Primary vs Specialist

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3 Primary vs Specialist Specialist services: Referral-based Preselected Mental health and/or addiction problem salient Primary care: First point of contact Undifferentiated Mental health and/or addiction issues less obvious More associated with physical health

4 General Practice Under siege Small business Volume of demand Time pressures

5 Care Plus programme Long-term condition management Nurse-led Extended consultation time Protected time Successful in Manaia PHO

6 Credentialing Initiative from Health Workforce New Zealand Contracted Te Ao Maramatanga NZ College of Mental Health Nurses Chance to get MH&A on the primary care radar [Not just about psychiatric patients ] Collaboration between Manaia PHO and DHB Mental Health Services

7 The Credentialing Programme Six training days over six months Not an academic programme Four Streams: Theory / Knowledge Skills / Practice Services / Resources Portfolio / Reflection Group clinical supervision Mentors

8 Benefits of group Establishes a cohort that can Share experiences / learn from each other Experience group supervision Offer on-going support Provides opportunity to Tailor content to local need Meet local providers Important to grow the cohort

9 We have have grown in knowledge and emotional intelligence listening and being mindful of what is truly important. Now we are nursing in the way we were meant to.

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11 Mental Health.the elephant in the room?

12 Descartes has a lot to answer for..

13 Mental Health Conditions In Primary Care: Common Under-recognised Disabling But highly treatable

14 The MaGPIe study Mental health and General Practice Investigation A project collaborating with the World Health Organisation study of psychological problems in primary care

15 Common Mental Disorders in Primary Care: Percentage of attenders with DSM-IV disorder in the last 12 months Any Anxiety Disorder Any Depression or or Any Substance Use Disorder } 35.7%

16 Disability and Burden of Disease Data WHO Global Burden of Disease study 5 of the top 10 causes of disability are mental health conditions (depression, anxiety disorders, alcohol misuse conditions, bipolar disorder, schizophrenia) Depression alone accounts for 12% of all disability WINZ data mental health conditions account for over 40% of all people on sickness benefit for more than 12 months most not getting effective treatment

17 Young People Aged Years Receiving a Sickness Benefit by Cause of Incapacity New Zealand April 2009 (n=8,519)

18 Stigma is the polite word for discrimination It pervades our entire social structure Integrating mental health education in schools may help destigmatise mental illness

19 Causes of Depression and Anxiety 71% thought mental illness was due to emotional weakness 65% attributed it to bad parenting 45% thought it was the victim s fault and could be willed away 43% thought it was incurable 35% thought it was the consequence of sinful behaviour 1990s survey of general population (UK)

20 A Role of Primary Care To integrate mental health, addiction and psychosocial interventions into the management of physical health problems (and vice versa). Ministry of Health website

21 Integrate because. Mental health operates as an independent risk factor for the development of physical disease There is a higher incidence of mental disorders in people with chronic physical health problems There is a higher rate of physical health problems in people with mental health disorders Ministry of Health website

22 Mental and Physical Health Intertwined In an integrated and evidence-based model of health, mental health (including emotions and thought patterns) emerges as a key determinant of overall health. Anxious and depressed moods, for example, initiate a cascade of adverse changes in endocrine and immune functioning, and create increased susceptibility to a range of physical illnesses. Research has shown that mental and physical health influence each other via two main pathways WHO Report 2001 A Public Health Approach to Mental Health

23 Mental Health is a Key Determinant of Health Status The first is directly through physiological systems, such as neuroendocrine and immune function; the second is through health behaviour. Further, these two pathways are distinct but not independent physiology effects health behaviour, health behaviour effects physiological functioning. The link between mental and physical health has yet to be fully recognised and acted upon by the health system, but the evidence is clear mental health is fundamentally linked to physical health outcomes. WHO Report 2001 A Public Health Approach to Mental Health

24 Depression - Recognition In primary care depression often presents as Vague physical complaints Symptoms of anxiety In NZ, of people with depression Up to 50% also have an anxiety disorder About 20% also have substance abuse disorders (MaGPie, 2003) Over 50% of people with depression had a concurrent medical condition (Yates, et al., 2004)

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27 Co-Morbidity of Medical Illness and Depression Illness % with Depression Cancer 40 50% Heart Disease 18 26% Diabetes 33% Multi-infarct Dementia 27 60% Multiple Sclerosis 30 60% Parkinson s Disease 40% Stroke 30 50%

