The effective joint management of bipolar between primary and

secondary careDr Nick Stafford, Consultant Psychiatrist, Lichfield CMHT, South Staffordshire

& Shropshire Healthcare Foundation Trust

Case study

Mr. A, age 32, has a history of recurrent depression

Saw a celebrity talking about his diagnosis of bipolar on TV so went to see his GP due to his mood swings

Repeated treatments with antidepressants ineffective

Smoker, excessive alcohol, overweight, impaired glucose tolerance

One previous serious suicide attempt, current suicidal ideation

Mood swings and irritability impact on marriage & work

Content of talk

When GPs should consider bipolar

Public education about bipolar

Clues to unrecognized bipolar

Co-morbidities, lifestyles and physical health

Risks

Impact on functional ability

How effective team work between GP & CMHT can be effective

Optimal care – how do we achieve it?

Patient view

(what do I want?)

System view

(what is evidence based?)

Provider view

(what can I afford?)

What do service users and carers want?

A patient centered

relationship

Immediacy of help

Range of choices

available

Education on self-

management

NICE CG136 Dec 2011 – Service User Experience in Mental HealthDoH North East Regional Government, Mental Health Promotion in Primary Care 2005Joint Commissioning Panel for Mental Health

Models of care

Medical model

Recovery model

Person-centered care

Pragmatic model

Chronic (collaborative) care model

That which fits any current economic & political environment

As cheap as possibly possible model

NICE 2011, 2013, 2014

Whole system problem, solution

http://jech.bmj.com/content/56/5/334.full

COMPLEX DISORDER

COMPLEX SERVICES

Chronic Care Model - Principles

Group Health Research Institute

Chronic Care Team– what’s the structure?

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational servicesInfrequent interactions

Frequent interactions

https://aims.uw.edu/collaborative-care/team-structure

Psychiatric services

Chronic Care Team – Primary Care

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational servicesInfrequent interactions

Frequent interactions

https://aims.uw.edu/collaborative-care/team-structure

Psychiatric services

Journey of primary to secondary care

Public knowledge

Primary careSecondary psychiatric

care

Other specialist care

CAPTURE MISSED BIPOLARINTER-EPISODE MONITORINGMANAGE RELAPSE

IMPROVE DIAGNOSTIC ACCURACYRESPONSIVE TO GP & PATIENTACUTE, MAINTENANCE, EDUCATION

Optimism about recovery

Benefits aboutseeking professional

help

Knowledge of risks (c.f. Cancers)

Real life stories Hollywood

News Research

Public Knowledge – Mental health literacy

Stigma Reluctance to discuss mental disorders

GP Constraints with bipolar - dimensions

10 minutesInformation

amountClinical

uncertaintyNeed for specialist

Diagnosis complexity

Relapse dimensions

Medication variety

Suicide risk high

http://www.todayshospitalist.com/?b=articles_read&cnt=6

Care Team– GP / CMHT relationship

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational servicesInfrequent interactions

Frequent interactions

https://aims.uw.edu/collaborative-care/team-structure

Patient perspective – immediacy of help

http://www.kingsfund.org.uk/blog/2014/10/waiting-mental-health-care-what-does-public-think

Unrecognized bipolar in primary care

3.3% - 21.6% GP patients with unipolar disorder may actually have bipolar disorder

HCL-32 and BSDS may be more useful for detecting broader definitions of bipolar disorder than DSM-IV

Other studies vary in recommendations on screening

GPs not likely to do screening tools unless QOFd

Smith et al 2011

GPs: When to be suspicious of bipolar?

1. Depressive symptoms

2. Depressive symptoms

3. Depressive symptoms

Mood screening questionnaires are well validated in research but are time resource intensive, can divert and interrupt the consultation.

May be better left to specialist services.

More rapid access to secondary care is more important.

The right questions in primary care

If a GP sees depression they should have a reflex consideration of bipolar disorder every time and

ask relevant questions for it.

a. Do you have a family history of bipolar disorder?

b. Do you have significant variations in mood, energy and activity levels? (quantifiable)

c. Do you ever feel irritable or have thoughts you can’t slow down?

