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

When – Depression



Mild

– – (PHQ-9: < 10)

Avoid

Unless: – Past h/o severe depression – Not responding to other interventions 

Moderate

– –

Consider

(PHQ-9: 10 Discuss with patient – 19) 

Severe

– – (PHQ-9: 20+)

Encourage

to take Evidence best for comb’n of AD + Psychological therapy

When – Anxiety Disorders

 Mild/moderate – Avoid – Psychological Therapy 1 st line (NICE)  Moderate/severe – – Consider if loss of function Should be an adjunct to Psychological therapies

When – Depression/anxiety

 If depression is accompanied by marked anxiety….



TREAT DEPRESSION FIRST

 Consider AD as appropriate

Draft NICE guidance re ADs

 Generic SSRI 1 st 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

 2 nd 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 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)

 1 st line: – Sertraline  2 nd line – Change class  Mirtazapine  Venlafaxine  Duloxetine

Which – Anxiety (Salford)

 1 st Line – Citalopram  2 nd line – Escitalopram – Venlafaxine

Cost per monthly prescriptions  Fluoxetine 20mg  Citalopram 20mg  Sertraline 50mg  Escitalopram 10/20mg  Mirtazapine 30/45mg   Duloxetine 60mg Venaxx/venlalic 75 –225mg 69p £1.24

£1.37

£15/£25 £3.28 - £19 £27.72

£10 - £30

Good prescribing tips

 Considerations – Length of initial prescription – Toxicity in overdose – When to review – Careful in < 30 years old

Good prescribing tips

 How often to review?

– (1) week – 2 weeks – 4 or 5 weeks – 8 weeks – 12 weeks – 1 – 2 monthly thereafter

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 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 tips

 Tricyclics – Avoid subtherapeutic doses – Helps anxiety symptoms but not depression 

Avoid dosulepin altogether

– – No new initiations Consider switching

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

A £173,000  B £1.73 million  C £ 17.3million

 D £173 million

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

 D £173 million

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

1

st

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)

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)

Low Intensity Workers

 Low intensity interventions - Medication management – – – Behavioural activation Problem-solving Guided self-management – – Brief CBT Signposting  4 – 6 sessions x 30 minutes

Step 4 Step 3 Step 2 Step 1 Condition requiring treatment Complex Disorders Significant Trauma Abnormal Grief Reactions Who’s responsible for care?

Non-IAPT (Psychologists,counsellors) What do they do?

Medication Complex psychological interventions Combined treatments Moderate/severe depression/anxiety disorders not responding to LI PTSD/Severe OCD High Intensity IAPT CBT IPT Mild depression/anxiety Moderate/severe anxiety disorders Recognition Low Intensity IAPT workers (PCMHS) Watchful waiting Medication Management Behavioural Activation Problem-solving Brief CBT Signposting GP and practice team Assessment

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

Step 5 Step 4 Step 3 Condition requiring treatment Risk to life Severe Self- Neglect Treatment-resistant Atypical & Psychotic Depression & those at significant risk Moderate/severe depression Who’s responsible for care?

Acute inpatient service Clinical psychology (non-IAPT) CMHT input if appropriate GPwSI Honorary Consultant Psychiatrist High Intensity IAPT (PCPS) Gateway Workers Case Management (PCMHS) What do they do?

Assessment, Medication, observation, therapies, 24hr in-patient care Medication Complex psychological interventions Combined treatments Medication Liaison CBT & Counselling Case Management Step 2 Step 1 Mild/moderate disorders Recognition Low Intensity IAPT workers (PCMHS) Social Prescribing Third Sector GP and practice team Watchful waiting Behavioural Activation Problem-solving Brief CBT Signposting Arts on Prescription Comm Health Trainers Computerised CBT Assessment

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

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

Cardiovascular Risk Factors and Schizophrenia

Non-modifiable risk factors Gender Modifiable risk factors Obesity 1 Prevalence in schizophrenia 30–40% (1.5–2 × ) Family history Personal history Smoking 2 Diabetes 3 50–80% (2–3 × ) 11–15% (2 × ) Age Ethnicity Hypertension 4 Dyslipidaemia 4 58% 45% 1 Davidson et al.

Aust NZ J Psychiatry.

2001;35:196 –202;

Schizophr Bull.

2000;26:903 –912; 4 Kato et al.

2 Herran et al.

Schizophr Res.

Prim Care Companion J Clin Psychiatry.

2000;4:373 –381; 2005;7:115 –118 3 Dixon et al.

Metabolic Syndrome (IDF Definition 2005)

•

Metabolic syndrome defined as criterion one plus any two of next four criteria : 1. Central obesity

Blood pressure Triglycerides

Men



94 cm (37inches) Women



80 cm (31.5 inches)

≥130/85 mmHg ≥1.7 mmol/L HDL cholesterol Fasting blood glucose Men <1.03 mmol/L Women <1.29mmol/L ≥5.6 mmol/L IDF = International Diabetes Federation; HDL = High-density Lipoprotein; Available at www.idf.org

The core problem...?

40 30 20 10 0 70

Prevalence of Metabolic Syndrome According to BMI

59.6

60 50 50 4.6

22.4

6.2

28.1

Healthy BMI <25 Overweight BMI 25 –29.9 Obese BMI ≥30 Healthy BMI <25 Overweight BMI 25 –29.9

Obese BMI ≥30 Men Women

n=12,363 BMI = Body Mass Index Park et al.

Arch Intern Med.

2003;163:427 –436

10 5 0 30 25 20 15

Prevalence of Obesity is Increased in Schizophrenia

Normal weight Overweight Schizophrenia No schizophrenia Obese BMI category

BMI = Body Mass Index Allison et al.

J Clin Psychiatry

. 1999;60:215 –220

Metabolic Syndrome Increases Total

20 18

and Cardiovascular Mortality

*** 18.0

Metabolic syndrome present Metabolic syndrome absent 16 14 *** 12.0

12 10 8 6 4.6

4 2 0 2.2

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

30 25 20 15

Prevalence of Diabetes in Schizophrenia vs. General Population

General population People with schizophrenia 10 5 0 15 –35 25 –35 35 –45 Age range (years)

n=415 patients with schizophrenia De Hert et al.

Clin Pract Epidemiol Mental Health.

2006;2:14

45 –55 55 –65

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

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

Further Findings from Osborn et al, 2007 

Increased HRs irrespective of:



sex for CHD mortality occurred



SMI diagnosis



Or prescription of antipsychotic medication



However a higher prescribed dose of antipsychotics predicted greater risk of mortality from CHD and stroke

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

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

Mental Health Indicator 9 Other issues to consider  Cervical Screening  Dental & Eye Care  Imms & Vaccs  Medication compliance & side effects

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

Salford Initiatives

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

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)

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

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

“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

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

 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

Case Study 1

 AF: 28y, male – 1 st episode of depression x 6w – Lost job, financial difficulties – Losing contact with friends – Stopped going to the gym – Putting on weight – PHQ score 11

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

Case Study 2

 MS, 42y, female  Chronic depression – On maintenance dose of fluoxetine 20mg ¹ 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

Case Study 2 – what happened next?

  Severe depression Increased fluoxetine 40mg ¹ – Agitated, not sleeping – Increasing thoughts of self-harm  Referred Psychology (non-IAPT - Step 4)  PHQ 22 (Nov 2008)

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)

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

Case Study 3 – what happened next?

  Recurrent depression Started citalopram 20mg ¹   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

Case Study 3

 Switched to duloxetine 60mg ¹  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

Thanks for your attention Any questions?