Download to - Salford GP Learning Hub

Everything you need to
know about Mental Health
in 60 minutes…
Dr Tom Tasker
GP with Special Interest in Mental Health
NHS Salford
Overview
Antidepressants
 New NICE guidance
 Improving Access To Psychological
Therapies (IAPT)
 Stepped Care Model
 Physical health in SMI
 Case Studies

When – 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 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/anxiety

If depression is accompanied by marked
anxiety….
 TREAT

DEPRESSION FIRST
Consider AD as appropriate
Draft 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 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 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)

1st line:
– Sertraline

2nd line
– Change class
 Mirtazapine
 Venlafaxine
 Duloxetine
Which – Anxiety (Salford)

1st Line
– Citalopram

2nd line
– Escitalopram
– Venlafaxine
Cost per monthly prescriptions







Fluoxetine 20mg
Citalopram 20mg
Sertraline 50mg
Escitalopram 10/20mg
Mirtazapine 30/45mg
Duloxetine 60mg
Venaxx/venlalic 75–225mg
69p
£1.24
£1.37
£15/£25
£3.28 - £19
£27.72
£10 - £30
Good prescribing tips

Considerations
– Length of initial prescription
– Toxicity in overdose
– When to review
– Careful in < 30 years old
Good prescribing tips

How often to review?
– (1) week
– 2 weeks
– 4 or 5 weeks
– 8 weeks
– 12 weeks
– 1 – 2 monthly thereafter
Good 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 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 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
Access to Psychological Therapies programme
in the next 3 years?

A £173,000

B £1.73 million

C £ 17.3million

D £173 million
How much is being invested in the Improving
Access to Psychological Therapies programme
in the next 3 years?

D £173 million
Improving Access to Psychological
Therapies (IAPT)

Comprehensive Spending Review 2007
– £30 million in 2008/9
– £70 million in 2009/10
– £70 million in 2010/11
1st 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)
IAPT

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 Workers

Low intensity interventions
- Medication management
– Behavioural activation
– Problem-solving
– Guided self-management
– Brief CBT
– Signposting

4 – 6 sessions x 30 minutes
Condition requiring
treatment
Who’s responsible for care?
What do they do?
Step 4
Complex Disorders
Significant Trauma
Abnormal Grief Reactions
Non-IAPT
(Psychologists,counsellors)
Medication
Complex psychological
interventions
Combined treatments
High Intensity IAPT
Step 3
Moderate/severe
depression/anxiety
disorders not responding
to LI
CBT
IPT
PTSD/Severe OCD
Step 2
Mild depression/anxiety
Low Intensity IAPT workers (PCMHS)
Moderate/severe anxiety
disorders
Step 1
Recognition
GP and practice team
Watchful waiting
Medication Management
Behavioural Activation
Problem-solving
Brief CBT
Signposting
Assessment
Stepped 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
Step 5
Step 4
Step 3
Step 2
Condition requiring
treatment
Who’s responsible for care?
What do they do?
Risk to life
Severe Self- Neglect
Acute inpatient service
Assessment, Medication,
observation, therapies,
24hr in-patient care
Treatment-resistant
Atypical & Psychotic
Depression & those at
significant risk
Clinical psychology (non-IAPT)
CMHT input if appropriate
Medication
Complex psychological
interventions
Combined treatments
GPwSI
Honorary Consultant Psychiatrist
High Intensity IAPT (PCPS)
Gateway Workers
Case Management (PCMHS)
Medication
Liaison
CBT & Counselling
Case Management
Moderate/severe
depression
Mild/moderate disorders
Third Sector
Watchful waiting
Behavioural Activation
Problem-solving
Brief CBT
Signposting
Arts on Prescription
Comm Health Trainers
Computerised CBT
GP and practice team
Assessment
Low Intensity IAPT workers (PCMHS)
Social Prescribing
Step 1
Recognition
Physical 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 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
and Schizophrenia
Non-modifiable
risk factors
Modifiable risk
factors
Prevalence in
schizophrenia
Gender
Obesity1
30–40% (1.5–2 ×)
Family history
Smoking2
50–80% (2–3 ×)
Personal history
Diabetes3
11–15% (2 ×)
Age
Hypertension4
58%
Dyslipidaemia4
45%
Ethnicity
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
(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...?
Prevalence of Metabolic Syndrome
According to BMI
70
59.6
Prevalence (%)
60
50
50
40
28.1
30
22.4
20
10
6.2
4.6
0
Healthy
BMI <25
Overweight
BMI 25–29.9
Men
n=12,363
BMI = Body Mass Index
Park et al. Arch Intern Med. 2003;163:427–436
Obese
BMI ≥30
Healthy
BMI <25
Overweight
BMI 25–29.9
Women
Obese
BMI ≥30
Prevalence of Obesity is Increased in
Schizophrenia
Schizophrenia
No schizophrenia
30
Percentage
25
Normal
weight
Overweight
20
15
10
5
0
BMI category
BMI = Body Mass Index
Allison et al. J Clin Psychiatry. 1999;60:215–220
Obese
Metabolic Syndrome Increases Total
and Cardiovascular Mortality
20
***
18.0
Metabolic syndrome present
Metabolic syndrome absent
18
16
***
12.0
Mortality (%)
14
12
10
8
6
4.6
4
2.2
2
0
Total mortality
***p<0.001 vs. patients without metabolic syndrome
CV = Cardiovascular
Isomaa et al. Diabetes Care. 2001;24:683–689
CV mortality
Median follow-up: 6.9 years
30
Prevalence of Diabetes in
Schizophrenia vs. General
Population
25
General population
People with schizophrenia
Prevalence (%)
20
15
10
5
0
15–35
25–35
35–45
Age range (years)
n=415 patients with schizophrenia
De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14
45–55
55–65
Osborn et al, Arch Gen Psychiatry Vol
64 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
2007

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


Further Findings from Osborn et al, 2007

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
Other Common Physical
Health 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 Annual 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 Other issues to consider
Cervical Screening
 Dental & Eye Care
 Imms & Vaccs
 Medication compliance & side effects

Mental Health Indicator 6 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 Initiatives

Shared Care Protocol for Atypical
Antipsychotics

Tackling DNA rates for physical health
checks
SCP 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 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’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 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
Survey

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 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 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 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 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?

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 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 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?






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 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 attention
Any questions?