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

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Management of Depression in Primary CareDr
Carole McIlrathSenior Professional
OfficerNorthern Ireland Practice Education
Council
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BACKGROUND
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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

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INCIDENCE

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

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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 ?

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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

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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

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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

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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

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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)

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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
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• 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)

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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

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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

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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

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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?

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Design Methodology

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

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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)

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Pilot Study

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

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Findings

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

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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

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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)

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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

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

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• 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

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PHASE TWO

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

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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
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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?
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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)

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• 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).

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• 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.

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• 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.

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• 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).

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• 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

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• 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.

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

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• 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).

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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)
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Recommendations

• Investment/enhanced
• Priority
• Primary care team/lead
• All practitioners
• Early intervention
• Training/time
• Partnerships/protocols

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SERVICE MODEL
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NEW MODEL
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Contact Details

• carole.mcilrath_at_nipec.n-i.nhs.uk
• 028 90238152