1 st edition – september 2007. written by haringey pc lit. developed from haringey and c&i...

Primary Care Guidelines for Common Mental IllnessPrimary Care Guidelines for Common Mental Illness

1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.

Contents (click on heading to go to page):

Depression – Identification and assessment

Depression – Management

Antidepressants – drug choice guidance

Anxiety – Identification and management

Anxiety drug treatment guidance

Eating disorders

Psychosis and schizophrenia – identification, assessment and referral

Psychosis and schizophrenia – management following discharge from complex care team

Psychosis and schizophrenia – managing physical health

Assessing and managing risk to self

Assessing and managing risk to others

These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems. They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.

These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT cannot be responsible for the content or accuracy of any external web site).

If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.

The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)

NICE

Where you see this sign, click on it to be directed to the latest NICE guidelines for that condition

Higher Risk Groups• Past history of depression• Family history of depression• Women who are pregnant and up to 6 months post- childbirth• Socially isolated• Those with ongoing difficult relationships• Concurrent physical illness• Multiple adverse events eg. loss, bereavement, childhood separation or abuse• Drug & alcohol misusers• Carers• Those in residential care

Higher Risk Groups• Past history of depression• Family history of depression• Women who are pregnant and up to 6 months post- childbirth• Socially isolated• Those with ongoing difficult relationships• Concurrent physical illness• Multiple adverse events eg. loss, bereavement, childhood separation or abuse• Drug & alcohol misusers• Carers• Those in residential care

Core Clinical Symptoms• depressed mood, and/or

• loss of interest, and/or • loss of energy & fatigue

Additional Symptoms

• poor concentration• reduced self-esteem & self-

confidence

• disturbed sleep• change in appetite or weight• feelings of guilt or worthlessness• agitation/slowing• pessimism/ hopelessness • suicidal thoughts or acts

Most of the day for at least 2 weeks

Other clinical signs• “Tired all the time”• Irritability• Loss of libido• Medically unexplained physical

symptoms• Depression associated with physical

illness• Frequent attendance• Self-neglect• Diurnal variationIf further systematic assessmentneeded, consider use of PHQ9, HADS or EPNDS

Core Clinical Symptoms• depressed mood, and/or

• loss of interest, and/or • loss of energy & fatigue

Additional Symptoms

• poor concentration• reduced self-esteem & self-

confidence

• disturbed sleep• change in appetite or weight• feelings of guilt or worthlessness• agitation/slowing• pessimism/ hopelessness • suicidal thoughts or acts

Most of the day for at least 2 weeks

Other clinical signs• “Tired all the time”• Irritability• Loss of libido• Medically unexplained physical

symptoms• Depression associated with physical

illness• Frequent attendance• Self-neglect• Diurnal variationIf further systematic assessmentneeded, consider use of PHQ9, HADS or EPNDS

Ante and Post Natal Care:• 1st contact – enquire about past/current mental health history

• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV and hospital services

• Agree and write care plan

• See woman every month ante and post natal

• Observe specific pharmacological guidance

Ante and Post Natal Care:• 1st contact – enquire about past/current mental health history

• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV and hospital services

• Agree and write care plan

• See woman every month ante and post natal

• Observe specific pharmacological guidance

Mild Depression:

At least 2 core symptoms plus at least 2 additional. Person has some difficulty continuing with ordinary activities but does not cease to function.

Mild Depression:

At least 2 core symptoms plus at least 2 additional. Person has some difficulty continuing with ordinary activities but does not cease to function.

Dysthymia:

Mild depression >2yrs

Dysthymia:

Mild depression >2yrs

Moderate Depression:

At least 2 core symptoms plus at least 3/4 additional. Person usually has considerable difficulty in continuing with normal social & work activity.

Moderate Depression:

At least 2 core symptoms plus at least 3/4 additional. Person usually has considerable difficulty in continuing with normal social & work activity.

Severe Depression:

All 3 typical symptoms plus at least 4 additional, some of which are severe. Person shows considerable distress & agitation (or retardation) & unlikely to be able to continue with normal activity.

Severe Depression:

All 3 typical symptoms plus at least 4 additional, some of which are severe. Person shows considerable distress & agitation (or retardation) & unlikely to be able to continue with normal activity.


Depression - Identification & Assessment

First Questions to ask …

• Have you been bothered by feeling down, depressed or hopeless? How bad is this?

• Have you lost interest in things? Do you get less pleasure from things you used to enjoy?

• Are you more tired than usual?

If “yes” to the above, prompt further about individual symptoms (see core symptom box)

First Questions to ask …

• Have you been bothered by feeling down, depressed or hopeless? How bad is this?

• Have you lost interest in things? Do you get less pleasure from things you used to enjoy?

• Are you more tired than usual?

If “yes” to the above, prompt further about individual symptoms (see core symptom box)

Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelinesBack to contents


Depression - Management

Psychological Management

Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or other (ie Derman, Mind, NAFSAT, ACLC)

Psychological Management

Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or other (ie Derman, Mind, NAFSAT, ACLC)

Psychological ManagementRefer to START for consideration for talking therapy such as CBT, IPT, CAT

Psychological ManagementRefer to START for consideration for talking therapy such as CBT, IPT, CAT

Pharmacological Management

Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically indicated.


Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically indicated.


Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine


Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine


Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine


Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine

BEHMHT will consider crisis and/or inpatient needs

BEHMHT will consider crisis and/or inpatient needs

under 18 – CAMHS on 020 8442 6467

18 to 65 yrs – call START on 020 8442 6714

Over 65 – call 020 8442 6702

under 18 – CAMHS on 020 8442 6467


Over 65 – call 020 8442 6702

Clin

ical

judg

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Primary Care and psychological Management

• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social support • Consider other family members

•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+

Primary Care and psychological Management

• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social support • Consider other family members

•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+

Primary Care Management • Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •

• Increase social support • Consider other family members •Also consider social care input – Harts, 60+

Primary Care Management • Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •

• Increase social support • Consider other family members •Also consider social care input – Harts, 60+

Primary Care Management • Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for

support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer of out of hour support.

Primary Care Management • Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for

support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer of out of hour support.

Patie

nt c

hoic

e

ASSESS RISKASSESS RISK

Mild DepressionMild Depression

Severe DepressionSevere Depression

DysthymiaDysthymia

Moderate DepressionModerate Depression

Actively suicidal & urgent risk to self or others

Actively suicidal & urgent risk to self or others

POOR RESPONSE to adequate treatments/ complex management issues

POOR RESPONSE to adequate treatments/ complex management issues



Antidepressants - Drug Choice Guidance

Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007

• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)

• Prescriptions when possible should be generic. PCT recommend 1st line – Fluoxetine or Citalopram.

• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2nd line - Venlafaxine

• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet

• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)

• Prescriptions when possible should be generic. PCT recommend 1st line – Fluoxetine or Citalopram.

• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2nd line - Venlafaxine

• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet

Key Facts Key Facts

Drug Oral Start Dosemg/d

Toxicity in overdose

CV efects Sedation Anticholinergic effects

Nausea Weight gain Cost (28 days)

SSRI'sFluoxetine 20mg 0 0 0 0 ++ £2Citalopram 20mg 0 0 0 0 ++ £3Paroxetine 20mg 0 0 0 0 ++ £6Sertraline 50mg 0 0 0 0 ++ £3Tricyclics (TCA)Amitriptyline 125mg +++ +++ +++ +++ ++ £5Clomipramine 125mg + ++ ++ +++ ++ £13Dothiepin 125mg +++ ++ +++ ++ 0 £4Imipramine 125mg +++ ++ + ++ ++ £9Lofepramine 140mg 0 0 + ++ + £31OthersVenlafaxine 75mg ? ++ + 0 ++ Wt. Loss £24Mirtazapine 30mg 0 0 ++ 0 0 Wt. Gain £11Reboxetine 8mg 0 + 0 + + £19Trazodone 150-300mg + + ++ + +++ £19 to £39

Weight gain well documented

Tendency for initial weight loss then regain

No reports of weight changes


• Is the patient at risk of suicide? YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose• Is sedation needed? YES – Mirtazapine or ‘Older’ tricyclics • Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine• Does the patient have significant other illness? YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment• Is the patient taking OTC or prescribed medications? YES – check BNF for significant interactions• Does the patient have symptoms of anxiety? YES - see anxiety guidelines• Is the patient pregnant or breastfeeding? YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of

not treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525

• Is the patient at risk of suicide? YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose• Is sedation needed? YES – Mirtazapine or ‘Older’ tricyclics • Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine• Does the patient have significant other illness? YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment• Is the patient taking OTC or prescribed medications? YES – check BNF for significant interactions• Does the patient have symptoms of anxiety? YES - see anxiety guidelines• Is the patient pregnant or breastfeeding? YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of

not treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525

Questions to consider when choosing antidepressantsQuestions to consider when choosing antidepressants


Antidepressants - Drug Treatment Guidance

RESPONSE

No response or poorly tolerated

(CHECK COMPLIANCE FIRST)

Poorly tolerated

NO RESPONSE


RESPONSE

RESPONSE• Give selected antidepressant

• Titrate to therapeutic dose

• Assess response over 4-6wks (longer in elderly)

• Increase dose after 2 & 4 weeks if appropriate

• Give selected antidepressant




• Give an antidepressant from a different class




• Give an antidepressant from a different class




Continue for 4-6 months at same dosage once well (12mths in the elderly)

Continue for 4-6 months at same dosage once well (12mths in the elderly)

For patients with 3+ episodes in the last 5yrs, or a total of 5+ episodes, consider maintenance treatment for 5 years

For patients with 3+ episodes in the last 5yrs, or a total of 5+ episodes, consider maintenance treatment for 5 years

• Give an antidepressant from a different class (or from within class – see BNF for washout periods)




• Give an antidepressant from a different class (or from within class – see BNF for washout periods)




To stop treatment, taper dose and/or frequency over a min. of 4wks

To stop treatment, taper dose and/or frequency over a min. of 4wks

Taper dose over 6mths for those on longer-term maintenance treatment

Taper dose over 6mths for those on longer-term maintenance treatment

Advise the patient:

• That it may take 2-4wks to start noticing the positive effects (4-8wks in older people)

• Of the common side effects they are likely to experience

• That they need to keep taking the medication even when they feel better

• That antidepressants are NOT addictive – but must not stop suddenly

• Of dosing& titration regime where appropriate• To come back and see you in 1-4wkswhether or not

they have been taking medication

• That they should consult you before stopping taking the medication

Advise the patient:

• That it may take 2-4wks to start noticing the positive effects (4-8wks in older people)

