how to set up a mood disorders clinic
DESCRIPTION
Evidence shows us that specialised mood disorder clinics deliver cost savings, better clinical outcomes and improved patient satisfaction. Presented to the Trent Division of the Royal College of Psychiatrists, November 2013, Sheffield.TRANSCRIPT
How to set up amood disorders clinic
Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire,Leicestershire Partnership Trust
Royal College of Psychiatrists, Trent DivisionSheffield 6 November 2013
W1 Workshop
DisclosuresPharmaceuticalsAstra Zeneca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kline LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd
Private PracticeClinical Partners LtdNuffield HealthSutton Coldfield ConsultingNick Stafford Ltd
MediaBBC Radio 4BBC World ServiceBBC Radio ScotlandChannel 4CB FilmsLOOKPsychologies
OtherBipolar UKUGLEWyley Brothers USAMy Mind BooksMy Mind Apps
Thank you
• Donna Stafford CPN/NMP• Dr. Mark McConnochie ST5• K Gallagher CMHT Manager• Lynn Walters PA• Dr. Mike McHugh, Consultant
in Public Health• Joan Armstrong-Morton, OT• Dr. Julia Kestleman ST6• Dr. David Steadman GP2• Dr. Shahid Hussain ST4• BPE Cymru, Beating Bipolar
PARTNERS• Leicestershire
Partnership Trust• LLR PCT• Astra Zeneca
THIRD SECTOR• Rethink• Depression Alliance• Bipolar UK
Specialist services NICE 2006DoH Guidelines 2007
• All trusts should provide:– Specialist Mental Health Services– Access to specialist advice from designated
experienced clinicians– Referral on to tertiary services
• This has been provided with the Mood Disorders clinic and provides other benefits
Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom, Nick Stafford
Public Education/Professional Attitude
Praised by the public for going public Criticised by psychiatrists for going public
The Leicester Model
• A model easily replicated in other adult services• Within a generic CMHT setting• Set up when NWW introduced to LPT• Not commissioned• Within existing time and financial resources• No changes to job plan• Not academic• No research or service development grants (yet)
Specialists within specialisms
• What does it mean?• Increasingly differentiated with medical progress
• In psychiatry– A need for generalists and specialists– ADHD, ASD, EDS, CFS / PIER, AOT / CAMHS, MHSOP
• Medicine and surgery– The norm in all areas
Pros and Cons of a Bipolar Clinic
Pros• Reduce readmissions• Increase patient satisfaction• Better continuity of care• Improved education and
research• Lower cost
Cons• Not always more effective• Fragmentation of care• Tertiary setting distance• Gaps in overall care• Could focus less on functional
outcomes
• Need for greater peer support and expertise
Time to hospital readmission for patients treatedin the mood disorder clinic v. standard out-patient care.
Kessing L V et al. BJP 2013;202:212-219
©2013 by The Royal College of Psychiatrists
N=158Single manic episodeAfter 1st, 2nd or 3rd IP admissPOM = time to readmission
HR = 0.6095%CI = 0.37 – 0.97P=0.034
Kessing L V et al. BJP 2013;202:212-219
Economic analysis
Who?
• Patients with– Bipolar Disorder– Recurrent depressive disorder– Depression not responding to treatment >6/12
• This services is yet to be started
• Comorbidity is not an exclusion
• Anyone in adult services (and some MHSOP)
Why?• Specialist clinics work• They make working life interesting• Patient satisfaction is high
• Complex phenotype with high external validity• Requires broad knowledge of
– Psychopathology, Neuropsychology– (Poly) Psychopharmacology, Psychotherapy
• Better continuity of care• Improved education and research in the team
• Develop the use of non-medical prescribers
Non-medical prescribers
• Supplementary prescribers• MDT model in service• 1 hour MDT supervision end of clinic• Focus on BAP & WFSBP guidelines• Regular teaching• Developing 6/12 Mood Disorders Magazine• Advice from Professor Hale’s Kent clinic
Integration in South Leicestershire outpatient clinic services
CMHT Outpatient
Clinic Services
Generic OPC & wellbeing
services
NMP & CPN assessment
clinic
Bipolar specialised
clinic
Integrated depression
clinic
The philosophy of the pathway design
Apply what is known Nothing new
Engineer the parts Feedback to clinicians
Don’t be cleverA model that can be
applied anywhere
Simple appliance of science
The diagnosis of bipolar disorder
Whole systems problems
Whole systems solutions
COMPLEXDISORDER
COMPLEXSERVICES
Where bipolar is missed
Public knowledge
Primary care
Secondary psychiatric
care
Other specialist
care
Each element is complex and requires its own solutions
CAPTURE MISSED BIPOLARPREVENT UNDERDIAGNOSIS
IMPROVE DIAGNOSTIC ACCURACYPREVENT OVERDIAGNOSIS
This isn’t possible by just focusing on one elementor designed just by psychiatrists
Primary care red flags
Presenting complaint: Could it be:• Breast lump
• Blood on toilet paper
• Facial weakness
• Depression
• Breast cancer?• Bowel cancer?• CVA?• Bipolar
disorder?
The goal in primary care
“If a GP sees Depressive Disorder they should have a reflex consideration of bipolar disorder every time and ask relevant questions to probe for it”
• How do we make this happen?
Practical solutions in primary care
Education for everyone
Screening tool – choice, is it
used?
