Methods of training and education about depression Copyright © World Psychiatric Association Linda Gask and David Goldberg

Knowledge Attitudes Skills Training can be focused on: Copyright © World Psychiatric Association

KnowledgePharmacology of antidepressants Guidelines for use AttitudesDepression is treatable – these people are not simply wasting the doctor’s time! SkillsProviding information Negotiating skills Example: using antidepressants to treat depression Copyright © World Psychiatric Association

Brief lecture presentations using overhead projection or slides Opportunity for questions and discussion Brief handouts with key references and web links Acquiring the knowledge Copyright © World Psychiatric Association

Discussion triggered by –Case discussion- real cases –Videotaped interviews –Real patient experience Changing attitudes Copyright © World Psychiatric Association

Skills: some definitions An Open Question is one that does not suggest what the patient should tell you eg: How have you been feeling? A Directive Question, suggests a topic, but lets the patient say what they like: eg: Can you describe the pain? A Closed Question can be answered with a simple “yes” or “no” eg: Are you waking early? Are you waking early? Copyright © World Psychiatric Association

Non-verbal: Blushing, weeping, tremor, nervous manner Quality of the patient’s voice Restlessness, agitation Verbal: Spoken words indicating distress A “cue” suggesting emotional distress: Copyright © World Psychiatric Association

GP’s who are good at detecting mental disorders Make good eye contact Clarifies presenting complaint Uses directive questions for physical complaints Begins with open questions, moves on to closed questions later Early in the interview: Copyright © World Psychiatric Association

Clarification of the presenting complaint: Getting the patient to say in own words, exactly what s/he has experienced Avoid use of jargon or technical terms Making sure you understand what this patient has experienced Copyright © World Psychiatric Association

Sensitive doctors: Make empathic comments Pick up verbal cues Pick up non-verbal cues Do not read notes or look at their computer while patient is speaking Deal with over-talkativeness Focus their questions on the present problem Copyright © World Psychiatric Association

Deal with emotion by drawing attention to it: Obvious Distress: “You still seem very upset by your mother’s death” Anger: “You seem very angry about this. Tell me about it” Embarrassment: ”This is something that is difficult for you to talk about” Copyright © World Psychiatric Association

Draw attention to non-verbal cues: “You look quite sad” “You sound very upset about this” “You’ve got quite a tremor when you talk about this” Copyright © World Psychiatric Association

Make supportive comments when needed: “You’ve been going through a bad time” “Things have been very difficult for you” “That must have been really frightening” Copyright © World Psychiatric Association

Assessment skills in depression Assessing severity of depression Assessing suicidal intent Any psychotic features Past or family history of depression Alcohol and drug use Physical examination Social difficulties & social support Copyright © World Psychiatric Association

Management during the consultation: Copyright © World Psychiatric Association Listen, empathise Negotiate, don’t lay down law Making links - how symptoms relate to social & interpersonal problems Motivate change in behaviour

Negotiating a treatment plan Explain diagnosis Address patients ideas and concerns Agree a problem list Agree the treatment plan Self-help literature Restore sleep rhythms Problem solve interpersonal problems Antidepressants- when needed Arrange follow-up to monitor progress

Brief psychological interventions: Behavioural activation Self-help Problem-solving Anxiety management Computerised treatment “CCBT” Simple motivational strategies

Negotiating antidepressants Inform patient of efficacy and benefits –Mode of action –Not addictive –Side effects –Possible delay before start to work –When to take treatment –Length of treatment –Withdraw gradually Address patient’s ideas, concerns

Teaching new skills This is what most GP’s need most Describe the skill to be acquired Engage the whole class in an open discussion At least some of the class will be good at the chosen skill, but add comments of your own Copyright © World Psychiatric Association

Some key skills in depression Assessing the severity of depression Negotiating a treatment plan with the patient Copyright © World Psychiatric Association

The Fundamental Principle There are three stages to learning a new skill : 1. Have the skill described 2. See the skill demonstrated —modelled in front of them, or on videotape 3. Practice the skill at once! Copyright © World Psychiatric Association

Management in your health care system What are the resources in your team/area? Establish liaison, communication, case discussion Develop services Copyright © World Psychiatric Association

Using video To make ‘demonstration’ tapes to keep Culture specific Disposable’ video For teaching skills Role play or real patient interviews Watch in group setting Copyright © World Psychiatric Association

Role-play—three methods Paired Role Play Trios Group Method Copyright © World Psychiatric Association

Using recorded consultations Real patients Role-played patients — get clinicians to play scripted patients or their own patients Simulated patients — trained actors can be briefed to play wide range of roles Standardised patients — trained lay people who can reliably play limited range of scripted patients and provide feedback in and out of role Using audiotapes — if no TV equipment, audio is pretty good – get doctor to decide which excerpt to play Copyright © World Psychiatric Association

