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Validation of Global Mental Health Scale - Prize Presentation

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Dr Vikram Palanisamy

Dr Vikram Palanisamy

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  • 33
  • Nn Goldberg D. Epidemiology of mental disorders in primary care settings. Epidemiol Rev 1995; 17(1): 182–190. 5. Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Pract 1997; 7(421): 515–520. 6. Dowrick C, Buchan I. Twelvemonth outcome of depression in general practice: does detection or disclosuremake a difference? BMJ 1995; 311(7015): 1274–1276. 7. Kendrick T, King F,Albertella L, Smith PW. Treatment decisions for patients with depression: an observational study. Br J Gen Pract 2005; 55(513): 280–286. 8. Hyde J, Evans J, Sharp D, et al.Deciding who gets treatment for depression and anxiety: a study of consecutive GP attenders. Br J Gen Pract 2005; 55(520): 846–853. 9. Department of Health. Fast-forwarding primary care mental health ‘ gateway workers’. London: The Stationery Officeh, 2002. 10. SharmaVK,Wilkinson G,Dowrick C, et al.Developingmental health services in a primary care setting: Liverpool Primary CareMental Health Project. Int J Soc Psychiatry 2001; 47(4): 16–29. 11. England E, Lester H. Implementing the role of the primary caremental health worker: a qualitative study. Br J Gen Pract 2007; 57(536): 204–211. 12. McMahon L, Foran KM, Forrest SD, et al.Graduatemental health worker casemanagement of depression in UK primary care: a pilot study. Br J Gen Pract 2007; 57(544): 880–885. 13. Ryan T,Hatfield B, Sharma I.Outcomes of referrals over a six-month period to amental health gateway team. J PsychiatrMent Health Nurs 2007; 14(6): 527–534. 14. The Sainsbury Centre forMental Health. An executive briefing on primary care mental health services. (Briefing 19). London: Sainsbury Centre for Mental Health, 2003. 15. SharmaVK, Lepping P,
  • GPs are poor at detecting or treating depression (Cooper J., British journal of psychiatry:2003) GPs, with their limited time in the primary care clinics (surgeries), and in some instances with only limited training and experience, are often criticised for failing to recognise a sizeable number of those suffering from mental disorders or to treat them adequately if they do.4,5 (Nn Goldberg D. Epidemiology of mental disorders in primary care settings. Epidemiol Rev 1995; 17(1): 182–190. 5. Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Pract 1997; 7(421): 515–520.) GPs, with their limited time in the primary care clinics (surgeries), and in some instances with only limited training and experience, are often criticised for failing to recognise a sizeable number of those suffering from mental disorders or to treat them adequately if they do.4, The problems that GPs and other primary care workers have with patients with mental illness are related to knowing what questions to ask; and how to make diagnosis from the symptoms elicited. Whereas the type of questions can be fairly easily learned, making a diagnosis is a skill requiring experience and is probably more difficult than is supposed by psychiatrists. what questions to ask – easy to learn how to make diagnosis from the symptoms elicited- difficult and needs experience Responsibility of Psychiatrists- Scope to Devise a tool to help GPS Help in what questions to ask How to diagnose
  • You will be familiar with available interview tools. Only few are validated in OLD Age population. Its worth mentioning GMA AGECAT and CAMDEX are widely known. However they either are designed for use in research, take a long time to complete. Other tools such as Quick Psycho Diagnostics panel, PRIME MD (primary care evaluation of mental disorders) , SDDS PC (Symptom Driven Diagnostic system for Primary care) look at only a narrow range of mental illness, usually not aimed at diagnosing psychotic or organic illness. Assessment tools such as the Primary Care Evaluation of Mental Disorders (Spitzer et al., 1994) and the Symptom Driven Diagnostic System for Primary Care (SDDS/PC) (Brodhead et al., 1995) have been developed for the use by primary care professionals. A self-administered scale based on hand-held computers, the Quick Psycho Diagnostic Panel (QDP) (Shelder et al., 2000) covers only a narrow range of disorders. None of these tools detect psychotic or organic disorders and their use in older people and in settings other than primary care is not well established. Equally, assessment or screening tools designed for an old age population such as GMS/AGECAT (Copeland et al 1976, 1987), CAMDEX (Roth et al 1986), Geriatric Depression Scale (Yesavage et al, 1983) or the Mini Mental State Examination (Folstein et al, 1975) either take a long time to administer, require extensive training or are restricted to a few disorders such as depression or dementia.
