mental health

Mental Health

Mental Health – RCGP Mental Health – RCGP curricculumcurricculum

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

RCGP - Key MessagesRCGP - 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

RCGP - Key MessagesRCGP - Key Messages• Depression and anxiety are common in people

with long-term physical conditions, and increase the morbidity and mortality from

these conditions

RCGP - Key MessagesRCGP - Key Messages• Percentage of people with mental health

problems across their lifespan who are managed in primary care?

90%

DepressionDepression & NICE& NICE

Some definitionsSome definitions• Symptoms should have been present for

at least

2 weeks

before a diagnosis of depression is made.

Some definitionsSome definitions• If the person has depression which has

gone on for more than

2 years

they are said to have chronic depression.

Recognising Recognising DepressionDepression

• It is estimated that up to

50 % of people with depression are not recognized in primary care

 [National Collaborating Centre for Mental Health, 2009].

• 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].

• Healthcare professionals may have personal barriers to recognition…

• Examples?

• 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, ordissatisfied with availability of psychological

interventions.  [Burroughs et al, 2006]

• 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].

• The undetected cases are more likely to be milder forms of depression [Kessler et al, 2003].

How can GPs improve How can GPs improve this?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].

What are the two What are the two magic questions?magic questions?

• During the last month have you often been bothered by:

oFeeling down, depressed, or hopeless?

oHaving 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.

Scoring systems?Scoring systems?• Do GPs use them?

• In what ways?

BMJ 2009: BMJ 2009: Southampton studySouthampton 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.

Suicide?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.

Have a go…Have a go…• Doctor and Patient

• Remember the ‘Two Questions’

• Remember to assess suicide risk

Social characteristics History Clinical/diagnostic features

Male genderYoung age (< 30 years)Advanced ageSingle or living alone

Prior suicide attempt(s)Family history of suicideHistory of substance abuseRecently started on antidepressants

HopelessnessPsychosisAnxiety, agitation, panic attacksConcurrent physical illnessSevere depression

[NICE, 2009]

Risk factors for suicide?

• 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

““Stepped-care” Stepped-care” approachapproach

Stage of depression Intervention

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]

St John’s Wort?St John’s Wort?

AnxietyAnxiety & NICE& NICE

Some more definitionsSome 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.

Some more definitionsSome 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…

Another Stepped Another Stepped ApproachApproach

• 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

• Step 2: Diagnosed GAD that has not improved after step 1 interventions:

• Low-intensity psychological interventions

• Step 3: GAD with marked functional impairment or that has not improved after step 2

• Treatment options……

Read all about it…..Read all about it…..

A bit ofA bit of

QOF

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

QOFQOF• 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’.

MH8MH8• Patient on Mental Health register

• Who are they?

People with People with SchizophreniaSchizophrenia, ,

Bipolar DisorderBipolar Disorder, ,

and other and other psychosespsychoses

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

Also….Also….– Lithium patients

• Creatinine and TSH• Lithium levels in range

– Care Plan agreed (mental health personal care plan)

““QOF Review” for RegistrarsQOF Review” for Registrars

Example: Mental HealthExample: 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’.

• 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.

• 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?

• 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?

• 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?

• 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?

• 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?

That’s All, FolksThat’s All, Folks