Khalida Ismail IMPARTS Seminar 1 21 st March 2012

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

2. What is a Health Innovations and Education Cluster? • An infrastructure for rapid translation • … enables high quality patient careand 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 1 3 4 2 10 9 8 7 6 5 Bethlem Southwark 298,073 Bolingbroke Hospital 2 . 3 4 4 Epsom Hospital Greenwich 262,145 5 1 15 10 Guy’s Hospital Lambeth 329,174 Bexley 233,333 9 King’s College Hospital Wandsworth 269,300 5 8 6 Kingston Hospital 8 2 Lewisham 284,746 11 Lambeth Hospital 17 3 5 4 7 2 1 6 8 9 7 10 16 14 13 15 11 17 12 Maudsley Richmond 174,400 10 Mayday Hospital 5 13 Merton 192,300 6 Oxleas Queen Mary’s Hospital Kingston 150,000 7 Royal Marsden – Sutton Hospital Bromley 335, 914 16 9 South London Healthcare Croydon 336,600 Sutton 180,900 14 St Helier Hospital St Thomas’ Hospital Greenwich University 1 Tolworth Hospital King’s College London (The Strand) University Hospital Lewisham King’s College London (Waterloo) 12 King’s College London (Guy’s) 3 King’s College London (St Thomas’) King’s College London (Institute of Psychiatry) Kingston University Lambeth College London Southbank University St George’s University

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

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. Common: 10% ICD-10 depression Associated with worse biomedical outcomes: HbA1c, complications, mortality May represent ‘worse’ diabetes Under-detected Under-treated Potentially treatable condition Rationale for more education on depression in diabetes

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

9. 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 E-learning: techniques

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

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

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

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 • 6th minute is about unworthiness and excessive guilt

21. Fatigue Appetite loss Sleep disturbances Reduced concentration Suicidal ideation Unworthiness or excessive guilt Psychomotor agitation Or retardation Clinical Assessment Step 4: Eliciting additional symptoms What is your energy level liked? • Has there be any change in your appetite/weight? • Has there be any change in your sleep pattern? How would you describe your concentration? • Have you been wondering if your life is not worth living? • Have you had thoughts of being worthless or feeling • guilty about everything? Have others noticed that you are very restless or slow down?

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. assess glycaemic control assess DSM-IV depression + NO IMPROVEMENT HbA1c high Depression absent HbA1c high Depression present HbA1c acceptable Depression present Intensify diabetes care Mild depression Intensify diabetes care Low intensity psychological intervention Mild depression Low intensity psychological intervention Moderate depression Low intensity psychological intervention First line antidepressant Intensify diabetes care Low intensity psychological interventions Moderate depression Intensify diabetes care Low intensity psychological intervention First line antidepressant 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

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