initiating more structured management. why focus on depression? high morbidity burden in primary...

RECURRENT DEPRESSION

INITIATING MORE STRUCTURED MANAGEMENT

WHY FOCUS ON DEPRESSION?

HIGH MORBIDITY BURDEN IN PRIMARY CAREDIAGNOSIS OF MAJORITY SEEN IN LLWN HUBRISK OF RECURRENCE RECOGNISED IN MANY

ACCESSING INTEGRATED PRIMARY CARE TTGROWING EVIDENCE ON BENEFITS OF OFFERING

LTC MODEL OF MANAGEMENT TO THOSE AT RISK OF RECURRENCE

COULD IMPROVE OUTCOMES FOR MOST SERIOUSLY AFFECTED AND REDUCE ACUTE PRESENATIONS

DEFINITIONTWO OR MORE EPISODES IN A 5 YEAR PERIOD INCREASE

RISK OF FUTURE RECURRENCEAFTER 5 YEARS WITHOUT DEPRESION RISK ‘NORMAL’THOSE IDENTIFIED CONSTITUTE AN ‘AT RISK’ REGISTER

GETTING STARTED – THOSE ACCESSING TT SERVICE WITH MODERATE AND SEVERE SEVERITY – PHQ9 SCORE 15 AND ABOVE + ONE OR MORE EPISODES IN PAST 5 YEARS

- PEOPLE ALREADY IN CARE - MANAGEABLE NUMBERS TO DEVELOP NEW APPROACH

WHAT CONSTITUTES LTC MODEL FOR DEPRESSION? SUPPORT ‘AGENCY’ OF SERVICE USER

- INFORMATION - SELF HELP/LIFE STYLE CHANGE - IDENTIFY SOCIAL PROBLEMS AND SOURCE SUPPORT - OPTIMISE ACCESS TO TREATMENT, TALKING THERAPY AND ANTIDEPRESSANT MEDICATION - WITH SERVICE USER ASSESS PARTICULAR RISK FACTORS FOR RECURRENCE - FORMULATE FOLLOW UP PLAN AND PUT ARRANGEMENTS IN PLACE - CONSIDER ‘KEY WORKER’ ARRANGEMENT

* MANAGING DEPRESSION EPISODES TO POINT THAT SYMPTOMS HAVE RESOLVED REDUCES LIKELIHOOD OF RELAPSE WITHIN 15 MONTHS BY TWO THIRDS

Questions to exploreWho gets most benefit from being referred to the hub?Who’s best placed to undertake the vulnerability assessment and

formulate follow up plan?Should this group be offered more talking therapy sessions, and how

much more?Should GP undertake a review of antidepressant prescribing as soon

as risk of recurrence is detected? Implications for co-exiting physical conditions Is telephone follow up enough for some people?Who might benefit most from a key worker, and how is that role to be

sourced?Monitoring?

Lambeth CMD Detection Levels (adjusted) by Practice (Lambeth Datanet CMD Report 2012)

DATA ISSUES

SERVICE USER FEEDBACK

WHEN ANXIETY AND DEPRESSION CO-EXIST CODE SEPARATELY – STOP USING ‘ANXIETY WITH DEPRESSION’ CODE

WHY RECORD PHQ9 LEVELS?

PROCESS MEASURES:

‘SOCIAL SUPPORT’ LLW HUB/BENEFITS ADVICE/HOUSING SUPPORT/ DEBT COUNSELLING

FOLLOW UP PLAN AGREED

KEY WORKER IN PLACE

RECORD OF FOLLOW UP APPOINTMENTS

Lambeth Talking Therapies

1. Depression:– Current referrals– Recognition and diagnosis in primary care– The 10 minute consultation – group exercise

2. Access to Talking Therapy

3. Perinatal talking therapies pilot

Depression - current picture

• Adults with depression known to GPs as % of all patients on the GP register

Lambeth: 4.9 England: 5.8• New cases of depression: Adults with a

new diagnosis of depression as % of all patients on the GP register

Lambeth :1.0 England:1.0

Public Health England ‘Fingertips’ report (20112 /13)

