facilitator manual english-haiti introduction to mental

ENGLISH-HAITI

Introduction to Mental Health

and DepressionCurriculum for Psychologists

and Social Workers

FACILITATOR MANUAL

II Partners In Health | FACILITATOR MANUAL

Introduction to Mental Health and Depression Curriculum for Psychologists and Social Workers

Partners In Health (PIH) is an independent, non-profit organization founded over twenty years ago in Haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment and to address the root causes of their illnesses. Today, PIH works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease—through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

PIH’s work begins with caring for and treating patients, but it extends far beyond; to the transformation of communities, health systems, and global health policy. PIH has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in Haiti. Through collaboration with leading medical and academic institutions like Harvard Medical School and the Brigham & Women’s Hospital, PIH works to disseminate this model to others. Through advocacy efforts aimed at global health funders and policymakers, PIH seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

PIH works in Haiti, Russia, Peru, Rwanda, Sierra Leone, Liberia, Lesotho, Malawi, Kazakhstan, Mexico and the United States. For more information about PIH, please visit www.pih.org.

Many PIH and Zanmi Lasante staff members and external partners contributed to the development of this training. We would like to thank Tatiana Therosme; Père Eddy Eustache, MA; Reginald Fils-Aime, MD; Jennifer Sévère, MD; Giuseppe Raviola, MD, MPH; Jenny Lee Utech; Helen Verdeli, PhD; Gary Belkin, MD, PhD, MPH; Dave Grelotti, MD; Shin Daimyo, MPH; Seiya Fukuda; Andrew Rasmussen, PhD; Helen Knight; Kate Boyd, MPH; Leigh Forbush, MPH; Ketnie Aristide; Wilder Dubuisson. We would also like to thank Virginia Allread who compiled and edited the final version of the Facilitator Manual and PowerPoint slide sets.

This training includes content adapted from: IPT-EST for Depression in Haiti: for Patients Who Have Screened Positive for Depression, Myrna Weissman and Lena Verdeli (copyrighted unpublished manual), 2012; World Health Organization, http://www.who.int/features/qa/62/en/index.html; Promoting Mental Health: Concepts, Emerging Evidence, Practice, World Health Organization, Dept. of Mental Health and Substance Abuse, Victorian Health Promotion Foundation, and University of Melbourne (Geneva: World Health Organization), 2004; The Manas Model for Health Counsellors: A Program to Improve the Care for Patients with Common Mental Disorders in Primary Health Care, 1st edition, Sangath Society for Child Development and Family Guidance (Goa, India: Sangath), 2011; The World Health Report 2001: Mental Health: New Understanding, New Hope, World Health Organization (Geneva: World Health Organization), 2001; Where There Is No Psychiatrist, Vikram Patel (London: The Royal College of Psychiatrists [Gaskell]), 2003; Manual for Health Counselors, Sangath (Goa, India: Sangath); Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions, Giuseppe Raviola, Eddy Eustache, Catherine Oswald, and Gary S. Belkin (Harvard Review of Psychiatry 2012;20:68–77); National Institute of Mental Health, http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorderptsd/; An Introduction to Mental Health: Facilitator’s Manual for Training Community Health Workers in India, BasicNeeds (Warwickshire, UK: BasicNeeds), 2009; National Institutes of Health (NIH): www.nlm.nih.gov/medlineplus.

We would like to thank Grand Challenges Canada for its financial and technical support of this curriculum and of our broad mental health systems-building in Haiti.

© Text: Partners In Health, 2015 Photographs: Partners In Health Design: Mara Seibert and Partners In Health, 2015


Partners In Health | FACILITATOR MANUAL III

This manual is dedicated to the thousands of health workers whose tireless efforts

make our mission a reality and who are the backbone of our programs to save lives

and improve livelihoods in poor communities. Every day, they work in health centers,

hospitals and visit community members to offer services, education, and support, and

they teach all of us that pragmatic solidarity is the most potent remedy for pandemic

disease, poverty, and despair.

IV Partners In Health | FACILITATOR MANUAL



Partners In Health | FACILITATOR MANUAL V

Table of Contents

Introduction to Mental Health and DepressionIntroduction ...........................................................................1

Objectives .............................................................................2

Time Required .......................................................................4

Materials Needed ..................................................................5

Session 1: Introductions Pre-Test and Confidentiality ............6

Session 2: Epidemiology of Depression and Stigma .............14

Session 3: Diagnosis of Depression ......................................21

Day 1: Review .....................................................................28

Session 4: Medical Evaluation and Management of Depression ......................................................................30

Session 5: Initial Mental Health Evaluation ..........................34

Session 6: The ZLDSI ...........................................................42

Session 7: Managing the Suicidal Patient .............................46

Session 8: Basics of Interpersonal Psychotherapy (IPT) ........51

Session 9: Interpersonal Psychotherapy (IPT): Practice .........59

Day 2 and 3: Review ...........................................................66

Session 10: Medication Management and Other Treatments for Depression ..................................................... 68

Session 11: Follow Up and Documentation .........................75

Session 12: Depression and mhGAP ....................................79

Session 13: Review, Post-Test and Feedback .......................86

VI Partners In Health | FACILITATOR MANUAL


Annex Pre-test and Post-test ........................................................95

Pre-test and Post-test Answer Key ....................................100

Depression Bingo Review Game ........................................105

Depression Checklist .........................................................118

Psychologist/Social Worker Patient Encounter Form ..........121

Initial Mental Health Evaluation Form ................................122

Suicidality Screening Instrument ........................................130

Suicidality Treatment Guidelines ........................................131

Safety Plan ........................................................................133

Medication Card for Depression ........................................134

Mental Health Follow Up Form ..........................................135

Training Evaluation Form ...................................................138


Partners In Health | FACILITATOR MANUAL 1

Introduction to Mental Health and Depression

INTRODUCTION

According to the World Health Organization, untreated mental disorders account for 13% of

the total global burden of disease. Unipolar depressive disorder is the third leading cause

of disease burden, however current predictions suggest that by 2030, depression will be the

leading cause of disease burden globally. The gap between the need for treatment for mental

disorders and its provision is wide all over the world. Between 76% and 85% of people with

severe mental disorders receive no treatment for their mental health problem in low- and

middle-income countries.1

Disability due to depressive disorder and the lack of mental health services is acutely felt

in Haiti. The devastating 2010 Haiti earthquake highlighted a lack of formal biomedical

mental health services. For Partners In Health and Zamni Lasante, the earthquake became

a catalyst for the integration of mental health into Zanmi Lasante’s system of care. This new

mental health system of care is a model that is framed within the Haitian cultural context,

underpinned by evidence-based biopsychosocial approaches.2

This curriculum marks a major step in Partners In Health/Zanmi Lasante’s efforts to meet

the need for mental health services in Haiti by training non-specialist health providers. It

is the front line healthcare providers who have played an important role in helping us to

recognize the need for mental health and will play an instrumental role in scaling up services:

community health workers, nurses, psychologists and social workers, and physicians. Through

this curriculum, healthcare providers will possess the technical knowledge and skills to

identify, manage and treat major depressive disorder and act as advocates for the rights of

patients with mental illness. By the end of this training, psychologists and social workers

will understand how to work hand-in-hand with community health workers, nurses, and

physicians to provide high-quality, humane medical and mental health care for patients

suffering from depression.

1. WHO Secretariat. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. 1 December 2011. Available at: http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9-en.pdf

2. Raviola G, Severe J, Therosme T, Oswald C, Belkin G, Eustache E. The 2010 Haiti Earthquake Response. Psychiatric Clinics. September 2013Volume 36, Issue 3, Pages 431–450.

2 Partners In Health | FACILITATOR MANUAL


OBJECTIVES

By the end of this training, participants will be able to:

Session 1:a. Describe the purpose of the training

b. Demonstrate prior knowledge of the training topic

c. Establish ground rules that create a respectful and trusting environment

d. Identify the need for mental health services

Session 2:e. Describe the epidemiology of depression

f. List the responsibilities of the psychologist/social worker in the depression care pathway

g. Describe the importance of mental health care within a human rights context

h. Identify stigma surrounding mental illness and its impact on patient care and outcomes

Session 3:i. Apply the biopsychosocial approach to depression diagnosis and care

j. List the four sign and symptom areas (ABCDs) of depression

k. Describe differential diagnoses of illnesses related to depression

Session 4:l. Identify the importance of a performing a medical evaluation before a mental

health evaluation

m. Define delirium

n. Identify the most common medical conditions and mental illnesses that can present with depression-like symptoms

o. Correctly complete the Patient Encounter Form

Session 5:p. Model appropriate interviewing skills

q. Correctly complete the psychologist/social worker sections of the Initial Mental Health Evaluation

Session 6:r. Conduct the Zanmi Lasante Depression Screening Inventory

s. Explain the collaboration between the physician and psychologist/social worker in evaluating patients with symptoms of depression



Session 7:t. Explain how to screen for suicidal ideation and manage suicidal patients consistent

with their severity and risk level

Session 8:u. Provide an overview of the general principles of Interpersonal Psychotherapy (IPT)

v. Outline the key steps in each of the three phases of IPT

w. Discuss the strategies used during IPT to help patients deal with depression and prevent future episodes of depression

Session 9:x. Facilitate initial, middle and termination phase IPT sessions

Session 10:y. Describe the non-pharmacologic and pharmacologic treatment options for depression

z. List the indications, dosage, mechanism of action, and adverse effects of depression medications amitriptyline and fluoxetine

aa. List the key psychoeducation messages for patients with depression

Session 11:ab. Explain the process of follow up for people living with depression

ac. Correctly complete the psychologist/social worker sections of the Follow Up Form

Session 12:ad. Describe how to use mhGAP for the management of depression.

ae. Describe how to use mhGAP for the management of self-harm/suicide.

Session 13:af. Review all unit objectives

ag. Demonstrate learning through a post-test

ah. Give feedback on the training



TIME REQUIRED 4 1/2 days (24 hours and 35 minutes of training sessions)

DAY 1: 5 hours 20 minutes of training sessions

Session Content Methods Time

1Introductions, Pre-test and Confidentiality

• Introductions• Pre-test• Facilitator presentation

2 hours

2Epidemiology of Depression and Stigma

• Facilitator presentation• Large and small group discussions

1 hour 50 minutes

3Diagnosis of Depression • Facilitator presentation

• Case studies1 hour 45 minutes

DAY 2: 5 hours and 30 minutes training sessions


Review Day 1 Review • Group Presentations 30 minutes

4Medical Evaluation and Management of Depression

• Facilitator presentation• Small group work

1 hour

5Initial Mental Health Evaluation • Facilitator presentation

• Role plays2 hours

6The ZLDSI • Facilitator presentation

• Role play• Case studies

1 hour 20 minutes

7Managing the Suicidal Patient • Facilitator presentation

• Role play40 minutes

DAY 3: 6 hours of training sessions


8 Basics of Interpersonal Psychotherapy (IPT) and Psychoeducation

• Facilitator presentation• Small group discussion• Group presentations

2 hours

9Interpersonal Psychotherapy (IPT): Practice

• Facilitator presentation• Role play

4 hours



DAY 4: 5 hours of training sessions


Review Day 2 and 3 Review • Bingo 30 minutes

10Medication Management and Other Treatments for Depression

• Facilitator presentation• Case studies

1 hour 30 minutes

11Follow Up and Documentation • Facilitator presentation

• Case studies1 hour 30 minutes

12Depression and mhGAP • Facilitator Presentation

• Role play1 hour 30 minutes

DAY 5: 2.5 hours of training sessions


13

Review, Post-Test and Feedback • Facilitator Presentation• Case studies• Assessment• Evaluation

2 hours 30 minutes

MATERIALS NEEDED

Materials

� Facilitator Manuals—one copy/facilitator

� Participant Handbooks—one copy/participant

� Depression PowerPoint presentation

� Pre-/post-test (two copies/participant)

� Flip chart

� Markers, pens

� Tape

� WHO mhGAP Intervention Guide

� Post-it notes (estimate five/participant)

� IPT Manual—one copy/participant

� Computer and projector

� Participant bingo cards—one card/participant. (There are 10 different cards in the Annex; if there are 20 participants, make two copies of each card)

� Small prizes for winners of Bingo game (ex. sweets)



SESSION 1: Introductions, Pre-test and Confidentiality

Methods: Introductions, pre-test, facilitator presentation

Time: 2 hours

Materials: � PowerPoint presentation � Pre-test (one copy/participant) � Flip chart

� Markers, pens � Tape � Post-it notes (one or two/participant)

Preparation:

• Post a blank sheet of paper on the flip chart and title it “Goals & Expectations”

• Post a blank sheet of paper on the flip chart and title it “Training Ground Rules”

• Photocopy the pre-test

• Review the Facilitator Manual, PowerPoint slides 1–23

Objectives:Participants will be able to:

a. Describe the purpose of the trainingb. Demonstrate prior knowledge of the training topicc. Establish ground rules that create a respectful and trusting environmentd. Identify the need for mental health services

NOTE FOR FACILITATOR PREPARATION:

General Tips for Presenting PowerPoint (PPT) Slides:

When presenting PPT slides, it is not necessary to read everything on each slide. Instead, use the slides as an “aide memoire”, i.e., notes to guide the trainer in his/her explanation and exploration of the topic.

Some slides have a conversation bubble. Use the bubble prompts to ask the audience questions and hear their feedback before clicking forward to reveal the answers. Other slides have discussion questions that appear in the Facilitator Manual (rather than on the slides). There are a number of reasons to use these prompts: to engage participants; to support them to learn from each other as well as from you, the trainer; to encourage participants to recognize that they know more about this topic than they might currently recognize; and for you to gauge their current knowledge level.



STEPS

45 minutes

1. Turn on the projector before the training and show Slide 1: Introduction to Mental Health and Depression as participants enter the room. Start the training by welcoming participants.

2. Introduce yourself, giving a one minute overview of your expertise in this field.

3. Explain that the purpose of this training is to prepare psychologists and social workers to address problems related to mental disorders, specifically related to depression. This training will provide psychologists/social workers with the tools to diagnose and address mental disorders. Mental disorders are common. However, treatment is available and effective.

4. Introductions: Pass out one Post-it note to each participant. Ask the participants to take a minute and write down one goal or expectation that they have for this training. Then ask participants to introduce themselves by stating, in turn, their:

• Name

• Place of employment

• One goal or expectation that they have for this training

After each person speaks, place their Post-it note on the flip chart entitled ‘Goals and Expectations’.

5. Summarize introductions by telling participants that many of their goals and expectations will be met during this training. Expectations not met today will be addressed in some other way, either with individual follow-up, monthly meetings, ongoing communication or in future trainings.

Be sure to save the flip chart with Post-it notes, you will need it on the last day of training!

6. Introduce participant handbooks: Explain to the participants that they have materials and resources that will be referred to throughout the training. The materials and resources will also be a resource to them once the training has finished, such as when they are seeing patients or need clarification on the topics covered in the training.

7. Ask participants to turn to the agenda. Tell them that the training is divided into a series of sessions as they can see listed in the agenda.



8. Ask the participants to turn to their participant handbooks. Tell them that each session has learning objectives associated with it. Tell them that the learning objectives represent what they should learn during each session of the training. The participants should re-visit the learning objectives throughout the training to ensure that they are meeting the expectations for the training. Request that participants ask for clarification or more information if ever they feel like they cannot meet a learning objective.

9. Turn on the projector.

10. Show Slide 2: Session 1: Introductions, Pretest and Confidentiality, and Slides 3–7: Learning Objectives.

Explain that each session has training objectives. Provide an overview of the training, reading the objectives of the training as they appear on the slides. Note that the objectives also appear in their participant handbooks.

11. Remind the participants that they are responsible for their own learning. As such, encourage them to ask questions throughout the training, especially if they do not feel like they are able to fulfill the training objectives.

12. Designate someone as the ‘time keeper’. The role of the time keeper is to keep the training running smoothly by being aware of time, and to signal to the facilitator when there is five minutes left in a session. The time keeper should have a watch or cell phone.

13. Turn off the projector.

30 minutes

14. Distribute the pre-test and explain how it should be completed.

15. Collect the completed pre-tests.

16. Explain that the participants will take a post-test at the end of the training to measure what they have learned.

15 minutes

17. Explain that in order to ensure an effective training, the group will follow some ground rules. Invite participants to brainstorm ground rules. Write the ground rules on a sheet of flip chart paper and keep them in view during the training. Ground rules can include punctuality, confidentiality, participation in discussions and activities, respect for different opinions and cell phones being switched off.



CONFIDENTIALITY

Confidentiality is one of the most important parts of being a healthcare provider. All providers, from physicians and psychologists/social workers to the reception and janitorial staff, must keep confidential everything learned about a patient and his/her family as well as anything learned about a patient’s condition. A health provider may only share such information with other providers when needed in the care or treatment of that patient.

When sharing patient cases within this training or outside of the training, ensure that patient confidentiality is maintained: do not use the person’s name, do not state where she or he lives, and do not give any other information that would reveal the individual’s identity.

Additionally, do not share information about your fellow participants learned during this training. If, for example, a colleague admitted during the training that he feels uncomfortable screening for depression, that acknowledgement stays in this classroom. Adults tend to be most comfortable learning and sharing in environments where they will be treated nonjudgmentally, and where their fellow participants are trustworthy.

18. Write ‘parking lot’ on a sheet of flip chart paper and hang it on the wall. Tell participants that when a question is raised that might not be answerable or relevant at that particular moment, it will go to the parking lot. When there is a lull in the training, or at the end of each day the facilitator can take the time to address some of the questions in the parking lot. By the end of the training all questions in the parking lot will hopefully be answered, and if not, the facilitators should guide the participants to the resources to answer any remaining questions.

30 minutes

19. Show Slide 8: Mental Illness.

Explain each bullet point in turn. The following background information is provided as context.

• Mental illness is a public health crisis. According to the World Health Organization (WHO), 14% of the global burden of disease is attributed to mental, neurological, and substance use disorders. These disorders are common in all regions of the world, affecting every community and age group across all income countries.

• One in every four (25%) people experience a mental illness during their life. Although it may not be important to remember this exact figure, the point here is that mental illness is very common. Look around this room, if there are 20 people here, there is a good chance that about five of us have dealt with or will deal with a mental illness at some point in our lives. Depression, like so many other mental illnesses, can affect anyone and it is one of the most widespread illnesses, often co-existing with other



serious illnesses. According to the World Health Organization, depressive disorders were ranked as the third leading cause of the global burden of disease in 2004 and will move into the first place by 2030.

• If depression is diagnosed, it can be treated. One of the biggest barriers to treatment, other than cost, is stigma.

20. Show Slide 9: Photo of Earthquake.

Explain that this photograph was taken one month after the earthquake. The earthquake highlighted and exacerbated the significant need for mental health services in Haiti. Encourage discussion about this photograph.

Ask:

• What is your response to the image of the man seated on the ground?

Ask follow up questions as needed to focus the discussion on the lack of access to services and the need for a mental health system of care.

21. Show Slide 10: Need for Mental Health Services.

Explain that, for many reasons, there is a significant need for mental health services in Haiti. This need is underscored by the fact that there are less than 20 psychiatrists, and one neurologist in Haiti.

22. Show Slide 11: The ZL emergency response: mental health.

Explain that Zanmi Lasante and Partners In Health responded to the earthquake by developing the human resource capacity to deliver such services, and mounting a mental health response both in the Internally Displaced Persons (IDP) settlements in Port-au-Prince, and in building a system of care in the Central Plateau.

23. Show Slide 12: Mental Health Priority Areas for PIH/ZL.

Zanmi Lasante is supporting the Ministry of Health by piloting a “system of care” for mental health that is integrated into the mental health system of care, using not only psychologists and social workers, but other providers including physicians, nurses and community health workers, who are not mental health specialists.

24. Show Slide 13: ZL Mental Health Team 2013.

Explain that guided by this commitment the ZL Mental Health team has developed a number of initiatives in mental health care.

25. Show Slide 14: Grand Challenges Canada, 2012–2015.

Explain that in 2012, ZL received a grant from Grand Challenges Canada to support this work.



26. Show Slide 15: Long-term Response and Developing a “System of Care”.

This diagram shows the skills needed within the system of care to provide comprehensive mental health care.

27. Show Slide 16: Assigning tasks to provider roles.

Given the lack of specialists, a range of people can potentially provide components of psychosocial and /or mental health services (“task sharing”):

• Community members (leaders, religious figures, teachers)

• Community health workers

• Nurses

• Social workers

• Psychologists

• Physicians

Additional components include:

• Psychosocial assistance (such as financial, nutritional, and housing support or establishing a safe environment)

• Psychoeducation

• Screening

• Triage and referral

• Psychotherapeutic treatments

• Psychopharmacologic treatments

Each level of provider and staff fulfill different roles in this system of care. This is what is meant by “task shifting” in mental health care.

28. Show Slide 17: Over the next three years:

• (CLICK 4 times) Zanmi Lasante will scale up comprehensive, community-based mental health services integrating CHWs in Haiti’s Central Plateau.

• (CLICK 2 times) Zanmi Lasante will support the strengthening of national institutions such as the schools of medicine and nursing so that the methods learned can be integrated with training and early professional development of generalist providers. If the pilot is proven successful then the government will take the materials created with the potential to scale up services (CLICK) more broadly to both governmental and nongovernmental entities who ideally should be sharing methods and practices.



• (CLICK) This will require coordinated communication and collaboration—focused on mental health—among a range of diverse stakeholders. This work provides a very real chance for Haiti to develop a sustainable, community-based mental health system for the long-term.

29. Show Slide 18: Psychologists and Social Workers.

While psychologists and social workers are a critical component of the system of care, they cannot do the work alone. The psychologists are the mental health specialists in the system, and should be seeing the most acute cases. Both psychologists and social workers are currently being trained to deliver evidence-based psychotherapy for patients.

30. Show Slide 19: Physicians.

Physicians (such as Dr. Reginald Fils-Aime) have an important role to play, which includes:

• Completing a basic mental health evaluation

• Recognizing basic categories of mental disorders

• Working collaboratively with psychologists and social workers in providing care

• Managing the prescription of medications for mental disorders, which psychologists cannot do. Medications provide an essential element of effective care for many patients.

31. Show Slide 20: Nurses.

Often, medical problems present with mental health problems. People with significant mental illness who are vulnerable deserve to have the same care as those with other medical conditions, despite the complexity of their illness and prevailing undercurrent of stigma.

As the only specialized mental health centers in the country are in Port-au-Prince, healthcare providers, particularly nurses, at health centers throughout the country have a vital role to play in the care of people with mental illness. Zanmi Lasante mental health trainings will prepare nurses to safely and humanely serve people with mental disorders in hospital and clinic settings.

32. Show Slide 21: Community Health Workers.

Community health workers have critical roles in the delivery of mental health services:

• Screening: Zanmi Lasante has developed screening tools for CHWs to identify people with mental health problems and refer them to the clinic for further evaluation by psychologists and social workers.

