LONG TERM CONDITIONS AND MENTAL HEALTH

Dr. Justin Shute Liaison Psychiatry Consultant MRCPsych MRCP

LTCs

Long Term conditions 30% of the population of England (c. 15.4m people)

MH PROBLEMS

Mental health problems 20% of the population of England (c. 10.2m people) 30% (c. 4.6m) of those with an LTC have a mental health problem 46% (c.4.6m) of those with a mental health problem have an LTC Naylor Parsonage et al 2012 based on Crimpean and Drake 2011

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

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

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

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

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

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 programmes Benton et al 2007; Katon 2003  Poorer dietary control and adherence to medication Vamos et al 2009

Prevention

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

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.

The stepped-care model

Focus of the intervention STEP 4:

Severe and complex 1 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

Nature of the intervention

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care Medication, high-intensity psychological interventions, combined treatments, collaborative care 2 , and referral for further assessment and interventions

STEP 2:

Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 1:

All known and suspected presentations of depression Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions 1,2 see slide notes

Case identification and recognition

• Be alert to possible depression – Particularly in patients with a past history of depression or – • 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? – a chronic physical health problem with associated functional impairment.

During the last month, have you often been bothered by having little interest or pleasure in doing things?

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 .

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

– behavioural couples therapy.

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.

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.

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

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 .

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

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

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

Stepped Care

Secondary Services 1:1 or group CBT Self help, coping skills, psycho-ed courses, CCBT, behavioural programmes

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

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

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

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

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