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Common mental health problems: Clinical case scenarios

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1 Common mental health problems: Clinical case scenarios
for primary care Support for education and learning ABOUT THIS PRESENTATION: Clinical case scenarios are an educational resource that can be used for individual or group learning. They have been developed to improve the identification, assessment and treatment of common mental health problems such as anxiety or depression within primary care. They illustrate how the recommendations from ‘Common mental health disorders: identification and pathways to care’ (CG123) can be applied to the care of people presenting in primary care. Each scenario has been written by a different contributor with experience in this field, and reflects the different contributors’ styles. The scenarios are available in two formats: this PowerPoint version which can be used for group learning, and a PDF version which can be used for individual learning. These slides could be added to the standard NICE slide set that was developed to support the Common mental health disorders guideline, which provides an overview of the recommendations and background on potential costs and savings from putting the guidance into practice locally. The slide set can be found on the CG123 guideline page. Please note: the PDF version of the scenarios includes a further three case studies, additional background information and copies of tools that can help support GPs when establishing a diagnosis of a common mental health problem. It may be helpful to print a copy of the full PDF document for reference when using these slides in a learning or development session. Outline: Each question should be considered by the individual or group before referring to the answers. You will need to refer to the NICE clinical guideline to help you decide what steps you would need to follow to diagnose and manage each case, so make sure that users have access to a copy either online at or as a printout. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. The guideline is available in a number of formats, including a quick reference guide which can be downloaded from the NICE website. You can add your own organisation’s logo alongside the NICE logo. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. May 2012 NICE clinical guideline 123

2 Session overview Epidemiology Learning objectives Core principles
Clinical case scenarios 1 – 5 Stepped care model NICE Pathways and find out more NOTES FOR PRESENTERS: Key points to raise: This session begins with an overview of epidemiological data related to common mental health problems, underlining why the guideline is important. This information along with the key priorities from the guideline and information on costs and savings is also available in the topic slide set on the NICE website: should you wish to incorporate a more detailed overview of the topic. We will then run through the key learning objectives for the clinical case scenarios followed by the scenarios, one at a time. The clinical decisions surrounding diagnosis and management will then be examined through a question and answer approach. Finally, we will end the presentation with further information about the support provided by NICE for putting this guideline into practice.

3 Learning objectives To apply the NICE clinical guideline CG123 to clinical practice in four key areas: Recognising the signs and symptoms of common mental health problems (CMHPs) Applying the stepped care model in routine practice When and how to initiate investigations for CMHPs The role of a GP in review and continuity of care NOTES FOR PRESENTERS: By the end of this session, participants should be able to describe and demonstrate: the factors, signs and symptoms to prompt investigations for a common mental health problem key points to consider when providing care for, and engaging people from a minority ethnic cultural background principles of stepped care and be able to describe examples of this applied to practice insights from practice of effective approaches for engaging people who are experiencing distress in a collaborative consultation evidence based approaches that support investigations for common mental health problems with people within their care how the principles of psychoeducation and active monitoring can be applied in practice the importance of review and continuity of care for people with common mental health problems, and the pivotal role that a GP can have in this effective approaches for multi-disciplinary working or for establishing local treatment and referral pathways.

4 Epidemiology 15% of the population are affected by common mental health disorders Women are 1.5 to 2.5 times more likely to experience depression than men 34% of South Asian women have a common mental health disorder compared with 10% of South Asian men NOTES FOR PRESENTERS: Key points to raise: Half of those affected by a common mental health disorder have significant symptoms that warrant a professional healthcare intervention. Depression and anxiety disorders tend to have a higher prevalence in women. Prevalence rates are significantly higher for women across all categories of disorder, except for panic disorder and obsessive-compulsive disorder. Between 1993 and 2007 common mental health disorders in women aged years increased by about one fifth. In South Asian women, the impact of having children, exposure to domestic or sexual violence, adverse experiences in childhood and women’s relative poverty are all cited as reasons for the higher prevalence of common mental health disorders. The 2007 Office for National Statistics household survey of adult psychiatric morbidity in England found people living in households with the lowest levels of income were more likely to have a disorder than those living in the highest income households. King and colleagues (2008) identified five immutable risk factors for depression: younger age, female gender, lower educational achievement, previous history of depression and family history of depression (see the full version of the guideline for further details).