• Follow up: CHWs are being trained in basic support skills to follow up with patients with mental health problems in the community.



33. Show Slide 22: Zanmi Lasante Mental Health Care Scale-Up.

With the support of Grand Challenges Canada, over the next three years ZL will scale up care for priority conditions that include:

• Depression in Year 1

• Bipolar disorder, psychosis and epilepsy in Year 2

• Child and adolescent conditions in Year 3

These efforts will include the integration of multiple components: integration of training and curriculum, monitoring and evaluation, IT and electronic medical records.

34. Show Slide 23: This is long term…

Read the slide and conclude the session.

35. Ask participants if they have any questions on this session.



SESSION 2: Epidemiology of Depression and Stigma

Methods: Facilitator presentation, large and small group discussions

Time: 1 hour 50 minutes

Participant Handbook page: 4

Materials: � PowerPoint presentation � Flip chart

� Markers, pens � Tape

Preparation:



e. Describe the epidemiology of depression f. List the responsibilities of the psychologist/social worker in the depression care pathwayg. Describe the importance of mental health care within a human rights contexth. Identify stigma surrounding mental illness and its impact on patient care and outcomes

STEPS

20 minutes

1. Show Slide 24: Session 2: Epidemiology of Depression and Stigma

Introduce this session by reading the objectives.

2. Show Slide 25: Age-standardized DALYs for Noncommunicable Diseases, 2004.

Explain that mental illness is common:

• Noncommunicable diseases now account for nearly half of the global burden of disease, and almost 45% of the adult burden in low-and middle-income countries.

• The distribution of noncommunicable diseases is illustrated in this slide. The bar charts show the age-standardized DALYs (disability-adjusted life year) for noncommunicable diseases by major cause group, sex, and country income group in 2004. Notice that the distribution of neuropsychiatric conditions (medium orange color) makes up a notable percentage, and a fairly consistent percentage of the DALYS across both genders and all country income groups.3

3. WHO. 2008. The Global Burden of Disease, 2004 Update. Part 4, Burden of disease: DALYs. Figure 25. Available at: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/



• One DALY is, for all practical purposes, a lost year of “healthy” life. DALYs are the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences. DALYs represent the burden of disease as well as the gap between current health status and an ideal health situation.4

3. Show and read Slide 26: Treatment Gap.

4. Show Slide 27: Leading Causes of Disease, Global 2004 and 2030.

Note that Unipolar depressive disorders was the third leading cause of burden of disease globally in 2004 (point out the yellow highlighted text in the left column). But, it is expected to be the leading cause of burden of disease globally by 2030 (point out yellow highlighted text in column to right), causing 44% MORE DALYs in 2030 than in 2004.

5. Show and read Slide 28: Epidemiology of Depression.

6. Show and read Slide 29: Psychosocial Risk Factors.

7. Show and read Slide 30: Distribution of Depression.

8. Show Slide 31: Mental Illness and Health.

Ask participants the first question on the slide, give them about three to five minutes to respond. Then ask the second question, giving them another five minutes to respond.

9. Show Slide 32: Mental Illness and Health.

Show the slide and read the definitions. Note that Zanmi Lasante’s goal in treating mental illness is mental health. Explain that during this training, participants will learn about mental health and their role in helping people to achieve good mental health and get help for mental disorders.

Explain to participants that:

• Good mental health is part of good health. If someone does not have good mental health, that person is considered to have a mental health disorder or mental health problem. There are a number of mental disorders, some of which will be discussed during this training.

• This training focuses on how psychologists and social workers can provide safe, effective, evidence-based and culturally sound care for people suffering from depression and other mental disorders. There are a number of skills participants will learn in this training. Given the lack of specialists such as psychiatrists, the shortage of psychologists and social workers, and the limited number of clinicians

4. For more information, see WHO. “Health statistics and information systems“ at: http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/



trained in mental health, as well as the fact that good treatment for mental disorders requires a collaborative approach, participants will be expected to take responsibility for the care of people with depression and other mental disorders in collaboration with other providers.

• Animate the speech bubble. Ask participants: What do you think are the responsibilities of psychologists/social workers in ensuring optimal health for their patients?

10. Show Slide 33: Depression Checklist.

Refer participants to the Depression Checklist in the annex. Animate the arrows (two clicks) to point out the columns that list the psychologist/social worker roles. Give them a couple of minutes to review the psychologist/social worker role as well as that of the CHW, physician and nurse. Ask participants:

• How do you see the role of the psychologist/social worker fitting in with the roles of other healthcare workers?

• What advantages do you see with this distribution of roles?

• What disadvantages?

• How can we minimize the disadvantages?

11. Ask participants:

• What does the psychologist/social worker do in the initial evaluation?

• How about in the follow-up evaluation?

Record responses on a sheet of flip chart paper.

12. Show Slides 34–35: Responsibilities of Psychologists/Social Workers.

Add any roles and responsibilities that participants may have missed.

13. Show Slide 36: Psychologists/Social Workers Must Also Understand …

Note that the diagnosis, care and treatment of those with mental illness requires a full understanding of the cultural context, patient rights, the roles and responsibilities of other care providers.


• We will now focus on mental health in the context of stigma, culture and religion. We will do this while also considering mental health and human rights.

• This training will also explore the developing “system of care” for mental health, and your role as psychologists/social workers in that system of care.



45 minutes

14. Show Slide 37: Mental Health and Human Rights.

Explain to participants that the next few slides will explore the concept of human rights, including the roles and responsibilities of psychologists/social workers in helping patients and their families. Read the slide aloud.

15. Facilitate the Human Rights Exercise:

Post a blank sheet of flip chart paper.

• Animate the speech bubble. Ask participants the following question and write their responses on the sheet:

– What are some examples of human rights? In other words, what are some examples of things or conditions that all people need in order to live freely and with dignity?

If participants have trouble naming examples, invite them to think about the rights that they, their friends and family have come to expect or currently enjoy. If need be, offer one or two examples to start the brainstorming.

When participants have named all the examples they can think of, read the flip chart paper list aloud. If your list does not include the rights included in the box below, add these to the list participants compiled on flip chart paper.

ALL PEOPLE HAVE THE RIGHT TO:

• Live freely and be safe from harm

• Not be treated cruelly

• Not be enslaved

• Choose their religion

• Think and express themselves freely

• Participate in their government [voting, etc.]

• Marry and have a family

• Own property

• Work and be paid and treated fairly

• Have a standard of living adequate for the health and well-being of oneself and of one’s family, including the right to access to food, clothing, housing, medical care, and necessary social services

• Get an education

• Participants may name other examples

16. Show Slide 38: Universal Declaration of Human Rights (1).

Explain that in 1948 (after World War II), representatives from over 48 countries joined together to create a document called the Universal Declaration of Human Rights. The Declaration names all the rights that human beings must have to live freely and with dignity. The Declaration states, “All human beings are born free and equal in dignity and rights.” The Universal Declaration of Human Rights names many rights, including the ones named during the brainstorm. Among the rights named are the right to health care



and a good standard of living. The Declaration also states that governments, communities, and individuals are all responsible for upholding and protecting human rights.

Read articles 1, 3, and 5 aloud.

17. Show Slide 39: Universal Declaration of Human Rights (2).

Read Article 25 aloud and explain that the Universal Declaration of Human Rights says that all people are born free and equal in dignity and rights. All people have the right to life, liberty, and security of person. No one should be treated cruelly or degradingly. All people have the right to good food, clothing, housing, and medical care. This includes people with mental health problems. Not having good food, clothing, housing, and medical care can, in turn, affect physical and mental health. Mental health care is part of medical care, and all people—men, women and children—have a right to care for mental disorders.

18. Show Slide 40: Discussion Questions.

Ask participants to answer both questions on the slide, drawing from their experiences as psychologists/social workers. Take four or five minutes to discuss the first question, then another four or five minutes to discuss the second.

45 minutes

19. Show Slide 41: Denial of Human Rights.

Read the slide aloud. Animate the speech bubble. Then ask and encourage a brief discussion by asking: “What are the factors that contribute to the discrimination against people with mental illness?”

If appropriate, recall the discussion of the photo taken after the earthquake (Slide 9).

20. Ask participants: Turn to the person next to you and share with him/her what you think about the status of human rights in Haiti:

• What are the challenges?

• Who has these rights and who does not?

• Is this situation improving?

After about five to ten minutes ask participants to reconvene. Ask how they answered the first question. Once you have a group consensus, repeat the process with the second and third questions. Summarize the discussion on the status of human rights in Haiti and then move onto the next slide.

21. Show Slide 42: Words for Mental Health.



Ask participants:

• What are some of the words that you have heard used to describe people with problems related to mental health?

Record their responses on a sheet of flip chart paper. Once there are 5–10 responses (in addition to the words on the slide), ask participants:

• How many of these terms are derogatory (vs complimentary or neutral)?

• Given these stereotypes about mental health, what does that mean in terms of our job diagnosing and treating mental health disorders?

• What do providers say or believe about people with mental disorders?

• What do community members say or believe about people with mental disorders? Why?

• How are people with mental health disorders treated in the healthcare system? Why?

• How are people with mental disorders treated in their communities? Why?

22. Show Slide 43: Stigma can Lead to Discrimination to summarize the discussion.

Note that stigma can:

• Deter people with mental illness from seeking help

• Make it difficult to find a job or establish healthy relationships

23. Show Slide 44: Questions for Discussion.

Ask participants to get into groups of three. In their small groups, invite participants to discuss the three questions on this slide, the questions also appear below. One person should act as group reporter.

• What beliefs or practices have you had in the past about people with mental disorders?

• How have you dealt with people with mental disorders?

• How can you work to change your own beliefs and practices?

While the groups are discussing, prepare two sheets of flip chart paper: the first should have the title “Past beliefs/practices”. The second should be titled “Action points for change”.

After 10 to 15 minutes, ask the group to reconvene as one large group. Ask if any of the groups would like to volunteer to summarize the group discussion. Take notes on the prepared sheets of flip chart paper; separate out the agreed action point onto the second sheet of flip chart paper.



Invite the remaining groups to add any key points that they discussed not reported by the first group.

24. Show Slide 45: Care Pathway: Depression.

Explain to participants that after a qualitative assessment in 2011 indicated that depression was a major concern, Zanmi Lasante prioritized the development of the care pathway for depression. Zanmi Lasante developed a locally validated, easy-to-use screening tool for depression. The care pathway includes screening for depression by CHWs with this screening tool to obtain a numerical score:

• Those with a lower level of depression are followed up by a CHW. This is a 3-session intervention adapted from Interpersonal Therapy (IPT).

• Those with a higher depression score are referred for re-evaluation by a psychologist or social worker, who refers the person for IPT.

• Those with the highest scores are referred to a physician for evaluation to start medication.



SESSION 3: Diagnosis of Depression

Methods: Facilitator presentation, case studies





Preparation:

• Review the case study, Facilitator Manual, PowerPoint slides 46–66.


i. Apply the biopsychosocial approach to depression diagnosis and carej. List the four sign and symptom areas (ABCDs) of depressionk. Describe differential diagnoses of illnesses related to depression

STEPS

45 minutes

1. Show Slide 46: Session 3: Diagnosis of Depression.


2. Show Slide 47: Biopsychosocial Approach.

Explain to participants that Zanmi Lasante’s approach to the diagnosis, care and treatment of mental illness is from a wider perspective than is often used in conventional medicine. This approach can be thought of as the biopsychosocial approach.

The biopsychosocial model is a broader and integrated approach to human behavior and disease in comparison to the more traditional biomedical model. The biopsychosocial approach can be applied to any condition or illness. It suggests that psychosocial factors affect the onset and course of almost all chronic physical and mental disorders and, as such, the behavioral and emotional aspects of a patient should be considered when making decisions about treatment and support.

A balanced biopsychosocial approach to diagnosis, evaluation, care and treatment is essential.



Ask participants:

• What biological factors do you think might affect a patient’s vulnerability to mental health problems? (Record responses on flip chart paper.)

• What social factors do you think contribute to risk of mental health problems? (Record responses on flip chart paper.)

• What psychological factors might make an individual more prone to mental health problems? (Record responses on flip chart paper).

3. Divide participants into small groups of three or four participants per group. Refer participants to the case study in their participant handbooks.

4. Give groups 15 minutes to read and discuss the case and then respond to the case questions.

CASE: THE BIOPSYCHOSOCIAL APPROACH

Leila is a 16 year-old female recently admitted to the hospital because of active suicidal ideations. Leila was found holding a 2 liter-size jug of pesticide up to her mouth at home. Leila has a history of suicidal ideation and has tried to cut herself in the past, but reported that the knife would not penetrate her skin. She said that she would not be able to stop herself again.

Leila reported depression for the past 2 years and thoughts of death for the last 18 months. Leila is an overweight female who appeared sad, making poor eye contact and demonstrating poor social skills. She says that she has no friends at school; her affect was flat and apathetic. Leila reported difficulty sleeping, decreased energy, irritable mood and trouble with her appetite. She also reported significant feelings of worthlessness, helplessness and hopelessness.

Leila related that her depression had worsened in the past 2 weeks because her sister was living at home again. Her sister is abusive towards her (she started choking Leila for borrowing her clothing last week), and Leila believes her mother does not punish her sister appropriately.

Leila’s parents divorced when she was 10 years old. Her mother is a victim of domestic violence, and her father is an alcoholic. Leila denies any substance abuse history.

Case questions

1. From a biopsychosocial perspective, what is going on in this case? What are the possible biological, psychological, and social factors involved?

Biological: Given that Leila’s father is an alcoholic, and her mother tolerated years of domestic violence, it is quite possible that both parents are depressed. Much of this may have been precipitated by the onset of puberty, which often exacerbates mental health issues. Leila also might be vulnerable to alcoholism.



CASE: THE BIOPSYCHOSOCIAL APPROACH (continued)

Social: Leila is growing up in a dysfunctional home, made worse by an abusive sister over whom the parents have no control.

Psychological factors: Leila may feel that she does not fit in either at home or at school, alienating her and creating a situation that makes one more vulnerable to mental illness.

2. What other issues must be considered or explored in this case?

Does Leila have a medical illness that needs to be ruled out?

Does she have evidence of mania? Anxiety? Psychosis?

Is there a history of violence in the house?

Is there a history of sexual violence against Leila? Any other trauma?

Has she received any care or treatment for her mental illness?

How is Leila doing in school? What do people at school think of her?

What is the contribution of poverty to these difficulties?

How do the remaining family members understand her illness?

Adapted from: Sekhar, Deepa. 2000. Major Depressive Disorder in Adolescence: a case study. Available at: www.brown.edu/Courses/BI.../Deepa%20Sekhar.doc

5. When groups have finished answering the case questions, ask each group to report on one answer or aspect of the case. Encourage discussion.

6. Show Slide 48: Basic Risk Factors for Mental Health Problems.

Compare participant discussion to the case study with those on this slide.

7. Show Slide 49: Biology: Causes.

Explain that the participants will now take a closer look at some of the biological factors affecting depression. Review the bullet points on the slide.

8. Show Slide 50: Biology: Genetics.

Discuss the role of genetics in individual vulnerability to depression.



1 hour

9. Show Slide 51: ABCDs of Major Depressive Disorder (1)

Tell the participants that they are going to transition now from discussing the biopsychosocial model to the signs and symptoms of mental illness. Explain that generally, when considering how to think about and describe symptoms and signs of mental illness, four symptom areas should be considered: the ABCDs.

Describe the As and Bs: Affect and mood, and Behavior. Animate the speech bubble and ask participants to give examples of both affect/mood and behavior, drawing from their experience.

10. Show Slide 52: ABCDs of Major Depressive Disorder (2)

Explain the Cs and Ds: Cognition and perception, and Development. As a point of clarification, cognition includes attention, remembering, producing and understanding language, solving problems, and making decisions.

Animate the speech bubble and ask participants to give examples of cognition/perception. Animate the second speech bubble and ask participants for examples of development, drawing from their experience. Then ask participants:

• What affect/mood might you expect a depressed patient to display?

• What behavior would you expect in a typical depressed patient?

• How would you expect a depressed patient to describe his/her cognition/perception?

• How would you expect a depressed patient to describe his/her development?

11. Show Slide 53: The Signs and Symptoms of Major Depressive Disorder.

Compare participant responses from the previous discussion questions with those on the slide.

12. Show Slide 54: Diagnosing Severe Depression.

Review the key points on the slide. Explain that ZLDSI score will be discussed in later sessions. Note that:

• As long as a medical issue is not the cause of depression, these patients will improve over time with psychotherapy.

• Medications (amitriptyline or fluoxetine) can help, but only if patient is severely depressed (as defined by ZLDSI score and suicidal ideation).

• When screening for suicide, enquire about symptoms over the past two weeks.

13. Show Slide 55: Explaining Other Symptoms



Read the key points on the slide.

14. Show Slide 56: Dysthymia.

Explain to the participants that:

• Dysthymia is also called neurotic depression, dysthymic disorder or chronic depression.

• It is a mood disorder similar to depression, but with less severe but longer-lasting symptoms (by definition, at least two years for adults, one year for children and adolescents).

• People with dysthymia may believe that depression is part of their character, so may not think to discuss their symptoms with doctors.

• As the treatment is different from depression, it should be differentiated from such.

15. Show Slide 57: Bipolar & Adjustment Disorder

Review content. Explain to participants that depression can be “unipolar”, that is indicative of a depressed mood over time, it can be “bipolar”, meaning that mood fluctuates between depression and hypomania or mania, and depression can also be accompanied by psychosis in certain instances. It is important to differentiate between unipolar and bipolar depression, as the treatment is different.

16. Show Slide 58: Bereavement

Review content. Ask participants if they have any related comments, questions or stories that they would like to share about any of their patients.

17. Show Slide 59: Somatization Disorder.

Explain to participants that in the DSM-IV, somatoform disorders comprise the disorders also called “psychosomatic”. Somatization and conversion are two types of somatization disorders.

Review the bullet points. Explain to participants that somatization disorder is more common in women, but it occurs in men as well. Animate the speech bubble and ask participants:

• Can anyone give an example of a patient they classified as having somatization disorder?

18. Show Slide 60: Somatic Symptoms.

Animate the speech bubble and ask participants: What are some common somatic symptoms for Haitians?

Animate the rest of the slide and read the bullet points. Explain to participants that most often, somatic symptoms represent some underlying depression and anxiety. But somatic symptoms can also be indicative of other problems.



Tell participants that when the chief complaint is headache, there is often depression; whether headache is a somatic symptom of depression or part of a comorbid headache syndrome is difficult to determine.

19. Show Slide 61: Conversion Disorder.

Explain to participants that conversion disorder is a loss or change in sensory or motor function that is suggestive of a physical disorder but caused by psychological factors. Review bullet points. Add additional information as necessary:

• With a conversion disorder, the symptoms are not under voluntary control, although the patient may be able to control their severity. Symptoms are not intentionally produced or feigned.

• Explain to participants that those with depression might be predisposed to developing Somatoform disorders. It is important to note that patients with somatic symptoms that are not depressed require care and treatment that is different from that for depression.

• The focus of treatment for somatoform disorders is improving daily functioning, not on managing symptoms. Stress reduction is often an important part of getting better. Counseling for family and friends may also be useful.

20. Show Slide 62: Depression, Other Differential Diagnoses.

There are other diagnoses that can appear similar to depression, but less often. These include:

• Panic Disorder, which causes discrete episodes of intense fear or discomfort in which anxiety symptoms began abruptly and peak within about ten minutes and are accompanied by a panic attack: dizziness, palpitations, chest pain, sweating, chills, trembling, numbness or tingling, shortness of breath, choking, nausea, feelings of unreality, fear of losing control, fear of dying.

• Generalized anxiety disorder, which is characterized by excessive worry and anxiety, more days than not, for six months. Person has trouble controlling these anxieties or worries.

• Post-traumatic stress disorder, which is characterized by:

– Re-experience of a traumatic event that was witnessed or experienced. The traumatic event would have been intensely horrifying.

– PTSD patients often feel socially detached or emotionally numb. They may display symptoms of hyperarousal; symptoms can cause significant distress or interference with school, relationships, important activities

• Epilepsy: Epilepsy is a chronic condition, characterized by recurrent unprovoked seizures. It has several causes; it may be genetic or may occur in people who have a past history of birth trauma, brain infections or head injury. In some cases, no specific cause can be identified.



– The two major forms of seizures are convulsive and non-convulsive.

– Non-convulsive epilepsy has features such as change in awareness, behavior, emotions or senses (such as taste, smell, vision or hearing) similar to mental health conditions, so may be confused with them.

– Convulsive epilepsy has features such as sudden muscle contraction, causing the person to fall and lie rigidly, followed by the muscles alternating between relaxation and rigidity, with or without loss of bowel or bladder control. This type is associated with greater stigma and higher morbidity and mortality.

21. Show Slide 63: Mental Health Crisis.

Explain to participants that, in some cases, during screening or in other situations, you will encounter people with mental disorders who are suffering from very serious, acute conditions. These conditions are referred to as mental health crises. A mental health crisis can be a symptom of severe depression.

Probably the most extreme and dramatic mental health crisis is the patient who is considering or attempting suicide. Suicidal ideation should be considered a sign of severe depression. Screening for suicidality and the care and treatment of patients at risk of suicide is discussed in depth in Session 7.



DAY 1: Review

Methods: Group presentations

Time: 30 minutes

Materials: � Flip chart or laptop computers � Markers

� Tape


• Recall key points taught in Sessions 1, 2, and 3

STEPS

30 minutes

1. Explain to participants that they will be reviewing yesterday’s sessions by participating in group presentations.

2. Tell the participants that they will be divided into small groups and will be assigned a session from yesterday. The groups will have 10 minutes to create a three-to-five minute presentation summarizing the most important information from their assigned session. Each group will be given a piece of flip chart paper and markers—participants are free to draw, create a map or write down an outline to present their information to the audience. Encourage the groups to draw information from their participant handbooks. If they prefer they can create a PowerPoint presentation rather than using flip chart paper.

3. Divide participants into three groups. Distribute the flip chart paper and markers. Assign one of the following sessions to each group (if there are more than five participants in each group, divide participants into further groups and assign the same session to more than one group):

Session 1: Introductions, Pre-Test and Confidentiality

Session 2: Epidemiology of Depression and Stigma

Session 3: Diagnosis of Depression



4. Read the following questions aloud to the participants to guide their work:

• What were some of the key points raised during the session?

• What ideas and suggestions are you taking away from this training?

5. After 10 minutes, invite each group to the front of the room to present. Instruct the timer to time each group so that no group goes over the five-minute time limit. Thank each group after they have presented.



