Trainer Notes& Activities

Comorbidity O

I Trainer Notes T

Y & Activities

Overview

KEY POINTS 1. Clients experiencing concurrent mental health and AOD-related problems are extremely vulnerable, so care must be taken to minimise patient stress during treatment.

2. Outcome expectations must be realistic – long-term management and frequent relapse should be anticipated and incorporated in client management plans.

3. GPs have a key role as the mainstay of treatment for patients with concurrent issues, many of whom have had poor experiences with health services.

4. Caution must be taken in prescribing to avoid undesirable interactions between prescribed medications and the patient’s usual pattern of psychoactive drug use.

SUGGESTED OBJECTIVES To enable GPs to:  identify contributing factors and common associations (including risk of suicide)

 structure screening and assessment in relation to comorbidity

 articulate the approaches required to engage vulnerable patients

 formulate appropriate management strategies

 commit to involvement in shared care arrangements.

Please check that these objectives are relevant for the particular group you are about to train. If not, write down alternatives.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Topic Contents

SLIDES The slides with slide notes cover:  prevalence

 contributing factors

 common associations

 screening

 special needs of comorbid patients in treatment

 pivotal role of the GP.

The slides are on the Resource Kit CDROM under this topic. Trainers are encouraged to select and/or adapt this slide set to meet the focus of the training and information needs of their participants.

ACTIVITIES The activities provide opportunities for GPs to:  articulate and discuss key issues

 explore problem identification cues, assessment cues/tools, treatment plans and monitoring

 commit to a pivotal role in the management of comorbid cases.

Resource Kit for GP Trainers on Illicit Drug Issues Part B3 Clinical Complexity: Comorbidity 3

HANDOUTS R

1. Mental Health Problems and Associated Psychoactive Drug Use I

Pagliaro, A. & Pagliaro, L. 2000, ‘Mental Disorders, in Addition to Addiction and I

Habituation, that are Commonly Associated with Abusable Psychotropic Use’, Y Substance Use Among Women, table 10.1, Brunner/Mazel, Philadelphia, p.183. 2. What is Comorbidity and Why Does It Matter? Teesson, M. & Burns, L. (eds.) 2001, National Comorbidity Project, National Drug Strategy and National Mental Health Strategy, National Drug and Alcohol Research Centre (NDARC), University of NSW, Commonwealth of Australia, Sydney, Executive Summary, http://www.health.gov.au/pubhlth/publicat/document/comorbidity.pdf. 3. Management of Concurrent Mental Health and Drug and Alcohol Problems Evans, M. & Willey, K. 1999, Management of Concurrent Mental Health and Drug and Alcohol Problems, GP Drug and Alcohol Supplement No. 11, Central Coast Area Health Service, NSW. 4. Models of Mental Health Shared Care Holmwood, C., 2001, Models of Mental Health Shared Care and their Effectiveness, Primary Mental Health Care Australian Resource Centre (PARC) Available from http://som.flinders.edu.au/FUSA/PARC/

Please refer to the Resource Kit CDROM for a copy of handouts (in PDF and Word).

Slides, Activities & Handouts from other topics may be useful. Please refer to Part A3 for: Examples of Potential Links to Other Slides, and for a Listing of Activities and Handouts.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Sources of Additional Information

PATIENT RESOURCES Lifeline, ‘Toolkit for Beating the Blues’ www.lifeline.org.au [accessed 5 February 2004]. The Mental Health and Wellbeing Fact Sheets http://www.mentalhealth.gov.au/index.htm [accessed 5 February 2004] includes:  Bipolar Mood Disorder  What is Depression?  What are Anxiety Disorders?  What is an Eating Disorder? NHMRC 1997, Getting Up From Feeling Down, Australian Government Publishing Service, Canberra, http://www.nhmrc.gov.au/publications/pdf/cp40.pdf [accessed 5 February 2004]. SANE Factsheets, www.sane.org [accessed 5 February 2004]  Cannabis and Psychotic Illness  SANE Factsheet: Psychosis

Please refer to the Resource Kit CDROM for a copy of the above resources or go to the website addresses.

Patient resources are a valuable tool in the clinical setting. They can be obtained through ADIS or the publisher – free or at nominal cost.

