Domain – Mental health (case)

Sofia, aged 36, works part-time in an administrative role at the local council and has two children aged eight and five. She saw your colleague a few weeks ago and had a series of blood tests for fatigue, which were all normal. She has come to see you today because this feeling of overwhelming fatigue is getting her down, and she is now sleeping badly which is making things even worse. She is feeling irritable with the kids and her partner, and is frequently tearful.

What communication skills could help you to engage Sofia in sleep management strategies?

What communication techniques could you use to encourage Sofia to try behavioural strategies to manage her symptoms?

How would your communication be different (or the same) if Sofia was an Aboriginal or Torres Strait Islander woman? Or if her first language was not English?

Communication Skills for Sleep Management Strategies

1. Active Listening: Show Sofia that you are fully present and attentive. This involves maintaining eye contact, nodding, and providing verbal acknowledgments like “I see” or “That sounds difficult.”
2. Empathy: Express understanding and compassion for her situation. For example, “It sounds like you’ve been going through a really tough time with the fatigue and its impact on your sleep and mood.”
3. Open-Ended Questions: Encourage Sofia to share more about her experiences and feelings. Questions like, “Can you tell me more about how your fatigue and sleep issues are affecting your daily life?” can help her open up.
4. Reflective Listening: Paraphrase what she has said to show understanding and validate her feelings. For instance, “So, you’re finding it hard to manage your energy levels during the day, and it’s affecting your mood and interactions with your family.”
5. Normalize Her Feelings: Reassure her that what she’s experiencing is common and can be managed. “Many people who experience ongoing fatigue feel overwhelmed and find it impacts their sleep and mood. There are strategies we can try to help with this.”

Encouraging Behavioral Strategies

1. Motivational Interviewing: Use techniques to explore Sofia’s readiness to change and enhance her motivation. Ask, “On a scale from 1 to 10, how motivated do you feel to try some new strategies to improve your sleep?”
2. Education: Provide information about the connection between sleep, mood, and fatigue in a clear and concise manner. “Good sleep hygiene practices can significantly improve both sleep quality and daytime energy levels.”
3. Collaborative Goal Setting: Work with Sofia to set achievable and specific goals for sleep management. “Let’s set a small, manageable goal to start with, like establishing a consistent bedtime routine.”
4. Positive Reinforcement: Encourage and support her efforts. “It’s great that you’re willing to try these strategies. Even small changes can make a big difference.”
5. Providing Resources: Offer handouts or recommend websites/apps that can help with sleep hygiene and relaxation techniques.

Adapting Communication for Different Backgrounds

If Sofia was an Aboriginal or Torres Strait Islander woman:

1. Cultural Sensitivity: Acknowledge and respect her cultural background. Show awareness of cultural differences in health beliefs and practices.
2. Building Trust: Spend more time building a rapport and showing genuine respect for her experiences and background.
3. Involving Family and Community: Recognize the importance of family and community in health decisions. Offer to include family members in the discussion if appropriate and desired.
4. Using Plain Language: Avoid medical jargon and ensure that explanations are clear and easily understood. Use visual aids if helpful.
5. Cultural Competence: Be aware of and sensitive to cultural practices and beliefs related to health and wellness.

If Sofia’s first language was not English:

1. Language Support: Use professional interpreters if needed to ensure clear communication.
2. Simplified Language: Speak slowly and use simple, clear language. Avoid idiomatic expressions that might be confusing.
3. Confirm Understanding: Frequently check for understanding by asking Sofia to repeat back what she has understood or by asking clarifying questions.
4. Visual Aids: Use diagrams, pictures, or written materials in her preferred language to support verbal communication.
5. Patience and Time: Allow extra time for the consultation to ensure that Sofia feels comfortable and fully understands the information and advice provided.

Clinical information gathering and interpretation

What further information do you need for a full mental health assessment?

Further Information for a Full Mental Health Assessment

1. Detailed History of Presenting Complaint:
   • Onset, duration, and progression of fatigue and sleep disturbances.
   • Any associated symptoms (e.g., changes in appetite, weight, concentration, memory).
   • Impact on daily functioning and quality of life.
2. Psychiatric History:
   • Previous episodes of mental health issues, including depression, anxiety, or other disorders.
   • Past treatments and their effectiveness.
   • Family history of mental health disorders.
3. Medical History:
   • Any chronic medical conditions (e.g., thyroid disorders, diabetes, anemia).
   • Current medications and supplements.
   • History of substance use (alcohol, drugs, caffeine).
4. Social History:
   • Detailed information about her job, work hours, and job satisfaction.
   • Family dynamics, including relationship with partner and children.
   • Social support network, including friends and extended family.
5. Psychosocial Stressors:
   • Any recent significant life changes (e.g., bereavement, relocation, job loss).
   • Financial stressors or concerns.
   • Any history of trauma or adverse childhood experiences.
6. Lifestyle Factors:
   • Diet, exercise habits, and sleep hygiene practices.
   • Hobbies and leisure activities.
   • Screen time and use of electronic devices.

