Everything you need to Everything you need to know about Mental Health know about Mental Health

in 60 minutes…in 60 minutes…

Dr Tom Tasker

GP with Special Interest in Mental Health NHS Salford

OverviewOverviewAntidepressantsNew NICE guidanceImproving Access To Psychological

Therapies (IAPT)Stepped Care ModelPhysical health in SMICase Studies

When – DepressionWhen – Depression Mild (PHQ-9: < 10)

– Avoid – Unless:

– Past h/o severe depression– Not responding to other interventions

Moderate (PHQ-9: 10 – 19)– Consider – Discuss with patient

Severe (PHQ-9: 20+)– Encourage to take– Evidence best for comb’n of AD + Psychological therapy

When – Anxiety DisordersWhen – Anxiety Disorders

Mild/moderate– Avoid– Psychological Therapy 1st line (NICE)

Moderate/severe– Consider if loss of function– Should be an adjunct to Psychological therapies

When – Depression/anxietyWhen – Depression/anxiety

If depression is accompanied by marked anxiety….

TREAT DEPRESSION FIRST

Consider AD as appropriate

Draft NICE guidance re ADsDraft NICE guidance re ADs

Generic SSRI 1st line– Efficacy– Better tolerated– Favourable risk-benefit ratio– Less likely to be discontinued because of side

effects– Low acquisition-cost

– (Paroxetine: higher rate of discontinuation symptoms)

Draft NICE Guidance for ADsDraft NICE Guidance for ADs

2nd line:– Different SSRI– Better tolerated newer generation AD

Combining ADs– Remit of GPSI/psychiatrist– SSRI plus mirtazapine

Do not initiate dosulepin– Increased cardiac risk – Toxicity in OD

Draft NICE guidance for ADSDraft NICE guidance for ADS

What is the best strategy following 6-8 weeks of adequate treatment?

– Suggest RCT to assess: Continuing same/increasing dose of SSRI Switch to another SSRI Switch to AD of different class

Which – Depression (Salford)Which – Depression (Salford)

1st line:– Sertraline

2nd line– Change class

Mirtazapine Venlafaxine Duloxetine

Which – Anxiety (Salford)Which – Anxiety (Salford)

1st Line– Citalopram

2nd line– Escitalopram– Venlafaxine

Cost per monthly prescriptionsCost per monthly prescriptions

Fluoxetine 20mg 69p Citalopram 20mg £1.24 Sertraline 50mg £1.37 Escitalopram 10/20mg £15/£25 Mirtazapine 30/45mg £3.28 - £19 Duloxetine 60mg £27.72 Venaxx/venlalic 75–225mg £10 - £30

Good prescribing tipsGood prescribing tips

Considerations– Length of initial prescription– Toxicity in overdose– When to review– Careful in < 30 years old

Good prescribing tipsGood prescribing tips

How often to review?– (1) week– 2 weeks– 4 or 5 weeks– 8 weeks– 12 weeks– 1 – 2 monthly thereafter

Good prescribing tipsGood prescribing tips

When to consider increasing dose?– No response – 2-3 weeks– Partial response – 4 – 6 weeks– Switch after 4-6w if unsatisfactory

response

Good prescribing tipsGood prescribing tips

How long to treat for?– At least 6 months after remission– If recurrent consider 1 – 2 years

Consider acute v repeat prescriptions

Try to avoid ADs in bereavement (except in past h/o depression)

Good prescribing tipsGood prescribing tips

Tricyclics– Avoid subtherapeutic doses– Helps anxiety symptoms but not depression

Avoid dosulepin altogether– No new initiations– Consider switching

How much is being invested in the Improving How much is being invested in the Improving Access to Psychological Therapies programme Access to Psychological Therapies programme

in the next 3 years?in the next 3 years?

A £173,000

C £ 17.3million

B £1.73 million

D £173 million

How much is being invested in the Improving How much is being invested in the Improving Access to Psychological Therapies programme Access to Psychological Therapies programme

in the next 3 years?in the next 3 years?