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Depression - Current picture – LTT referrals and outcomes

In 2013/ 14:

1. 433 service users with recurrent depression enter treatment (about 9% of total)

2. Recovery rate of 42% (lower than for other conditions)

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So, today, aims and agenda

Increasing your Mental Health skills in routine practice:

1. Recognising patients at increased risk of depression

2. Detection and assessment

3. What you can do– Self-help resources

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High risk of depression:

• Watch out for - those with a history of: – Previous episode of depression – bipolar affective disorder / mania – suicide attempt – Other mental health problems– Family history of depression

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Detection of depression

Under-represented groups?

Older adultsMay present with other conditions

People with long term conditionstreatment can improve quality of life, reduce use of emergency services, and reduce care costs

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Detection of depression in primary care

Screening Questions• PHQ-2 :• During the last month, have you often

been bothered by: – feeling down, depressed, or hopeless? – having little interest or pleasure in doing

things?  • Use the PHQ-9?

Generalised Anxiety Disorder GAD Screening

• GAD -2;– Feeling nervous, anxious or on edge– Not being able to stop or control worrying

• Use the GAD – 7?

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Further assessment – areas to cover

• Severity, impact• Duration• How are you spending your day?

– Activities, social support?• Physical symptoms

– Tired, sleep, eating, concentration, slowed or agitated

• Thoughts about self, others, future– Negative, failure / worthless, rumination

• History, previous episodes• Risk – suicidal -Thoughts, plans, actions?

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Diagnosis issues

Watch out for:

Over use of ‘mixed anxiety and depression’ as a ‘catch all’

- use a depression or anxiety disorder diagnosis if you can / or adjustment disorder?

Under reporting of recurrent depressive disorder, (had a previous episode)

Assessment - Physical aspects of depression

• Bodily state influences mood• Bodily symptoms interpreted as signs of

inadequacy, failure, not as symptoms of depression

• Diagnose and Normalise symptoms and their responses– E.g. you’re not lazy - being tired, low energy is part of

depression• Point out – avoidance helps them feel better in

that moment, but keeps them stuck longer term

What you can do –levels of interventionC

BT

BehaviouralActivation

Structure, routine, monitor the problem(s)

Assessment incl. vicious cycle

First steps after assessment:

• What’s their view of it? Listening to their explanation:– ‘Lazy’, = this is me - stable trait

• Offer alternative CBT model:– Learnt views of yourself– Using bad strategies– In a hole and digging

• Self fulfilling prophecies– vicious circles

Guidelines

Effective psychological treatments:•Depression – guided self help, behavioural activation, CBT, IPT•Can be used in combination with medication, especially if more severe

Guided self helpGSH booklets:

1.Psycho education about the disorder

2.Simple CBT strategies to overcome it

3.Diary and monitoring sheets

•Need to be literate •Most only in English •Wide range of topics

Guided Self help resources

• Google – ‘nhs self help’ – wide range of leaflets

http://www.ntw.nhs.uk/pic/selfhelp/– ‘CCI Australia’ – series of modules– http://www.cci.health.wa.gov.au/resources/con

sumers.cfm– livinglifetothefull.com / mood gym– Getselfhelp – lots of resources

– Apps – Moodkit, CBT Experiments, CBT Diary

How to use Guided self help• Read it yourself so you know what’s in it• Ask patient to read, does it fit with their

experience? • Arrange follow up where they know you will ask

them about it• Emphasise its not just reading, but a workbook

to write in, put into practice, and keep a diary of the outcomes

• Very important to follow up: What did you learn?– What have you tried to do differently? / How did that

go? Next steps?

Behavioural Activation –Woody Allen

• ‘80% of success is just turning up’

VignettesExercise – discuss in pairs:

1. First presentation– What would you do?– Extra questions?– Extra tests?

2. Follow up meeting– What would you do?

Vignette

1. A 50 year old white male, with diabetes, attending several times, complaining of various vague headaches, back pain, lost interest in doing things and had stopped exercising, or going out unless necessary.

