Improving general practitioners’ interviewing skills in managing patients with depression and anxiety: a randomized controlled clinical trial

Figures & data

Table

Practice points

•Educational intervention helps physicians to acquire only certain communication skills to care for patients with depression and anxiety disorders.

Table 1.  Demographic characteristics of doctors

	Intervention (n = 16)	Control (n = 16)	p-value
Gender
Male	9 (56.3%)	10 (62.5%)	0.719^NS
Female	7 (43.8%)	6 (37.5%)
Age
<30	0 (0.0%)	1 (6.3%)	0.824^NS
30–40	3 (18.8%)	3 (18.8%)
40–50	6 (37.5%)	5 (31.3%)
50–60	5 (31.3%)	6 (37.5%)
>60	2 (12.5%)	1 (6.3%)
Postgraduate training
Yes	7 (43.8%)	7 (46.7%)	0.870^NS
No	9 (56.3%)	8 (53.3%)
Undergraduate training
Hong Kong	8 (50.0%)	10 (62.5%)	0.476^NS
Overseas	8 (50.0%)	6 (37.5%)	Đ

**Notes: NS - Statistically insignificant (p > 0.05).

Table 2.  Inter-rater agreement

Case	Total scores (Pearson correlation)	Global ratings (Spearman correlation)
Pre–Case 1	0.598**	0.077^NS
	n = 32	n = 32
Pre–Case 2	0.488**	0.262^NS
	n = 32	n = 32
Post–Case 1	0.632**	0.543**
	n = 32	n = 32
Post–Case 2	0.617**	0.676**
	n = 32	n = 32
Overall agreement	0.527**	0.322**
Đ	n = 128	n = 128

Notes: Statically significant at 0.01 level. NS-Statically insignificant.

Table 3.  Change in interviewing skills between the control and intervention groups

		Intervention			Control
Task	Description	Pre	Post	Change	Pre	Post	Change	p-value
1	Initiating the session/opening	3.55	3.33	−0.22	3.58	3.20	−0.38	0.499
2	Non-verbals	3.13	3.19	0.06	3.30	2.92	−0.38	0.062
3	Active listening and facilitating patient's response	3.13	3.16	0.03	3.28	2.83	−0.45	0.011*
4	Understanding patient's perspective	2.72	2.86	0.14	2.89	2.61	−0.28	0.054
5	Structuring the consultation	3.03	3.14	0.11	3.03	2.98	−0.05	0.396
6	Negotiating mutual plan of action	2.69	2.94	0.25	2.84	2.67	−0.17	0.063
7	Explanation and planning	2.70	3.00	0.30	2.75	2.66	−0.09	0.124
8	Closure	2.64	2.78	0.14	2.73	2.45	−0.28	0.157
Total score		29.39	30.48	1.09	30.53	27.83	−2.70	0.030*
Global rating		2.88	2.94	0.06	3.03	2.69	−0.34	0.052

*Statistically significant at 0.05 level. Maximum score out of 5 for tasks 1 to 8 and global ration. Maximum score out of 50 for total score.

Table 4.  Doctors’ performance in desired interviewing behaviour in pre and post-intervention consultations

	Intervention Control			Intervention Control
		Number (%)		Number (%)
Doctors' performance in desired interviewing behavior	(n = 16)	(n = 16)	p	(n = 16)	(n = 16)	p
PRE	Case 1 (CW)			Case 2 (US)
Assessed
Major depression criteria	8 (50.0)	9 (56.3)	0.723	7 (43.8)	4 (25.0)	0.264
GAD criteria	1 (6.3)	0 (0.0)	0.310	2 (12.5)	3 (18.8)	0.626
Suicidal ideation	10 (62.5)	9 (56.3)	0.719	10 (62.5)	8 (50.0)	0.476
Stresses at home/work	15 (93.8)	14 (87.5)	0.544	15 (93.8)	16 (100.0)	0.310
Discussed possibility of depression/GAD	11 (68.8)	9 (56.3)	0.465	8 (50.0)	10 (62.5)	0.476
Prescribed or suggested use of antidepressants	10 (62.5)	8 (50.0)	0.476	10 (62.5)	11 (68.8)	0.710
Scheduled follow up arrangement	5 (31.3)	4 (25.0)	0.694	7 (43.8)	7 (43.8)	1.000
POST	Case 3 (CW)			Case 4 (MY)
Assessed
Major depression criteria	4 (25.0)	2 (12.5)	0.365	12 (75.0)	8 (50.0)	0.144
GAD criteria	7 (43.8)	3 (18.8)	0.127	1 (6.3)	0 (0.0)	0.310
Suicidal ideation	4 (25.0)	4 (25.0)	1.000	12 (75.0)	12 (75.0)	1.000
Stresses at home/work	16 (100.0)	15 (93.8)	0.310	14 (87.5)	16 (100.0)	0.144
Discussed possibility of depression/GAD	10 (62.5)	6 (37.5)	0.157	10 (62.5)	12 (75.0)	0.446
Prescribed or suggested use of antidepressants	10 (62.5)	8 (50.0)	0.476	11 (68.8)	11 (68.8)	1.000
Scheduled follow up arrangement	6 (37.5)	4 (25.0)	0.446	8 (50.0)	5 (31.3)	0.280