KEY READINGS R

Holmwood, C. 2002, Comorbidity of Mental Disorders and Substance Use: A Brief I

Guide for the Primary Care Clinician, Primary Mental Health Care, Australian I

Resource Centre (PARC), Department of General Practice, Flinders University, Y Adelaide, http://som.flinders.edu.au/FUSA/PARC/comorbidityresource2.pdf McCabe, D. & Holmwood, C. 2002, Comorbidity in General Practice: The Provision Of Care for People with Coexisting Mental Health Problems and Substance Use by General Practitioners, Primary Mental Health Care, Australian Resource Centre (PARC), Department of General Practice, Flinders University, Adelaide, http://som.flinders.edu.au/FUSA/PARC/comorbidityreportrevised2002.pdf NCETA (National Centre for Education and Training on Addiction) 2003, ‘Coexisting Mental Illness’, Alcohol and Other Drugs, A Handbook for Health Professionals, 3rd edn, ch. 18, Commonwealth Department of Health & Ageing, Canberra. NHMRC (National Health and Medical Research Council) 1997, Depression in Young People: A Guide for General Practitioners, Australian Government Publishing Service, Canberra, http://www.nhmrc.gov.au/publications/pdf/cp38.pdf Teesson, M. & Proudfoot, H. (eds.) 2003, Comorbid Mental Disorders and Substance Use Disorders: Epidemiology, Prevention and Treatment. National Drug and Alcohol Research Centre, University of New South Wales. http://www.health.gov.au/pubhlth/publicat/document/metadata/mono_comorbid.htm Todd, F. 2002 ‘Coexisting Alcohol and Drug Use and Mental Health Disorders’ in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, Oxford University Press, South Melbourne, pp.141–157.

ADDITIONAL RESOURCES Kranzler, H.R. & Rounsaville, B.J. 1998, Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders, Marcel Dekker, New York. McCabe, D. & Holmwood, C. 2002, Comorbidity in General Practice: The Provision of Care for People with Coexisting Mental Health Problems and Substance Use by General Practitioners, Primary Mental Health Care, Australian Resource Centre, Department of General Practice, Flinders University, Adelaide, http://som.flinders.edu.au/FUSA/PARC/comorbidityreportrevised2002.pdf Saunders, J.B. & Barnes, P. 2002, Training Package for Medical Practitioners in the Effective Identification and Treatment of Pharmaceutical and Illicit Drug Problems, module 16, ADTRU, (Alcohol and Drug Training and Research Unit), Queensland Divisions of General Practice and Department of Psychiatry, University of Queensland, Brisbane. Teesson, M. & Burns, L. (eds.) 2001, National Comorbidity Project, National Drug Strategy and National Mental Health Strategy, National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, Commonwealth of Australia, http://www.health.gov.au/pubhlth/publicat/document/comorbidity.pdf [Accessed 25 July 2003]. Todd, F. 2002, ‘Coexisting Alcohol and Drug Use and Mental Health Disorders’ in Hulse, G., White, J. & Cape, G. (eds.), Management of Alcohol and Drug Problems, Oxford University Press, South Melbourne, pp. 141–157.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity KEY LINKS Mental Health and Wellbeing http://www.mentalhealth.gov.au/index.htm This provides a wealth of information, and access to:  mental health, crisis and support services  publications and brochures for primary care practitioners, consumers and their families  information about suicide prevention and special access programs

The Auseinet Project (Australian Network for Promotion, Prevention and Early Intervention for Mental Health) http://www.auseinet.com/about/index.php This project is funded by the Australian Government Department of Health and Ageing under the Mental Health Strategy and the National Suicide Prevention Strategy. Initially targeting early intervention for the mental health of children and young people, the project is being expanded to include promotion, prevention and early intervention, as well as suicide prevention, across the entire lifespan. The website provides access and links to:  information about suicide prevention  resources for carers and consumers  a resource database  links to AUSEINET newsletters, publications, conferences, ejournals  links to mental health services Australia-wide.

Beyond Blue http://www.beyondblue.org.au/site/index.asp This aims to increase community awareness about depression and provide relevant and evidence-based information, resources, referrals and advice. The website includes:  common symptoms of depression  information about the causes and treatments of depression  examples of genuine treatment experiences  feedback to professionals about what consumers find most useful  links to other information services and support groups  communications of hope and stories of recovery.

