LONG TERM CONDITIONS AND MENTAL HEALTH

1. LONG TERM CONDITIONS AND MENTAL HEALTH Dr. Justin Shute Liaison Psychiatry Consultant MRCPsych MRCP

2. LTCs MH PROBLEMS 46% (c.4.6m) of those with a mental health problem have an LTC 30% (c. 4.6m) of those with an LTC have a mental health problem Naylor Parsonage et al 2012 based on Crimpean and Drake 2011

3. People with LTCs 2-3 X more Likely to have Mental Illness • Depression 2-3 X more common in cardiac disease, coronary artery disease, stroke, angina, congestive heart failure, or following a heart attack • Fenton and Stover 2006; Benton et al 2007; Gunn et al 2010; Welch et al 2009 • Prevalence between 20 & 50% • But 2-3 X increase compared with controls is consistent across studies

4. People with LTCs 2-3 X more Likely to have Mental Illness • Diabetes 2-3 X more likely to have depression than the general population • Fenton and Stover 2006; Simon et al 2007; Vamos et al 2009 • Chronic obstructive pulmonary disease 3 X more mental illness than general population • NICE 2009 • Anxiety disorders are very common; panic disorder 10 X • Livermore et al 2010 • World Health Surveys: 2 or more LCTs 7X more likely to have depression than people without LCT • Moussavi et al 2007

5. Does It Really Matter ? • Cardiovascular patients with depression experience 50% more acute exacerbations per year and have higher mortality rates • Katon 2003 • Depression leads to 2-3 X negative outcomes for people with acute coronary syndromes • Barth et al 2004 • Depression increases mortality rates after heart attack by 3-5 X • Lesperance et al 2002

6. Does It Really Matter ? • 2 X mortality after heart bypass surgery over an average follow-up period of 5 years • Blumenthal et al 2003 • Chronic heart failure 8 X more likely to die within 30 months if they have depression • Junger et al 2005 • People with diabetes & depression 36-38% increased risk of all-cause mortality over a 2 year follow-up period • Katon et al 2004 • Poorer glycaemic control, more diabetic complications and lower medication adherence • Das-Munshi et al 2007

7. Does It Really Matter ? • Relationship between LTCs and mental illness is exacerbated by socio-economic deprivation: • greater proportion of people in poorer areas have multiple long term conditions • effect of this multi-morbidity on mental health is stronger when deprivation is also present

8. Why are Outcomes Worse ? • Co-morbid mental health problems impair active self-management • Reduced motivation and energy for self-management leads to poorer adherence to treatment plans DiMatteo et al 2000 • Cardiac patients, depression increases adverse health behaviours (eg. physical inactivity) and decrease adherence to self-care regimens such as smoking cessation, dietary changes and cardiac rehabilitation programmesBenton et al 2007; Katon 2003 • Poorer dietary control and adherence to medication Vamos et al 2009

9. Prevention • Befriending • Debt advice • Wellbeing in the workplace initiatives • Knapp et al 2011 Hampered by “hard wired separation of physical and mental health care”

10. Principles for Assessment • When assessing a patient with a chronic physical health problem who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. • Take into account: • the degree of functional impairment and/or disability associated with the possible depression and • the duration of the episode.

11. The stepped-care model Focus of the intervention Nature of the intervention Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care STEP 4: Severe and complex1 depression; risk to life; severe self-neglect STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions STEP 1: All known and suspected presentations of depression Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions 1,2 see slide notes

12. Case identification and recognition • Be alert to possible depression • Particularly in patients with a past history of depression or • a chronic physical health problem with associated functional impairment. • Consider asking patients who may have depression two questions, specifically: • During the last month, have you often been bothered by feeling down, depressed or hopeless? • During the last month, have you often been bothered by having little interest or pleasure in doing things?

13. Low-intensity psychosocial interventions • For patients with: • persistent sub-threshold depressive symptoms or mild to moderate depression and a chronic physical health problem • Sub-threshold depressive symptoms that complicate care of chronic physical health problem • Consider offering one or more of the following interventions, guided by patient preference: • structured group physical activity programme • group-based peer support (self-help) programme • individual guided self-help based on CBT • computerised CBT.