• Of the common side effects they are likely to experience

• That they need to keep taking the medication even when they feel better

• That antidepressants are NOT addictive – but must not stop suddenly

• Of dosing& titration regime where appropriate• To come back and see you in 1-4wkswhether or not

they have been taking medication

• That they should consult you before stopping taking the medication

Drug CounsellingDrug Counselling

• Choose drug in line with drug choice guidelines

overleaf• Aim for the minimum effective dose • Agree follow-up plan – Review every 1-2 weeks at

start of treatment. Monitoring of suicide risk essential if high risk. If low risk, every two to four weeks

• Provide good, clear drug counselling plus a patient information leaflet

• Choose drug in line with drug choice guidelines

overleaf• Aim for the minimum effective dose • Agree follow-up plan – Review every 1-2 weeks at

start of treatment. Monitoring of suicide risk essential if high risk. If low risk, every two to four weeks

• Provide good, clear drug counselling plus a patient information leaflet

Initiating medicationInitiating medication Treatment RegimeTreatment Regime




RESPONSE



Link to United Kingdom psychiatric pharmacy group web site

Core Symptoms

• Mental symptoms: eg. feeling ‘on edge’, apprehension, worry about future, fear of something bad happening, difficulty concentrating, depressive symptoms

• Physical tension & arousal: eg. restlessness, muscle tension, inability to relax, sweating, stomach or chest pains, dizziness, overbreathing NB. May present as physical complaint

• Behaviour change: eg. avoidance of feared situations

Core Symptoms

• Mental symptoms: eg. feeling ‘on edge’, apprehension, worry about future, fear of something bad happening, difficulty concentrating, depressive symptoms

• Physical tension & arousal: eg. restlessness, muscle tension, inability to relax, sweating, stomach or chest pains, dizziness, overbreathing NB. May present as physical complaint

• Behaviour change: eg. avoidance of feared situations

Predisposing factors• Life events/ stressors• Anxious personality

Predisposing factors• Life events/ stressors• Anxious personality

Assessment• Screening questions:“How are you feeling in yourself?”“Have you found yourself worrying a lot?”• Consider other causes of symptoms e.g.

thyrotoxicosis, stimulant drug use• Consider comorbidity inc depression• Look out for drug/alcohol use• Consider somatic problems, eg pain• Determine:

- duration of symptoms- severity of impairment- degree of avoidance- degree of accompanying depression

• Assess risk

Assessment• Screening questions:“How are you feeling in yourself?”“Have you found yourself worrying a lot?”• Consider other causes of symptoms e.g.

thyrotoxicosis, stimulant drug use• Consider comorbidity inc depression• Look out for drug/alcohol use• Consider somatic problems, eg pain• Determine:

- duration of symptoms- severity of impairment- degree of avoidance- degree of accompanying depression

• Assess risk

Primary care management• Educate about anxiety• Provide self-help information & support• Book prescription• Encourage relaxation techniques, regular

exercise and sleep & stress management• Avoid over-investigation of physical

symptoms and help patient make links between anxiety & presenting physical symptoms

• Manage comorbidity & substance use• Watchful waiting

Primary care management• Educate about anxiety• Provide self-help information & support• Book prescription• Encourage relaxation techniques, regular

exercise and sleep & stress management• Avoid over-investigation of physical

symptoms and help patient make links between anxiety & presenting physical symptoms

• Manage comorbidity & substance use• Watchful waiting

Primary care psychological management

• Consider referral for talking therapies, in particular guided self help (Health in Mind)

• CBT, as second line treatment if symptoms are causing significant distress or impairment of functioning

Primary care psychological management

• Consider referral for talking therapies, in particular guided self help (Health in Mind)

• CBT, as second line treatment if symptoms are causing significant distress or impairment of functioning

Pharmacological management

• Medication should be a third line treatment in the management of anxiety

• Drugs may be indicated if:- significant depressive symptoms (esp. in Mixed Anxiety Depression)- persistent or very disabling anxiety symptoms-Short term only

Pharmacological management

• Medication should be a third line treatment in the management of anxiety

• Drugs may be indicated if:- significant depressive symptoms (esp. in Mixed Anxiety Depression)- persistent or very disabling anxiety symptoms-Short term only


Anxiety - Identification & Management

Discuss with START (020 8442 6714) if:• Chronic, severe, disabling symptoms• Poor response to other treatments• Risk of suicide or self-harm

Discuss with START (020 8442 6714) if:• Chronic, severe, disabling symptoms• Poor response to other treatments• Risk of suicide or self-harm

Mixed Anxiety & Depression (MAD)• Low or sad mood & loss of interest or pleasure• Prominent anxiety or worry• Multiple depressive or anxiety symptoms

Mixed Anxiety & Depression (MAD)• Low or sad mood & loss of interest or pleasure• Prominent anxiety or worry• Multiple depressive or anxiety symptoms

Generalised Anxiety Disorder (GAD)• Excessive anxiety & worry about several events or activities• Trouble controlling these feelings• Symptoms present at least half the days in last 6 mths

Generalised Anxiety Disorder (GAD)• Excessive anxiety & worry about several events or activities• Trouble controlling these feelings• Symptoms present at least half the days in last 6 mths

Panic Disorder• Recurrent panic attacks• Worry about the cause or consequences• Attempt to avoid situations that trigger attacks • May be associated with agoraphobia

Panic Disorder• Recurrent panic attacks• Worry about the cause or consequences• Attempt to avoid situations that trigger attacks • May be associated with agoraphobia

Phobic Disorders• Agoraphobia• Social phobia• Specific phobia

Obsessive-compulsive (OCD)• Recurrent thoughts or impulses• Attempts to suppress or “neutralise” these• Repetitive physical or mental behaviours

