Mental Health issues and Primary Care: applying the evidence to practice

1
Mental Health issues and Primary Care applying
the evidence to practice

• Carolyn Chew-Graham
• General Practitioner
• Senior Lecturer, University of Manchester
• Clinical Champion, Mental Health, Royal College
  of General Practitioners

2
Aims

• Present evidence for managing mental health
  problems in primary care, particularly Anxiety
  and Depression
• Place care of the mind as an equal priority
  with care of the body for all GPs
• Encourage you to reflect on take-home messages
  for your practice

3
Mental health problems are common

• GPs spend a third of their time on mental health
  issues
• 90 of all people with mental health problems are
  managed in primary care
• Future proofing the procession

4
Primary Care offers

• Low stigma
• Accessible setting
• Care close to home
• Contextualised care
• Holistic approach to care
• Longitudinal continuity
• (Personal care)
• Robust IT systems

5
The reality of Primary Care

• 269 million consultations each year
• 10minute consultation
• Random presentation of patients
• Public expectations
• DH expectations (NSF/NICE/QOF/Access)

6
And the reality as it sometimes seems
7
Access
8
Some people find it hard to access care

• Including
• People with mental health problems
• People vulnerable to developing MH problems
• Elderly
• Physical co-morbidity/disability
• hard-to-reach groups homeless, BME

9
Access

• The Disability Discrimination Act 1995 (DDA)
  confers a duty on GP practices to make
  reasonable adjustments for people with a
  disability. This constitutes the removal of
  policies that make access for disabled people
  impossible or unreasonably difficult.
• This includes people with mental health problems
• ReThink publication Mental illness and
  disability law in your GP practice
  www.mentalhealthshop.org

10
Reflections

• How easy is it for people with mental health
  problems to access your practice?

11
Case

• Write down your thoughts.
• Monday morning
• Chris, a roofer, comes in requesting a sick note.
  Been off work two weeks with back pain. Doesnt
  feel he can go back thinks he would struggle
  with heights.
• Girlfriend has chronic depression. Daughter
  4years and son 18/12. feels irritable with the
  lot of them.
• Chris says he cant get up in the morning, cant
  be bothered, admits to poor appetite and
  skipping meals reports episode of difficulty
  getting a decent breath and had to leave
  grandmothers funeral 2weeks ago
• Say he used to feel that he was a strong bloke -
  now not so sure

12
Anxiety

• Common
• Often missed and often mixed with depression
• Patients with anxiety are high utilisers /
  frequent attenders
• May be associated with MUS

13
Anxiety

• Ask about anxiety whenever you are asking about
  depression
• Use HADS or GAD-7 not PHQ9 alone
• Think about
• PTSD in anxious patients
• Anxiety in patients who use alcohol
• Alcohol use in patients with anxiety

14
Management of anxiety symptoms

• Treatment
• Facilitating self-management (including
  reducing alcohol activity/exercise
  bibliotherapy)
• CBT (cCBT, group and one-to-one)
• Medication (avoid benzos except for short-term
  SSRIs)

15
Management within the consultation

• Advice and support
• Psycho-education explain panic cycle
• Exercise, breathing and relaxation
• Getting the balance right
• Problem solving
• Self help materials
• Phobias - face the fear exposure work
• Panic - face the fear education and practice

16
Panic cycle

• INTERNAL /
  EXTERNALTRIGGER
• PERCEIVED THREAT
• ANXIETY
• MISINTERPRETATION PHYSICAL / COGNITIVE
  SYMPTOMS
• Once panic attacks have occurred, at least
  three other factors contribute to the maintenance
  of the problem
• Selective attention to bodily events -
  hypervigilance
• In-situation safety behaviours
• Avoidance

17
Management - referral

• What services do you have locally for you to
  refer people to?
• Third sector
• Primary Care Mental Health Team
• IAPT

18
Reflections
19
Case

• A patient informs you that her 69 year old
  neighbour, Mr B, (who is also registered with
  your practice) has become withdrawn, miserable
  and is not looking after himself and has lost
  weight after the death of his wife.
• What would you do?

