Rcpsych Workshop - Depression in medical settings (Mar11)Alex J Mitchell
Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.
Here are the most anticipated time-trial (triathlon) bikes of 2012. Carbon fibre masterpieces designed to go fast in a straight line. Image resolution 1600x1000 approx.
Rcpsych Workshop - Depression in medical settings (Mar11)Alex J Mitchell
Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.
Here are the most anticipated time-trial (triathlon) bikes of 2012. Carbon fibre masterpieces designed to go fast in a straight line. Image resolution 1600x1000 approx.
Alex J Mitchell Alcohol Detection by Clinician (Aug2012)Alex J Mitchell
Powerpoint slides on detection and identification of alcohol problems (alcohol use disorder) by clinicians.
See related paper:
http://bjp.rcpsych.org/content/201/2/93.abstract
Royalty free for personal use, but please cite with credit to AJMitchell (Leicester)
Illustration of Mental Health Clustering Calculator ajmitchellAlex J Mitchell
Our team has created a clustering calculator for mental health diagnoses. This is a preview of how it works. The idea is to allow clinicians to work out the correct cluster from the problem list inputs. The calculator is in MS excel and follows the suggested algorithms precisely
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
Photos from Tour of Britain London Stage (Sept11) taken by me (alex mitchell). Photos mostly used a sports panning technique to capture movement with some fill-in flash. Available to download.
POCOG - The Future of Psycho-Oncology (Aug 2011)Alex J Mitchell
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.
This is a combined one page one side screener consisting of the PHQ9 and GAD7. Both are in the public domain seperately, but here I have simply combined the two. The PHQ9 includes the standard question on function.
patient health questionnaire, generalized anxiety disorder
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
COH Online- The future of screening for distress in cancer settings (February11)Alex J Mitchell
This is a presentation I did at the us city of hope comprehensive cancer center in february 2011. The topic was future of screening for distress (and depression) in cancer; including an overview of recent screening findings.
Top 100 Most Cited People in Psychiatry (Mental Health) (Jan 2011) [aka Top 1...Alex J Mitchell
This is an uptodate list of the top 100 most highly cited people in psychiatry (mental health). List includes neuroscientists and psychologists publishing in this field. Note that to qualify an author must be listed on a peer reviewed paper on web of science; not necessarily the lead author. Current as of 31-Jan-2011. Presentation also known as list of Top 100 Psychiatrists
Top 100 Papers & People in Psychiatry (Jan2011)Alex J Mitchell
Short slideshow of the top100 people and papers in psychiatry as of january 2011 based on Web of science. British emphasis, worlwide list in preparation.
Organizational chart of NHS staffing ratios 1999-2009Alex J Mitchell
This is an illustrative chart of NHS staffing, normalized per hospital consultant. In other words...for every 1 hospital consultant in the NHS there are X nurses; X managers X ambulance drivers etc.
Prepared by Alex J Mitchell (ajm80@le.ac.uk) from public data.
This is a 2010 update of my previous 911 slideshows, focussing on the iconic 911 turbo. Porsche have recently announced the discontinuation of this iconic car (in 997 guise).
This is a late 2010 update of my previous slideshow "Homage to the iconic Porsche 911" adding several new models including the 911GTS, 911RS hybrid and 911GT2RS the most powerful model ever! This version is the 100 best slides in my opinion; see also the top 20 highlight show. Porsche have recently announced the discontinuation of this iconic car.[Sorry, download is 16mb and images are 1200x750]
Meta-depression Symptom Inventory [email ajm80@le.ac.uk for permission]Alex J Mitchell
This is the Meta-depression Symptom Inventory (link) a new 39 item self-report tool designed to assess multiple symptoms of depression. Its strengths are that it allows scoring on PHQ9, H.A.D.S-D; and C.E.S-D and also includes distress and dysfunction. Best of all it is on one side of A4. Seek advice regarding permissions
[online] Reforming the NHS Clinical Excellence Award Scheme (Oct10)Alex J Mitchell
The NHS clinical excellence award system, administered by the ACCEA is in short a broken system criticized by the media for unfair consultant bonuses worth up to £75k per year. Partial (cost saving) reforms were suggested in 2010. Here I make my own suggestions how the CEA scheme should be reformed.
