Download Management of severe and chronic Management of severe and

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CLAHRC NDL
Management of severe and chronic Management
of severe and chronic
depression in England: CLAHRC findings on current performance & NICE
NICE service models for the future
i
d l f th f t
Richard Morriss
Professor of Psychiatry and Community f
f
hi
d
i
Mental Health,
IMH and CLAHRCs NDL and EM, University of Nottingham, Nottingham, England
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
WHERE IS SEVERE/CHRONIC DEPRESSION TREATED?
Specialisms
3rdd sector & secondary care
Serious Mental Illness in Serious
Mental Illness in
secondary care
Common
Mental health
IAPT
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CLAHRC NDL
OUTLINE OF TALK
• NIHR CLAHRC NDL audit of usual care
• NIHR CLAHRCs NDL and CP RCT of clinical and cost
effectiveness of specialist treatment for mood disorder
for chronic severe depression.
• NIHR CLAHRC EM study of depression and repeat selfharm.
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
HOW IS CHRONIC DEPRESSION TREATED?
•
To date there is no detailed picture of what treatment as usual for people
with moderate/severe chronic depression is within secondary care
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Standards for best practice can be drawn from the most recent NICE
guidance (CG90, 2009), which recommends that at least 70% of patients
should meet treatment standards
•
This audit aims to explore whether a stepped care approach as outlined by
NICE was being adhered to in one secondary care mental health trust.
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CLAHRC NDL
PARTICIPANTS IN AUDIT
• Patients who meet NICE criteria for moderate to severe depression
• Patients who have been offered or received direct care for Patients who have been offered or received direct care for
depression from one or more health professionals in the 6 months preceding randomisation into the study
• Patients who were under the care of secondary care community mental health teams at the time of randomisation
Participants were randomised into into – Specialised Mood Mood
• Participants were randomised
Disorders Team OR mental health treatment as usual (50:50)
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Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
METHOD
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•
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A sample of 80 patients was selected from both arms of the study (50:50)
The audit tool was adapted from the patient data collection tool for h
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d
df
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lf
depression (NICE guidelines 2004, updated 2009) and used to determine whether patients received NICE recommended treatment standards in their usual care prior to their inclusion in the RCT
Data was collected retrospectively from case notes held at secondary care mental health services
care mental health services
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
PARTICIPANTS IN RCT
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186 participants
Mean age 51 years (range 20‐84)
g
y
( g
)
114 female, 72 male
Hamilton Depression Scale mean 27 (16‐38)
a to ep ess o Sca e ea
( 6 38)
Global Assessment of Function mean 57 (25‐60)
Mean duration of current episode 89 weeks
Mean duration of current episode 89 weeks
Costs of usual care £4,000 per year
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DIAGNOSIS, ASSESSMENT AND FOLLOW UP
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Documentation of a diagnosis based on a comprehensive assessment met NICE standards at 89%. Those with suicidal intent were followed up after the recommended one h
i h i id l i
f ll
d
f
h
d d
week in only 47% of cases The recommended follow‐up period of two weeks after starting a new pp
g
anti‐depressant occurred in only 36% of cases
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
ASSESSMENT AND FOLLOW UP
Diagnosis with Assessment
Suicide Risk Followed up
Suicide Risk Followed up
Follow‐Up on new Mx
0
20
40
60
80
100
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DISCUSSION WITH PATIENTS ON MEDICATION
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Less than 25% of case notes had documented evidence of
discussion about treatment length, discontinuation symptoms,
interactions and risk of increased agitation and suicidal ideaton.
ideaton
70% dose escalation of antidepressant, 50% switching and
augmentation
Discussions about general side effects was only reported in 54% of
cases.