What you can do

1. Assess and diagnosis

2. Psycho education / guided self help

3. Medication +/or refer to LTT

4. Compliance• Ask – how feel about medication / taking it? /

did they read the gsh booklet / go to the workshop / therapy appointment / do the homework?

Primary Care Update 2014 – Lambeth Talking Therapies (LTT)

1. What is available to support you

2. LTT - A brief reminder

3. How are we doing?

4. New developments

What we are doing..• An immediate treatment intervention

package from the first triage call: 1. Workshops

2. Self help materials, books on prescription

3. Links to Community activities• Let patients know:

– For them to start something straight away– If it is not effective, can go onto further

treatment

Active support…

»

• Triage action

plan

self help

• Workshops Community activity

Key IAPT performance measures I

• Access– Clients entering treatment as a proportion of

estimated need– Target is 15% per year

• Recovery– Clients in recovery as a proportion of clients

completing treatment (who were at ‘caseness’ at first appointment)

– Target is at least 50%

Last quarter – Recovery rate - beat 50% target

Access – beat 15% target

Performance

• Access – seen 7,101 – 17% of need -target of 15%, in 14/15

• Recovery rates – more variable, – hit 51%, target 50% in last quarter

A brief reminder……

• .

Referral path – North Lambeth

If straightforward, If significant

can use therapy If lifestyle social issues,

If need multi-disciplinary

team, high risk

Personality issues

GP

LTT triage

Assessment & TreatmentPsychotherapy

Living WellNetworkLEIPS

Referral path – South (for now)

If straightforward, If significant

can use therapy If lifestyle social issues, and/or if

need multi-disciplinary

team, high risk

Personality issues

GP

LTT triage

PsychotherapyAssessment & treatment

Team, Community OptionsCentre 70

LEIPS

Lambeth Talking Therapies

LTT Triage

IAPT Step 2Step 3

CounsellingStep 2Step 3

Employment support

Stepped care• Stepped care – least intensive option first

Step 2: • Workshops, groups, Psychological Wellbeing

Practitioners, on-line programmes• Counselling - 6 sessions

Step 3:• Cognitive Behaviour Therapy -CBT• Counselling – 12 sessions• Waterloo Community Counselling for counselling in

other languages (up to 18 sessions).

• Most triaged within 2 days of opting in• Wait for treatment – if flexible:

– Step 2 low intensity a couple of weeks– Step 3 High Intensity around 12 weeks

Waiting times

Our partners:

How to get to us• Simply give people the self referral

leaflet and ask them to ring

– They ring to opt-in, have telephone triage

– OR– Send referral form to highlight key

information– Give them the leaflet and ask to ring

in– Anyone can refer / self refer - OR- on-line self referral

www.slam-iapt.nhs.uk

Further developments?• For us, we are now constricted by

room space issues– Space in your surgery?

• Recurrent depression – pilot of LTC model, with keyworkers:– More relapse prevention?– Role of GP?– More feedback?– How to code / monitor implementation?

Perinatal developments

• LEAP Big Lottery funding– Coldharbour / Loughbrough junction

focus• Recent Kennington pilot now finished• For pregnant and new mums• Can self refer but preferably use the

referral form and note gestation / due date

• Please keep referring!

Perinatal pilot initial findings • As much GAD, anxiety as depression

– Screen for both• Low referral rates

– How do we change our practice to ask the PHQ 2 and GAD 2 screening questions?

• Stigma– Clinic in Children’s centres?

• Specialist needs?– couple work? Adjustment? Attachment to

baby?• Capacity to prioritise

We used your feedback Now we need it again

• Developments of triage package, workshops and post therapy support groups led directly from your feedback

• Now we need it again – GP satisfaction survey

• Link • Please fill in paper copies today!

