Everything you need to know about Mental Health in 60 minutes…

1
Everything you need to know about Mental Health
in 60 minutes

• Dr Tom Tasker
• GP with Special Interest in Mental Health NHS
  Salford

2
Overview

• Antidepressants
• New NICE guidance
• Improving Access To Psychological Therapies
  (IAPT)
• Stepped Care Model
• Physical health in SMI
• Case Studies

3
When Depression

• Mild (PHQ-9 lt 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 combn of AD Psychological
  therapy

4
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

5
When Depression/anxiety

• If depression is accompanied by marked anxiety.
• TREAT DEPRESSION FIRST
• Consider AD as appropriate

6
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)

7
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

8
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

9
Which Depression (Salford)

• 1st line
• Sertraline
• 2nd line
• Change class
• Mirtazapine
• Venlafaxine
• Duloxetine

10
Which Anxiety (Salford)

• 1st Line
• Citalopram
• 2nd line
• Escitalopram
• Venlafaxine

11
Cost 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 75225mg 10 - 30

12
Good prescribing tips

• Considerations
• Length of initial prescription
• Toxicity in overdose
• When to review
• Careful in lt 30 years old

13
Good prescribing tips

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

14
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

15
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)

16
Good prescribing tips

• Tricyclics
• Avoid subtherapeutic doses
• Helps anxiety symptoms but not depression
• Avoid dosulepin altogether
• No new initiations
• Consider switching

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How much is being invested in the Improving
Access to Psychological Therapies programme in
the next 3 years?

• A 173,000
• C 17.3million

• B 1.73 million
• D 173 million

19
How much is being invested in the Improving
Access to Psychological Therapies programme in
the next 3 years?

• D 173 million

20
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

21
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)

22
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)

23
Low Intensity Workers

• Low intensity interventions
• - Medication management
• Behavioural activation
• Problem-solving
• Guided self-management
• Brief CBT
• Signposting
• 4 6 sessions x 30 minutes

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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

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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

28
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

29
Cardiovascular Risk Factors and Schizophrenia
1Davidson et al. Aust NZ J Psychiatry.
200135196202 2Herran et al. Schizophr Res.
20004373381 3Dixon et al. Schizophr Bull.
200026903912 4Kato et al. Prim Care Companion
J Clin Psychiatry. 20057115118
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Metabolic Syndrome (IDF Definition 2005)

• Metabolic syndrome defined as criterion one plus
  any two of next four criteria

IDF International Diabetes Federation HDL
High-density Lipoprotein Available at www.idf.org
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The core problem...?
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Prevalence of Metabolic Syndrome According to BMI
n12,363 BMI Body Mass Index Park et al. Arch
Intern Med. 2003163427436
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Prevalence of Obesity is Increased in
Schizophrenia
Schizophrenia No schizophrenia
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Normal weight
25
Overweight
Obese
20
Percentage
15
10
5
0
lt20
2022
gt2225
gt2628
gt2830
gt3033
gt3335
gt35
gt2426
BMI category
BMI Body Mass Index Allison et al. J Clin
Psychiatry. 199960215220
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Metabolic Syndrome Increases Total and
Cardiovascular Mortality

20
Metabolic syndrome present
18.0
Metabolic syndrome absent
18
16

14
12.0
12
10
Mortality ()
8
6
4.6
4
2.2
2
0
Total mortality
CV mortality
Median follow-up 6.9 years
plt0.001 vs. patients without metabolic
syndrome CV Cardiovascular
Isomaa et al. Diabetes Care. 200124683689
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Prevalence of Diabetes in Schizophrenia vs.
General Population
Prevalence ()
2535
1535
3545
4555
5565
Age range (years)
n415 patients with schizophrenia
De Hert et al. Clin Pract Epidemiol Mental
Health. 2006214
36
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 gt 75 yrs

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Osborn et al, Arch Gen Psychiatry Feb 2007

• For stroke deaths, the HRs were
• 2.53 (95 CI, 0.99-6.47) for those lt 50 yrs
• 1.89 (95 CI, 1.50-2.38) for 50 - 75 yrs
• 1.34 (95 CI, 1.17-1.54) for gt 75 yrs

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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

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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

40
Mental Health Indicator 9 -Annual Physical
Health Check

• Alcohol drug misuse
• Smoking
• BMI/waist circumference
• BP
• Diabetes screening
• Lipid profiles in patients
• gt 40 years
• Those on atypical antipsychotics

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Mental Health Indicator 9 -Other issues to
consider

• Cervical Screening
• Dental Eye Care
• Imms Vaccs
• Medication compliance side effects

42
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 patients preferred course of action in
  event of relapse
• Social situation
• CAB, Welfare, Benefits

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Salford Initiatives

• Shared Care Protocol for Atypical Antipsychotics
• Tackling DNA rates for physical health checks

44
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)

45
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

46
Follow up of DNAs

• 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

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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
• Dont like attending GP surgeries
• Dont like environment
• Stigmatised
• Physical symptoms attributed to SMI
• Not listened to

49
Survey

• Service User Representative
• Wider report to looked at
• How to deliver promotional campaign
• raise awareness
• education
• Check out why they wont attend GP
• How to facilitate attendance at GP surgeries
• Types of interventions they want to see at CMHT
  level

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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
• gt90 of checks done at GP surgery
• Reassured GP knows about physical health
• Barriers
• Getting appointment
• GP running late

51
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

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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

53
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

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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)

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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)

56
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

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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

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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

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Thanks for your attentionAny questions?