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
MEDICATION
Treatment Length
Interactions
Discontinuation Sx
G
General Side Effects
l Sid Eff t
0
20
40
60
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PSYCHOLOGICAL TREATMENT
11
24
Discussed, referred & unsuitable
Th
Therapy not discussed
t di
d
48
Dicussed, referred and accepted into therapy
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CURRENT CARE FOR CHRONIC DEPRESSION
• Generalist (from qualitative interviews, n=55)
– Psychiatrists quickly run up against the limits of what they feel capable/entitled to do
– GP often de facto prescriber due to resulting therapeutic conservatism conservatism
– CBT therapists (IAPT or secondary care) – struggle with engagement, and risk of suicide and self‐neglect • Isolation
– Little collaboration between professionals leads to mixed messages – confusion –
messages –
confusion – worse compliance
worse compliance
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NICE CG90
• Physical and pharmacological management
– ‘For a person whose depression has failed to respond to various p
p
p
strategies….consider referral to a practitioner with a specialist interest in treating depression, or to a specialist service’ (also CG23)
• Service delivery
– ‘Th
‘The systematic search of the economic literature undertaken t
ti
h f th
i lit t
d t k
for the guideline update identified no eligible studies on service level interventions for people with depression in the UK’
p p
p
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CLAHRC NDL
AIMS OF RCT
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To investigate the clinical and cost effectiveness of a specialised service to deliver care for patients with chronic unipolar depressive disorder in comparison to treatment as usual
comparison to treatment as usual
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To analyse barriers and drivers to implementation of specialised treatment for people with chronic depression
for people with chronic depression.
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Main presentation slides
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
INTERVENTIONS IN RCT
• Specialised Mood Disorders Team
– Psychiatrist and CBT therapist carry out joint assessment and work together with service user to develop treatment plans
work together with service user to develop treatment plans tailored to their individual needs. – Deliver evidence based pharmacological and psychological treatments for unipolar depression within a stepped care model treatments for unipolar
depression within a stepped care model
as outlined by the NICE guidelines.
– Followed medication algorithms of evidence based research when developing treatment plans
when developing treatment plans.
– Liaise with referring team regarding management and treatment in long‐term
• TAU (usual care team)
TAU (
l
)
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ADAPTATIONS OF PSYCHOLOGICAL TREATMENT
• Traditional CBT service
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Suitability criteria used to screen referrals ‐ many turned away y
y
deemed ‘unsuitable’
clinical presentation less acutely symptomatic and any risks y p
y
patient referred out of service to crisis team
Avoidance and ambivalence
Avoidance and ambivalence utilised as factors which deem patient unsuitable for therapy. •
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SSpecialist mood disorder service
i li t
d di d
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Take everyone who is referred and offer treatment
Complex; co‐morbid; acute symptoms; high levels of risk which is worked with
which is worked with psychologically
Actively engage the patient in addressing avoidance and ambivalence Collaboration for Leadership in Applied Health Research and Care for
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EXAMPLES OF ADAPTATION
EEngagement t
•James age 62: feels ‘out of control’ of emotions (anger; control
of emotions (anger;
anxiety; sadness) Therapist is experienced as ‘being in his h d’
head’ i.e. knowing his mind
k
h
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•Anger and irritability
•D
•Depression is shameful
i i h
f l
•Accepting help is humiliating Riskk
Ri
•Alice: 32 entered study 2 months after a serious o/d
after a serious o/d
•First 3 months: Hopeless, guilty and angry
•Impulsivity •Issues of trust ‐‘let you down’ •Poly drug use to manage mood •Highly avoidant coping style Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC EM DEPRESSION AND SELF‐HARM
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Audit of Nottingham crisis resolution team – 70% referrals depression with threat or completed self‐harm/suicidality.
Management – assessment, short‐term support, some antidepressants, h
id
social care e.g. Debt advice.
NICE CG self‐harm (2011) –
(
) all patients who repeatedly self‐harm should p
p
y
have 10 sessions problem solving therapy (best results in depression)
Collaboration for Leadership in Applied Health Research and Care for
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WHO WILL OFFER THIS CARE?
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Self‐harm services provide assessment, few have psychological treatment skills
IAPT and secondary care refuse because of risk.
d
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Yet risk can be managed (RCT Specialist Mood Disorder Team) and 9 RCTs tested such intervention.
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Thank you for listening
[email protected]
i h d
i @
i h
k
www.clahrc-ndl.nihr.ac.uk
@
_
Twitter: @CLAHRC_NDL
This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire (NIHR CLAHRC NDL). The views expressed in this presentation are those of the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.