Transcript Mental Health - Barnsley VTS

Mental
Health
Mental Health – RCGP
curricculum
as a GP you should:
• 1.1 Understand the epidemiology of mental health problems in
general practice
• 1.2 Understand the roles and the power of emotions and their
relevance in well-being and mental illness
• 1.3 Understand and empathise with people who are distressed and
fully assess them (including risk) and offer appropriate support and
management
• 1.4 Ensure that you appropriately explore both physical and
psychological symptoms, family, social and cultural factors, in an
integrated manner
• 1.5 Understand the place of instruments in case-finding for depression
and for assessment of severity of symptoms
• 1.6 Understand the primary care management of patients with
common mental health problems
• 1.7 Understand the initial management of a patient with a suspected
psychotic illness
RCGP - Key Messages
• You should consider the mental health of a patient
in every primary care consultation, but be aware of
the dangers of..
medicalising distress
RCGP - Key Messages
• Depression and anxiety are common in people with
long-term physical conditions, and increase the
morbidity and mortality from
these conditions
RCGP - Key Messages
• Percentage of people with mental health problems
across their lifespan who are managed in primary
care?
90%
Depression & NICE
Some definitions
• Symptoms should have been present for at
least
2 weeks
before a diagnosis of depression is
made.
Some definitions
• If the person has depression which has gone
on for more than
2 years
they are said to have chronic depression.
Recognising Depression
• It is estimated that up to
50 %
of people with depression are not
recognized in primary care
[National Collaborating Centre for Mental Health, 2009].
• At least two-thirds of depressed people who see
their GP present with physical/somatic symptoms
rather than psychological symptoms and are less
likely to be recognized as being depressed
[National Collaborating Centre for Mental Health, 2009].
• Healthcare professionals may have personal
barriers to recognition…
• Examples?
• opening 'Pandora's box'
(esp. in a time-limited consultation)
• collude with the patient - 'therapeutic nihilism‘
• may consider depression to be a normal response
to difficult times
• may be sceptical of treatment options, or
dissatisfied with availability of psychological
interventions.
[Burroughs et al, 2006]
• Meta-analysis of 41 studies suggests that GPs are
good at ruling out depression in most people who
are not depressed, and that misidentifications (false
positives) outnumber missed cases (false
negatives) [Mitchell et al, 2009].
• The undetected cases are more likely to be milder
forms of depression [Kessler et al, 2003].
How can GPs improve
this?
• Use of case-identification questions
• A 'yes' response to one of the two questions has:
• high specificity for depression (0.95, 95% CI 0.91 to
0.97)
• low sensitivity (0.66, 95% CI 0.55 to 0.76)
•
[National Collaborating Centre for Mental Health, 2009].
What are the two magic
questions?
• During the last month have you often been
bothered by:
oFeeling down, depressed, or
hopeless?
oHaving little interest or pleasure
in doing things?
• An answer of 'yes' to either question indicates that
the person may be depressed and should prompt a
more detailed assessment.
Scoring systems?
• Do GPs use them?
• In what ways?
BMJ 2009: Southampton
study
Abstract:
• Objective - To determine if general practitioner
rates of antidepressant drug prescribing and
referrals to specialist services for depression vary in
line with patients’ scores on depression severity
questionnaires.
• Conclusions - General practitioners do not decide
on drug treatment or referral for depression on the
basis of questionnaire scores alone, but also take
account of other factors such as age and physical
illness.
Suicide?
• directly asking people with depression about
suicidal ideation and current intent.
• Ask if the person feels hopeless or that life is not worth living.
• Do not avoid the word 'suicide'.
• Suggested questions are..?
o Do you ever think about suicide?
o Have you made any plans for ending your life?
o Do you have the means for doing this available to you?
o What has kept you from acting on these thoughts?
• Follow up on the 'not really' answers.
Have a go…
• Doctor and Patient
• Remember the ‘Two Questions’
• Remember to assess suicide risk
Risk factors for suicide?
Social characteristics
History
Clinical/diagnostic
features
Male gender
Young age (< 30 years)
Advanced age
Single or living alone
Prior suicide attempt(s)
Family history of suicide
History of substance
abuse
Recently started on
antidepressants
Hopelessness
Psychosis
Anxiety, agitation, panic
attacks
Concurrent physical
illness
Severe depression
[NICE, 2009]
• NICE - diagnose major depression, this requires at least one of
the core symptoms:
• Persistent sadness or low mood nearly every day, or
• Loss of interests or pleasure in most activities.
