‘It’s a lot easier than you think’: Demonstration of a 7 minute consultation

for assessing depression

Khalida IsmailIMPARTS Seminar 1

21st March 2012

What is a Health Innovations and Education Cluster?

An infrastructure for rapid translation

… enables high quality patient care and services by quickly bringing the benefits of research and

innovation directly to patients, and by strengthening the co-ordination of education and training so that is has the breadth and depth to support excellence …

South London HIEC

Richmond174,400

Wandsworth269,300

Kingston150,000

Merton192,300

Sutton180,900

Croydon336,600

Bromley 335, 914

Lewisham284,746

Lambeth329,174

Southwark298,073

Greenwich262,145

.

Bexley233,33311

2

6

5

9

14

12

3

4

15

58

717

13

1

10

24

5

9

8 6

1

10

7

3

16

2

3

4

5

6

7

8

9

10

1

11

12

13

14

15

16

17

Bethlem

Bolingbroke Hospital

Epsom Hospital

Guy’s Hospital

King’s College Hospital

Kingston Hospital

Lambeth Hospital

Maudsley

Mayday Hospital

Oxleas

Queen Mary’s Hospital

Royal Marsden – Sutton Hospital

South London Healthcare

St Helier Hospital

St Thomas’ Hospital

Tolworth Hospital

University Hospital Lewisham

1 Greenwich University

2 King’s College London (The Strand)

3 King’s College London (Waterloo)

4 King’s College London (Guy’s)

5 King’s College London (St Thomas’)

6 King’s College London (Institute of Psychiatry)

7 Kingston University

8 Lambeth College

9 London Southbank University

10 St George’s University

Shows how

Does

Knows how

KnowsDeclarative knowledge

Procedural knowledge

Competence .

Performance .

Developing clinically focused education

Improved patient

level health

Improved population level health

Developing the Diabetes Workforce

Integrating education, clinical care and service organisation

HIEC - Diabetes

• Depression: a common problem

• Type 2 diabetes education: poor uptake

Rationale for more education on depression in diabetes

• Common: 10% ICD-10 depression• Associated with worse biomedical outcomes:

HbA1c, complications, mortality• May represent ‘worse’ diabetes• Under-detected• Under-treated• Potentially treatable condition

E-learning development

Aim to embed into clinical care

E-learning: techniques

• Pre-module test: knowledge and confidence• Facts and figures: AV presentations• Clinical skills: AV presentations and video• Integrated management: AV presentations• Clinical assessment tool• Resources for professionals and patient

Pre-module test

Part 1. Depression in diabetes

• Prevalence of depression in diabetes compared to the general population• Risk factors associated with the depression- diabetes link• The adverse effects of depression in diabetes

Part 2. Assessing depression in diabetes

• Clinical features of depression• Clinical assessment tools for depression• Suicide risk• Differential diagnoses

DSM-IV diagnostic criteria for depression

Rule of thumb 1: 2 weeks, most days, most of the dayRule of thumb 2: loss of functioning

Core symptomsLow moodAnhedonia

Additional symptoms FatigueAppetite loss/weight changesSleep disturbances Reduced concentrationPsychomotor agitation/retardation Suicidal ideation Unworthiness, excessive guilt

Number of symptoms

Seve

rity

of &

func

tiona

l im

pairm

ent

moderatemildsubclinical severe

5-6symptoms + minor

functional impairment

≥5symptoms + some

functional impairmentSe

verit

y of

& fu

nctio

nal i

mpa

irmen

t

moderatemildsubclinical severe

5-6symptoms + minor

functional impairment

≥5symptoms + some

functional impairment

≥7symptoms + severe interference with

function

Depression is a continuous construct

Clinical Assessment Step 1: How to start the interview ?

You could start with an opening statement such as:

Many people with diabetes are troubled with feeling low in spirits or having anxious or panicky feelings. Have you ever been troubled by these feelings?

↓How would you describe your mental health in recent

weeks?

Clinical Assessment Step 2: Eliciting main symptoms

Open questions to assess symptoms:

MoodHow would you describe your mood in recentweeks?

AnhedoniaAre you able to enjoy your everyday activities as much as usual?’

Video

• First 2 minutes is about low mood.• What am I trying to assess?

Clinical Assessment Step 3: Assessing severity

Severity of each symptom depends on two features:1. How distressing/intrusive/disabling

2. How frequent the symptoms

Rule of thumb 1: 2 weeks, most days, most of the day

Rule of thumb 2: loss of functioning

Video

• 6th minute is about unworthiness and excessive guilt

Clinical Assessment Step 4: Eliciting additional symptoms

Fatigue

Appetite loss

Sleep disturbances

Reduced concentration

Suicidal ideation

Unworthiness or excessive guilt

Psychomotor agitation Or retardation

What is your energy level liked?

Has there be any change in your sleep pattern?

Has there be any change in your appetite/weight?

Have others noticed that you are very restless or slowdown?

How would you describe your concentration?

Have you had thoughts of being worthless or feeling

guilty about everything?

Have you been wondering if your life is not worth living?

Part 3. Integrated management of depression and diabetes• An integrated treatment model• Prescribing antidepressants in diabetes• Low intensity psychosocial interventions• High intensity psychological interventions

HbA1c highDepression absent

NO IMPROVEMENT

NO IMPROVEMENT

assess DSM-IV depression

assess glycaemic control

+

HbA1c highDepression present

HbA1c acceptableDepression present

Mild depressionIntensify diabetes careLow intensity psychological intervention

Intensify diabetes care

Intensify diabetes careLow intensity psychological interventions

Moderate depressionIntensify diabetes careLow intensity psychological interventionFirst line antidepressant

Mild depressionLow intensity psychological intervention

Tier 3/4 diabetes careHigh intensity psychological interventionsSocial interventions

Severe depressionTier 3/4 diabetes careHigh intensity psychological interventionFirst line or switch to second line antidepressant

Severe depressionTier 3/4 diabetes careHigh intensity psychological interventionFirst line or switch to second line antidepressant

Moderate depressionLow intensity psychological interventionFirst line antidepressant

Integrating e-module into professional clinical practice

Clinical Assessment

Summary

• Addressing important measureable clinical outcomes

• Learning embedded into care delivery• Simple transferable model to drive education• Integrated care for professionals and patients