Cindy LK Lam, clklam@hku.hk Weng Y Chin, Tai Pong Lam, Yvonne YC Lo, FMU

1. CADENZA Symposium 2009The Primary Care Approach to Psychological Problems in the Elderly: From Screening to Problem-solving Cindy LK Lam, clklam@hku.hk Weng Y Chin, Tai Pong Lam, Yvonne YC Lo, FMU Peter WH Lee, Department of Psychiatry, Daniel YT Fong, Department of Nursing Studies The University of Hong Kong

2. HCPF (# 218016), Food and Health Bureau, the Government of the HKSAR • Ethics Committee, Faculty of Medicine, the University of Hong Kong (EC 1293-99). • Dr. Stephen WK Chow, Dr. Kevin KL Pang, Dr. Johnny CY Lam, Dr. Sam CS Au, Dr. Jacky HH Sze and Dr. Brigitte E Schlaikier who provided PST-PC • Ms. On-On Cheng and Alice OL Cheung for co-ordination of data collection and analysis Acknowledgment

3. From Screening to Problem-solving • Challenges & opportunities in PC • Study on screening & brief PST- PC for elderly with screened positive psychological problems • Implications for clinical practice & future research Psychological Problems in the Elderly in Primary Care

4. Poverty (1/5 on CSSA) & ill-health (2/3 chronically ill) • Suicide rate (32/100,000, 2004) of HK elderly is second highest in the world • 86% victims had psychiatric problems • Elderly population survey prevalence • 19% screened positive of depression • 5% known psychological problems • 0.4% known depression Challenges : Tip of the Iceberg

5. 77% consulted within 1 month before suicide • 85% of elderly consulted at least once/yr • Mean 5-8 consultations/yr • Continuity of care • Trusting doctor-patient relationship • Whole-person care • 20% elderly had psychological problems but 48% undiagnosed Opportunities in PC

6. Unrecognized Psychological Problems in the Elderly (UPPE) Is it important? Is screening useful? Is PST-PC effective? Courtesy of photolibrary@hku.hk

7. Aims & Objectives • Prevalence & risk factors • Impact on HRQOL & consultation rates • Nature of the problems • Effectiveness of brief PST- PC for elderly patients screened positive of psychological problems Screening & PST-PC for UPPE in PC

8. 5225 consecutive GOPC patients aged 60+ 1371 screened negative 1473 refused, 1614 not eligible, 285 incomplete interviews 482 HADS screened positive 183 Refused RCT 299 Agreed to RCT 149 randomized to3x PST-PC 132 attended ≥1 PST-PC sessions 150 randomized to 3 x placebo 132 attended ≥1 video session Blinded assessment at week 6, 12, 26 & 52; 69% completion Blinded assessment at week 6, 12, 26 & 52; 71% completion

9. Screening by Hospital Anxiety & Depression Scale (HADS): positive if anxiety score ≥3 or depression score ≥6 • The MOS SF-36 Health Survey on HRQOL (PCS & MCS) • Structured Q. on monthly consultation rates, sociodemography & co-morbidity • PST-PC record form Study Instruments

10. Three 3-hour training workshops for FM residents • 3 structured brief PST-PC sessions (20-45 min)  Establish rapport  Identify any psychiatric diagnosis  Patient identifies & prioritize problems  Patient to think of possible solutions for main problem  Suggest more solutions  List advantages and disadvantages of each solution  Prioritize solutions  Settle on the preferred solution: break it down into steps  Patient is to work on the first step of the solution Intervention: PST-PC