Appendix 2 Calgary Cambridge Observation Guide

Task	Description of task	Global Rating(0–5)#	Comments
I. Initiating the session/Opening	1. GREETS patient by name 2. INTRODUCES SELF (and clarifies role) 3. DEMONSTRATES INTEREST AND RESPECT (attends to physical comfort, here and throughout interview) 4. IDENTIFIES AND CONFIRMS PATIENT'S PROBLEM LIST or issues, e.g. “So headache, fever-anything else you’d like to talk about?” 5. NEGOTIATES AGENDA, taking both patient's and doctor's perspective into account
II. Non-verbal of doctor & patient	1. DEMONSTRATES APPROPRIATE NON-VERBAL BEHAVIOUR: 1a. eye contact, facial expression, 1b. posture and position, 2. FACILITATE PATIENT'S RESPONSES NON-VERBALLY, movement, tone and pace of voice 3. APPEARS CONFIDENT and reasonably relaxed 4. PICKS UP NON-VERBAL CLUES, i.e. body language, speech, facial expression, affect, CHECKS OUT and acknowledges as appropriate
III. Active listening and  facilitating patient's response	1. ENCOURAGES PATIENT TO TELL STORY of problem(s), FACILITATES PATIENT'S RESPONSES VERBALLY (use of encouragement, silence, repetition, paraphrasing, interpretation, reflective statements). 2. Uses open and closed questioning techniques. APPROPRIATELY MOVES FROM OPEN TO CLOSED. 3. LISTENS ATTENTIVELY, allows patient to complete statements without interruption and leaves space for patient to think before answering or go on after pausing. 4. CLARIFIES PATIENT'S STATEMENTS which are vague or need amplification, e.g. “Could you explain what you mean by lightheaded?” 5. EMPATHIZES AND SUPPORTS PATIENT, e.g. expresses concern, understanding, willingness to help, acknowledges coping efforts and appropriate self-care.
IV. Understanding patient's perspective	1. DETERMINES AND ACKNOWLEDGES PATIENT'S IDEAS, i.e. beliefs regarding cause. 2. EXPLORES CONCERNS (including worries, effects on lifestyle) regarding each problem. 3. DETERMINES PATIENT'S EXPECTATIONS regarding each problem. 4. ENCOURAGES EXPRESSION OF FEELINGS AND THOUGHTS 5. PICKS UP VERBAL AND NON-VERBAL CUES, e.g. patient's need to contribute information or ask questions, information overload, distress.
V. Structuring the consultation	1. SUMMARIZES AT END OF A SPECIFIC LINE OF INQUIRY (present Hx, past Hx) to verify own interpretation of what patient has said, to ensure no important data were omitted 2. PROGRESSES from one section to another USING TRANSITIONAL STATEMENTS; includes rationale for next section 3. STRUCTURES interview in LOGICAL SEQUENCE 4. ATTENDS TO TIMING and keeping interview on task 5. OVERALL ORGANIZATION
VI. Negotiating mutual plan of action (Collaborative attitude rather than authoritarian style)	1. INVOLVES PATIENT by making suggestions rather than directives and ENCOURAGES PATIENT TO CONTRIBUTE their IDEAS, suggestions, preferences, beliefs. 2. DISCUSS OPTIONS & NEGOTIATES A MUTUALLY ACCEPTABLE PLAN 3. REVEALS RATIONALE for opinion 4. ELICITS PATIENT'S UNDERSTANDING, REACTIONS AND CONCERNS about plans and treatments, including acceptability and OBTAINS PATIENT'S VIEW OF NEED for action, PERCEIVED BENEFITS, BARRIERS, MOTIVATION; accepts and advocates alternative viewpoint as necessary. 5. ENCOURAGES PATIENT to be involved in implementing plans, TO TAKE RESPONSIBILITY and be self-reliant.
VII. Explanation & planning	1. GIVES EXPLANATION AT APPROPRIATE TIMES (avoids giving advice, information, opinions prematurely) 2. GIVES INFORMATION IN CLEAR, WELL-ORGANIZED, complete fashion without overloading patient; avoids or explains jargon. 3. RELATES EXPLANATIONS TO PATIENT'S ILLNESS FRAMEWORK: to previously elicited beliefs, concerns and expectations. 4. CHECKS PATIENT'S UNDERSTANDING AND ACCEPTANCE of explanation and plans; ensures that concerns have been addressed 5. ASKS ABOUT PATIENT SUPPORT SYSTEMS, discusses other support available *Bonus: Use of diagrams or aids and pamphlets
VIII. Closure	1. SUMMARIZES session briefly, may ask patient to summarize. 2. CONTRACTS WITH PATIENT regarding next steps for patient and physician. 3. CHECK THAT PATIENT AGREES and is comfortable with plan and ASKS IF ANY CORRECTION, QUESTIONS or other items to discuss 4. ENCOURAGES PATIENT TO DISCUSS ANY ADDITIONAL POINTS and provides him/her with opportunity to do so, e.g. “Are there any questions you’d like to ask or anything at all you’d like to discuss further?” 5. SAFETY NETS APPROPRIATELY, what to do if plan is not working, when and how to seek help.

Total Score = I + II + 2 x III + IV + V + 2 x VI + VII + VIII = 50 maximum. Comment if any fatal mistakes: e.g. ethical problem- broke patient confidentiality.

Global Rating: Please rate the doctor's performance globally from 0–5

 0      1      2        3       4         5

Very poor    Poor     Inadequate   Adequate   Good   Impressive performance Task in diagnosing and managing major depression and GAD    Yes or No?

Assessment of suicidal ideation

Assessment of stresses at home/work

Discussed possibility of depression/GAD

Prescribed or suggested the use of antidepressants (benzo. for GAD)

Scheduled follow up arrangements