor Modules

Teaching session worksheet

The following areas for discussion cover a broad range of points about the practicalities of managing people with depression in the general practice setting.

As part of their Mental Health Education Program, Block Releases are held for Basic, Advanced and Subsequent term Registrars that cover many aspects of this topic. This tutorial is an opportunity to consolidate and build on some of this learning in a local setting. It would be useful to ask your Registrar if they have attended the Block Release and discuss any pertinent aspects or issues.

Full details of the Block Release including useful resources are available here.

Below is a summary of the learning objectives from the Block Releases that are relevant to Depression.

Basic Term Registrars (Module 1)
Objectives:

• Increase knowledge of prevalence of depression in the community and causation of depression
  
• Increase knowledge of methods of recognising and assessing depression in general practice
  
• Increase understanding of how to develop a suitable mental health management plan
  
• Increase knowledge of the appropriate use of pharmacotherapy
  
• Increase critical understanding of various models of patient management (including long term management strategies)
  
• Outline and practice of psychological treatment strategies
  
• Increase understanding of managing suicidality
  
• Determine methods of self care and review the importance of peer support

Advanced Term Registrars (Modules 2 and 3)
Objectives:

• Build on the core skills gained in module 1 on depression
  
• Introduction to assessment and general practice management of mental health issues with more complex underlying co-morbidities
  
• Develop an understanding of how co-morbidities, including drug & alcohol issues, eating disorders, somatisation, chronic pain and personality disorders interplay with mental health presentations, assessment and management in general practice
  
• Introducing use of case studies, role play and "fish bowl" scenarios as registrar education tools in topics of complex mental health presentations
  

With your Registrar please select one or more key questions to be discussed at your next in-practice teaching session. The Registrar should do some of the related activities prior to the next session.

The dot points are points for discussion that you might be able to use as prompts during the session.

The actual amount of Registrar work involved will vary depending on whether all key questions are covered.

Part A. How do we deal with the time demands?
Registrars often report that one of the major difficulties in dealing with depression in general practice is the impact of the resultant long consultations on the rest of the session. How they manage time and how they “package” their mental health consultations in general can have a big impact on their satisfaction and confidence in managing this illness. Supervisors will have developed a unique set of skills that work for them, but how do we help the Registrar to develop their own effective mechanism?

Suggested points for discussion:

• How to end consults appropriately
  Is there something to be gained by further prolonging the current consult? What are the clear “need to be covered” points and what can wait until next time? Help Registrars gain confidence to not have to do everything all in one visit.
  
  
• How to plan follow up
  Having a structure in mind from the start about follow up in both the short and the long term can aid time management. Discuss the use of GP Mental Health Plans as an aid to formalising follow up. Use of “homework” for patients may help them to view the follow up plan as a positive part of the therapeutic model. How can formal follow up plans improve patient care? (eg reducing the risk of missing important information)
  
  
• How to manage running late
  How do we feel after an unexpectedly long consult? Is it always possible or even appropriate to try to “catch up” time? How do we deal with the personal response to being behind with a full waiting room? Supervisors may wish to share some of their personal coping strategies.
  

Part B. Dealing with emotional response
Why should we acknowledge our own responses to patients?

Certain reactions can and do occur when dealing with the depressed patient. This may include a response to vicarious exposure to traumatic events, despairing thoughts and situations.

Registrars may feel overwhelmed by these responses, and may even begin to develop negative feelings about treating patients with depression because of this. Occasionally, doctors fail to identify that they are experiencing an emotional response, instead mistaking their reactions for physical responses to overwork or tiredness.

You might want to discuss a recent consultation that has left you or the Registrar with a strong personal response. What was the response? Did you identify at the time that there was something going on, or was it a more ‘delayed reaction’? Did it have any impact on the rest of your consulting day? If not, are you able to identify any strategies, which you used to reduce your response?

You might wish to discuss strategies that enable you to maintain empathy in a way that is also sustainable. It may be helpful to reflect back to the Registrar about any positive personal responses you have had to managing a depressed patient to balance the perception that all such responses are a negative influence.

All Registrars undertake the Registrar Well Being Program as part of their out of practice training, which in part provides a framework for self care and prevention of burnout by doctors.

Part C. Real world versus EBM
What does EBM say about depression?

EBM is a powerful tool for rationalising our clinical care. Depression is a significant public health problem. The aim of this key question is to raise awareness about the controversies in EBM regarding depression. The Registrars are taught that “watchful waiting” is a very reasonable approach to many situations during their Mental Health Block Releases.

• Discuss current evidence on prevalence, identification and identification thresholds, management and prognosis
  
• What is the evidence on treatments such as antidepressants and CBT?
  
• (How) do they affect outcomes?
  
• What is the power of placebo in the management of depression?

What are your initial approaches to the distressed patient?

The aim of this key question is to bring management back to the real world of clinical practice. The Registrars [through their Block Releases] should be familiar with the concept of watchful waiting.

The following questions might be useful to cover:

• Is everyone who presents as distressed depressed?
  
• What other types of underlying problems may present as general distress? How might you try to differentiate?
  
• What are your priority tasks with a distressed patient and what might their sequence be?
  
• What “red flags” might make you very concerned about a patient? How might you then respond?
  
• What sort of interventions might you put in place for mild, moderate or severe depression?
  
• Whom might you refer the patient to? When? How?
  
• How do you structure follow up?

What triggers might lead you to change your approach? When?

The aim of this key question is to raise awareness of the need for monitoring of patient outcomes, awareness of developments that might cause you to reconsider the diagnosis or your management.

• What do you look for when you are reviewing a patient with depression?
  
• When would you expect a response to interventions such as simple behavioural interventions, structured problem solving, anti-depressants, or to CBT?
  
• Who might you get advice from?
  
• What alternative/additional diagnoses might you want to consider?
  
• What changes to management might be appropriate?

Part D. Identifying and dealing with “Blocks”
If you are seeing many/few depressed patients why might that be?

Clinicians have a mix of clinical skills and personal styles that may impact on the patients they see. If your Registrar feels they are seeing a larger than expected proportion of depressed patients, explore the reasons for this. Can they make the diagnosis of depression confidently? Do they have a consulting style that encourages “offloading” by patients? Reflect on your own style of practice. Are there any dynamics within your own practice that impact on the Registrar’s experiences?

How do you feel about public initiatives raising awareness of depression?

There are different perspectives on the incidence and diagnosis of depression that vary from under diagnosis and high prevalence on the one hand, to claims of “disease mongering” and over prescription of antidepressants on the other. An understanding of where both of your attitudes sit on this continuum is important context for any discussions on depression. Explore with your Registrar both of your views on these initiatives.

Other ideas that can be covered:

• Assessment of suicidality – Discuss how you assess suicidality in a general practice context. Do you do it as part of every consult for depression?
• Decisions to intervene

1. When do you prescribe medication for depression in a general practice setting? What antidepressants do you use and how do you decide on the dose? How does this affect timing of follow up?
2. When do you detain someone under the Mental Health Act? What are the local procedures that apply in this instance? What are some of the risks associated with detaining as opposed to not detaining a patient?
3. When do you refer? What local resources are available to assist in the management of depressed patients and how are they accessed?