March 2025 Clinical challenge

How to use AJGP for your CPD

Each issue of the Australian Journal of General Practice (AJGP) focuses on a specific clinical or health topic. Many GPs find the entire issue of interest and relevance to their practice and others explore the issue more selectively.

However you prefer to engage with the issue, you can use AJGP for your CPD. If you want to use the entire issue for CPD, carefully and critically work your way through each focus article, considering how you might adjust your practice in response to what you have learnt, then complete the Clinical challenge.

Your CPD will be automatically recorded for you

When you complete the AJGP Clinical challenge and/or Measuring Outcomes (MO) companion activity through gplearning, your CPD hours will be automatically recorded on myCPD Home within 12 hours.

Self-recorded reading

If you prefer to read and reflect on specific articles without completing the Clinical challenge, record this via quick log on myCPD Home. As guidance, each article in AJGP can be recorded for up to two CPD hours, split evenly between EA and RP CPD time.

Self-directed MO options

You can also do self-directed MO CPD related to this issue of AJGP. Choose any topic area from within the issue and undertake a quality improvement activity. This can be done on your own, with a colleague, in a group, or perhaps with the assistance of our practice manager or PHN quality improvement team.

Consider evaluating your practice setting’s current capability to effectively and responsibly prescribe medicinal cannabis. Assess how you respond to patient requests, prescribe safely when clinically appropriate and address barriers to care, as outlined in the article by Martin et al. A simple evaluation might be recorded for several MO hours, while a more comprehensive PDSA approach would provide at least 10 hours of MO CPD. Log in to myCPD Home (https://bit.ly/myCPDhome) for guides and templates to complete your self‑directed quality improvement activities and record your MO hours.

The RACGP’s evidence-based and impartial education on medicinal cannabis is available now at https://bit.ly/myCPDSolutions.

MO companion activity

The MO companion activity assists you to implement and evaluate changes in your practice in line with the guidance provided in a specific article in this issue of AJGP.

Visit https://bit.ly/MarchCCMO and select the ‘Register’ button to find both the Clinical challenge and Measuring Outcomes companion activity.

These questions are based on the Focus articles in this issue. Please choose the single best answer for each question.

Case 1

Sadiya, a woman aged 42 years, is receiving treatment with sertraline for her first episode of moderately severe depression, which has been managed in primary care. There has been an excellent clinical response to sertraline, with no side effects. Sadiya presents after six months of therapy to discuss discontinuation as she has read online that six months of treatment is adequate.

Question 1

The recommended duration of antidepressant therapy for a first episode of moderate-severity depression is:

1. 3–6 months
2. 6–9 months
3. 9–12 months
4. 12–24 months

Question 2

Consultations with patients about antidepressant discontinuation should include a discussion about the risks of depression relapse. In the ANTidepressants to prevent reLapse in dEpRession randomised controlled trial (ANTLER-RCT), the relapse rate after discontinuation of antidepressants was:

1. 25%
2. 39%
3. 56%
4. 65%

Question 3

During antidepressant discontinuation, withdrawal phenomena might develop. Distinguishing between these phenomena and relapse symptoms can be challenging. Which of the following is not a typical withdrawal phenomenon?

1. Dizziness and associated nausea after antidepressant discontinuation
2. Rapid onset of symptoms after antidepressant discontinuation
3. Rapid resolution of symptoms when the antidepressant is restarted
4. Severe vertigo and vomiting that does not resolve when the antidepressant is restarted

Case 2

Yasser, a male aged 26 years, has been diagnosed with borderline personality disorder (BPD) by your local outpatient psychiatry service. He has recently experienced mental health crises, characterised by intense distress, anger, emotional dysregulation and impulsive behaviours. Yasser presents to request a prescription for medication to use during a mental health crisis.

Question 4

Caution should be exercised when prescribing psychotropic medications for people living with BPD. The following statements explain the rationale for this caution – with the exception of which statement?

1. One-quarter of people living with BPD are reported to have attempted suicide with prescribed psychotropic medications
2. One-third of people living with BPD are also living with obesity, which can be further complicated by the metabolic side effects of psychotropic medications
3. The lifespan of people living with BPD is reduced by 20 years, partly due to the metabolic side effects of some psychotropic medications
4. There is a significantly increased risk of diversion of psychotropic medications when prescribed to people with BPD

Question 5

Yasser presents to your clinic for wound care the day after intentionally cutting his left forearm several times with a razor blade. In the context of BPD, which statement about non-suicidal self-injury (NSSI) is incorrect?