What social issues (employment, relationship, financial) may be impacting on Sofia’s physical and psychological wellbeing?

Potential Social Issues Impacting Sofia’s Wellbeing

1. Employment:
   • Job stress, workload, and work-life balance.
   • Part-time employment might be contributing to financial stress.
   • Job satisfaction and fulfillment.
2. Relationship:
   • Relationship quality with her partner.
   • Support from her partner in managing household responsibilities and childcare.
   • Any conflicts or communication issues within the relationship.
3. Financial:
   • Financial stability and any recent changes in financial situation.
   • Stress related to managing household expenses and children’s needs.
   • Potential impacts of part-time employment on financial wellbeing.

What screening or assessment tools could help you in this situation?

Screening or Assessment Tools

1. Depression:
   • Patient Health Questionnaire-9 (PHQ-9)
   • Beck Depression Inventory (BDI)
2. Anxiety:
   • Generalized Anxiety Disorder-7 (GAD-7)
   • Beck Anxiety Inventory (BAI)
3. Sleep:
   • Pittsburgh Sleep Quality Index (PSQI)
   • Epworth Sleepiness Scale
4. Fatigue:
   • Fatigue Severity Scale (FSS)
   • Multidimensional Fatigue Inventory (MFI)
5. General Mental Health:
   • Kessler Psychological Distress Scale (K10)
   • General Health Questionnaire (GHQ)

What if Sofia was elderly? What if her youngest child was six weeks old?

Special Considerations

If Sofia Was Elderly

1. Additional Information:
   • Assess for cognitive impairment or dementia using tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA).
   • Evaluate for physical health issues that are more common in the elderly (e.g., arthritis, cardiovascular disease).
2. Social Issues:
   • Potential social isolation or loneliness.
   • Changes in physical abilities and mobility.
   • Need for caregiver support.

If Her Youngest Child Was Six Weeks Old

1. Additional Information:
   • Screen for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS).
   • Assess for postpartum anxiety or obsessive-compulsive disorder.
2. Social Issues:
   • Impact of sleep deprivation related to caring for a newborn.
   • Adjustments in family dynamics with the new baby.
   • Need for support from partner, family, and friends.

Making a diagnosis, decision making and reasoning

What are the diagnostic criteria to make a diagnosis of major depression? If you diagnose depression, how would you explain this to Sofia as a cause of her fatigue?

Diagnostic Criteria for Major Depression (DSM-5)

A. At least five of the following symptoms must be present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:

1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day.
3. Significant weight loss when not dieting, weight gain, or decrease/increase in appetite.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive/inappropriate guilt.
8. Diminished ability to think or concentrate, or indecisiveness.
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt/specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

D. The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Explaining Depression to Sofia as a Cause of Her Fatigue

“Sofia, based on our discussions and the symptoms you’ve described, it appears that you may be experiencing major depressive disorder. Depression doesn’t only affect your mood; it can also cause physical symptoms like the fatigue you’ve been feeling”

1. Sleep Disruption: Depression can make it difficult to get restful sleep, crucial for feeling energized.
2. Chemical Changes in the Brain: Depression alters levels of brain chemicals that control mood, energy, and motivation, leading to constant fatigue.
3. Emotional Stress: Dealing with the emotional stress of depression can be exhausting.
4. Combined Effects: These factors combined can make simple tasks feel overwhelming and tiring.
5. Common Symptom: Fatigue is a common symptom of depression.
6. Treatment: Treatment can help improve both mood and energy levels.

What are the criteria for other mood disorders that may present in this way, such as adjustment disorder or dysthymic disorder?

Adjustment Disorder

Key Features:

• Onset: Emotional or behavioral symptoms in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s).
• Symptoms:
  • Marked distress out of proportion to the severity or intensity of the stressor.
  • Significant impairment in social, occupational, or other important areas of functioning.
• Duration: Symptoms do not persist for more than an additional 6 months once the stressor or its consequences have terminated.
• Exclusions:
  • Does not meet criteria for another mental disorder.
  • Not an exacerbation of a preexisting mental disorder.
  • Not normal bereavement.

