1. Training GPs and others in mental health skills Course for Young Psychiatrists Addis Ababa, 27 th April 2006 David Goldberg Institute of Psychiatry

2. A WPA Training Package Goldberg, Gask & Sartorius ; 2002 A paper: “Training Physicians in Mental Health Skills” Five videotapes: on 3 CD-ROMs; containing five teaching sessions And files teaching notes for trainers, additional scales, and role- plays A small box containing:-

3. The Paper Goldberg, Gask & Sartorius ; 2002 Why is a course necessary? Methods of teaching Planning your own course Headings: Knowledge deficits; unhelpful attitudes; skill lack Modelling; role play; using videos; micro-skills Managerial; course content; training teachers

4. The Videotapes Goldberg, Gask & Sartorius ; 2002 Depression Unexplained somatic symptoms Chronic fatigue Psychosis Dementia Five programmes:

5. The Extra Files Goldberg, Gask & Sartorius ; 2002 The paper Power point slides for a lecture on skills Notes for teachers on each video Role plays suitable for each video Four files:

6. Training in the United Kingdom

7. We use the packs to train “GP tutors”, whose task it is to train future GPs. Linda Gask uses the packs over a 12 week course, and has shown this is highly effective But in London we are lucky to get the GPs for a single afternoon – so we have measured what can be achieved with this

8. Walters et al: training in a single afternoon 22 GP registrars in training; “Medically unexplained somatic symptoms” demonstrated, followed by role-plays We measured their interviewing skills before the course, and 3 weeks afterwards

9. Walters et al., results:  doctors used a more “negotiating style”, and were rated as more empathic  they were better at “changing the agenda”  they were better at “making links” between distress and somatic symptoms  they improved at telling patients why they thought they were depressed  and better at checking the patient’s understanding of what had been learned As a result of training,

10. HONG KONG

11. Training objectives in Hong Kong:  to train a GP tutor to take over the training after my visits stopped  To assist GP’s to diagnose depression  To correct some of their misunderstandings about drug treatments  To assist them dealing with unexplained somatic symptoms  To teach them “problem solving”

12. Teaching problem solving: 1) First, a brief lecture describing problem solving 2) This was followed by two ‘modelling’ videotapes; the first, from the WPA package with a London GP; and the second a locally made tape in Cantonese, showing the technique adapted to the local culture 3)We then did 3 role plays each; each role play had been adapted to the local culture and dealt with a different problem.

13. SIBERIA: Ekaterinburg

14. Training objectives in Ekaterinburg:  To set up a course to teach common mental health skills for primary care physicians  to train a GP tutor to take over the training after my visits stopped  to familiarise them with role-playing as a teaching method  To teach GP’s how to diagnose depression  To teach them how to treat depression  To teach them to deal with unexplained somatic symptoms

15. After four visits to Ekaterinburg:  two GP tutors were now responsible for mental health training  The WPA videotapes were initially dubbed into Russian, but were finally replaced with locally made tapes, in Russian  By year 4, 75 physicians who had previously worked in polyclinics had been trained to become “family physicians”, and this included mental health skills

16. Assessment of training in Ekaterinburg:  “I never see depression in my practice” – 50% before, 29% afterwards  “depression is diagnosed only by the general appearance” - 57% before, 18% afterwards  “I now tell patients when I think they are depressed” - 26% before, 60% after  “I prescribe an antidepressant if they are depressed” - 8% before, 40% afterwards  “I give them a follow-up appointment” - 47% before, 96% afterwards The first 75 doctors trained: DEPRESSION

17. Assessment of training in Ekaterinburg:  “I never see M.U.S. in my practice” – 40% before, 18% afterwards  “I ask them about problems in their lives” - 37% before, 65% afterwards  “I assess them for depression” - 37% before,75% after  “I explain mechanisms distress -> symptoms” - 49% before, 68% afterwards  “I give them a follow-up appointment” - 53% before, 71% afterwards The first 75 doctors trained: MEDICALLY UNEXPLAINED SYMPTOMS

18. TANZANIA

19. VARIOUS TEACHING MATERIALS WERE DEMONSTRATED Psychiatrists in training and nurses in Dar es Salaam

20. Three ways to role play: 1 The participants go into sets of three, and within each set there is a doctor a patient and an observer 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.

