1. Its a lot easier than you think: Demonstration of a 7 minute consultation for assessing depression Khalida Ismail IMPARTS Seminar 1 21 st March 2012

2. 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 …

3. South London HIEC Richmond 174,400 Wandsworth 269,300 Kingston 150,000 Merton 192,300 Sutton 180,900 Croydon 336,600 Bromley 335, 914 Lewisham 284,746 Lambeth 329,174 Southwark 298,073 Greenwich 262,145. Bexley 233,333 11 2 6 5 9 14 12 3 4 15 5 8 7 17 13 1 10 2 4 5 9 8 6 1 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 Guys Hospital Kings College Hospital Kingston Hospital Lambeth Hospital Maudsley Mayday Hospital Oxleas Queen Marys Hospital Royal Marsden – Sutton Hospital South London Healthcare St Helier Hospital St Thomas Hospital Tolworth Hospital University Hospital Lewisham 1 Greenwich University 2 Kings College London (The Strand) 3 Kings College London (Waterloo) 4 Kings College London (Guys) 5 Kings College London (St Thomas) 6 Kings College London (Institute of Psychiatry) 7 Kingston University 8 Lambeth College 9 London Southbank University 10 St Georges University

4. Shows how Does Knows how Knows Declarative knowledge Procedural knowledge Competence. Performance. Developing clinically focused education Improved patient level health Improved population level health

5. Developing the Diabetes Workforce Integrating education, clinical care and service organisation

6. HIEC - Diabetes Depression: a common problem Type 2 diabetes education: poor uptake

7. 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

8. E-learning development Aim to embed into clinical care

9. 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

10. Pre-module test

11. 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

13. Part 2. Assessing depression in diabetes Clinical features of depression Clinical assessment tools for depression Suicide risk Differential diagnoses

14. DSM-IV diagnostic criteria for depression Rule of thumb 1: 2 weeks, most days, most of the day Rule of thumb 2: loss of functioning Core symptoms Low mood Anhedonia Additional symptoms Fatigue Appetite loss/weight changes Sleep disturbances Reduced concentration Psychomotor agitation/retardation Suicidal ideation Unworthiness, excessive guilt

15. Number of symptoms Severity of & functional impairment moderatemildsubclinicalsevere 5-6 symptoms + minor functional impairment 5 symptoms + some functional impairment Severity of & functional impairment moderatemildsubclinicalsevere 5-6 symptoms + minor functional impairment 5 symptoms + some functional impairment 7 symptoms + severe interference with function Depression is a continuous construct

16. 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?

17. Clinical Assessment Step 2: Eliciting main symptoms Open questions to assess symptoms: Mood How would you describe your mood in recent weeks? Anhedonia Are you able to enjoy your everyday activities as much as usual?

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

19. 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

20. Video 6 th minute is about unworthiness and excessive guilt

21. 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 slow down? 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?

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

23. HbA1c high Depression absent NO IMPROVEMENTNO IMPROVEMENT NO IMPROVEMENTNO IMPROVEMENT assess DSM-IV depression assess glycaemic control + HbA1c high Depression present HbA1c acceptable Depression present Mild depression Intensify diabetes care Low intensity psychological intervention Intensify diabetes care Low intensity psychological interventions Moderate depression Intensify diabetes care Low intensity psychological intervention First line antidepressant Mild depression Low intensity psychological intervention Tier 3/4 diabetes care High intensity psychological interventions Social interventions Severe depression Tier 3/4 diabetes care High intensity psychological intervention First line or switch to second line antidepressant Severe depression Tier 3/4 diabetes care High intensity psychological intervention First line or switch to second line antidepressant Moderate depression Low intensity psychological intervention First line antidepressant

24. Integrating e-module into professional clinical practice Clinical Assessment

28. Summary Addressing important measureable clinical outcomes Learning embedded into care delivery Simple transferable model to drive education Integrated care for professionals and patients