14. Treatment for moderate depression • For patients with initial presentation of moderate depression and a chronic physical health problem: • offer the following choice of high intensity psychological interventions: • group-based CBT or • individual CBT or • behaviouralcouples therapy.

15. Antidepressant drugs (1) • Do not use antidepressants routinely for sub-threshold depressive symptoms or mild depression in patients with a chronic physical health problem • Consider antidepressants for people with: • a past history of moderate or severe depression or • mild depression that complicates the care of the physical health problem or • Sub-threshold depressive symptoms present for a long time or • Sub-threshold depressive symptoms or mild depression that persist(s) after other interventions.

16. Antidepressant drugs (2) • When an antidepressant is to be prescribed, tailor it to the patient, and take into account: • additional physical health disorders • side effects, which may impact on the underlying physical disease • lack of evidence supporting the use of specific antidepressants for people with particular chronic physical health problems • interactions with other medications.

17. What is collaborative care? Four essential elements • collaborative definition of problems • objectives based around specific problems • self-management training and support services • active and sustained follow up

18. Collaborative Care • Consider collaborative care for patients with: • moderate to severe depression • a chronic physical health problem with associated functional impairment whose depression has not responded to: • initial high-intensity psychological interventions or • pharmacological treatment or • a combination of psychological and pharmacological interventions.

19. Detection • > 90% of people with depression alone were diagnosed in primary care • Depression detected < 25%among people with LTC • Bridges and Goldberg 1985 • Majority of cases of depression among people with physical illnesses go undetected and untreated • Cepoiu et al 2008; Katon 2003 • Active case-finding in people with LTCs needed • NICE 2010

20. Treatment • Standard interventions eg. antidepressants or CBT are effective • Fenton & Stover 2006; Yohannes et al 2010, Ciechanowski et al 2000 • Psychological therapy was associated with reduced emergency department attendance • De Lusigman et al 2011 • Treating co-morbid mental illness by itself doesn’t always translate into improved physical symptoms • Cimpean & Drake 2011; Benton et al 2007; Perez-Prada 2011

21. Integration • Integrating treatment for mental health and physical better than overlaying mental health interventions • Fenton & Stover 2006; Yohannes et al 2010 • Adding a psychological component to COPD rehab programmes: improved completion rates and reduced re-admissions for COPD • Abell et al 2008 • CBT-based disease management programme for angina = 33% fewer hospital admissions in following year, saving £1,337 per person • Moore et al 2007

22. Stepped Care

23. What Can GPs Do ? • Identify patients with co-morbidity • Help patients recognise mental health problems • Help patients understand links between LTC and mental health problems • “hard-wired separation of physical and mental care” • Monitor uptake of psychological services by people with LTCs • Identify successful and unsuccessful referral pathways • Build relationships between physical and mental healthcare professionals

24. Monitoring and Follow Up • See patients started on antidepressants not at risk of suicide • after 2 wks, • every 2 - 4 wks for next 3 mths • less frequently if response is good. • If < 30 yrs (increased risk on anti depressants) see • after 1 wk • less frequently thereafter until no longer risk • If at increased suicide risk, refer

25. Side Effects If side effects develop: • monitor symptoms closely and stop anti depressant if patient finds side effects unacceptable or change if the patient prefers; or • If mild anxiety/insomnia/agitation consider benzodiazepine for 2 wks max. • Caution for those • at risk of falls; or • with chronic anxiety

26. When to refer • Concerns about risk • Inadequate response to psychological interventions • Inadequate response to 1 or 2 antidepressants • Atypical / complicated presentation • “Gut feeling” • Severity and risk will determine urgent or routine referral

27. Where can I find out more? • Pack for good practice and recovery information • BEHMHT GP Intranet site – includes our more detailed treatment guidelines • PCA web resources – in development • NICE Guidance • RCPsych website