5 Core principles include:
Good communication skills; including active listening Demonstrating empathy and being perceptive for emotional distress, where it is present Fostering a collaborative approach with patients Explaining diagnoses, symptom profiles and possible treatment options Approaching discussions of treatment options with optimism; underlining recovery is possible. NOTES FOR PRESENTERS: Core principles: Good communication skills can be demonstration by, for example: - making eye contact with people during a consultation, - demonstrating empathy - explaining and talking through diagnoses, symptom profiles and possible treatment options. It has been found that where practitioners have enabled their patients to exhibit distress during a session, it has then enhanced the opportunity for it being detected.^ Sometimes people may experience distress or anxiety in response to challenging life events, or as a result of workplace pressures and job insecurity and in the communication skills and clinical judgement of their GP will be crucial in ensuring that this distress is not unduly medicalised.   The longstanding relationship that a GP may often have with patients within their care can help to optimise the quality of any investigations and assessments. The continuity of a person’s relationship with their GP, or at a minimum, the GP practice can also help when attempting to establish the characterisation of a patient’s problems and (where appropriate) establishing a diagnosis. The evidence base shows that adopting a collaborative approach with patients can help facilitate a greater engagement from them in any resulting treatments. Additional information: Some personal accounts of people who currently have or have had symptoms of generalised anxiety disorder (GAD) is provided alongside the clinical case scenarios on the NICE website also included to provide some insights into their experiences. Reference: ^ Goldberg, D. P. & Bridges, K. (1988), Somatic presentations of psychiatric illness in primary care settings. Journal of Psychosomatic Research, 32, 137–144; Goldberg, D. P., Jenkins, L., Millar, T., et al. (1993), The ability of trainee general practitioners to identify psychological distress among their patients. Psychological Medicine, 23, 185–193

6 Case study 1, Shubha Effective local pathways:1
Presentation Shubha is a 26-year-old woman, referred by the local baby clinic. She speaks limited English and is unhappy about the appointment. She has attended to see you – a white male GP - with her husband, who acts as an interpreter for her. He says Shubha is reluctant to get out of bed or to look after their baby, and complains of pain in her stomach constantly and mentions that his mother thinks she is lazy. Shubha emigrated from Bangladesh to the UK three years ago with her husband and his family, and gave birth to a baby girl one month ago. She has had an arranged marriage and the family have struggled with financial pressures since the move. Her husband is very close to his mother, who advises him on all issues related to the baby. NOTES FOR PRESENTERS: Key points to raise: You are a GP for Shubha’s husband and members of his extended family are registered at your practice. This is the first time you meet Shubha. Case 1

7 Effective local pathways : 2
Medical history No past medical of psychiatric history is available On examination An initial physical examination does not reveal anything abnormal. A full blood count and testing for vitamin D deficiency are conducted. Question 1) How may you need to tailor your approach? 2) Should the content of your assessment be modified? NOTES FOR PRESENTERS: Key points to raise: Please guide participants through the questions on this slide. Answers are supplied on the following slide. Case 1

8 Effective local pathways : 3
Answer 1) Be sensitive to diverse cultural, ethnic and religious backgrounds when working with people with common mental health problems You should be competent in: - culturally sensitive assessment - using different models to explain common mental health problems - addressing cultural differences when developing treatment plans - working with families from diverse ethnic and cultural backgrounds. 2) If you use a validated tool to support your diagnosis, such as PHQ9 you should not significantly vary the content of the tool as there is little evidence to support the efficacy of this. Next steps for diagnosis: Question You suspect Shubha may have postnatal depression. How do you confirm this? NOTES FOR PRESENTERS: Key points to raise: The Royal College of Psychiatrists has developed a resource to support practitioners’ in developing culturally sensitive approaches in their work. Royal College of Psychiatrists: Building a culturally capable workforce — an educational approach to delivering equitable mental health services, available via the RCPsych website. Tools that support diagnosis, such as PHQ-9 should not be adapted to address specific cultural or ethnic factors, beyond being directly translated into another language. Additional information: Gender can be a significant issue for patients from some cultural backgrounds. Shubha may prefer to be assessed by a female health professional, especially if a physical examination is required. It may be helpful to offer Shubha the option of using an independent translation service – ideally with a female translator, if available – for the next consultation. Health professionals should be aware that patients from some cultural backgrounds may be reluctant to shake hands or to make eye contact and this should not be automatically considered as a symptom of a common mental health problem. Some patients may have a louder tone of voice and use hand gestures, but this does not always mean that they are being aggressive. Relevant recommendations: from ‘Common mental health disorders’: section 1;Improving access to services: ( ) – ( ) and ( ). Case 1

9 Effective local pathways : 4
Answer People from some cultural backgrounds may not always be forthcoming during the consultation. Start by asking Shubha about her physical health and the health and wellbeing of her baby, so she feels listened to. Once you have built a rapport, symptoms of mental distress can then be investigated. Ask Shubha two questions: During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things? NOTES FOR PRESENTERS: Key points to raise: Perceptions of shame and stigma regarding mental health problems in some communities means Shubha may feel reluctant to acknowledge any symptoms of depression that she has, and she may present with somatic symptoms. If Shubha answers yes to either of the questions then a depression screening questionnaire should be used. For example, the 9-item Patient Health Questionnaire (PHQ-9) or the Improving Access to Psychological Therapies (IAPT) screening prompts tool could be used. These questions are also known as the ‘Whooley questions’. Whooley MA, Avins AL, et al (1997) Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med Jul;12(7):439-45 Additional information: The IAPT screening prompts tool is located within Chapter C of the IAPT Data Handbook Appendices version June 2011 Relevant recommendations include: ( ), recommendations for assessment (section 1.3.2): ( ), ( ), ( ), ( ), ( ), ( ). In addition, recommendations on arranging help appropriate to the level of risk (see section 1.3.3) ( ). Case 1