1. Episodes of NSSI typically reflect intense emotional pain
2. NSSI can provide a soothing effect by stimulating endorphin release
3. NSSI is observed in 70% of people living with BPD
4. The frequency of NSSI can be significantly reduced by psychotherapeutic therapy

Question 6

You undertake a suicide risk assessment for Yasser. Which of the following is not known to be associated with an increased risk of suicide for people living with BPD?

1. History of sexual abuse
2. Increasing patterns of substance use
3. Previous high-lethality suicide attempts
4. Stable pattern of chronic suicidality

Case 3

Alison, a woman aged 67 years, living with chronic non-cancer pain, presents for her regular monthly prescription of tapentadol. You discuss with Alison the risks of long-term opiate therapy, including the dose-related risks of unintentional overdose.

Question 7

What is the threshold dose, in morphine equivalents per day, for an unintentional opiate overdose?

1. 10 mg
2. 20 mg
3. 30 mg
4. 100 mg

Question 8

A check of the real-time prescription monitoring system reveals that Alison has visited three different pharmacies in the last 90 days and obtained a tapentadol script from a general practitioner (GP) in a different suburb. The provision of high-risk, psychoactive substances by multiple providers increases the risk of uncoordinated care. What outcome is not known to be associated with multiple opiate providers?

1. Diversion of opiates
2. Misuse of opiates
3. Opiate overdose
4. Rationalisation of opiate therapy

Question 9

Alison asks about the process for obtaining a prescription for medicinal cannabis as she is considering this as an alternative to tapentadol. In Australia, medical cannabis can be prescribed by:

1. Any GP without additional legal and administrative requirements
2. A GP who is a Therapeutic Goods Administration (TGA) authorised prescriber of medical cannabis
3. A GP who has applied to the Special Access Scheme B (SAS-B) to prescribe medical cannabis for a patient under their care
4. Options B and C

Case 4

Con is a man aged 75 years whom you are treating for a left-sided facial nerve palsy, which you have diagnosed as Bell’s palsy. Six days ago, you commenced a daily dose of 50 mg of prednisolone. His wife rings you today to report that Con has become very irritable and anxious and believes there are people watching him in his bedroom.

Question 10

Approximately what proportion of people being treated with oral glucocorticoids develop serious psychiatric side effects?

1. 0.5%
2. 1%
3. 6%
4. 12%

These questions are based on the Focus articles in this issue. Please write a concise and focused response to each question.

Case 1

Sadiya, a woman aged 42 years, is receiving treatment with sertraline for her first episode of moderately severe depression, which has been managed in primary care. There has been an excellent clinical response to sertraline, with no side effects. Sadiya presents after six months of therapy to discuss discontinuation as she has read online that six months of treatment is adequate.

Question 1

List three common side effects of antidepressants which might affect a patient’s quality of life.

Question 2

Discuss three areas within Sadiya’s agenda (ie her request for antidepressant discontinuation) that are important to explore with her.

Question 3

List three predictors of depression relapse that should ideally be explored with Sadiya.

Case 2

Yasser, a male aged 26 years, has been diagnosed with borderline personality disorder (BPD) by your local outpatient psychiatry service. He has recently experienced mental health crises, characterised by intense distress, anger, emotional dysregulation and impulsive behaviours. Yasser presents to request a prescription for medication to use during a mental health crisis.

Question 4

List three clinical features of BPD.

Question 5

Discuss four important principles in the provision of primary care to people living with BPD.

Question 6

Discuss four important principles when providing care to people living with BPD who have undertaken non-suicidal self-injury (NSSI).

Question 7

Spend a few minutes thinking about a patient who has BPD, and who has exhibited one of the clinical features of BPD. Reflect on how that made you feel. How can the principles in the provision of primary care to people living with BPD that you identified earlier be used to reframe those feelings that you experienced?

Case 3

Alison, a woman aged 67 years, living with chronic non-cancer pain, presents for her regular monthly prescription of tapentadol. You discuss with Alison the risks of long-term opiate therapy, including the dose-related risks of unintentional overdose.

