Common mental health disorders: identification and pathways to care

1. Common mental health disorders: identification and pathways to care Implementing NICE guidance within primary care 2011 NICE clinical guideline 123

2. What this presentation covers • Scope • Background • Key recommendations for implementation Primary care costs avoided and benefits Discussion • Find out more

3. Scope • The guideline aims to improve access to care and the identification and recognition of common mental health disorders, and provide advice on principles for local care pathways. Advice from existing NICE guidelines has been combined with new recommendations on access, assessment and local care pathways. • Common mental health disorders include depression, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder.

4. Epidemiology • 15% of the population are affected by common mental health disorders • Women are 1.5 to 2.5 times more likely to experience depression than men • 34% of South Asian women have a common mental health disorder compared with 10% of South Asian men

5. Background • Depression is a leading cause of disability – and it is projected to become the second most common cause of loss of disability-adjusted life years in the world • Only a small minority of people who experience anxiety disorders receive treatment • Recognition of anxiety disorders in primary care is particularly poor

6. Abbreviations used • CBT - cognitive behavioural therapyERP - exposure and response preventionEMDR - eye movement desensitisation and reprocessingGAD - generalised anxiety disorderOCD - obsessive compulsive disorderIPT - interpersonal psychotherapyPTSD - post-traumatic stress disorderA full glossary of terms used in the guidance can be foundalongside this slide set on the NICE website

7. Key priorities for implementation Areas identified as key priorities for implementation: • Identification • Improving access to services • Developing local care pathways

8. Identification: depression Be alert for possible depression, particularly in those with a past history or possible somatic symptoms of depression, or a chronic physical health problem Consider asking: • 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?

9. Identification: anxiety 1 • Be alert to possible anxiety disorders, particularly in those with a past history or possible somatic symptoms of an anxiety disorder, or who have experienced a recent traumatic event. • Consider asking about feelings of anxiety and the ability to stop or control worry, using the GAD-2 scale.

10. Identification: anxiety 2 Consider asking: • Over the last two weeks, how often have you been bothered by the following problems? • Feeling nervous, anxious or on edge • Not being able to stop or control worrying GAD-2 is the first two questions of the GAD-7 scale The GAD-7 tool was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

11. Identification: anxiety 3 • Score of 3 or more consider an anxiety disorder and follow the recommendations for assessmentScore of less than 3 but you still have concerns that the person may have an anxiety disorder ask: Do you find yourself avoiding places or activities and does this cause you problems? N.B. The scoring of more or less than 3 applies to the use of the two GAD-2 questions

12. Identification • For significant communication difficulties, consider using the Distress Thermometer and/or asking a family member or carer about the person’s symptoms If identification questions indicate a common mental health disorder, a competent practitioner should perform a mental health assessmentIf this professional is not the person’s GP, informthe GP of the referral

13. Assessment Consider using: • A diagnostic or problem identification tool, for example the Improving Access to Psychological Therapies (IAPT) screening prompts tool • A validated measure relevant to the disorder to informassessment and support evaluation of interventions: - 9-item Patient Health Questionnaire (PHQ-9) - Hospital Anxiety and Depression Scale (HADS) - 7-item Generalized Anxiety Disorder scale (GAD-7) • Ask directly about suicidal ideation and intent

14. Assessment: core components • Staff conducting assessments should be able to:- determine the nature, duration and severity of the presenting disorder- take into account symptom severity and associated functional impairment- identify appropriate treatment and referral options in line with relevant NICE guidance • Consider factors that may affect the development,course and severity of a person’s presenting problem:- history of mental health disorder or chronic physical health - past experience and response to treatments - quality of interpersonal relationships - living conditions and social isolation

15. Severity of common mental health disorders: definitions • Mild relatively few core symptoms, a limited duration and little impact on day-to-day functioning • Moderate all core symptoms of the disorder plus other related symptoms, duration beyond that required by minimum diagnostic criteria, and a clear impact on functioning • Severe most or all symptoms of the disorder, often of long duration and with very marked impact on functioning • Persistent subthreshold symptoms and associated functional impairment that do not meet full diagnostic criteria but have a substantial impact on a person’s life, and which are presentfor a significant period of time

16. Stepped-care model

17. Improving access to services Collaborate to develop local care pathways that: • support integrated delivery across primary and secondary care • have clear and explicit entry criteria • focus on entry and not exclusion criteria • have multiple means and points of access,including self-referral • have a designated lead to oversee care • promote access for people from sociallyexcluded groups

18. Developing local care pathways:1 Design local care pathways that promote a stepped-care model of integrated delivery to: • provide least intrusive, most effective interventions first • have explicit criteria for different levels of intervention • not base movement between levels on a single criteria • monitor progress and outcomes • minimise the need for transition between services • establish clear access and entry points • have designated staff responsible for coordinationof care

19. Developing local care pathways: 2 Develop protocols for communicating information: • for service users about their care • with other professionals (including GPs) • between services within the pathway • to services outside the pathway Robust systems should be in place to ensure routine reporting of outcomes

20. Primary care costs avoided and benefits • Due to variation in current practice, it is not possible to quantify the national cost impact of the NICE recommendations.The following areas may incur savings through drug costs avoidedby meeting additional demand with treatments such as talking therapies.

21. Interventions for anxiety: potential costs

22. Interventions for depression: potential costs

23. Discussion • How are diagnostic or problem identification tools used in primary care?What audit activity reviews their use? • How do our care pathways compare with the NICE guidance? • What methods are used to review service user treatment outcomes? • How can we address cases where there is persistent subthreshold CMHD symptoms?

24. Find out more • Visit www.nice.org.uk/guidance/CG123 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • baseline assessment • Resource for primary care • online educational tools

25. Presenter notes • The previous slide marks the end of the presentation;slides from this point on are for use by the presenter. For information, the stepped-care table on slide 16 contains action buttons that link to more detailed content (which is stored within slides 25-28).Action buttons only operate when the presentationis in slide show view. The presenter will need to click on a hyperlink to access the further detail.

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27. Stepped care: depression Back tostepped caretable

28. Stepped care: GAD and panic disorder Back tostepped caretable

29. Stepped care: obsessive-compulsive disorder Back tostepped caretable

30. Stepped care: post-traumatic stress disorder Back tostepped caretable