Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice & Education Council.

Similar presentations


Presentation on theme: "Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice & Education Council."— Presentation transcript:

1 Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice & Education Council

2 BACKGROUND

3 DEPRESSION many mood disorders with varying severity, symptoms and persistencemany mood disorders with varying severity, symptoms and persistence dysthymia, major depressive disorder, bipolar disorder, psychotic depression, post-partum depression & seasonal affective disorderdysthymia, major depressive disorder, bipolar disorder, psychotic depression, post-partum depression & seasonal affective disorder leading cause of disability worldwide (121 million)leading cause of disability worldwide (121 million) 70% of recorded suicides70% of recorded suicides psychiatric disorder 90% of suicide victimspsychiatric disorder 90% of suicide victims

4 INCIDENCE Taiwan cases per 100 adultsTaiwan cases per 100 adults New Zealand5.8 - New Zealand 6% - Australia6% - Australia 5% - 10% - UK5% - 10% - UK 10% - USA10% - USA 23.5% - Japan23.5% - Japan

5 NORTHERN IRELAND 21% aged over 1621% aged over 16 24% women & 17% men24% women & 17% men mental health needs 25%  than Englandmental health needs 25%  than England Prescriptions –Prescriptions – –anti-depressants 37% , –psychosis & related disorders 66%  –hypnotics & anxiolytics 75% 

6 CO-MORBIDITY cancerscancers 4.5% to 58%4.5% to 58% cardiovascular disorderscardiovascular disorders myocardial infarction 20-30%myocardial infarction 20-30% chronic conditionschronic conditions asthma & diabetes – 50%asthma & diabetes – 50% neurological disordersneurological disorders Parkinson’s Disease 40-50%Parkinson’s Disease 40-50% Stoke 16-60%Stoke 16-60% GPs –GPs – three times more likely to miss major depression in minor physical illness & five times more likely to miss major depression in serious physical illness

7 POLICY CONTEXT increasing recognition of mental illnessincreasing recognition of mental illness major public health issuemajor public health issue emphasis on promotion of mental & emotional healthemphasis on promotion of mental & emotional health 30 years refocusing of service provision away from hospital settings towards community care30 years refocusing of service provision away from hospital settings towards community care Greater understanding of mental illnessesGreater understanding of mental illnesses developments in psychopharmacologydevelopments in psychopharmacology changes in social policychanges in social policy vast array of legislative changevast array of legislative change Sex Discrimination Act 1975; Race Relations Act, 1976; Mental Health Act, 1983; Disabled Persons Act, 1999; NHS & Community Care Act, 1990Sex Discrimination Act 1975; Race Relations Act, 1976; Mental Health Act, 1983; Disabled Persons Act, 1999; NHS & Community Care Act, 1990

8 PRIMARY CARE early 1990s - the development of primary care early 1990s - the development of primary care support mental health services support mental health services improve collaboration between secondary care & primary care professionals improve collaboration between secondary care & primary care professionals potential for early detection, intervention, utilisation of voluntary sector organisations and mental health promotion potential for early detection, intervention, utilisation of voluntary sector organisations and mental health promotion to support this - NSF for Mental Health to support this - NSF for Mental Health set national standards and defined service models set national standards and defined service models seven standards - first three relevant to and promote the development of primary care mental health services seven standards - first three relevant to and promote the development of primary care mental health services NI has lagged significantly behind developments NI has lagged significantly behind developments

9 NORTHERN IRELAND regional strategic objectives highlighted mental health as a priority for action:regional strategic objectives highlighted mental health as a priority for action: Health and Well-Being into the Millennium (97-02)Health and Well-Being into the Millennium (97-02) Health and Social Well Being Survey (02)Health and Social Well Being Survey (02) Programme for Government (NIE, 02)Programme for Government (NIE, 02) Investing for Health Strategy (02)Investing for Health Strategy (02) Promoting Mental Health Strategy & Action Plan (03)Promoting Mental Health Strategy & Action Plan (03) Bamford Review of Mental Health (05 &06)Bamford Review of Mental Health (05 &06) “each individual with a mental health problem should be given the opportunity to have their mental health needs understood and addressed promptly within primary care settings, taking into account biological, psychological and social dimensions” “each individual with a mental health problem should be given the opportunity to have their mental health needs understood and addressed promptly within primary care settings, taking into account biological, psychological and social dimensions”