  • Developer The current authors believe that a semi-structured mental health assessment process using the Global Mental Health Assessment Tool — Primary Care Version (GMHAT/PC) can help practitioners to know which questions to ask and how to diagnose with the help of a computer-assisted interview format. Developed by Dr Sharma, Wirral. Full and Primary care version Initially developed to help GPs to make diagnosis- However soon it was evident that there was a wider scope Current there is a steering group based in Wirral. Why it was devised What is it about Computerised Semi structured Stems Screening questions - symptoms cluster Developed based on GMS-AGECAT Rating of symptoms Diagnosis Referral letter
  • This tool is shown to be valid and easy to use in Working age adults in general practice and in medical setting. It retains its validity even when used by general nurses The Global Mental Health Assessment Tool - Primary Care Version (GMHAT/PC). Development, reliability and validity Vimal K Sharma, 1 Peter Lepping, 1 Anthony GP Cummins et al., World Psychiatry. 2004 Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study Vimal K Sharma, Peter Lepping, Murali Krishna et al., Br J Gen Pract 2008. Krishna M, Lepping P, Sharma VK, et al. Epidemiological and clinical use of GMHAT-PC (Global Mental Health Assessment Tool – Primary Care) in cardiac patients. Clinical Practice and Epidemiology in Mental Health 2009;5:7.
  • by comparing the agreement between a consultant psychiatrist’s ICD-10 criteria based clinical diagnosis and the GMHAT/PC diagnosis
  • Different settings- varying psychopathology I took the lead in wirral. I developed the interview leaflets and obtained informed consent from the patient Patients thought to be eligible to participate were informed about the purpose of this study with a written leaflet. Only those who gave valid consent participated in the study. We approached 181 consecutive patients over the age of 60 attending these centres for assessment and/or treatment.
  • Independent Clinical Assessment by Consultant Psychiatrist-ICD diagnosis- case notes, previous knowledge of the patient Full ethical approval was obtained from the Cheshire Research Ethics committee (National Research Ethic Service – reference 05/Q150612) . The study was carried out between August 2006 and February 2008. The interviewers had a training session of one to two hours duration to familiarise themselves with the GMHAT/PC before interviewing patients and to give them guidance about how to rate symptoms.
  • Results- continued Depression and organic illness were the commonest disorders diagnosed. Tool doesn’t differentiate- delirium and dementia Thirty-three (19.5%) subjects were diagnosed as having an organic illness and 33 patients (19.5%) as suffering from depression. Ten patients were diagnosed by the Consultant psychiatrist as suffering from anxiety disorders and two with psychosis. Time taken – 14 min– positive feedback from patients and researchers
  • Subgroup analysis Organic sensitivity was 0.60 but with a high specificity of 95 Depression even better
  • Find sensitivity and specificity for organic disorders for other tools 1) Feasibility- time taken, routine practice in liaison settings 2) Kappa The Geriatric Mental State (GMS) with its computerised diagnostic system ‘Automated Geriatric Examination for Computer Assisted Taxonomy’ (AGECAT) [ 14] - 0.74 -- 0.84 Quick Psycho Diagnostics panel[ 13] - 0.64 -- 0.79, Primary Care Evaluation of Mental Disorders (PRIME-MD –[11] ) - 0.71 Symptom Driven Diagnostic System for Primary Care (SDDS-PC- [ 12] - 0.50 GMHAT/PC with kappa values of 0.72 for all mental illness, 0.84 for depression and 0.67 for organic illness compares well with the other structured assessment tools mentioned above. The specificity of GMHAT/PC was exceptionally good in our study being above 95% for all mental illness, depression and organic illness. 3) It has already been shown that GMHAT/PC had good validity in identifying a wide range of mental illnesses including the less common but serious psychotic disorders, kappa: 0.78 (20). Sharma et al 2008, Journal of Royal College of General Practitioners ( 2008) 58 (551) , 411-416 Nurses use of GMHAT/PC for mental health assessments and diagnosis GMHAT-PC was 14 minutes (SD-6.38 min and range 4-32 min). Our study shows GMHAT/PC correctly identifies organic illness as well, albeit the number of cases with organic and other disorders in this study was small. 4) Used across age groups Sharma V et al. World Psychiatry :2004)
  • GMHAT is a valid tool, that’s easy to administer, covers a wide range of disorders and can be used across age ranges. Identifies organic and psychotic illness Used across age groups
  • A good sample size and subjects from different health care settings is the main strength of this study. We used Consultant Psychiatrists’ diagnoses as a gold standard rather than other measurement or diagnostic tools, as we wished to keep the GMHAT/PC assessment as close to routine clinical practice as possible. Consultant Psychiatrists and professionals doing the assessment in our study were blind to each other’s diagnoses. The relatively small number of subjects with organic disorders and psychotic disorders in this study could limit the power of agreement for this group of disorders. Some disagreements are likely to have arisen partly because the symptoms of both depression and dementia are considered to lie on a continuum with normal behaviour. The mental "cut points" for distinguishing cases from non-cases are likely to differ between psychiatrists on borderline examples. The GMHAT PC provides at least, a standardised method.