The Primary Mental Health Care Australian Resource Centre (PARC) M http://som.flinders.edu.au/FUSA/PARC/ O

This is a Clearinghouse and Electronic Library for Australian Primary Mental Health I

Care and an Information Service in Primary Mental Health Care for General I

Practitioners and the Divisions of General Practice – part of the Primary Mental Y Health Care Initiative of the National Mental Health Strategy. The PARC team is based in the Department of General Practice at Flinders University (Adelaide, South Australia). The website provides access to:  GP relevant clinical resources for mental health  links to services and published resources  an online reference search tool.

Lifeline http://www.lifeline.org.au/ Lifeline provides 24-hour telephone counselling services via phoning 13 11 14 for the cost of a local call. Lifeline Centres also offer face-to-face counselling services (this varies according to the needs of each regional or local area). Access this site for:  patient resources, or Toolkits, to assist patients to manage their problems (e.g., depression, panic attacks)  list of Australia-wide services and telephone numbers  a guide to relevant books and other publications for health professionals about mental health issues.

Mental Illness Fellowship of Australia (formerly Schizophrenia Fellowship's Council of Australia) http://www.sfca.powerup.com.au/ This Fellowship was established to carry out the successful work of the State and Territory bodies to the national level and to ensure that mental illness, and in particular schizophrenia, receives adequate and appropriate attention in both policy and legislation. It has the largest membership base of any single national mental health organisation in Australia. The site provides access to:  services for people experiencing mental illness, particularly schizophrenia, Australia wide  resources for health professionals  resources for patients and carers.

ADDITIONAL WEBLINKS The Mental Health Institute of Victoria http://www.mhri.edu.au/institute-2003.html This is an independent not-for-profit research organisation based in Melbourne, established to further knowledge in mental health, behaviour and neuroscience. Researchers investigate the nature, origins and causes of psychiatric diseases, and apply the knowledge gained to improve diagnosis and treatment, and ultimately prevent, mental illnesses (e.g., Alzheimer's disease, schizophrenia and depressive

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity illness). This site provides access to a range of information and resources such as fact sheets, publications and newsletters (e.g., on depression and psychosis). The Mental Health Council of Australia http://www.mhca.com.au/pages/aboutus_aboutmhca.html This independent non-Government peak body was established under the National Mental Health Strategy (http://www.health.gov.au/hsdd/mentalhe/) to represent and promote the interests of the mental health sector, and to advise on mental health in Australia.

OTHER RESOURCES FOR PATIENTS, FAMILY AND FRIENDS DepressioNet http://www.depressionet.com.au/links/famandfriends.html DepressioNet provides a comprehensive online resource for Australians living with depression, and for carers and friends of people with mental health issues. The site contains access to information, help and support. The DepressioNet team are Australians from a variety of backgrounds who have personal experiences with depression. The site provides access to resources, conferences, literature, national surveys, and a medical advisory team.

Sane Australia www.sane.org SANE Australia is a national charity helping people affected by mental illness through campaigns, education and research. Medical information published by SANE Australia has been reviewed and approved by appropriately qualified medical practitioners from the SANE Medical Advisory Panel, unless otherwise stated. The SANE website provides general information only – it does not provide specific advice, which should be sought from an appropriately qualified professional person. The site provides access to a range of information including:  free patient resources (e.g., psychosis, cannabis)  booklets and publications available through the bookshop  an online ‘helpline’ for typing in questions about mental health  youth specific information.

True Blue Friends http://www.truebluefriends.au.com/ This site is dedicated to dealing with the effects of living with depression and depression-related mental illnesses.

Reachout http://www.reachout.com.au ReachOut, an information and referral service, is an initiative of the Inspire Foundation. They do not operate as a counselling service. The website provides information and youth-specific printable resources for patients, friends and carers.