Post Traumatic Stress Disorder (PTSD)• Lasting response (at least 2 weeks) to a traumatic event that impairs functioning• Intrusive memories: flashbacks/ nightmares• Avoidance behaviour• Numbness, detachment• hyperarousal, anxiety, irritability• Treatment only indicated following several months of symptoms

Phobic Disorders• Agoraphobia• Social phobia• Specific phobia

Obsessive-compulsive (OCD)• Recurrent thoughts or impulses• Attempts to suppress or “neutralise” these• Repetitive physical or mental behaviours

Post Traumatic Stress Disorder (PTSD)• Lasting response (at least 2 weeks) to a traumatic event that impairs functioning• Intrusive memories: flashbacks/ nightmares• Avoidance behaviour• Numbness, detachment• hyperarousal, anxiety, irritability• Treatment only indicated following several months of symptoms

Common Anxiety Disorders in Primary Care (co-existence should be considered)

Common Anxiety Disorders in Primary Care (co-existence should be considered)

Other Anxiety Disorders Other Anxiety Disorders


Mild

Moderate

Severe


Anxiety - Drug Treatment GuidanceNB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms

NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms

Anxiety DisorderAnxiety Disorder Licensed DrugLicensed Drug

Mixed Anxiety & Depression (MAD)Mixed Anxiety & Depression (MAD)

Generalised Anxiety Disorder (GAD)Generalised Anxiety Disorder (GAD)

Obsessive-Compulsive Disorder (OCD)Obsessive-Compulsive Disorder (OCD)

Social Phobia (Generalised)Social Phobia (Generalised)

Post-Traumatic Stress Disorder (PTSD)Post-Traumatic Stress Disorder (PTSD)

Panic Disorder (and agoraphobia)Panic Disorder (and agoraphobia)

Specific PhobiasSpecific Phobias

Social Phobia (Non-Generalised)Social Phobia (Non-Generalised)

Acute Stress DisorderAcute Stress Disorder

No specific drug licensed. Follow antidepressant prescribing guidelines. Consider drug anxiolytic properties.

No specific drug licensed. Follow antidepressant prescribing guidelines. Consider drug anxiolytic properties.

• 1 - Paroxetine• 2 - Venlafaxine• 3 - Buspirone

• 1 - Paroxetine• 2 - Venlafaxine• 3 - Buspirone

• Paroxetine• Paroxetine

• 1 - Citalopram• 2 - Paroxetine

• 1 - Citalopram• 2 - Paroxetine

• 1 - Fluoxetine• 2 - Paroxetine• 3 - Sertraline• 4 - Clomipramine

• 1 - Fluoxetine• 2 - Paroxetine• 3 - Sertraline• 4 - Clomipramine

Only consider pharmacotherapy for symptomatic management in one-off/ short-term circumstances e.g. beta-blockers/ benzodiazapines for air travel

Only consider pharmacotherapy for symptomatic management in one-off/ short-term circumstances e.g. beta-blockers/ benzodiazapines for air travel

• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.

Key message: “Start Low, Go Slow”

• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.

• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.

Key message: “Start Low, Go Slow”

• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.

• Benzodiazepines ( avoid short acting such as Lorazapam) • Up to 7 days. With caution.

• Benzodiazepines ( avoid short acting such as Lorazapam) • Up to 7 days. With caution.

Treatment RegimeTreatment Regime


Preferred options

as advised by the

Haringey TPCT pharmacy team

Core Clinical SymptomsANOREXIA NERVOSA • Body weight maintained 15% below expected for

age and height/ BMI < 17.5kg/m2

• Weight loss self-induced by

•Restricting intake

•Self induced vomiting and/or purging

•Excessive exercise

•Use of drugs

• Morbid dread of fatness

• Self set low weight threshold

• Disturbance of endocrine system

• Anorexia Nervosa has the highest death rate of any psychological disorder

BULIMIA NERVOSA

• Bingeing, with preoccupation with food and craving

• Attempts to counteract excess calorie intake by

•Self induced vomiting

•Self induced purging

•Alternating periods of starvation and bingeing

•Use of drugs and/or neglect of insulin use in diabetes



• Possible history of anorexia

Core Clinical SymptomsANOREXIA NERVOSA • Body weight maintained 15% below expected for

age and height/ BMI < 17.5kg/m2

• Weight loss self-induced by

•Restricting intake

•Self induced vomiting and/or purging

•Excessive exercise

•Use of drugs



• Disturbance of endocrine system

• Anorexia Nervosa has the highest death rate of any psychological disorder

BULIMIA NERVOSA

• Bingeing, with preoccupation with food and craving

• Attempts to counteract excess calorie intake by

•Self induced vomiting

•Self induced purging

•Alternating periods of starvation and bingeing

•Use of drugs and/or neglect of insulin use in diabetes



• Possible history of anorexia

Mild Anorexia:

BMI >17kg/m2

No additional co morbidity

Mild Anorexia:

BMI >17kg/m2

No additional co morbidity

Moderate Anorexia:

•BMI 15 – 17kg/m2

•No evidence of system failure

Moderate Anorexia:

•BMI 15 – 17kg/m2

•No evidence of system failure

Severe Bulimia

Daily purging

Electrolyte imbalance

Co-morbidity

Severe Bulimia

Daily purging

Electrolyte imbalance

Co-morbidity

Severe Anorexia

BMI <15kg/m2

Rapid weight loss

Evidence of system failure

Severe Anorexia

BMI <15kg/m2

Rapid weight loss

Evidence of system failure


Eating Disorders- Identification & Management

Assessment

• Height and Weight, BMI (weight kg /height m squared)

