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Title: Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice


1
Management of Depression in Primary CareDr
Carole McIlrathSenior Professional
OfficerNorthern Ireland Practice Education
Council
2
BACKGROUND
3
DEPRESSION
  • many mood disorders with varying severity,
    symptoms and persistence
  • dysthymia, major depressive disorder, bipolar
    disorder, psychotic depression, post-partum
    depression seasonal affective disorder
  • leading cause of disability worldwide (121
    million)
  • 70 of recorded suicides
  • psychiatric disorder 90 of suicide victims

4
INCIDENCE
  • Taiwan - 0.8 cases per 100 adults
  • 5.8 - New Zealand
  • 6 - Australia
  • 5 - 10 - UK
  • 10 - USA
  • 23.5 - Japan

5
NORTHERN IRELAND
  • 21 aged over 16
  • 24 women 17 men
  • mental health needs 25 ? than England
  • Prescriptions
  • anti-depressants 37 ?,
  • psychosis related disorders 66 ?
  • hypnotics anxiolytics 75 ?

6
CO-MORBIDITY
  • cancers
  • 4.5 to 58
  • cardiovascular disorders
  • myocardial infarction 20-30
  • chronic conditions
  • asthma diabetes 50
  • neurological disorders
  • Parkinsons Disease 40-50
  • Stoke 16-60
  • GPs
  • three times more likely to miss major depression
    in minor physical illness
  • five times more likely to miss major depression
    in serious physical
  • illness

7
POLICY CONTEXT
  • increasing recognition of mental illness
  • major public health issue
  • emphasis on promotion of mental emotional
    health
  • 30 years refocusing of service provision away
    from hospital settings towards community care
  • Greater understanding of mental illnesses
  • developments in psychopharmacology
  • changes in social policy
  • vast array of legislative change
  • Sex Discrimination Act 1975 Race Relations Act,
    1976 Mental Health Act, 1983 Disabled Persons
    Act, 1999 NHS Community Care Act, 1990

8
PRIMARY CARE
  • early 1990s - the development of primary care
  • support mental health services
  • improve collaboration between secondary care
    primary care professionals
  • potential for early detection, intervention,
    utilisation of voluntary sector organisations and
    mental health promotion
  • to support this - NSF for Mental Health
  • set national standards and defined service models
  • seven standards - first three relevant to and
    promote the development of primary care mental
    health services
  • NI has lagged significantly behind developments

9
NORTHERN IRELAND
  • regional strategic objectives highlighted mental
    health as a priority for action
  • Health and Well-Being into the Millennium (97-02)
  • Health and Social Well Being Survey (02)
  • Programme for Government (NIE, 02)
  • Investing for Health Strategy (02)
  • Promoting Mental Health Strategy Action Plan
    (03)
  • Bamford Review of Mental Health (05 06)
  • each individual with a mental health problem
    should be given the opportunity to have their
    mental health needs understood and addressed
    promptly within primary care settings, taking
    into account biological, psychological and social
    dimensions

10
PRIMARY CARE
  • It is the first level of contact of individuals,
    the family
  • and community with the national health system
    bringing
  • health care as close as possible to where people
    live and
  • work, and constitutes the first element of a
    continuing
  • health care process
  • (WHO, 1978)

11
Membership of the primary care team
Medical Paramedical Administrative Therapists Social
General practitioner Community nurse Practice manager Physiotherapist Social worker
Dentist Practice nurse Receptionist Chiropodist Community psychiatrist
Community geriatrician Ophthalmic optician Assistant Speech therapist Psychologist
School medical officer Midwife Secretary Osteopaths Counsellor
Health visitor Dietician Domiciliary aid
Pharmacist
12
  • Almost 20,000 people actively involved in the
    provision
  • of primary care services
  • 1,200 GPs
  • 5,000 Nurses
  • 250 Midwives
  • 700 Dentists
  • 1,000 Community Pharmacists
  • 1,000 Allied Health Professionals
  • 500 Optometrists
  • 4,000 Social Workers and
  • 6,000 Home-helps.
  • Source DHSSPS (2005)

13
PRIMARY CARE
  • ? 90 cared for and managed
  • ? 50 of attendees from depression
  • patients present with ? somatised medical
    problems
  • nearly three times the consultation rates
  • ? suicide link
  • variations
  • 50 missed
  • ? 10 spent

14
PROFESSIONAL ISSUES
  • Primary care nurses increasingly involved in
    identifying, assessing and caring for people with
    depression
  • little time allocated
  • often untrained unsupported
  • CMHNs - mild or moderate mental illness
  • widely accepted in April 1993 - GP fund-holders
  • CMHNs well regarded
  • many GPs favour closer liaison
  • much criticism however
  • at risk of abandoning most vulnerable SMI
  • little attention paid to their selection
    preparation
  • many torn between the demands of GPs and their
    employing Trust