Further information:• Referrals and queries

GP direct line 07972527160020 3228 6747 is main lineslm-tr.LambethPTS@nhs.net LIAPTScreeningteam@slam.nhs.uk

• john.manley@slam.nhs.uk07792292070

• Website - www.slam-iapt.nhs.uk

The Living Well Network Hub

Emma Willing Programme Manager

The Hub A front door to mental health services in Lambeth• Receive referrals for mental health treatment and support for adults in

North Lambeth, this will be opened up to South Lambeth residents June 29th

• An introductions coordinator will screen the introductions for suitability, urgency and need.

• Provide assessment and up to 12 weeks of intervention to support people to manage their mental health and wellbeing. This may be a clinician, peer intern or a community support guide

The Hub aims to: • To work with people earlier to reduce crisis• Provide quicker and easier access to support• Offer a greater emphasis on social as well as clinical support• To help support GPs to work with people with mental health needs in

primary care• Refer onto secondary care when needed

The Hub

We cannot:

• House people• Provide a crisis response • Work with people who have a primary diagnosis of substance misuse• Provide talking therapies• Offer outpatient psychiatric clinics• Provide seven day follow up appointments following admissions

• BUT WE CAN LINK PEOPLE TO SERVICES IN THE COMMUNITY WHO MAYBE ABLE TO HELP

The Hub

Coproduction:

–Recognising people as assets – Building on people’s existing capabilities – Peer support networks – Blurring distinctions – Facilitating rather than delivering – Mutuality and reciprocity

How is the Hub Changing

Introductions Team

• Small group expert clinicians, peer interns and community guides that will provide phone and face to face contact introductions to screen all the people introduced to the Hub identifying where people’s needs are best met

• Gatekeep access to secondary care in Lambeth• Provide up to 12 weeks of holistic intervention to support people to

manage risk and symptoms to enable them to recover, provide psychoeducation, social inclusion, occupational performance and to support people to access other services or organisations to meet their needs

How is the Hub Changing?

Locality Teams • Team of Community Support Guides, Social

Worker, OT and peer interns working within the GP localities

• Provide one to one practical and social support for up to 12 weeks around tenancies, benefits, debt, housing, social inclusion, education and vocation

How the Hub is Changing?

• Provide advice on mental health, treatment and resources to practices

• Offer groups to support well being and mental health• To link people with their communities and support

within those communities• Support GP’s to holistically support people and their

carer’s in primary care

How the Hub is Changing?

• We will be based in Streatham Job Centre Plus• Community facing (most of our work will be in the

community and people’s homes• People will be able to self introduce themselves via

phone • The Hub will hold walk in sessions for people to come

along to enable them to engage with their local communities to get well and stay well

The Living Well Network

Living Well Partnership / Mosaic Clubhouse– Information Hub– 12 week offer for social inclusion and vocational reablement– Includes in house courses and the Recovery College– Clubhouse for longer term support

Network Open MorningLast Thursday of the Month11:00am – 12:30pm Living Well Partnership65 Effra Road, Brixton, SW2 1BZ

How the Hub is Changing?

• CIS is being renamed as the GP+ service but it’s aims remain the same

• Promotes people to be moved from secondary care to primary care • Resources available are staff, training and financial incentives.• PASS will identify people and work with Care Coordinators and GPs

to facilitate discharge• People will have access to hub resources and the network • People will be seen every 3 months to review their physical and

mental wellbeing• All people will have a coproduced crisis plan to provide an easy

route back into services should they require extra support

• Questions and any issues?