10 Effective local pathways : 5
Next steps for diagnosis On further probing you discover Shubha feels it will be better for her baby if she was dead. She believes that she is worthless and that her husband's family do not like her. She tells you that she is sometimes reluctant to feed the baby, she often misses meals, and has found she does not have the energy to look after herself as well as she used to. Question What factors should you consider in Shubha's risk assessment and monitoring? NOTES FOR PRESENTERS: Key points to raise: Please guide participants through the question on the slide. The answer is supplied on the following slide. Case 1

11 Effective local pathways : 6
Answer As well as considering factors that may have affected development of Shubha's symptoms you should also assess the risk Shubha's symptoms may pose by asking directly about suicidal ideation and intent. Next steps for management Shubha presents a high risk of potential harm both to her baby (she has been refusing to feed) and to herself through self- neglect. Refer Shubha urgently to specialist services. Question How could your subsequent risk assessment and monitoring of Shubha be effectively conducted?   NOTES FOR PRESENTERS: Key points to raise: If you think there is a risk of self-harm or suicide then you should: assess whether Shubha has adequate social support and find out if she is aware of sources of help assess whether there are any protective factors that can help Shubha arrange help appropriate to the level of risk advise Shubha to seek further help if the situation deteriorates monitor Shubha’s physical health during any subsequent consultations Taken from: Management of self-harm and coordination of care in primary care Self-harm: longer-term management. NICE clinical guideline 133 Relevant recommendations include: Common mental health disorders: ( ) to ( ). Case 1

12 Effective local pathways : 7
Answer Further risk assessment and monitoring needs handling in a sensitive manner. Engagement of Shubha’s family is also crucial. Shubha’s family may not be supportive and could pressure her to disengage from services. The health visitor or any other professionals in contact with Shubha should be encouraged to engage with her at this point in time. Immediate referral to specialist perinatal services should be made. The welfare and care of the baby should be investigated. Schedule a follow up appointment with Shubha, ideally for a week’s time (dependent on whether she is admitted to specialist care). NOTES FOR PRESENTERS: Key points to raise: Families may sometimes expect a 'quick cure' following the appointment and if this is not achieved may contact traditional healers or priests. It is worth noting that some patients from minority cultures may expect their health professionals to have a paternalistic rather than collaborative approach when advising them about their care. Additional information Referring to the NICE antenatal care Pathway would be helpful, as well as relevant topic pages on NHS Evidence A raising sensitive issues training pack is also available from the NICE website via: Relevant recommendations include: From Common mental health disorders: section 1.4: Steps 2 and 3 (see slide 35); Treatment and referral for treatment, and specifically ( ) and ( )]. Case 1

13 Case study 2, Barbara Multiple morbidities: 1
Presentation Barbara is 42-year-old woman, diagnosed three years ago with early stage (stage 3a) chronic kidney disease associated with hypertension which is managed by a combination of drugs that includes an ACE inhibitor, and dietary restrictions. Barbara is complaining of ‘these heads of mine’ that she says make her feel poorly, and a discomfort in her back and abdomen. Medical history A previous doctor has prescribed Barbara benzodiazepines for nervous complaints. You have treated her mother in the past for depression. NOTES FOR PRESENTERS: Key points to raise: Barbara is presenting at your surgery for a routine appointment. Case 2

14 Multiple morbidities : 2
On examination Barbara describes her symptoms in a flat, monotonous voice and looks anxious and ill at ease. You find that she uses vague phrases such as “these heads of mine” without properly describing them. During the consultation she attributes her symptoms to her chronic kidney disease. Further exploration reveals that Barbara is describing headaches which she attributes to her kidney problems. Question What else might you look for to help with establishing a diagnosis? NOTES FOR PRESENTERS: Key points to raise: Please guide participants through the question on this slide. The answer is supplied on the following slide. Case 2

15 Multiple morbidities : 3
Answer 1) Non-verbal cues may be helpful, for example, Barbara may fidget, she might avoid eye contact, and her posture might be collapsed. A person’s voice - in this case Barbara’s monotonous and uninflected tone - could also provide another cue 2) Picking up on Barbara's earlier mention of her feelings could be useful, for example: ‘You mentioned earlier that your headaches make you feel poorly. What do you mean by that?’ Also, try asking Barbara how things are at work and at home. Next steps for diagnosis Question What else could help you to establish a diagnosis? NOTES FOR PRESENTERS: Key points to raise: After further questioning, the GP establishes that Barbara’s headaches fit the symptom profile for stress or episodic headaches. For further information please see the NICE clinical guideline: Headaches: diagnosis and management of headaches in young people and adults (in development at time of publication). Case 2

