Pic 0: Titlescreen opens with the words “Behavioral Health Risk”. The screen transitions to a doctor’s office with Danielle Eber and a man named Dr. Rodgers. They are both seated with a table in between them. Their chairs are turned to face the learner.
RODGERS: We know that identifying and managing patients who have behavioral health conditions is important because the physical and mental wellbeing of our patients are often very closely connected.
We also know this can be challenging, especially when we’re pressed for time… and, after all, we’re not behavioral health experts.
DANIELLE: Right. Patients with behavioral health conditions often seek help from other health care providers instead of going straightaway to a behavioral health professional.
This is why health care providers are in an ideal position to recognize distress signals and manage treatment.
Pic 1: Next to Danielle, the following list appears:
Behavioral Health Conditions
DANIELLE: Today we’ll talk about four common behavioral health conditions: depression, substance use disorders, Generalized Anxiety Disorder (or GAD), and Post Traumatic Stress Disorder (or PTSD). Left untreated, all four can have lasting impacts on patients’ physical health and quality of life. They can also lead to suicidal thoughts and attempts.
The first step in connecting patients to treatment is to notice distress signals and be aware of risk factors.
Pic 2: The list updates with an icon of a hazard sign on the top:
Risk Factors:
DANIELLE: Risk factors for behavioral health conditions include exposure to trauma, a severe or chronic medical condition, exposure to life stressors, such as job or financial loss, prior history or family history of behavioral health disorders, and death or illness of a loved one.
Some of these may be indicated in a patient’s history or physical exam, but others you may only discover by talking with the patient.
Pic 3: Screen zooms out so that Danielle and Dr. Rodgers can both be seen.
RODGERS: And… you mentioned some distress signals I should be aware of?
DANIELLE: Yes. Patients with behavioral health conditions may exhibit physical and behavioral distress signals. In fact, these patients’ physical complaints are often caused by, or exacerbated by, their behavioral health conditions.
Let’s take a look at a few patients who were referred to me by healthcare providers and note the distress signals they presented that prompted their referrals.
Alex developed depression after losing his job. He went to his doctor for a loss of appetite and considerable weight gain. Alex showed up for his appointment looking exhausted and reported feeling lethargic, despite sleeping 10 to 12 hours per night. When questioned about his physical activities, Alex revealed that he recently quit his soccer league.He said he feels sad and stressed most of the time and doesn’t think he’ll ever feel better. His answers to the depression screening indicated high risk.
Here are some other signs of depression you might notice in your patients.
Pic 4: A health profile of Alex is shown with a photo clipping of a young man. A hazard sign icon is shown on top.
Depression Warning Signs
DANIELLE: Margot presented with high risk use of alcohol, as indicated on her substance use screening form. She initially went to her primary care physician for an ankle injury sustained after tripping on her staircase while intoxicated. When asked about her drinking patterns, she explained that she’d been caring for her sick mother and had gotten in the habit of drinking several glasses of wine each night and a few wine spritzers in the morning to relax and take her mind off of things. She said she sometimes has trouble making it to work after drinking the night before.
Here are some other signs you might notice in patients with risky substance use.
Pic 5: A health profile of Margot is shown with a photo clipping of a young woman. A hazard sign icon is shown on top.
Risky Substance Use Warning Signs
DANIELLE: Phil has Generalized Anxiety Disorder. He presented to his primary care doctor with difficulty falling asleep; he’d lay awake thinking about his day and worrying about the upcoming day. When questioned, he said he was constantly concerned that he’d be fired or evicted, though he said he was in good standing with his boss and his landlord or that someone in his family would die of a terminal illness, though they were all currently in good health. During the exam, he was restless and fidgety, biting his nails and picking at his cuticles.
Here are some other signs of Generalized Anxiety Disorder.
Pic 6: A health profile of Phil is shown with a photo clipping of a middle aged man. A hazard sign icon is shown on top.
GAD Warning Signs
DANIELLE: Nina developed PTSD after she was mugged walking home from work one night. She went to her primary care doctor complaining of insomnia.
During the exam, she seemed on edge. When asked about her daily life, Nina reported that she had stopped going out with her friends, due to her fear of walking anywhere alone, which causes flashbacks of the mugging. She says she drinks more now to deal with heightened stress. At her appointment, she was irritable and easily agitated and even had an angry outburst at the nurse who took her vitals.
Pic 7: A health profile of Nina is shown with a photo clipping of a young woman. A hazard sign icon is shown on top.
PTSD
Pic 8: Screen returns to the doctor’s office with Danielle and Dr. Rodgers.
DANIELLE: There’s a patient in your waiting room right now who you can meet with to practice what we’ve been discussing.
Pic 9: Next to Dr. Rodgers, a thumbnail of Nicky can be seen with the caption “Nicky: Second appointment”.
RODGERS: Great. This is Nicky’s second visit with us. We identified hypertension and a risk for heart disease. Nicky received a prescription for Amlodipine to help with the hypertension, and Wellbutrin to help quit smoking. Nicky is also taking gender affirming hormonal medication.
I just reviewed Nicky’s chart, but I didn’t see all the information I need. Not every electronic medical record has fields to easily enter relevant information for a transgender patient. I’ll try to clarify some information with Nicky at the start of the visit, and update the chart in a notes section or wherever I can.
DANIELLE: You’ll help Clark speak with Nicky about hypertension and heart disease risk. As you do, you may notice some of the distress signals we talked about. Your goal is to ensure Nicky feels comfortable enough with you to share experiences and challenges. Using the techniques you learned earlier, gather more information and determine the best course of action to address barriers to improving Nicky’s health.
Pre Conversation Screens:
MI Techniques to Use:
Gender Affirming Care
Use gender neutral language: request and document pronouns.
Use transitional phrasing: explain the reason before asking challenging or unexpected questions.
Apologize if appropriate: mistakes can happen whether you meant offense or not, and a simple apology can make a big difference. Try not to get defensive or overapologize.
Patient History & Physical Chart