Association for the Relatives and Friends of the Mentally Ill (ARAFMI) M This is a mutual support group where relatives and friends of people with mental or O

R emotional health problems can exchange information and experiences. Each State B

I has a separate website. D

ARAFMI QLD http://www.lrvnet.org.au/arafmi/ Y ARAFMI SA http://www.span.com.au/mhrc/arafmi.html ARAFMI TAS http://www.tased.edu.au/tasonline/mhcrc/ ARAFEMI VIC http://www.arafemi.org.au/ ARAFMI WA http://www.arafmi.asn.au/

Carers Associations http://www.carers.asn.au/ This Association aims to increase community awareness of the role of, and need for, carers, and brings their needs to the attention of government and policy makers, among other things. Each state has a separate website, and each contains information, resources and access to services for carers and their families about specific problems.

Children of Parents with a Mental Illness National Initiative http://www.aicafmha.net.au/copmi/index.htm In 1999, the Australian Infant, Child, Adolescent and Family Mental Health Association Ltd (AICAFMHA) undertook a national scoping project to identify the services available and future plans for services, for children of parents with a mental illness. This site is a gateway to the project, its activities and products.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Page 24 Resource Kit for GP Trainers on Illicit Drug Issues Part B3 Clinical Complexity: Comorbidity 3

Comorbidity B

Activities Y

Activity 1: Identify Comorbid Issues

PURPOSE To identify specific comorbid issues and challenges that regularly present in participants’ practices.

PROCESS 1.1 Divide participants into small groups

1.2 Instruct participants to: o discuss issues encountered when dealing with comorbid patients o list specific challenges encountered o suggest management strategies that have not been tried for particular instances

1.3 Groups present their response to the whole group for open discussion

1.4 Facilitate discussion (i.e., setting limits and realistic goals for patients and GPs, monitoring of progress etc).

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Activity 2: Scenarios – Paul, Christina, Andrew & GPs’ own

The scenarios and question prompts are from a GP Comorbidity Survey. This investigated what GPs with an interest in comorbidity thought ‘ought to be the approach’ for the ‘average GP’. There are no right answers to the questions posed. PURPOSE To explore responses to a series of case scenarios in terms of  initial presentation  problem identification cues  assessment process  treatment plans and outcomes.

In addition, the case scenarios highlight the scope for opportunistic intervention.

PROCESS 2.1 Divide participants into pairs or small groups

2.2 Give each pair/group the case scenarios or one case per group (see below)

2.3 Ask each group to discuss and note down responses to the questions posed

2.4 Each group presents their responses to the whole group for discussion

2.5 Invite participants to outline a patient that they have encountered in their clinical practice with both substance use and mental health features, and to provide information about: o how this person initially presented o detection: cues that alerted you to the possibility of substance use and a mental health problem in this patient o assessment: how did you proceed to assess this patient? What key questions did you ask? How did your recognition of comorbidity influence your assessment? o treatment: What were your treatment ideas/plans and how did you implement these? What referrals did you consider/make? What interventions did you consider/make? What factors did you consider in deciding care with this patient? o outcome: What follow-up did you have with this patient? What features were you able to use to assess change? Were there improvements in this patient? What do you think allowed/prevented improvement in this patient? What are your thoughts/feelings regarding your role in this patient’s care? Note: The above question prompts are provided on forthcoming pages

2.6 Facilitate discussion with the group on issues that arise from participants’ experiences, and be supportive in what GPs can realistically achieve in this complex area.

SCENARIO: PAUL R

Paul is a 26 year-old man you have seen a few times over the past five I

years with intercurrent illnesses and a few sports related injuries. You see Y him one morning for removal of sutures from a large scalp laceration that he sustained after a fall outside a pub the week before. He’s had a tetanus shot and feels fine. The wound is well healed.

What kind of information might you try to glean from Paul while extracting his sutures from the mat of crust and hair that overlies the healed laceration? 1. ______2. ______3. ______

It turns out that he fell after having an indeterminate number of drinks the previous Saturday night. When you ask, he reports that he has a pattern of drinking mostly when he is socialising. Weekends and social functions are the most common situations. He has about 10 or more standard drinks on these occasions (usually a couple of glasses of mixers, then full strength beer). Two years ago he had a drink-driving conviction (BA 0.10 %) and had his licence suspended for 12 months. He also sustained a facial laceration after a pub brawl about 12 months ago where he came off second best.