Persistent Depressive Disorder (Dysthymia)

Key Features:

• Duration: Depressed mood for most of the day, for more days than not, for at least 2 years (1 year for children and adolescents).
• Symptoms (at least two of the following):
  • Poor appetite or overeating.
  • Insomnia or hypersomnia.
  • Low energy or fatigue.
  • Low self-esteem.
  • Poor concentration or difficulty making decisions.
  • Feelings of hopelessness.
• Consistency: Symptoms are persistent, with no symptom-free period lasting more than 2 months.
• Overlap with MDD: Criteria for major depressive disorder may be continuously present for 2 years.
• Exclusions:
  • Never had a manic or hypomanic episode.
  • Not better explained by schizoaffective disorder, schizophrenia, delusional disorder, or other psychotic disorders.
  • Not attributable to the physiological effects of a substance or another medical condition.
• Impairment: Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

How might your differential diagnosis for Sofia’s fatigue be different if Sofia was over 60?

Differential Diagnosis for Sofia’s Fatigue if She Was Over 60

If Sofia was over 60, the differential diagnosis for her fatigue would include a broader range of possibilities:

1. Medical Conditions:
   • Thyroid disorders (e.g., hypothyroidism).
   • Cardiovascular disease (e.g., heart failure).
   • Anemia.
   • Chronic kidney disease.
   • Chronic obstructive pulmonary disease (COPD).
   • Diabetes.
   • Cancer (including occult malignancies).
2. Medication Side Effects:
   • Many older adults are on multiple medications, which can contribute to fatigue. Common culprits include antihypertensives, antidepressants, antipsychotics, and sedative-hypnotics.
3. Sleep Disorders:
   • Sleep apnea.
   • Restless legs syndrome.
   • Periodic limb movement disorder.
4. Psychiatric Conditions:
   • Depression.
   • Anxiety disorders.
   • Bipolar disorder.
5. Nutritional Deficiencies:
   • Vitamin B12 deficiency.
   • Vitamin D deficiency.
   • Iron deficiency.
6. Cognitive Impairment:
   • Dementia.
   • Mild cognitive impairment.
7. Chronic Fatigue Syndrome:
   • Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) should be considered if other causes are ruled out and the fatigue is profound and persistent.

Clinical management and therapeutic reasoning

What are the pros and cons of available pharmacological therapies to help Sofia to sleep?

Pharmacological Therapies for Sleep: Pros and Cons

1. Benzodiazepines (e.g., Temazepam)
   • Pros:
     • Effective for short-term relief of acute insomnia.
     • Quick onset of action.
   • Cons:
     • Risk of dependence and tolerance with long-term use.
     • Potential for daytime drowsiness and cognitive impairment.
     • Risk of falls, especially in older adults.
     • Can exacerbate depression symptoms.
2. Non-Benzodiazepine Hypnotics (e.g., Zolpidem)
   • Pros:
     • Effective for short-term management of insomnia.
     • Generally fewer side effects than benzodiazepines.
     • Less risk of dependence and tolerance.
   • Cons:
     • Still a potential for dependence and misuse.
     • Risk of complex sleep behaviors (e.g., sleepwalking, sleep-driving).
     • Can cause daytime drowsiness and dizziness.
3. Melatonin Receptor Agonists (e.g., Melotin MR)
   • Pros:
     • Non-habit forming and well-tolerated.
     • Suitable for long-term use.
     • No significant next-day drowsiness.
   • Cons:
     • May be less effective for severe insomnia.
     • Takes longer to work compared to other hypnotics.
4. Antidepressants (e.g. Mirtazapine, Doxepin)
   • Pros:
     • Can address both insomnia and underlying depression/anxiety.
     • Lower risk of dependence compared to benzodiazepines.
   • Cons:
     • Side effects such as weight gain, daytime drowsiness, and dry mouth.
     • Risk of orthostatic hypotension.
     • Potential for next-day sedation.
5. Over-the-Counter Options (e.g., Doxylamine, BENADRYL/Diphenhydramine)
   • Pros:
     • Readily available and easy to use.
     • Can be effective for occasional use.
   • Cons:
     • Risk of next-day drowsiness and cognitive impairment.
     • Potential for anticholinergic side effects (e.g., dry mouth, constipation).
     • Not recommended for long-term use due to tolerance and side effects.

What e-mental health resources or modules could you suggest?

If you decided Sofia was depressed and would benefit from medications, what would you try first, and why?