My previous slideset on this topic was here http://www.slideshare.net/ajmitchell/online-nhs-clinical-excellence-awards-sept08-presentation
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Alex J Mitchell Alcohol Detection by Clinician (Aug2012)Alex J Mitchell
Powerpoint slides on detection and identification of alcohol problems (alcohol use disorder) by clinicians.
See related paper:
http://bjp.rcpsych.org/content/201/2/93.abstract
Royalty free for personal use, but please cite with credit to AJMitchell (Leicester)
Illustration of Mental Health Clustering Calculator ajmitchellAlex J Mitchell
Our team has created a clustering calculator for mental health diagnoses. This is a preview of how it works. The idea is to allow clinicians to work out the correct cluster from the problem list inputs. The calculator is in MS excel and follows the suggested algorithms precisely
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
Photos from Tour of Britain London Stage (Sept11) taken by me (alex mitchell). Photos mostly used a sports panning technique to capture movement with some fill-in flash. Available to download.
POCOG - The Future of Psycho-Oncology (Aug 2011)Alex J Mitchell
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.
This is a combined one page one side screener consisting of the PHQ9 and GAD7. Both are in the public domain seperately, but here I have simply combined the two. The PHQ9 includes the standard question on function.
patient health questionnaire, generalized anxiety disorder
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
COH Online- The future of screening for distress in cancer settings (February11)Alex J Mitchell
This is a presentation I did at the us city of hope comprehensive cancer center in february 2011. The topic was future of screening for distress (and depression) in cancer; including an overview of recent screening findings.
Top 100 Most Cited People in Psychiatry (Mental Health) (Jan 2011) [aka Top 1...Alex J Mitchell
This is an uptodate list of the top 100 most highly cited people in psychiatry (mental health). List includes neuroscientists and psychologists publishing in this field. Note that to qualify an author must be listed on a peer reviewed paper on web of science; not necessarily the lead author. Current as of 31-Jan-2011. Presentation also known as list of Top 100 Psychiatrists
Top 100 Papers & People in Psychiatry (Jan2011)Alex J Mitchell
Short slideshow of the top100 people and papers in psychiatry as of january 2011 based on Web of science. British emphasis, worlwide list in preparation.
Organizational chart of NHS staffing ratios 1999-2009Alex J Mitchell
This is an illustrative chart of NHS staffing, normalized per hospital consultant. In other words...for every 1 hospital consultant in the NHS there are X nurses; X managers X ambulance drivers etc.
Prepared by Alex J Mitchell (ajm80@le.ac.uk) from public data.
This is a 2010 update of my previous 911 slideshows, focussing on the iconic 911 turbo. Porsche have recently announced the discontinuation of this iconic car (in 997 guise).
This is a late 2010 update of my previous slideshow "Homage to the iconic Porsche 911" adding several new models including the 911GTS, 911RS hybrid and 911GT2RS the most powerful model ever! This version is the 100 best slides in my opinion; see also the top 20 highlight show. Porsche have recently announced the discontinuation of this iconic car.[Sorry, download is 16mb and images are 1200x750]
Meta-depression Symptom Inventory [email ajm80@le.ac.uk for permission]Alex J Mitchell
This is the Meta-depression Symptom Inventory (link) a new 39 item self-report tool designed to assess multiple symptoms of depression. Its strengths are that it allows scoring on PHQ9, H.A.D.S-D; and C.E.S-D and also includes distress and dysfunction. Best of all it is on one side of A4. Seek advice regarding permissions
[online] Reforming the NHS Clinical Excellence Award Scheme (Oct10)Alex J Mitchell
The NHS clinical excellence award system, administered by the ACCEA is in short a broken system criticized by the media for unfair consultant bonuses worth up to £75k per year. Partial (cost saving) reforms were suggested in 2010. Here I make my own suggestions how the CEA scheme should be reformed.