The role plays are prepared beforehand – we provide examples in the WPA package. They are printed to groups of three: The doctor The “patient”, and The Observer Each participant is given a sheet of paper, describing his or her role Each group of three Copyright © World Psychiatric Association

Practicing the skill This step is absolutely essential! Unless the new skill is practiced in a safe environment, and the doctor receives feedback, he or she will never try it out with a real patient Tell them – don’t ask them – that they will now practice the skill demonstrated Form them into groups of three Copyright © World Psychiatric Association

The doctor (or nurse!)… …is told what they knew about this patient before today, as well as what has been said until this point in the session. (The purpose of this is to SAVE TIME during the role play) In developed countries, the first of these in important – but it may not be in developing countries. Copyright © World Psychiatric Association

The “patient” Is usually asked to be their own gender, and their own age. They are told exactly what symptoms they have, that have caused them to seek care; (and if necessary, what has happened up till now in the consultation). They are sometimes also told what they expect from the consultation, & what they think the problem is due to Copyright © World Psychiatric Association

Basic rules for giving feedback When giving feedback:  Person trying out new skills gets to feedback first  Always be positive about the other's performance  Identify the good parts of the interview: be specific about what was good and why  Discuss the parts which could be improved  Always suggest positive alternatives Copyright © World Psychiatric Association

Giving feedback Doctor What went well? What could I have done better/differently? Patient What went well? What could have been done differently? What would I have done? Observer What went well? What could have been done differently? What would I have done? Copyright © World Psychiatric Association

Video group feedback sessions Set ground rules Set an agenda Provide opportunities for rehearsing new skills Be constructive Make the group do the work Conclude positively Copyright © World Psychiatric Association

Setting ground rules Check whether person has seen video themselves; obtain their permission to go on Ensure group realises this may be difficult for the doctor being shown Anyone can stop tape - and say what they would have done Ensure group realises this is a real consultation - thus, confidentiality Copyright © World Psychiatric Association

Set an agenda Clarify purpose of the session Fill in background of this recording Engage group in asking questions What does person being shown want from group? Copyright © World Psychiatric Association

Provide opportunities for learning new skills: Stop the tape at key points; encourage others to stop it as well Ask group to comment on what they have seen — how do they deal with situations like this? Label key skills yourself throughout Invite a person suggesting a new skill to demonstrate it, becoming patient yourself and giving them a cue to start Copyright © World Psychiatric Association

Make group do the work: Facilitate the group, don’t demonstrate to them Summarise suggestions and keep session flowing Ensure group sticks to the agenda Copyright © World Psychiatric Association

Conclude positively: Summarise Ask feedback from person being shown Facilitate development of action plan for future consultation with this patient Assist formulation of new learning goals Copyright © World Psychiatric Association

Other ways to role play Ask a doctor to become their own most difficult patient. Get another doctor to interview him/her. When the interview deadlocks (which it will!) ask them to give feedback; then get audience to suggest different ways of dealing with the patient. Copyright © World Psychiatric Association

HOW TO EVALUATE YOUR TRAINING Copyright © World Psychiatric Association

Planning a course—the basics Knowledge, attitudes or skills? Collaboration with primary care teachers Timing/incentives Responsive to local agenda Real material Training co-teachers Linking into the healthcare system- consultation and support Copyright © World Psychiatric Association

Evaluation: impact on clinicians Is it possible to bring about a change in clinician knowledge, attitudes or skills? Does the intervention improve morale or confidence? How satisfied are the clinicians with the intervention? Copyright © World Psychiatric Association

Assessing knowledge Self-evaluation – whether the trainees think they have learned anything objective measures: ensure you only test things that you have taught! Copyright © World Psychiatric Association

Skill acquisition Videotaped interviews with real or role-played patients –rated ‘blind’ using structured rating scales Observed Structured Clinical Examinations –rate against predefined scorecard. Changes in ability to identify or make accurate assessments of emotional disorder using comparison of patient GHQ rating and PCP rating. Copyright © World Psychiatric Association

Improvement in morale/confidence Self-rated linear analogue scales Interviews Post-training assessment rated against pre-training self-assessment of needs/objectives Copyright © World Psychiatric Association

Clinician satisfaction Questionnaires Interviews Copyright © World Psychiatric Association

Process of care: –frequency and length of visits –prescription of medication –referrals –use of investigations –hospitalisations Copyright © World Psychiatric Association Evaluation: impact on process and outcome of care

Patient satisfaction Compliance with treatment Clinical outcome –symptoms –disability Social functioning Economic outcome Copyright © World Psychiatric Association