16 Multiple morbidities : 4
Answer part 1 1) Ask the following questions – In view of Barbara's worry and restless movements (use GAD-7):   a) Have you recently been feeling nervous, anxious or on edge? b) Have you not been able to control worrying? In view of her flat monotonous voice (use PHQ-9): c) Have you recently felt down or depressed for most of the time? d) Have you recently experienced much less interest or pleasure than is usual for you? If there are any positive replies, you will need to investigate further. NOTES FOR PRESENTERS: Key points to raise: Examples of tools that can support diagnosis, including GAD-7 and PHQ-9 are included in the PDF version of this case scenarios tool. The PDF version can be found via the CG123 guideline page on the NICE website. Relevant recommendations: Section 1.3 Step 1; Identification and assessment of the Common mental health disorders guideline. Case 2

17 Multiple morbidities : 5
Answer part 2 2) Barbara's chronic kidney disease may be responsible for some of her symptoms - try to avoid questioning solely on neurovegetative symptoms such as poor appetite and loss of weight. Ask if she is: - feeling worthless or inferior to others? - blaming herself for how she feels? - having guilty feelings? - feeling completely hopeless? (if yes) is she having thoughts of or planning to end her life? (and) what stops her from harming herself? Next steps for management Question If Barbara's replies lead you to suspect depression what should you do next? NOTES FOR PRESENTERS: Key points to raise: Neurovegetative signs of depression are the symptoms that affect the patient's functioning: for example, sleep, appetite and concentration. In order to make a diagnosis of major depression, a clinician will check for these neurovegetative symptoms, as well as a depressed mood. The questions for Barbara on the slide will tend to elicit information about symptoms unlikely to be caused by a physical illness. Please refer to the NICE guideline on Depression in adults with a chronic physical health problem, or the NICE Depression Pathway for more information. Case 2

18 Multiple morbidities : 6
Answer Ask Barbara how she is feeling, and if she is affected at all by her symptoms, for example: - have these problems prevented you from doing any of your usual activities? - (if yes) has this been more than one activity? - (if no) have you been able to carry on with your usual activities, but only with increased effort? This additional questioning will help you in establishing the severity of Barbara's depression, and will help formulate a diagnosis based on the number of depressive symptoms and the extent of any associated impairment. NOTES FOR PRESENTERS: Key points to raise: Refer to the NICE pathway for Depression in adults for advice on next steps, treatment options and management for adults with a chronic physical health problem. A hyperlink is provided to this Pathway and other relevant Pathways on slide 37. Relevant recommendations: Section 1.3 Step 1; Identification and assessment of the Common mental health disorders guideline. Case 2

19 Multiple morbidities : 7
Additional information: If an antidepressant is considered for a person with a physical health problem - during the consultation explain and explore: - any likely side effects there may be for them from taking an SSRI, as well as any potential interactions with any existing medication or any physical health problems they may have - their thoughts on the proposed medication and its likely benefits for their condition. Reassure that SSRIs are not addictive - any possible initial side effects and the importance of taking the medication as prescribed, as well as the length of time it may take for the full antidepressant effect to develop Schedule a follow-up appointment ideally in two weeks, to monitor the person’s symptoms closely, especially regarding any side effects, and to be able to answer any questions. NOTES FOR PRESENTERS: Key points to raise: Where an SSRI is being considered for a person with a chronic physical health problem, citalopram or sertraline should be considered as they have a lower propensity for interactions. Case 2

20 Case study 3, Fred Longstanding anxiety: 1
Presentation Fred, aged 45, is a locksmith. He has longstanding and persistent worries that he has not done his job properly and that someone might get burgled as a result. He often imagines the worst happening and states that when he worries, he often feels sick, has headaches, feels butterflies in his stomach and is aware of his heart pounding. Fred often gets hot and sweaty and says his anxiety makes it difficult to concentrate and do his job or play with his children. At the start of the consultation Fred states he is attending due to problems sleeping. After questioning about how things have been for him recently, Fred discloses he is feeling under considerable stress. Medical history Fred has no medical history of note. NOTES FOR PRESENTERS: Key points to raise: Fred is an existing patient at your surgery but you have not seen him for at least three years. Case 3

21 Longstanding anxiety: 2
On examination On examination, no physical problem can be found. Fred looks distressed and is clearly sweating despite the fact that it is not warm in the GP surgery. The GP asks Fred how things are for him at work and at home, and Fred mentions that he has found work a bit difficult recently. He says that he worries his stress levels will make him go mad. Question How should you approach Fred's case and what should your first step be? NOTES FOR PRESENTERS: Key points to raise: Fred also mentions that he fears his levels of stress and anxiety will cause him to make a mistake at work and someone will get burgled. Case 3