10 PRIMARY CARE “It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process” (WHO, 1978)

11 Membership of the primary care team MedicalParamedicalAdministrativeTherapistsSocial General practitionerCommunity nursePractice managerPhysiotherapistSocial worker DentistPractice nurseReceptionistChiropodistCommunity psychiatrist Community geriatrician Ophthalmic opticianAssistantSpeech therapistPsychologist School medical officer MidwifeSecretaryOsteopathsCounsellor Health visitorDieticianDomiciliary aid Pharmacist

12 Almost 20,000 people actively involved in the provision of primary care services: – 1,200 GPs; –5,000 Nurses; –250 Midwives; –700 Dentists; –1,000 Community Pharmacists; –1,000 Allied Health Professionals; –500 Optometrists; –4,000 Social Workers; and –6,000 Home-helps. Source: DHSSPS (2005)

13 PRIMARY CARE  90% cared for and managed  90% cared for and managed  50% of attendees from depression  50% of attendees from depression patients present with  somatised medical problems patients present with  somatised medical problems nearly three times the consultation rates nearly three times the consultation rates  suicide link  suicide link variations variations 50% ‘missed’ 50% ‘missed’  10% spent  10% spent

14 PROFESSIONAL ISSUES Primary care nurses increasingly involved in identifying, assessing and caring for people with depression: Primary care nurses increasingly involved in identifying, assessing and caring for people with depression: little time allocated little time allocated often untrained & unsupported often untrained & unsupported CMHNs - “mild” or “moderate” mental illness CMHNs - “mild” or “moderate” mental illness widely accepted in April GP fund-holders widely accepted in April GP fund-holders CMHNs well regarded CMHNs well regarded many GPs favour closer liaison many GPs favour closer liaison much criticism however much criticism however at risk of abandoning most vulnerable – SMI at risk of abandoning most vulnerable – SMI little attention paid to their selection & preparation little attention paid to their selection & preparation many torn between the demands of GPs and their employing Trust many torn between the demands of GPs and their employing Trust

15 RESEARCH Recommendations from:Recommendations from: Bamford Review of MH & LD (DHSSPS, 2005)Bamford Review of MH & LD (DHSSPS, 2005) New GP Contract (BMA & NHS Confederation, 2004)New GP Contract (BMA & NHS Confederation, 2004) ideal vehicles for developing primary care depression services, some nurse-led.ideal vehicles for developing primary care depression services, some nurse-led. Nonetheless,Nonetheless, clarity of roles & responsibilitiesclarity of roles & responsibilities gaps in the knowledge & training of primary care nursesgaps in the knowledge & training of primary care nurses no consensus on what standards, guidelines or benchmarks constitute an effective primary care based nursing service for adults with depression.no consensus on what standards, guidelines or benchmarks constitute an effective primary care based nursing service for adults with depression. develop, support and guide their practicedevelop, support and guide their practice benchmark – a standard to judge or measure something againstbenchmark – a standard to judge or measure something against

16 Research Questions 1. What are the most appropriate benchmarks for an effective primary care based nursing service for adults (18-64 years) with depression? 2. To what extent do existing primary care based nursing services for adults with depression in Northern Ireland conform to these benchmarks? 3. What are the best strategies for enhancing existing primary care based nursing services for adults with depression?

17 Design & Methodology Exploratory survey designExploratory survey design Qualitative approach multiple methodsQualitative approach multiple methods Two phasesTwo phases Ethical IssuesEthical Issues

18 Phase One Delphi techniqueDelphi technique Purposive SamplingPurposive Sampling Inclusion criteriaInclusion criteria 84 potential experts84 potential experts 67 (80%)67 (80%) Mental Health Nurses (n=36)Mental Health Nurses (n=36) Health Visitors (n=9)Health Visitors (n=9) Practice Nurses (n=2)Practice Nurses (n=2) GPs (n=16)GPs (n=16) Psychiatrists (n=4)Psychiatrists (n=4)