20
Depression

• Depression is common
• Most of it is managed in primary care
• Depression is major cause of worklessness
• Depression is associated with suicide
• Depression often co-exists with other physical
  morbidities
• High health and social care costs

21
But.

• Hugely variable phenomenon
• May not always be useful to label it depression
  
• Often mixed with anxiety / alcohol
• Think about each individual as having unique
  version of depression and thus a unique response

22
Diagnosis

• Clinical Intuition picking up patient cues
• Some groups of patients at risk
• Recent new major physical illness or hospital
  admission
• Chronic illness/Long term conditions
• In receipt of high levels of home care
• Recent bereavement
• Socially isolated people
• Those people persistently complaining of
  loneliness
• Patients complaining of persistent sleep problems

23
Main features of depressive disorder

• Core symptoms
• Depressed mood sustained for at least 2 weeks
• Loss of interest or pleasure in normal
  activities
• Decreased energy or increased fatigue
• Additional symptoms
• Loss of confidence or self-esteem
• Inappropriate and excessive guilt
• Recurrent thoughts of death, suicidal thoughts
  or behaviour
• Diminished evidence of ability to think,
  impaired concentration
• Change in psychomotor activity (inactivity or
  agitation)
• Sleep disturbance
• Appetite change and weight change

24
Diagnosis

• For mild depressive episode
• Two core symptoms
• At least four additional symptoms
• For moderate depressive episode
• Two core symptoms
• At least six additional symptoms
• For severe depressive episode
• All three core symptoms
• At least five additional symptoms
• May be presence of psychotic symptoms or stupor

25
Assessment of severity

• PHQ-9 or HADS
• GDS

26
Risk assessment

• Do you feel that things are so bad that you might
  harm yourself?
• Have you made any plans? Can you describe them to
  me?
• What stops you?

27
Risk assessment

• Useful formula
• Long term factors short term risk factors
  protective factors overall risk

28
What can you do in the consultation?

• NICE Depression update
• Assessment, referral, psycho-education, active
  monitoring and support
• Problem solving therapy
• Bibliotherapy / self-help materials
• Behavioural activation and diaries
• CBT approaches in general practice

29
Importance of the longitudinal relationship
30
Talking treatments

• Cognitive behaviour therapy (cCBT)
• Counselling
• Psychotherapy
• Interpersonal therapy
• Behavioural activation
• Family therapy
• ?? befriending

31
Talking treatments

• None of them (even CBT) is that good
• Hard to come by even with IAPT

32
Management-referral

• What services do you have locally for you to
  refer people to?
• Third sector
• Primary Care Mental Health team
• IAPT

33
Use of Antidepressants

• AD treatment is not that good and needs FU
• ADs dont work much better than placebo but
  that works well!
• Initial severity and Antidepressant benefits
  Kirsch et al 2008
• May invite passivity on the part of the patients
  how do you make treatment collaborative?

34
Antidepressants

• Wide range of antidepressants (19 or more
  available)
• Adequate trial of 6-8 weeks
• Previous response
• Side effects

35
Antidepressants

• SSRIs Fluoxetine, Sertraline, Paroxetine,
  Citalopram
• Tricyclics Amitriptyline, Imipramine,
  Clomipramine
• SNRIs Venlafaxine
• NASSe Mirtazepine
• Atypicals Trazodone

36
SSRIs

• Recommended first line antidepressants
• Side-effects
• Insomnia
• Agitation
• Gastro-intestinal symptoms
• Headache
• Fine tremors
• Sexual dysfunction
• Hyponatraemia

37
TCAs

• Not recommended as first line
• Side-effects
• Sedation
• Anticholinergic effects
• Orthostatic hypotension
• Weight gain
• Useful in low doses for chronic pain

38
Treatment resistance

• Older age
• Social isolation
• Psychological (loss)
• Organic (pain, chronic illness, anaemia, thyroid,
  drugs, alcohol, cerebrovascular disease)
• Consider bi-polar

39
What might secondary care offer?

• Mood stabilising agents
• Li
• Carbamazepine
• Quetiapine
• ECT

40
Models of care
41
Stepped care

• Stepped care the least intrusive intervention
  likely to make a difference
• Patients can be stepped up and down as necessary
• Principal of low intensity interventions
• Available in community
• In general practice
• As part of IAPT and condition management
  programmes

42
(No Transcript)
43
Principals of collaborative care

• Depression case manager providing co-ordinated
  care
• Algorithm / protocol of care
• Medication management
• Regular and timely access to specialist
• Pro-active, systematic and co-ordinated care

44
Reflections
45
Case

• Busy Monday morning surgery
• Mrs S attends again complaining of abdominal
  pain, tiredness and back ache. You see that the
  new GP Registrar investigated her (again) and
  every test has come back normal. Its getting me
  down, doctor.
• What are your thoughts?