Initial Pharmacological Therapy for Depression

First-Line Medication: Selective Serotonin Reuptake Inhibitors (SSRIs) – e.g., Sertraline, Escitalopram.

Rationale:

• SSRIs are generally well-tolerated and have a favorable side effect profile.
• Effective in treating both depression and anxiety, which may be contributing to Sofia’s symptoms.
• Low risk of overdose and safer in long-term use compared to older antidepressants.

How would you explain to her how to take the medication and what side effects and benefits to expect?

Explanation to Sofia:

“Based on your symptoms, I believe an SSRI like Sertraline could help manage your depression and improve your overall mood and energy levels. It’s important to take it once daily, preferably in the morning to reduce the risk of insomnia. You might start to notice some improvement in your mood and energy levels within 2-4 weeks, but it may take 6-8 weeks to feel the full benefits.

Possible Side Effects:

• Common side effects can include nausea, headache, dry mouth, and insomnia. These usually improve after a few weeks.
• You might also experience some increased anxiety initially, but this should settle as your body adjusts to the medication.
• It’s important to let me know if you have any severe or persistent side effects or if you notice any changes in mood, particularly if you feel more depressed or have thoughts of harming yourself.

Benefits:

• Improved mood and energy levels.
• Better ability to manage daily activities and enjoy life.
• Potential improvement in sleep once your mood starts to lift.”

What would your approach be if Sofia was pregnant or breastfeeding?

Approach if Sofia Was Pregnant or Breastfeeding

Pregnancy:

• Risk-Benefit Analysis: Carefully weigh the benefits of treating depression against the potential risks to the fetus.
• Medication Choice: SSRIs like Sertraline are often preferred due to a relatively favorable safety profile in pregnancy.
• Non-Pharmacological Options: Emphasize non-drug therapies such as CBT, mindfulness, and supportive counseling.
• Monitoring: Regular monitoring and collaboration with obstetric care providers.

Breastfeeding:

• Safety: Sertraline and other SSRIs are considered relatively safe during breastfeeding, with low levels excreted in breast milk.
• Monitoring: Close monitoring of both mother and baby for any adverse effects.
• Support: Provide additional support and education about managing side effects and ensuring the well-being of the infant.

Preventive and population health

What behavioural and psychological strategies could you suggest for Sofia to manage her symptoms?

1. Cognitive Behavioral Therapy (CBT):
   • Work with a therapist to identify and change negative thought patterns and behaviors contributing to her symptoms.
   • Techniques such as cognitive restructuring, behavioral activation, and mindfulness can be beneficial.
2. Mindfulness and Relaxation Techniques:
   • Practice mindfulness meditation to reduce stress and improve emotional regulation.
   • Engage in progressive muscle relaxation, deep breathing exercises, or guided imagery to promote relaxation and reduce anxiety.
3. Sleep Hygiene:
   • Establish a consistent sleep schedule by going to bed and waking up at the same time every day.
   • Create a bedtime routine that includes relaxing activities like reading or taking a warm bath.
   • Optimize her sleep environment to be cool, dark, and quiet.
4. Regular Physical Activity:
   • Encourage engaging in moderate physical activities, such as walking, swimming, or yoga, for at least 30 minutes most days of the week.
   • Physical exercise can improve mood, reduce anxiety, and promote better sleep.
5. Healthy Eating Habits:
   • Maintain a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats.
   • Avoid excessive caffeine and sugar, which can exacerbate anxiety and disrupt sleep.
6. Stress Management:
   • Use time management techniques to balance work and personal life effectively.
   • Set realistic goals and prioritize tasks to avoid feeling overwhelmed.
   • Practice saying no to unnecessary commitments to reduce stress.

Who could you refer Sofia to in your practice or local community?

• Psychologist or Therapist: For CBT and other forms of counseling.
• Psychiatrist: For medication management if her symptoms are severe.
• Sleep Specialist: If sleep disturbances persist despite behavioral interventions.
• Support Groups: Local or online groups for individuals with depression or insomnia.

How would you address any issues about access to services, especially if you were working in a rural or remote region?

• Telehealth Services: Utilize telehealth for remote therapy and counseling sessions, making it easier for Sofia to access mental health professionals.
• Community Health Centers: Refer to local community health centers that may offer mental health services on a sliding scale based on income.
• Mobile Health Clinics: Suggest mobile health clinics that visit rural areas to provide essential health services.
• Online Resources: Recommend credible online resources and apps for mental health support (e.g., Headspace, Smiling Mind, MoodGym, Sleepio).