SESSION 4: Medical Evaluation and Management of Depression

Methods: Facilitator presentation, small group work

Time: 1 hours




Preparation:


• Review the Patient Encounter Form and the Initial Mental Health Evaluation Form


l. Identify the importance of a performing a medical evaluation before a mental health evaluation

m. Define deliriumn. Identify the most common medical conditions and mental illnesses that can present

with depression-like symptomso. Correctly complete the Patient Encounter Form

STEPS

40 minutes

1. Show Slide 64: Session 4: Medical Evaluation and Management of Depression


2. Show Slide 65: The Physical Examination: Essential to Mental Health Care.


• Diagnosis of mental health disorders requires a team approach.

• Although psychologists/social workers are central to diagnosis and treatment, physicians are responsible for assisting by doing a proper medical evaluation of patients.



• Patients die because a medical problem is misunderstood to be a psychiatric one, and as a result the person does not receive an adequate medical evaluation.

• Similarly, patients with mental disorders are often not evaluated for co-morbid medical conditions, leaving these patients at risk from potentially preventable illness.

3. Show Slide 66: Key Points Before Considering a Patient “Psychiatric”.

Review each of the bullet points.

4. Show Slide 67: Delirium.

Mention the differences between delirium and psychosis (which are often confused):

• Hallucinations, most often auditory, “hearing voices”

• Seeing hallucinations that are not transient

• Usually develops more slowly; family has often noticed problems for a long time

• Symptoms usually change over weeks to months

5. Show and read Slide 68: Medical delirium is not a psychiatric problem!

6. Invite participants to break into groups of three. Assign one set of questions to each of the groups (if there are more than three groups, assign sets of questions to more than one group). Give participants ten minutes to discuss their answers to the questions assigned to their group.

Group 1:

• What are the symptoms of alcohol withdrawal?

• Who do you think is at risk of alcohol withdrawal? Why do you say this?

• How would you differentiate between the patient with depression and the patient with alcohol withdrawal?

Group 2:

• What drugs and poisons can cause psychiatric symptoms if ingested?

• Who do you think is at risk of drug or poison ingestion/overdose? Why do you say this?

• How would you differentiate between the patient with depression and the patient experiencing a drug overdose/poisoning?

Group 3:

• What medical conditions, unrelated to alcohol and drugs, can mimic a psychiatric illness?

• Who do you think is at risk of these medical conditions? Why do you say this?



• How would you differentiate between the patient with each of these medical conditions and a patient with depression?

7. Wander from group to group and provide support as needed. After ten minutes, ask the groups to reconvene, invite the groups that discussed the first set of questions to present their answers to each of the questions. Do the same for the second and third set of questions.

8. Show Slide 69–70: Medical Condition.

Then compare participant answers to those on the slide.

9. Show Slide 71: Poisons and Drugs.

Read slide and compare participants’ answers.

10. Show Slide 72: Medical Conditions Can Cause Depression.


11. Show Slide 73: Medical Conditions: Neurologic Problems.


20 minutes

12. Show Slide 74: Do a Physical Examination First!

Although the psychologist/social worker is occasionally the first to see a patient with suspected depression, most patients referred by CHWs or nurses for depression will, as a matter of routine, first see the physician to eliminate physical causes of illness. Even the occasional patient who sees the psychologist first must be referred to the physician before the psychologist/social worker can make a final diagnosis.

13. Show slide 75: Components of the Physical Examination.

List the components of the Physical Examination section of the Initial Mental Health Evaluation Form, which can be found in the annex of their participant handbooks. The physician will complete this section.

14. Show Slides 76: Neurological Exam.

The physical exam includes the neurologic exam. The physician will also complete this section.

15. Show Slide 77: Patient Encounter Form.

The Patient Encounter Form guides the psychologist/social worker at first contact. Refer participants to this form in the annex of their participant handbooks. Suggest they follow along as this form is reviewed.



The first step is to fill in the date and patient demographic information at the top of the form (animate the circle). Note that the physician, nurse and CHW also have patient encounter forms, but they are slightly different from that for the psychologist/social worker.

Animate the arrows: Notice that the top row of rectangles screen for suicidality, danger to others, mental health crisis, prescribed medication and medical symptoms (including epilepsy and psychosis). Should the patient fall into any of these categories, he/she will be referred for same day treatment referral to physician as well as depression screening by psychologist/social worker. All other patients are triaged based on their ZLDSI score.

Give participants a few minutes to read through the Patient Encounter Form. Then give them a few quick examples to see if they can trace the recommended pathways for the following patients (although there are three cases below, you should feel free to go through the last two quickly). After each of the three patients, ask participants to point to the patient encounter form projected on the screen/wall and trace each patient’s pathway, reading the text in each rectangle that creates that path. Then animate the slide to check the answer.

A. Patient 1 is homicidal, trace her pathway on the patient encounter form.

Animate Slide 78: Patient Encounter Form, Patient 2 to show the pathway.

B. Patient 2 has just been diagnosed by the physician as having epilepsy, trace his pathway on the patient encounter form.


C. Patient 3 is suicidal, trace his pathway on the patient encounter form.




SESSION 5: Initial Mental Health Evaluation

Methods: Facilitator presentation, role plays

Time: 2 hours




Preparation:

• Review the role plays, Facilitator Manual, PowerPoint slides 81–94

• Review the Initial Mental Health Evaluation


p. Model appropriate interviewing skillsq. Correctly complete the psychologist/social worker sections of the Initial Mental

Health Evaluation

STEPS

30 minutes

1. Show Slide 81: Session 5: Mental Health Evaluation.


2. Show Slide 82: Expectation.

Explain to participants that the expectation is that you will work with the physician to ensure the completion of the complete initial mental health evaluation, as described on the slide.

Throughout this session and the next, emphasize the importance of working collaboratively with the physicians, nurses and community health workers at their sites. A multidisciplinary, integrative approach is essential to the success of this work.

3. Show Slides 83–84: Mental Health Care General Principles.

Review each bullet point. Ask participants what they think of this list. Be sure to emphasize the important of being aware of your own current emotional states, for example, if tired, upset, hungry, or irritable. Ask participants:



• Would you like to add anything to this list?

• Are there any principles that would be difficult to adhere to?


• If a patient thought that you were judging them, what do you think they would do? (Ensure the group recognizes that patients who feel uncomfortable in a clinic setting tend to drop out of care.)

• What other interview skills are important when discussing sensitive health information with a patient? Record participant responses on a sheet of flip chart paper.

5. Show Slide 85: Basic Interview Skills.

Compare participant responses with the skills listed on the slide. Stress that these are essential skills not only for doing a mental health evaluation, but for all patient interactions. These skills are helpful in personal communication as well!

For the following skills, ask participants to come to the front of the room and give examples of how this is done. Elicit as many examples as possible, one skill at a time:

• Show empathy

• Active listening

• Ask open-ended questions

50 minutes

6. Ask a volunteer to come forward and assist with a role play. Ask the volunteer to play the physician while you play the role of the patient in the case study below.

INTERVIEW ROLE PLAY 1: JOSIE

Background Information to Inform Role Play:

Josie is a 52-year old woman who has come to your clinic. She says that “she has no interest in anything.” Her physical symptoms include low energy, shaking and trembling throughout her body, irregular menstrual flows, and insomnia. When asked about her family, Josie admits that she resents her mother and father (who have now passed away): her father married multiple times. He was also verbally and physically abusive to her. Josie’s mother, because she was divorced from Josie’s father when she was six years old, moved to Port-au-Prince. Because money was tight, Josie’s mother dealt with the stresses of life by becoming angry and violent with her and her siblings (Josie was the oldest child).



INTERVIEW ROLE PLAY 1: JOSIE (continued)

Josie left home at 17, married at 25 and eventually had four children. This episode of depression was triggered when her oldest daughter, who is now 26, did not meet her expectations. Josie found herself reacting angrily to her daughter, as her mother had done to her so many years ago. Josie’s communication with her husband is very poor.

Script:

Psychologist: Could you please tell me a bit about the problem that led to your coming here for treatment?

Patient: responds according to the story

Psychologist: Can you tell me a little bit more about (problem/symptom/illness)? (explore chronology of events)


Psychologist: Are you currently treated for this (problem/symptom/illness)? How? Are you taking any medications for this? Have you even taken any medication for this?


Psychologist: Over the past two weeks how often have you felt little interest or pleasure in doing things?


Psychologist: Over the past two weeks how often have you been feeling down, depressed, or hopeless?


Psychologist: OK. I’m going to ask a few questions about your medical history now… (role play ends).

Adapted from: Flower Essence Society, Journey out of Depression. Available at: http://www.flowersociety.org/journey.htm

Role play for a few minutes, until the volunteer has had a chance to model all three skills.

7. Lead a brief discussion with the whole group, asking participants:

• How did the psychologist show empathy?



• How did s/he show she was listening actively?

• What open-ended questions did she ask?

8. Divide participants into pairs. Each pair should choose a role play from the box below to practice the following skills:

• Show empathy

• Use active listening

• Ask open-ended questions that will help you to understand the problems that the person is having in her or his life

9. After five minutes participants should switch roles; they may switch role plays as well if they want. As pairs practice, circulate, observe/listen, and support.

10. Ask one pair to come forward and perform their role play for the whole group. Lead a brief discussion on the pair’s performance.

INTERVIEW ROLE PLAY 2: CATHELINE

Your patient, Catheline, is a 45-year old woman whose daughter died giving birth about two months ago. People have gone back to their usual routine and the expectation is that she, too, will return to normal. In reality, Catheline has just begun to grieve. She is depressed, confused, questioning, looking for answers, and angry with the recently deceased daughter, who (in the days before her death two months ago) refused to go to the maternity ward when she started bleeding.

INTERVIEW ROLE PLAY 3: EMMANUEL

The CHW brings Emmanuel to the clinic, Emmanuel is 35 years old. Emmanuel hardly speaks and when he does, it is monosyllabic. There are long silences. Sentences are started and stopped midway through. Thoughts are not completed. The man seems somewhat distracted. It seems that his wife left him and he feels this indicates a real failure, a personal disgrace, and a humiliation.

INTERVIEW ROLE PLAY 4: GABY

Despite earning good grades in secondary school, your patient, Gaby—a 19-year old woman, was not accepted to university to study medicine. Her life had been totally centered on this goal and now it feels as if the world has come crashing in around her. Complaints are somatic, i.e., unable to sleep, loss of appetite, weight loss, sadness, without energy.



11. Discuss the remaining skills briefly one at a time (whole story, energy level, follow the patient’s lead regarding religion or spirituality), asking for examples how each is done.5

40 minutes

12. Show Slide 86: Initial Mental Health Evaluation, Page 1.

Explain to participants that the interview skills that they have just learned are important for any patient consultation, but certainly for the initial consultation. These skills set the tone for all future consultations, determine level of trust between provider and patient, affect whether the patient will return for follow-up care, and determine—at least in part—the successfulness of your overall intervention.

Tell participants that we are now going to transition from interview skills to the application of these skills in the initial mental health evaluation.

Invite participants to turn to the Initial Mental Health Evaluation Form in the annex of their participant handbooks. This form should be used to guide the mental health evaluation and can be used to ensure that the evaluation is thorough. It is critical for psychologists/social workers to understand how to conduct, and document, a basic mental health evaluation. This form was introduced in the last session, when the sections to be completed by the physician were pointed out; it will be discussed in more depth now.

Give participants about five minutes to read the form.

USE THE INITIAL MENTAL HEALTH EVALUATION FORM

Use the evaluation form (rather than the slides) to guide your presentation of the patient evaluation procedure.

13. Explain that the psychologist/social worker would typically complete everything on the Initial Mental Health Evaluation Form with the exception of the sections completed by the physician, which are:

• Medical review of systems

• Physical Exam

• Mental Status Exam

14. On page 1 of the Initial Mental Health Evaluation Form, the psychologist/social worker completes the following sections:

5. Lena Verdeli



• Demographic section

• Chief Complaint

• History of Present Illness

The demographic section at the top of page 1 is straight-forward, but the other two sections deserve further discussion.


• How do you ask about the chief complaint? Elicit several ideas from the group. Ensure that answers are open-ended questions.

Explain to participants that eliciting the chief complaint allows us to practice some of the basic interview skills, including: using active listening; asking open-ended questions; trying to learn the person’s whole story by starting with their own words; and following the person’s lead. Because people who are experiencing a mental health problem are potentially marginalized and their human rights potentially violated, it is particularly important to take your time with chief complaint and history of present illness.


• What are some ways that we can elicit the history of present illness? Elicit several ideas from the group, ensure suggested questions are open-ended. Possible answers:

– Could you briefly describe the events or circumstances that led to your coming to the hospital?

– What is your understanding of why these things have happened/what the problem is? Why do you think these things are happening?

– Can you tell me a little bit more about (problem/symptom/illness)? (explore chronology of events)

– Are you currently treated for this (problem/symptom/illness)? How? Are you taking any medications for this? Have you even taken any medication for this?


Psychiatric review of symptoms: refer participants to the listing of questions on the evaluation form under the categories of depression, mania, anxiety and psychosis; as well as the questions under suicide, violence/homicide, substance abuse, and trauma (trauma is on page 3 of the form). Give them a moment to read all of the questions. Note that the questions are written as the psychologist/social worker would ask the patient; in other words, the healthcare provider can read the questions to the patient and record the patient’s response on the form.

Ask participants what questions or comments they have about these psychiatric screening questions. If there are participants in the group who have experience using the form, ask them to share their experiences.



Explain to participants that the goal of taking a thorough history is to obtain a range of information by moving from the open-ended to the specific. The evaluation form contains specific questions to assist you in obtaining specific information related to a range of possible mental disorders.


• Physical symptoms: Refer participants to the physical symptoms table on the third page. Explain to participants that they should ask each of the questions in all 12 categories (from pain and whole body to neurological).

• Ask participants: What would you ask your patient to obtain a complete psychiatric history, including family psychiatric history?

At the bottom of the third page, ask if the patient has ever experienced head injury or lost consciousness. If so, record approximate date. Ask about date of last menstrual period and record. Under “Other things” enter any information shared by the patient that doesn’t fit elsewhere on the form.


Explain to participants that on this page they will ask and record information about:

• Medication/Allergies/Side effects. Ask the patient:

– What medications are you taking? Please include medicines that may have been given to you by family members, friends or traditional healers.

– What allergies do you have?

• Medical Family History. Ask participants how they enquire about family medical history. After a few responses have been offered, note that questions are usually asked in a similar fashion to the questions about family psychiatric history (above).

• Social/Cultural History including legal problems. Explain to participant that social history is an essential component of the evaluation, and provides very important information to help better understand the patient. In this part of the evaluation form, the psychologist/social worker would ask the patient about childhood family configuration, urban or rural setting, level of education, romantic relationships, and occupation or other means of financial support as well as home life, school, neighborhood, religion, and legal problems. Ask participants with experience to share how they take social histories, and to give examples from their experiences (maintaining patient confidentiality).

The physician will complete the section on the physical exam (including neurologic exam) and the mental status exam (on page 5 of the form).



Ask participants:

• What do you do when you complete an evaluation to help you pull all the information elicited together and decide on a plan for your patient? Give participants a few minutes to think this through.

20. Show Slide 90: Summary, Formulation and Decision-Making.

Compare the key questions on this slide with participants’ responses to the question above. The responses to these questions will help you complete the biopsychosocial formulation on page 5 of the Evaluation Form.


Explain to participants that the biopsychosocial formulation and diagnosis sections of the Evaluation Form may be completed after the patient leaves the office. The biopsychosocial section should include the psychologist/social worker’s overall assessment of the patient’s strengths and coping strategies. The psychologist/social worker should record here key observations that will assist with the therapy, psychoeducation including medication adherence support or any other part of the plan.

22. Show Slide 92: Multiaxial Diagnostic Assessment-DSM IV.

The Initial Mental Health Evaluation Form lists Axis I-IV. This system, developed from the DSM-IV, is intended to help healthcare providers articulate and communicate diagnostic impressions. The psychologist/social worker will need to fill in the patient’s diagnostic assessment against the most accurate axis.

23. Show Slide 93: DSM

While the Diagnostic and Statistical Manual of Mental Disorders (DSM IV, 1994) represents the official classification system of psychiatric conditions in the United States, it should be used with caution in other contexts and cultures. WHO endorses the International Statistical Classification of Diseases and Related Health Problems (ICD). In some circumstances, neither of these may capture particular clinical presentations in local context. The protocols have been adapted carefully from the DSM, based on the experience of Zanmi Lasante clinicians and with attention to local context.

24. Show Slide 94: Plan/Disposition.

This is the last section of the Initial Mental Health Evaluation Form, where the psychologist/social worker should fill in the date of next visit, recommended follow-up activities and actions required.

25. Ask participants what questions they have on the Initial Mental Health Evaluation.



SESSION 6: The ZLDSI

Methods: Facilitator presentation, role play, case studies





Preparation:

• Review the role play, case studies, Facilitator Manual, PowerPoint slides 95–99.

• Review the Zanmi Lasante Depression Screening Inventory.


r. Conduct the Zanmi Lasante Depression Screening Inventory s. Explain the collaboration between the physician and psychologist/social worker in

evaluating patients with symptoms of depression

STEPS

60 minutes

1. Show Slide 95: Session 6: The ZLDSI.



Explain to participants that they will remember the depression care pathway from Session 2, when it was introduced as a screening/referral as well as a tracking tool and to guide care. The pathway relies on ZLDSI scores to guide the treatment plan.

3. Show Slide 97: ZLDSI.

Refer participants to the ZLDSI in their participant handbooks. The depression screening tool, called the Zanmi Lasante Depression Screening Inventory, has 13 items and was developed so that it could be used by any level of healthcare provider: CHW, nurses, social workers, psychologists and physicians.

Tell participants that today, we will learn how to use the ZLDSI:



• The intention of the ZLDSI is to provide not only a numerical score that can guide assessment and referral, but also a score that can guide treatment over time, and as a measure of clinical improvement.

• It is intended to be a simple and quick tool to use. However, there are certain steps which will make its use easier. One of those steps is preparing the patient to respond to the format of the questions; the questions may confuse patients unless properly introduced. The healthcare provider should also be sure to take his/her time when eliciting patient responses, and not rush through the questions.

4. Show Slides 98: How to Use the ZLDSI.

Review the bullet points on the slide.

5. Then explain that the group will now practice using the ZLDSI. Ask your co-facilitator or an experienced participant to come to the front of the room to role play with you, to model how the ZLDSI should be used. Play the role of the physician, and ask your colleague to play the role of David (see box below).

ZLDSI ROLE PLAY 1

Background Information:

David is a 28 year-old married male. He has a very demanding, high stress job in the Ministry of Health. David has always been a high achiever. He graduated with top honors and still has very high standards for himself and can be very self-critical when he fails to meet them. Lately, he has struggled with significant feelings of worthlessness and shame due to his inability to perform as well as he always has in the past.

For the past few weeks David has felt unusually fatigued and found it increasingly difficult to concentrate at work. His coworkers have noticed that he is often irritable and withdrawn, which is quite different from his typically upbeat and friendly disposition. He has called in sick on several occasions, which is completely unlike him. On those days he stays in bed all day, watching TV or sleeping.

At home, David’s wife has noticed changes as well. He’s shown little interest in sex and has had difficulties falling asleep at night. His insomnia has been keeping her awake as he tosses and turns for an hour or two after they go to bed. She’s overheard him having frequent sad-sounding phone conversations with a brother, which has her worried. When she tries to get him to open up about what’s bothering him, he pushes her away with an abrupt “everything’s fine”.

Although he hasn’t ever considered suicide, David has found himself increasingly dissatisfied with his life. He gets frustrated with himself because he feels like he has every reason to be happy, yet can’t seem to shake the sense of doom and gloom that has been clouding each day as of late.



ZLDSI ROLE PLAY 1 (continued)

Role Play Instructions:

The physician should use the ZLDSI to screen for depression.The patient should respond according to the information given in the background section.

Adapted from: DeepDiveAdmin. PsyWeb.com. May 15, 2013. Available at: http://www.psyweb.com/Casestudies/CaseStudies.jsp

6. Ask participants to observe carefully, and to mark their copies of the ZLDSI as the patient responds.

7. When the role play has concluded, ask participants for their observations and comments about how you handled the ZLDSI, and discuss as needed. Then, for each ZLDSI question, ask the group how they answered and discuss as needed.

8. Finally, ask participants:

• If David was a poor village farmer (and not an MOH employee in a high stress job), whose answers to the screening questions were the same, but less articulately voiced, would you have scored him the same way?

• How do you think the farmer’s symptoms might present in contrast with those of David’s?

9. Return to Slide 96: Care Pathway: Depression.

Place this patient’s score on the pathway. Ask participants: given his score what should be done next?

10. Show Slide 99: When in doubt about a diagnosis

Emphasize to participants that it is critical that as general practitioners they learn to do a basic mental health evaluation. Explain to participant that:

• If you find yourself in doubt about a diagnosis, or have a question about a case you are seeing, then you should consult with the mental health team.

20 minutes

11. Divide participants into small groups of three or four participants each, refer them to the case below.

12. Give groups 10 minutes to discuss the case and answer the questions that follow each one.



ZLDSI CASE STUDY

Case Questions

1. You see a young man at the clinic. You perform an evaluation, as you have been trained to do. He reports some potential depression symptoms. You find that he has a ZLDSI score is 13. What is your course of action?

Answer: Refer patient to the local CHW that can perform follow up and IPT in the community.

2. A 35 year old woman who has had difficulty participating in her regular activities for the past six months is screened for depression by a CHW using the ZLDSI. This woman has a score of 32 so she is referred to you. You perform an evaluation, as you have been trained to do. You determine that it is most likely that the woman is depressed. What is your course of action?

Answer: Refer to psychologist. Discuss providing medication. Ensure she is supported in the community by the CHW.

13. When groups have finished working, ask each group to report on one answer or aspect of the case. Encourage discussion as needed.

14. Ask participants what questions they have on the ZLDSI.



SESSION 7: Managing the Suicidal Patient


Time: 40 minutes




Preparation:

• Review and practice the role plays, Facilitator Manual, PowerPoint slides 100–111

• Review the Suicidality Screening Instrument, Suicidality Treatment Guidelines, Safety Plan


t. Explain how to screen for suicidal ideation and manage suicidal patients consistent with their severity and risk level.

STEPS

40 minutes

1. Show Slide 100: Session 7: Managing the Suicidal Patient.

Introduce this session by reading the objective.

2. Show Slide 101: Definitions: Self-Harm/Suicide

Read the definitions of self-harm and suicide.

3. Show slide 102: Evaluating Patients for Suicide: True or False?

Click once to show the statement, than ask participants if the statement is true or false. Click again to show the answer, and then a third time to show the explanation. Tell participants that a key component of safety includes the identification and triage of patients who may have suicidal ideation. Ask participants:

• Who do you think should be screened for suicide?



