Intelligent Targets for Depression Dr Adrian Jones, ACOS Dr Alys Cole King, Consultant Liaison Psychiatrist Dr Teresa Ching, Consultant Respiratory Physician Sean Clarke, Project Manager

e n g a g i n g p e o p l e

Patients symptoms Family and friends Physical illness Performance at work Financial impact Surface Level The Hidden Cost of Depression

Preliminary targets  Work began January 2009  5 targets for depression put forward for pilot September )Improve the rate of detection for people with depression in primary care and general hospital services 2)Measure symptom severity and functioning levels

Targets explained 3) Ensure people receive appropriate intervention for their depression 4) Improve the level of response provided by secondary care services 5) Improve the level of satisfaction with services

Development of the primary intelligent target  Focus on case identification of possible depression in co-morbid populations in general hospital settings  Proposed use of the two question screen followed by the PHQ-9  Tested on a medical assessment unit and a surgical ward for 4 weeks  Predominantly a simple algorithm devoid of context

Further target development  Working group to develop a user friendly method to ask patients ‘how they are feeling’ – both professional and user development process  Focus groups demonstrated acceptability by patient groups to self administer the tool  Larger patient group plus varied clinical environments for second audit February 2010

Second pilot phase  10 clinical areas in general hospital setting including community setting plus a mental health setting  Development of a ‘how to guide’, precursor to the 1000lives campaign document to support staff to implement the depression screen

Clinical areas 1 Acute coronary care unit managing high volume presentations for conditions such as myocardial infarction 2 Day hospital for patients with stroke, Parkinson’s disease, renal disorders 3 Community cardiac team 4 Clinic for respiratory conditions, notably chronic obstructive pulmonary disease 5 Medical ward for renal and diabetic conditions 6 GP referred for depression mental health group 7 Surgical ward for colorectal, vascular and general surgical conditions 8 Rehabilitation medical ward for stroke, other long term medical conditions 9 Medical ward for respiratory conditions 10 Medical ward for cardiac conditions 11 Community cardiac rehabilitation team

Results  Over 4 weeks, 390 patients received the ‘how do you feel’ booklets in 11 clinical areas. Considerably more patients did not complete the screen than did so but the ratio’s not collected.  43% indicated a positive screen for depression on the 2 questions  When further case assessed, 41% scored above threshold on PHQ-9

Slide 1  When patients completed the two questions, 57% scored both questions in the negative, 17% for one question positive and 26% for both questions positive

Slide 2  All patients who scored positive on the two question screen then went onto complete the PHQ-9.  Excluding the mental health group, of the 151 patients that were screened positive on the 2 questions, 41% scored above threshold on the PHQ-9

Slide 3

Slide 4  81% patients found the booklet helpful to identify their mood  We correlated 121 depression screens with depression satisfaction forms  Patients scoring positive or negative on the two question screen (p=.77), scoring above threshold on PHQ (p=.83) or if they had a past history of depression (p=.81) had no bearing on their satisfaction rating of the booklet

End comment  Findings of this pilot mirror prevalence of depression in COPD (44%), MI (30%) & diabetes (18%-31%)  81% patients satisfied with the booklet to help identify their mood  Now onto implementation

How to implement – Action Planning Dr Adrian Jones, ACOS Dr Alys Cole King, Consultant Liaison Psychiatrist Dr Teresa Ching, Consultant Respiratory Physician Sean Clarke, Project Manager

Getting started  Use the 1000lives document to select and organise your teams  Choose disease areas that are highly prevalent for depression listed in the guide  Select areas that have a degree of control over the care pathway  Make the process simple and easy to collect data when required

5 opportunities  On hospital admission  During hospital admission  At the point of discharge  When the patient is at home  When the patient attends a clinic

5 disease areas disease diseaseareas Diabetes Cancer RespiratoryconditionsNeurologicalconditions Coronary conditions conditions

Getting started  How will you go about selecting your disease area?  What would make the best clinical area to implement the depression screen?  Who should be in your PDSA team?

PDSA cycle  How will you recognise compliance with the target?  What will you count?  How will you ensure communication of the result to GP’s / other care providers?

Conclusion  Use a simple care process to implement the depression screen  Think plural about who can administer the depression screen  Plan lateral mechanisms to collect data  PDSA frequently to test change