What might be the impact of Sofia’s condition on her family/children?

Impact on Sofia’s Family/Children

1. Emotional Impact:
   • Children: Sofia’s fatigue and irritability may lead to less patience and increased conflicts with her children, affecting their emotional well-being.
   • Partner: Her partner may feel stressed and overwhelmed by the additional responsibilities and emotional strain, potentially leading to relationship tensions.
2. Practical Impact:
   • Household Responsibilities: Sofia’s decreased energy and motivation may result in difficulties managing household tasks and childcare, increasing the burden on her partner and family.
3. Behavioral Impact:
   • Modeling Behavior: Children may observe and internalize Sofia’s coping mechanisms, both positive and negative, which can influence their own behavior and coping strategies.
   • Family Dynamics: Changes in Sofia’s mood and behavior can alter family dynamics, potentially leading to a need for family therapy to address these changes.
4. Support Needs:
   • Communication: Open and honest communication within the family about Sofia’s condition can help manage expectations and foster a supportive environment.
   • Involvement in Treatment: Involving family members in Sofia’s treatment plan can provide additional support and help them understand her condition better.
   • External Support: Accessing external support networks, such as extended family, friends, or community resources, can help alleviate some of the burdens on Sofia’s immediate family.

Professionalism

How would you approach the situation if you considered Sofia’s children to be at risk due to her mental state?

1. Immediate Assessment:

• Evaluate the Situation: Assess the extent of Sofia’s impairment and its potential impact on her ability to care for her children. Look for signs of neglect, emotional distress, or any form of harm.
• Ask Directly: Gently inquire about her capacity to care for her children and whether she feels overwhelmed or unable to meet their needs. For example, “Sofia, it’s important to understand how your symptoms might be affecting your ability to take care of your children. Do you feel like you’re able to meet their needs right now?”

2. Engage with Sofia:

• Express Concern Compassionately: Let Sofia know that your primary concern is the well-being of her and her children. For example, “I’m concerned about the well-being of your family, and I want to ensure that you all get the support you need.”
• Collaborate on a Plan: Work with Sofia to develop a plan that addresses her mental health while ensuring her children’s safety. This could include arranging for additional support from family or friends.

3. Involve Support Services:

• Refer to Social Services: If there is a significant concern for the children’s safety, make a referral to child protective services or social services. They can provide support and resources to ensure the children’s well-being.
• Access Community Resources: Connect Sofia with community resources such as parenting support groups, mental health services, and respite care.

4. Follow-Up:

• Regular Monitoring: Schedule regular follow-up appointments to monitor Sofia’s progress and the family’s situation. This ongoing support can help address any emerging issues promptly.

How could you get feedback on your consultation with Sofia or your management plan?

How would you identify and address any gaps in your knowledge and skills?

Self-Assessment:

General practice systems and regulatory requirement

What are the Medicare requirements for a GP mental health treatment plan?

1. Patient Eligibility:
   • The patient must have a diagnosable mental health disorder.
   • The disorder must be significantly impacting the patient’s day-to-day life.
2. Preparation of the Plan:
   • Assessment: Conduct a comprehensive assessment of the patient’s mental health, including history, symptoms, and impact on daily functioning.
   • Diagnosis: Formulate a diagnosis based on the assessment.
   • Goal Setting: Work with the patient to set achievable and measurable goals for treatment.
   • Treatment Options: Discuss and document the various treatment options available, which may include psychological therapy, medications, lifestyle changes, and referrals to other healthcare professionals.
   • Referrals: If needed, provide referrals to mental health professionals such as psychologists, psychiatrists, or counselors.
3. Documentation:
   • Written Plan: Prepare a written plan that includes the patient’s personal details, diagnosis, goals, proposed treatments, and any referrals.
   • Patient Agreement: Ensure that the patient understands and agrees with the plan.
4. Review:
   • Initial Review: Schedule an initial review to assess the patient’s progress. This should typically occur within four weeks of implementing the plan.
   • Ongoing Reviews: Schedule regular reviews (every three months is common) to monitor progress and make necessary adjustments to the treatment plan.
5. Medicare Item Numbers:
   • Preparation of the Plan: Use item number 2700 (short consultation) or 2701 (long consultation).
   • Review of the Plan: Use item number 2712.

What strategies do you have in your practice to check if patients come back for their planned review?

