Topic: Stepped Care for Behavioral Health

Shubha is a 26-year-old woman who has been referred to you by the local mother and baby clinic. You are a PCP for Shubha's husband and members of his extended family are registered at your practice, but this is the first time that you have met her. Shubha emigrated from Bangladesh to Macon three years ago with her husband and his family, and gave birth to a baby girl one month ago. She has had an arranged marriage and the family have struggled with financial pressures since the move. Her husband is very close to his mother, who advises him on all issues related to the baby.

Shubha can speak limited English. She is unhappy about the appointment with the PCP as she feels this will bring shame to the family. She sees you - a white male PCP - with her husband, who acts as an interpreter. Her husband says that Shubha seems unhappy and does not want to doanything. She is reluctant to get out of bed or to look after the baby, and complains of pain in her stomach constantly. He discloses that his mother thinks she is lazy because she is unwilling to do household chores.

Medical History: Her husband says Shubha did not disclose any past medical history to him, so her past psychiatric history is unknown.

On examination: An initial physical examination does not reveal anything abnormal. A blood sample for full blood count and testing for vitamin D deficiency are taken.

1) After receiving the referral from the baby clinic, how may you need to tailor your approach within this consultation?

2) Should the content of your assessment also be changed?

3) You suspect Shubha may have postnatal depression. How do you confirm this?

4) What factors should you consider in Shubha's risk assessment and monitoring?

5) From a stepped care approach, what are the next steps you should take when working with Shubha and her family (Discuss at least 4 levels/steps of interventions)?