My previous slideset on this topic was here http://www.slideshare.net/ajmitchell/online-nhs-clinical-excellence-awards-sept08-presentation
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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RCPsych AGM10 - Diagnosing depression in primary care and hospital settings new evidence (v3)
1. Diagnosing Depression in Primary Care and Hospital
Settings - Towards a change in clinical practice
Alex Mitchell ajm80@le.ac.uk
Consultant in Liaison Psychiatry & Psycho-oncology
RCPsych Workshop 2010 – 9.45 – 11am
2. Which Are Recognized Symptoms of MDD?
Loss of confidence
Low motivation / drive
Withdrawal
ALL
Avoidance
Social isolation
Worry SOME
Feelings of dread
Helplessness
Hopelessness NONE
Psychic anxiety
Somatic anxiety
Anger UNSURE
Lack of reactive mood
Cognitive Change (=> memory complaints)
Perceptual distortion
=> plan
3. Special
Physicians
Symptoms
Physical
Illness
Primary
Symptoms
DSMV Older people Care
ICD11
Cultural
effects
Detection
Under-
Depression
served Quality
of care
Prescribing
Impairment
Scales
Distress
Follow-up
Screening
Monitoring
Help Seeking
Se Change
5. % Receiving Any treatment for Depression (CIDI)
20
17.9
18 n=84,850 face-to-face interviews
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6. 90 84.384.5 Depression Alone (=883)
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Young et al (2001) The Quality of Care for Depressive and Anxiety
Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61
An
7.
8. 1093 (100%)
Population
462 needs
462 (42%) 322 DSMIV
Meetable Needs
17.3%
25%
388 (84%)
Aware of Need
172 (44%)
Requested Help
80 (47%)
Needs Met
Patient & provider factors
=> DUD
10. N=23 studies; 50% some treatment 33% minimal treatment N=19 studies; 30% 1 in 1/12; 10% 3 in 3 months
11. 5 Steps to Improve QoC….and change clinical practice
1. Re-look at concept / criteria /symptoms
2. Understand Detection Problems
3. Understand special populations
4. Consider Enhanced Detection
5. Tie Detection to Clear Action
12. Depression Care: Who Provides it?
2/3rds 1/3rd
Primary Care
10% 25%
cg42 cg90 Medical Psychiatry
13. Percentage of U.S. retail psychotropic prescriptions written from August 2006 to jul07
Mark et al. PSYCHIATRIC SERVICES September 2009 Vol. 60 No. 9
14. Comment: Slide illustrates added proportion of all
depression treated in each setting. Most depression
is treated in primary care
1.20
1.00
1.00
0.80
0.64
0.60
0.40
0.26
0.20
0.10
0.00
All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N
=10,474)
J Gen Intern Med. 2006 September; 21(9): 926–930.
15. 1a. Re-examination of Depression
Is depression a disease; disorder (syndrome) or normally distributed
16. Graphical – two diseases
Comment: Slide illustrates the concept of
discrimination using one symptom severity of “low
mood”
Healthy
Stroke
#
of
Individuals
With symptom Point of Rarity
Severity of Infarct
17. Graphical – two disorders
Healthy
# ?Point of Rarity
of
Individuals Optimal cut
With symptom
Diabetes
HBA1c
18. Graphical - Dimension
Comment: Slide illustrates added hypothetical
distribution of mood scores in a population with
hidden depression
Non-Depressed
Depressed
#
of
Individuals
With symptom
Severity of Low Mood
20. 0
500
1000
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2000
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21. Comment: Slide illustrates added actual distribution
of mood scores on the HADS in a cancer
population with hidden depression from the
Edinburgh cancer centre
22. Distress Ratings (n=2,200) clinical significance criterion
Proportion
20.0%
Insignificant Minim al Mild Moderate Severe
18.0%
16.0%
14.0%
12.0%
10.0%
18 .4 %
8.0%
12 .9 %
6.0% 12 . 3 %
11.9 %
11.2 %
p124
4.0% 8 .1%
7.7%
7.2 %
5. 0 %
2.0%
2 .8 % 2 .6 %
0.0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten
50%
23. Back to Basics Lessons
Depression is on a continuum using current
scales……..
