1. Mental Health

2. Mental Health – RCGP curricculum as a GP you should: 1.1 Understand the epidemiology of mental health problems in general practice 1.2 Understand the roles and the power of emotions and their relevance in well-being and mental illness 1.3 Understand and empathise with people who are distressed and fully assess them (including risk) and offer appropriate support and management 1.4 Ensure that you appropriately explore both physical and psychological symptoms, family, social and cultural factors, in an integrated manner 1.5 Understand the place of instruments in case-finding for depression and for assessment of severity of symptoms 1.6 Understand the primary care management of patients with common mental health problems 1.7 Understand the initial management of a patient with a suspected psychotic illness

3. RCGP - Key Messages You should consider the mental health of a patient in every primary care consultation, but be aware of the dangers of.. medicalising distress

4. RCGP - Key Messages Depression and anxiety are common in people with long-term physical conditions, and increase the morbidity and mortality from these conditions

5. RCGP - Key Messages Percentage of people with mental health problems across their lifespan who are managed in primary care? 90%

6. Depression & NICE

7. Some definitions Symptoms should have been present for at least 2 weeks before a diagnosis of depression is made.

8. Some definitions If the person has depression which has gone on for more than 2 years they are said to have chronic depression.

9. Recognising Depression It is estimated that up to 50 % of people with depression are not recognized in primary care [National Collaborating Centre for Mental Health, 2009].

10. At least two-thirds of depressed people who see their GP present with physical/somatic symptoms rather than psychological symptoms and are less likely to be recognized as being depressed [National Collaborating Centre for Mental Health, 2009].

11. Healthcare professionals may have personal barriers to recognition… Examples?

12. opening 'Pandora's box' (esp. in a time-limited consultation) collude with the patient - 'therapeutic nihilism‘ may consider depression to be a normal response to difficult times may be sceptical of treatment options, or dissatisfied with availability of psychological interventions. [Burroughs et al, 2006]Burroughs et al, 2006

13. Meta-analysis of 41 studies suggests that GPs are good at ruling out depression in most people who are not depressed, and that misidentifications (false positives) outnumber missed cases (false negatives) [Mitchell et al, 2009].Mitchell et al, 2009 The undetected cases are more likely to be milder forms of depression [Kessler et al, 2003].Kessler et al, 2003

14. How can GPs improve this? Use of case-identification questions A 'yes' response to one of the two questions has: high specificity for depression (0.95, 95% CI 0.91 to 0.97) low sensitivity (0.66, 95% CI 0.55 to 0.76) [National Collaborating Centre for Mental Health, 2009].National Collaborating Centre for Mental Health, 2009

15. What are the two magic questions? During the last month have you often been bothered by: o Feeling down, depressed, or hopeless? o Having little interest or pleasure in doing things? An answer of 'yes' to either question indicates that the person may be depressed and should prompt a more detailed assessment.

16. Scoring systems? Do GPs use them? In what ways?

17. BMJ 2009: Southampton study Abstract: Objective - To determine if general practitioner rates of antidepressant drug prescribing and referrals to specialist services for depression vary in line with patients’ scores on depression severity questionnaires. Conclusions - General practitioners do not decide on drug treatment or referral for depression on the basis of questionnaire scores alone, but also take account of other factors such as age and physical illness.

18. Suicide? directly asking people with depression about suicidal ideation and current intent. Ask if the person feels hopeless or that life is not worth living. Do not avoid the word 'suicide'. Suggested questions are..? o Do you ever think about suicide? o Have you made any plans for ending your life? o Do you have the means for doing this available to you? o What has kept you from acting on these thoughts? Follow up on the 'not really' answers.

19. Have a go… Doctor and Patient Remember the ‘Two Questions’ Remember to assess suicide risk

20. Social characteristicsHistoryClinical/diagnostic features Male gender Young age (< 30 years) Advanced age Single or living alone Prior suicide attempt(s) Family history of suicide History of substance abuse Recently started on antidepressants Hopelessness Psychosis Anxiety, agitation, panic attacks Concurrent physical illness Severe depression [NICE, 2009] Risk factors for suicide?

