1. 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

2. 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

3. 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

4. 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

5. Thanks to: CLAHRC and Murali
My colleagues in Cambridge Specialist Depression Service
Rajini Ramana, Consultant Psychiatrist
Joy Hodgkinson, CPN
Julie McKeown, Admin

6. Patients
Depression persisting despite combined intervention (medication + therapy)
Patients from own caseload
receiving multidisciplinary input
could not be discharged despite strong directives
N=6

7. 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

8. 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

9. 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)

10. Nature of patients Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Age 56 43 40 47 53
Sex F M
Years since 1st depressed 33 22 12 29 9
Episodes 4 3 1 2
Duration 11 5 8

11. Staff contacts Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Years in services 10 6 9 8
Number of staff seen 16 14 27 30 18
Staff > 12 months 5 4 3
Number of contacts (per year)
342
(34)
126
(21)
482
(48)
231
(26)
152
(17)
251
(31)

12. Staff costs Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Total
(per year)
151983
15198
11614
1936
47852
4785
19590
2177
25984
2887
20829
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
4368
10920

13. 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 9
Antipsychotics 1
Mood stabilisers
Anxiolytics

14. 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!

15. Summary Contacts vastly exceed acute pathway boundaries
Great variability due to high cost of hospitalisation
Yearly community cost approx £3000 (cf IAPT £750)

16. 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

17. Implementation Tools New information system
Implementation of NICE Guidelines
PPI for chronic depression
Potential influence on pathway design

18. 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!

19. Practical difficulties of Fellowship
Time, time, time
Competing demands
Organisational change
Sensitivity
Difficulties -> implementation ‘spin offs’