  • Care pathways have been developed with global perspective so that the pathways can be used in countries with limited resources. It needs to be seen if following care pathways influences outcomes It needs to be seen if GMHAT-PC would be able to pick up change in symptoms if repeated over a course of time. If so there is a potential to use this tool to measure change and as a possible outcome measure. GMHAT-Full Version has been developed. Detailed psychometric analysis of this tool is ongoing. If successful this tool can be used in secondary care. Apart from coming up with a diagnosis this tool also assess risk and measures the quality of life.
  • Chinese Spanish Dutch German Arabic Hindi Tamil As this tool can be used other health professional with minimal psychiatric training- this has wider implications in countries where the psychiatric services are not well developed.
  • Studies in progress UK Netherlands Belgium Ghana Abu Dhabi Singapore Australia India Translations Spanish, Dutch, German, Hindi, Chinese and Arabic, with French, Portuguese and Tamil versions in preparation Preliminary results are very encouraging- Results appear not have been affected by cultural variation
  • Acknowledgement

Transcript

  • 1. Validation and feasibility of Global Mental Health Assessment Tool – Primary care version (GMHAT/PC) in the older adults. Presenter: Vikram Palanisamy
  • 2. Background
    • Under-detection of mental illness in older people is widespread- The NSF for older people (DH, 2001)
    • Emphasis is on primary care to identify and assess common mental illness (NSF 1999), (Everybody’s business, DH, 2005)
    • GPs are poor at detecting or treating depression (Cooper 2003)
  • 3. Background- Probable Reasons
      • Limited Training
        • What questions to ask?
        • How to make diagnosis from the symptoms elicited?
      • Limited time
  • 4. Need for an interview tool..,
  • 5. Global Mental Health Assessment Tool/Primary Care version (GMHAT/PC)
    • Developer- Dr Vimal K Sharma
    • Prof John RM Copeland
    • Steering group- Dr Murali Krishna, Dr Peter Lepping, Dr Patricia Mottram, Dr Mahesh Odiyoor, Prof Kenneth Wilson, Dr Rashmi Parhee, Dr Steven Lane, Dr Ben Quinn (G.P), Dr Vikram Palanisamy
  • 6. GMHAT-PC
    • Computerised Tool
    • Covers wide range of disorders
    • Needs minimal training
  • 7. Published Literature
    • Sharma and Copeland, Ment Health Fam Med. 2009
    • Krishna M, Lepping P, Sharma VK, et al. Clinical Practice and Epidemiology in Mental Health 2009.
    • Vimal K Sharma, Peter Lepping, Murali Krishna et al., Br J Gen Pract 2008.
    • Vimal K Sharma, Peter Lepping, Anthony GP Cummins et al., World Psychiatry. 2004
  • 8.  
  • 9.  
  • 10.  
  • 11. Aims and objectives
    • To assess the validity and feasibility of the GMHAT/PC in the population over the age of 60.