4. Show Slide 103: Self-Harm/Suicide Screening, Who?

Read the slide and ask participants if they have any questions about who should be screened for suicidality (the tendency to commit suicide).

Tell participants that in a moment they will see that the Suicidality Screening Instrument asks about thoughts or plans of self-harm in the last two weeks and last year.

5. Explain to participants that psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. If the patient does have a history of suicide attempts, as determined during the Initial Mental Health Evaluation, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk.

If it is not immediately apparent if the patient has a history of suicide attempts, but there is a concern about the possibility of self-harm (either because of a history of self-harm, or because the patient didn’t preclude the possibility during the Initial Mental Health Evaluation, or for any other reason), the psychologist/social worker should also administer the Suicidality Screening Instrument. Ask participants:

• Raise your hand if you have worked with patients who have committed acts of self-harm or have attempted suicide.

• Would anyone like to share their experiences in handling those patients?

• What steps did you take, as a psychologist, when you learned about the patient’s act of self-harm or suicidal ideation?

6. Show Slide 104: Suicidality Screening Instrument.

Refer participants to the one-page Suicidality Screening Instrument in the annex of their participant handbook. Explain that psychologists/social workers will use the Suicidality Screening Instrument to determine the severity of suicidal ideation depending on the answers of the patient. Give the participants one to two minutes to read over the screening instrument.

7. Tell the participants that they will ask the six questions on the Suicidality Screening Instrument in order, and for each question the psychologist/social worker will inquire whether the patient had those thoughts in the past two weeks and/or in the past year. The psychologist/social worker will check the answer that the patient gives for each question (yes or no). If the patient gives details or information during the screening, it should be written down in the appropriate “description” space. If a patient says no to a question in both columns, the interview ends there and should not continue (because each question builds on the one before it, assuming “yes” was indicated).

8. Explain when the psychologist/social worker has finished asking the questions (or has received a no for both columns, ending the interview), the psychologist/social worker will



add up the number of “yes” in each column and write the total number of “yes” for each column on the scoring line. Then, the participants will look at the scoring criteria below and determine the risk depending on the scores for the current column and the past column. Ask participants:

• Does anyone have experience using this particular screening instrument? If so, what was your experience with it? Did you find it helpful? What was the outcome?

9. Tell participants they will now have the opportunity to practice screening for suicidality through one guided role plays (see the box that appear below). Divide participants into pairs: one person will play the psychologist/social worker, while the other will play the patient.

10. Ask participants to turn to the role play in their participant handbook. Participants will have three minutes to complete it, following the script in the participant handbook. Once the role play is complete, the psychologist/social worker role will have the responsibility of scoring the interview. After participants have finished the role play (it should take no more than three minutes), remind the psychologists/social workers to record their score on the sample screening instrument in their participant handbooks.

ROLE PLAY

Psychologist/Social Worker: Hello Emmanuel.

Patient: Hello.

Psychologist/Social Worker: I’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the health facility is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that I would like to be helpful to you.

Patient: OK.

Psychologist/Social Worker: Sometimes, when things are particularly difficult, some people have thoughts of not wanting to live. Over the last two weeks, have you wished you were dead?

Patient: No.

Psychologist/Social Worker: Over the last year, have you wished you were dead in the past year?

Patient: Yes.

Interview continues because patient said yes.

Psychologist/Social Worker: Over the last two weeks, have you had thoughts of killing yourself?



ROLE PLAY (continued)

Patient: No.

Psychologist/Social Worker: Over the past year, have you had thoughts of killing yourself?

Patient: Yes. Things were just so hard!

Interview continues because patient said yes.

Psychologist/Social Worker: Over the last two weeks, have you been thinking of ways to do this?

Patient: No.

Psychologist/Social Worker: Over the past year, have you been thinking of ways to do this?

Patient: No. I never decided to do anything.

Interview ends because patient said no to each column of a question.

11. After the participants have finished the role play, bring them back together.

12. Show Slide 105: Determining Suicide Risk: Scoring of Screening Instrument.

Animate the title. Ask the participants who were the psychologists/social workers in the role play what score they determined. Take a few answers from the participants. Animate the slide text. Tell them the correct scoring is:

• Now/In Past 2 Weeks = 0

• In Past Year = 2

Go over any questions if participants determined a different score.

13. Tell participants that once they have a score from the Suicidality Screening Instrument, they can determine category of risk. There are three categories of risk: low, medium and high. The level of risk takes into account both the scoring from the questions “now or in the past two weeks” and “in the past year”. The category of risk is important as it guides the psychologists/social workers when using the Suicidality Treatment Guidelines.

14. Ask participants to use the score for the last role play to determine the level of risk for the patient. Ask:

• What is Emmanuel’s risk category? Wait for participants to give answers. Confirm that he would be “medium risk”.



15. Show Slide 106: Suicidality Treatment Guidelines.

Explain that once a level of risk is determined, psychologists/social workers will use the Suicidality Treatment Guidelines to treat the patient accordingly. Have the participants look at the Suicidality Treatment Guidelines in their participant handbooks. Explain that the guidelines walk the user though that which they should do, say, refer to, record and follow up with in terms of treatment for the patient. Follow the steps on the first page (“For ALL Patients”) with all patients, including those who are low-risk. If a patient is medium or high risk follow the steps in the next box, at the top of page 2 (“For patients with MEDIUM risk…”). If a patient is high risk, they should also receive the treatment listed in the third and last box, “For patients with high risk….”

16. Show Slide 107: Safety Plan.

Tell participants to look at the first row in the Treatment Guidelines under “for all patients”; the row labeled “Act”. The third point refers to developing a safety plan. Tell participants that all patients who are screened for suicidality, whether low risk or high risk, need a safety plan. A safety plan is a plan, collaboratively developed by the patient and psychologist/social worker, that supports patients to decrease their risk of suicide. Have the participants turn to the Safety Plan in the annex of their participant handbook.

17. Show Slide 108: Suicidality: Safety Plan.

Explain that psychologists/social workers will go through creating a plan with the patient that will outline how the patient will recognize when they are in a crisis, and how to prevent suicide through five distinct steps (if one step fails to decrease the level of suicide risk, the next consecutive step is followed).

18. Show Slides 109–110: Safety Plan Instructions.

Have a participant read through the steps on the slide that outline the components of a safety plan. Remind participants that their role as psychologist/social worker is to support patients in creating this plan (the psychologists/social worker is not creating this plan for the patient!).

19. Show slide 111: Considerations When Creating a Safety Plan.

Read the points on the slide and emphasize that the most important aspect of the safety plan is its accessibility and ease of use. A safety plan will not be helpful if there are obstacles in the plan that the patient cannot overcome. The psychologist’s/social worker’s role is to discuss with the patient the feasibility of each step in the plan so the patient is prepared.

Ask if there are any questions about the Safety Plan.

20. Conclude the session by noting that safety is the first pillar of emergency management. Talking to a patient effectively and helping the patient to feel safe and respected—not simply medicating a patient—is a key part of safety and evaluation.



SESSION 8: Basics of Interpersonal Psychotherapy (IPT)

Methods: Facilitator presentation, small group discussion, group presentations

Time: 2 hours


Materials: � PowerPoint presentation � IPT Manual (one for every facilitator

and participant)

� Flip chart � Markers, pens � Tape

Preparation:


• Write the 4 interpersonal problem areas on four sheets of flip chart paper: 1) Strategies to handle grief 2) Strategies for Interpersonal Disputes 3) Strategies for Role Transitions 4) Strategies for Interpersonal Deficits, Social Isolation


u. Provide an overview of the general principles of Interpersonal Psychotherapy (IPT)v. Outline the key steps in each of the three phases of IPTw. Discuss the strategies used during IPT to help patients deal with depression and prevent

future episodes of depression

STEPS

30 minutes

1. Show Slide 112: Session 8: Basics of Interpersonal Psychotherapy (IPT).


2. Show Slide 113: Assigning tasks to provider roles.

This slide, which participants have already seen (Session 2), illustrates the tasks involved in a system of care designed to identify and provide care to patients with depression. It also illustrates how IPT and other targeted psychological interventions fit into the team approach to the treatment of depression. Explain to participants that target psychological interventions are central to the psychologist/social worker role.



3. Show Slide 114: Psychotherapy & the Role of the Psychologist/Social Worker.

Ask participants:

• What psychotherapy approaches have you used before?

Animate the slide to fill in any approaches not listed by participants. Explain to participants that this is a partial listing of the spectrum of targeted psychological interventions available to psychologists and social workers to support patients with depression and/or other mental illnesses. The following is background information on the more common techniques:

• Interpersonal therapy: Effective for depression. Addresses relationships in the “here and now,” with a focus on four areas: grief; role transitions; role disputes; and interpersonal deficits.

• Supportive psychotherapy: Aims to minimize levels of emotional distress. It can include the provision of support by giving the person and family hope, assigning the person the sick role if appropriate, and helping the person and the family to mobilize social supports.

• Cognitive-behavioral therapy: First-line treatment for anxiety and mild depression. Based on the theory that antecedent events stimulate thoughts and beliefs that cause emotional consequences. Problem-oriented.

• Family Therapy: Problems exist in family interactions and not just in individuals. Solutions involve improving communication, reframing of behaviors and giving directives to disrupt dysfunctional patterns.

The following support is typically provided as part of therapy or as a complement to therapy, based on patient need:

• Psychoeducation

• Family and social support

• Vocational training

• Addressing stressors

• Relaxation techniques

• Problem solving

• Encouraging activity


Ask participants to recall the care pathway for depression. IPT appears in two of the boxes in the flowchart. Not only is IPT appropriate for those with mild depression,



for whom it can be provided by the CHW; but it is also appropriate for patients with ZLDSI greater than 18 (for whom medication is or is not indicated—as per physician recommendation), for whom it is offered by the psychologist/social worker.

5. Show Slide 116: IPT in the Depression System of Care.

Read the slide as background to IPT in Haiti.

6. Show Slide 117: IPT: General Principles.

Read the bullet points.

7. Show Slide 118: IPT: Problems Associated with Depression.

Review the bullet points. Explain that we will get back to these four problems in a moment.

It is important to note that community health workers are being trained to undertake interpersonal assessments. The interpersonal assessment involves finding out what might be causing the person’s depression, given the four main triggers, or interpersonal problem areas listed on this slide.

8. Show Slide 119: The Focus of IPT.

Review the bullet points as background information on IPT.

9. Show Slides 120–121: IPT: Three Phases

Provide an overview of the three phases of IPT using this slide. Explain to participants that the middle phase is generally 6-12 sessions, until remission of depression. We will discuss these three phases in more depth later.


• Thinking of the depressed patients with whom you have worked, what would you say triggered their depression?

• Record responses on the sheets of flip chart paper that you prepared earlier. Group participant responses into the appropriate category/on the corresponding flip chart paper: grief, disputes, life changes and social isolation.

• Then present the content below, drawing upon stories shared by participants.

11. Show Slide 122: Interpersonal Problems & Depression, Grief

Explain to participants that we are going to now go back to the interpersonal problems associated with depression and discuss each in turn. The first is grief.

12. Show Slide 123: Interpersonal Problems & Depression, Disputes



Explain to participant that the ongoing disagreement usually has to do with a different expectation between two people close to each other about how to handle situations or about what each person wants from the other. Depression arises when the patient does not believe that the disagreement can be solved.

Explain the stages of disagreement:

• Renegotiation—still trying to resolve the disagreement. The therapist helps the person find different ways of talking to the other person to manage the problem. A person in this stage still wants to work things out, but needs help with how to do it.

• Impasse—feels like nothing will work. The person feels stuck. Talking has stopped and there is a lot of anger. The person thinks that nothing can be done to make things better. The therapist tries to get the person to “try one more time,” and to find new ways of handling the problem.

• Dissolution—end of the relationship. It is too late for anything to get better and the therapist helps the person end the relationship and move on.

Use the bullet points on the slide to present the goals of therapy.

13. Show Slide 124: Interpersonal Problems & Depression, Life Changes.

Explain to participants that depressive symptoms can begin around the time of a life change. Explain that examples of changes are: a spouse having an affair, a new daughter-in-law moving into a husband’s home, a person learning that she has a medical illness, caring for someone who is dying, moving away from the family, not finding a job, a loved one moving away, poverty after the death of the household wage earner, separation or rejection by a lover.

14. Show Slide 125: Interpersonal Problems & Depression, Social Isolation

Read the slide.

30 minutes

15. Show Slide 126: Initial Phase, Session 1

Tell participants that they will now discuss how the IPT session proceeds starting with the initial phase, then the middle and termination phases. In the next session of this training (Session 9) the participants will have an opportunity to role play sessions during each of the IPT phases. They will start with the initial phase.

Explain to participants the key steps that the psychologist/social workers would work through during the first session: the Initial Phase. These key steps are listed on the slide. Most of the steps are self-explanatory, but the following key points maybe be helpful as you present:



• Step 3: Explain how sessions work. During this step, the psychologist/social worker will want to emphasize confidentiality, regular attendance, dropping out (“if you feel that you would like to stop coming, it’s important to come and discuss this, maybe we can find what the problem is and deal with it”), need for safety (suicidality/safety planning), and policy about cell phone usage during the session.

• Step 4: Review depression symptoms. During this step use the questionnaire. Once you have completed administering the questionnaire, discuss with patient their depression status, saying explicitly that the patient has depression using local terms.

• Step 7: Problem-solve with the patient about reducing the impact of depression on his/her current daily routine (find out who can help her now that he/she is trying to heal, for example, which relatives/friends can help with cooking, take care of children, etc.)

• Step 8: Find out what happened around the time when the patient became depressed (was there grief, dispute, transition or interpersonal deficit, which is long standing isolation or difficulty keeping friendships). It’s possible that there was a combination of more than one problem area.

• Step 9: Conduct the Interpersonal Inventory:

– Ask questions about the important people in the patient’s life, both alive and dead. The psychologist/social worker could ask: “I’m interested in knowing about the important people in your life. Who shall we start with? Tell me about him/her”

– Draw Circle of Important People to illustrate the relationships-the three concentric circles (optional)

• Step 10: When the psychologist/social workers summarizes the session, he/she will also:

– Reiterate that patient will get better

– Plan next meeting

16. Show Slide 127: Initial Phase, Session 2.

Discuss with participants the key steps that the psychologist/social workers would work through during the second session, which is still part of the Initial Phase. These key steps on listed on the slide. Most of the steps are self-explanatory, but the following key points maybe be helpful as you present:

• Step 4: Identify major problem area(s). The psychologist/social worker outlines his/her understanding of the patient’s interpersonal problem. Based on the information gathered, the psychologist/social worker determines the problem area(s) related to the current depression and choose one or two of the following:

– Grief

– Interpersonal Disputes

– Role Transitions



– Interpersonal Deficits

• Step 5: Get agreement from patient that this is the problem area(s) that he/she believes is causing depression and that he/she would like to change. Do not choose more than two problem areas; start slow.

• Step 7: If the patient disagrees with the chosen problem area, focus on the problem area as described and perceived by the patient. During the middle phase, the psychologist/social worker can link the patient’s identified issue to the issue previously named by the psychologist/social worker as the key problem area.

• Step 8: Explain the principles and rules of IPT. This should include: confidentiality; length and frequency of treatment; policy for missed appointments; ways to contact therapist during the week if there is a crisis.

17. Show Slide 128: Middle Phase.

Explain to participants that during the Middle Phase, the psychologist/social worker discusses with the patient the interpersonal problems that triggered the depressive episode. They also discuss strategies to improve symptoms and functioning. The Middle Phase lasts until remission of depression, typically 10–14 weeks.

As for sessions during other phases, the psychologist/social worker will want to start and end sessions as close to the time agreed as possible. The steps for sessions during the Middle Phase are listed on the slide. Most of the steps are self-explanatory, but the following key points maybe be helpful as you present:

• Step 3: Link depression to events from previous week and events from previous week to depression. For example, if patient says “I felt really down during the weekend”, find out what happened in the interpersonal events linked to his problem area. If patient says “I had a lot of fights with my mother in law” find out how this affected his depression symptoms before exploring what happened.


• What strategies do you use to help your patients handle grief? Record these strategies on flip chart and then compare with those listed on Slide 129: Strategies for Grief.


• What strategies do you use to help your patients handle interpersonal disputes? Record these strategies on flip chart and then compare with those listed on Slides 130–132: Strategies for Interpersonal Disputes. Explain that they will discuss the communication analysis, decision analysis and role play analysis techniques shortly.




• What strategies do you use to help your patients handle role transitions? Record these strategies on flip chart and then compare with those listed on Slide 133: Strategies for Role Transitions.

• In reference to the 9th strategy, explain that the psychologist/social can encourage the patient to talk to persons in power in the community by helping the patient identify these advocates and rehearsing what to say.


• What strategies do you use to help your patients handle interpersonal deficits, such as social isolation? Record these strategies on flip chart and then compare with those listed on Slide 134: Strategies for Interpersonal Deficits, Social Isolation.

30 minutes

22. Explain to participants that they are going to teach the next section of this session. Start by asking them to count off in 3s (participants should count off: 1, 2, 3, 1, 2, 3, 1 etc). All of the 1s should get together in one corner of the training room, the 2s in another, and the 3s in a third area. Assign participants the following topics:

• Group 1 will present on Communication Analysis

• Group 2 will present on Decision Analysis

• Group 3 will present on Role Play technique

23. Direct participants to their IPT-Haiti manuals, Section V. “IPT techniques used in the middle phase,” on approximately page 23. Tell participants that they will have about 10 minutes to prepare their presentations. Their presentations should include:

• An overview of this analysis/technique (what it is, when you might use it)

• An example of this analysis/technique, which could take the form of a role play or a story or recollection of using this technique in a clinical setting.

Participants may use PowerPoint slides or flip chart paper or any other training technique to convey key points. Small group presentations should be no longer than five minutes each.

24. Once participants have finished preparing their presentations, ask the first group to present (groups may present in any order). Listen carefully to ensure they mention all key points. Once they have completed their presentation, applaud and then invite questions and discussion. Repeat the process for the remaining two groups.



10 minutes

25. Show Slide 135: Termination Phase.

The Termination Phase is the last two weeks of IPT. Remind participants that the completion of IPT is explicitly discussed throughout therapy. Read the steps for each session during the termination phase.

26. Show Slide 136: Tips for the Psychologist/Social Worker.

Review the tips as listed on the slide. In reference to the fourth point, the following are examples of direct and open-ended questions.

• Direct questions might include:

– Could you tell me about your children?

– Who are the important people in your life?

– Who did you see this week?

• Open-ended questions include:

– Tell me about your depression and when you think it began.

– What is the reason you felt so sad this week?

See Section VIII in the IPT Manual “Suggestions for the therapist” for more information.

27. Refer participants to Section XI Appendix in their IPT Manuals (starting on approximately page 36). Point out the attendance forms, template for pre-group meeting notes, template for IPT post-group session note, the IPT Supervisory Meeting Preparation Form, and IPT Group Termination Notes. Given them five to ten minutes to read these documents.

28. Inform participants that in the next session they will be practicing IPT through a series of role plays. Ask if there are any questions on the content presented on IPT presented in this session.



SESSION 9: Interpersonal Psychotherapy (IPT): Practice


Time: 4 hours


Materials: � PowerPoint presentation � IPT Manual (one for every facilitator

and participant)

� Flip chart � Markers, pens � Tape

Preparation:

• Review the Facilitator Manual, PowerPoint slide 137

• Identify a colleague experienced in IPT (or psychotherapy in general), or a few experienced participants, to do the demonstration role plays with you. Practice the role plays ahead of time if possible.


x. Facilitate initial, middle and termination phase IPT sessions

STEPS

P A R T 1 – I P T I N I T I A L P H A S E

1 hour

1. Show Slide 137: Session 9: Interpersonal Psychotherapy (IPT): Practice.

Introduce this session by reading the objective. Explain to participants that this session is an opportunity to actually practice the IPT skills presented in the last session. Participants will spend most of the day doing role plays. The goal of the session is that participants will actually feel comfortable facilitating initial, middle and terminations phase IPT sessions for patients with any of the four problems associated with the onset of depression: grief, disputes, transitions, or loneliness and social isolation.


• Who can recall the general principles of IPT?

• What are the three phases of IPT?

• If you need to, go back to Slides 112–136 (Session 8 slide set) as a brief review.



3. Ask participants to put aside their IPT manuals. Ask your experienced colleague to come to the front of the room and role play the main components of session 1 of the initial phase of IPT (see section III. Initial phase – getting to know the person and the interpersonal context of their depression, on approximately page 6 in the IPT Manual). Use the script below as a guide. Limit the role play to 5–10 minutes.

DEATH OF A LOVED ONE—GRIEF, CASE 1

Paula is a 20 year old woman who has had two recent deaths in her family. Nine months ago her husband died of an unknown illness and four months ago her infant daughter also died. Paula just can’t get over their deaths. She cries every day, has trouble taking care of her two remaining children, she isn’t eating, can’t take care of her home, and feels that the future holds no happiness. She says that she never cried after her husband died because she didn’t have time. She was numb after her infant died. Her husband’s family took all of her possessions. When friends come to visit, Paula doesn’t want to talk and quickly finds reasons to have the friend leave. She stays at home whenever she can. Paula is fearful that she might die and leave her other children without any parent.

4. Ask participants to name the most important steps accomplished by the psychologist/social workers during the role play. As participants name them, write them up on to a sheet of chart paper in the correct order. Help or correct as needed.

5. Ask participants to find the information about IPT initial phase session 1 in their guides and review the information briefly. Ask participants to reflect on how the therapist did each of the session 1 steps.

6. Emphasize that an important part of the initial phase is conducting the personal inventory to identify the personal problem area(s) that is/are causing the depression.

7. For each interpersonal problem area, ask participants to name a few examples from their professional or personal experiences (maintaining confidentiality):

• Grief

• Disputes

• Transitions

• Loneliness and social isolation

8. Ask participants to close their guides. For each interpersonal problem area (one at a time), ask participants for examples of open-ended (also closed) questions that the therapist can ask in order to determine which problem area(s) is/are causing the depression. Write the examples onto the sheets that you posted.



9. Divide participants into pairs. Ask pairs to choose one of the four interpersonal problem areas and role play the therapist and patient, with the therapist conducting the personal inventory in order to determine the problem area(s). (The person playing the patient should invent a situation and details as needed.) Give pairs about 10 minutes to role play. Circulate and observe. If there is time, ask participants to switch roles.

10. Ask one pair to demonstrate their role play for the whole group for a few minutes.

11. Ask the following questions and encourage a brief discussion for 10-15 minutes:

• What did you learn by doing these role plays?

• What worked best? Why?

• What was most challenging? Why?

• How could you address the challenges?

12. Ask participants to open their IPT guides to pages 9-10 and read the sample questions for each interpersonal problem area.