Consider

• Other causes of weight loss, inc thyroid disease, stimulant use

• Investigations Full blood count, blood chemistry, pulse, blood pressure

• Other difficulties associated with binging and purging ie Tooth decay

• Symptoms of depression (difficult to treat until nutritional state is successfully being treated)

Assessment

• Height and Weight, BMI (weight kg /height m squared)

Consider

• Other causes of weight loss, inc thyroid disease, stimulant use

• Investigations Full blood count, blood chemistry, pulse, blood pressure

• Other difficulties associated with binging and purging ie Tooth decay

• Symptoms of depression (difficult to treat until nutritional state is successfully being treated)


Monitor for 8 weeks

Give information

Book prescription

Use of self help books

Food diary

Explore extent of problem

Consider involvement of family

Consider referral if failure to respond

Monitor for 8 weeks

Give information

Book prescription

Use of self help books

Food diary

Explore extent of problem

Consider involvement of family

Consider referral if failure to respond

Mild and moderate Bulimia

Mild and moderate Bulimia

Urgent referral and admission to

acute medical hospital if life-

threatening

Urgent referral and admission to

acute medical hospital if life-

threatening

under 18 – CAMHS on 020 8442 6467


under 18 – CAMHS on 020 8442 6467


The Phoenix Wing, St Ann's

Hospital, St Ann's Road,

London N15 3TH

Telephone Number: 020 8442 6387Fax Number: 020 8442 6192

The Phoenix Wing, St Ann's

Hospital, St Ann's Road,

London N15 3TH

Telephone Number: 020 8442 6387Fax Number: 020 8442 6192


Psychosis and Schizophrenia – Assessment & referral

Higher Risk Groups• Family history of psychoses• Past history of psychoses• Drug misusers• Onset most commonly in 2nd or 3rd decade –

but can occur at any age

Higher Risk Groups• Family history of psychoses• Past history of psychoses• Drug misusers• Onset most commonly in 2nd or 3rd decade –

but can occur at any age

Urgent /Emergency Referral to START 020 8442 6714Urgent /Emergency Referral to START 020 8442 6714

In all cases consider starting antipsychotic medication Risperidone is first line treatment

In all cases consider starting antipsychotic medication Risperidone is first line treatment

Discussion with Link worker/psychiatrist – refer to START with patient’s agreement.

Consider referral to START depending on:• Patients views• Previous history • Problems with medication• Concerns about comorbid substance misuse• Level of risk

Discussion with Link worker/psychiatrist – refer to START with patient’s agreement.

Consider referral to START depending on:• Patients views• Previous history • Problems with medication• Concerns about comorbid substance misuse• Level of risk

Referral to START 020 8442 6714

(NB: START will refer patients to Early Intervention Service when established)

Referral to START 020 8442 6714

(NB: START will refer patients to Early Intervention Service when established)

Hypomania: Over the past year, have there been times when you felt very happy indeed without a break for days on end? If yes - Was there an obvious reason for this? Did your relatives or friends think it was strange or complain about it? Thought insertion: Over the past year, have you ever felt that your thoughts were directly interfered with or controlled by some outside force or person? If yes - Did this come about in a way that many people would find hard to believe, for instance, through telepathy? Paranoia: Over the past year, have there been times when you felt that people were against you?If yes - Have there been times when you felt that people were deliberately acting to harm you or your interests?· Have there been times when you felt that a group of people were plotting to cause you serious harm or injury? Strange experiences: Over the past year, have there been times when you felt that something strange was going on? If yes - Did you feel it was so strange that other people would find it very hard to believe?Hallucinations: Over the past year, have there been times when you heard or saw things that other people couldn't? If yes- Did you at any time hear voices saying quite a few words or sentences when there was no-one around that might account for it?

Hypomania: Over the past year, have there been times when you felt very happy indeed without a break for days on end? If yes - Was there an obvious reason for this? Did your relatives or friends think it was strange or complain about it? Thought insertion: Over the past year, have you ever felt that your thoughts were directly interfered with or controlled by some outside force or person? If yes - Did this come about in a way that many people would find hard to believe, for instance, through telepathy? Paranoia: Over the past year, have there been times when you felt that people were against you?If yes - Have there been times when you felt that people were deliberately acting to harm you or your interests?· Have there been times when you felt that a group of people were plotting to cause you serious harm or injury? Strange experiences: Over the past year, have there been times when you felt that something strange was going on? If yes - Did you feel it was so strange that other people would find it very hard to believe?Hallucinations: Over the past year, have there been times when you heard or saw things that other people couldn't? If yes- Did you at any time hear voices saying quite a few words or sentences when there was no-one around that might account for it?

Prodromal Period• Early signs of deterioration in

personal functioning• Changes in affect, cognition,

thought content, motivation and behaviour

• 50% do not develop frank psychosis

• active follow up in primary care

Prodromal Period• Early signs of deterioration in

personal functioning• Changes in affect, cognition,

thought content, motivation and behaviour

• 50% do not develop frank psychosis

• active follow up in primary care

New diagnosis of psychosis – first presentation

New diagnosis of psychosis – first presentation

Patient new to the area - with previously diagnosed psychosis

Patient new to the area - with previously diagnosed psychosis

Known patient (sole management in Primary Care)

Known patient (sole management in Primary Care)

Assessment (PSQ Bebbington and Nayani, 1995)Assessment (PSQ Bebbington and Nayani, 1995)

Ante and Post Natal Care:• 1st contact – enquire about past/current MI history• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV and hospital services• Refer to START - agree and write care plan Also consider social care input – Harts,• See woman every month ante and post natal

Ante and Post Natal Care:• 1st contact – enquire about past/current MI history• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV and hospital services• Refer to START - agree and write care plan Also consider social care input – Harts,• See woman every month ante and post natal

Discussion with Link worker/psychiatrist• Manage in primary Care with SMI care plan• Anti psychotic prescribing, with pt leaflet • Monitor repeat prescribing• Consider wider social and support issues• Refer to exercise and work/education

opportunities

Discussion with Link worker/psychiatrist• Manage in primary Care with SMI care plan• Anti psychotic prescribing, with pt leaflet • Monitor repeat prescribing• Consider wider social and support issues• Refer to exercise and work/education

opportunities

Significant impact on dependant children?