D £173 million

Improving Access to Psychological Improving Access to Psychological Therapies (IAPT)Therapies (IAPT)

Comprehensive Spending Review 2007

– £30 million in 2008/9– £70 million in 2009/10– £70 million in 2010/11

11stst wave - IAPT 2008/9 wave - IAPT 2008/9

35 pilot sites in 2008/9

5 sites in NW SHA

Salford – 26 new trainees– 11 Low Intensity (Graduate Workers)– 15 High intensity (CBT workers)

IAPTIAPT

NICE-compliant (Stepped care model) Step up/down as necessary Step 2

– Low Intensity Interventions Step 3

– High Intensity Interventions (CBT, IPT) Step 4

– Non-IAPT (Psychology Services)

Low Intensity WorkersLow Intensity Workers

Low intensity interventions- Medication management– Behavioural activation– Problem-solving– Guided self-management– Brief CBT– Signposting

4 – 6 sessions x 30 minutes

Condition requiring Condition requiring treatmenttreatment

Who’s responsible for care?Who’s responsible for care? What do they do?What do they do?

Step 4Step 4

Complex DisordersComplex Disorders

Significant TraumaSignificant Trauma

Abnormal Grief ReactionsAbnormal Grief Reactions

Non-IAPTNon-IAPT

(Psychologists,counsellors)(Psychologists,counsellors)

Medication

Complex psychological interventions

Combined treatments

Step 3Step 3

Moderate/severe depression/anxiety disorders not responding to LI

PTSD/Severe OCD

High Intensity IAPTHigh Intensity IAPT

CBT

IPT

Step 2Step 2 Mild depression/anxietyMild depression/anxiety

Moderate/severe anxiety Moderate/severe anxiety disordersdisorders

Low Intensity IAPT workers (PCMHS)Low Intensity IAPT workers (PCMHS)

Watchful waiting

Medication Management

Behavioural Activation

Problem-solving

Brief CBT

Signposting

Step 1Step 1 RecognitionRecognition GP and practice teamGP and practice team Assessment

Stepped Care ModelStepped Care Model

Framework in which to organise services

Aim is to provide the least intrusive, most effective intervention first

Patients should enter at the step that is appropriate to them but generally the least intensive

Patients can be stepped up or down as necessary

Condition requiring Condition requiring treatmenttreatment

Who’s responsible for care?Who’s responsible for care? What do they do?What do they do?

Step 5Step 5

Risk to lifeRisk to life

Severe Self- NeglectSevere Self- Neglect

Acute inpatient serviceAcute inpatient service Assessment, Medication, observation, therapies,

24hr in-patient care

Step 4Step 4

Treatment-resistantTreatment-resistant

Atypical & Psychotic Atypical & Psychotic Depression & those at Depression & those at significant risksignificant risk

Clinical psychology (non-IAPT)Clinical psychology (non-IAPT)

CMHT input if appropriateCMHT input if appropriate

Medication

Complex psychological interventions

Combined treatments

Step 3Step 3

Moderate/severe depression

GPwSIGPwSI

Honorary Consultant PsychiatristHonorary Consultant Psychiatrist

High Intensity IAPT (PCPS)High Intensity IAPT (PCPS)

Gateway WorkersGateway Workers

Case Management (PCMHS)Case Management (PCMHS)

Medication

Liaison

CBT & Counselling

Case Management

Step 2Step 2 Mild/moderate disordersMild/moderate disorders Low Intensity IAPT workers (PCMHS)Low Intensity IAPT workers (PCMHS)

Social Prescribing Social Prescribing

Third SectorThird Sector

Watchful waiting

Behavioural Activation

Problem-solving

Brief CBT

Signposting

Arts on Prescription

Comm Health Trainers

Computerised CBT

Step 1Step 1 RecognitionRecognition GP and practice teamGP and practice team Assessment

Physical Health & SMIPhysical Health & SMI

Life expectancy– Reduced by 10 – 15 years– Younger patients at very high risk compared with general

population

Cardiovascular Disease– Mortality in excess of 2x that of general population

Diabetes– Up to 5x that of general population

Other health related issuesOther health related issues

Health inequalities Lifestyle Smoking

– 61% schizophrenia, 46% BPD(Social Exclusion Unit Report - Mental health and social exclusion) 2004

Alcohol & Drug Misuse Obesity Metabolic Syndrome Hyperprolactinaemia

Cardiovascular Risk Factors Cardiovascular Risk Factors and Schizophreniaand Schizophrenia

Non-modifiable risk factors

Modifiable risk factors

Prevalence inschizophrenia

Gender Obesity1 30–40% (1.5–2 ×)

Family history Smoking2 50–80% (2–3 ×)

Personal history Diabetes3 11–15% (2 ×)

Age Hypertension4 58%

Ethnicity Dyslipidaemia4 45%

1Davidson et al. Aust NZ J Psychiatry. 2001;35:196–202;; 2Herran et al. Schizophr Res. 2000;4:373–381; ; 3Dixon et al. Schizophr Bull. 2000;26:903–912; 4Kato et al. Prim Care Companion J Clin Psychiatry. 2005;7:115–118