13. Ask participants to close their guides. Ask your experienced colleague to come to the front of the room and role play the main parts of session 2 of the initial phase of IPT (see page 7 of the IPT Manual) focusing on #4-#8. Feel free to use the case study below as a guide. Limit the role play to 5-10 minutes.

DISAGREEMENTS—DISPUTES, CASE 2

A 32 year old woman, Carol, is married with four children. Since she became sick with a medical illness nine months ago, she was unable to care for her children, husband, and home as she had in the past. She tires easily and frequently felt so sick that she could not get out of bed. Carol says that she and her husband have been arguing more over the past few months. Her husband criticized her because the house was dirty, the dinner was not cooked, and she was not herself. He did not seem to understand, she says, that she doesn’t feel well anymore. He wants to take another wife so that he will be happy. Carol says that their home just isn’t happy anymore. She feels like giving up. Carol cries every day, she’s not eating or sleeping, she’s angry all the time, and she feels that she’s letting her husband and children down.

14. Ask participants to name the main things that the psychologist/social worker did during the role play, saying what the therapist did and how she or he did it. As participants name them, write the things (the what) onto a sheet of chart paper. Help or correct as needed.

15. Ask participants to find the information about IPT initial phase session 2 in their guides and review the information briefly (page 7 of the IPT guide).



P A R T 2 – I P T M I D D L E P H A S E

1 hour

16. Divide participants into four small groups and assign each group one of the four interpersonal problem areas (grief, disputes, transitions, loneliness/social isolation).

17. Ask small groups to read the overview for middle phase sessions on page 14 of the IPT Manual and then the tasks and examples for the problem area assigned to their group (Pages 14-22 in the IPT Manual). Groups should discuss and clarify the information as needed and write down any questions that have about it.

18. Ask each group to share the questions they recorded in the last step. Encourage experienced participants to answer and share their experiences.

19. Ask small groups to find the descriptions of IPT techniques used in the middle phase on pages 23-25 of the guide. These are the techniques taught using the group presentations method in Session 8. Review them briefly. Ask participants to share any experiences that they have using these techniques.

20. Ask participants to put aside their IPT manuals. Ask your experienced colleague to come to the front of the room and role play samples of an early and middle phase session. You can use the sample case study below as a guide.

LIFE CHANGES—TRANSITIONS, CASE 3

Susan is a 40 year old woman and mother of three children. Last year she and her family moved to another village. At first she was happy about the move because her husband had found a better paying job. For the past two months, Susan hasn’t felt as happy as she did when she first moved. She missed her old friends and did not feel close to her new friends. In her former town, Susan saw her two sisters and mother every day. Since the move she’s seen them only once. Her husband isn’t home as much as he was in his former job as he must work harder and longer hours. Susan finds that she’s angrier than ever before, she feels sad all the time, she doesn’t have any energy, and she can’t sleep at night. She wants to move back to her old home.

21. After role playing each sample, ask participants to identify the steps and techniques that the psychologist/social worker used and how she or he handled each step or technique. Encourage discussion.

22. Form small groups of participants and ask them to practice a role play of an IPT middle phase session for the problem area assigned to them previously (grief, disputes, transitions, loneliness/social isolation). Groups should choose one members to play the



psychologist/social worker and another to play the role of patient; other members should give feedback at the completion of the role play. Use the case below to guide the role play.

DEATH OF A LOVED ONE—GRIEF, CASE 4

A married woman in her early 60s lives with her husband and was diagnosed to be depressed. The woman was initially resistant to the process of IPT, but finally agreed to begin treatment. The first HIV related death struck her home in 1990 and by 2002 she had lost six of her eight children. One year after the deaths of the children, her married son disappeared and after a while she received information that her daughter had also died. She did not know exactly what happened and never saw the body nor buried her son. Together with her husband they had educated their children up to university level and most of the dead were the wage earners for their families. During the initial phase of IPT, she spent most of the time crying, and very little time talking about her problems. She spoke slowly and reported having difficulties sleeping, loss of memory, walking, eating, was emotionally exhausted, fearful, sad and very angry. She mentioned that she was sick but did not know what she was suffering from.

23. When groups have finished practicing, encourage a reflection and discussion of their experiences.

• What did you learn by doing these role-plays?

• What worked best? Why?

• What was most challenging? Why?

• How could you address the challenges?

24. If you have time, ask members from one group to come forward and perform their role play for the whole group. Limit the performance to 10 minutes or so.

25. Ask participants to provide constructive feedback, including what the performers did well and what could be improved.

P A R T 3 – I P T T E R M I N A T I O N P H A S E

1 hour

26. Ask participants to find the information about the IPT termination phase on pages 28-30. Divide participants into pairs. Ask them to review the information in pairs.

27. Ask pairs what questions they have about the information and clarify and discuss as needed.

28. Ask pairs to practice role playing a termination session, inventing a situation and details as needed.




A middle-aged man in a small village had his own business, which went bankrupt in 1992. He tried again but failed. At this point he felt useless and a failure as a man and became depressed. He began IPT treatment with the hope of dealing with his depression and finding something to do. During the initial phase, he was quiet and depressed. He saw his depression as clearly related to the difficulties associated with the failure in his business, which disrupted his life and left him with no role in the village.

29. When pairs have finished practicing, invite reflection and discussion the role play experience. If there is extra time, invite a pair forward to role play for the whole group, and afterwards invite constructive feedback from participants.

P A R T 4 – I P T P R A C T I C E

1 hour or more

30. Divide participants into pairs for role play practice. Ask them to role play an initial, middle, and/or termination phase IPT session (all three if there is time), using one of the case examples below, or inventing their own cases.

DEATH OF A LOVED ONE —GRIEF, CASE 6

The son of an old man died in the earthquake in Port-au-Prince. This son was his father’s sole helper. The old man began treatment in the hope of getting material help. According to him, the trigger for depression was grief plus the loss of assistance from his son. The belongings of the boy were still in Port-au-Prince, but the father didn’t have the money to collect them. This made him feel even worse.

DISAGREEMENTS—DISPUTES, CASE 7

Maria lives a quiet life in Port-au-Prince with her husband of six years and three children. Her husband has been a good father to their children and a good wife to Maria. Two months ago, a new woman moved into the neighborhood and the husband confessed he is attracted to this new woman. Months later, Maria found out that her husband has been having an affair with this woman and he stopped providing money, food, and psychological support to their family.




A depressed man in his late 50’s began IPT treatment to see whether it might help him feel better. In the initial phase, he told the therapist that his real problem was that he had been impotent for nine years since developing prostate cancer. His illness and impotence brought about his divorce. He told his story of how he learned about his prostate cancer and when his sexual problem began.

31. Organize the practice as best fits the time that you have and the level of participants’ experience.

32. After pairs have practiced, lead at least one reflection and discussion.

33. If you have time, ask at least one pair to perform a role play, followed by constructive feedback from the group.



DAY 2 AND 3: Bingo Review Game

Methods: Game

Time: 30 minutes

Materials: � Markers, pens � Small prizes for winners of Bingo

game (ex., sweets, etc.)

Preparation:

• Review the 37 bingo questions on the Bingo Questions Sheet in the annex

• Cut out the bingo cards in the annex so that there is one bingo card per participant. There are 10 different cards. If you have 20 participants, make two copies of each card, shuffle and distribute randomly, one to each participant.


• Recall key points taught in Sessions 4, 5, 6, 7, 8 and 9

STEPS

1. Distribute the prepared bingo cards to participants. Explain that the participants will now review Day 2 and Day 3 training content using a game called Depression Bingo.

2. Explain to participants that you [the facilitator] will read a question from your question cards. Read the questions in random order (do not read them in order from 1–37!). Check off each question as you read it so that it is not read more than once. Do not reveal the answer.

3. After a question is read, participants should think of the answer, and then look for the answer to that question on their Bingo cards. Note: there are 37 questions and each card has only 24 answers, so there’s a 35% chance that the correct answer is NOT on their card!

4. Participants who think they have the correct answer on their Bingo Card should quickly raise their hand (or stand up). The facilitator should choose one person to answer the question. If that person is correct, all participants with that particular answer on their Bingo Card may cross off the corresponding box on their Bingo card. If the participant provides an incorrect answer, the next person may venture a guess (continue until the question is answered correctly). Ensure that everyone has a chance to answer at least one question.



5. The first player to mark five squares across, up/down, or diagonally should yell “BINGO”. If someone has yelled bingo, the facilitator should ask that participant to read the answers that were marked to verify that there were no errors. If all answers are correct, then play to see who gets 2nd and 3rd place or stop the play.

6. When the game is over, review all remaining questions by reading the questions to the group and then asking someone (a different participant each time) to provide the correct answer. If the answer provided is incorrect, invite someone else to answer the question. Go through all 37 questions.

7. During this game, questions about the training content often arise. Use the game to clarify information and answer questions that the participants may have.

8. Reward the winners at the end of the game!



SESSION 10: Medication Management and other Treatments for Depression






Preparation:

• Review the case studies, Facilitator Manual, PowerPoint slides 138–156


y. Describe the non-pharmacologic and pharmacologic treatment options for depressionz. List the indications, dosage, mechanism of action, and adverse effects of depression

medications amitriptyline and fluoxetine aa. List the key psychoeducation messages for patients with depression

STEPS

30 minutes

1. Show Slide 138: Session 10: Medication Management and other Treatments for Depression.


2. Show Slide 139: Treatment: General Principles.

Explain to participants that treatment options for depression include medications (fluoxetine, amitriptyline). Medication is provided to those for whom it is indicated, as decided by the physician in collaboration with the psychologist/social worker. Medication is typically provided as an adjunct to the IPT, CBT or other form of counseling provided by CHWs, psychologists/social workers.

3. Show Slide 140: Medications for Depression.

Review the classes of medications as listed. SSRI = Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitors.



4. Show Slide 141: Prescribing: Key Definitions.

Review the bullet points on the slide. Note that:

• PO = Oral (per oral)

• IM = Intramuscular

• IV = Intravenosa/Intravenous

Animate the speech bubble, then ask participants:

• What are the key factors that go into a decision of whether to prescribe and what to prescribe?

• Record responses on flip chart paper.

5. Show Slide 142: True or False.

CLICK and ask question. Once participants have had an opportunity to respond to the question, CLICK again for the answer.

6. Shows Slide 143: Prescribing: Principles.

Review the bullet points on the slides and compare with participant responses on flip chart paper. Emphasize the importance of asking patients about traditional medications as well as those prescribed by a healthcare provider in a clinic.

7. Show Slide 144: Formulary.

Note that there are a range of medications across several types/classes (SSRI, TCA, Benzodiazepine, Typical Antipsychotic, Anticonvulsant, etc) used in the treatment of depression and other types of mental illness.

Tell participants that today we will discuss primarily fluoxetine and amitriptyline.

8. Show Slide 145: Fluoxetine.

Review the key points. Ask participants what questions they have about fluoxetine. Remind them that although they, themselves, are not prescribing, it is important that they understand this information. Show Slide 146: Fluoxetine, Adverse Effects

Review the adverse effects.

9. Show Slide 147: Medication Card for Depression

Refer participants to the Medication Card for Depression. They will see that the key points on fluoxetine are summarized on the Medication Card, as are the key points for amitriptyline, which will be discussed next. Give participants a minute or two to review the column on fluoxetine. Ask if there are any questions about this medication.



10. Show Slide 148: Amitriptyline.

Review the key points.

11. Show Slide 149: Amitriptyline, Adverse Effects.

Refer participants to the Medication Card for Depression, where they will find key points on amitriptyline. Give participants a minute or two to review the column on fluoxetine. Ask if there are any questions about this medication.

12. Tell participants that other than fluoxetine and amitriptyline, medications that are commonly prescribed for mental illnesses other than depression include:

• Diazepam, which is indicated for anxiety disorders, catatonia (characterized by muscular rigidity and mental stupor, sometimes alternating with great excitement and confusion), insomnia, seizures (status epilepticus), alcohol withdrawal.

• Lorazepam, which is indicated for anxiety disorders, catatonia, insomnia, seizures (status epilepticus), alcohol withdrawal.

• Haloperidol, which is indicated for schizophrenia, schizoaffective disorder, bipolar disorder in pregnant women, agitation in delirium.

• Risperidone, which is indicated for treatment of schizophrenia schizoaffective disorder, bipolar disorder, irritability in autism.

• Valproic Acid, which is indicated in the treatment of seizures and bipolar disorder. It is considered the most teratogenic of all antiepileptics, use carbamazepine for women who are pregnant.

13. Show Slide 150: Depression in Pregnancy

Review the bullet points in turn.

14. Show Slide 151: Geriatric Depression

Review the bullet points in turn.

15. Show Slide 152: Pediatric Depression

Review the bullet points in turn. Ask participants what experience they have had with caring for pregnant, geriatric or pediatric patients with depression. Where they treated? What were the outcomes?

40 minutes

16. Inform participants that they are going to transition from the provision of medication to psychoeducation. Psychoeducation is an essential component of depression care. Psychoeducation involves letting the patient know that she or he may have a mental



health problem or disorder (naming the problem), and explaining to the person and family members (if the patient consents) what that means in context.

Psychoeducation includes not only education about medication and adherence to medication, it includes discussion about the non-pharmacological treatments for mental illness and the provision of information tailored to the patient on changes they can make in their own lives to help them deal with depression and to prevent future episodes. Psychoeducation is integrated into every mental health patient visit, including repeat visits.

17. Ask participants to break into groups of three or four participants per group to brainstorm the following question:

• What are the core messages that should be included in psychoeducation for depressed patients?

• What additional messages are provided to patients on medications?

• Do these messages differ for different patients? If so, explain.

18. After 10 minutes ask participants to reconvene. Invite the first group to give two or three key psychoeducation messages for depressed patients, starting with patients not on medication. Then ask the next group for two or three additional messages. Repeat the process until all the groups have contributed to the list or until participants run out of new points. Then repeat the process for the next questions. Record their points on flip chart paper.

Finally discuss the third question (Do these messages differ for different patients? If so, explain). Ensure participants understand the important of tailoring messages to the patient’s level of understanding and situation (“meet your patient where she is”). The best way to gauge their level of understanding and interest is to ask questions and listen to their responses. Facilitate a five or ten minute discussion on this topic. Ask participants:

• What are some questions you might ask your patient to find out if s/he understood the psychoeducation messages you have just provided? (Possible answers: What questions do you have for me? Can you summarize what I’ve just said in your own words? What are you going to do tomorrow in light of what I’ve just suggested?)

19. Show Slide 153: Psychoeducation Key Messages and Slide 154: Psychoeducation About Medication.

Compare participants’ list with the points on the slides.

20. Show Slide 155: Medication Psychoeducation, Amitriptyline.

Use this slide to discuss common side effects of amitriptyline.

21. Show Slide 156: Medication Psychoeducation, Fluoxetine



Use this slide to provide an overview of the side effects of fluoxetine. Animate the speech bubbles (one at a time) and ask participants:

• On follow up visits, what do you ask a patient to find out how well they are adhering to their medication regimen? (Possible answer: How many times did you miss a dose of your medication over the past seven (or four) days? Did you take your medication yesterday? How about the day before yesterday?)

• What do you do when adherence is poor? (Possible answer: find out why adherence is poor; if it is due to side effects, help patient deal with minor side effects or discuss with physician switching medications if side effects are more severe. If adherence is poor because the patient forgets, discuss ways to remember.)

20 minutes

22. Divide participants into small groups of three or four participants per group. Refer participants to the case study in their participant handbooks. Give the groups 10 minutes (or more) to discuss the case that appears in the box below and respond to the question(s) that follow.

MEDICATION PSYCHOEDUCATION CASE STUDY

Your patient is a 68 year old male who is agitated and complains of appetite loss and low mood over the previous two months. During the consultation he was visibly sad, complains of inability to sleep, and loss of interest in farming and visiting children and grandchildren. He states that he always used to go to the field to work six days a week, but lately he just can’t get the energy to tend to the fields. The patient denies any suicidal thoughts. The physician’s physical examination and other investigations are normal, and the diagnosis of major depression is made by you [the psychologist/social worker]. This man was put on fluoxetine.

a. What psychoeducation messages will you discuss with him on the day he is first provided with his medications?

Answer:

• Depression is a very common problem

• Treatment is available and effective

• It is important for you to continue activities that used to be interesting or give pleasure, regardless of whether these currently seem interesting or give pleasure

• Maintain a regular sleep schedule

• Minimize alcohol use

• Store medication at room temperature, ensure it is not in the sun



MEDICATION PSYCHOEDUCATION CASE STUDY (continued)

• It may take up to 4 weeks before your symptoms improve

• Do not stop using fluoxetine suddenly, stopping suddenly can cause unpleasant withdrawal symptoms.

• Warn about possible side effects: nervousness, insomnia, nausea, headache, sexual dysfunction and explain that they will reduce with time. If he has any manic symptoms, thoughts of self-harm, or suicidal ideation he should return to the clinic immediately.

b. Assuming he is not experiencing any major side effects, what psychoeducation messages will you discuss with him during his first follow-up visit?

Answer:

• Discuss adherence, ask: Over the last seven days, how many days have you taken your medicine? At what time of day do you take your medicine?

• Discuss minor side effects and how to deal with them

• Find out what activities he has resumed

• Find out if he is sleeping enough and regularly; discuss alcohol use

• Find out where he stores his medications and make sure it is out of the sun and away from children

c. How about during his second follow-up visit, assuming no major side effects?

Answer:

• Discuss adherence, ask: Over the last seven days, how many days have you taken your medicine? At what time of day do you take your medicine?

• Discuss minor side effects and how to deal with them

• Find out what activities he has resumed

• Find out if he is sleeping enough and regularly; discuss alcohol use

• Discuss when he takes his medication and if he remembers to take it every day

Adapted from National Prescribing Service Limited, Case Study 10: Depression (September 2000). Available at: http://www.nps.org.au/__data/assets/pdf_file/0006/35367/Case_10_results.pdf

23. When groups have finished discussing the case, ask each group to report on one or two of the answers. Encourage discussion.

24. Ask participants if they have any questions on medications and prescribing.



SESSION 11: Follow Up and Documentation






Preparation:

• Review the case study, Facilitator Manual, PowerPoint slides 157–169

• Review the Mental Health Follow-Up Form


ab. Explain the process of follow up for people living with depressionac. Correctly complete the psychologist/social worker sections of the Follow Up Form

STEPS

30 minutes

1. Show Slide 157: Session 11: Follow Up and Documentation.

Introduce this session by reading the objectives. Start by asking participants:

• Why is follow up important?

• Why is follow up important for patients who are depressed?

Emphasize that continuity of care for patients with chronic illnesses require a lot of healthcare provider time at initial visit, and follow up by a multi-disciplinary team to manage their complex conditions.

2. Show Slides 158–159: Psychologist/Social Worker Responsibilities, Follow up Evaluation.

Explain to participants that this list is from the Depression Checklist, which is in the annex of the participant handbook. Refer participants to this document to also review the follow-up responsibilities of the physician, nurse and CHW. Ask participants:

• In the follow up evaluation, who do you think the psychologist/social worker works most closely with? (Answer: participants will discuss, the likely answer is that the psychologist/social worker collaborates with the physician the most.)



• How will your evaluation benefit from feedback of the other cadres (physician, nurse and CHW)?

3. Show Slide 160: Frequency of Follow Up.

When a new medication is started, the physician should see the patient within 2–4 weeks. As the patient becomes stable on the medication, appointments can be reduced to monthly, then every two months, then every three months (depending on the patient and their situation). If a patient is depressed, but not on medication, the CHW and psychologist/social worker will be working with the patient and will refer to the physician if needed.

4. Show Slide 161: Review Initial Mental Health Evaluation with Physician.

Read slide.

5. Show Slide 162: Determine if Patient is Improving.

Read slide.

6. Show Slide 163: Medication: Continue or Change.

Stress the importance of:

• Continuing to work with the physician to determine if the patient is improving.

• Changes in medication dosage are based on patient progress and side effects.

Tell participants that a patient who has already experienced an episode of depression is at high risk of relapse. The patient who has experienced two episodes of depression is at an ever higher risk of relapse.

7. Show Slide 164: Continuing or Stopping Amitriptyline and Fluoxetine.

Review each bullet point. Ask participants what questions they have.

8. Show Slide 165: Document Evaluation and Plan.

Review all points on the slide.

Refer participants to the Mental Health Follow-up Form in the annex of their participant handbooks. Give them three or four minutes to review this form.

9. Show Slide 166: Mental Health Follow-Up Form, Page 1

Animate the slide to highlight the parts of the Follow-Up form that need to be completed by the physician. This is the form on which the physician records his/her patient observations during the follow-up visit and records and changes in medication or medication dosage.



Animate the slide to highlight the sections of the form for which the psychologist/social worker is responsible, this includes:

• Demographic information

• Initial diagnosis

• Contacts since last visit

• Evolution, that is, how the patient’s condition has changed since the last visit

• Ongoing psychotherapy, focusing on progress

• ZLDSI score

• Last menstrual period (women only)

• Current medications and side effects

Advise participants to use their counselling skills, including open-ended questions to get information from their patients to document progress.

10. Show Slides 167: Mental Health Follow-Up Form, Page 2

Animate the slide to highlight the parts of page 2 of the Follow-Up form that need to be completed by the physician. Sections circled in red are usually completed by the physician alone; those in purple are completed by both the physician and psychologist/social worker.

Animate the slide to circle the sections that the psychologist/social workers needs to complete:

• Observations from the mental health examination

• Diagnosis (DSM-IV):

• Response to recent interventions, which is completed in collaboration with physician

• Plan, which is also completed in collaboration with physician

• Plan discussed with patient and he (she) approves

• Name of person completing form

Note that this form is initiated and completed by the psychologist/social worker, to whom it should be returned upon completion of the physician sections.

Ask participants what questions they have on completing the Follow-Up form.

45 minutes

11. Divide participants into small groups of three or four participants per group. Refer participants to the case study in their participant handbooks.



12. Give the groups 15 minutes (or more) to discuss the case and respond to the question(s) that follow.

FOLLOW UP CASE STUDY

Chief Complaint:

A 25 year old woman you saw initially four months ago for depression returns to the clinic. She continues to be depressed. She tells you that she’s tired, has a headache and still feels terrible.

History of Present Illness:

Initially she presented with fatigue, difficulty concentrating, weight gain and suicidal thoughts. She now reports little change in her symptoms since starting an antidepressant. She spends most of the day sleeping in bed and finds that she does not enjoy any of the activities she used to enjoy such as being with friends and attending church.

Physical Examination:

• Vital Signs: Bradycardia (HR 56), hypotension (BP 80/40)

• Skin is course and dry. Diminished reflexes throughout. On Mental Status Exam speech is slowed with deep voice. She can recall only one of three objects after five minutes and has difficulty counting backwards by sevens. She has completed high school education and is a student at university.