Significant impact on dependant children?

Urgent referral to Children Services on

020 8489 5402

Urgent referral to Children Services on

020 8489 5402

Acutely disturbedAcutely disturbed



Psychosis and Schizophrenia – Management following discharge from CMHT (inc Support and Recovery Teams)

If acute relapse – instigate crisis and contingency plan

Discussion with Link worker or psychiatrist –

refer to START with patient’s knowledge.• Patients views• Previous history • Problems with medication• Concerns about comorbid substance

misuse• Level of risk

If acute relapse – instigate crisis and contingency plan

Discussion with Link worker or psychiatrist –

refer to START with patient’s knowledge.• Patients views• Previous history • Problems with medication• Concerns about comorbid substance

misuse• Level of risk

Depot medicationAgree planCompetent practice nurseAppointments opportunity to assess

Depot medicationAgree planCompetent practice nurseAppointments opportunity to assess

Concordance and repeat prescriptionsMonitor repeat prescription picked upCheck for side effectsUse pt leaflet

Concordance and repeat prescriptionsMonitor repeat prescription picked upCheck for side effectsUse pt leaflet

Crisis and Contingency Plan in place (CPA)

Crisis and Contingency Plan in place (CPA)

Discharge Planning and Care PlanPt identifiedPlan agreedDates agreed

Discharge Planning and Care PlanPt identifiedPlan agreedDates agreed

Shared CareIn agreement with psychiatrist, explicitly agrees who is doing what, when, how, why and with whom.

Shared CareIn agreement with psychiatrist, explicitly agrees who is doing what, when, how, why and with whom.

Physical HealthProactive plan – utilise health action planAssess and review at least once a yearTarget smoking, eating and exercise behaviour

Physical HealthProactive plan – utilise health action planAssess and review at least once a yearTarget smoking, eating and exercise behaviour

SMI RegisterOn listCare plan in placeReviewed at least once a year

SMI RegisterOn listCare plan in placeReviewed at least once a year

Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines

Patients needs stableSpecialist input no longer required

Patients needs stableSpecialist input no longer required

Sole Primary Care Management

Sole Primary Care Management

Relapse IndicatorsWhy, When, Who, HowTo refer back to START

Relapse IndicatorsWhy, When, Who, HowTo refer back to START

CarersCares assessment and needsSupport and counselling for carers (Health in Mind)Regular review of carers needs

Is there a child carer? – assess needs and refer to children services

CarersCares assessment and needsSupport and counselling for carers (Health in Mind)Regular review of carers needs

Is there a child carer? – assess needs and refer to children services

Work with patient to helpimprove general well-being andfeelings of worthAccess to employment and education –

‘Tomorrow's People, Richmond Fellowship, New deal, Job centre Plus.

Consider referral/signposting to therapeutic network, and or day services

Book prescription for stress and esteem issuesStress management and relaxation skillsStructure and activity planning and

Problem solvingDebt managementAlso consider social care input – Harts, 60+

and Services for All

Work with patient to helpimprove general well-being andfeelings of worthAccess to employment and education –

‘Tomorrow's People, Richmond Fellowship, New deal, Job centre Plus.

Consider referral/signposting to therapeutic network, and or day services

Book prescription for stress and esteem issuesStress management and relaxation skillsStructure and activity planning and

Problem solvingDebt managementAlso consider social care input – Harts, 60+

and Services for All

Back to contents


Psychosis and Schizophrenia - Physical Health Care

Focus on

Provide routine physical health checks at least 1x every year. Record on SMI register

Provide routine physical health checks at least 1x every year. Record on SMI register

Monitor increased risk of cardiovascular disease

Monitor increased risk of cardiovascular disease

Promote healthy lifestylePromote healthy lifestyle

Monitor drug side effectsMonitor drug side effects

NeurologicalNeurological

Consider:• Extrapyramidal side effects• Tardive dyskinesia

Consider:• Extrapyramidal side effects• Tardive dyskinesia

Regular monitoringRegular monitoring

To be provided usually in primary careTo be provided usually in primary care If no contact with primary careIf no contact with primary care Secondary care should monitor physical healthSecondary care should monitor physical health

Consider:• Primary prevention (use standard scoring systems)• Secondary prevention in those with established heart disease• Specific monitoring in relation to certain antipsychotic drugs (see BNF)

Consider:• Primary prevention (use standard scoring systems)• Secondary prevention in those with established heart disease• Specific monitoring in relation to certain antipsychotic drugs (see BNF)

For example, good diet and exerciseActively encourage smoking cessation

For example, good diet and exerciseActively encourage smoking cessation

EPS/akathisia LethargyWeight gain/diabetes Effects on eyesSexual dysfunction

EPS/akathisia LethargyWeight gain/diabetes Effects on eyesSexual dysfunction

Metabolic and endocrineMetabolic and endocrine WeightWeight Other side effects of medicationOther side effects of medication

