‘It’s a lot easier than you think’: Demonstration of a 7 minute consultation for assessing depression Khalida Ismail IMPARTS Seminar 1 21 st March 2012
Jan 27, 2016
‘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