Methods of training and education about depression Copyright © 2011. World Psychiatric Association...

Methods of training and education about depressionMethods of training and education about depression

Copyright © 2011. World Psychiatric Association

Linda Gask and David Goldberg

• Knowledge• Attitudes• Skills

Training can be focused on:


Knowledge Pharmacology of antidepressantsGuidelines for use

Attitudes Depression is treatable – these people are not simply wasting the doctor’s time!

Skills Providing informationNegotiating skills

Example: using antidepressants to treat depression


• Brief lecture presentations using overhead projection or slides

• Opportunity for questions and discussion

• Brief handouts with key references and web links

Acquiring the knowledge


• Discussion triggered by

– Case discussion- real cases

– Videotaped interviews

– Real patient experience

Changing attitudes


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?


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:


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:


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


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


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”


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”


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”


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


Management during the consultation:


• 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


Some key skills in depression

Assessing the severity of depression

Negotiating a treatment plan with the patient


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!


Management in your health care system

• What are the resources in your team/area?

• Establish liaison, communication, case discussion

• Develop services


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


Role-play—three methods• Paired Role Play

• Trios

• Group Method


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


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


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


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.


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


Basic rules for giving feedbackWhen 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


Giving feedbackDoctor• 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?


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


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


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?


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


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


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


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.


HOW TO EVALUATE YOUR TRAINING


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


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?


Assessing knowledge

• Self-evaluation – whether the trainees think they have learned anything

• objective measures: ensure you only test things that you have taught!


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.


Improvement in morale/confidence

• Self-rated linear analogue scales• Interviews• Post-training assessment rated against pre-training

self-assessment of needs/objectives


Clinician satisfaction

• Questionnaires• Interviews


• Process of care: – frequency and length of visits– prescription of medication– referrals– use of investigations– hospitalisations


Evaluation: impact on process and outcome of care

Evaluation: impact on process and outcome of care

• Patient satisfaction• Compliance with treatment• Clinical outcome

– symptoms– disability

• Social functioning• Economic outcome


Methods of training and education about depression Copyright © 2011. World Psychiatric Association...

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Transcript of Methods of training and education about depression Copyright © 2011. World Psychiatric Association...