Question 8

Based on the introduction of SafeScript, discuss:

1. two potential benefits for patients of introducing a real-time prescribing system for schedule 8 (S8) medications
2. one potential unintended consequence of introducing a real-time prescribing system for S8 medications that might be harmful to patients.

Question 9

Using the concept framework of access to healthcare, discuss three ‘dimensions of accessibility’ that might be barriers for patients trying to access medicinal cannabis in Australia.

Case 4

Con is a man aged 75 years whom you are treating for a left-sided facial nerve palsy, which you have diagnosed as Bell’s palsy. Six days ago, you commenced a daily dose of 50 mg of prednisolone. His wife rings you today to report that Con has become very irritable and anxious and believes there are people watching him in his bedroom.

Question 10

Based on the available evidence, discuss two important therapeutic interventions for people who develop psychosis as a result of oral glucocorticoids.

January–February 2025 Multiple-choice question answers

Answer 1: C

During the 2019–20 Black Summer bushfires, air contamination was the major health challenge identified to require management. This, along with other environmental contamination due to exposure to bushfire smoke or prolonged indoor isolation, led to eye and throat irritation, respiratory issues, exacerbation of asthma and reduced physical and mental health.

Answer 2: A

In Australia, the two natural disasters that have the greatest mortality rate are heatwaves and floods. Heatwaves have the greatest mortality rate of disasters in Australia and globally. Floods are the second most deadly disaster in Australia. A review of 35 global epidemiological studies identified increases in mortality rates of up to 50% in the first year post-flood.

Answer 3: A

The definition of climate distress is the psychological state of an individual overwhelmed by climate change. This can present with a wide range of mental health symptoms, including anxiety, depression, trauma-related symptoms or disordered eating and might be triggered by traumatic events or grief.

Answer 4: C

In patients with severe mental illness, significant risk factors for heat-related morbidity include poor physical health, poverty and prescribed medications. People with a severe mental illness (SMI) are placed at added risk of heat-related morbidity because of the medication (such as anti-psychotics) they are prescribed. Their behaviours, such as substance use, agitation or even wearing multiple layers of clothing, can also increase that risk. The danger of these factors is magnified by the poor physical health of many people with a SMI. Their poverty and social marginalisation make it harder for them to adapt their surroundings to climate change by insulating their homes or using air conditioning.

Answer 5: B

In addition to increased rates of diabetes, hypertension, asthma and cerebrovascular events, the other medical condition that observes an increased rate of presentation in disaster-affected communities is cardiovascular disease including myocardial infarction, heart failure, pulmonary embolism and cerebrovascular accidents, which all increase following a disaster.

Answer 6: C

In the event of a natural disaster, an emergency coordinator is responsible for the activation of an emergency plan. In planning for natural disaster response, appoint an emergency management coordinator whose responsibilities include developing the practice emergency response plan, communicating it with practice team members and activating the plan in the setting of a natural disaster.

Answer 7: A

The Royal Australian College of General Practitioners’ Standards include standards that relate to practice preparedness for disasters. This includes maintaining a communication policy to  ‘manage and triage incoming communication during a crisis, emergency or disaster’ and deliver to patients ‘open, timely and appropriate communication about their health care during a crisis, emergency or disaster’, and maintaining a business continuity and information recovery plan, including operating a server back-up log that stores back-up files offsite in a secure location. For general practices, ensuring they have an up-to-date emergency or disaster plan is essential to mitigate disaster impacts, maintain business continuity and the provision of critical health services during disasters, and to ensure business sustainability in the long term.

Answer 8: D

Four overlapping phases of disaster management exist – prevention (or mitigation), preparedness, response, recovery (and rehabilitation). All disaster responders need to be involved in preparedness, which includes planning, before they can be effectively involved in a response. General practitioners are one of the few disaster healthcare professionals who have a role to play in each phase.

Answer 9: D

Major Incident Medical Management and Support (MIMMS) training is required for those attending a mass casualty incident. An outer cordon is established to control the flow of trained authorised required personnel to the site. General practitioners wishing to assist have sometimes not been admitted onto the site due to lack of formal training or integration into the planning.

