Transcript Methods of training and education about depression

Methods of training and
Methods of training and
education
aboutdepression
depression
education about
Linda Gask and David Goldberg
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Training can be focused on:
• Knowledge
• Attitudes
• Skills
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Example: using antidepressants
to treat depression
Knowledge
Pharmacology of antidepressants
Guidelines for use
Attitudes
Depression is treatable –
these people are not
simply wasting the doctor’s
time!
Skills
Providing information
Negotiating skills
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Acquiring the knowledge
• Brief lecture presentations using overhead projection or slides
• Opportunity for questions and discussion
• Brief handouts with key references and web links
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Changing attitudes
• Discussion triggered by
– Case discussion- real cases
– Videotaped interviews
– Real patient experience
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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
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you waking early?
A “cue” suggesting emotional distress:
Non-verbal:
• Blushing, weeping, tremor, nervous manner
• Quality of the patient’s voice
• Restlessness, agitation
Verbal:
• Spoken words indicating distress
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GP’s who are good at detecting mental
disorders
Early in the interview:
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Make good eye contact
Clarifies presenting complaint
Uses directive questions for physical complaints
Begins with open questions, moves on to closed questions later
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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
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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
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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”
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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”
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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”
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Assessment skills in depression
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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
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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
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Negotiating a treatment plan
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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:
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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
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Some key skills in depression
Assessing the severity of depression
Negotiating a treatment plan with the patient
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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!
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Management in your health care system
• What are the resources in your team/area?
• Establish liaison, communication, case discussion
• Develop services
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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
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Role-play—three methods
• Paired Role Play
• Trios
• Group Method
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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
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Each group of three
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
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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
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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.
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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
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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
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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?
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Video group feedback sessions
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Set ground rules
Set an agenda
Provide opportunities for rehearsing new skills
Be constructive
Make the group do the work
Conclude positively
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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
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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?
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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
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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
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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
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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.
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HOW TO EVALUATE
YOUR TRAINING
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Planning a course—the basics
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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
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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?
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Assessing knowledge
• Self-evaluation – whether the trainees think they have
learned anything
• objective measures: ensure you only test things that
you have taught!
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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.
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Improvement in morale/confidence
• Self-rated linear analogue scales
• Interviews
• Post-training assessment rated against pre-training
self-assessment of needs/objectives
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Clinician satisfaction
• Questionnaires
• Interviews
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Evaluation: impact on process
and outcome of care
• Process of care:
– frequency and length of visits
– prescription of medication
– referrals
– use of investigations
– hospitalisations
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Evaluation: impact on process
and outcome of care
• Patient satisfaction
• Compliance with treatment
• Clinical outcome
– symptoms
– disability
• Social functioning
• Economic outcome
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