There will always be a trade-off of sensitivity vs specificty
=> Categorial
25. Core Symptoms ICD10 DSMIV
Persistent sadness or low mood Yes (core) Yes (core)
Loss of interests or pleasure Yes (core) Yes (core)
Fatigue or low energy Yes (core) Yes
Disturbed sleep Yes Yes
Poor concentration or Yes Yes
indecisiveness
Low self-confidence Yes No
Poor or increased appetite Yes No
Suicidal thoughts or acts Yes Yes
Agitation or slowing of Yes Yes
movements
Guilt or self-blame Yes Yes
Significant change in weight No Yes
26. Symptom Significance in Depression
Depression ICD10 DSMIV HADs D Score
Severity
Healthy 0 or 1 0 symptom 0-3
symptom
Sub-syndromal 2 or 3 1 or No core 4-7
symptoms symptoms
Mild 4 symptoms 2-4 symptoms 8 -11
(2+2) (minor)
Moderate (5 or )6 5 symptoms 12 - 15
symptoms (Mj)
Severe (7 or) 8 Unspecified 16 - 21
symptoms
(3+4)
Change in practice – ICD10 2/4/6/8 + CS
27. “Common” Symptoms of Depression
Item Depressed Frq Non-Depressed Frq
Depressed mood 0.93 0.18
Diminished drive 0.88 0.30
Loss of energy 0.87 0.32
Concentration/indecision 0.87 0.27
Sleep disturbance 0.83 0.32
Diminished concentration 0.82 0.24
Diminished interest/pleasure 0.81 0.12
Insomnia 0.70 0.27
Anxiety 0.69 0.42
Worthlessness 0.61 0.12
Psychic anxiety 0.59 0.33
Thoughts of death 0.56 0.12
Mitchell, Zimmerman et al n=2300
29. -0.10
0.00
0.10
0.20
0.30
0.40
0.50
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le
Comment: Slide illustrates added value of each
ss nes
s
symptom when diagnosing depression and when
Hope
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omot
or c h
ang e
Ps ych
o mot o
r ret a
rdatio
n
Sl eep
dis tu
rban
ce
Soma
ti c a
n x iety
Rule-In Added Value (PPV-Prev)
Thou
g
Rule-Out Added Value (NPV-Prev)
hts o
f dea
th
Wor t
hle s sne
ss
30. 1 Depressed Mood
S Diminished interest/pleasure
e Diminished drive
0.9 n
s Loss of energy
i Sleep disturbance
0.8
t Diminished concentration
i
0.7 v
i
t
0.6 y
0.5
0.4
0.3 Comment: Slide illustrates summary ROC curve
sensitivity/1-specficity plot for each mood
symptom
0.2
0.1
1 - Specificity
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
n=1523
31. Back to Basics Lessons
Symptoms of depression are not
necessarily optimal
Further research is required against course and burden
33. Cancer Staff Psychiatrists
Current Method (n=226)
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
=> Psychiatrists
