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Everything you need to know about Mental Health in 60 minutes…. Dr Tom Tasker GP with Special Interest in Mental Health NHS Salford . Overview. Antidepressants New NICE guidance Improving Access To Psychological Therapies (IAPT) Stepped Care Model Physical health in SMI Case Studies.

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everything you need to know about mental health in 60 minutes

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

Dr Tom Tasker

GP with Special Interest in Mental Health NHS Salford

overview
Overview
  • Antidepressants
  • New NICE guidance
  • Improving Access To Psychological Therapies (IAPT)
  • Stepped Care Model
  • Physical health in SMI
  • Case Studies
slide3

When – Depression

  • Mild (PHQ-9: < 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 comb’n of AD + Psychological therapy
slide4

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
slide5

When – Depression/anxiety

  • If depression is accompanied by marked anxiety….
  • TREAT DEPRESSION FIRST
  • Consider AD as appropriate
draft nice guidance re ads
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)
draft nice guidance for ads
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
draft nice guidance for ads8
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
which depression salford
Which – Depression (Salford)
  • 1st line:
    • Sertraline
  • 2nd line
    • Change class
      • Mirtazapine
      • Venlafaxine
      • Duloxetine
which anxiety salford
Which – Anxiety (Salford)
  • 1st Line
    • Citalopram
  • 2nd line
    • Escitalopram
    • Venlafaxine
slide11

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 75–225mg £10 - £30
good prescribing tips
Good prescribing tips
  • Considerations
    • Length of initial prescription
    • Toxicity in overdose
    • When to review
    • Careful in < 30 years old
slide13

Good prescribing tips

  • How often to review?
    • (1) week
    • 2 weeks
    • 4 or 5 weeks
    • 8 weeks
    • 12 weeks
    • 1 – 2 monthly thereafter
slide14

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
good prescribing tips15
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)
good prescribing tips16
Good prescribing tips
  • Tricyclics
    • Avoid subtherapeutic doses
    • Helps anxiety symptoms but not depression
  • Avoid dosulepin altogether
    • No new initiations
    • Consider switching
slide18

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
slide19

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

  • D £173 million
slide20

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
slide21

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)
slide22

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)
slide23

Low Intensity Workers

  • Low intensity interventions

- Medication management

    • Behavioural activation
    • Problem-solving
    • Guided self-management
    • Brief CBT
    • Signposting
  • 4 – 6 sessions x 30 minutes
slide25

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
slide27

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
slide28

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
slide29

Cardiovascular Risk Factors and Schizophrenia

1Davidson et al. Aust NZ J Psychiatry. 2001;35:196–202;2Herran et al. Schizophr Res. 2000;4:373–381; 3Dixon et al. Schizophr Bull. 2000;26:903–912;4Kato et al. PrimCare Companion J Clin Psychiatry. 2005;7:115–118

slide30

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

slide32

70

59.6

60

50

50

40

Prevalence (%)

28.1

30

22.4

20

10

6.2

4.6

0

Overweight

Obese

Healthy

Overweight

Obese

Healthy

BMI 25–29.9

BMI ≥30

BMI <25

BMI 25–29.9

BMI ≥30

BMI <25

Men

Women

Prevalence of Metabolic Syndrome According to BMI

n=12,363

BMI = Body Mass Index

Park et al. Arch Intern Med. 2003;163:427–436

slide33

Prevalence of Obesity is Increased in Schizophrenia

Schizophrenia

No schizophrenia

30

Normal weight

25

Overweight

Obese

20

Percentage

15

10

5

0

<20

20–22

>22–25

>28–30

>30–33

>33–35

>35

>26–28

>24–26

BMI category

BMI = Body Mass Index

Allison et al. J Clin Psychiatry. 1999;60:215–220

slide34

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

***p<0.001 vs. patients without metabolic syndrome

CV = Cardiovascular

Isomaa et al. Diabetes Care. 2001;24:683–689

slide35

Prevalence of Diabetes in Schizophrenia vs. General Population

Prevalence (%)

15–35

25–35

35–45

45–55

55–65

Age range (years)

n=415 patients with schizophrenia

De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14

slide36

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 > 75 yrs
slide37

Osborn et al, Arch Gen Psychiatry Feb 2007

  • For stroke deaths, the HRs were:
  • 2.53 (95% CI, 0.99-6.47) for those < 50 yrs
  • 1.89 (95% CI, 1.50-2.38) for 50 - 75 yrs
  • 1.34 (95% CI, 1.17-1.54) for > 75 yrs
slide38

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
slide39

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
slide40

Mental Health Indicator 9 -Annual Physical Health Check

  • Alcohol & drug misuse
  • Smoking
  • BMI/waist circumference
  • BP
  • Diabetes screening
  • Lipid profiles in patients
    • > 40 years
    • Those on atypical antipsychotics
slide41

Mental Health Indicator 9 -Other issues to consider

  • Cervical Screening
  • Dental & Eye Care
  • Imms & Vaccs
  • Medication compliance & side effects
slide42

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 patient’s preferred course of action in event of relapse
  • Social situation
    • CAB, Welfare, Benefits
slide43

Salford Initiatives

  • Shared Care Protocol for Atypical Antipsychotics
  • Tackling DNA rates for physical health checks
slide44

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)
slide45

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
slide46

Follow up of DNA’s

  • 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
slide48

“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
    • Don’t like attending GP surgeries
      • Don’t like environment
      • Stigmatised
      • Physical symptoms attributed to SMI
      • Not listened to
slide49

Survey

  • Service User Representative:
    • Wider report to looked at:
      • How to deliver promotional campaign:
        • raise awareness
        • education
      • Check out why they won’t attend GP
      • How to facilitate attendance at GP surgeries
      • Types of interventions they want to see at CMHT level
results of survey
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
    • >90% of checks done at GP surgery
    • Reassured – GP knows about physical health
    • Barriers:
      • Getting appointment
      • GP running late
slide51

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
slide52

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
slide53

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
slide54

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)
slide55

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)
slide56

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
slide57

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
slide58

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