Prescribing antidepressants

Dr Nozomi AkanumaConsultant Psychiatrist

South Lambeth Assessment & Liaison TeamSouth Lambeth MAP Treatment Teams

Overview

• How to diagnose depression• Who should be considered treatment with

antidepressants• What to tell when prescribing antidepressants

Symptoms of major depression

• Depressed mood*• Diminished interest or pleasure in all activities*• Weight loss, decreased or increased appetite• Insomnia or hypersomnia • Psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness or inappropriate guilt• Diminished ability to think or concentrate• Recurrent thoughts of death or suicide

Major depressive episode – DSM IV

A. 5+ symptoms, 2+ weeks, functional impairmentB. Not a mixed episodeC. Clinically significant distress or impairment in social,

occupational, or other important areas of functioning

D. Not due to the direct physiological effects of a substance or a general medical condition

E. Not better accounted by bereavement

Grade of severity

• Subthreshold: < 5 symptoms• Mild: 5+ symptoms + minor functional impairment.• Moderate: Between 'mild' and 'severe’.• Severe: Most symptoms + marked interference with

functioning, with/without psychotic symptoms

Indications for antidepressants

• First-line of treatment (step 4) for:– Moderate and severe episode in adults– Subthreshold depression lasting for 2+ years

• An option (step 3) for:– Past history of moderate to severe episode– Episode lasting for >2-3 months

• Not a first line treatment (step 1 & 2) for:– Short episode of subthreshold episode or mild to

moderate episode without past history

What to tell when prescribing

• You need to take antidepressant every day.• You may experience side effects which are well

tolerated and disappear within weeks.• Symptoms start improving in week 1-2 but you may

not notice it until week 3-4 weeks.• You may feel worse or more anxious initially.• Once stabilised, you need to take it for months to

stay well.• You may experience discontinuation symptoms when

missing doses or stop it abruptly.

Discontinuation symptoms• Semantic difference: “discontinuation” vs “withdrawal”• May occur after missing doses or stopping abruptly• Experienced by a third of patients.• May be entirely new or similar to some of the original

symptoms:– Affective, GI, neuromotor, vasomotor, neurosensory, or

other neurological• Onset usually within 5 days• Usually mild and self-limiting within a month• More common when on treatment for 8+ weeks, or with

drugs with short half-life (e.g., paroxdetine, venlafaxine)• Gradual discontinuation over 4 weeks to avoid• May need to replacing the original drug with a longer short-

life drug (eg fluoxetine), or symptomatic treatment

Suicidality

• Antidepressant associated with increased risk of suicidal thoughts

• In particular in adolescents and young adults, <30 years old

• Higher risk during the first 28 days• Risk may increase during 28 days after stopping

antidepressant• Relative risk elevated, but absolute risk small• Suicidality is greatly reduced by use of

antidepressants

Guidelines for antidepressants prescribing

Eromona WhiskeyMedicines Information, SLaM

Outline

• Choice of antidepressant

• Monitoring treatment outcomes

• Switching antidepressants

Maudsley Medicines Information

2500 enquiries/year

Psychiatrists

GPs, CPNsPharmacists

Patients/Carers

History of the Maudsley Guidelines

Choice of antidepressant

Choice of antidepressant

• Is there psychiatric co-morbidity?• Concurrent medical illness• Other prescribed medications• Patient preference• Previous treatment response• Likely side effects profile• Pregnancy and lactation• Safety in overdose

Antidepressant in pregnancy

Response and Remission

Normalcy Remission Recovery

Response

Improvement

Symptom

Syndrome

Treatment phases Acute Continuation Maintenance

Adapted from Kupfer 1991

Relapse Rates

• Aim for remission

• Almost 80% relapse in patients with residual symptoms

• 20% relapse in those with no residual symptoms

• Paykrl ES et al. Psychol Med. 1995;25(6):1171-1180

Relapse rates

Switching antidepressants

Factors to consider when switching antidepressants

Drug considerations in antidepressant switching:

Considerations in how to switch antidepressants:

Pharmacokinetics Fluoxetine to Sertraline

Drug Interactions Nortriptyline to Duloxetine

Withdrawal effects Paroxetine to Clomipramine

Concurrent use Venlafaxine to Mirtazapine

Pharmacology MAOI to Tricylic

Summary….

Switch after 4 weeks if no response, but consider longer trials in patients who have failed a number of treatments

Use a standardised rating instrument where possible

Aim for remission of symptoms

Pay particular attention to antidepressant properties when switching