Answer 10: A

The Sendai Framework 2015–30 identifies chronic disease healthcare, the principal work of general practitioners, as a major disaster healthcare demand. ‘People with life-threatening and chronic disease, due to their particular needs, should be included in the design of policies and plans to manage their risks before, during and after disasters, including having access to life-saving services’.

January–February 2025 Short answer question answers

Answer 1

Discussing the patient concerns with empathy and without judgement. Ascertain their understanding of climate change and their exposure to climate-related events, whether it be personal experiences, within their family and community, or via the media. Assess for mental health comorbidities and associated interventions. Assess the severity of symptoms, impact on patient quality of life and any coping strategies. Assessment of suicide risk when feelings of despair and hopelessness are expressed. Using a HEEADSSS screen can be a valuable tool for understanding the patient’s social and environmental context.

Answer 2

The main ways that general practitioners can provide support to pregnant women and families with young children during and after a disaster are:

• helping with emergency preparedness, such as encouraging parents to create emergency plans and prepare evacuation kits
• advocating for the inclusion of the needs of pregnant women and families with infants and young children in local emergency plans
• ensuring their practices have emergency plans and offering their offices as evacuation venues
• providing pregnancy support, proactive assistance with infant feeding and medical care in evacuation centres
• assisting parents in understanding and addressing behavioural concerns in their children
• conducting thorough enquiries into environmental exposures, medication adherence, disruptions to daily routines and changes in diet and physical activity.

Answer 3

Three specific health issues that were related to, or exacerbated by, the Black Summer bushfires are:

• environmental contamination, including exposure to bushfire smoke and ash-contaminated water
• infrastructure and healthcare disruption, including limited access to food, power and telecommunications disruption, and difficulty accessing essential medications and healthcare services
• aggravated health conditions, such as asthma, gastroenteritis, pregnancy complications, breastfeeding difficulties, formula feeding issues and increased behavioural issues in children.

Answer 4

Four factors that can contribute to climate distress in young people are:

• exposure to traumatic events related to climate change
• feeling overwhelmed by the existential threat of climate change
• grief over personal losses due to climate disasters
• guilt over contribution to climate change through personal habits and consumption.

Answer 5

The role a general practitioner plays in dealing with the health impacts on chronic conditions observed following a natural disaster is to:

• provide crucial ongoing preventative care and management of chronic conditions
• actively monitor and review patients with chronic conditions and update management plans as necessary
• plan for and implement mechanisms to maintain access to medical review, essential medications and medical supplies
• identify those affected by disruptions to specialised healthcare needs and provide support in finding alternative options.

Answer 6

Four population groups who might be identified as being at higher risk during natural disasters are:

• individuals with chronic diseases caused by increased morbidity and who need ongoing healthcare services
• older individuals who have an increased risk of morbidity, mortality and deterioration of existing health conditions
• evacuees, who might lack access to their usual healthcare services and medications
• pregnant women who are at risk of gestational diabetes.

Answer 7

Four medication-related challenges faced by individuals with chronic diseases during natural disasters are:

• altered medication type and/or dosage requirement due to deterioration in condition or development of new conditions
• poor medication adherence, particularly among males, older people and evacuees
• poor access to specialised medication, particularly opiates and highly specialised drugs
• compromised medication integrity due to flooding or extremes of temperature.

Answer 8

These are the items you would consider including in a practice emergency kit to be used in response to a natural disaster:

• disinfectant and hand sanitiser
• bottles of clean water
• mobile phone and charger
• office stationery, prescription pads, manual Medicare slips
• detergent
• non-perishable food
• fire extinguisher
• emergency contact list
• first aid kits
• battery powered radio and batteries
• doctor’s bag
• gloves, boots
• garbage bags
• torch and batteries
• medications.

Answer 9

Three key disaster health management concepts that general practitioners need to understand to be effectively integrated into a disaster health management response are:

• understanding the definition of a disaster
• knowing the four overlapping phases of disaster management
• awareness of how general practitioners link to a broader disaster health response.

Answer 10

Four ways that Primary Health Networks can support general practitioners in disaster health management are:

• development of general practitioner resources and disaster health pathways
• ‘In practice’ support for general practices in disaster planning
• providing training and education opportunities for general practitioners in disaster management
• coordination of general practitioner disaster management advisory and interest groups.