Motivational interviewing techniques : facilitating behaviour change in the general practice setting

Background: One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks.

Objective: To explore current understanding regarding how and why people change, and the potential role of motivational interviewing in facilitating behaviour change in the general practice setting.

Discussion: Research into health related behaviour change highlights the importance of motivation, ambivalence and resistance. Motivational interviewing is a counselling method that involves enhancing a patient's motivation to change by means of four guiding principles, represented by the acronym RULE: Resist the righting reflex; Understand the patient's own motivations; Listen with empathy; and Empower the patient. Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management.

Managing panic disorder in general practice

BACKGROUND: Panic disorder (PD) is common in the community and contributes to significant distress and decreased quality of life for people who suffer from it. Most people with PD will present in the first instance to their general practitioner or hospital emergency department for assistance, often with a focus on somatic symptoms and concerns.

OBJECTIVE: This article aims to assist the GP to manage this group of patients by providing an outline of aetiology, approaches to assessment, and common management strategies.

DISCUSSION Although GPs have an important role to play in ruling out any causal organic basis for panic symptoms, the diagnosis of PD can usually be made as a positive diagnosis on the basis of careful history taking. Thorough and empathic education is a vital step in management. The prognosis for PD can be improved by lifestyle changes, specific psychological techniques, and the judicious use of pharmacotherapy.

Making decisions about fertility : three facts GPs need to communicate to women

Background Average annual fertility rates in industrialised countries have been below two children per woman for the past 3 decades. The reasons behind women’s childbearing behaviour are complex. However, a lack of awareness regarding the consequences of delayed childbearing and the inability of reproductive technologies to overcome the ‘biological clock’ may be contributory factors.

Objective A narrative review guided by the research question: What do women need to know about the consequences of delayed childbearing in order to make informed decisions about their fertility?

Discussion There are three facts that women need to know in order to make informed decisions around their fertility: Some women want to have more children than they are able to have because they postpone childbearing; there can be medical consequences to delaying childbearing and; some women’s ideas about their fertility don’t match the ‘the scientific facts’. General practitioners are well placed to play a strategic role in the provision of timely, relevant information to help women make informed decisions about their fertility. Further research is needed to identify the most appropriate ways for GPs to communicate this information.

Managing borderline personality disorder and substance use : an integrated approach

Background : Although substance use is a common feature of borderline personality disorder, regular use is associated with greater levels of psychosocial impairment, psychopathology, self harm and suicidal behaviour and leads to poorer treatment outcomes. Management of co-occurring substance use disorder and borderline personality disorder within primary care is further compounded by negative attitudes and practices in responding to people with these conditions, which can lead to a fractured patient-doctor relationship.

Objective : This article provides an overview of how the general practitioner can provide effective support for patients with co-occurring borderline personality disorder and substance use disorder, including approaches to assessment and treatment, the therapeutic relationship, referral pathways and managing risk and chronic suicidality.

Discussion : Despite the complexities associated with this population, GPs are ideally placed to engage patients with co-occurring borderline personality disorder and substance use disorder in a long term therapeutic relationship, while also ensuring timely referral to other key services and health professionals. To provide the most effective responses to this patient group, GPs need to understand borderline personality disorder and its relationship to substance use, develop an ‘explanatory framework’ for challenging behaviours, implement mechanisms for reflective practice to manage negative countertransference, as well as learn skills to respond adequately to behaviours which jeopardise treatment retention.

Anxiety disorders : assessment and management in general practice

Background: Anxiety is a normal physiological response to a threat. Anxiety disorders occur when this normal physiological response is associated with high levels of autonomic arousal, erroneous cognitions and dysfunctional coping strategies. Anxiety disorders are highly prevalent and present commonly to general practice. Anxiety disorders are often comorbid with other psychiatric and medical disorders and may be associated with significant morbidity.

Objective: This article describes the diagnosis, assessment and management of anxiety disorders in the general practice setting.

Discussion: Assessment in patients presenting with anxiety symptoms involves excluding a medical cause, identifying features of specific anxiety disorders as well as other coexisting psychiatric disorders, and assessing the degree of distress. Management options include psychoeducation, psychological treatments (particularly cognitive behaviour therapy) and pharmacological treatments. Patients with a diagnosis of an anxiety disorder can access Medicare funded psychological care under a number of Australian government initiatives. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are the first line pharmacological agents used to treat anxiety disorders. Regular review is vital to monitor for clinical improvement and more complex presentations may require specialist psychological or psychiatric referral.

e-Mental health for mood and anxiety disorders in general practice

Background Australia is a world leader in the development of internetdelivered programs for the prevention and management of mood and anxiety disorders. Despite a strong evidence base of time- and cost-effectiveness, as well as clinical efficacy, the uptake of these programs in general practice remains low. Objective To familiarise general practitioners (GPs) with the range of online programs in Australia that have demonstrated efficacy and are currently available for use by patients with mental health problems. Discussion E-mental health programs provide an efficacious and accessible form of mental healthcare and have the potential to fill the gap for those for whom such care is inaccessible, unaffordable or unacceptable. Clinicians can also use it in a stepped-care manner to augment existing healthcare services. There are a number of online resources currently available to Australians who have mood or anxiety disorders. These resources have strong evidence to support their effectiveness. Online portals facilitate access to these programs. Recently the Australian Federal Government has funded an education program (eMHPrac) for GPs and mental health professionals, to outline what is available, indicate situations where recommending such resources is appropriate, and suggest ways in which they can be incorporated into general practice.

Self-reported access to and quality of healthcare for diabetes : Do the severely obese experience equal access?

Background: Given reported pejorative views that health professionals have about patients who are severely obese, we examined the self-reported views of the quality and availability of diabetes care from the perspective of adults with type 2 diabetes (T2DM), stratified by body mass index (BMI). Methods: 1795 respondents to the Diabetes MILES - Australia national survey had T2DM. Of these, 530 (30%) were severely obese (BMI ≥35 kg/m2) and these participants were matched with 530 controls (BMI <35 kg/m2). Data regarding participants' self-reported interactions with health practitioners and services were compared. Results: Over 70% of participants reported that their general practitioner was the professional they relied on most for diabetes care. There were no betweengroup differences in patient-reported availability of health services, quality of interaction with health practitioners, resources and support for selfmanagement, or access to almost all diabetes services. Discussion: Participants who were severely obese did not generally report greater difficulty in accessing diabetes care.

Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery.

BACKGROUND: Clinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients' ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses' facilitation of patient participation in pulmonary interventions has not been explored. OBJECTIVE: To explore patients' ability and willingness to participate in pulmonary interventions and nurses' facilitation of pulmonary interventions. DESIGN: Single institution, case study design. Multiple methods of data collection were used including preadmission (n=130) and pre-discharge (n=98) patient interviews, naturalistic observations (n=48) and nursing focus group interviews (n=2). SETTING: A cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. PARTICIPANTS: One hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward. OUTCOME MEASURES: Patients' understanding of their role in pulmonary interventions and patients' preference for and reported involvement in pulmonary management. Nurses' facilitation of patients to participate in pulmonary interventions. RESULTS: Patients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management. CONCLUSIONS: Patients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients' participation in their recovery is a fundamental aspect of care delivery in this context.