Metabolic Syndrome Metabolic Syndrome (IDF Definition 2005)(IDF Definition 2005)

• Metabolic syndrome defined as criterion one plus

any two of next four criteria:1. Central obesity Men 94 cm (37inches)

Women 80 cm (31.5 inches)

Blood pressure ≥130/85 mmHg

Triglycerides ≥1.7 mmol/L

HDL cholesterol Men <1.03 mmol/L

Women <1.29mmol/L

Fasting blood glucose

≥5.6 mmol/L

IDF = International Diabetes Federation; HDL = High-density Lipoprotein; Available at www.idf.org

The core problem...?The core problem...?

n=12,363BMI = Body Mass IndexPark et al. Arch Intern Med. 2003;163:427–436

Prevalence of Metabolic Syndrome Prevalence of Metabolic Syndrome According to BMIAccording to BMI

Men Women

BMI ≥30

4.6 6.2

22.428.1

59.6

50

0

10

20

30

40

50

60

70

Pre

vale

nce

(%

)

Healthy

BMI <25

Overweight

BMI 25–29.9

Obese Overweight

BMI 25–29.9

Healthy

BMI <25 BMI ≥30

Obese

BMI = Body Mass IndexAllison et al. J Clin Psychiatry. 1999;60:215–220

Prevalence of Obesity is Increased in Prevalence of Obesity is Increased in SchizophreniaSchizophrenia

Normal weight Overweight Obese

0

5

10

15

20

25

30

BMI category

Schizophrenia

No schizophrenia

<2020–22

>22–25

>24–26

>26–28

>28–30

>30–33

>33–35>35

Per

cen

tag

e

Isomaa et al. Diabetes Care. 2001;24:683–689

4.6

2.2

12.0

18.0

0

2

4

6

8

10

12

14

16

18

20

Total mortality CV mortality

Mo

rtal

ity

(%)

Metabolic syndrome absent

Metabolic syndrome present

***p<0.001 vs. patients without metabolic syndromeCV = Cardiovascular

Median follow-up: 6.9 years

Metabolic Syndrome Increases Total Metabolic Syndrome Increases Total and Cardiovascular Mortalityand Cardiovascular Mortality

***

***

Prevalence of Diabetes in Prevalence of Diabetes in Schizophrenia vs. General Schizophrenia vs. General

PopulationPopulation

0

5

10

15

20

25

30

General population

People with schizophrenia

Pre

vale

nce

(%

)

25–3515–35 35–45 45–55 55–65

Age range (years)

De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14n=415 patients with schizophrenia

Osborn et al, Arch Gen Psychiatry Vol Osborn et al, Arch Gen Psychiatry Vol 64 Feb 200764 Feb 2007

46 136 people with SMI 300 426 without SMI were selected for the study

Hazard ratios (HRs) in people with SMI compared with controls were:

for CHD mortality 3.22 (95% CI, 1.99-5.21) for people 18 - 49 yrs 1.86 (95% CI, 1.63-2.12) for those 50 - 75 yrs 1.05 (95% CI, 0.92-1.19) for those > 75 yrs

Osborn et al, Arch Gen Psychiatry Feb Osborn et al, Arch Gen Psychiatry Feb 20072007

For stroke deaths, the HRs were:

2.53 (95% CI, 0.99-6.47) for those < 50 yrs 1.89 (95% CI, 1.50-2.38) for 50 - 75 yrs 1.34 (95% CI, 1.17-1.54) for > 75 yrs

Increased HRs for CHD mortality occurred irrespective of:

sex SMI diagnosis Or prescription of antipsychotic medication

However a higher prescribed dose of antipsychotics predicted greater risk of mortality from CHD and stroke

Further Findings from Osborn et al, 2007

Other Common Physical Other Common Physical Health ProblemsHealth Problems

People with schizophrenia are also at increased risk for:– Hyperprolactinaemia

Particularly associated with conventional antipsychotics, risperidone, amisulpride

– Sexual dysfunction May also be a consequence of conventional

antipsychotic therapy; the causal link with atypical antipsychotics is less clear

Mental Health Indicator 9 -Mental Health Indicator 9 -Annual Physical Health CheckAnnual Physical Health Check

Alcohol & drug misuse Smoking BMI/waist circumference BP Diabetes screening Lipid profiles in patients