11. Results Courtesy of photolibrary@hku.hk

12. Prevalence of UPPE in PC

13. Negative (n=1372) PST-PC (n=149) Video (n=150) Refused (n=183) Age, mean (SD) 72.8 (6.8) 71.6 (6.5) 72.0 (7.1) 72.2 (7.5) Gender (% male) 55.9§ 45.0 41.3 38.3 No formal educ % 47.9§ 55.7 51.3 67.2# Married, living spouse % 62.4§ 65.8 61.3 65 >2 chronic disease % 12.5 § 27.5 24.0 21.3 HADS mean AS (SD) 0.4 (1.7) § 5.0 (3.7) 4.7 (2.8) 4.9 (3.1) HDAS mean DS (SD) 1.1 (1.4)§ 4.9 (4.4) * 3.9 (3.5) * 4.7 (4.0) SF-36 PCS mean (SD) 43.5 (10.9)§ 36.8 (13.6) 37.2 (13.3) 33.4 (13.2)# SF-36 MCS mean (SD) 62.1 (6.7)§ 49.2(12.3) 51.9 (12.8) 51.1 (12) Monthly WM consult (SD) 1.23 (1.1) § 1.4 (1.1) 1.5 (1.3) 1.5 (1.7) Baseline Characteristics of Subjects §,*, #Significant difference betweenPSC & video groups, HADS positive & negative groups, and RCT & refused RCT groups, respectively

14. Risk Factors of UPPE(Adjusted Odds Ratio by Multivariate Logistic Regression)

15. Adjusted Effects UPPE on HRQOL & Monthly Consultation RatesMultivariate linear regression coefficients (95% CI) * Results from population survey 1998

19. Changes in SF-36 & HADS Scores from Baseline * Significant difference after adjusting for multiplicity by Holm’s procedure, baseline DS and MH, socio-demographics and co-morbidity

20. Changes in Monthly Consultations No Significant difference in consultation rates from baseline

21. * Significant by linear mixed effects analysisadjusting for baseline DS & MH scores, sociodemography and co-morbidity

22. Is it important? Is screening useful? Is PST-PC effective? Courtesy of photolibrary@hku.hk

23. UPPE were important: common, impair QOL & increase consultation • Screening increased detection, target >2 chronic diseases & married females • Majority did not meet DSM IV criteria • Family, health & finance problems • Solutions required changes • Brief PST-PC had short-term benefits • Group viewing of video improved QOL Key Findings

24. Quality of PST: assured in that tasks were achieved in >80% sessions on random review • Many elderly could not identify problem/ solution • 3 sessions of PST-PC were not sufficient? • Lack of motivation? • Milder problems less responsive to treatment? • Cultural factors? • The placebo intervention was too powerful? Limited Benefit of Brief PST-PC

25. Need for PC-relevant diagnostic taxonomy • Psychological diagnosis & treatment cannot be separated from physical & social problems • Little indications for drugs • A multi-disciplinary system approach integrated with routine PC • Family interventions are needed • The family doctor’s role in detection, motivation, co-ordination & maintenance Implications for Clinical Practice & Future Research

26. Primary Care for HK…the way forwardThursday, 15 Oct 2009 2:00 – 4:30 pm Officiating Guests of Honour Dr York Chow, Secretary for Food and Health, Professor Raymond Liang, President, HKAM Keynote by Prof. Barbara Starfield “Measuring Primary Care & Its Benefits” Forum Discussion Cheung Kung Hai Conference Centre L.K.S. Faculty of Medicine, HKU 21 Sassoon Rd, HK. www.hku.hk/fmunit

27. Lam CLK, Lee PWH, Fong DYT, Lam TP. A randomised controlled trial on the effectiveness of screening and brief problem-solving counselling for elderly patients with undiagnosed psychological problems in primary care. H K Med J 2008; 14(6) Suppl: 31-35. • Lam CLK, Chin WY, Lee PWH, Lo YYC, Fong DYT, Lam TP. Unrecognized psychological problems impair quality of life and increase consultation rates in Chinese elderly patients. Int J Geriatr Psychiatry 2009; 24:979-989. • Lam CLK, Fong DYT, Chin WY, Lee PWH, Lam ETP, Lo YYC.Brief Problem-solving Treatment in Primary Care (PST-PC) Was Not More Effective than Placebo for Elderly Patients Screened - Positive of Psychological Problems.Int J Geriatr Psychiatry (in press) Publications

28. HRQOL by HADS Classification All differences between groups significant (p<0.001) by 2-sample t test

29. Consultations by HADS Classification * Significant (p<0.05) by 2-sample t test