19 Pilot Study QuestionnaireQuestionnaire Content and face validityContent and face validity 10 professionals10 professionals 100% response100% response Minor adjustmentsMinor adjustments –Layout –Design –Content

20 Findings Round One QuestionnaireRound One Questionnaire 96% response rate96% response rate 53% post / 47% 53% post / 47% statements1216 statements 239 benchmarks239 benchmarks 3 categories3 categories

21 Benchmarks Structures – 126 a primary care based depression service should support and utilise guidelines which have been modified for local circumstances (NICE)a primary care based depression service should support and utilise guidelines which have been modified for local circumstances (NICE) protected time should be provided to primary care practitioners to manage depression, attend reviews, supervision sessions and education programmes related to depression servicesprotected time should be provided to primary care practitioners to manage depression, attend reviews, supervision sessions and education programmes related to depression services all practice nurses should have attended at least a one day training course on depressionall practice nurses should have attended at least a one day training course on depression

22 Benchmarks Processes – 70 Structured assessments should be completed by primary care practitioners using validated rating scales to diagnose depression (PHQ-9, HADS, EPNS)Structured assessments should be completed by primary care practitioners using validated rating scales to diagnose depression (PHQ-9, HADS, EPNS) Clients with depression should have access to and choice of a range of support/treatments following a clear stepped care modelClients with depression should have access to and choice of a range of support/treatments following a clear stepped care model Interventions provided in primary care should be structured, time limited, evidenced based and adapted for use in a busy primary care setting (CBT)Interventions provided in primary care should be structured, time limited, evidenced based and adapted for use in a busy primary care setting (CBT)

23 Benchmarks Outcomes – 43 There should be an increase in the number of primary care nurses with the training and skills to assist in the management of clients with depressionThere should be an increase in the number of primary care nurses with the training and skills to assist in the management of clients with depression There should be a reduction in the amount of time clients with depression have to wait for psychotherapeutic interventionsThere should be a reduction in the amount of time clients with depression have to wait for psychotherapeutic interventions There should be a reduction in the number of episodes of relapse of depressionThere should be a reduction in the number of episodes of relapse of depression

24 Round Two QuestionnaireRound Two Questionnaire 95% response rate95% response rate 26% post / 74% 26% post / 74% consensus 70%consensus 70% descriptive statisticsdescriptive statistics 22 benchmarks22 benchmarks

25 Round Three QuestionnaireRound Three Questionnaire 95% response rate95% response rate 10% post / 90% 10% post / 90% consensus 70%consensus 70% descriptive statisticsdescriptive statistics consensus benchmarksconsensus benchmarks »45 (61%) structures »18 (25%) processes »10 (14%) outcomes

26 PHASE TWO Multiple Methods - triangulationMultiple Methods - triangulation InterviewsInterviews ObservationObservation Document analysisDocument analysis Stratified purposiveStratified purposive Content AnalysisContent Analysis

27 BENCHMARKING TOOLKIT Practice ManagerPractice Manager NoBenchmarkEvidenceGuidance 1.2 Enhanced depression services should be provided by all primary care teams and rewarded within the Quality Outcomes Framework QOF Contract for enhanced services Inspect specification. Check register, annual reviews, relevant audits 2.2 Primary care depression services should support and utilise guidelines which have been modified for local circumstances (NICE) Guidelines & Protocols Inspect guidelines & protocols followed to identify, manage, treat and refer

28 BENCHMARKING TOOLKIT GPs, Nurses, Health VisitorsGPs, Nurses, Health Visitors NoBenchmarkEvidenceGuidance 8.7 Protected study time should be available to primary care practitioners to allow for training and updates in managing depression Courses & updates Training& education records Interview pc practitioners Describe any protected study time for depression management. If none, what are the main barriers? 15.2 Structured assessments should be completed by primary care practitioners using validated rating scales/tools to diagnose depression (PHQ-9, HAD, EPNS) Assessment policy/protocols Interview pc practitioners Describe how you carry out an assessment? What screening tools do you use?