Always be alert (as with cancer)
Asking just a few questions
can be effective
Low level of suspicion
Collateral history from
someone close
Educating Primary Care
Bipolar DisorderGuidance on recognition in
Primary CareA pragmatic review and brief management commentary
Daniel Dietsch, Nick Stafford, Daniel Mann, Daniel Smith, Carolyn Chew-Graham
Primary care education in Leicester
• Face to face large group seminars (50+)• RCGP meetings• Individual practice seminars (3-15)• All Primary HCPs invited (not just GPs)• Learn and discuss the diagnosis of bipolar• Complex case examples• How to make it work in their practice
– Bespoke to their needs
Primary care screening options
• Ask more questions – But which? (e.g. BRIDGE)
• Collateral history encouraged• EMIS / Systm1 alerts
– Surprisingly less popular with GPs• Formal screen HCL-32
– How useful is it in practice?– Frequency of use
• MDQ preferable?
If GP refers to the Clinic
• Standard GP letter (no forms to fill in)• HCL-32 if appropriate, not mandatory
– MDQ if preferred• Option to use the Mental Health Facilitator• Patient educated about possible bipolar• Leaflets given (pre- and post-diagnosis)• Mood diary before OPC appointment
Specialised Bipolar Clinic Model
New assessments Follow ups
Tertiary service Group and individual BPE
MDT
Preparing the clinic setting
• Reducing the outpatient clinic load• 720 caseload to 250• Caseload percentages
– New referrals– Existing mood disorders– 30% total caseload managed in specialised clinic
• Initially half day/week (first 18 months)• Now one day a week• Preparing additional specialist depression clinic
Utilizing existing resources (caseload)
• There are enough cases of bipolar in a CMHT caseload to stream them through a single weekly clinic– Bipolar = 25%
• We are now beginning to do the same with more difficult to treat depression cases– Depression = 30-40%
Staff (bipolar clinic)
• Consultant psychiatrist• ST4 Trainee psychiatrist• GP trainee• 3 non-medical prescribers• Visiting clinicians• Occupational therapist• Administrative staff
Staff (depression), (provisional)
• 2 Consultant general adult psychiatrists• 2 Consultant psychiatrist psychotherapists CBT
• ST4 psychiatrist & GP trainee• Non-medical prescribers (two)
• Improve initial care pathway• Specialize difficult to treat cases
• Overlap with bipolar clinic
Elements of the Clinic 1st Assessment
Pre-Interview Questionnaire• Lengthy (up to 3 hrs.)• Patients enjoy
completing• Structure similar to
semi-structured interview
• Question based around DSM-IV criteria
Semi-Structured Interview• Detailed focus on
moods• Predominant Polarity• Bipolarity Index• Detailed medication
history• Comorbidities examined• PD screening (IPDE)• Occupational therapy• Multi-axial DSM-IV
diagnosis (DSM-5 July)
MDT• Consultant• ST4• Non-medical prescriber
• Visiting clinicians• CPN• OT (BPE)• Social Worker
• Adequate time built in for assessments and follow ups
Specialised bipolar clinic model essential to make this work
Soon to commence a parallel specialised depression clinic
Assessment elements
Comprehensive reportCopied to patient
Holistic management planTx - Medical, Psychological
Health advice, Quality information
Multi-dimensionalCo-morbidities managedDetailed risk assessment
Health & Wellbeing groupMetabolic screening
Managed with GP
Pre-assessment questionnaire
• Video of questionnaire removed due to size
ISBD Taskforce BD/UD
Semi structured assessment
• Face to face interview:– Questionnaire structure maintained– Clarify pre-interview questionnaire– Extra detail were needed– Are diagnostic criteria met? Listed in conclusion.– Bipolar I, II etc…– Predominant Polarity & Polarity Index– Review of comorbidity
• Axis I + addictions• Axis II – IPDE
– Occupational therapy assessment & intervention
Management algorithms
• International Guidelines for bipolar treatment– BAP– WFSBP
• Weekly OPC initially if necessary• Management of comorbidity• Lifestyle advice• Psychoeducation (online and face to face)
• MDT approach and enhanced capacity
New psychoeducation course
• Traditional syllabus• In addition:• DBT (Interpersonal effectiveness)• Functional remediation
– Cognitive remediation– Occupational therapy
• Family Focused Treatment• Interpersonal Social Rhythm Therapy• New manuals (patient, carer, professional)
Survival curve on time to recurrence.
Colom F et al. BJP 2009;194:260-265
BPE group cf. Control group:
Fewer recurrences3.86 v. 8.37, F=23.6, P<0.0001
Less time acutely ill154 v. 586 days, F=31.66, P=0.0001
Less hospitalised days (median)45 v. 30, F=4.26, P=0.047
In development
• New Psychoeducation Course• Web based support• App development
MDT Benefits
• Weekly case based discussions• Monthly teaching seminars• Updates on current research
Specialised commissioned/Embedded in 2ry care
• Simpler models that can fit into any secondary care unit
• Cedars Centre vs. Maudsley specialised centre
• List specialised centres
Prof. Morriss’s RCT and planned specialised depression model
Private sector developments
• Clinical Partners Ltd• Nuffield Health
• Joint assessments with psychologist• Clinics offer same services (except groups)
• Clinics in– London– Leicester– West Midlands
Improved interfaces
• Primary care• Psychological therapies• Personality Disorder services• Etc…
Funding
• Partial funding for set up from Astra-Zeneca• AZ dissolved partnership with Seroquel 2012
• No additional funding received since• ‘Verbal’ support by Trust and PCT / CCG
• Operates within resources of the CMHT• Plan to introduce into other Leicester localities
Key Conclusions
• Specialised bipolar clinic essential and possible• Whole care pathway maximizes impact• Education of primary HCPs• Structured pre-interview questionnaire• Semi-structured interview• Follow treatment guidelines (WFSBP & BAP)• Integrate into existing OPC structure• MDT approach• Continually engineer pathways and components
Media attention & public education is possible, even for a small project