IMPARTS: Integrating Mental and Physical Healthcare: Research Training and Services

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1 IMPARTS: Integrating Mental and Physical Healthcare: Research Training and Services Matthew Hotopf Lauren Rayner, Faith Matcham, Anna Simpson, Jane Hutton, Annabel Price, Lia Ali, Rina Dutta

2 The overlap between mental and physical Patients with chronic physical disease are at considerable increased risk of depression and related disorders. Mental disorders are associated with Poorer quality of life Poorer adherence Higher costs Worse physical health outcomes Premature mortality People with severe mental illness have years reduction in life expectancy. 50% of all first presentations with physical symptoms are medically unexplained Alcohol and drugs are major contributor to many physical illnesses

3 Barriers to integration of care Commissioning separation of mental and physical health built into systems of commissioning. Limited sharing of information across IT systems Workforce issues training and capacity Who owns the agenda?

4 IMPARTS Phase I: Mapping of mental health services provided to general hospitals: recommendations: Improved informatics Improved transparency of funding Developing training Developing services Phase II: Development of a toolkit for physical healthcare providers to enhance provision of mental health services Development of research infrastructure Development of the IMPARTS course

5 The IMPARTS package Informatics Routine collection of patientreported outcomes with advice on care & referral Care pathways Development of mental health care pathways for patients identified via screening Training Training in mental health skills with ongoing supervision from a mental health specialist Self-help Portfolio of bespoke self-help materials, tailored to specific long-term conditions New treatments Development of new low cost psychological treatments e.g. e-health

6 IMPARTS Screening Concept Uses a web based interface To screen medical outpatients for CMD and other symptoms Whilst they wait for their appointment. Results are immediately available to the clinician Prior to consultation IMPARTS flags up any psychological issues to address

7 Domains of assessments conducted Mental health depression, anxiety PTSD Physical health symptoms, HRQoL, Functioning occupational functioning Substance use alcohol, drugs, smoking Health beliefs, adherence

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11 Referral pathway Suicidal ideation AND severe depression (PHQ-9 score=20-27) Urgent referral to liaison psychiatry Suicidal ideation OR severe depression (PHQ-9 score=20-27) Referral to liaison psychiatry Mild to moderately severe depression (PHQ-9=<19) WITH complex interaction with medical problem Mild to moderately severe depression (PHQ-9=<19) WITHOUT complex interaction with medical problem Referral to clinical psychology Referral to IAPT

12 Implementation at KCH Rheumatology Limb reconstruction Hepatitis C Multiple Sclerosis Neurotrauma Cough Adolescent Liver Liver transplant Endocarditis COPD Paediatric Hepatitis Breast Cancer Stroke Adult cystic fibrosis Palliative care Hepatitis B Sarcoid

13 Implementation at GSTT Pain Services Adult Congenital Heart Disease Dermatology Kidney Transplant review Teenage and Young Adult Cancer Dialysis Satellite Units Palliative care Multiple Sclerosis

14 Depression (PHQ-9) CLINIC Rheumatology Limb Reconstruction Hepatitis C Adult congenital heart disease Chronic Pain Psoriasis Screens n=1080 n=570 n=580 n=276 n=304 n=352 Unique patients Probable Major Depression (MDD) Suicidal ideation Severe depression Moderate MDD n=785 n=276 n=103 n=273 n=294 n= (23.2%) 61 (22.1%) 19 (18.5%) 18 (6.6%) 179 (60.9%) 36 (10.8%) 46 (5.9%) 18 (6.5%) 3 (2.9%) 6 (2.2%) 51 (17.4%) 14 (4.2%) 72 (9.2%) 21 (7.6%) 5 (4.9%) 3 (1.1%) 100 (34.0%) 15 (4.5%) 73 (9.3%) 30 (10.9%) 8 (7.8%) 12 (4.4%) 64 (21.8%) 17 (5.1%) Mild MDD 37 (4.7%) 10 (3.6%) 6 (5.8%) 3 (1.1%) 15 (5.1%) 4 (1.2%)

15 Alcohol (AUDIT) & Drugs CLINIC Limb Reconstruction n=275 Hepatitis C n=92 Screens Unique patients Probable Alcohol Dependence 5 (1.8%) 0 Harmful drinking 1 (0.4%) 2 (2.2%) Hazardous drinking 28 (10.2%) 4 (4.4%) Probable Drug Dependence 10 (4.7%) 10 (17.2%)

16 Smoking CLINIC Rheumatology n=529 Limb Reconstruction n=270 Chronic pain n=190 Currently smoke 84 (15.9%) 42 (15.6%) 60 (31.6%)

17 Onward referral: Referral - % for eligible patients 39% 46% Referred on Refused 4% 15% Already receiving services Unknown

18 Training Specialty Rheumatology Limb Reconstruction Multiple sclerosis Adult Congenital Heart Disease Dermatology Topics Eliciting concerns and listening; How and when to refer; Encouraging adherence; Problem-solving; Needle-phobia; Using the depression self-help booklet; Sleep hygiene; Telling people about your condition; Motivational interviewing; Review session Introductory session; Managing anger; Supporting adjustment; Scheduling activity; Increasing adherence Adjustment, Supporting self-management; Structuring sessions, Working with unhelpful thoughts, Anger and acute distress Asking questions; Helping patients increase their activity levels; Supporting patients who are fearful of procedures; Working with general fears and worries; Managing transitions Introductory session; Helping patients respond to negative reactions; Motivational interviewing; Referral pathways; Challenges around relationships and disclosure

19 Research Potential Research database Trial recruitment IMPARTS screening data EPR clinical & demographic data We have ethical approval to prospectively request consent for contact for the IMPARTS interface IMPARTS pseudonymised Research Database I agree that a researcher can contact me to ask me if I m willing to take part in a research project Yes No More information RESEARCHER If the patient consents, it is possible to de-anonymise their record, enabling a researcher to contact them

20 IMPARTS Research Proposals Observational studies 1 IMPARTS Overview IMPARTS progress to date, presenting data on: 1) The feasibility and acceptability of screening 2) The prevalence of common mental disorder 2 Rheumatology Prevalence, severity and predictors of depression in Rheumatoid Arthritis 3 Rheumatology The role of dependency on others in Rheumatoid Arthritis: 4 Hepatitis C The impact of illness perceptions on medication adherence in Hepatitis C RCTs 1 Pain Ecological momentary assessment for depressive symptoms 2 Multiple sclerosis Self-management programme for psychological distress in MS 3 Dialysis E-health intervention for psychological distress in dialysis

21 The IMPARTS Course Master s level course designed for any health professional working in physical healthcare 5 days: 5 topics: The confused/agitated patient Adjusting to illness Substance misuse and dependence Medically unexplained physical symptoms Difficult encounters with patients Brilliantly organised, motivated teaching

22 Join the IMPARTS mailing list Subscribe at: //mailman.kcl.ac.uk/mailman/listinfo/mentalphysicalhealthcareinterface the group: For more information on IMPARTS: