Effects of a depression education program on residents’ knowledge, attitudes, and clinical skills

doi:10.1016/S0029-7844(02)02510-3

Obstetrics & Gynecology

Volume 101, Issue 1, January 2003, Pages 167-174

https://doi.org/10.1016/S0029-7844(02)02510-3 Get rights and content

Abstract

Objective

To determine whether an interactive educational program would improve obstetrics and gynecology residents’ knowledge, attitudes, confidence, and skills in caring for depressed patients.

Methods

We recruited 74 residents from eight residency programs to attend the Depression Education Program, which consists of a 1-hour lecture and two 2-hour workshops combining discussion, diagnosis and treatment tools, critique of a videotape, practice with feedback, and audiotape self-assessment. Before and after the program, participants 1) completed a questionnaire measuring knowledge, attitudes, and reported actions taken with a recent depressed patient; 2) received a standardized patient visit; and 3) kept lists of patients they suspected were depressed. Clinic patients completed a depression screening questionnaire. To assess improvement, we used paired t tests, McNemar χ² tests, and multivariate models adjusting for training site.

Results

The education program led to 3-month improvements in participants’ reported use of formal diagnostic criteria (38% before, 66% after; P = .004), clinical actions documented for suspected depression (P = .035), and perceived self-efficacy in depression care (P < .001). Perceived preparedness to diagnose depression, treat with medications, and comanage with a mental health practitioner improved (P < .05 for each). Small improvements in clinical behaviors with standardized patients and clinic-based depression detection rates were not statistically significant.

Conclusion

The Depression Education Program improved residents’ knowledge, confidence, and reported clinical actions with depressed patients, but did not improve most objectively assessed outcomes.

Section snippets

Materials and methods

We approached the directors of eight residency programs in the western United States and obtained their permission to recruit their residents for participation in the study. The eight residency programs included four university-based programs, three Kaiser Permanente programs, and one public hospital program. Approval was obtained from the institutional review boards governing each program. Of the 84 eligible residents, 74 (88%) enrolled in the study and, where required, gave written consent.

Results

Of the 74 residents enrolled in the study, 67 (90%) were available to attend the curriculum. The seven unavailable residents were on at night, off service, on extramural rotations, or taking family, medical, or administrative leave. Of the 67 enrolled and available residents, 57 (85%) attended or read the lecture, 59 (88%) attended the first workshop session, and 52 (78%) attended the second workshop session. Overall, 43 (64%) of the available residents attended the entire three-component

Discussion

A 5-hour Depression Education Program for residents in obstetrics and gynecology produced immediate and sustained improvements in knowledge and self-efficacy and in self-reported and charted clinical behaviors with patients suspected to be depressed. The relative magnitude and persistence of these improvements is impressive given the lack of reinforcement of the intervention during the 3-month follow-up period. Reported use of formal diagnostic criteria with a recent depressed patient improved

Acknowledgements

Pam Edwards, MD, is gratefully acknowledged for skillfully cofacilitating all of the workshops with local faculty, including Drs. Ann Eastman (Kaiser-Permanente Medical Center, Oakland), Michelle Young (Kaiser-Permanente Medical Center, Santa Clara), Kathy Blenko (Santa Clara Valley Medical Center), and Hal Holbrook (Stanford University).

References (24)

J.B. Williams et al.
Gender differences in depression in primary care
Am J Obstet Gynecol
(1995)
M. Bixo et al.
Patients with psychiatric disorders in gynecologic practice
Am J Obstet Gynecol
(2001)
L. Schmidt et al.
Treatment of depression by obstetrician-gynecologistsA survey study
Obstet Gynecol
(1997)
S. Cole et al.
The MacArthur Foundation depression education program for primary care physiciansBackground and rationale
Gen Hosp Psychiatry
(2000)
(1993)
G.E. Simon et al.
Recognition, management, and outcomes of depression in primary care
Arch Fam Med
(1995)
J. Ormel et al.
Recognition, management and course of anxiety and depression in general practice
Arch Gen Psychiatry
(1991)
M.S. Gerrity et al.
Identifying physicians likely to benefit from depression education. A challenge for health care organizations
Med Care
(2001)
L.W. Badger et al.
Psychosocial interest, medical interview, and the recognition of depression
Arch Fam Med
(1994)
Depressive disorders in women: Diagnosis, treatment and monitoring
(1997)

ACGME Outcome Project. Chicago: Accreditation Council for Graduate Medical Education. Available at...

R.M. Epstein et al.

Defining and assessing professional competence

JAMA

(2002)

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Increasing training during residency could help to foster physician confidence in screening and treating mental health disorders in women over time. Similar programs have been shown to increase ob/gyns’ perceived knowledge and confidence, although more steps may be needed in order to see impacts on clinical practice (Learman et al., 2003; Dietrich et al., 2003). In addition, training programs offering specialization or exposure to psychiatric educational opportunities might help to increase ob/gyns’ comfort in working on these issues with patients.
Mental health concerns, particularly depression and anxiety, are common among women of all ages. Because obstetrician/gynecologists (ob/gyns) often serve as a primary source of care for women, they are in a unique position to detect and target mental health symptoms early. In this context, we define ethics as the balance between one's competency in practice, and the need to treat patients with conditions outside of that competency. This paper discusses the ethical challenges that ob/gyns may face in identifying and treating mental health conditions due to lack of expertise, training, and experience. We also focus on the ethical considerations that favor interventions on the part of ob/gyns, and how improved training could help to resolve this ethical dilemma. In addition, the expansion of collaborative care networks may help to build continuity of care.
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It has been argued that the assessment of depressive disorders should be extended to include anxiety disorders, since there is an excess of each in chronic physical disease [2], and assessments should include the distinctive contribution made by each [3]. There are also additional reasons for supposing that the criteria for each disorder should be simplified for use in general medical settings: not only do many clinicians have difficulty remembering the full list of nine symptoms necessary for the diagnosis of depression [11–13], but pencil-and-paper tests, although undoubtedly useful, often contain the same symptoms which often occur due to the physical disease [14]. In busy clinical settings across the world, pencil-and-paper tests are often either not available, or have to be read aloud to illiterate patients.
The primary health care version of the ICD-11 is currently being revised.
To test two brief sets of symptoms for depression and anxiety in primary care settings, and validate them against diagnoses of major depression and current generalised anxiety made by the CIDI.
The study took place in general medical or primary care clinics in 14 different countries, using the Composite International Diagnostic Interview adapted for primary care (CIDI-PC) in 5,438 patients. The latent structure of common symptoms was explored, and two symptom scales were derived from item response theory (IRT), these were then investigated against research diagnoses.
Correlations between dimensions of anxious, depressive and somatic symptoms were found to be high. For major depression the 5 item depression scale has marked superiority over the usual 2 item scales used by both the ICD and DSM systems, and for anxiety there is some superiority. If the questions are used with patients that the clinician suspects may have a psychological disorder, the positive predictive value of the scale is between 78 and 90%.
The two scales allow clinicians to make diagnostic assessments of depression and anxiety with a high positive predictive value, provided they use them only when they suspect that a psychological disorder is present.
Concordance between a simpler definition of major depressive disorder and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: An independent replication in an outpatient sample
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A meta-analysis of studies examining primary care physicians' diagnostic practice found that most of patients diagnosed with depression by primary care physicians do not have MDD [16]. Before these recent reports, a number of studies demonstrated that most nonpsychiatrist physicians are unable to recall most of the MDD symptom criteria [17-21]. A potential consequence of the failure to determine whether depressed patients meet the MDD criteria, and thus appropriately distinguish between patients who have MDD and milder variants of mood problems such as adjustment disorder with depressed mood, is the over prescription of antidepressant medication to patients for whom it has not been established that antidepressants are effective.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptom criteria for major depressive disorder (MDD) are somewhat lengthy with several studies showing that clinicians have difficulty recalling all 9 symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. To address these problems, a simpler definition of MDD was developed that did not include the somatic symptoms. Previous reports found high levels of agreement between the simplified and full DSM-IV definition of MDD. However, the same research group has conducted all previous studies of psychiatric patients. The goal of the present study was to determine if a high level of concordance between the 2 definitions would be replicated in an independent setting. We interviewed 2907 psychiatric outpatients presenting for treatment at the Boston University Center for Anxiety and Related Disorders. A trained diagnostic rater administered a semistructured interview and inquired about all symptoms of depression for all patients. A high level of agreement was found between the DSM-IV and the simpler definition of MDD. The absolute level of agreement between the 2 definitions was 95.5% and the κ coefficient was 0.88. Thus, consistent with previous studies, a high level of concordance was found between a simpler definition of MDD and the DSM-IV definition. This new definition offers 2 advantages over the current DSM-IV definition—it is briefer, and it is easier to apply with medically ill patients because it is free of somatic symptoms. Implications of these findings for DSM-5 are discussed.