15
RESEARCH
  • Recommendations from
  • Bamford Review of MH LD (DHSSPS, 2005)
  • New GP Contract (BMA NHS Confederation, 2004)
  • ideal vehicles for developing primary care
    depression services, some nurse-led.
  • Nonetheless,
  • clarity of roles responsibilities
  • gaps in the knowledge training of primary care
    nurses
  • no consensus on what standards, guidelines or
    benchmarks constitute an effective primary care
    based nursing service for adults with depression.
  • develop, support and guide their practice
  • benchmark a standard to judge or measure
    something against

16
Research Questions
  • 1. What are the most appropriate benchmarks for
    an effective
  • primary care based nursing service for adults
    (18-64 years)
  • with depression?
  • 2. To what extent do existing primary care based
    nursing
  • services for adults with depression in Northern
    Ireland conform
  • to these benchmarks?
  • 3. What are the best strategies for enhancing
    existing primary
  • care based nursing services for adults with
    depression?

17
Design Methodology
  • Exploratory survey design
  • Qualitative approach multiple methods
  • Two phases
  • Ethical Issues

18
Phase One
  • Delphi technique
  • Purposive Sampling
  • Inclusion criteria
  • 84 potential experts
  • 67 (80)
  • Mental Health Nurses (n36)
  • Health Visitors (n9)
  • Practice Nurses (n2)
  • GPs (n16)
  • Psychiatrists (n4)

19
Pilot Study
  • Questionnaire
  • Content and face validity
  • 10 professionals
  • 100 response
  • Minor adjustments
  • Layout
  • Design
  • Content

20
Findings
  • Round One Questionnaire
  • 96 response rate
  • 53 post / 47 email
  • 1216 statements
  • 239 benchmarks
  • 3 categories

21
Benchmarks
  • Structures 126
  • a primary care based depression service should
    support and utilise guidelines which have been
    modified for local circumstances (NICE)
  • protected time should be provided to primary care
    practitioners to manage depression, attend
    reviews, supervision sessions and education
    programmes related to depression services
  • all practice nurses should have attended at least
    a one day training course on depression

22
Benchmarks
  • Processes 70
  • Structured assessments should be completed by
    primary care practitioners using validated rating
    scales to diagnose depression (PHQ-9, HADS,
    EPNS)
  • Clients with depression should have access to and
    choice of a range of support/treatments following
    a clear stepped care model
  • Interventions provided in primary care should be
    structured, time limited, evidenced based and
    adapted for use in a busy primary care setting
    (CBT)

23
Benchmarks
  • Outcomes 43
  • There should be an increase in the number of
    primary care nurses with the training and skills
    to assist in the management of clients with
    depression
  • There should be a reduction in the amount of time
    clients with depression have to wait for
    psychotherapeutic interventions
  • There should be a reduction in the number of
    episodes of relapse of depression

24
  • Round Two Questionnaire
  • 95 response rate
  • 26 post / 74 email
  • consensus 70
  • descriptive statistics
  • 22 benchmarks

25
  • Round Three Questionnaire
  • 95 response rate
  • 10 post / 90 email
  • consensus 70
  • descriptive statistics
  • consensus - 22 51 benchmarks
  • 45 (61) structures
  • 18 (25) processes
  • 10 (14) outcomes

26
PHASE TWO
  • Multiple Methods - triangulation
  • Interviews
  • Observation
  • Document analysis
  • Stratified purposive
  • Content Analysis

27
BENCHMARKING TOOLKIT
  • Practice Manager

No Benchmark Evidence Guidance
1.2 Enhanced depression services should be provided by all primary care teams and rewarded within the Quality Outcomes Framework QOF Contract for enhanced services Inspect specification. Check register, annual reviews, relevant audits
2.2 Primary care depression services should support and utilise guidelines which have been modified for local circumstances (NICE) Guidelines Protocols Inspect guidelines protocols followed to identify, manage, treat and refer
28
BENCHMARKING TOOLKIT
  • GPs, Nurses, Health Visitors

No Benchmark Evidence Guidance
8.7 Protected study time should be available to primary care practitioners to allow for training and updates in managing depression Courses updates Training education records Interview pc practitioners Describe any protected study time for depression management. If none, what are the main barriers?
15.2 Structured assessments should be completed by primary care practitioners using validated rating scales/tools to diagnose depression (PHQ-9, HAD, EPNS) Assessment policy/protocols Interview pc practitioners Describe how you carry out an assessment? What screening tools do you use?
29
FINDINGS
  • 42 primary care professionals
  • eight primary care practices
  • 2 from each of the Board areas.
  • This included
  • GPs (n8), practice managers (n8), practice
    nurses (n8), nurse practitioners (n2), health
    visitors (n8) CMHNs (n8)

30
  • Primary care nurses view the provision of
    depression care as part of
  • their role
  • all practice nurses (87.5, n7) and one nurse
    practitioner (50) reported that they provided a
    limited role in the care of patients with
    depression and did not view further depression
    care as part of their current role
  • These views reflected the responses from three
    quarters of the GPs (n6) interviewed. They also
    viewed practice nurses and nurse practitioners as
    having a limited role in the care of patients
    with depression. They suggested that mental
    health nursing services should be provided by the
    Trusts rather that GPs.
  • Potential barriers perceived by practice nurses
    and nurse practitioners preventing greater
    involvement in depression care included
    insufficient time (70, n7) a lack of knowledge
    and confidence (70, n7) and a lack of GP
    support (80, n8).