Laboratory Studies:

• Electrolytes and CBC: normal

• RPR nonreactive

• HIV negative

• You send her for thyroid testing and find an increased TSH and low total T4

Case Questions and Answers

a. Discuss what you suspect might be the differential diagnosis for this case.

Answer: Depression can be caused by a medical condition if an underlying disorder tends to cause depression by a known physiologic mechanism. Common examples include hypothyroidism, cerebrovascular disease, multiple sclerosis, cancer (especially pancreatic and CNS), Cushing’s disease, SLE, viral illness, Addison’s disease, medications (beta-blockers, reserpine), sleep apnea, and Parkinson’s Disease.



FOLLOW UP CASE STUDY (continued)

b. What treatment do you think the physician might recommend?

Answer: Treatment of the underlying medical condition should take priority; concurrent antidepressant therapy may be indicated if the depression is severe and slow to respond. In this case, treat hypothyroidism with thyroxine.

Adapted from: Bhushan V, Le T, Amin C, et al. Underground Clinical Vignettes: Psychiatry. S2S Medical Publishing. 1999.

13. When groups have finished discussing the case, ask each group to report their findings. Encourage discussion. Ask participants if they have any lessons learned from follow-up visits that they would like to share.

14. Show Slide 168: Monitoring and Evaluation, and Quality Improvement.

Mention that a critical component of the integration of mental health services into the healthcare system, is the use of monitoring and evaluation, and quality improvement practices.

15 minutes

15. Show Slide 169: Documenting Care Provided.

Explain to participants that the psychologist/social worker is responsible for helping other clinicians correctly complete this form. The purpose of this form is to document both initial and follow-up visits for quality assurance and monitoring/evaluation. Ask that participants refer to the checklist in the annex of their participant handbooks.

Explain to participants how to complete the checklist:

• The first step in completing the form is to enter the date, patient name, and patient date of birth (page 3)

• Check off if the visit was an initial or follow-up visit (page 3)

• Enter the name of the nurse, CHW, physician, and psychologist/social worker involved in this patient’s care in the column on the right (page 3)

• Check off the activities completed by each of the care providers in the rectangular boxes on page 3. Explain to participants that they may have to discuss with each provider what they did in their consultation with the patient if not documented elsewhere.

16. Ask participants what questions they have about the follow up care of patients who have depression.



SESSION 12: Depression and mhGAP

Methods: Facilitator presentation, role play





� Copies (1/participant) of WHO mhGAP Intervention Guide

Preparation:

• Review the role play, Facilitator Manual, PowerPoint slides 170–187.

• Review the mhGAP Intervention Guide.


ad. Describe how to use mhGAP for the management of depression.ae. Describe how to use mhGAP for the management of self-harm/suicide.

STEPS

45 minutes

1. Show Slide 170: Session 12: Advanced Practice–Depression and mhGAP.

Introduce this session by reading the objectives. Tell participants that in this next session they will learn about mhGAP and how it connects to their work with patients who are depressed.

2. Show Slide 171: mhGAP Intervention Guide.

Explain to participants that in 2011 the World Health Organization developed the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings.

Distribute the mhGAP copies to each participant.



Explain to participants that the mhGAP has been developed for use in non-specialized health-care settings, particularly non-mental health providers such as physicians, nurses, psychologists/social workers at first- and second-level facilities (local clinics as well as district hospitals).

Ask the participants if anyone has referenced mhGAP in their work. If so, ask for the participant to describe the experience of using mhGAP.

3. Show Slide 172: Table of Contents.

This slide illustrates the spectrum of conditions included in this document.

4. Show Slide 173: Master Chart (page 8).

Ask participants to turn to page 8 in their mhGAP guides as you explain the next slides.

(CLICK twice) Specifically, this year, in Year 1 of the scale-up process, Zanmi Lasante will focus on depression care. Depression includes (read on left side, Depression chapter description).

5. Show Slide 174: Master Chart (page 9).

(CLICK TWICE) Also in Year 1 Zanmi Lasante will focus on Self-harm/Suicide. A recent study indicated that 6% of people in the Plateau Central have suicidal ideation.

6. Show Slide 175: Depression, Assessment and Management Guide (page 10).

Ask participants to open their mhGAP to page 10. Explain to participants that the mhGAP Intervention Guide is useful in thinking about how to assess for depression. Focus on the left side of the page, which describes what should be considered in assessing someone for depression.

Choose a participant to read out Step 1 in the Depression Assessment and Management Guide (DEP1). Mention that participants have already learned about the listed symptoms of depression. Notice that the patient would need to answer “yes” to all three boxes of questions before moderate-severe depression is considered likely. If moderate-severe depression is likely the flowchart then directs the reader to the appropriate paragraphs on pages 13–16 to guide their consultation.

Ask participants to take a minute and silently read the end boxes on page 10 that describe the actions for a patient with moderate-severe depression, other complaints or bereavement. Recommend that they turn to sections DEP 2 and DEP 3 on pages 13–16.

Ask participants: What resource will the physician use to determine what medication to prescribe a patient? Take responses. (Correct answer: Medication Card for Depression.)




Have the participants turn to the next page in mhGAP (page 11), which guides the user through the differential diagnoses of bipolar depression, depression with psychotic fea-tures and concurrent conditions. Allow the participants to read this page silently for a few minutes. Mention the fact that it is common that patients may be suffering from multiple mental or physical health conditions at once. Conditions should be treated as necessary.

Explain to participants that mention of self-harm refers the reader to the “Master Chart”, on pages 8 and 9. However, the self-harm/suicide flowcharts start on page 73. Tell participants that we will return to self-harm/suicide shortly.


Have participant turn to page 12 in their mhGAP guide, which guides the user through specific special populations: women of child-bearing age and children/adolescents. Give participants a few minutes to read this page silently and flip to the various sections to which the boxes on the right half of the page refer.

9. Show Slide 178: Depression, Intervention Details (page 13).

Have the participants continue to the next page in mhGAP (page 13).

• Section 2.1: Psychoeducation: Mention that one of the most useful tools that mhGAP offers is psychoeducation messages. The messages on this page are depression-specific. Allow participants to read over the psychoeducation materials in their mhGAP.

• Invite participants to peruse the remaining four sections—Section 2.2: Addressing current psychosocial stressors, Section 2.3: Reactivate social networks, Section 2.4: Structured physical activity programme, and Section 2.5 Offer regular follow-up. Ask if there are any comments or questions.

10. Show Slide 179: Depression, Intervention Details (pages 14–16).

Invite participants to skim through section 3 on pages 14 to 16, which provides guidance on initiating medication, special populations, monitoring patients on medication, and terminating medication.

11. Show Slide 180: Is there Imminent Risk?

Ask the question. Once you have a number of responses, CLICK to show the answer.

12. Show Slide 181: Self-harm/Suicide (pages 74–76).

Refer participants to pages 74–76 and invite them to read through these pages. They should use the case on the previous slide to move from the box on the left (answer would be “NO” to the lower box on the right). They should feel free to flip ahead to sections SUI 2.1, 2.2 and 2.4.



Emphasize the importance of immediate follow-up by a psychologist/social worker if the patient is at imminent risk for self-harm/suicide. Tell participants that self-harm and suicide can be attempted by anyone who might have mental health issues, including depression, epilepsy, psychosis and bipolar disorder.

Emphasize that no matter the condition of the patient, it is important not to leave the patient alone.

• Ask: What does “offer and activate psychosocial support” (bottom of page 74) mean? (Answer is on page 77.)

Participants will also notice that the self-harm/suicide section recognizes that there can be concurrent conditions, including complex emotional or pain symptoms.

They will see that the flow charts progress through attempted medically serious act of self-hart, to imminent risk of suicide, concurrent disorders, chronic pain and (number 5 on page 76) emotional symptoms severe enough to warrant clinical management.

13. Show Slide 182: Self-harm/Suicide (pages 77–78).

Ask them to refer to their own mhGAP documents and read through these pages. Ask if there are comments or questions.

14. Show Slides 183 and 184: Oher Significant Emotional or Medically Unexplained Complaints.

Review the points on the slide and explain to participants that often, depression can be accompanied by significant anxiety. At other times, anxiety can be predominant, without depression. In addition, “depression” is a concept that has been developed in the Western context. In different cultures, people have different ways of describing how emotional distress manifests both physically and psychologically. The way that the mhGAP Interven-tion Guide manages this is by describing “Significant Emotional or Medically Unexplained Symptoms.” These are symptoms that represent some combination of depression, anxiety and medically unexplained symptoms. When emotional distress manifests physically, the symptoms are referred to as “somatic” (of the body).

15. Show Slide 185: Oher Significant Emotional or Medically Unexplained Complaints (pages 80–81).

Repeat the process as you did before, inviting participants to read through these two pages and then flip back to DEP 2.2, DEP 2.3 and DEP 2.4 to re-review the sections to which the final box on the right side lists.

16. Show Slide 186: Advanced Psychosocial Interventions (pages 82–83).



Refer participants to pages 82 and 83 in their mhGAP documents. Invite them to take five minutes to read through the advanced psychosocial interventions, many of which have been mentioned previously in this training.

17. Show Slide 187: DSM.

There are places in which the mhGAP refers to certain other conditions. The DSM-4 will be used to describe these conditions. While the Diagnostic and Statistical Manual of Mental Disorders (DSM 4, 1994) represents the official classification system of psychiatric condi-tions in the United States, it should be used with caution in other contexts and cultures. WHO endorses the International Statistical Classification of Diseases and Related Health Problems (ICD). In some circumstances, neither of these may capture particular clinical presentations in local context. The protocols have been adapted carefully from the DSM, based on the experience of ZL clinicians and with attention to local context.

45 minutes

18. Tell participants that they will now practice using mhGAP through a role play. Ask for three volunteers: one to play the role of the psychologist/social worker, the other the patient, and the third the patient’s wife. The volunteers should come to the front of the room to conduct their 10 minute role play in front of the group.

The role play appears in the box below.

MHGAP CASE STUDY

Background

Today a 30 year old, married, male patient has been referred to you; he and his wife were accompanied to the clinic by the CHW. The CHW brought him to the clinic as his depression screening by the CHW was positive: he mentioned to the CHW that he feels so tired lately, and he just doesn’t feel like working (he is a clothing vendor in the local market). He has missed work every day for the last week and, to make it worse, he feels so guilty about it, especially because he has a wife and two children to support. He is not sleeping well, and doesn’t have an appetite.

This man does not have any episodes of manic symptoms nor does he exhibit any psychotic features or other concurrent conditions. The psychologist/social worker should go through the screening questions on pages 10 and 11 of the mhGAP guide.

The psychologist/social worker should turn to page 10 of the depression mhGAP guide and initiate the interview as if this man were a new patient.



MHGAP CASE STUDY (continued)

Script

The psychologist/social worker: Good afternoon, how may I help you today?

The patient: Greets physician. Reluctantly tells physician about his ZLDSI screening with the community health worker.

The wife: Fills in additional information that the patient didn’t mention.

The psychologist/social worker:

• Over the last two weeks, how often have you felt down, depressed, or hopeless?

• Over the last two weeks, how often have you felt little interest or pleasure in doing things?

• Over the last two weeks how often have you had trouble falling or staying asleep or sleeping too much?

• Over the last two weeks how often have you felt like you were tired or had little energy?

• How has your appetite been over the past two weeks? (screen for overeating as well as poor appetite)

• Over the past two weeks how often have you felt bad about yourself, feeling like you were a failure or as if you had let yourself or your family down?

• Over the past two weeks have you had trouble concentrating on things, such as reading or your daily chores?

• Over the past two weeks have you or anyone else mentioned that you are moving or speaking slowly or, the opposite, been fidgety or restless?

The patient: Responds according to background history.

The psychologist/social worker: Screens for bipolar depression, psychotic features and concurrent conditions as per page 11 of the mhGAP Guide.

Once the role play had been completed, the facilitator should then lead a debriefing by asking:

• What did the psychologist/social worker ask that enabled him/her to get an answer to questions 1 on page 10 (DEP1)? (The questions at the top of that page reads: “Does the person have moderate-severe depression”?)

• How did the patient respond in terms of the core depression symptoms (top/left white box)?

• How did the patient respond in reference to the other features of depression (middle/left white box)?



• Does this patient have “difficulties carrying out usual work, school, domestic, or social activities” (third from top white box on left)?

• How did the mhGAP assessment and management guide lead the clinician from there?

• Moving to the second page of DEP1 (page 11 in the mhGAP guide), did the psychologist/social worker screen for bipolar depression? What question did the psychologist/social worker ask? What was the outcome?

• Had this patient answered “yes” to the question about prior manic episodes, which algorithm should have been followed?

• Had this patient answered “no” to the question about prior manic episodes, but “yes” to the question about hallucinations, which algorithm should have then been followed?

• If this man said something that indicated he was at risk of suicide, what should have been done?

19. Ask participants what questions they have on the mhGAP guide.



SESSION 13: Review, Post-Test and Feedback

Methods: Facilitator presentation, case studies, assessment, evaluation

Time: 2 hours 30 minutes


Materials: � PowerPoint presentation � Flip chart � Markers, pens � Tape � Flip chart sheet with Post-it notes listing

participants’ goals and expectations as articulated during introductions (Session 1)

� Post-it notes � Post-test (1/participant) � Post-Test Answer Key (on a computer

to be projected) � Training Evaluation Forms (in

the annex)

Preparation:

• Review the case studies, Facilitator Manual, PowerPoint slides 188–189

• Photocopy the pre-test and training evaluation form

• Create three flip chart pages, each individually titled:

– How will you share what you’ve learned?

– What strategies will you use to ensure collaboration with other team members?

– When I’m unsure or struggling I will...


af. Review all unit objectivesag. Demonstrate learning through a post-testah. Give feedback on the training

STEPS

60 minutes

1. Show Slide 188: Session 12: Review, Post-Test and Feedback.


Explain that we will discuss case studies as a way to review the management of patients with depression and to become more familiar with the forms and tools that are available to help with patient management.



2. Divide the participants into small groups of three or four people. Ask participant to turn to the case studies in their participant handbook.

3. Tell participants that they will have 45 minutes to complete the case study questions in their groups. Remind the participants to reference the tools and forms with which they have been provided. Encourage them to think about the system of care more broadly and their roles within the system. Ask the participants to consider how they should best work with community health workers, nurses, social workers and physicians, and other members of the care team.

4. After 45 minutes, ask everyone to join the larger group again. Review the case studies by asking a different group to present each case and their answers. Use the questions included in the case studies to guide the conversation.

5. Answer any questions that arise.

CASE STUDY 1

Use the Depression Checklist to determine how to manage this case.

The physician presents this case to you using the Initial Mental Health Evaluation Form and the ZLDSI: Marie-Flor is a 24-year-old woman whose mother died one year ago, leaving her to care for her seven brothers and sisters. She finished her primary education and wishes to go to university, but all of her money must be spent on her siblings. She has no family member helping her take care of her siblings. Her ZLDSI score is 30, she is not sleeping nor eating well, and she has lost weight.

Cast Study Questions and Answers

1. What are your core responsibilities for this patient the first time you meet her?

Answer:

Core Responsibilities:

• Coordinate and track care with physician, nurse and CHW using checklist and Initial and Follow-Up Mental Health Evaluation forms

• Consult physician to do a physical exam to check for physical illness

• Diagnosis of mental health issue

• Psychoeducation

• Schedule proper follow-up

• Enter patient into registry. File ZLDSI, complete checklist/patient encounter form



CASE STUDY 1 (continued)

2. Which forms will you use?

Answer:

Tools:

• Depression Checklist

• Patient Encounter Form

• Initial Mental Health Evaluation Form

• ZLDSI

3. You diagnose Marie-Flor with severe depression because her functioning is impaired (she is not sleeping or eating), and her ZLDSI score is high and she sometimes thinks about dying. The physician prescribes amitriptyline. What messages would you give to Marie-Flor about her medication?

Answers:

• Explain that the most common side effects are sedation, lightheadedness/dizziness (from orthostatic hypotension), constipation/difficulty urinating, dry mouth, blurred vision.

• Advise the patient to drink a lot of water to offset these side effects.

• Sometimes young people ages 18–25 become suicidal after starting an antidepressant. People who have bipolar can develop manic symptoms after starting an antidepressant. For both problems, the patient must stop the medication and come to the clinic/hospital immediately.

4. Look at the Depression Checklist. Which tasks did you complete? Which ones do you still need to do?

• For the checklist, look at the “Psychologist/Social Worker Initial Evaluation” section.

5. Look at the diagram on the other side. Which boxes would you check off for this patient care encounter?

• For the diagram, the physician and psychologist have been involved in the system of care, so they should be checked.



CASE STUDY 2

Chief Complaint:

You are asked to see a 72 year old woman, named Yveline, with weight loss, fatigue and insomnia for the past 2 months. When you meet her and ask how she is doing, she responds, “I am very tired…”

History of Present Illness:

Yveline says that she has not felt the same since she moved from her home to live with her daughter. She feels that she is burdening her daughter, but has failing health and has no other choice. Her friends have all passed away, and she says that she doesn’t have anything to live for and thinks about death frequently. She denies any suicidal plan but feels that she’d be better off dead. She also reports poor concentration and trouble remembering things. She no longer enjoys the things that she used to do and often feels worthless.

Physical Examination:

• Vital Signs: normal

• Mental Status Exam significant for depressed mood, psychomotor retardation, impaired short term memory, and difficulty attending to the interview

Laboratory Studies:

• Electrolytes and CBC: normal

• RPR nonreactive

• HIV negative

Case Study Questions and Answers

1. What ABCD’s of major depressive order are present in this case?

Answer:

• Affect and mood: Yveline has not felt like herself since she moved in with her daughter, she seems to feel a sense of guilt for relying on her daughter, she does not feel good about herself and her role

• Behavior: the fact that she has lost weight, assuming there has been no physical illness, suggests that she may be depressed; she admits to fatigue and insomnia; she takes little joy from daily activities

• Cognition and perception: Yveline seems to lack the will to leave; she is also experiencing poor concentration, trouble remembering things




• Development: Yveline is 72 and experiencing a number of normal changes for someone her age; however, many of these changes are difficult, particularly the loss of friends and partner and the loss of good health

2. What are the possible psychological and social risk factors in this case (the bio-psycho-social model)?

Answer:

• Biological factors: age, failing health, probably chronic health problems, possibly a disposition to depression.

• Social Factors: many of her friends have passed away, although she is living with her daughter, this does not appear to be helpful, possibly poverty.

• Psychological Factors: feeling like a burden on her daughter.

3. If you suspect depression, what should your next steps be?

Answer:

• Rescreen with the ZLDSI, decide if medication might be necessary

• Complete a safety evaluation of the patient with regard to risk of harming herself as part of the evaluation and follow-up

• Conduct Suicidality Screening

4. What should you communicate to Yveline?

Answer:

• Psychoeducation, messages should include:

– Depression is a very common problem

– Treatment, which includes medication and/or therapy, is available and effective

– Adherence to prescribed treatment is important

– It is important for you to continue activities that used to be interesting or give pleasure, regardless of whether these currently seem interesting or give pleasure

– Maintain a regular sleep schedule

– Minimize alcohol use

– It is important to recognize thoughts of self-harm or suicide and seek help if those occur

– Date of follow up appointment

– Follow up with CHW in community; the CHW will provide additional support




• Medication psychoeducation

– What the medication is for

– How to take the medication properly

– Common side effects

– Toxic side effects and when to seek immediate medical care

– How long it takes for medication to work

Adapted from: Bhushan V, Le T, Amin C, et al. Underground Clinical Vignettes: Psychiatry. S2S Medical Publishing. 1999.

CASE STUDY 3

A 30 year old male patient that you initially saw 6 weeks ago has returned for a follow-up visit. When you ask him how he’s been doing, he states that the medicine has made him feel restless. He has difficulty concentrating, his mind is always racing. And now his wife is threatening to leave him because he’s started gambling again. When you question him further, it’s obvious that he’s not only spending money on betting, but he’s also staying out late and spending his money on “ladies”.

Case Question

1. How would you manage this case?

Case Answer

Ask the patient if he experienced these periods of restlessness before he started the medication. There’s a good chance that he did, and that his depression is actually misdiagnosed bipolar disorder. Giving an antidepressant to someone with bipolar disorder could trigger a manic episode. Manic episodes can be dangerous, as suggested by this particular case.

Antidepressants are used to treat both anxiety disorders and depression. However, someone with bipolar disorder needs a different set of drugs: a mood stabilizer and anti-manic medication, as discussed in the Agitation, Delirium and Psychosis training.

This cases emphasizes the fact that mental illness can be more complex that they seem at first visit. It’s important that patients are interviewed and fully assessed before they are prescribed medication.

Case 3 is adapted from: Davis, JL. WebMD Misdiagnosis: Depression, When Sadness Masks the Read Problem. Available at: http://www.webmd.com/depression/misdiagnosed-depression-6/depression?page=1



P O S T - T E S T :

40 minutes

6. After the case study discussions have finished, administer the post- test to the participants. Allow them 30 minutes to complete the post-test. Participants may not use their notes or participant handbooks during the test.

7. Once the post-test is finished, and all tests have been collected, project the post-test answer key. Go over each question and the correct answer. Answer any questions that arise.

R E F L E C T I O N :

30 minutes

8. Ask participants to recall the first day of training, when each participant introduced him/herself. At that point in time everyone was asked to state their:

• Name

• Place of employment

• One goal or expectation that they have for this training

Go back to the flip chart entitled “Goals and Expectations” where you posted participants Post-it notes on the first day of training. Read each one out loud and ask if this goal/expectation was achieved (no need to read duplicates). Where there are goals or expectations that have not been met, provide a plan for meeting it in the future (maybe this goal will be met in a different training, or through one-one-one mentoring), if not mentioned previously.

9. Show Slide 189: Reflection.

Ask participant to break into groups of three or four people per group. In their groups they should spend five minutes brainstorming each of the following questions:

• How will you share what you’ve learned?

• What strategies will you use to ensure collaboration with other team members?

• When I’m unsure or struggling I will…

10. Post the flip chart sheets that were prepared in advance. After 15 minutes ask the groups to reconvene. Ask the first group how they responded to the first question, ask other groups if they’d like to add anything. Then ask the second group to respond to the next question, repeating the process until all three questions have been discussed. Take notes on the pre-prepared flip chart sheets.



E V A L U A T I O N

20 minutes

11. Explain that you would like to gather participants’ comments and feedback on this training, to revise and improve future trainings if needed.

12. Invite participants fill in the evaluation. As they fill in the evaluation, circulate and help as needed.

13. Once all participants have finished their evaluations, collect the written evaluation forms.

14. Congratulate the participants on having completed this training. Thank them for their participation. Distribute certificates as appropriate.