Leicestershire & Staffordshire

Depressed patient visits GP

GP assesses patientand considers bipolar

HCL-32 screen

Bipolar UK literature and mood diary

Primary care staff group lunch timeteaching

Pre-interview questionnaire

CMHT - Pre-interview questionnaire

More information, greater diagnostic accuracy

Takes 2-3 hours to complete (patients like it as it validates their experiences by asking questions they identify with)

Saves clinic time, allows consideration of issues before assessment

Details of mood swings against DSM-V criteria

Questions on common co-morbidities

Screening questionnaires HCL-32

Depression/Mania

IPDE

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational services

Improved outcomes and economics ofspecialist bipolar disorder clinics

Pros & Cons:Specialist care is rareReduced banding of CMHT staffFunctionalization with NWW

Specialized clinics for bipolar disorder

Consultant psychiatrist led

Non-Medical Prescribers / CPNs (Care Co-ordinators)

Consultant nurse

ST6 Psychiatrist in training (when available)

More structured information to GP to aid ongoing care

More information provided to CMHT to improve diagnosis

Supported by bipolar psychoeducation groups and other psychology

Structured management helps GP

Staying well programme

Proper detailed correspondence with advice:

In case of hypomania

In case of depression

In case of comorbidities

On discharge information in correspondence to guide GP

GP calls psychiatrist/CMHT if in need of support

GPs may utilize outdated practice – try to stop

e.g. using antidepressants in bipolar depression

GP – Shared Care with CMHT

Shared management (SSSFT – CQUIN, RPIW, Clusters 11-13)

Seen within 4 weeks

Early warning / relapse prevention plan started at assessment

Advanced Statement of wishes

Rapid re-referral system (Fast Track)

Metabolic screening & Physical health care – annual checks

Consultants’ mobile phone number for GP

Link CMHT worker for GP

Lithium monitoring (see later)

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational services

De-commissionedservicesprovided for bysingle trust

Steps in managing bipolar comorbidity

Some service within CMHT, some are separate Care manager co-ordinates this

Alcohol and substance misuse – Separate SMS service

Anxiety – within CMHT GAD, Social Phobia, OCD, PTSD, Panic Disorder

Personality disorders – Locality based psychology service

Awareness of ADHD – specific team member

Medical comorbidities – e.g. cardiovascular, obesity, diabetes Some in CMHT, mainly with GP & associated specialist

http://www.psychiatrictimes.com/bipolar-disorder/comorbidity-bipolar-disorder/page/0/1

Steps in managing bipolar physical health

Lester UK Adaptation 2014 Update

Lithium and chronic renal disease

GPs are familiar with managing lithium levels

Results not often shared with psychiatrist

GP can refer to nephrologist under advice

Often seeks psychiatrists’ view first

GPs have better IT systems for tracking eGFR than CMHTs

GPs – EMIS Web & Systm1

CMHTs – RiO

The same is true of the management of chronic disease

Only real solution is to have open access IT systems

Supporting bipolar carers

GP / CMHT Working

Carers’ psychoeducation

GP / CMHT working together can be useful in this area

Professionals meetings for difficult cases

Rethink

Bipolar UK carers self-help groups in some areas

Public information

http://beatingbipolar.org

Bipolar Disorder for Dummies (2nd edition). Wiley Brothers Publishers USA.

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational services

Education andSelf-management

Psychoeducation

GPs can do detailed psychoeducation

http://beatingbipolar.org The best book (in my opinion)

Other psychological approaches

GPs can refer directly to these services in those with diagnosed bipolar as usually in maintenance

Cognitive Behavioural Therapy techniques – focus on inter-episode functioning

Several small RCTs (+), one large (+), one large (-)

Interpersonal and Social Rhythm Therapy – focus on routines

Single small RCT weakly (+), second (+)

Family Focused Therapy – focus on family dynamics

One small (+), several larger ones (+ or =)

Collaborative RESearch Team to study Bipolar Disorder (UBC)

CareManager

Consultant Psychiatrist

Primary care

provider

Other Specialist Clinicians

Patient

Community support & Occupational services

Commissioning3rd sectorPeer led

Community support & Social Inclusion

Usually self-referral. GPs usually also able to sign post or refer to.

Agencies

Thank you