34. Cancer Staff Psychiatrists
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
Comment: Slide illustrates preferences of cancer
clinicians vs psychiatrists for detecting
Current Method
depression
35. Sl e
ep
di s
tur
ban
Los ces
so ; in
fa som
ppe ni a
De ti te ; ea
; ov rly
0
10
20
30
40
50
60
70
80
90
pre
sse ere wa 100
dm a tin ke n
ood g; w ing
; ho e ig
pe ht c
Los Ap les han 86.8
so a th sne ges
f in y; l ss;
ter eth sad
est arg
;w y; t ; gl
oom
ithd
raw
ired
nes y
al ; s; l
55.6 54.4
Los in d ass
so iffe i tud
fe ren e
ner ce;
Los gy; lo n
43.3
so l os eli n
f lib so ess
ido f dr
; lo i ve
36
ss ; bu
An of s rnt
xio ex ou
Sleep
us; dri
ve; t
ag i mp
29.8
itat
ed; Te ote
irri t ars nce
So Fe abl ;w
ma eli n e; r eep
tic; est ing
Appetite
ve g gw l es ; cr
eta ort s, t yi n
tive hl e
ss; ens g
sym gui e; s
pt o l ty; t re
Low
sse
ms
;m lac
ko d
ala f se
i se
26.2 25.6 25.2
Su ;m lf e
i ci d ste
Los ulti
ple em
so e th
f co ou con
Energy
23.8
nce ght sul
ntr s; t ta t
hou ion
atio
n; p ght s
of
24
Dim oor sel
ini s me f in
mo jur
hed ry, y
per poo
f or r th
ma i nk
nce i ng
Em ; in
Los otio abi
21.4 21.2
na li ty
so
fa l la to
cop
Be
ha Los ffec
t; f
bil i
ty; e
vi o so lat mo
ura fe
njo a ff od
l pr ym
ect
; lo sw
ing
obl
em ent ss s
s; a or of e
13.9 12.8
ggr pl e mo
ess asu tion
ive re ;
nes lac
9.5
Pe ko
s; b fh
ssi eh um
mi s avi or
m; our
ne al c
7.2
What do GPs Ask about:
gat han
Ps ive ges
ych atti
tud
7
Ap om es,
pe oto wo
ara r re rry
nce tar ing
; sp dat
7
eec i on
h; e ; sl
xce He ow
nes
ssi
ve
ada
che s
sm
5.9
He s; d
avy i li n izz
g; v i ne
use ag ss
of a uen
4.8
l co ess
De hol , et
l us , to c.
i on bac
Re co
4.1
s; h
act all u or
ion ci n dru
to p atio gs
rob ns;
2.6
abl con
Fa ec fus
mil aus ion
yo es
or
1.8
r pa life
st h
looking for depression
i sto eve
ry nts
Ob of d
1.8
ses epr
si v ess
e id i on
eat
1.3
i on
; ph
ob
ias
Comment: Slide illustrates which
Lac
symptoms are asked about by GPS
0.9
Pe ko
ri o f in
do sig
f l if ht
e(
0.4
me
no
pau
se )
0.4
36. GP Recognizes:
Proportion of Individual Symptoms Recognised by GPs
80.0 76.1
70.0
60.0
50.0
40.0 36.4
34.6
31.6
30.0
21.6
20.0 16.7
13.3
9.1 8.3 8.3
10.0
0.0
s
ng
a
d
gy
s
ia
st
ty
ism
es
oo
si
ni
ex
re
xie
pi
er
ia
m
ln
m
m
te
Co
or
en
dr
An
so
fu
in
i
An
w
ss
on
ar
In
t
of
Lo
No
of
Pe
Te
ch
ss
ss
po
Lo
Lo
Hy
O’Conner et al (2001) Depression in primary care.
Int Psychogeriatr 13(3) 367-374.