Are there other questions you might try to get answers to here? 1. ______2. ______3. ______

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Besides having identified a potentially harmful pattern of drinking, might there be some type of underlying problem with Paul that needs to be identified? What things/problems/diagnoses come to mind? 1. ______2. ______3. ______

It turns out that Paul drinks when out to ‘calm his nerves’. Since his mid- teens he has been using alcohol to relieve the symptoms he has when he socialises. He also uses cannabis for the same reason but alcohol is more convenient and accessible. He admits to a couple of cones most weekends.

What would your approach be to Paul?

Step 1. ______Step 2. ______Step 3. ______

You briefly talk with Paul about his alcohol use and the emerging picture M of social phobia. He’s amenable to seeing you again to talk. You get Paul O

back for a longer appointment and take a more detailed history of his B

I social phobia. His main focus of anxiety is people thinking he’s a ‘nerd’ D

I because he can’t easily make conversation. Both alcohol and dope help T him a lot with this, and in fact he has a broad set of friends. He hasn’t Y developed any other coping strategies and has no real avoidance behaviour. He has a supportive girlfriend. When asked he admits she’s been ‘on his back’ to cut down on the alcohol.

What specific interventions might you use with Paul? 1. ______2. ______3. ______

You give him a more detailed AUDIT questionnaire to complete on his alcohol consumption patterns. You give him some information on his social phobia as well as an explanation of how the alcohol consumption and the social phobia might be inter-related.

You briefly discuss some of the treatment options for the phobia. Don’t forget that you have Paul’s girlfriend as a potential ally. When asked, he certainly has been thinking about his alcohol consumption and the problems it has been causing him. He is amenable to trying to do something about the social phobia although he is a bit sceptical and thinks that it’s just in his nature to be shy and lack self-confidence.

Where to from here? What do you think might be reasonable options for Paul at this stage? 1. ______2. ______3. ______Is there any particular sequence to the way that you would do things or recommend that they be done? If so, please number the above in the order that you think they ought to be approached.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity What factors might determine the priorities or sequence of management steps for Paul? ______What would make you decide to refer Paul? 1. ______2. ______3. ______Who would you refer Paul to? 1. ______2. ______3. ______What are the barriers that you expect to experience with such referrals? 1. ______2. ______3. ______

SCENARIO: CHRISTINA R

Christina has moved into your area recently and has come in for the I

second time in three or four weeks for a script for oxazepam. Christina is Y a 48 year-old ethnic Croatian refugee who has been in Australia with her husband and three children for the past 13 years. She has good English skills. This is only the second time she has come to the surgery. The first time you recommended that she book a longer appointment so that you could get a better past history and get your head around the oxazepam use. This time she books for half an hour. You are running on time for once.

What issues might you like to explore with Christina? 1. ______2. ______3. ______What specific questions would you ask Christina? 1. ______2. ______3. ______

It turns out that Christina has been depressed for the past 6 months. She has some anxiety symptoms. When her thoughts dwell on various negative experiences in her past she becomes acutely lacking in confidence, and from time to time she gets panicky. This occurs in all types of situations but more commonly when she is going out. Over the past six months she has been becoming less sociable and more withdrawn, she has lost her enthusiasm for life, and has lost 4 kg in weight. Her appetite is down. She has pervasive thoughts of lack of self worth and life’s futility. She has had suicidal thoughts but doesn’t dwell on these, and because of the effect suicide would have on her children and husband she discounts this as an option. She felt like this back in Croatia when she was in her twenties. She was treated with medication there.

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Christina was prescribed some oxazepam to help her sleep a few months ago by her previous GP. She has used the oxazepam more frequently as it has helped with the panicky feelings that have developed, but the relief is short-lived. She sometimes feels a bit anxious when she is low on the oxazepam and she feels she relies on it somewhat.

Christina is married. Her husband, who was previously a public servant, is a floor polishing contractor. She works part-time for the Telephone Interpreter Service, as she is quite bilingual. There are no acute financial problems. They have three children, aged 10, 13 and 15 years.