22 Longstanding anxiety: 3
Answer 1) The GP asks Fred the GAD-2 questions (see slide 16). Fred feels anxious for a lot of the time during the day, every single day. 2) The GP then asks Fred to say a bit more about the difficulties his anxiety is causing for him, in terms of how he is functioning in his daily life at work and at home. 3) Fred discloses that he has anxiety upon waking which stays with him throughout the day. He feels like his head is going to explode and his heart will jump out of his chest. He feels overwhelmed with fear, cannot work properly and cannot play with his children. Next steps for diagnosis Question What should your next course of action be? NOTES FOR PRESENTERS: Key points to raise: GAD-2 is the first two questions of the GAD-7 tool. These two questions have been found to be effective in helping to identify cases of anxiety within primary care settings. Fred initially appears hesitant in answering the GPs questions, and is looking uncomfortable. The GP tries to reassure Fred by telling him it is okay to take his time and that the GP is here to help. To refer to the recommendations that underpin this scenario: please see the Generalised anxiety disorders guideline and Pathway. Case 3

23 Longstanding anxiety: 4
Answer 1) The GP asks Fred to complete a GAD-7, introducing it with: “Please could you complete this form so I can get a bit more information on the nature of your worries? It won’t take very long and it will help me to work out how best to help you.” 2) The GP also asks Fred how long he has had these symptoms for and if there is anything else that he feels may be relevant, such as any worries at work or if he has had any periods of worry of mental health problems before. Next steps for diagnosis and management Question As Fred's GAD-7 score and his background information point to a diagnosis of generalised anxiety disorder (GAD): a) When should this be communicated to Fred? b) And what would be the best approach for this? NOTES FOR PRESENTERS: Key points to raise: Other questions that the GP could ask to help establish a fuller picture include: - “I can see from your records you haven’t got a history of physical health problems. Have you ever had any help for your anxiety?” - “Has anyone else in your family ever had worries similar to yours?” - “You mentioned some problems with your wife – how are you getting along with people generally?” Employment support services are provided by IAPT in many regions and may be helpful if a patient has concerns regarding their job, money worries, or other similar pressures. Contact your local IAPT lead for details of local provision. Case 3

24 Longstanding anxiety: 5
Answer 1) The GP should explain the diagnosis of GAD to Fred straight away, to help him begin to understand it and offer effective treatment promptly. 2) In addition, the GP should provide information and education about the nature of GAD and the options for treatment. Information and education should be provided verbally and in writing. 3)The GP agrees an arrangement with Fred that enables the monitoring of his symptoms and functioning (active monitoring) through follow-up appointments or telephone consultations. Next steps for management Question During a follow-up appointment, four weeks later, Fred tells you that his symptoms are not improving. What action should you take? NOTES FOR PRESENTERS: Key points to raise: If written information is not available during the consultation, then Fred should be directed to appropriate websites and other sources of support. Education and active monitoring may improve less severe presentations of GAD and avoid the need for further interventions. As Fred has a diagnosis of GAD, his GP should also discuss with him the use of any over-the-counter medications and preparations, as some of these could increase his symptoms of anxiety. Additional information: NICE has produced a summary of the GAD guideline called ‘Understanding NICE guidance’ for patients and carers. NICE has also produced a ‘Guide to self-help resources for generalised anxiety disorder (available from the NICE GAD guideline page). Relevant recommendations: See to in the ‘Generalised anxiety disorder’ NICE guideline. Case 3

25 Longstanding anxiety: 4
Answer If Fred’s symptoms do not improve after four weeks of education and active monitoring, the GP should consider step 2 interventions (see slide 35) and discuss the options available with Fred. Specifically, the GP should offer one or more of the following as a first-line intervention, guided by Fred’s preference: - individual non-facilitated self-help - individual guided self-help - psychoeducational groups Further information on the treatment and interventions recommended by NICE can be found in the NICE Generalised anxiety disorders Pathway NOTES FOR PRESENTERS: Additional information: A hyperlink to the NICE Generalised anxiety disorders Pathway is included on slide 37. Details of the recommended interventions for step 2 treatments for GAD can be accessed from the stepped care model on slide 35. Case 3

26 Case study 4, Jerome Active monitoring: 1
Presentation Jerome is a 35-year-old welder who lives with his partner and two children aged 3 and 5 years. Jerome has come to see you at your surgery as he is feeling tired all the time. Medical history Jerome has a history of anxiety and depression. He joined your surgery 5 years ago, at which time he was taking sertraline for moderately severe depression and associated panic attacks. This was prescribed by his previous GP. The sertraline was effective and Jerome stopped taking the medication after 6 months of treatment. He has not returned to the surgery since that time. Jerome is otherwise physically fit and well and is not prescribed any medication. Case 4

27 Active monitoring: 2 On examination Jerome describes a lack of energy for the past six weeks and feels stressed at having to face his job. He admits to using alcohol to cope with disrupted sleep patterns and is now drinking 3 pints of beer every night. His physical examination is normal but he appears in low mood. Jerome replies ‘yes’ to one of the Whooley questions and scores 11/27 on the PHQ-9. He has no thoughts of self-harm and is still functioning at work and home with his family. You diagnose a mild depressive episode. However, there is also associated anxiety and excess alcohol use. Question What should your next step be? NOTES FOR PRESENTERS: Key points to raise: The Whooley questions are: During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things? Case 4