37. GP Detection of Depression – Meta-analysis
Methods
– 140 studies of GP recognition
rate =>
– 90 depression
– 40 interview
– 19 se sp (+2)
– 10 countries
45. 0.25
65%
0.22
0.21
0.20
0.19
0.20
0.15
0.10
Geraghty JGIM 2007
0.05
0.05
0.03
0.02 0.02
0.01 0.01
0.01 0.01 0.01 0.01
0.00
s
s
s
s
s
s
s
s
s
s
s
s
s
s
in
in
in
in
in
in
in
in
in
in
in
in
in
in
m
m
m
m
m
m
m
m
m
m
m
m
m
5m
10
15
20
25
30
35
40
45
50
55
60
65
70
48. 0
500
1000
1500
2000
2500
3000
Ze
r o
O
ne
Tw
o
Th
re
e
Fo
ur
Fi
ve
Si
x
Se
HADS-D
ve
n
ei
gh
t
N
in
e
Te
n
El
ev
en
Tw
el
ve
Th
irt
ee
Fo n
ur
te
en
Fi
fte
en
Si
xt
ee
Se n
ve
nt
ee
Ei n
gh
te
en
49. 0.05
0.15
0.25
0
0.1
0.2
0.3
Ei
gh
t
N
in
e
Te
n
El
ev
en
Tw
el
ve
Th
irt
ee
HADS-D
n
Fo
ur
te
en
Fi
fte
en
Si
xt
ee
n
Se
ve
nt
Proportion Missed
ee
n
Proportion Recognized
Ei
gh
te
en
N
in
et
ee
n
Tw
en
Tw ty
en
ty
-o
ne
50.
51. CNS in Oncology N=401
100.0
5.9
11.1
14.3
90.0 Comment: Slide illustrates diagnostic 21.4
accuracy according to score on DT 11.8
25.9
80.0 38.7 38.1
43.5 22.2 14.3
46.7
70.0 59.6
21.4
72.4
60.0 Judgement = Non-distressed
33.3 Judgement = Unclear
19.4 19.0 Judgement = Distressed
50.0
26.1
24.4 82.4
40.0
71.4
66.7
30.0
25.0 57.1
41.9 42.9 40.7
20.0 15.8
30.4 28.9
10.0
15.4
11.8
0.0
Zero One Two Three Four Five Six Seven Eight Nine Ten
52. 80
74
70 69.6
70
61.5
59.6
60 56.7 56.7 55.6
54.2
50 45.7
43.9
39.7
40
30 28.4
22.2
21
19.3
20
10
0
ns
L
ri s
i
n
a
n
r
go
z
an
ai
a
tle
re
ro
ak
te
TA
ge
ar
n
rli
n
gh
he
lo
Pa
ai
i
ad
ia
ro
at
es
as
ne
k
Be
in
TO
ga
M
nt
An
an
Se
At
Ve
Ib
ch
g
Ja
n
Sa
n
Na
ro
Sh
an
Ba
de
G
M
o
Ri
Recognition from WHO PPGHC Study (Ustun, Goldberg et al)
54. Low confidence = more cautious, fewer false positives, more false negatives p180
1.00 Post-test Probability
0.90
0.80
0.70
0.60
Ave Confidence+
0.50
Ave Confidence-
0.40 Baseline Probability
Above Ave Confidence+
0.30
Above Ave Confidence-
High Confidence+
0.20
High Confidence-
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
High confidence = less cautious, more false positives, low false negatives
55.
56. Predictors of Recognition
Prevalence
10% rural 15% mean 20% urban 20% (oncology 25%)
Severity
70% mild 20% moderate 10% severe
International
Low in developing but in Western:
Italy > Netherlands >Australia > UK > US
Contact
Cummulative: 77% single 89% 3-6 months
Appointment Duration
Confidence &trust
58. Approaches to Somatic Symptoms of Depression
Inclusive
Uses all of the symptoms of depression, regardless of whether they may or
may not be secondary to a physical illness. This approach is used in the
Schedule for Affective Disorders and Schizophrenia (SADS) and the Research
Diagnostic Criteria.
Exclusive
Eliminates somatic symptoms but without substitution. There is concern that
this might lower sensitivity. with an increased likelihood of missed cases (false
negatives)
Etiologic
Assesses the origin of each symptom and only counts a symptom of
depression if it is clearly not the result of the physical illness. This is proposed
by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule
(DIS), as well as the DSM-III-R/IV).
Substitutive
Assumes somatic symptoms are a contaminant and replaces these additional
cognitive symptoms. However it is not clear what specific symptoms should be
substituted