What might your approach to treating Christina be at this stage? ______What [if anything] would you do about the oxazepam? ______Is there any particular sequence to your management or would you do several things in parallel? Please describe. ______What might help you determine the sequence or priorities in management? ______What would prompt you to refer Christina? ______

Who would you refer her to? M

______R

______D

______Y ______What are the barriers that present themselves in these referrals? ______What role do you think is reasonable for a GP in the future care of Christina? ______

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity SCENARIO: ANDREW Andrew is a 28 year-old man who has had schizophrenia for the past seven years. He has some persistent paranoid delusions that he keeps to himself. He doesn’t seem to have a lot of positive symptoms, but he certainly is withdrawn and only socialises with one or two friends who live in the same block of units in which he lives, as well as his immediate family. Andrew smokes two packets of cigarettes per week. He also uses cannabis three or four times per week. He has a couple of plants that do nicely on the sill of the north-facing window of his unit. He receives his depo-neuroleptics from your practice. He was previously on a Community Treatment Order until 12 months ago, but this has been revoked. He now turns up for his medication every two weeks. He has been stable the last three years, but his quality of life is not that great. He receives a Disability Pension.

Do you think that his cannabis use is a problem? Please elaborate. ______What extra information might you want to determine whether this is a problem? ______If you think that it is a problem, what would your approach to this cannabis use be? ______If you don’t think that it is a problem, what type of situation would make you concerned and perhaps want to intervene specifically? ______

What strategies might you use to help him reduce his cannabis usage (and perhaps M to cut down on his tobacco use)? O

______I

______T

Y ______What services might you refer him to if he were willing? ______Are you aware of problems with accessing these services? ______

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity ACTUAL EXAMPLE FROM YOUR PRACTICE Recall a case that you have encountered in your clinical practice in the past three months that is similar to the three scenarios that have been outlined in the previous sections. Focus on a case where the patient presented with both substance use and mental health features.

Please provide details/notes regarding this person as he/she initially presented. ______Regarding detection, what cues alerted you to the possibility of both a substance abuse and a mental health problem in this patient? (This might include contextual knowledge and actual features of the presentation) ______Regarding assessment, how did you proceed to assess this patient? What key questions did you ask? How did your recognition of comorbidity influence your assessment? ______

Regarding treatment, what were your treatment ideas/plans and how did you M proceed in implementing these? O

What referrals did you consider/make? What interventions did you consider/make? B

I What factors did you consider in deciding care with this patient? D

I ______T

Y ______Regarding outcome, describe the follow-up that you had with this patient. What features were you able to use to assess change? Were there improvements in this patient? What do you think allowed/prevented improvement in this patient? What are your thoughts/feelings regarding your role in this patient’s care? ______

Source: adapted from McCabe, D. & Holmwood, C. 2002, Comorbidity in General Practice: The Provision of Care for People with Coexisting Mental Health Problems and Substance Use by General Practitioners, Primary Mental Health Care, Australian Resource Centre, Department of General Practice, Flinders University, Adelaide, pp. 87–98, http://www.health.gov.au/pubhlth/publicat/document/comorbid_gp.pdf Other cases are available at: http://som.flinders.edu.au/FUSA/PARC/comorcases.htm

Resource Kit for GP Trainers on Illicit Drug Issues Page 5 Part B3 Clinical Complexity: Comorbidity Activity 3: Construct a Links Diagram

PURPOSE To construct a diagram of links between General Practice and local services for comorbid patients.

PROCESS 3.1 Divide participants into groups based on comparable practices (e.g., single practices, medical centres, rural practices, etc.)

3.2 Instruct participants to: o construct a model of services required by comorbid patients and ideal linkages and relationships required for optimal service provision o focus on ways to highlight and enhance the GP’s role o draw the model on an overhead transparency or butcher’s paper o select a spokesperson to present the model to the rest of the group

3.3 Each group presents their model for comment and critique.

Activity 4: Debate Rationale for GP Role

PURPOSE To debate the GP’s role in management of comorbid presentations.

PROCESS 4.1 Write the debate motion in a visible place – ‘GPs should not be expected to play a pivotal role in the management of patients with comorbid mental health problems and AOD use’

4.2 Divide the group into two and assign one group to support, and the other to oppose, the debate motion

4.3 Explain the debate process: o each speaker has two minutes o no team is declared the winner in a formal sense

4.4 Give the groups five minutes to prepare their arguments and select their debating team

4.5 Facilitate debate

4.6 Facilitate post-debate discussion of issues that were raised. If strong feelings were raised, conduct a debrief.

Resource Kit for GP Trainers on Illicit Drug Issues Part B3 Clinical Complexity: Comorbidity