1. Can a mental health awareness programme increase the confidence of primary care nurses in managing depression? Sally Gardner Nurse Consultant OOH Trainer /Facilitator Mental Health

2. DEPRESSION Large Personal, Psychological and Economic Costs Mental Health Problems = £32 Billion Lost Employment = £12 Billion & Productivity 91 Million working days lost Treatment costs = £4.2 Billion

3. Diminished Quality of Life Excessive use of Medical Services 1 of the 4 most disabling illnesses in the world Primary Care cares for 90% of these Patients 1 Patient in every surgery session suffering from Depression

4. Some of the facts: Depression is common and treatable GPs and nurses are at the “front line” Only 50% is acknowledged Depression is treatable with both drug and non-drug approaches Simply acknowledging depression improves the outcome Over 5000 people commit suicide each year in England …. 1 every 2 hours 9 out of 10 people who commit suicide have some form of mental illness ….. Mostly depression Suicide is 3 times more likely in men than women 66% of people who commit suicide have consulted their doctor within the past month …. 30% have expressed intent 1 in 20 adults suffer from depression Psychotropic medication is the commonest and highest costing medication

7. MAJOR DEPRESSION Depressed mood and loss of interest and pleasure, plus 4 or more of the following: Feelings of worthlessness or guilt Impaired concentration Loss of energy or fatigue Thoughts of suicide Loss or increase in appetite Insomnia or hypersomnia Retardation or agitation …… for a minimum of 2 week’s duration Depressed mood and loss of interest and pleasure, plus 4 or more of the following: Feelings of worthlessness or guilt Impaired concentration Loss of energy or fatigue Thoughts of suicide Loss or increase in appetite Insomnia or hypersomnia Retardation or agitation …… for a minimum of 2 week’s duration

8. How common?

9. The Scale of the Problem

10. What does this mean? 2.75 million people consult with their GP Average GP practice of 2,000 pts 218 on list Primary care nurses ideally placed

11. Chronic Disease Management Asthma Diabetes Vascular Disease Depression and Anxiety?

12. The management of recognised cases of depression often falls short of best practice.

13. Rationale Developed mini clinic Reduced referrals to CMHT – 60% reduction BDI scores Mean = 23 at 4/12 Mean= 7 P=0.001 High levels pt satisfaction GP workload shared

14. Rationale Funding sought Developed training course (steering group) Audit & Evaluation demonstrated increased knowledge and confidence Further evaluation needed

15. PCT Training Level 1 Epidemiology Recognition Medication Risk Assessment SEMI Health Promotion Level 2,3 Clinical Governance Pharmacology Psychological Therapies Nurse Intervention Setting up a Service

16. The Study Postal Questionnaire 180 Primary Care Nurses Two Groups generated (training and No training) Comparisons made Analysis Outcomes

17. Analysis Scales in questionnaire – Cronbachs alpha Variables – MannWhitney U Test Confidence Attitude Satisfaction Open ended questions Coded, themes developed and comparisons made

18. Participants

19. Comparisons of scores

20. Comparisons of levels of training 1 v 2&3

21. Results Response rate 47.8% Training group scored higher on Confidence Attitude and Knowledge when compared to no training group Level 1 training improved attitude but did not statistically increase knowledge or confidence when compared to level 2&3 training

22. Qualitative 51 comments were coded into positive, negative and neutral 50% were positive ( “training is greatly needed”) 35% were negative (“not sure short courses provide necessary skills”) Neutral (“ protected time in short supply”)

23. Future Training

24. Training Courses

25. Options regarding role of nurses Role One – deliver enhanced recognition referral for assessment Role two – deliver a service in the assessment and monitoring of patients with depression Role three – development of depression mini clinics

26. What this study adds A training programme designed to increase confidence, improve attitudes towards depression and increase satisfaction with knowledge and training is effective · Primary care nurses are motivated to participate in future training in the management of depression. · Future courses should resemble the PCT training course · Depression “mini clinics” may require more organisation within primary care for them to be viable

27. Setting up a Service

28. Process Involve the whole team State clear Aim What are the objectives Where are we now Where do we want to be How do we know when we have got there

29. Who Who needs to be involved? Who will referrals come from? Who will have overall responsibility?

30. What What needs to be in place……… Job description Protocols Guidelines Referral guidelines Patient pathways Supervision

31. Setting up a clinic Level 1,2,3 Decide on service model Level 1 – All members of team Mental health awareness Mental health Promotion G/P implements evidence based guidelines

32. Setting up a clinic Level 2 Level 2 includes criteria from level 1 plus…… G/P diagnose a mental health problem Refers to Nurse clinic Works collaboratively with G/P (case reviews)

33. Setting up a clinic Level 2 Telephone support 1-2 weeks Nurse review 2-4 weeks Holistic assessment Nurse monitors mood and compliance to medication Risk assessment

34. Setting up a clinic Level 3 Level 3 Includes criteria from level 1&2 plus Identifies and differentially diagnose own patients Holistic assessment Arranges tests and investigations Diagnosis Decides on medical management Supplementary prescribing

35. Setting up a clinic Level 3 Liase with other members team Case Management Accountable Responsible Autonomous Refers Discharge

36. Implementation Team meeting Decide on service model Set realistic timescales Audit trail in place Regular reviews (team) Ongoing audit Patient satisfaction tools

37. Evaluation SWOT Analysis Forcefield Analysis Audit against standards What needs to change?? Make changes Implement and review

38. Conclusion Primary Care Nurses have an important role in managing depression Pilot study identified improved outcomes Evaluation study identified increased satisfaction with knowledge confidence and attitude.

39. Conclusion Training is effective Training is requested Short courses are the preferred option There are different options regarding management of depression Three models identified

40. Conclusion Training primary care nurses in depression management and delivering a service in primary care is posssible It can only be hypothesied that this will improve outcomes There is a need for a RCT comparing patient outcomes delivered by nurses with training and usual primary care.

41. THANKYOU QUESTIONS ? Sally Gardner Nurse Consultant Take Care Now Sally.gardner@takecarenow.co.uk