28 Active monitoring: 3 Answer 1) Use step 1 interventions: active monitoring and psychoeducation providing information and leaflets or weblinks on depression and discuss effective approaches for managing depressive feelings. In addition, provide information about the role that excess alcohol use has in exacerbating a depressed mood, as its effect on sleep. 2) Advise and collaboratively agree with Jerome that he reduces his alcohol intake < 21 units weekly, or to cut alcohol out completely. c) Arrange for Jerome to return in two weeks so you can reassess the effect on his mood. Next steps for management Jerome returns in two weeks and has reduced his alcohol intake to around four units per week but his mood is no better. Question What should you now advise? NOTES FOR PRESENTERS: Key points to raise: Written information and web links could be used to supplement the information that you provide to Jerome. For further information on managing alcohol related issues can be found in the NICE Pathway on alcohol-use disorders via: Additional information: Leaflets on depression and alcohol use are available from the Royal College of Psychiatrists website. Relevant recommendations include: ( ), ( ) and ( ) of the NICE Common mental health disorders guideline. Case 4

29 Active monitoring: 4 Answer 1) Follow the step 2 interventions (see slide 35). 2) Discuss Jerome’s alcohol use, and advise him to try and continue to reduce his alcohol use – aiming to reach abstinence from alcohol. 3) Discuss treatment options with Jerome, taking into account his preferences and previous response to treatment. 4) As Jerome previously had a good response to sertraline, he could restart medication and continue for 6 months after recovery (alone or in conjunction with recommended psychological treatment options). 5) Outline the principles of CBT and offer information leaflet/web link Jerome chooses individual facilitated self-help using CBT, and agrees to return to see you to reconsider talking sertraline if non- drug approaches are not effective. Question: What should Jerome’s treatment plan include? NOTES FOR PRESENTERS: Key points to raise: Step 2 intervention options to discuss and consider with Jerome include: - individual facilitated self-help based on the principles of cognitive behavioural therapy - computerised CBT - a structured group physical activity programme - antidepressants. Guided self-help at step 2 (and above) can make use of a mixture of face-to‑face professional input, information leaflets, CBT computer programmes and books. Useful resources: The Royal College of Psychiatrists information leaflet on CBT available via: Get the best from your medicines: your wellbeing in mind website from Norfolk and Suffolk Foundation Trust. This web resource for patients aims to support people in making a decision about their treatment. The site uses a question and answer approach to provide information on over 110 medicines used in mental health treatments. Free web-based CBT self-help programmes for depression and anxiety: and Self help books for depression that use CBT Principles: - Greenberger, D and Padesky, C A (1995), Mind over mood. New York: Guilford - Williams, C (2001) Overcoming Depression: a Five Areas Approach. London: Arnold Case 4

30 Active monitoring: 5 Answer: Over the next 2 months, Jerome receives a mixture of face-to-face and phone consultations as part of his low-intensity treatment plan. This also means he does not have to miss work. Jerome’s treatment includes the following interventions: explanation; monitoring of risk and alcohol consumption; activity scheduling and goal setting; challenging of unhelpful and extreme thinking; and written 'homework' diaries. Over time, Jerome’s depression and associated anxiety resolves. He also creates a written Staying Well (relapse prevention) plan with his mental health worker for the future. NOTES FOR PRESENTERS: After working through this answer with participants, please forward to the next case scenario. Case 4

31 Case study 5, Violet Review:1
Presentation Violet is 84 years old. She has been in a residential home for four months following time in hospital with a fractured femur after a fall. She is a widow and her only visitor has been her younger brother, who suffered a stroke six weeks ago and has not been able to visit her since. Violet has become increasingly quiet and withdrawn. The care staff report that she is not eating and is staying in her room much of the time. The GP is asked to visit Violet because her weight has dropped by 4 lb in 1 month. Medical history Violet has Type 2 diabetes and hypertension which have been reasonably well controlled. She is partially sighted because of macular degeneration and has widespread joint pains from osteoarthritis. NOTES FOR PRESENTERS: Key points to raise: Violet is a longstanding patient at your practice who has recently moved into a residential care home. Case 5

32 Review: 2 On examination The GP finds Violet to be alert and oriented. She looks sad and gets tearful when discussing her feelings and admits she is very lonely since her brother stopped coming to see her and is worried that he may never be fit enough to come again. She is sleeping poorly, has lost her appetite and ‘can’t be bothered’ to sit with other people in the care home. She denies being anxious or panicky and says she has never drank alcohol. Importantly, Violet says she does not feel like harming herself, but that she does wish that she will “just not wake up one morning”. The GP conducts a PHQ-9 with Violet, and her score is 20. A physical examination (including chest and abdomen) is normal, her BP is 146/82 and a dipstick urine test is negative. Next steps for diagnosis and management Question What should your next steps be? NOTES FOR PRESENTERS: Key points to raise: Violet mentions that she is finding other people in the care home ‘all get on my nerves’. Case 5