29 FINDINGS 42 primary care professionals42 primary care professionals eight primary care practiceseight primary care practices 2 from each of the Board areas.2 from each of the Board areas. This includedThis included GPs (n=8), practice managers (n=8), practice nurses (n=8), nurse practitioners (n=2), health visitors (n=8) & CMHNs (n=8)GPs (n=8), practice managers (n=8), practice nurses (n=8), nurse practitioners (n=2), health visitors (n=8) & CMHNs (n=8)

30 Primary care nurses view the provision of depression care as part of their role: all practice nurses (87.5%, n=7) and one nurse practitioner (50%) reported that they provided a limited role in the care of patients with depression and did not view further depression care as part of their current roleall practice nurses (87.5%, n=7) and one nurse practitioner (50%) reported that they provided a limited role in the care of patients with depression and did not view further depression care as part of their current role These views reflected the responses from three quarters of the GPs (n=6) interviewed. They also viewed practice nurses and nurse practitioners as having a limited role in the care of patients with depression. They suggested that mental health nursing services should be provided by the Trusts rather that GPs.These views reflected the responses from three quarters of the GPs (n=6) interviewed. They also viewed practice nurses and nurse practitioners as having a limited role in the care of patients with depression. They suggested that mental health nursing services should be provided by the Trusts rather that GPs. Potential barriers perceived by practice nurses and nurse practitioners preventing greater involvement in depression care included insufficient time (70%, n=7); a lack of knowledge and confidence (70%, n=7) and a lack of GP support (80%, n=8).Potential barriers perceived by practice nurses and nurse practitioners preventing greater involvement in depression care included insufficient time (70%, n=7); a lack of knowledge and confidence (70%, n=7) and a lack of GP support (80%, n=8).

31 There are adequate levels of primary care nurses to enable effective involvement in depression services: Three quarters of health visitors (n=6) reported that they felt current levels were inadequate to deal with post natal depression due to current work pressures.Three quarters of health visitors (n=6) reported that they felt current levels were inadequate to deal with post natal depression due to current work pressures. All practice nurses (n=8) and nurse practitioners (n=2) interviewed reported inadequate numbers to enable them to take on new roles in depression care.All practice nurses (n=8) and nurse practitioners (n=2) interviewed reported inadequate numbers to enable them to take on new roles in depression care. All CMHNs (n=8) suggested that current levels of primary care nurses were inadequate to deal with the high prevalence of depression in primary care. Six (75%) CMHNs indicated that they were being referred patients with less serious levels of depression who they thought should be managed by practice nurses. Five (62.5%) reported that more CMHNs or mental health nurses dedicated to primary care were needed to ensure patients were treated as early as possible following a diagnosis of depression. Concerns were expressed relating to a possible dilution of the CMHN role and diversion of resources for the care of people with severe mental illness due to the demands of a group of people described as less seriously ill.All CMHNs (n=8) suggested that current levels of primary care nurses were inadequate to deal with the high prevalence of depression in primary care. Six (75%) CMHNs indicated that they were being referred patients with less serious levels of depression who they thought should be managed by practice nurses. Five (62.5%) reported that more CMHNs or mental health nurses dedicated to primary care were needed to ensure patients were treated as early as possible following a diagnosis of depression. Concerns were expressed relating to a possible dilution of the CMHN role and diversion of resources for the care of people with severe mental illness due to the demands of a group of people described as less seriously ill.

32 Alternative service delivery models are used by primary care nurses to support patients with depression: Most practice nurses (75%, n=6) and all nurses practitioners (n=2) interviewed referred to face-to-face consultations at the practice. Services provided within these consultations included, health promotion, basic screening, provision of information and advice and referral to the GP for follow up if appropriate. The two practice nurses (25%) reported using telephone follow up, but this was only provided occasionally. Six (75%) CMHNs reported that their main method of service delivery involved outpatient appointments or home visits. However, the CMHN attached to primary care and one other CMHN, who was employed by a community mental health trust, reported that they provided mental health triage as an alternative method of service delivery.