1. Appointment Scheduling and Reminders:
   • Automated Reminders: Implement an automated reminder system (via SMS, email, or phone calls) to notify patients of upcoming appointments.
   • Follow-Up Calls: Staff can make follow-up calls to patients a few days before their scheduled review to confirm the appointment.
2. Patient Engagement and Education:
   • Clear Communication: Explain the importance of follow-up appointments to patients, emphasizing how these reviews are crucial for monitoring progress and adjusting treatment as needed.
   • Written Information: Provide patients with written information about their treatment plan, including the dates and times of their next appointments.
3. Electronic Health Records (EHR) and Practice Management Systems:
   • Flagging System: Use your EHR or practice management system to flag patients who are due for a review. This can prompt staff to reach out and schedule the review.
   • Task Management: Assign tasks to staff members to follow up with patients who miss their appointments and reschedule them promptly.
4. Care Coordination:
   • Dedicated Care Coordinator: Employ a care coordinator or a nurse to manage follow-up appointments and track patients’ adherence to their treatment plans.
   • Multidisciplinary Approach: Involve other healthcare providers (such as psychologists or social workers) in the follow-up process, ensuring a comprehensive approach to the patient’s care.
5. Patient Portal:
   • Online Booking: Offer an online patient portal where patients can easily book, view, and manage their appointments.
   • Access to Health Information: Allow patients to view their health records and treatment plans, reinforcing the importance of follow-up visits.
6. Flexible Scheduling:
   • Extended Hours: Offer extended hours or weekend appointments to accommodate patients’ schedules, making it easier for them to attend follow-up visits.
   • Telehealth Options: Provide telehealth appointments for follow-up reviews, particularly useful for patients in rural or remote areas.

Managing uncertainty

How would you manage the situation if Sofia was adamant that there must be a physical cause for her symptoms and was unwilling to consider a mental health cause?

1. Active Listening and Empathy

• Show Understanding: Acknowledge Sofia’s concerns and validate her feelings. For example, “I understand that you are feeling very fatigued and it’s natural to want to find a physical cause for these symptoms.”
• Empathize: Demonstrate empathy by expressing that you take her symptoms seriously and are committed to helping her find relief.

2. Thorough Medical Evaluation

• Comprehensive Assessment: Perform a thorough medical evaluation to rule out any physical causes. This can include a detailed history, physical examination, and appropriate laboratory tests or imaging studies.
• Review Results Together: Go through the results of the tests with Sofia, explaining each finding and reassuring her if the results are normal.

3. Education and Reassurance

• Explain the Mind-Body Connection: Educate Sofia about the strong connection between physical and mental health. Use simple analogies, such as how stress can cause stomachaches or headaches, to illustrate the point.
• Provide Information: Share educational materials or reputable online resources about how mental health conditions like depression can manifest as physical symptoms such as fatigue.

4. Incremental Approach

• Suggest Gradual Steps: Propose starting with small, non-threatening steps towards addressing her mental health. For example, “Let’s try some strategies that can help improve your overall well-being, such as better sleep hygiene or stress management techniques. These can benefit both your physical and mental health.”
• Combine Approaches: Suggest a combined approach that includes addressing any potential physical causes while also exploring mental health strategies. This can make the idea of mental health treatment more acceptable.

5. Patient-Centered Care

• Respect Her Perspective: Show respect for Sofia’s viewpoint and involve her in decision-making. Ask for her input on what she thinks might help and discuss the pros and cons of different approaches.
• Collaborative Planning: Develop a care plan together, incorporating her preferences and gradually introducing mental health interventions.

6. Build Trust and Rapport

• Consistency and Follow-Up: Maintain regular follow-up appointments to monitor her condition and build a trusting relationship. Consistency in care can help Sofia feel more comfortable discussing mental health over time.
• Encourage Open Dialogue: Create a safe space for Sofia to express her concerns and fears without judgment. Encourage her to talk about her symptoms and how they affect her daily life.

7. Referral to Specialists

• Second Opinions: If Sofia remains unconvinced, suggest a referral to a specialist such as an endocrinologist or neurologist for further evaluation. This can help reassure her that all possible physical causes are being explored.
• Mental Health Specialist: Gradually introduce the idea of consulting a mental health specialist, framing it as a way to gain additional insights and support.

8. Use of Therapeutic Techniques

• Motivational Interviewing: Use motivational interviewing techniques to explore Sofia’s ambivalence about mental health treatment and help her find her own motivations for considering it.
• Behavioral Activation: Encourage activities that can improve mood and energy levels, such as physical exercise or engaging in hobbies, without explicitly labeling them as mental health interventions.