94 Partners In Health | FACILITATOR MANUAL | ANNEX


Annex

95Partners In Health | FACILITATOR MANUAL | ANNEX


� PRE-TEST � POST-TEST (check one)

Name: Date:

Site: Supervisor:

Circle the most correct response. All questions have just ONE correct response.

1. Approximately what percentage of people world-wide experience a mental illness during their life?

(______ / 1 point)

a. 1%

b. 15%

c. 25%

d. 50%

2. Of the leading causes of burden of disease globally in 2004, unipolar depressive disorder ranked how high?

(______ / 1 point)

a. First

b. Third

c. Eighth

d. Tenth

e. Fifteenth

3. As per the depression checklist, what is (are) the responsibility/responsibilities of the psychologist/social worker in the initial evaluation?

(______ / 1 point)

a. Consider diagnosis and give psychoeducation.

b. Take vital signs and triage.

c. Schedule proper follow-up, both with CHW and physician.

d. All the above

e. A and C

4. True or False: Genetics is one of the risk factors for mental illness.

(______ / 1 point)

a. True

b. False



5. True or False: Poverty is one of the risk factors for mental illness.

(______ / 1 point)

a. True

b. False

6. True or False: Delirium is a mental illness.

(______ / 1 point)

a. True

b. False

7. To have major depressive disorder, a patient must have symptoms most of the day nearly every day for how long?

(______ / 1 point)

a. 2 weeks

b. 3 weeks

c. 5 weeks

d. 8 weeks

8. What medications are as antidepressants?

(______ / 1 point)

a. Bupropion and amitriptyline

b. Fluoxetine and duloxetine

c. Venlafaxine and bupropion

d. Duloxetine and mirtazapine

e. Amitriptyline and fluoxetine

9. The ZLDSI is used to screen for depression. If a patient’s score on the ZLDSI is 16, what should happen?

(______ / 1 point)a. The patient does not require further assessment for depression but

should be provided with community follow-up, IPT and assessment for other problems through the chief complaint

b. No mental health follow up is necessary, this person is not depressed

c. Consider antidepressants

d. Immediate referral to a health facilitye. A and C



10. If a patient’s score on the ZLDSI is between 18 and 27, what should happen?

(______ / 1 point)

a. The patient does not require further assessment for depression but should be assessed

for other problems through the chief complaint, history of present illness, and

social history

b. Referral to the community health worker

c. Referral to the psychologist/social worker and community health worker for IPT

d. Immediate referral to a health facility

e. All of the above

11. For which of the following medical conditions is a differential diagnosis NOT typically necessary (because its symptoms are not typically confused with those of depression)?

(______ / 1 point)

a. Multiple sclerosis

b. Typhoid Fever

c. Stroke

d. Hypothyroidism

e. HIV

f. Addison’s diseaseg. Epilepsy

12. Which of the following points is NOT typically included in psychoeducation?

(______ / 1 point)

a. Importance of good adherence to prescribed medicationb. Continue to do activities that used to give you pleasure, even if they don’t give you

pleasure right now

c. Maintain a regular sleep schedule

d. Minimize alcohol use

e. Simply push suicidal thoughts out of your mind



13. In interpersonal Psychotherapy (IPT) what are the problem areas associated with the onset of depression?

(______ / 1 point)

a. Grief—death of a loved one

b. Disputes—unsolvable disagreement with someone important

c. Transitions—any life change, bad or good

d. Loneliness and Social Isolation—feeling lonely, bored and/or cut off from others

e. Relationships—particularly those that are unhealthy

f. All the above

g. A, B, C, and D

14. True or False: IPT is a time-limited treatment for depression.

(______ / 1 point)

a. True

b. False

15. True or False: IPT stresses that the patient needs to accept blame for their depression.

(______ / 1 point)

a. True

b. False

16. Which of the following is/are common side effect(s) of amitriptyline?

(______ / 1 point)

a. Induction of mania in patients with Bipolar disorder

b. Sexual dysfunction

c. Serious cardiac arrhythmias

d. Ringing in the ears

e. Frequent urination

f. All the above

g. A and C only



17. Which of the following is/are common side effect(s) of fluoxetine?

(______ / 1 point)

a. Induction of mania in patients with bipolar disorder





f. All the above

g. A and B only

18. In the initial phase of interpersonal therapy, which of these interventions is not recommended?

(______ / 1 point)

a. Give patient the sick role

b. Relaxation training

c. Make/complete the interpersonal inventory

d. Focus on patient’s perception of the problem areas

e. Give hope

f. Conduct a relaxation exercise

19. The first step in the Mental Health Safety Plan that a psychologist/social worker would discuss with the patient is….

(______ / 1 point)a. Internal coping strategies—activities that can be done without other to distract

myself from my problems

b. People and social environments that offer distractions and support.

c. Professionals and agencies I can contact during a crisis.

d. Warning signs that a crisis is developing (such as thoughts, images, moods,

situations, behavior)

20. What are the ABCDs of depression?

(______ / 1 point)

a. Abnormal Beliefs Cause Depression

b. Attitude, Beliefs, Cause, Disorder

c. Affect and mood, Behavior, Cognition, Development

d. Affect and mood, Behavior, Causation, Distress



PRE-TEST AND POST-TEST ANSWER KEY

Name: Date:

Site: Supervisor:

Circle the most correct response. All questions have just ONE correct response.

1. Approximately what percentage of people world-wide experience a mental illness during their life?

(______ / 1 point)

a. 1%

b. 15%

c. 25%

d. 50%

2. Of the leading causes of burden of disease globally in 2004, unipolar depressive disorder ranked how high?

(______ / 1 point)

a. First

b. Third

c. Eighth

d. Tenth

e. Fifteenth

3. As per the depression checklist, what is (are) the responsibility/responsibilities of the psychologist/social worker in the initial evaluation?

(______ / 1 point)

a. Consider diagnosis and give psychoeducation.

b. Take vital signs and triage.

c. Schedule proper follow-up, both with CHW and physician.

d. All the above

e. A and C

4. True or False: Genetics is one of the risk factors for mental illness.

(______ / 1 point)

a. True

b. False



5. True or False: Poverty is one of the risk factors for mental illness.

(______ / 1 point)

a. True

b. False

6. True or False: Delirium is a mental illness.

(______ / 1 point)

a. True

b. False

7. To have major depressive disorder, a patient must have symptoms most of the day nearly every day for how long?

(______ / 1 point)

a. 2 weeks

b. 3 weeks

c. 5 weeks

d. 8 weeks

8. What medications are as antidepressants?

(______ / 1 point)

a. Bupropion and amitriptyline

b. Fluoxetine and duloxetine

c. Venlafaxine and bupropion

d. Duloxetine and mirtazapine

e. Amitriptyline and fluoxetine

9. The ZLDSI is used to screen for depression. If a patient’s score on the ZLDSI is 16, what should happen?

(______ / 1 point)a. The patient does not require further assessment for depression but

should be provided with community follow-up, IPT and assessment for other problems through the chief complaint

b. No mental health follow up is necessary, this person is not depressed

c. Consider antidepressants

d. Immediate referral to a health facilitye. A and C



10. If a patient’s score on the ZLDSI is between 18 and 27, what should happen?

(______ / 1 point)

a. The patient does not require further assessment for depression but should be assessed

for other problems through the chief complaint, history of present illness, and

social history

b. Referral to the community health worker

c. Referral to the psychologist/social worker and community health worker for IPT

d. Immediate referral to a health facility

e. All of the above

11. For which of the following medical conditions is a differential diagnosis NOT typically necessary (because its symptoms are not typically confused with those of depression)?

(______ / 1 point)

a. Multiple sclerosis

b. Typhoid Fever

c. Stroke

d. Hypothyroidism

e. HIV

f. Addison’s diseaseg. Epilepsy

12. Which of the following points is NOT typically included in psychoeducation?

(______ / 1 point)

a. Importance of good adherence to prescribed medicationb. Continue to do activities that used to give you pleasure, even if they don’t give you

pleasure right now

c. Maintain a regular sleep schedule

d. Minimize alcohol use

e. Simply push suicidal thoughts out of your mind



13. In interpersonal Psychotherapy (IPT) what are the problem areas associated with the onset of depression?

(______ / 1 point)

a. Grief—death of a loved one

b. Disputes—unsolvable disagreement with someone important

c. Transitions—any life change, bad or good

d. Loneliness and Social Isolation—feeling lonely, bored and/or cut off from others

e. Relationships—particularly those that are unhealthy

f. All the above

g. A, B, C, and D

14. True or False: IPT is a time-limited treatment for depression.

(______ / 1 point)

a. True

b. False

15. True or False: IPT stresses that the patient needs to accept blame for their depression.

(______ / 1 point)

a. True

b. False

16. Which of the following is/are common side effect(s) of amitriptyline?

(______ / 1 point)

a. Induction of mania in patients with Bipolar disorder





f. All the above

g. A and C only



17. Which of the following is/are common side effect(s) of fluoxetine?

(______ / 1 point)

a. Induction of mania in patients with bipolar disorder





f. All the above

g. A and B only

18. In the initial phase of interpersonal therapy, which of these interventions is not recommended?

(______ / 1 point)

a. Give patient the sick role

b. Relaxation training

c. Make/complete the interpersonal inventory

d. Focus on patient’s perception of the problem areas

e. Give hope

f. Conduct a relaxation exercise

19. The first step in the Mental Health Safety Plan that a psychologist/social worker would discuss with the patient is….

(______ / 1 point)a. Internal coping strategies—activities that can be done without other to distract

myself from my problems

b. People and social environments that offer distractions and support.

c. Professionals and agencies I can contact during a crisis.

d. Warning signs that a crisis is developing (such as thoughts, images, moods,

situations, behavior)

20. What are the ABCDs of depression?

(______ / 1 point)

a. Abnormal Beliefs Cause Depression

b. Attitude, Beliefs, Cause, Disorder

c. Affect and mood, Behavior, Cognition, Development

d. Affect and mood, Behavior, Causation, Distress



DEPRESSION BINGO REVIEW GAME QUESTION & ANSWER SHEET FOR SESSIONS 4, 5, 6, 7, 8 AND 9

ASK QUESTIONS IN RANDOM ORDER Mark off each questions after it has been asked

1. What is the name of the form that guides the physician at first patient contact? Answer: Patient Encounter Form �

2. Severe alcohol withdrawal can cause what?Answer: Delirium Tremens �

3. If a patient had a ZLDSI score of 30, what would be the correct course of action?Answer: Refer to physician to consider medication �

4. How long does it take for amitriptyline and fluoxetine to reach full effect?Answer: 4–6 weeks �

5. What percentage of women suffer from depression or anxiety during pregnancy?Answer: 20% �

6. What is the definition of delirium?Answer: Disturbance of consciousness, reduced awareness with cognitive deficit �

7. What population is considered at increased risk for depression because of isolation, losses and medical illness?Answer: Elderly

�

8. What disorder requires a history of at least one manic or hypomanic episode?Answer: Bipolar disorder �

9. Name a neurologic disease that can present as delirium.Answer: Stroke or severe hypertension �

10. Name an endocrine disorder that can present as delirium.Answer: Thyroid or glucose dysregulation �

11. What is the definition of heavy alcohol use?Answer: > 4 drinks or >2 large bottles per day �

12. Which develops over a period of days (rather than weeks or months), delirium or psychosis?Answer: Delirium

�



13. Name two neurologic conditions that can present as a psychiatric problem:Answer: Vitamin B 12 deficiency, Cancer: brain tumor �

14. When discontinuing amitriptyline or fluoxetine, it should be tapered over what period of time?Answer: Over 2 weeks or more

�

15. What is the name of the form that guides the patient’s first mental health and physical health assessment after intake?

Answer: Initial Mental Health Evaluation Form�

16. What is one of the essential interview skills for all patient interactions?Answer: Ask open-ended questions �

17. Which exam includes cranial nerves, motor, sensory, reflexes, and coordination/gait? Answer: Neurological Exam �

18. What was the first Mental Health Care General Principle?Answer: Do no harm �

19. If a patient had a ZLDSI score of 20, what would be the correct course of action?Answer: Refer to psychologist/SW for IPT �

20. What is the name of the depression screening tool that provides a score that guides the provider through the Depression Care Pathway for a patient?Answer: ZLDSI

�

21. How many “items” are on the ZLDSI depression screening tool?Answer: 13 �

22. Name one important psychoeducation messages for patients.Answer: Minimize alcohol use �

23. Mild depressive symptoms can often be treated with what?Answer: Psychotherapy and psychosocial interventions alone �

24. Amitriptyline is in what class of medication?Answer: Tricyclic antidepressant �

25. Fluoxetine is in what class of medications?Answer: SSRI �



26. What is the official classification system of psychiatric conditions in the United States?Answer: Diagnostic and Statistical Manual of Mental Disorders �

27. The Suicidality Screening Instrument asks about suicidal thoughts over what time period?Answer: Past 2 weeks and past year

�

28. At what time of day should fluoxetine be taken?Answer: Mornings �

29. The Suicidality Screening Instrument has how many questions?Answer: 6 �

30. What are the IPT phases??Answer: Initial, middle and termination �

31. Because amitriptyline can cause side effects that include constipation, urinary difficulties, and dry mouth, patients taking it should be advised to do what? Answer: Drink lots of water

�

32. IPT is typically how many sessions?Answer: 10–16 �

33. At what time of day should amitriptyline be taken?Answer: At bedtime �

34. In the IPT termination phase, how many sessions are there?Answer: 2 �

35. In IPT, what is the goal for the person whose depression is due to grief?Answer: Help person mourn their loss �

36. Two of the severe side effects of fluoxetine and amitriptyline can include manic symptoms and suicidal ideation. If this happens, what should you do?Answer: Stop the drug immediately

�

37. The care of youth with depression is important for a number of reasons, particularly their risk of suicide. What percentage of depressed adolescents attempt suicide?Answer: 30%

�



DEPRESSION BINGO REVIEW GAME—CARDS FOR PARTICIPANTS

Print/photocopy two copies of each card (or enough so that each participant has one). There are ten cards in this annex; each is slightly different.

BINGOInitial Mental

Health Evaluation Form

Thyroid or glucose

dysregulationElderly

Diagnostic and Statistical

Manual of Mental Disorders

2

Do no harm> 4 drinks or >2 large bottles per

day

Refer to psychologist/SW

for IPT

Past 2 weeks and past year

Help person mourn their loss

Psychotherapy and psychosocial

interventions aloneDelirium FREE Mornings

Stop the drug immediately

20%

Vitamin B 12 deficiency and Cancer: brain

tumor

13 6 30%

Disturbance of consciousness,

reduced awareness with cognitive

deficit

Over 2 weeks or more

Minimize alcohol use

Initial, middle and termination

Drink lots of water



BINGO

MorningsStroke or severe

hypertensionNeurological

ExamSSRI At bedtime

Refer to physician to consider medication

> 4 drinks, or >2 large bottles per

day30%


Bipolar disorder

Drink lots of water Delirium FREE Tricyclic antidepressants




tumor


6Refer to

psychologist/SW for IPT

20% 13Minimize alcohol

useInitial, middle and

termination


reduced awareness with cognitive deficit



BINGO

13Ask open-ended

questionsTricyclic

antidepressants6 30%

Delirium Tremens 20%


tumor



2

Morning Delirium FREE Drink lots of water 4–6 weeks

Elderly> 4 drinks or >2 large bottles per

day


interventions alone


Neurological Exam

Patient Encounter Form

Stroke or severe hypertension

Thyroid or glucose dysregulation

Initial Mental Health Evaluation

FormAt bedtime



BINGODisturbance of consciousness,


deficit


10–16Initial, middle and

terminationBipolar disorder

SSRIThyroid

or glucose dysregulation

Do no harm



2



dayFREE Past 2 weeks and

past yearHelp person

mourn their loss

Elderly> 4 drinks or >2 large bottles per

dayDelirium Tremens 4–6 weeks




Neurological Exam


interventions alone

At bedtime



BINGO

Delirium TremensThyroid


Do no harm



Initial Mental Health

Evaluation Form

Drink lots of water Delirium ZLDSI Mornings 4–6 weeks


Stroke or severe hypertension FREE Over 2 weeks or

moreAt bedtime

Bipolar disorder SSRIMinimize alcohol

useElderly

Neurological Exam


> 4 drinks or >2 large bottles per

day


interventions alone



reduced awareness with cognitive deficit



BINGORefer to physician

to consider medication


for IPT Delirium



Drink lots of waterAsk open-ended

questionsZLDSI Mornings



Stroke or severe hypertension FREE SSRI At bedtime


day


tumor

Elderly 6


interventions alone

13> 4 drinks or >2 large bottles per

day30% 4–6 weeks 20%



BINGO

Bipolar disorder ZLDSITricyclic

antidepressants10–16 30%



day


for IPT



13 Delirium FREE Mornings 4–6 weeks

Drink lots of waterThyroid


Do no harm



2

20%


tumor

Delirium Tremens 6Ask open-ended

questions



BINGO

Drink lots of water Delirium ZLDSI MorningsStop the drug immediately

13 2Refer to




Initial Mental Health Evaluation

Form

Stroke or severe hypertension FREE SSRI At bedtime

20%


tumor


6 30%



deficit




Neurological Exam



BINGO

20%Tricyclic

antidepressants13 6 30%

Diagnostic and Statistical Manual

of Mental Disorders

Thyroid or glucose

dysregulationDo no harm


tumor

Delirium Tremens

Bipolar disorderAsk open-ended

questions FREE 10–16Refer to


Drink lots of water DeliriumOver 2 weeks or

moreMornings 4–6 weeks



deficit

ZLDSIMinimize alcohol


terminationPast 2 weeks and past year



BINGODiagnostic and

Statistical Manual of Mental Disorders


Neurological Exam

SSRI At bedtime

Thyroid or glucose dysregulation

Delirium ZLDSI Mornings 4–6 weeks

Same dayAsk open-ended

questions FREEInitial Mental

Health Evaluation Form

Bipolar disorder


> 4 drinks or >2 large bottles per

day


interventions alone


Drink lots of water



deficit

ElderlyMinimize alcohol


terminationPatient

Encounter Form



CH

WPS

YC

HO

LOG

IST/

SWN

UR

SES

PHY

SIC

IAN

S

Init

ial E

valu

atio

nIn

itia

l Eva

luat

ion

Init

ial E

valu

atio

nIn

itia

l Eva

luat

ion

o

Doc

umen

t w

ith In

itial

Vis

it Fo

rm.

o

Det

erm

ine

tria

ge/r

efer

ral

o

If s

uici

dal,

initi

ate

de-e

scal

atio

n,

acco

mpa

ny p

atie

nt t

o se

e ps

ycho

logi

st im

med

iate

ly.

o

If Z

LDSI

>13

; or

conc

ern

for

suic

idal

id

eatio

n, p

sych

osis

, or

epile

psy,

ref

er

patie

nt t

o ps

ycho

logi

st.

o

If Z

LDSI

<13

, man

age

in c

omm

unity

.

o

Ask

pat

ient

/fam

ily t

o gi

ve p

sych

olog

ist

Ref

erra

l For

m.

o

Begi

n ba

sic

IPT

(giv

ing

hope

, nam

ing

and

expl

aini

ng il

lnes

s).

o

Prov

ide

psyc

hoed

ucat

ion.

o

Giv

e ZL

DSI

and

Initi

al V

isit

Form

to

psy

chol

ogis

t.

o

Rev

iew

Dep

ress

ion

Che

cklis

t w

ith

CH

W/n

urse

to

trac

k ca

re.

o

Doc

umen

t w

ith In

itial

Men

tal H

ealth

Ev

alua

tion

form

. Use

CH

W/n

urse

inpu

t.

o

To d

iagn

ose

depr

essi

on, c

onsi

der

ZLD

SI

scor

e, s

uici

dalit

y, a

nd m

ania

.

o

Con

sult

phys

icia

n fo

r su

icid

al id

eatio

n,

epile

psy/

oth

er m

edic

al p

robl

ems,

ps

ycho

sis,

or

seve

re d

epre

ssio

n.

Acc

ompa

ny p

atie

nt a

nd p

rese

nt

info

rmat

ion

to p

hysi

cian

in p

erso

n.

o

Trac

k ph

ysic

ian

care

with

D

epre

ssio

n C

heck

list.

o

Do

psyc

hoed

ucat

ion.

C

heck

med

icat

ion

supp

ly.

o

Det

erm

ine

CH

W r

ole:

fol

low

up

and

supp

ort/

educ

atio

n fo

r m

oder

ate/

seve

re

depr

essi

on o

r tr

ansf

er t

o C

HW

for

m

ild d

epre

ssio

n.

o

Sche

dule

pro

per

follo

w-u

p (w

ith

psyc

holo

gist

, CH

W, p

hysi

cian

).

o

Ente

r pa

tient

into

reg

istr

y.

File

ZLD

SI, c

ompl

ete

chec

klis

t/Pa

tient

En

coun

ter

Form

.

o

Iden

tify

patie

nts

at r

isk

for

depr

essi

on

and

chec

k fo

r de

pres

sion

sym

ptom

s in

nu

rsin

g pr

otoc

ol.

o

Dec

ide

refe

rral

to

phys

icia

n or

ps

ycho

logi

st, b

ased

on

depr

essi

on

sym

ptom

sco

re.

o

Take

vita

l sig

ns a

nd c

heck

for

hea

dach

e,

abdo

min

al p

ain,

and

hig

h bl

ood

pres

sure

; con

tact

phy

sici

an if

any

ar

e pr

esen

t.

o

Doc

umen

t in

Nur

se In

patie

nt E

ncou

nter

Fo

rm f

or d

epre

ssio

n, a

s w

ell a

s

patie

nt d

ossi

er.

o

Base

d on

ref

erra

l pro

cess

, pro

vide

ps

ycho

educ

atio

n an

d su

ppor

t to

pat

ient

an

d fa

mily

.

o

Rev

iew

Initi

al M

enta

l Hea

lth E

valu

atio

n w

ith p

sych

olog

ist/

SW.

o

For

suic

idal

pat

ient

s, w

ork

with

ps

ycho

logi

st/S

W t

o de

term

ine

risk

and

to e

nsur

e sa

fety

pla

n.

o

Do

med

ical

eva

luat

ion

sepa

rate

fro

m

men

tal h

ealth

eva

luat

ion.

o

Base

d on

ZLD

SI s

core

, sui

cida

l ide

atio

n,

and

seve

rity

of d

epre

ssio

n sy

mpt

oms,

de

cide

whe

ther

to

pres

crib

e. C

hoos

e flu

oxet

ine

or a

mitr

ipyl

ine

base

d on

sy

mpt

oms,

age

, com

orbi

dity

.

o

Prov

ide

psyc

hoed

ucat

ion

ab

out

med

icat

ion.

o

Ensu

re f

ollo

w-u

p w

ith p

sych

olog

ist/

SW.

o

Doc

umen

t ev

alua

tion

and

plan

in In

itial

M

enta

l Hea

lth E

valu

atio

n.