Is developmental and behavioral pediatrics training related to perceived responsibility for treating mental health problems?
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Weighted means and standard deviations were used to describe continuous measures, and unweighted counts and weighted proportions were used to summarize categorical measures. The Rao-Scott chi-square test and weighted logistic regression analyses were used to assess bivariate associations between perceived responsibility for treating/managing ADHD, depression, and anxiety with the key explanatory variables (duration of DBP residency rotation; training and self-rated competencies), as well as potential confounders of clinical interest (future clinical practice goals) or those identified from previous studies (gender or interest in pediatric MH issues22–25). For categorical variables with more than 2 levels, post hoc pair-wise comparisons were examined if the overall P value was statistically significant (P < .05).
The aim of this study was to investigate training in developmental and behavioral pediatrics (DBP) for graduating residents, their competencies in diagnosing and treating child mental health (MH) problems, and whether the amount of DBP training and/or perceived competencies are associated with perceived responsibility for treating 3 MH problems.
Data were collected from 636 residents who completed the American Academy of Pediatrics's 2007 Graduating Residents Survey. The survey included questions on training and self-rated competencies in multiple MH skill areas and perceived responsibility for identifying and treating/managing children's MH problems. Weighted multivariable logistic regression analyses examined associations between training, competencies, and perceived responsibility for treating/managing attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression.
Ninety percent of respondents completed a DBP rotation, with 86% reporting >3 to 4 weeks of training. Duration of DBP rotation was related to training and perceived competencies in MH skill areas, and nearly all residents who reported high competencies were trained in those skill areas. However, <50% reported their competencies as “very good” or “excellent.” Residents with training and high competency in dosing with medications were most likely to agree that pediatricians should be responsible for treating/managing ADHD, anxiety, and depression.
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An implementation study that evaluated the impact of previously adopted guidelines on the clinical practice of medical residents was conducted to improve the recognition and treatment of major depressive disorders (MDDs) in hospitalized patients with somatic diseases.
Guidelines were implemented in two wards (ENT and oncology) using intranet diffusion, interactive sessions with medical residents, and support material. Discharge letters of 337 and 325 patients, before and after the intervention, respectively, were checked for statement of diagnosis or treatment of MDDs and, in a post hoc analysis, for any mention about psychiatric management.
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A retrospective, self-reported, paper-and-pencil survey designed to assess health and risk behaviors was administered to 4726 low-income suburban women, aged 12 and 40 years, attending a family planning clinic in southeast Texas. The survey contained a background and demographic section in addition to six sections addressing health risk behaviors. Women also completed the 13-item Beck Depression Inventory to assess depressive symptoms.
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^☆: The development and evaluation of the Depression Education Program for Residents in Obstetrics and Gynecology was supported by grants from the Initiative on Depression and Primary Care of the John D. and Catherine T. MacArthur Foundation, Chicago, Illinois.

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Original researchEffects of a depression education program on residents’ knowledge, attitudes, and clinical skills☆

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Gen Hosp Psychiatry

Recognition, management, and outcomes of depression in primary care

Arch Fam Med

Recognition, management and course of anxiety and depression in general practice

Arch Gen Psychiatry

Identifying physicians likely to benefit from depression education. A challenge for health care organizations

Med Care

Psychosocial interest, medical interview, and the recognition of depression

Arch Fam Med

Depressive disorders in women: Diagnosis, treatment and monitoring

Defining and assessing professional competence

JAMA

Original research
Effects of a depression education program on residents’ knowledge, attitudes, and clinical skills☆