33 Review: 3 Answer 1) The GP should suggest to Violet that she might be depressed and that her symptoms do indicate this, they should also explain that it happens to many older people and ask what she feels about that. 2)The GP should discuss possible treatment options and explore her views about talking treatments and/or antidepressants. 3) Depending on Violet’s wishes, the GP should either refer her to the primary care mental health team, or offer an appropriate antidepressant. Another appointment should be offered to Violet by the GP for about two weeks’ time. 4) The GP should discuss with staff at the care home (with Violet’s consent) how they could help to encourage Violet. Additionally the GP should try to obtain a collateral history from the care home staff. Next steps for management Question What should you do at the review visit in two weeks? . NOTES FOR PRESENTERS: Key points to raise: The GP should discuss with a member of staff in charge at the care home (with Violet’s consent) what the problems are and how the staff could help to encourage Violet to participate in activities in the care home. Violet’s GP needs to be aware of the local referral pathways for primary care mental health services. In addition, the GP should be conscious that Violet's low mood might be the result of poor control of her diabetes, or another medical condition particularly as she has recently lost weight. And so, the GP should take blood for glucose, HbA1C, urea and electrolytes, full blood count, and thyroid function tests. Useful resources: Feeling Blue, an interactive workbook for older people with symptoms of depression or low mood; to support them discussing their symptoms with their GP RCGP: Mental Health in Older People online module Management of depression in older people: why this is important in primary care (February 2011) a factsheet from the Royal College of General Practitioners, Royal College of Psychiatrists, and others Relevant recommendations include: ( ), ( ), ( ), ( ), (1.4.1), ( ) and ( ). Case 5

34 Review: 4 Answer 1) The GP should ask Violet how she is and get an update on her collateral history from the care home staff. The PHQ-9 questionnaire should be repeated. 2) If Violet has agreed to try antidepressants, then a discussion regarding the period of time it will take for the medication to become fully effective and any side effects is important. 3) If Violet had previously declined antidepressants, and her PHQ-9 score is still high, then the GP should discuss whether antidepressants would now be appropriate and acceptable. 4) If Violet was referred for a talking treatment, the GP needs to ensure that this referral was received by the primary care mental health service and give Violet and the staff at the care home an indication of when she can be expected to be seen. 5) The GP should also discuss with care home staff and Violet how positive support can be given to her. NOTES FOR PRESENTERS: Key points to raise: If Violet has agreed to try antidepressants then the GP should also discuss the likely duration of treatment with her, and try to reach agreement with Violet that she will take the tablets for at least six months. Staff at the care home could provide positive support to Violet by for example, enabling her to telephone her brother. Useful resources: 'Let’s respect' toolkit for care homes Age UK: Depression in later life: Down but not out (web page) Age UK: Depression in later life, Resources. A series of downloadable leaflets that includes spotting the signs of and advice on coping with depression Relevant recommendations include: (1.4.1) and (1.5) of the Common mental health guideline. Case 5

35 Stepped-care model CMHDs presentation and severity
Recommended interventions Step 1 All disorders – known and suspected presentations All disorders: Identification, assessment, psychoeducation, active monitoring; referral for further assessment and interventions Step 2 Persistent subthreshold depressive symptoms or mild to moderate depression; GAD; mild to moderate panic disorder; mild to moderate OCD; PTSD (including mild to moderate) Depression GAD and panic disorder OCD PTSD All disorders – Support groups, educational and employment support services; referral for further assessment and interventions Step 3 Persistent subthreshold depressive symptoms; mild to moderate depression not responded to a low-intensity intervention; moderate or severe depression; GAD with functional impairment or has not responded to low-intensity intervention; moderate to severe panic disorder; OCD with moderate or severe functional impairment; PTSD GAD Panic disorder NOTES FOR PRESENTERS: Key points to raise: A stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. The model presents the key assessment and treatment interventions from this guideline. Recommendations focused solely on specialist mental health services are not included.

36 Find out more Visit www.nice.org.uk/guidance/CG123 for:
the guideline and quick reference guide ‘Understanding NICE guidance’ commissioning guide costing report and template baseline assessment tool podcast interview with GP Dr Barbara Compitus Full PDF version of the clinical case scenarios online modules on anxiety and depression NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all of the recommendations. A quick reference guide – a summary of the recommendations for healthcare professionals. ‘Understanding NICE guidance’ – information for patients and carers. The full guideline – all of the recommendations, details of how they were developed, and reviews of the evidence they were based on. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website: Commissioning guide - to assist commissioners, clinicians and managers to commission high-quality and evidence-based services across England Costing tools – a costing report and template allows people to estimate the local costs and savings involved Baseline assessment – for monitoring local practice Podcast interview with Bristol GP and member of the guideline development group, Dr Barbara Compitus discussing NICE’s common mental health disorders guidance in practice A full PDF version of these clinical case scenarios to support GPs and primary care leads’ individual learning needs in applying the recommendations in practice. Online educational tools from NICE and BMJ Learning: - Anxiety disorders in adults - Depression in adults - Depression in adults with a chronic health problem The modules are free to access, though registration is required. Additional information: A selection of resources have been compiled by the NHS Confederation Mental Health Network to provide advice and support with understanding and implementing mental health Payment by Results. Information can be accessed via Further resources are also available via the Forum for Mental Health in Primary Care (from RCGP and RCPsych) at

