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Mental Health

Marian R. Stuart, PhD (FMCR Consultant), with input from William B. Shore, MD, David Schneider, MD (Family Medicine Clerkship/PostClerkship Workgroup), Christine Matson, MD (PreClerkship Collaborative Workgroup), and Ardis Davis, MSW (FMCR Project Manager). Also, with input from STFM Group on Behavioral Sciences.

Overview

The provision of mental health care is an essential element of the health care continuum. Studies indicate that 11 to 36 percent of patients visiting a primary care provider have a psychiatric disorder.   These disorders are frequently unrecognized and, even when diagnosed, are often not treated adequately or appropriately. How mental health is interactive with medical problems is a topic at the core of family medicine and primary care.   The Institute of Medicine (IOM) report on Academic Health Centers: Leading Change in the 21st Century points out the need to include attention to the social, behavioral, and other factors that contribute to healing when training health professionals in the biological basis of disease and treatment of symptoms.

It is critical that students recognize how anxiety, depression, and other mental health problems can affect a person's ability to function. Students should also understand the interrelationships among mental and physical health and the circumstances of patients' lives, that is, the interactions between biological, psychological, social, and cultural factors that determine health or illness. Approaching patient treatment from a biopsychosocial rather than just a pharmacological perspective and relating to patients in a culturally competent manner leads to effective management. Recognition and treatment of mental health disorders, to include referral to appropriate providers when indicated, are significant responsibilities of primary care providers.

TOPIC LEARNING GOALS AND OBJECTIVES
(Organized by ACGME Competencies)

The starred (*) objectives are ones that are most appropriately addressed in the later stages of medical education (i.e., more suitable for more experienced students and clinical rotations).

Patient Care

GOAL:   Improve students' ability to provide patient care that incorporates attention to physical, psychological, social, and cultural factors.

OBJECTIVES:   Students will be able to:

  • Obtain a patient history with attention to presenting complaint, history of present illness, as well as the circumstances of patients' lives and their emotional reactions.
  • Elicit and recognize signs and symptoms of common mental health disorders listed under medical knowledge.
  • Discuss the mechanism by which emotional or sexual problems may masquerade as other medical problems.
  • Describe how the symptoms of chronic and severe mental illness may impair independent functioning.
  • Discuss how the symptoms of even mild mental disorders can damage the quality of life and adherence to treatment plans.
  • Perform a mental status exam.
  • * Explain how the effects of stress, coping skills, and social support affect chronic conditions as well as the body's ability to resist disease.
  • * Demonstrate basic stress management techniques.

Medical Knowledge

GOAL: Students will develop a basic understanding of the major causes of mental illness, its symptomatology, morbidity, potential mortality, and presentation and treatment in the primary care setting.

OBJECTIVES: Students will be able to:

  • Discuss normal and abnormal psychosocial growth and development across the life cycle.
  • Recognize a continuum of mental health from high functioning resilience to impairment.
  • Explain the interactions among biological, psychological, socio-cultural, and spiritual factors in determining physical and mental health or illness.
  • * Describe interactions among neuronal, hormonal, and immunological factors and a patient's cognitions in determining reactions to acute and chronic stress.
  • Describe the etiology, development, and symptomatology of common mental health conditions to include Anxiety, Depression, Somatoform, Eating, Attention Deficit, and Hyperactivity Disorders, and Schizophrenia and other psychotic states, including dual diagnoses, seen in the primary care setting.
  • Cite risk factors for suicide by teens and adults.

Practice-Based Learning and Improvement

GOAL: Students will actively seek out, appraise, and assimilate scientific evidence related to mental health and emotional well-being, and incorporate the information into their clinical practice.

OBJECTIVES: Students will be able to:

  • Assess and remediate their own learning needs in the area of mental health.
  • Cite evidence in support of recognizing mental health issues as underlying causes of many somatic complaints (e.g. chronic pain, fatigue, or sleep disorders.)
  • Cite evidence describing the roles and mechanisms related to the impact of emotions, expectations, fears, and stress on physical and mental health.
  • Describe significant differences between acute and chronic mental health conditions and their management in primary care practice.
  • Cite scientific evidence for the efficacy of treating depression with a combination of cognitive behavioral and pharmacological therapies.
  • Defend the importance of prescribing behavioral techniques (to include physical exercise) in the treatment of anxiety and other stress-related conditions.

Interpersonal and Communications Skills

GOAL:   Students will demonstrate interpersonal and communications skills that put others at ease, facilitate the accurate exchange of information, and provide social support.

OBJECTIVES: Students will be able to:

  • Demonstrate caring and respect when interacting with patients and their families even when confronted with atypical or emotionally charged behaviors.
  • Describe strategies for calming and supporting emotionally upset individuals.
  • Elicit and attend to patients' specific concerns.
  • Demonstrate validation of the patient's feelings by naming emotions and expressing empathy.
  • Display a non-judgmental manner in order to allow patients to raise mental health concerns.
  • * Use basic cognitive-behavioral interventions to help moderate patients' reactions to the circumstances of their lives.
  • Adapt communication strategies to special needs of mental health and developmentally disabled patients.
  • * Explain the need for referral to a mental health specialist to a patient and provide realistic expectations about what services would be provided.
  • * Communicate patient information in an organized, prioritized fashion that demonstrates understanding of the biopsychosocial nature of the clinical problem, the preliminary assessment, and possible treatment.