31
  • There are adequate levels of primary care nurses
    to enable effective
  • involvement in depression services
  • Three quarters of health visitors (n6) reported
    that they felt current levels were inadequate to
    deal with post natal depression due to current
    work pressures.
  • All practice nurses (n8) and nurse practitioners
    (n2) interviewed reported inadequate numbers to
    enable them to take on new roles in depression
    care.
  • All CMHNs (n8) suggested that current levels of
    primary care nurses were inadequate to deal with
    the high prevalence of depression in primary
    care. Six (75) CMHNs indicated that they were
    being referred patients with less serious levels
    of depression who they thought should be managed
    by practice nurses. Five (62.5) reported that
    more CMHNs or mental health nurses dedicated to
    primary care were needed to ensure patients were
    treated as early as possible following a
    diagnosis of depression. Concerns were expressed
    relating to a possible dilution of the CMHN role
    and diversion of resources for the care of people
    with severe mental illness due to the demands of
    a group of people described as less seriously
    ill.

32
  • Alternative service delivery models are used by
    primary care nurses to support patients with
    depression
  • Most practice nurses (75, n6) and all nurses
    practitioners (n2) interviewed referred to
    face-to-face consultations at the practice.
    Services provided within these consultations
    included, health promotion, basic screening,
    provision of information and advice and referral
    to the GP for follow up if appropriate. The two
    practice nurses (25) reported using telephone
    follow up, but this was only provided
    occasionally.
  • Six (75) CMHNs reported that their main method
    of service delivery involved outpatient
    appointments or home visits. However, the CMHN
    attached to primary care and one other CMHN, who
    was employed by a community mental health trust,
    reported that they provided mental health triage
    as an alternative method of service delivery.

33
  • The main barriers perceived by participants
    preventing the use of alternative service
    delivery models include the following a lack of
    opportunity for primary care nurses to be
    involved in depression care (26.9 n7) a lack
    of knowledge of available models (69.2, n18)
    funding and resources to lead and develop new
    models within primary care (80.7, n21) support
    from GPs and managers (88.4, n23) and a lack
    of relevant personnel to supervise specific
    programmes, for example, computer based therapy
    programmes (46.1, n12).

34
  • Primary care nurses are able to carry out a basic
    assessment to detect depression
  • Primary care nurses have knowledge of the causes,
    symptoms of depression and influences of
    co-morbidity
  • Primary care nurses have knowledge of relevant
    local statutory, voluntary and private services
    for patients with depression
  • Primary care nurses have knowledge of local
    guidelines/protocols for drug treatments and
    therapeutic doses/side effects

35
  • Primary care nurses are competent at assessing
    suicide risk
  • Primary care nurses have an identified level of
    depression training and competency
  • There is regular continuous professional
    development (CPD) for primary care nurses on the
    recognition and management of depression
  • most practice nurses (87.5, n7), nurse
    practitioners (100, n2), health visitors (63,
    n5) and CMHNs (75, n6) reported a lack of
    regular CPD on the recognition and management of
    depression. Barriers identified included lack of
    time, support from management and availability of
    courses.

36
  • Protocols for the recognition, treatment,
    management and referral of patients with
    depression are used by primary care nurses

37
  • A range of evidence based treatment interventions
    are
  • provided by primary care nurses to patients with
  • depression
  • Three quarters of practice nurses (n6) and all
    nurse practitioners (n2) saw their most
    important treatment intervention as listening to
    patients and letting them discuss their worries
    or problems. The other relevant treatment
    interventions most commonly reported included
    basic counselling (40, n4) and referral to the
    GP (90, n9).
  • The treatment interventions CMHNs reported using
    included case management (62.5, n5) marital,
    bereavement and general counselling (75, n6)
    psychosocial interventions (50, n4) anxiety
    management (50, n4) and CBT (25, n2).

38
Summary of benchmarks met by each practice
Practice Benchmarks Met Benchmarks Not Met
Practice A 42(58) 31 (42)
Practice B 39 (53) 34 (47)
Practice C 45 (61) 28 (39)
Practice D 37 (51) 36 (49)
Practice E 36 (49) 37 (51)
Practice F 37 (51) 36 (49)
Practice G 41 (56) 32 (44)
Practice H 47 (64) 26 (36)
39
Recommendations
  • Investment/enhanced
  • Priority
  • Primary care team/lead
  • All practitioners
  • Early intervention
  • Training/time
  • Partnerships/protocols

40
SERVICE MODEL
41
NEW MODEL
42
Contact Details
  • carole.mcilrath_at_nipec.n-i.nhs.uk
  • 028 90238152
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