Transcript Cognitive therapy for persistent depression

A long-term retrospective
evaluation of service use by
patients with chronic depression
Richard Moore
Clinical Psychologist
Cambridge Specialist Depression Service
Cambridgeshire and Peterborough
NHS Foundation Trust
Lack of response to treatment in
depression
Significant minority of patients fail to respond,
respond and relapse or become chronic (eg
15% over 23 year FU, Eaton et al, 2008)
No agreed treatment approach or service
provision
CPFT has not kept data on depression,
response or service use across time
RCT of the clinical and cost effectiveness of a
specialist mood disorders team for refractory
unipolar depressive disorder
Funded by CLAHRC
Collaboration of CP with NDL
Patients with major depression
Treated for > 6 months in secondary care
Still have HRSD > 16
Randomised to 12 months of treatment as usual vs
specialist service
Fellowship Project
Small sample of patients in local pathways with chronic
depression
Gather data over long-term retrospective period on
Use of mental health services
Costs of MH service use
Aims:
Provide contextual information for cost of trial and
future service implementation
Inform further information requirements
Thanks to:
CLAHRC and Murali
My colleagues in Cambridge Specialist
Depression Service
Rajini Ramana, Consultant Psychiatrist
Joy Hodgkinson, CPN
Julie McKeown, Admin
Patients
Depression persisting despite combined
intervention (medication + therapy)
Patients from own caseload
receiving multidisciplinary input
could not be discharged despite strong directives
N=6
Data gathering
Client Service Receipt Inventory (Beecham & Knapp, 2001)
Adapted for retrospective use with clinical records over 10 years
Mental health contacts
Discipline
Number
Duration
Medication
Psychotropic
Name
Dose
Duration
Sources of information
Clinical contacts
3 x electronic datasets (CRS, CDL, ECL)
Paper notes
Information sketchy, inconsistent
Essential to cross refer
Medication
CDL, paper notes, GP printouts
Information even patchier, less reliable
Costing information
No agreed local data
Standard costings: PSSRU (Curtis, 2011)
Many assumptions about gradings, overheads,
chargeable activity levels, training costs etc
Medication costs from BNF (2012)
Nature of patients
Patient 1 Patient 2 Patient 3
Patient 4 Patient 5
Patient 6
Age
56
43
40
47
40
53
Sex
F
F
F
M
F
F
Years since
1st depressed
33
22
12
29
9
22
Episodes
4
3
1
3
2
3
Duration
11
2
12
5
2
8
Staff contacts
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
Years in
services
10
6
10
9
9
8
Number of
staff seen
16
14
27
14
30
18
Staff > 12
months
6
5
8
4
3
5
Number of
contacts
(per year)
342
126
482
231
152
251
(34)
(21)
(48)
(26)
(17)
(31)
Staff costs
Patient 1
Patient 2
Patient 3 Patient 4
Patient 5
Patient 6
Total
151983
11614
47852
19590
25984
20829
(per year)
15198
1936
4785
2177
2887
2603
Psychiatry
6919
3000
3179
1237
3785
6531
Psychological
therapy
16132
6345
21500
7874
6480
10309
Community
10769
1757
14885
10478
4103
3989
Hospital
117666
0
4368
0
10920
0
Medication
Patient
1
Patient
2
Patient
3
Patient
4
Patient
5
Patient
6
Different
medications
7
8
17
5
11
12
Total cost
5020
4453
5928
753
693
13896*
Antidepressants
2
3
3
3
9
7
Antipsychotics
1
3
5
1
1
2
Mood stabilisers 1
1
1
1
1
1
Anxiolytics
1
8
0
0
2
3
Outcomes
Patient 1:
transferred to R&R with CRHTT input
Patient 2:
discharged to voluntary sector
Patient 3:
monthly relapse prevention group
Patient 4:
happily discharged
Patient 5:
monthly relapse prevention group
Patient 6:
unhappily discharged…re-referred!
Summary
Contacts vastly exceed acute pathway
boundaries
Great variability due to high cost of
hospitalisation
Yearly community cost approx £3000 (cf
IAPT £750)
Implications for services
Patients WILL
obtain long-term input
incur significant costs
Need to make as economical as possible
To be prevented:
Hospitalisation
Re-referral and re-assessment
Through consistency/maintenance treatments
Implementation Tools
New information system
Implementation of NICE Guidelines
PPI for chronic depression
Potential influence on pathway design
Can we afford to offer high quality
maintenance treatment for patients with
chronic depression?
No!
Can we afford NOT to offer high
quality maintenance treatment for
patients with chronic depression?
NO!
Practical difficulties of Fellowship
Time, time,
time
Competing demands
Organisational change
Time, time,
Sensitivity
time
Difficulties -> implementation ‘spin offs’