Professionalism

GOAL:   Students will demonstrate a commitment to their professional responsibilities, adherence to ethical principles, and sensitivity to contextual issues when relating to a diverse population including patients with mental disorders.

OBJECTIVES:   Students will be able to:

  • Recognize and admit areas of discomfort when dealing with patients displaying emotional or mental problems.
  • Explain the concept of respect for personal autonomy as a foundational principle for ethical conduct and how it influences the doctor-patient relationship when patients are mentally or emotionally impaired.
  • Demonstrate patience, respect, and empathy when caring for patients presenting somatic complaints that have no evident organic basis.
  • Describe the ethical and legal foundations for the right of patients to refuse medical treatment even when it might result in self-harm.
  • Discuss the legal and ethical requirements when dealing with patients who are at risk of serious harm to self or others.
  • Demonstrate acceptance of diverse belief systems that may be at odds with prevailing cultural mores.

Systems-Based Practice

GOAL: Students' understanding of the interrelationship between primary care providers and other health care professionals in the area of mental health will increase.

OBJECTIVES: Students will be able to:

  • Describe the role of primary care providers in the diagnosis and treatment of mental illness.
  • Describe the criteria and procedures for referring a patient to a mental health specialist.
  • Explain what is meant by "carve outs" for mental health services.
  • Discuss the role of mental health professionals in both providing and collaborating on patient care.
  • Defend the necessity for primary care physicians to provide care for patients suffering from psychiatric illness even when some of the services may not be reimbursed.
  • Promote the use of support groups and other community resources in the area of mental health.

Educational Methods and Resources

Teaching Strategies

  • Use of standardized patients
  • Case-based lectures
  • Videotaping and review of interview
  • Role play and group discussion regarding difficult patients
  • Assigned reading (e.g., The Fifteen Minute Hour)
  • Reflection (i.e., writing assignments or group process)

Clinical Experience

  • Office practice
  • Opportunity to interact with mental health consultants

Educational Resources

Additional FMCR clerkship resources that are available include:

Depression
http://fammed.musc.edu/fmc/data/Depression.htm

Domestic Violence
http://fammed.musc.edu/fmc/data/Domestic_Violence.htm

Recommended Text
Stuart MR and Liberman JA III. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care, 3rd ed., Philadelphia: Saunders: 2002.

This book, now in its third edition, focuses on interpersonal and behavior change techniques that primary care physicians can use to care more effectively for patients. Evidence for the mind-body connection with current references helps primary care physicians routinely incorporate therapeutic interventions into every day practice.   This how-to book not only helps students to recognize the importance of psychosocial factors but also shows them practical behavioral treatments. For completeness there is a chapter on pharmacotherapy.   The book is easy to read with clinically relevant case examples.

Other Published Material

  • American Academy of Family Physicians Position Paper: Mental Health Care Services by Family Physicians.
    http://www.aafp.org/x6928.xml
  • American Academy of Family Physicians Recommended Curriculum Guidelines for Family Practice Residents: Human Behavior and Mental Health.
    http://www.aafp.org/x16550.xml
  • Bloom MV and Smith DA. Brief Mental Health Interventions for the Family Physician.   New York: Springer-Verlag, 2001.
    This text provides guidance for diagnosis and treatment of common emotional and behavioral problems in primary care. A variety of psychosocial disorders with focus on management in the primary care setting are described.   Basic components of brief therapy are summarized and the benefits and risks of drug therapies are described.
  • Feldman MD and Christensen JF .   Behavioral Medicine in Primary Care: A Practical Guide.   New York:   McGraw, 2003.
    This text gives an organizational way to approach development of objectives for mental health. It lists mental health and behavioral disorders as including depression, anxiety, somatization, personality disorders, dementia, sleep disorders, and sexual problems. Special topics include stress and disease, pain, HIV/AIDS, mistakes in medical practice, domestic violence, chronic illness, and death and dying.
  • Stuart MR and Lieberman JA III, eds. Primary Care Clinics in Office Practice, Mental Health. Vol. 26:2, June 1999.
    Authoritative multi-authored resource focusing on the more common psychiatric conditions seen in practice: anxiety disorders, depression, somatization, personality disorders, alcohol abuse, and dementia.   Other chapters address psychosis, factitious disorders, and childhood attention deficit disorders.   There is additional material on stress management, behavioral management, and collaborative care.

Web Sites

ASSESSMENT STRATEGIES

  • Direct observation/clinical assessment
  • OSCE
  • Reflection papers
  • Pre/post rotation examination

 
 

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This page last updated October 15, 2005