Recovery From Depression Optimising Primary Care Management Dr Andrew Smithers Mental Health and LD Lead Coventry & Rugby CCG
CLINICAL TRIALS EXCELLENCE THE PHYSICIAN - LED NETWORK
Introduction Primarily a Primary Care Problem Prevalence: 3-10% of population in 1 year Prevalence: 2.3% 2 of population in 1 week Between 1:4 & 1:10 consultations are for MDD 1 to 4 new presentations per week Presentation physical or somatic features Depression vs. Anxiety
Core Symptoms Depressed mood Markedly diminished interest or pleasure in all, or almost all, activities Significant weight loss, or decrease or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or suicide attempt
Aims of Diagnosis Establish the presence of depressive complaints Identify the core symptoms of depression three = probably depression four = treatable depression Establish duration > 4 weeks Investigate psychosocial elements of causality Reactive vs: Endogenous Patients expectations Exclude other causes
Prevalence of Depression in Primary Care Historical Data is old Trends in Consultation Rates in General Practice 1995-2006 The burden of psychiatric disorder in primary care. International Review of Psychiatry, 1992 National Statistics Journal (1991 1992) My own and colleagues perception that Mental Health related consultations rate is increasing Pressure on secondary care is unprecedented Pressure on Primary Care is unprecedented Secondary Care waiting times are unacceptable Crisis Team referrals are problematic IAPT waiting times are unacceptable DOH funding is inhumanely unacceptable Cinderella Service Society is unacceptable Impact of Social Media
Data Analysis Presentations to Primary Care primarily because of poor mental wellbeing and/or defined mental illness. 2 month period Demographics Utilisation of Read codes Utilisation of Prescribing and referrals Consultations with Health Care Professionals
Overall consultation data where specific M/H Read codes exist Total consults October - 1853 Total M/H consults October - 181 Percentage that were of M/H - 9.8% Total consults November 1658 Total M/H consults November 158 Percentage that were of M/H - 9.5%
Low mood Anxiety with Stress related problem ADHD PND Insomnia Memory loss OCD Psychoses (all) Guilty ideas Morbin thoughts / [X]Psychogenic Emotional problem / Personality disorder Blunted affect Substance abuse Bereavement reaction 50 45 40 35 30 25 20 15 10 5 0 Read Code Usage (by consultation) October November Column1
Consultations by Gender 180 160 140 120 100 80 60 40 20 0 October November Male Female
Consultations by Age 250 200 150 100 November October 50 0 0-17 18-30 31-50 51-70 71-100
Depressive Anxiety symptoms Stress related OCD / Phobia / Memory / Demenia Sleep / insomnia ASD / ADHD Alcohol related Psychoses Behavioural Bereavement / Non-Read coded Consultations with 70 60 50 40 30 20 10 0 Mental Health Content October November
Overall consultation data where Read coded and free text M/H data exist Total consults October - 1853 Total M/H consults October - 389 Percentage that were of M/H - 21.0% Total consults November 1658 Total M/H consults November 291 Percentage that were of M/H - 17.5%
Observations from the audit Rates for neurotic disorders (depression and anxiety) have risen since the 2001 data, many factors: Increased awareness and lowered stigma Financial crash of 2008 Large ethnic difference between patients consulting and local population Wide variety of diagnostic and symptom codes used Peak incidence in 31 50 age range None coded mental health data increased consultation rates by almost double
The 10 Minute Consultation Impossible Telephone triage vs standard booking 4 minute history Double appointment for new presentation Continuity of care Telephone follow-up vs F2F Involve Primary Care Health workers Bathe Technique
Bathe Technique B: Background What is going on in your life? A: Affect How do you feel about that? T: Trouble What troubles you the most about that? H: Handling How are you handling that? E: Empathy That must be very difficult for you From The Fifteen Minute Hour by Stuart and Liebermann 4 th Edition
Treatment Listen Therapy Talk Therapy Drug Therapy Alternative Therapy Psychological Therapy Third Sector Referral to Secondary Care S/H, psychotic Sx, Rx resistance, severe complex Private referral
NICE Recommended Treatment Person Centred Care Low-intensity psychosocial interventions Drug Treatment Combination treatment (drugs, CBT & IPT) Continuation and relapse prevention Psychological interventions for relapse prevention
Treatment of Depression
Third Sector and Voluntary Organisations Mind (and Depression Alliance) http://www.mind.org.uk/ Rethink www.rethink.org British Association for Counselling and Psychotherapy http://www.bacp.co.uk/ Mental Health Foundation http://www.mentalhealth.org.uk/ PANDAS Foundation http://www.pandasfoundation.org.uk/ Together http://www.together-uk.org/ Local groups (Coundon Councillors, Light House, Tamarind Centre, Lamb Street The Pod
General Advice and Support Citizens Advice www.citizensadvice.org.uk Young Minds www.youngminds.org.uk Childline www.childline.org.uk Nightline http://nightline.ac.uk/ Age Concern www.ageuk.org.uk/ Relate www.relate.org.uk CRUSE http://www.cruse.org.uk/ Carers UK http://www.carersuk.org/home
Alternative Treatments Acupuncture Aromatherapy Breathing Exercises Exercise Meditation Nutrition and Diet Therapy EFT/EMDR Mindfulness Self Love and self help Homoeopathy
Recovery from Depression 3 Steps to Recovery What is the patient feeling What does the patient want What can the patient do about it Adequate treatment Open door policy MOT review and self resilience Recognition of vulnerability Mindfulness Exercise, exposure to green and blue Giving back
Well John, in the past two years you ve gone from being extremely depressed to being basically unhappy like the rest of us. My work here is done. NICE Subthreshold Depressive Symptoms.