1. ITEM 2
DR ALISON MUNN PRESENTATION
ITEM 2
DR ALISON MUNN PRESENTATION
Stevenage Practice Based Joint Commissioning Pilot for Adult Mental Health Overview and Scrutiny Committee 12/6/07

2. Gaps

3. NICE stepped care approach (Anxiety and Depression)
Risk to Life, Severe Symptoms/Need
Medication, combined treatments, ECT
Step 4:
Complex & Enduring Symptoms/Need
Medication, Complex Psychological Interventions, Combined Treatments
Step 3
Moderate or Severe Symptoms/Need
Medication, Psychological Interventions, Social Support
Step 2
Mild Symptoms/Need
Watchful Waiting, Guided Self help, Brief Psychological Interventions
Step 1
Recognition
Assessment

4. NICE stepped care approach (Anxiety and Depression)
Risk to Life, Severe Symptoms/Need
Medication, combined treatments, ECT
Step 4:
Complex & Enduring Symptoms/Need
Medication, Complex Psychological Interventions, Combined Treatments
Step 3
Moderate or Severe Symptoms/Need
Medication, Psychological Interventions, Social Support
Step 2
Mild Symptoms/Need
Watchful Waiting, Guided Self help, Brief Psychological Interventions
Step 1
Recognition
Assessment
NICE are very clear that drugs are overused in the treatment of mild anxiety and depression.
All sorts of theories abound that this is because the pharma industry controls doctors through the provision of pens and post it notes or that doctors have a soley biochemical model of mental illness
But my personal experience and that of my peers is that patients come to us asking for help. We talk to them, recognise mild depression or anxiety and want to offer them a treatment that will make them feel better
We currently have no service we can refer these patient to within the NHS. Even within the voluntary sector there is no one offering guided self help. Me personally (as a fairly odd GP) am trained to do brief problem solving therapy and I can also do guided self help CBT but although I have the skills I do not have the time as GMS general practice does not have room. A course of guided self help as I do it involves 4 hours of time. In GP terms that is 24 other patietns not seen and is a very very expensive resource.
So we can say to these patients: you are not ill enough to need medication. Your options are to wait and see if you get either better or bad enough to need medication, or to have some psychological treatment – oh that sounds good. Sorry the NHS doesn’t provide any.

5. Gaps
Psychological services for patients with mild symptoms / need

6. NICE stepped care approach (Anxiety and Depression)
Risk to Life, Severe Symptoms/Need
Medication, combined treatments, ECT
Step 4:
Complex & Enduring Symptoms/Need
Medication, Complex Psychological Interventions, Combined Treatments
Step 3
Moderate or Severe Symptoms/Need
Medication, Psychological Interventions, Social Support
Step 2
Mild Symptoms/Need
Watchful Waiting, Guided Self help, Brief Psychological Interventions
Step 1
Recognition
Assessment
In those who we see and assess as having moderate to severe symptoms or need NICE suggests a choice
Drug treatment
Psychological treatmetn
If more severe drug and psychological treatment
But currently the situation is that when these patients see their GP they will not be offered that choice as there is no choice to have a psychological treatment as there are not any available
So drugs or nothing

7. Gaps Psychological services for patients with mild symptoms / need
Psychological services for patients with moderate symptoms / need who would prefer a psychological approach over drug treatment

8. NICE stepped care approach (Anxiety and Depression)
Risk to Life, Severe Symptoms/Need
Medication, combined treatments, ECT
Step 4:
Complex & Enduring Symptoms/Need
Medication, Complex Psychological Interventions, Combined Treatments
Step 3
Moderate or Severe Symptoms/Need
Medication, Psychological Interventions, Social Support
Step 2
Mild Symptoms/Need
Watchful Waiting, Guided Self help, Brief Psychological Interventions
Step 1
Recognition
Assessment
In step 3 we also have what I feel to be the most important gap:
Those patients with moderate to severe illness who have failed to respond / responded incompletely to drug treatement
The eveidence is that these patients require a combination of on going drug treatment (which GPs can continue to provide inthr background) AND a psychological treatment.
If they do not get adequate treatment 1 of 2 things happen
They get more and more unwell until they are unwell enough to fall into the remit of the CMHT eg following an attempted suicide
They stay significantly unwell but not quite unwell enough to count as complex and enduring needs for a long time

9. Gaps Psychological services for patients with mild symptoms / need
Psychological services for patients with moderate symptoms / need who would prefer a psychological approach over drug treatment
Rapid access to psychological services for patients with moderate to severe symptoms / need who have not improved with drug therapy.

10. A composite story Wk 0 sees GP starts meds off work
Wk2 slight improvement
Wk4 feels more in control, v positive returns to work
Wk8 less good increase dose
Wk12 problem at work off work
Wk 13 DNA
Wk14 no change change drug, refer
Wk16 feels worse
WK 18 no change, start guided self help
Wk22 resigned from work
Wk 27 Saw OPD
Wk 31 no better no worse
Wk 36 Saw OPD
Wk 40 Had letter from psychology
Wk 44 saw OPD
Wk 48 letter from psychology

11. What we would like to see:
Wk 0 sees GP starts meds
Wk2 slight improvement
Wk4 feels more in control, v positive
Wk8 less good, referred to Primary Mental Health Care Team
Wk10 assessment and plan 6 weeks CBT
Wk 20 completed CBT, full resolution of symptoms.
Wk 46 end of meds

12. Aim to Provide:
Psychological services for patients with mild symptoms / need
Psychological services for patients with moderate symptoms / need who would prefer a psychological approach over drug treatment
Rapid access to psychological services for patients with moderate to severe symptoms / need who have not improved with drug therapy.