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

Gaps

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 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.

Gaps Psychological services for patients with mild symptoms / need

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

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

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

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.

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

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

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.