37 NICE Pathways Anxiety Depression Panic PTSD NOTES FOR PRESENTERS:
NICE Pathways: guidance at your fingertips Key points to raise: NICE Pathways provide quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allow you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended. Additional information If you are showing this presentation in slideshow and connected to the internet, you will be able to access relevant NICE Pathways by clicking one of the orange buttons on the slide. Each orange button links directly to a different NICE common mental health Pathways topic. All of NICE’s mental health Pathways can be accessed (via healthcare). Relevant Pathways from NICE include: Alcohol use disorders; Antenatal and postnatal mental health; Depression; Generalised anxiety disorder; Panic disorder; Post traumatic stress disorder and self harm. PTSD

38 NHS Evidence topic pages
NOTES FOR PRESENTERS: If you are showing this presentation when in slideshow and connected to the internet, click on the corresponding blue button to go straight to the NHS Evidence website topic page for anxiety, depression or PTSD. For the home page go to NHS Evidence topic pages Anxiety Depression PTSD

39 Contributors Dr Shanaya Rathod, Clinical Service Director, Southern Health NHS Foundation trust and NICE Fellow Dr Robert Nipah, Specialist Registrar in Renal and General Medicine, Salford Royal Hospital Dr Donal O'Donoghue, National Clinical Director for Kidney Care Professor Sir David Goldberg, Professor Emeritus, Institute of Psychiatry, KCL Professor Roz Shafran, University of Reading Professor Carolyn Chew-Graham, General Practitioner, NHS Manchester; and Professor of Primary Care, University of Manchester Health Sciences; and RCGP Curriculum Guardian, Mental Health Dr Richard Byng, General Practitioner and Senior Clinical Academic Lecturer in Primary Care, Institute of Health Service Research, University of Portsmouth Andy Bell, Deputy Chief Executive, Mental Health Centre Paul Blenkiron, Consultant Psychiatrist and Public Education Officer NHS North Yorkshire and York, and NICE Fellow Dr Gabriel Ivbijaro, General Practitioner, The Wood Street Medical Centre, London Dr Lucja Kolkiewicz, Associate Medical Director for Recovery and Well-being, East London NHS Foundation Trust NICE would like to thank the contributors on the slide for supplying case scenarios. We would also like to thank members of the National Collaborating Centre for Mental Health, the Common mental health disorders Guideline Development Group, and the Royal College of General Practitioners/Royal College of Psychiatrists Mental Health Forum especially: Dr Nick Kosky, Chair, General Adult and Community Faculty, Royal College of Psychiatrists; and Associate Medical Director – Dorset Healthcare University Foundation Trust Dr Rajini Ramana, Consultant Psychiatrist – Cambridge Specialist Depression Service

40 Presenter notes The previous slide marks the end of the presentation; slides from this point on are for use by the presenter. For information, the stepped-care table on slide 16 contains action buttons that link to more detailed content (which is stored within slides 29-32). Action buttons only operate when the presentation is in slide show view. The presenter will need to click on a hyperlink to access the further detail.

41 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete a short evaluation form If you are experiencing problems accessing or using this tool, please NOTES FOR PRESENTERS: Additional information: The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated. To open the links in this slide set right click over the link and choose ‘open link’ To open the links in this slide set right click over the link and choose ‘open link’

42 Stepped care: depression
Step 2 interventions Individual facilitated self-help Computerised CBT Structured physical activity Group-based peer support (self-help) programmes Non-directive counselling delivered at home* Antidepressants Self-help groups * for women during pregnancy or the postnatal period Step 3 interventions CBT IPT Behavioural activation Behavioural couples therapy Counselling Short-term psychodynamic psychotherapy Antidepressants Combined interventions Collaborative care (if chronic physical health problem) Befriending Rehabilitation programmes Self-help groups Back to stepped care table

43 Stepped care: GAD and panic disorder
Step 2 interventions GAD and Panic disorder Individual non-facilitated self-help Facilitated self-help Psychoeducational groups Self-help groups Step 3 interventions GAD CBT Applied relaxation Drug treatment Combined interventions Self-help groups Step 3 interventions Panic disorder CBT Antidepressants Self-help groups Back to stepped care table

44 Stepped care: obsessive-compulsive disorder
Step 2 interventions Individual CBT Group CBT (including ERP) Self-help groups Step 3 interventions CBT (including ERP) Antidepressants Combined interventions and case management Back to stepped care table

45 Stepped care: post-traumatic stress disorder
Step 2 interventions Trauma-focused CBT EMDR Step 3 interventions Drug treatment Back to stepped care table


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