21. NICE - diagnose major depression, this requires at least one of the core symptoms: Persistent sadness or low mood nearly every day, or Loss of interests or pleasure in most activities. Plus some of the following symptoms: Fatigue or loss of energy Worthlessness, excessive or inappropriate guilt Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts Diminished ability to think/concentrate or increased indecision Psychomotor agitation or retardation Insomnia/hypersomnia Changes in appetite and/or weight loss

22. “Stepped-care” approach Stage of depressionIntervention Step 1: all known and suspected presentations of depression. Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions. Step 2: persistent subthreshold depressive symptoms; mild-to- moderate depression. Low-intensity psychological and psychosocial interventions, medication, and referral for further assessment and interventions. Step 3: persistent subthreshold depressive symptoms or mild-to- moderate depression with inadequate response to initial interventions; moderate and severe depression. Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions. Step 4: severe and complex depression; risk to life; severe self- neglect. Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, and multiprofessional and inpatient care. Data from: [NICE, 2009]

23. St John’s Wort?

24. Anxiety & NICE

25. Some more definitions Generalised anxiety disorder (GAD) is a common disorder of which the central feature is excessive worry about a number of different events associated with heightened tension. It can exist in isolation but more commonly occurs with other anxiety and depressive disorders.

26. Some more definitions Panic disorder is characterised by recurring, unforeseen panic attacks followed by at least 1 month of persistent worry about having another attack and concern about its consequences…

27. Another Stepped Approach Step 1: All known and suspected presentations of GAD: ● Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder

28. Step 2: Diagnosed GAD that has not improved after step 1 interventions: Low-intensity psychological interventions

29. Step 3: GAD with marked functional impairment or that has not improved after step 2 Treatment options……

30. Read all about it…..

31. A bit of QOF QOF (Quality and Outcomes Framework) was set up to rate (and reward) practices according to certain measures of ‘quality of care’.

32. QOF An example is Mental Health follow-up, where the patient group looked at by the QOF software is given an indicator called ‘Mental Health 8’.

33. MH8 Patient on Mental Health register Who are they?

34. People with Schizophrenia, Bipolar Disorder, and other psychoses

35. With recording of Alcohol consumption BMI Blood Pressure Cholesterol Blood glucose Smear (last 5y)

36. Also…. – Lithium patients Creatinine and TSH Lithium levels in range – Care Plan agreed (mental health personal care plan)

37. “QOF Review” for Registrars Example: Mental Health QOF (Quality and Outcomes Framework) was set up to rate practices according to certain measures of ‘quality of care’. An example is Mental Health follow-up, where the patient group looked at by the QOF software is given an indicator called ‘Mental Health 8’. The ‘Mental Health 8’ indicator is intended to include those with ‘schizophrenia, bipolar affective disorder and other psychoses’.

38. The ‘Population Manager’ program on EMIS searches for relevant codes and found 91 patients incorporated in ‘Mental Health 8’, which should be for those with serious/enduring mental health problems of a type where regular review is indicated.

39. However, many seemed to be patients with past depressive episodes without long-term psychotic elements, where there was little indication for systematic reviews. How would you correct this system?

40. Many had no entry for ‘Mental Health Review’ in the last year (i.e. a review addressing the patient’s mental health status, where there was concurrent record of health promotion/preventative advice) How could the practice improve this?

41. Likewise many had no code for ‘Mental Health plan’ entered [i.e. clear evidence of an agreed plan covering sources of help/follow-up] How could the practice improve this?

42. How would correspondence from the psychiatrist or CMHT be useful? Where a review had taken place how would you arrange/put in place dates for future reviews? How would you deal with those whose Mental Health reviews were overdue currently?

43. What about non-attenders, and how to record contacts by telephone or by key- workers? What would you remind your partners to check, and how would you update them of any changes made? What published evidence can you find that regular review of patients with serious Mental Health problems is worthwhile?

44. That’s All, Folks