21. Three ways to role play: 2 The participants go into sets of three, and within each set there is a doctor a patient and an observer For beginners, ask two doctors to become doctor and patient, telling the “patient” why they are attending, and give the doctor the information that must be conveyed. Typical scenarios, breaking bad news, refusing a patient’s request

22. Three ways to role play: 3 The participants go into sets of three, and within each set there is a doctor a patient and an observer The participants go into sets of three, and within each set there is a doctor a patient and an observer

23. If there are 3 role plays, it is important that each members of the triad tries out each role once It is not necessary for each doctor to practice each role play as the “doctor”. They learn a lot from watching the others

24. The doctor - is told what they knew about this patient before today, as well as what has been said until this point in the session. In developed countries, the first of these in important – but it may not be in developing countries. The purpose of this is to SAVE TIME during the role play

25. 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 told what they expect from the consultation, and what they think the problem is due to

26. The Observer This is a key role! The observer MUST give feedback to the others at the end, about what they have seen. They must be told exactly what they are looking for

27. Timing The doctors often enter into it with enthusiasm, and have to be reminded that they are practicing only a small part of the interview Stop role plays that are going on more than 5 or 6 minutes, as the Observer has not yet done their important part The part with the observer must take at least as long as the enactment – this is when learning occurs

28. What the teachers do… Depends how many teachers there are, and how many doctors in the whole group. Ideally, you should be watching only about 3 triads – so, 9 doctors. Fairly easy to see which triad is doing badly, and to eavesdrop Try not to say much until afterwards however

29. Treating USS by “reattribution” 1)Feeling understood: patient feels doctor has understood his symptoms 2)Changing the attribution: the patient must “re-frame” symptoms - see them in a different way 3)Making the link: how emotion can cause the symptoms Three stages:

30. Feeling understood  Take a full history, clarify complaint  Elicit associated symptoms  Respond to mood cues, probe mood state  Explore social & family factors  Clarify health beliefs  Perform a focused physical examination

31. Changing the attribution  Feedback the results of physical examination & investigations  Acknowledge the reality of the patient’s symptoms  Reframe the patients complaints: remind them of other symptoms and life events

32. Making the link EXPLANATION: linked to depression or anxiety DEMONSTRATION: Practical; “here and now”; linked to life events IDENTIFICATION: other family members PROJECTION: family member - learned behaviour

33. Negotiating Treatment Explore patient’s views Acknowledge patient’s worries and concerns Problem-solving and coping strategies Relaxation Appropriate treatment of depression Specific plans for follow-upup

34. Changing the attribution  Feedback the results of physical examination & investigations  Acknowledge the reality of the patient’s symptoms  Reframe the patients complaints: remind them of other symptoms and life events

35. During the role play 1) Doctor must feedback the results of physical examination and CAT scan, and do this in a confident, reassuring way. 2) Doctor must acknowledge reality of the patient’s pain, in a convincing way 3) Doctor must remind the patient of the other symptoms, and get the patient to see that s/he has a whole set of problems, and that they started soon after the partner left.

36. What the observer must do: 1Ask the doctor how s/he felt the interview went. What pleased him/her? Was there anything that could have been improved? 2Ask the "patient" how s/he felt the problem was handled. After they have finished replying [if necessary] ask them what they liked; and what they disliked, about the way the doctor handled them 3Give the doctor your own feedback, based upon your observations.

37. What we want you, the audience to do now: If you were the teacher, listening to this trio, would you wish to say anything that should be added to what you have either seen or heard?