46
MUS

• People with MUS make disproportionately heavy
  demands on health services
• Doctors explanations of symptoms are in conflict
  with patients perceptions
• Most individuals with MUS provide cues which
  allow GP to explore and address psychological
  needs
• History of sexual or physical abuse in childhood
  are linked to development of MUS

47
MUS

• Irritable bowel syndrome
• Functional dyspepsia
• Atypical chest pain
• Hyperventilation
• Irritable bladder
• Fibromyalgia
• Repetitive strain injury
• Chronic back pain
• Chronic pelvic pain
• Atypical facial pain

48
MUS

• Early investigation of physical symptoms in
  patients with MUS does not lead to reassurance
• Explanations from doctors aimed at empowering
  patients can result in the patient and doctor
  working collaboratively to manage the problem and
  reduce healthcare contacts

49
Management in the consultation

• Elicit concerns
• Acknowledge symptoms and distress
• Offer explanation that fits with patients beliefs
  and concerns
• ADs help if there is co-existing depression

50
Reattribution

• Four crucial steps
• Feeling understood
• Broadening agenda
• Making the link
• Negotiation over management

51
Reflections
52
Case

• Friday afternoon
• Mr Z attends for a review of his medication. He
  has diabetes, COPD and hypertension. He doesnt
  like tablets. All these things are getting me
  down he says.
• What are your thoughts?

53
Physical and psychological co-morbidity
(multi-morbidity)

• The physical illness impacts on the patients
  view of self and may lead to depression or
  anxiety
• Co-existing depression or anxiety may cause
  problems in self-care

54
Depression Screening questions

• During the past month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the past month, have you often been
  bothered by having little interest or pleasure in
  doing things?
• A yes to either question is considered a
  positive test.
• A no response to both questions makes
  depression highly unlikely.
• Is this something you want help with?

55
Evidence-based treatments

• Improving depression can improve outcomes (eg
  HbA1C in diabetes)
• Evidence is that psycho-social interventions will
  improve either depression or diabetes NOT both.

56
Evidence-based treatments

• Psychological treatments have been shown to be
  effective in secondary care not in primary care
• Some evidence for CBT and counselling
  (equivalent)
• Limited evidence for Psychodynamic Interpersonal,
  Interpersonal and Problem-Solving therapies

57
Management within the consultation

• Help the patient to use own resources to manage
  their illness
• Little evidence that ADs are useful (except in
  severe or persistent depression, or with previous
  Hx)
• Explanation and support
• Use of self-help materials

58
Management - referral

• What services do you have locally for you to
  refer people to?
• Third sector
• Primary Care Mental Health team
• IAPT

59
Reflections
60
Case

• Receptionist mentions that Mrs P talked abouther
  worries for her son. He dropped out of University
  and is sitting around all day at home (and
  smoking). Mrs P wonders what best thing is to do.
• What do you think?

61
Psychosis

• Psychosis usually heralded by a gradual
  deterioration in intellectual and social
  functioning
• GP recognition of early changes, clinical
  intuition and acting on family concerns are the
  key to early detection

62
Psychosis

• Psychosis is one of the most serious conditions
  that can affect a young person
• Suicide 10 lifetime risk
• 88 end up with NO job

63
Specific questions

• Have you felt that something odd might be going
  on that you cannot explain?
• Have you been feeling that people are watching
  you or talking about you?
• Have you been feeling, hearing or seeing things
  that other people have not?
• Have you felt important in some way, or that you
  have special powers?

64
Early Intervention

• Has been shown to improve outcomes
• REFER early

65
Reflections

• Do you know contact details for your Ei team?

66
Physical health is important

• People with schizophrenia and bipolar disorder
  die up to 25 years earlier than the general
  population
• Most premature deaths due to cardiovascular,
  respiratory and infectious diseases rather than
  suicide or injury

67
Risk factors

• Lifestyle
• Sedentary
• Poor diet
• Risk of diabetes
• Smoking cigarettes and cannabis
• Side-effects of medication
• Metabolic syndrome
• Less likely to complain of physical symptoms
• Discrimination
• Less likely to receive eye checks if diabetes
• Less likely to receive appropriate treatment for
  MI

68
What should be done?

• Assess cardiovascular risk factors
• BP, BMI, waist circumference
• Smoking
• Cholesterol, BS (particularly if on
  anti-psychotics)
• Provide advice about smoking, diet and activity
• Work with families

69
Reflections
70
Resources

• The National Institute for Health and Clinical
  Excellence Clinical Guideline on Depression
  (NICE, 2004).
• Update out for consultation (ended 21st april 09)

71
Other NICE guidance

• Anxiety
• Depression in Chronic Physical Health Problems
  (consultation ended april 21st 09)
• Schizophrenia
• OCD
• PD

72
Joint statement

• A collective responsibility to act now on
  ageing and mental health a consensus statement
• www.olderpeoplesmentalhealth.csip.org.uk/if

73
Primary Care Mental Health Forum

• A collaboration between Royal College of
  Psychiatrists and Royal College of General
  Practitioners
• http//www.rcpsych.ac.uk/mentalhealthinfo/mentalh
  ealthinprimarycare.aspx

74
Thank you for listening!

• Any questions?
• cchew_at_manchester.ac.uk