    • Validity: Sensitivity, Specificity and Kappa coefficient
    • Feasibility: Duration and acceptance by patients and interviewers
  • 12. Methodology
    • Three settings in the UK: a Psychiatric Day Hospital for older people, mental health outpatient clinics and Cardiac Rehab setting
    • Consecutive patients were included in the study
  • 13. Methodology
    • Independent Clinical Assessment by Consultant Psychiatrist-ICD diagnosis
    • A general nurse practitioner or a Specialist Registrar (VP,SK) administered the GMHAT/PC to generate the diagnosis
    • Interviewers and Psychiatrists were blind to each others’ diagnosis
    • Demographics, Diagnosis, time taken and satisfaction
  • 14. Results- Demographics Site Number Male Mean Age Diagnosis Day Hospital (London) 30 10 79 ± 7
    • (83%)
    Out Patient (Wirral) 67 29 75 ± 9
    • (71%)
    DGH (Wrexham) 72 54 68 ± 6
    • (18%)
    Total 169 93 73 ± 9
    • (50.8)
  • 15. Results- continued
    • Mean time 14 min ( 4-32 minutes)
  • 16. Levels of Agreement between the Consultant’s diagnosis and GMHAT/PC diagnosis Kappa (95% CI) Sensitivity (95% CI) Specificity (95% CI) Mental Illness 0.72 (0.62, 0.83) 0.77 (0.68, 0.85) 0.96 (0.89, 0.98) Organic 0.67 (0.53, 0.82) 0.60 (0.43, 0.77) 0.95 (0.96, 1.00) Depression 0.84(0.72, 0.93) 0.84 (0.72, 0.97) 0.97 (0.85, 1.00)
  • 17. Results- Feasibility
    • Average time taken- 14 mins
    • Feedback - positive
  • 18. Discussion
    • Validity - Kappa value, sensitivity and specificity comparable/ better than other similar tools
    • Feasibility - Easy to administer, Takes a short time, acceptable to patients and interviewers
  • 19. Discussion
  • 20. Strengths and Limitations
    • Good sample size
    • Different health care settings
    • Assessment -Blind
    • Gold standard- Consultant Psychiatrists’ Diagnosis
    • Power of agreement for Anxiety/Psychosis
  • 21. Implications for future
    • Care pathways- Low and middle income countries
    • GMHAT- Full Version
  • 22. GMHAT/PC translated in different languages
    • Chinese
    • Hindi
    • Tamil
    • Dutch
    • Deutsch
    • Spanish
    • Arabic
  • 23. Studies completed or in progress
    • India
    • Singapore Australia
    • Germany
    • Holland Belgium
    • Abudhabi
    • Ghana
  • 24. Acknowledgement
    • Karen Keating, Jackie Cliff, Loraine Lockwood from the cardiac rehabilitation service of the Wrexham Maelor Hospital.
    • Karen Gill, St Catherine’s Hospital Wirral for administrative support.
    • Dr Ferran, Consultant Old Age Psychiatry, Cheshire and Wirral Partnership NHS Foundation Trust
    • Dr. Tobiansky, Consultant Old Age Psychiatry at Edgware Hospital, London
  • 25. References
    • Department of Health, 2001. National Service Framework for Older People.
    • Department of Health, 2005. Everybody’s business – Integrated mental health service for older adults: a service development guide.
    • Cooper JE ,2003. Detection and management of psychiatric disorders in primary care. British Journal of Psychiatry 2003.
    • Sharma VK, Lepping P, Krishna M et al. 2008. Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study. Br J Gen Pract, 58 (551): 411-416,
    • Sharma VK, Lepping P, Cummins A et al. 2004. The Global Mental Health Assessment Tool- Primary Care Version (GMHAT/PC). Development, reliability and validity. World Psychiatry 3(2): 115-119 .
    • Sharma VK., Copeland JRM, Dewey ME et al. 1998. Five year outcome of the depressed elderly living in the community (GMS-AGECAT), Psychological Medicine 28: 1329-1337
  • 26. My Role
    • Involved in designing the methodology
    • Lead the project in Wirral site
    • Designed the patient information leaflets, consent forms
    • Interviewed patients in Wirral, collected the data
    • Coordinated data collection from all the sites, standardised them
    • Did the descriptive analysis
    • Prepared this presentation
    • Wrote the draft paper