28 Mental/Physical Health Link Example 1: Diabetes and Depression Patients with diabetes have double the population incidence of depression for reasons which are poorly understood Depressed patients are three times more likely not to comply with medical treatment Outcome of co-morbid diabetes/depression poorer diet, more hyperglycaemia, greater disability, higher healthcare costs BUT treatment of depression/anxiety in diabetic patients results in dramatically improved mental and physical health outcomes, lower secondary care costs the treatment pays for itself within 1 year

29 Mental/Physical Health Link Example 2: Depression and Heart Disease Depression predicts the incidence of heart disease (indications are of a common underlying inflammatory basis) Depressed patients have greater than three times the risk of a cardiac event, in particular MI Depressed patients have reduced post-mi survival, poorer adjustment, slower return to function, increased disability, increased medical costs Treatment of co-morbid depression results in improved mental and physical health outcomes, and lower secondary care costs the treatment pays for itself

30 NZ Guidelines MH Primary Care (2008)

31 NZ Guidelines MH Primary Care (2008) Importance of the primary relationship / partnership between patient and practitioner Routine psychosocial assessment is the key Screening 2-3 questions and other tools Management of depression using a stepped care approach Self-management strategies Brief psychological interventions should be available in the primary setting

32 Relationship Quality of the relationship more important than techniques Advantage as a practice nurse Therapeutic relationship vs friendship

33 Therapeutic relationship?

34 Screening for Depression Three questions detect most cases of depression in primary practice IF Yes to question 1 OR 2 and Yes to question 3 THEN Likelihood ratio of depression 9.1 ( ) Sensitivity 96% (95%CI 86-99%) Specificity 89% (95%CI 87-91%) (Arrol, et al., 2005)

35 Screening Questions 1. During the past month have you often felt down, depressed or hopeless? 2. During the past month have you had little interest or pleasure in doing things? 3. Is this something with which you would like help? (Arrol, et al., 2005)

36 Screening Questions for Anxiety During the past month have you been worrying a lot about everyday problems? If YES Is this something that you would like help with?

37 Stepped Care Listening and supporting itself is therapeutic Psychoeducation (understanding the condition helps to give the person hope, a sense of control, and normalises) Lifestyle changes (stress reduction, reducing A+D use, exercise, activity scheduling etc.) Relaxation training (slow breathing, progressive muscle relaxation, TM etc.) Structured Problem Solving Psychological Therapies (esp. CBT, Beating the Blues) Medication (patient preferences, in combination) Monitor for outcome resolution or progression to more significant condition

38 Motivational Interviewing Tools for Behaviour Change

39 What We Will Cover Brief Intervention FLO framework The big picture of MI Strategies for each stage: Pre contemplation and Contemplation Preparation Action Maintenance

40 Practice Nurse phone follow-up and support getting maximum bang for your buck 2-4 x 5 min phone calls over the first 2-4 weeks following diagnosis/initiating treatment most often by practice nurse Provide support, encouragement, enquire re medication adherence, address any questions, reinforce key messages (incl time taken to respond to antidepressants) Treatment effect is as strong as that of SSRI is an extremely cost-effective intervention (Dr David Codyre)

41 Five ways to wellbeing. Connect Be active Take notice Keep learning Give

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43 Conclusion - some take home points Mental health problems are very common Mental health problems affect all health outcomes mental and physical health are inextricably entwined Treatment is relatively simple via stepped care Addressing health behaviour is fundamental to mental health treatment and the basis of chronic care management.

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45 The Brain

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47 Child & Adolescent Mental Health Promotion Decreasing risk factors Poverty Social isolation Family violence / child abuse / bullying Toxins (incl. alcohol, drugs) Increasing protective factors Attachment Healthy brain development in infancy, childhood, adolescence Self-regulation Competent parenting Social support of family and friends Connected to school

48 The Early Years. Many of the well-documented risk factors that can impair early brain development are embedded in the experiences of poverty and malnutrition, illiteracy, violence, toxic exposures, and substances abuse It requires a vigorous public health approach. Shonkoff, D. and Phillips, D. (2000) From Neurons to Neighbourhoods: The science of early childhood development. Washington, DC: National Academy Press

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53 John Hartigan