– > 40 years– Those on atypical antipsychotics

Mental Health Indicator 9 -Mental Health Indicator 9 -Other issues to considerOther issues to consider

Cervical ScreeningDental & Eye CareImms & VaccsMedication compliance & side effects

Mental Health Indicator 6 -Mental Health Indicator 6 - Psychiatry Care Plan Psychiatry Care Plan

Check contact details for:– Main Carer– Care Co-coordinator & all key people involved in care

Check follow up arrangements with specialist mental health services

Check patient awareness of early signs of relapse Check patient’s preferred course of action in event of

relapse Social situation

– CAB, Welfare, Benefits

Salford InitiativesSalford Initiatives

Shared Care Protocol for Atypical Antipsychotics

Tackling DNA rates for physical health checks

SCP for Atypical AntipsychoticsSCP for Atypical Antipsychotics

Incentivised scheme 3 visits: – baseline to be done by specialist MHS

– 3m & 6m checks to be done in Primary Care– Annually thereafter as part of QOF

At each visit:– BMI/waist– BP– Fasting BS– Fasting lipids (not at 3m visit)

Salford CMHT InitiativesSalford CMHT Initiatives

Care Programme Approach– Current CPA amended– Physical Illness Domain to be extended to include

physical health check

Care coordinator role– Pivotal– Responsibility to ensure health check has been done

Follow up of DNA’sFollow up of DNA’s

If patient DNAs their annual physical health check:

– Requirement under QuOF (MH 7)

– GP to cc DNA letter to care coordinator

– Care coordinator to follow up

““Hard to reach” SMI patientsHard to reach” SMI patients

CHUG (Cromwell House User group meeting):– No previous dialogue re physical health– Interested in physical health

Education, awareness

– Prefer to undergo check in CMHT– Don’t like attending GP surgeries

Don’t like environment Stigmatised Physical symptoms attributed to SMI Not listened to

SurveySurvey

Service User Representative:– Wider report to looked at:

How to deliver promotional campaign:– raise awareness– education

Check out why they won’t attend GP How to facilitate attendance at GP surgeries Types of interventions they want to see at

CMHT level

Results of SurveyResults of Survey

48 responses:– Education – want to talk to Care co-ordinator

(rather than leaflets/posters)– 70% had a physical health check in past 15m– >90% of checks done at GP surgery– Reassured – GP knows about physical health– Barriers:

Getting appointment GP running late

Case Study 1Case Study 1

AF: 28y, male– 1st episode of depression x 6w– Lost job, financial difficulties– Losing contact with friends– Stopped going to the gym– Putting on weight– PHQ score 11

Case Study 1 – Management PlanCase Study 1 – Management Plan

Mild depression Referred to Low Intensity Therapist

– Behavioural activation– Problem-solving approach– Signposted to CAB

Referred for cCBT for relapse prevention Liaison with JCP PHQ score 4 on discharge

Case Study 2Case Study 2

MS, 42y, female Chronic depression

– On maintenance dose of fluoxetine 20mg¹ x 5y Relapse Oct 08

– Relationship breakdown 2008– Miscarriage 2007– Sexually abused by her father 3y ago

PHQ 23 – fleeting suicidal ideation but no plans

Case Study 2 – what happened next?Case Study 2 – what happened next?

Severe depression Increased fluoxetine 40mg¹

– Agitated, not sleeping– Increasing thoughts of self-harm

Referred Psychology (non-IAPT - Step 4) PHQ 22 (Nov 2008)

Case Study 2Case Study 2

Switched to mirtazapine 30mg nocte– Much calmer– Sleeping better– Appetite improved– No longer having thoughts of self-harm

Started psychology PHQ 14 (Jan 2009)

Case Study 3Case Study 3

TF, 58y, male Depressive episode x 1y Past h/o 2 episodes of depression T2DM Controlled Hypertension BMI 33 PHQ 18 – no suicidal ideation

Case Study 3 – what happened next?Case Study 3 – what happened next?

Recurrent depression Started citalopram 20mg¹ After 3w, no subjective improvement (PHQ 19) Citalopram increased to 40mg¹ Referred to Low Intensity Therapist

– Medication Management– Behavioural activation– 6 sessions x 30 mins

6w after presentation - PHQ score 20

Case Study 3Case Study 3

Switched to duloxetine 60mg¹

Stepped up from Low Intensity to High Intensity i.e. step 2 step 3

10w later PHQ 8

Maintenance therapy – 2y according to NICE

Referred to Arts on Prescription

Thanks for your attentionThanks for your attentionAny questions?Any questions?