33 The main barriers perceived by participants preventing the use of alternative service delivery models include the following: a lack of opportunity for primary care nurses to be involved in depression care (26.9% n=7); a lack of knowledge of available models (69.2%, n=18); funding and resources to lead and develop new models within primary care (80.7%, n=21); support from GPs and managers (88.4%, n=23); and a lack of relevant personnel to supervise specific programmes, for example, computer based therapy programmes (46.1%, n=12).The main barriers perceived by participants preventing the use of alternative service delivery models include the following: a lack of opportunity for primary care nurses to be involved in depression care (26.9% n=7); a lack of knowledge of available models (69.2%, n=18); funding and resources to lead and develop new models within primary care (80.7%, n=21); support from GPs and managers (88.4%, n=23); and a lack of relevant personnel to supervise specific programmes, for example, computer based therapy programmes (46.1%, n=12).

34 Primary care nurses are able to carry out a basic assessment to detect depressionPrimary care nurses are able to carry out a basic assessment to detect depression Primary care nurses have knowledge of the causes, symptoms of depression and influences of co-morbidityPrimary care nurses have knowledge of the causes, symptoms of depression and influences of co-morbidity Primary care nurses have knowledge of relevant local statutory, voluntary and private services for patients with depressionPrimary care nurses have knowledge of relevant local statutory, voluntary and private services for patients with depression Primary care nurses have knowledge of local guidelines/protocols for drug treatments and therapeutic doses/side effectsPrimary care nurses have knowledge of local guidelines/protocols for drug treatments and therapeutic doses/side effects

35 Primary care nurses are competent at assessing suicide riskPrimary care nurses are competent at assessing suicide risk Primary care nurses have an identified level of depression training and competencyPrimary care nurses have an identified level of depression training and competency There is regular continuous professional development (CPD) for primary care nurses on the recognition and management of depressionThere is regular continuous professional development (CPD) for primary care nurses on the recognition and management of depression most practice nurses (87.5%, n=7), nurse practitioners (100%, n=2), health visitors (63%, n=5) and CMHNs (75%, n=6) reported a lack of regular CPD on the recognition and management of depression. Barriers identified included lack of time, support from management and availability of courses.most practice nurses (87.5%, n=7), nurse practitioners (100%, n=2), health visitors (63%, n=5) and CMHNs (75%, n=6) reported a lack of regular CPD on the recognition and management of depression. Barriers identified included lack of time, support from management and availability of courses.

36 Protocols for the recognition, treatment, management and referral of patients with depression are used by primary care nursesProtocols for the recognition, treatment, management and referral of patients with depression are used by primary care nurses

37 A range of evidence based treatment interventions are provided by primary care nurses to patients with depression Three quarters of practice nurses (n=6) and all nurse practitioners (n=2) saw their most important treatment intervention as listening to patients and letting them discuss their worries or problems. The other relevant treatment interventions most commonly reported included basic counselling (40%, n=4) and referral to the GP (90%, n=9).Three quarters of practice nurses (n=6) and all nurse practitioners (n=2) saw their most important treatment intervention as listening to patients and letting them discuss their worries or problems. The other relevant treatment interventions most commonly reported included basic counselling (40%, n=4) and referral to the GP (90%, n=9). The treatment interventions CMHNs reported using included case management (62.5%, n=5); marital, bereavement and general counselling (75%, n=6); psychosocial interventions (50%, n=4); anxiety management (50%, n=4) and CBT (25%, n=2).The treatment interventions CMHNs reported using included case management (62.5%, n=5); marital, bereavement and general counselling (75%, n=6); psychosocial interventions (50%, n=4); anxiety management (50%, n=4) and CBT (25%, n=2).

38 Summary of benchmarks met by each practice PracticeBenchmarks MetBenchmarks Not Met Practice A42(58%)31 (42%) Practice B 39 (53%)34 (47%) Practice C 45 (61%)28 (39%) Practice D 37 (51%)36 (49%) Practice E 36 (49%)37 (51%) Practice F 37 (51%)36 (49%) Practice G 41 (56%)32 (44%) Practice H 47 (64%)26 (36%)

39 Recommendations  Investment/enhanced  Priority  Primary care team/lead  All practitioners  Early intervention  Training/time  Partnerships/protocols

40 SERVICE MODEL

41 NEW MODEL

42 Contact Details


Download ppt "Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice & Education Council."

Similar presentations


Ads by Google