Plus some of the following symptoms:
• Fatigue or loss of energy
• Worthlessness, excessive or inappropriate guilt
• Recurrent thoughts of death, suicidal thoughts, or actual
suicide attempts
• Diminished ability to think/concentrate or increased indecision
• Psychomotor agitation or retardation
• Insomnia/hypersomnia
• Changes in appetite and/or weight loss
“Stepped-care” approach
Stage of depression
Intervention
Step 1: all known and suspected
presentations of depression.
Assessment, support,
psychoeducation, active monitoring,
and referral for further assessment
and interventions.
Step 2: persistent subthreshold
depressive symptoms; mild-tomoderate depression.
Low-intensity psychological and
psychosocial interventions,
medication, and referral for further
assessment and interventions.
Step 3: persistent subthreshold
depressive symptoms or mild-tomoderate depression with inadequate
response to initial interventions;
moderate and severe depression.
Medication, high-intensity
psychological interventions,
combined treatments, collaborative
care, and referral for further
assessment and interventions.
Step 4: severe and complex
depression; risk to life; severe selfneglect.
Medication, high-intensity
psychological interventions,
electroconvulsive therapy, crisis
service, combined treatments, and
multiprofessional and inpatient care.
Data from: [NICE, 2009]
St John’s Wort?
Anxiety & NICE
Some more definitions
• Generalised anxiety disorder (GAD) is a
common disorder of which the central
feature is excessive worry about a number
of different events associated with
heightened tension.
• It can exist in isolation but more commonly
occurs with other anxiety and depressive
disorders.
Some more definitions
• Panic disorder is characterised by recurring,
unforeseen panic attacks followed by at least
1 month
of persistent worry about having another attack and
concern about its consequences…
Another Stepped
Approach
• Step 1: All known and suspected presentations of
GAD:
● Identify and communicate the diagnosis of GAD as
early as possible to help people understand the
disorder
• Step 2: Diagnosed GAD that has not improved after
step 1 interventions:
• Low-intensity psychological interventions
• Step 3: GAD with marked functional impairment or
that has not improved after step 2
• Treatment options……
Read all about it…..
A bit of
QOF
QOF (Quality and Outcomes Framework) was
set up to rate (and reward) practices according
to certain measures of ‘quality of care’.
QOF
• An example is Mental Health follow-up, where the
patient group looked at by the QOF software is
given an indicator called ‘Mental Health 8’.
MH8
• Patient on Mental Health register
• Who are they?
People with
Schizophrenia,
Bipolar Disorder,
and other psychoses
With recording of
•
•
•
•
•
•
Alcohol consumption
BMI
Blood Pressure
Cholesterol
Blood glucose
Smear (last 5y)
Also….
– Lithium patients
• Creatinine and TSH
• Lithium levels in range
– Care Plan agreed (mental health personal care plan)
Example: Mental Health
• QOF (Quality and Outcomes Framework) was set
up to rate practices according to certain measures
of ‘quality of care’.
• An example is Mental Health follow-up, where the
patient group looked at by the QOF software is
given an indicator called ‘Mental Health 8’.
• The ‘Mental Health 8’ indicator is intended to
include those with ‘schizophrenia, bipolar affective
disorder and other psychoses’.
• The ‘Population Manager’ program on EMIS
searches for relevant codes and found 91
patients incorporated in ‘Mental Health 8’,
which should be for those with
serious/enduring mental health problems of
a type where regular review is indicated.
• However, many seemed to be patients with past
depressive episodes without long-term psychotic
elements, where there was little indication for
systematic reviews.
• How would you correct this system?
• Many had no entry for ‘Mental Health Review’ in
the last year (i.e. a review addressing the patient’s
mental health status, where there was concurrent
record of health promotion/preventative advice)
• How could the practice improve this?
• Likewise many had no code for ‘Mental Health
plan’ entered [i.e. clear evidence of an agreed
plan covering sources of help/follow-up]
• How could the practice improve this?
• How would correspondence from the
psychiatrist or CMHT be useful?
• Where a review had taken place how
would you arrange/put in place dates for
future reviews?
• How would you deal with those whose
Mental Health reviews were overdue
currently?
• What about non-attenders, and how to
record contacts by telephone or by keyworkers?
• What would you remind your partners to
check, and how would you update them of
any changes made?
• What published evidence can you find that
regular review of patients with serious
Mental Health problems is worthwhile?
That’s All, Folks