9. Monitor and Reassess

• Ongoing Evaluation: Continuously monitor Sofia’s symptoms and adjust the care plan as needed. Be prepared to revisit the discussion about mental health if her symptoms persist despite addressing potential physical causes.
• Flexibility: Be flexible and patient, allowing Sofia to come to terms with the idea of a mental health component at her own pace.

Identifying and managing the significantly ill patient

How would you assess Sofia’s risk of self-harm or suicide? How could you assess Sofia’s risk of experiencing domestic violence? What would you do if you found out that Sofia was at high risk of suicide or if her children were at risk?

Assessing Sofia’s Risk of Self-Harm or Suicide

• Prevalence of Suicidal Ideation: Approximately 3.9% of the general population experiences suicidal thoughts in a given year.
• Previous Attempts: Individuals with a history of suicide attempts are 20 times more likely to attempt again.
• Mental Health Disorders: About 60-70% of people who die by suicide have a mood disorder at the time of death.
• Protective Factors: Strong social support can reduce the risk of suicide by up to 50%.

Conduct a Comprehensive Risk Assessment

A. Ask Direct Questions About Suicidal Thoughts and Behaviors:

• Current Ideation:
  • “Have you had thoughts of hurting yourself or ending your life?”
  • “How often do you have these thoughts?”
• Plans and Means:
  • “Have you made any plans to take your own life?”
  • “Do you have access to the means to carry out this plan (e.g., medications, weapons)?”
• Previous Attempts:
  • “Have you ever attempted to harm yourself before?”
  • “Can you tell me more about what happened and how you were feeling at the time?”
• Specific Details:
  • “Do you have a specific method or date in mind?”

B. Assess the Severity and Intensity of Suicidal Thoughts:

• Frequency: “How often do you think about suicide?”
• Intensity: “How strong are these thoughts?”
• Duration: “How long do these thoughts last when they occur?”

C. Evaluate Psychological Symptoms and Risk Factors:

• Hopelessness: “Do you feel hopeless about the future?”
• Despair and Worthlessness: “Do you feel that life is not worth living?”
• Mood and Anxiety: Assess for severe depression, anxiety, and agitation.
• Substance Use: “Have you been using drugs or alcohol more than usual?”
• Psychotic Symptoms: Assess for hallucinations or delusions that may influence suicidal thoughts.

D. Assess Protective Factors:

• Support Network: “Do you have family or friends you can talk to when you’re feeling down?”
• Responsibilities: “Are there things in your life that keep you going, like your children or a job?”
• Beliefs: “Do you have any religious or personal beliefs that discourage suicide?”

Self-Harm or Suicide

Risk Factor	High Risk	Intermediate Risk	Low Risk
Suicidal Ideation	Persistent, frequent, and intense suicidal thoughts	Occasional suicidal thoughts	Fleeting or rare suicidal thoughts
Plans and Means	Specific plan with access to means (e.g., medications, weapons)	Vague or incomplete plan, no access to means	No plan or means
Previous Attempts	Recent attempt or multiple previous attempts	One previous attempt	No previous attempts
Psychiatric Symptoms	Severe symptoms (e.g., major depression, psychosis)	Moderate symptoms (e.g., moderate depression, anxiety)	Mild symptoms (e.g., mild depression or anxiety)
Substance Use	Current substance abuse, especially with increased use	Occasional or past substance abuse	No substance abuse
Psychotic Symptoms	Active psychosis (e.g., hallucinations, delusions)	History of psychotic symptoms but currently stable	No history of psychotic symptoms
Hopelessness	Severe and pervasive sense of hopelessness	Moderate feelings of hopelessness	No or minimal feelings of hopelessness
Social Support	Lack of social support, isolation	Limited or inconsistent social support	Strong social support network
Chronic Illness	Chronic pain or severe chronic illness	Manageable chronic illness	No chronic illness
Recent Life Events	Recent significant stressors or losses (e.g., death of a loved one, divorce)	Moderate life stressors (e.g., job change, relationship issues)	Minimal or no significant life stressors
Responsibilities	No perceived responsibilities or reasons for living	Some responsibilities but feels overwhelmed	Strong sense of responsibility (e.g., caring for children, job commitments)
Beliefs	No protective beliefs, may see suicide as a solution	Conflicted beliefs about suicide	Strong protective beliefs against suicide

Summary of Risk Levels

High Risk:

• Persistent and intense suicidal ideation.
• Specific plan with means to carry it out.
• Recent or multiple previous attempts.
• Severe psychiatric or psychotic symptoms.
• Current substance abuse.
• Severe hopelessness.
• Lack of social support.
• Significant recent life stressors.
• No responsibilities or perceived reasons for living.
• No protective beliefs.