DEP

RES

SIO

N C

HEC

KLI

ST

Dat

e:

Pro

vide

r N

ame:

S

ite:



CH

WPS

YC

HO

LOG

IST/

SWN

UR

SES

PHY

SIC

IAN

S

Follo

w-U

p Ev

alua

tion

Follo

w-U

p Ev

alua

tion

Ong

oing

Car

eFo

llow

-Up

Eval

uati

on

o

Doc

umen

t w

ith F

ollo

w-U

p Fo

rm.

o

Che

ck f

or m

edic

atio

n co

mpl

ianc

e an

d si

de e

ffec

ts.

o

Det

erm

ine

tria

ge/r

efer

ral

o

If s

uici

dal,

initi

ate

de-e

scal

atio

n,

acco

mpa

ny p

atie

nt t

o se

e ps

ycho

logi

st im

med

iate

ly.

o

If Z

LDSI

>13

, med

icat

ion

prob

lem

, or

con

cern

for

sui

cida

l ide

atio

n,

psyc

hosi

s, o

r ep

ileps

y, r

efer

pat

ient

to

psy

chol

ogis

t.

o

If Z

LDSI

<13

, man

age

in c

omm

unity

.

o

Ask

pat

ient

/fam

ily t

o gi

ve p

sych

olog

ist

Ref

erra

l For

m.

o

Con

tinue

IPT

(exp

lain

illn

ess,

giv

e ho

pe,

beha

vior

al a

ctiv

atio

n).

o

Prov

ide

psyc

hoed

ucat

ion.

o

Giv

e ZL

DSI

and

Initi

al V

isit

Form

to

psy

chol

ogis

t.

o

Rev

iew

Dep

ress

ion

Che

cklis

t w

ith

CH

W/n

urse

to

trac

k ca

re.

o

Doc

umen

t w

ith M

enta

l Hea

lth

Follo

w-U

p Fo

rm.

o

Che

ck if

dep

ress

ion

is im

prov

ing

base

d on

pat

ient

rep

ort,

ZLD

SI, m

enta

l sta

tus

exam

, CH

W/f

amily

inpu

t. C

heck

m

edic

atio

n co

mpl

ianc

e an

d si

de e

ffec

ts.

o

Con

sult

phys

icia

n fo

r su

icid

al id

eatio

n,

epile

psy/

othe

r m

edic

al p

robl

ems,

ps

ycho

sis,

or

seve

re d

epre

ssio

n.

Acc

ompa

ny p

atie

nt a

nd p

rese

nt

info

rmat

ion

to p

hysi

cian

in p

erso

n.

o

Trac

k ph

ysic

ian

care

with

D

epre

ssio

n C

heck

list.

o

Do

psyc

hoed

ucat

ion,

incl

ude

med

icat

ion

side

eff

ects

. Che

ck s

uppl

y

of m

edic

atio

n.

o

Det

erm

ine

CH

W r

ole:

fol

low

up,

su

ppor

t/ed

ucat

ion

for

seve

re

depr

essi

on; t

rans

fer

to C

HW

for

m

ild d

epre

ssio

n.

o

Sche

dule

pro

per

follo

w-u

p (w

ith

psyc

holo

gist

, CH

W, p

hysi

cian

).

o

Ente

r pa

tient

into

reg

istr

y. F

ile Z

LDSI

, co

mpl

ete

chec

klis

t/Pa

tient

En

coun

ter

Form

.

o

Befo

re d

isch

argi

ng p

atie

nt, p

rovi

de

psyc

hoed

ucat

ion

abou

t tr

eatm

ent

and

med

icat

ion.

Mak

e su

re p

atie

nt

has

follo

w-u

p ap

poin

tmen

ts w

ith

psyc

holo

gist

/SW

and

phy

sici

an,

if ne

eded

.

o

If pa

tient

has

bee

n su

icid

al d

urin

g ho

spita

lizat

ion,

che

ck fo

r sui

cida

l ide

atio

n be

fore

disc

harg

e. If

pat

ient

is s

uici

dal,

cont

act p

sych

olog

ist im

med

iate

ly.

o

Rev

iew

Initi

al M

enta

l Hea

lth E

valu

atio

n w

ith p

sych

olog

ist/

SW.

o

Det

erm

ine

whe

ther

pat

ient

is im

prov

ing.

o

For

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PARTNERS IN HEALTH MENTAL HEALTH & PSYCHOSOCIAL SERVICES ADULT MENTAL HEALTH EVALUATION

Record Number: EMR Number: Date: / /

Site :

Surname: Given Name: Nickname:

Sex: M F Date of Birth (Day/Month/Year): / / Age:

Referred by:

Address:

Commune: Profession: Telephone:

Religion: Marital Status:

Name of Emergency Contact: Relation:

Address: Telephone:

Name of Provider:

Name of Community Health Worker/Telephone:

Chief Complaint (in the patient’s own words):

History of Present Illness (Date of symptom onset, precipitants, course, any prior treatment):



PSYCHIATRIC REVIEW OF SYSTEMS

DEPRESSION MANIA ANXIETY PSYCHOSIS

• Have you felt sad or lost interest in things for a two week period?

• Do you feel like you’ve lost interest in everything or only in some things?

• Zanmi Lasante Depression Symptom Inventory (ZLDSI): /39

• Did you feel very happy for any reason in the last few days?

• Did you get angry more often in the last few days?

• Do you:

oHave any difficulties of staying attentive?

oSpeak of things that you shouldn’t?

oFeel like you’re worth more than before?

oHave a racing thoughts going through your head?

oHave an increase in activities?

oSleep less?

oTalk without ceasing?

• Are you a worrier?

• What do you worry about?

• Are you experiencing:

oPanic attacks

oFear of crowded places

oSleep problems

oDifficulty concentrating

oFatigue

o Irritability

oMuscle tension

oRestlessness

• Do you often experience any 4 of these problems such as:

o increased in heartbeat

obreathlessness

osweating

o trembling

o fear; fear of losing control; fear of becoming crazy; fear of death

o feeling dizzy

o feel like you’re losing consciousness

• Do you hear things like voices that other people don’t hear?

• Do you see things that other people don’t see?

• Do you feel that people are conspiring to harm you – even people whom you don’t know?

• Are the voices in your head controlling your thought process?



SUBSTANCE ABUSE

Do you use any of the following?

Beer Home Brew Liquor Tobacco Marijuana Cocaine

Past

Present

If yes, explain quantity, first use, last use:

Need to cut down? Annoyed or angered by others who comment on your use? Guilty about using?

In order to function properly, do you need to take that substance before starting your day?

TRAUMA

Did you ever experience a trauma, such as physical, sexual, or emotional abuse, that is impacting your current functioning?

Physical Emotional Sexual Re-experiencing Hyperarousal Avoidance

Past

Present

If yes, explain:

Do you feel safe in your current environment?

SUICIDE VIOLENCE/HOMICIDE

Have you ever thought of causing harm to yourself or committing suicide in the past? What about now?

Do you now or have you ever thought about harming others? Have you ever gotten into fights, quarrels or harmed someone else?

Ideation Attempts Ideation Acts

Past Yes No Yes No Yes No Yes No

Present Yes No Yes No Yes No Yes No

If yes, explain

Do you have a plan? Yes No Are there guns or other weapons in the household? Yes No



PAIN WHOLE BODY HEAD/EARS/EYES/NOSE/THROAT

NECK

oAre you experiencing pain in your body?

• Is there a change in your:

oWeight?

oThirst?

oFever?

oSight problems?

oHearing problems?

oVoice change?

oDizziness?

oGum and teeth status?

oDifficulty swallowing?

oStiffness of the neck?

BREATHING HEART/ARTERIES DIGESTIVE SYSTEM SKIN

oAre you having problems breathing?

oAre you coughing?

oDo you cough out blood or find blood in your snot?

oDo you have an increased heartbeat?

oHaving chest pain?

oAny swelling?

oHeart burn?

oGastric Reflux?

oVomiting?

oConstipation, diarrhea, gas?

oAny changes in your skin?

MUSCLES APPENDAGES(HANDS AND FEET)

GENITALS/URINATION NEUROLOGICAL

oAre they stiff?

oSwollen?

oReddened?

oSwollen? oDo you have any STDs causing discharge (more than usual) in your genitals? How much? How often?

oAny problems when urinating (pain, amount/color of urine, blood in urine)?

oAny numbness?

oUncontrolled movements?

PHYSICAL SYMPTOMS



PAST PSYCHIATRIC HISTORY

NAME OF THE ILLNESS HOSPITALISATION/ HOME TREATMENT

MEDICATION

None None None

Psychiatric Family History:

Past Medical History and Active Medical Problems

Head Injury: Last Date Of Menstruation: / /

Loss Of Consciousness: Other Things:

Medication/Allergies/Side Effects:

Medical Family History:

Social/Cultural History (include childhood family configuration, urban or rural setting, level of education, romantic relation-ships, and occupation or other means of financial support):

Legal Problems:



PHYSICAL EXAM (PHYSICIAN)

Vital Signs:

HEENT:

Chest/Lungs:

Cardio-vascular:

Abdomen:

Genitals:

Extremities:

Skin:

Lymph nodes:

NEUROLOGIC EXAM (PHYSICIAN)

Cranial nerves II to XII Intact If impaired, specify

Motor:

Pronator drift:

Sensory:

Vibration: Position:

Reflexes: DTR Clonus Babinsky

Coordination and Gait: Rapid alternating movements Nose finger test

Romberg Gait Heel toe walk test



General Appearance

well groomed disheveled overdressed, elaborate

Orientation O x 3 disoriented to time disoriented to place disoriented to person

Behavior WNL retardation agitation tremor

tics

Speech WNL slowed pressured slurred

Mood __________________________________________________________________________________

Affect euthymic dysphoric euphoric anxious

irritable suspicious labile flat

congruent with incongruent with other: speech content speech content

Thought Process linear tangential perseverative illogical

loose associations

Thought Content WNL vague

persistent preoccupation with:

suicidal ideation

homicidal ideation

Delusions:

none paranoid grandiose other:

Perceptual Disturbances/Hallucinations:

none auditory visual olfactory gustatory

tactile

Insight: poor limited good

Judgment/Impulse Control:

poor limited good

MENTAL STATUS EXAM

General Impressions:

BIOPSYCHOSOCIAL FORMULATION (including patient’s strengths and coping strategies):



DIAGNOSIS:

Axis I:

Axis II:

Axis III:

Axis IV:

PLAN/AVAILABILITY:

Next Visit:

Follow Up:

Reevaluation using the ZLDSI: When?

CHW: When? Name of CHW: Contacted

Psychotherapy: When? Name of psychologist/social worker: Contacted

Hospitalization: When?

Medical Evaluation: When? Referral Complete at

Necessary Intervention:

Safety:

Psychoeducation:

Medication (including name, dose, frequency, quantity, date of refill):

Other:

Signature of Evaluating Clinician Date

Print Name of Evaluating Clinician Discipline (Psychiatry, Psychology, Social Work, Primary Care)



LEVEL REACHED IN THE PAST TWO WEEKS? IN THE PAST YEAR?

1. Passive No Yes No Yes

Ask: Do you have any thoughts of ending your life, even if they are not clear in your mind?

Possible Response: I think about it from time to time, but I’ve never acted upon it...I would make my family feel too bad...God would not forgive me

Description:

2. Non-Specific Active No Yes No Yes

Ask: Do you want to die? Do you often think or talk about death?

Possible Response: desire/wish to be dead…prefer to be dead…think frequently/talk about death…God would rather have me

Description:

3. Methods but no Intent to Act No Yes No Yes

Ask: If you would do it, how would you do it?

Possible Response: bleach, pesticide, herbicide, battery acid, hang themselves, medication overdose, stop taking medication, a knife, a gun

Description:

4. Intent to Act No Yes No Yes

Ask: Do you intend to act on these thoughts?

Possible Response: I will kill myself but I do not know when… I do not think I can do so now…but it’s too much for me, I cannot yet

Description:

5. Planification No Yes No Yes

Ask: Have you started planning the details about how you will kill yourself?

Danger Signs: there is a sudden change in attitude, withdraws from everything; not interested in anything; say: “when I am not here anymore”; seeks to implement the plan, write a note (on paper).

Description:

6. Attempted No Yes No Yes

Ask: Have you tried to do something that could hasten the end of your life? Have you stopped preserving your life, like not eating and not taking medication?

Danger Signs: Realized did not want to die after the attempt failed, but it often gets worse again after a few days; might have some injuries or marks.

Description:

Low: Current = 0 Past = 0

Medium: Current = 1–2 yes OR Past = 1 or more yes

High: Current = 3 or more yes OR Past = 3 or more yes

Total “yes” in past two weeks

Total “yes” in past year

ZANMI LASANTE — MENTAL HEALTHSUICIDALITY SCREENING INSTRUMENT



For ALL Patients

Act 1. Ensure that the environment will be private, safe and non-threatening.

2. Begin the process of ensuring that the patient will be able to access necessary medication.

3. Always work with the patient to develop a Safety Plan.

Say 4. Use the patient’s name often, give hope, insist that there are other options, and declare your intent to help.

5. Start IPT and collect IP inventory.

6. Provide psychoeducation about depression, suicidality, psychopharmacology, therapy and ZL resources.

7. Identify specific current supports and potentially welcome supports (e.g. neighbors, clergy). (Write this on the copy of your Safety Plan, on the back side).

Contact 8. Always contact at least one person close to the patient to support and monitor them.

9. Contact as many of the current and potential supports as a patient will permit

• You should utilize the clergy early and heavily for supporting, home visiting, and monitoring patients

• When involving anyone, ensure that you preserve confidentiality if possible and define these:

1. Depression, suicidality

2. The needs of such patients

3. How others can help

4. How others can hurt

Team 10. Consult and involve colleagues to help.

Social Worker Psychologist Community Health Worker Doctor

Follow Up

11. If the patient has a higher risk level, continue to the guidelines below.

Provider: Location: Date: / /

Last Name: _________________________ First Name: Nickname: File #:

ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES



For patients with MEDIUM risk, include these additional aspects in your care.

Act 1. Maintain a high index of suspicion for understatement and concealed ideation. Be sure of your assessment.

Say 2. Ascertain what caused the ideation to increase in seriousness and specificity and/or what caused it to occur.

3. Seek agreement or at least acceptance that individuals in that patient’s milieu may need to be notified explicitly.

Contact 4. Close family should be informed quickly and explicitly of the patient’s suicidality.

Team 5. At least one social worker and psychologist should cooperate closely on all cases with greater than low risk.

Follow Up

6. If the patient is medium risk, schedule follow-up within 7 days. Date Time If the patient is high risk, continue to the guidelines below.

For patients with HIGH risk, include these additional aspects in your care.

Act 1. Ensure safety and calm. Remove potential weapons. Obtain help and apply physical/chemical restraint if necessary.

2. Seek to admit patient to the emergency room or another service with beds for at least 24 hours.

3. Determine who will be available to watch the patient and when so that they are not left unattended.

Name Time Name Time

Name Time Name Time

Name Time Name Time

Say 4. Despite the potential necessity of negating the patient’s autonomy, do as much as possible to preserve dignity.

Contact 5. Any and all accessible individuals from the patient’s milieu (you are justified in breaching confidentiality here).

6. Any and all potentially influential individuals (neighborhood elder, clergy, Freemason).

Team 7. MD: Make sure no attempt has been made occultly, and rule out remediable organic processes (especially pain).

8. Any available clinical staff can be called upon to help in monitoring - if necessary, other patients can be as well.

Follow Up

9. Keep the patient admitted and under continuous monitoring (e.g. 4x/hr).

10. Frequently re-assess risk level.

11. If the patient leaves or can’t be kept, follow through with continued intensive psychosocial activation.

ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES



ZANMI LASANTE — MENTAL HEALTH SAFETY PLAN

STEP 1 Warning signs that a crisis is developing (such as thoughts, images, moods, situations, behavior):

1. 2.

3. 4.

5. 6.

STEP 2 Internal coping strategies – activities that I can do without others to distract myself from my problems, such as relaxation techniques:

1. 2.

3. 4.

5. 6.

STEP 3 People and social environments that offer distractions and support:

Name Telephone

Name Telephone

Name Telephone

Where Where

Step 4 People and social environments that offer distractions and support:

Name Telephone __________________________________________

Name Telephone __________________________________________

Name Telephone __________________________________________

STEP 5 Professionals and agencies I can contact during a crisis:

Community Health Worker Telephone __________________________________________

Ajan Sante Telephone __________________________________________

Social Worker Telephone __________________________________________

Psychologist Telephone __________________________________________

Doctor Telephone __________________________________________

Spiritual Healer Telephone __________________________________________

Emergency Room/Hospital Telephone __________________________________________

STEP 6 Making the environment safe:

I, , will follow the steps when I’m in a crisis,and one thing more important to me than anything else that will help me live is…



MEDICATION CARD FOR DEPRESS ION

FLUOXETINE AMITRIPTYLINE

Antidepressant, SSRI: depression, anxiety

Use for: depression, anxiety, post-traumatic

stress disorder

Tricyclic antidepressant: depression, anxiety, migraine,

neuropathic pain

Use for: depression, anxiety, post-traumatic stress disorder,

migraines, neuropathic pain

DO NOT USE IF Manic • Manic, cardiac arrhythmia

• Caution in elderly; caution if patient is suicidal as fatal

in overdose

MUST CONSULT MENTAL HEALTH TEAM

Prior history of mania, heart condition Prior history of mania, heart condition

Starting Dose (Adult) • Dosing Forms: 20 mg capsules

• Dosage: Start with 20 mg every morning

• Dosing forms: 25 mg tablets

• Dosage: Start with 25 mg at bedtime

• Typical maintenance dosage: 50-75 mg daily

“Step” of Uptitration If necessary, increase by 20 mg increments each month

until a maximum of 80 mg daily.

If necessary, increase by 25 mg increments every two weeks

until a maximum of 200 mg daily.

Maximum Dose 80 mg 300 mg

Toxicities*If rash, stop medication and return to hospital

Serious Special warning: serotonin syndrome may occur for

4-6 weeks

Special warnings: less well tolerated than Fluoxetine. Risk of

death in overdose. High risk of arrhythmias and sudden death

due to prolonged QT interval and also high risk of myocardial

infarction. For patients over 40 years, we must obtain the

history of symptoms of arrhythmia, disorders of the cardiac

conduction system, diseases of the coronary arteries and make

an electrocardiac examination before starting treatment.

Serotonin

Syndrome

Mostly this is because of the use of two serotonin drugs simultaneously eg. SSRI’s such as fluoxetine, carbamazepine,

tramadol, amitriptyline, pentazocine, lithium or cocaine.

It can happen when increasing the dose of a single drug, such as fluoxetine.

Symptoms may include at least three of the following: restlessness, ataxia, diaphoresis, diarrhea, hyperreflexia, change in

mental state, myoclonus, tremor, or hyperthermia. Need to distinguish between the serotonin syndrome and neuroleptic

malignant syndrome that is characterized by rigidity and slowed movements.

Treatment: to stop serotonin medications, use ice, antipyretic drugs, fans in case of fever, and rehydration if the patient is

dehydrated. Treat other vital sign abnormalities as needed.

Common • Agitation

• Transient nausea

• Jitters

• Restlessness

• Drowsiness

• Headache

• Nausea

• Insomnia

• Sexual Dysfunction

(which can decrease after a few weeks)

• Drowsiness

• Dizziness

• Sedation

• Dry Mouth

• Blurred Vision

• Constipation

• Urinary Retention

• Tachycardia

• Confusion

• Delirium (especially among the elderly)

Tapering/DiscontinuingIf there is a life-threatening/

toxic side effect,

stop immediately.

Taper gradually over 2 or more weeks.

Antidepressant withdrawal syndrome can include insomnia, anxiety, irritability, nausea, headache.

Breastfeeding Safety unknown; caution advised. Probably safe; caution advised.



Department of Mental Health & Psychosocial ServicesMental Health Follow-Up Form

File Number:

EMR Number:

Location:

Date:

DD/MM/YYYY

Name of CHW: Number of visits: Date of last visit: / /

Patients’ Demographic Data

Name: Nickname:

Last Name:

Sex: M F

Address:

Change in phone number: Yes No

Date of Birth: DD/MM/YYYY Age:

1. Initial Diagnosis

Initial Diagnosis:

Contacts since the last visit:

Patient Parent Family Medication CHW Other

2. Evolution: (Comment on symptoms, aggravation and improvement, location, quality, severity, duration, schedule, context, modifying factors, and coping strategies):

3. Ongoing psychotherapy (Progress)

ZLDSI score for depression (if present):

Date of last menstrual period: DD/MM/YYYY

Current medications Yes No

Medication/s Dose/Freq

Side Effects Comments

Yes No Inc

Yes No Inc

Yes No Inc

Yes No Inc



4. Mental Status Examination

General appearance wnl Yes No

Speech wnl Yes No

Behavior wnl Yes No

Muscle tone and strength Yes No

Cognitive function wnl Yes No

Mood disorder Yes No

Poor introspection Yes No

Thought process wnl Yes No

Thought content wnl Yes No

Affect wnl Yes No

Danger to self, suicidal Yes No

Danger to others Yes No

Anxiety, phobia Yes No

Poor judgement Yes No

Observations from the mental health examination:

5. Positive results from the physical examination/labs:

6. Diagnosis (DSM-IV):

7. Response to recent interventions:

8. Interventions in the current session (I), Future treatment plan (P)

Interpersonal therapy, session #

Active listening

Reinforcement of alliance

Encouragement/support

Psychoeducation

Identify/express feelings

Discuss issues of protection

Evaluation/Safety planning

Relaxation

Acupuncture

Discuss medication

Review social activities

Identify family roles

Work on communication

Explore conflicts

Work on resources

Work on a plan of change

Therapeutic plan/social activities

Cognitive behavioral therapy

Anger management

Controlling motivations

Emotional regulation

Behavioral regulation

Training for self-control

Develop a behavior plan

Cognitive intervention

Sensory response

Plan/review progress

Collaborate with other clinicians

Other

9. Other recommendations (if necessary)



10. Plan

Plan discussed with patient and he (she) approves: Yes If No, explain:

Name of the person completing the evaluation: Date:



EVALUATION FORM

What training activity did you like the most? Why?

What training activity did you like the least? Why?

What did you learn that was valuable and that you will use in your work?

Was there anything you did not understand? Give specific examples.



What are your recommendations to improve this training? What would you change? (For example, what activities, illustrations, etc. would you change?)

Do you have any recommendations for the facilitators of this training?

What questions do you still have for the facilitators of this training?

Were there any questions during the training which the facilitators did not answer?

What additional comments do you have?

Thank you for completing this evaluation.

Partners In Health888 Commonwealth Avenue, 3rd Floor, Boston, MA 02215 www.pih.org

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