Integrating Care: Depression, Anxiety and Physical Illness | Week 3 | Course

Introduction | Step 1.9

Integrated care in practice

Karina Jackson | Dermatology Nurse Consultant
Adrian Iuga | Eye Liaison Officer Please note that this is
Kathleen Fan | Oral and Maxillofacial Surgeon a transcript of an online
lecture or interview, and
Karina: In dermatology, we see patients with a range of different is not an academic paper.
skin conditions; conditions such as severe eczema,
psoriasis, acne, urticaria and some skin cancers. A lot of the
conditions we look after are chronic and relapsing. That
means they can come and go, but they are often lifelong,
and they can have a range of symptoms - for example,
itching, soreness of the skin, maybe weeping. But
importantly, a lot of these conditions are visible.

Because of the visibility of skin conditions, a lot of people

feel embarrassed or ashamed and don't wish to show their
skin in public, and so they may become socially isolated.
They may become anxious or depressed about their skin.
And the chronic physical symptoms they're experiencing can
also add to their anxiety or depression. The mind and the
skin are undoubtedly inextricably linked. So if somebody is
experiencing a chronic skin condition, they may become
psychologically distressed. But equally, if somebody has got
a mental health problem, that may exacerbate their skin
condition, or it may make them less able to cope with their
condition and comply with a treatment plan.

I think it's really important to combine mental and physical

healthcare for patients so that you're taking a holistic
approach to the patient, as they are a whole person. I think
that will hopefully improve the whole outcome for the
patient. I think by engaging with patients, you're more likely
to develop a good relationship with them and gain trust from
the patient, and therefore, that will hopefully help whatever
physical health problem you're managing, as well.

In our service, we are very lucky in that we have teamed up

with the IMPARTS team, which is a King's Health Partners
project. This has enabled us to use a platform to help
screen for anxiety and depression in our patient cohort. We
do this at each visit when the patient comes to clinic by using
validated questionnaires which screen for anxiety,
depression and we also use a dermatology quality of life
questionnaire. Our patients complete these questionnaires
electronically before they come into the clinic room. So we
have an idea before we see the patient if there are any

© King’s College London, 2018 King’s Online

 specific areas we need to focus on during our consultation
and can tailor our consultation accordingly.

If we pick up that there are problems, we now have what's

called a stepped care plan with different levels of care that
the patient might benefit from, from self-help materials
through to seeing our clinical psychologist or psychiatrist if
really necessary. All of this is done in our specialist clinics,
and our patients have come to expect it. So, it's become
normal and acceptable to all our patients.

Adrian: I see patients with sight loss, and for them, it can often be
much more difficult to access the information they need, to
get help from the services that are relevant to them, to find
and maintain employment, to engage with other people
socially - and this can lead to a lot of frustration and a lot of
isolation. About half of the people with significant sight loss
experience symptoms of depression. But because of the
issues I just mentioned, it's much more difficult for them to
get the right help early on.

I think as healthcare professionals, we would need to have a

holistic approach to treatment to look at all the problems
that our patients come in with and to try to help as much as
we can. Now, mental health is often the other half of the
story, and unfortunately, often health professionals shy
away from helping with this because of perhaps lack of
knowledge, or perhaps the fear that they might not know
what to do, where to send the patient for help and support.

But I think if we try to join this up, we would be able to offer

a much better service to our patients and address their
problems more fully. We found that a little bit of training can
go a long way in supporting the staff to address the mental
health issues, and also the mind and body champion model
that we have helps as well, because it's good to have
someone who will make colleagues aware of training
opportunities, of mental health professional development
they can access. And then that makes it much more likely
for them to actually engage with training and to later on
support the patients they see.

I'm using the IMPARTS system to screen for anxiety and

depression in the patients that I see. Now, I was already
looking at mental health difficulties in this patient group
before, but it was very difficult to do it systematically. Now,
IMPARTS allows me to be sure that I address mental health
issues with all the patients that I see, and I do that early on.
It also allows me to track any changes in the mental health of
the patients I see. And finally, it gives me the choice of
treatment to make sure that I can refer the patients I see to

© King’s College London, 2018 King’s Online 2

 a treatment option that's suitable for them. It has proven
tremendously successful for my service and for the patients
that I see, and I think that's why two of my other colleagues
are looking at setting up similar screening programmes in
their own clinics.
Kathleen: I am an oral and maxillofacial surgeon. As such, I treat
patients with problems in the head and neck region. In
particular, those with problems affecting the face and the
jaw. I treat patients with facial injuries, patients with
asymmetrical faces, jaw joint problems, patients with skin
cancer, as well as those with lumps and bumps around the
head and neck.

When I'm treating patients for facial injury, I have to not only
ensure that I get a good functional result, but also ensure I
get the best possible cosmetic and aesthetic outcome for
that patient, because that's what's important to them. We
know from research that patients who look different have a
higher level of mental health difficulty, such as anxiety and
depression. So, for me and my team, it's essential that we
are able to identify patients with potential mental health
problems and manage them appropriately by referring them
for psychological support.

I work in a visual area which is bound up with our identity.

People make assumptions regarding our intelligence, our
honesty, our integrity and even our approachability as a
result of the way we look. For our pain patients, we know
that those who have low moods, anxiety or depression are
more likely to experience more pain. We therefore know it is
important for us to have information regarding our patients'
mental wellbeing.

The question is, how do we integrate this within our clinical

care? This is where IMPARTS comes in. Together with
IMPARTS, we were able to design and implement a package
specifically for maxillofacial surgery. Patients are offered an
iPad in the waiting room and asked to complete a number of
questionnaires, including questions on anxiety and
depression. By the time they're seen by the clinician, the
clinician already has the results. The clinician can decide
whether further questions are required. With this
information, the clinician is able to determine whether that
individual requires psychological support. So, the IMPARTS
package allows us to ensure our patients have the best
holistic care in maxillofacial surgery.

© King’s College London, 2018 King’s Online 3