September Blog 2025 - Mental Health: Making the Most of Every Consultation

Mental health and chronic conditions often go hand in hand, but it’s easy to overlook mental health when the focus is so often on a patient’s diabetes, asthma, or cardiovascular conditions. The good news? Primary care teams are well placed to identify mental health needs and integrate support into chronic condition management activities.

Make every consultation count

GP Chronic Condition Management Plan (GPCCMP) consultations and reviews are ideal opportunities to ask about mental wellbeing. Brief screening questions or validated tools like the K10 can be easily included in consultations.

Mental health doesn’t need to start as a separate conversation. If the person discloses distress, fatigue, sleep problems, or low mood, it’s appropriate to explore further and offer support even if their visit wasn’t ‘about’ mental health.

Include mental health in GP Chronic Condition Management Plans

GP Chronic Condition Management Plans can include mental health goals and referrals – especially if psychological distress is affecting someone’s ability to manage their physical condition. Some patients won’t qualify for a separate mental health treatment plan, but you can still consider including:

• Health and lifestyle goals like “improve sleep routine” or “reduce worry around health”
• Referrals to MBS-supported services and other funded programs and services
• Follow-up services provided by the practice nurse, Aboriginal Health Worker (AHW) or, Aboriginal and Torres Strait Islander Health Practitioner (AHP)

Documenting this in the plan helps with continuity and review.

When a Mental Health Treatment Plan is needed

If the person meets criteria for a mental health diagnosis (e.g. anxiety or depression), the GP can initiate a Mental Health Treatment Plan (2715/2717). These can be done alongside chronic condition management and care, and Aboriginal Health Workers and nurses can play a key role in gathering information, building trust, and supporting follow-up.

World Mental Health Month – October

October is World Mental Health Month – the perfect time to strengthen how your team supports mental health in chronic condition management.

Looking for a simple, practical quality improvement activity? Try our CDM Plus Mental Health Box, designed to help your team review mental health screening processes, refresh your approach to treatment planning, and improve follow-up care for patients living with chronic conditions and mental health concerns.

Includes posters, conversation starters, quick-reference guides, and PDSA-ready tools to use in team meetings or patient care.
Aligns with MBS items and supports team-based, culturally safe care.

Let’s make mental health part of every care plan – starting this October.