Consider:• Routine urine/blood screen for diabetes• Selective screen for other endocrine

disorders (high prolactin), eg amenorroea, glalactorrhoea

Consider:• Routine urine/blood screen for diabetes• Selective screen for other endocrine

disorders (high prolactin), eg amenorroea, glalactorrhoea

Consider routine weight monitoringConsider routine weight monitoring Photosensitivity and chlorpromazinePhotosensitivity and chlorpromazine

Cover key areas on regular basis; agree frequency with service user and document in notesCover key areas on regular basis; agree frequency with service user and document in notes

Primary and secondary care services identify/allocate and document responsibilities for monitoring physical healthPrimary and secondary care services identify/allocate and document responsibilities for monitoring physical health

Promote wider well being activity: Goal setting, problem solving, access to education and employment.Stress management – referral to Therapeutic Network and Day services

Promote wider well being activity: Goal setting, problem solving, access to education and employment.Stress management – referral to Therapeutic Network and Day services



Assessing & Managing Risk to Self– Suicide/Self-Harm

“Are you feeling like life is not worth living”or

“Have you had thoughts about harming or killing yourself?”

“Are you feeling like life is not worth living”or

“Have you had thoughts about harming or killing yourself?”

“Have you felt like acting on these thoughts”or

“Have you considered actually ending your life?

“Have you felt like acting on these thoughts”or

“Have you considered actually ending your life?

“Have you made any plans or preparations about how you would do this?”

Prompt: method, suicide note etc.

“Have you made any plans or preparations about how you would do this?”

Prompt: method, suicide note etc.

“How likely is it that you might act on these plans?”and

“Have you ever tried to harm yourself or end your life before?”Or (if psychotic)

“Have you heard voices telling you to harm yourself?”

“How likely is it that you might act on these plans?”and

“Have you ever tried to harm yourself or end your life before?”Or (if psychotic)

“Have you heard voices telling you to harm yourself?”

Yes

Likely/Yes

Yes

Yes

Unlikely/No

No

No

No

• Review routinely

• Enquire about risk again as appropriate

• Identify protective factors

• Review routinely



• Monitor regularly – every one to four weeks

• Check medication for toxicity & limit quantity

• Make shared action plan with patient about what they would do if felt more suicidal: eg. social support, contact GP, Samaritans, go to A&E etc.

• Active sharing of issues with carer

• Discuss with START if patient requires more intensive assessment


• Monitor regularly – every one to four weeks

• Check medication for toxicity & limit quantity

• Make shared action plan with patient about what they would do if felt more suicidal: eg. social support, contact GP, Samaritans, go to A&E etc.

• Active sharing of issues with carer

• Discuss with START if patient requires more intensive assessment


• Discuss directly with START or out of hours service 020 8442 6714

• If children in family – also consider referral to children services

• Discuss directly with START or out of hours service 020 8442 6714

• If children in family – also consider referral to children services

• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)

• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about their fears

• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)

• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about their fears

Suicide risk factors:

• History of prior attempts

• Current severity of depressive or other mental illness

• Alcohol & drug misuse

• Social isolation

• Low self esteem and perception of being a burden

• Rejected by loved ones

• Life-threatening/ chronic physical illness

• Being an single young man

• Impulsivity

• Recent discharge from psychiatric hospital

• Significant anniversaries

• Suicides in the family

Suicide risk factors:

• History of prior attempts

• Current severity of depressive or other mental illness


• Social isolation

• Low self esteem and perception of being a burden

• Rejected by loved ones

• Life-threatening/ chronic physical illness

• Being an single young man

• Impulsivity

• Recent discharge from psychiatric hospital

• Significant anniversaries

• Suicides in the family

Consider risk of harm due to:

•Self-neglect

•Domestic violence

•Sexual vulnerability

• Child abuse

• Adult and elder abuse

•Risk from partner

Consider risk of harm due to:

•Self-neglect

•Domestic violence

•Sexual vulnerability

• Child abuse

• Adult and elder abuse

•Risk from partner

ASSESSMENTASSESSMENT MANAGEMENTMANAGEMENT

IdeationIdeation

RiskRisk

PlanningPlanning

IntentionIntention

Remember: Any previous suicide attempts are the biggest indicator of future risk

Thoughts of self-harm related to psychotic symptoms may increase risk.

Clin

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Moderate RiskModerate Risk


Higher RiskHigher Risk

•Review routinely

•Enquire about risk again as appropriate

•Identify protective factors

Lower RiskLower Risk

Back to contents

Risk to children under 18years• Risk of harm to children direct or indirect?• See LSCB protocol• If in doubt, contact PCT child protection team

on 020 8442 6987

Risk to children under 18years• Risk of harm to children direct or indirect?• See LSCB protocol• If in doubt, contact PCT child protection team

on 020 8442 6987


Assessing & Managing Risk - Harm to others

ASSESSMENTASSESSMENT MANAGEMENTMANAGEMENT

“Have you had thoughts about harming other people?” Hostile/ suspicious/ angry presentation. Evidence of paranoid/ persecutory delusions, command hallucinations. Worries that someone trying to hurt you? Felt need to protect self?

“Have you had thoughts about harming other people?” Hostile/ suspicious/ angry presentation. Evidence of paranoid/ persecutory delusions, command hallucinations. Worries that someone trying to hurt you? Felt need to protect self?

“Are you afraid you might act on these thoughts”Or Overt threats made to othersHave these been acted on?