Intermediate Risk:

• Occasional suicidal thoughts.
• Vague or incomplete plan, no access to means.
• One previous attempt.
• Moderate psychiatric symptoms.
• Occasional or past substance abuse.
• Moderate feelings of hopelessness.
• Limited social support.
• Manageable chronic illness.
• Moderate life stressors.
• Some responsibilities but feels overwhelmed.
• Conflicted beliefs about suicide.

Low Risk:

• Fleeting or rare suicidal thoughts.
• No plan or means.
• No previous attempts.
• Mild psychiatric symptoms.
• No substance abuse.
• No psychotic symptoms.
• Minimal feelings of hopelessness.
• Strong social support network.
• No chronic illness.
• Minimal or no significant life stressors.
• Strong sense of responsibility.
• Strong protective beliefs against suicide.

Action Plan Based on Risk Level

Risk Level	Action Plan
High Risk	– Immediate intervention and safety planning – Consider hospitalization. – Continuous monitoring – Urgent referral to mental health services.
Intermediate Risk	– Close follow-up and monitoring – Safety planning. – Referral to mental health services. – Regular reviews and support.
Low Risk	– Regular follow-up. – Address underlying issues (e.g., therapy, medication). – Educate about crisis resources. – Strengthen support network.

Direct Inquiry:

• Ask Directly: It is important to ask direct questions in a non-judgmental manner. Examples include:
  • “Have you been feeling so overwhelmed that you’ve thought about hurting yourself?”
  • “Have you had any thoughts about ending your life?”
  • “If you have had these thoughts, do you have a plan for how you might do it?”

2. Use of Screening Tools:

• Kessler Psychological Distress Scale (K10): This can help assess the level of psychological distress.
• Patient Health Questionnaire-9 (PHQ-9): Includes questions specifically about thoughts of self-harm or suicide.
• Columbia-Suicide Severity Rating Scale (C-SSRS): A detailed tool for assessing suicidal ideation and behavior.

3. Assessing Risk Factors:

• Mental Health History: Previous attempts, family history of suicide, and presence of psychiatric disorders.
• Current Stressors: Recent life events, such as relationship breakdowns, financial difficulties, or job stress.
• Substance Use: Alcohol and drug use can increase risk.
• Protective Factors: Assess support networks, coping strategies, and reasons for living.

Assessing Sofia’s Risk of Experiencing Domestic Violence

1. Direct and Sensitive Inquiry:

• Framing the Question: Preface questions with a statement about the prevalence of domestic violence to normalize the inquiry.
• Direct Questions: Ask specific, direct questions in a private and safe environment:
  • “Have you ever felt afraid of your partner or someone else in your home?”
  • “Has your partner ever physically hurt you or threatened you?”
  • “Are you currently in a relationship where you feel unsafe or threatened?”

2. Use of Screening Tools:

• HITS (Hurt, Insult, Threaten, Scream) Screening Tool: Simple and quick tool for detecting domestic violence.

3. Observational Clues:

• Physical Signs: Unexplained injuries or frequent visits for injuries.
• Behavioral Signs: Anxiety, depression, withdrawal, or reluctance to speak in front of a partner.

Actions if Sofia is at High Risk of Suicide

1. Immediate Safety Plan:

• Ensure Safety: Remove means of self-harm if possible, such as medications, sharp objects, or firearms.
• Crisis Support: Provide information on crisis support services such as Lifeline (13 11 14) or the Suicide Call Back Service (1300 659 467).

2. Emergency Response:

• Emergency Services: If there is an immediate risk, contact emergency services (000) for urgent intervention.
• Hospitalization: Consider voluntary or involuntary hospitalization to ensure Sofia’s safety.

3. Mental Health Referral:

• Urgent Referral: Refer to a psychiatrist or mental health crisis team for immediate assessment and intervention.
• Ongoing Support: Arrange follow-up appointments to monitor her progress and provide ongoing support.

Actions if Sofia’s Children are at Risk

1. Mandatory Reporting:

• Child Protection Services: In Australia, health professionals are mandated to report if they suspect a child is at risk of harm. Contact the relevant child protection agency in your state or territory (e.g., Child Safety Services in Queensland, Department of Communities and Justice in NSW).

2. Safety Planning:

• Immediate Safety: Ensure that the children are in a safe environment. This may involve contacting social services or arranging for temporary care by trusted family members or friends.
• Support for Sofia: Provide Sofia with resources and support to address her mental health needs and improve her capacity to care for her children.