“Are you afraid you might act on these thoughts”Or Overt threats made to othersHave these been acted on?

“Have you made any plans or preparations about harming someone?” (risk to partner/family?)

“How you would do this?” Prompt: method, access to means

“Have you made any plans or preparations about harming someone?” (risk to partner/family?)

“How you would do this?” Prompt: method, access to means

“How likely is it that you might act on these plans?”What has stopped these plans being carried out so far? Previous history of harm to others“Have you heard voices telling you to harm others?”

“How likely is it that you might act on these plans?”What has stopped these plans being carried out so far? Previous history of harm to others“Have you heard voices telling you to harm others?”

Yes

Likely/Yes

Yes

Yes

Unlikely/No

No

No

No

• Review



• Review



• Monitor regularly

• Make shared action plan with patient/ carers about what they would do if felt risk had increased: eg. social support, contact GP, go to A&E, contact police etc.

• Discuss with/ refer toSTART if patient requires more intensive risk monitoring or further assessment

• Monitor regularly

• Make shared action plan with patient/ carers about what they would do if felt risk had increased: eg. social support, contact GP, go to A&E, contact police etc.

• Discuss with/ refer toSTART if patient requires more intensive risk monitoring or further assessment

• Urgent telephone referral to START• If immediate risk call police on 999

• Urgent telephone referral to START• If immediate risk call police on 999

Higher RiskHigher Risk

Moderate RiskModerate Risk

Ideation/ Mental State

Ideation/ Mental State

RiskRisk

PlanningPlanning

IntentionIntention

Remember: Previous history of violent behaviour is the biggest indicator of future risk.

Violent thoughts related to acute psychotic symptoms may increase risk.

• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider

• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS, your link worker or psychiatrist

• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider

• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS, your link worker or psychiatrist

Harm to others - risk factors:

• Prior history of violent behaviour

• Diagnosis of schizophrenia, paranoid psychosis, personality disorder, severe depression


• Unstable living arrangements

• Low educational attainment

• Unstable employment

• Being a younger man

• History of suffering chronic violence

Harm to others - risk factors:

• Prior history of violent behaviour

• Diagnosis of schizophrenia, paranoid psychosis, personality disorder, severe depression


• Unstable living arrangements

• Low educational attainment

• Unstable employment

• Being a younger man

• History of suffering chronic violence

Clin

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Difficulty of assessing risk

Difficulty of assessing risk


•Review routinely

•Enquire about risk again as appropriate


Lower RiskLower Risk

Back to contents

PROBLEM ISSUE

BOOK TITLE

AUTHOR(S) YEAR PROBLEM

ISSUE BOOK TITLE AUTHOR(S) YEAR

Anxiety

Overcoming Anxiety

Kennerley, Helen 1997 Social Anxiety/ Social Phobia

Overcoming Social Anxiety and Shyness

Butler, Gillian 1999

Overcoming Anxiety: A Five Areas Approach

Williams, Chris 2003 Stress

The Relaxation and Stress Reduction Workshop

Davis, Robbins, Eshelman & McKay

2000

Health Anxiety

Stop Worrying About Your Health!

Zgourides, George 2002

Managing Stress: Teach Yourself

Looker, Terry and Gregson, Olga

2003

Obsessions & Compulsions

Understanding Obsessions and Compulsions

Tallis, Frank 1992 Worry

How to Stop Worrying Tallis, Frank 1990

Panic

Overcoming Panic

Silove, Derrick 1997 Child Sexual Abuse (Adult Survivors)

The Courage to Heal Bass, Ellen and Davies, Laura

2002

Panic Attacks Ingham, Christine 2000 PTSD/Trauma

Overcoming Traumatic Stress

Herbert, Claudia & Wetmore, Ann

1999

Back to contents

PROBLEM ISSUE

BOOK TITLE

AUTHOR(S) YEAR PROBLEM

ISSUE BOOK TITLE AUTHOR(S) YEAR

Depression

Overcoming Depression

Gilbert, Paul 2000 Bereavement

Living with Loss McNeill Taylor, Liz 2000

Mind Over Mood

Greenberger, Dennis and Padesky, Christine

1995 Anorexia Nervosa

Breaking free from Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers

Treasure, Janet 1997

Overcoming Depression: A Five Areas Approach

Williams, Chris 2001

Overcoming Anorexia Nervosa

Freeman, Christopher & Cooper, Peter

2002

Self-Esteem

Overcoming Low Self-Esteem

Fennell, Melanie 1999 Binge-Eating Disorder and Bulimia Nervosa

Overcoming Binge Eating Fairburn, Chris 1995

Manic Depression

Overcoming Mood Swings

Scott, Jan 2001

Getting Better Bit(e) by Bit(e)

Schmidt, Ulrike and Treasure, Janet

1993

Back to contents

From 1stOctober 2007All referralsto Haringey Adult Mental Health Services should be made to:

START(Short term assessment and recovery team)

St Ann’s Hospital, St Ann’s Road, N15 3TH

020 8442 6714 or 6706

Fax 020 8442 6705START is the new single point of entry for mental health, replacing ERC and duty teams. The team is a MDT including psychiatry, nursing, social work and psychology.

START provides a 24 hour 7 day a week serviceBack to contents

1 st edition – september 2007. written by haringey pc lit. developed from haringey and c&i...

Documents

depression identification

dr belinda agoe gp mh

dr muhammed akunjee

dr martin lindsay gp

plan care

complex care team psychosis

national guidelines

ci guidelines