Mental Health Pathway Triggers for Mental Health Pathway Information for professionals Consider mainstream Mental Health Services (Green light Toolkit) Clinical Interface Protocol Clinical Assessment Information for service users/carers DIAGNOSIS Anxiety Obsessive Compulsive Disorder Depression Bipolar Disorder Psychosis Plan interventions/organise treatment goals Agree expected outcomes with patients and carers Consider other MDT involvement to facilitate outcomes MANAGEMENT/ TREATMENT Anxiety OCD Depression Bipolar Disorder Psychosis Significant Reduction in Symptoms No Significant Reduction in Symptoms Treatment resistance protocols Consider in patient assessment REVIEW Monitor improvement Monitor for side effects Promote recovery Enable rehabilitation Discharge Plan
Triggers HONOS-LD items to consider as triggers for discussion whether mental health assessment needed Anxieties/phobias/obsessive compulsive behaviour (score 2) Behaviour(s) sufficiently frequent and severe to produce some disruption of and impact on own or other people s functioning Problems with hallucinations or delusions (score 1) Occasional odd or eccentric beliefs or behaviours suggestive of hallucinations or delusions Problems associated with mood changes (score 2) Mood change producing significant impact on self or others (e.g. weeping spells, decrease in skills, withdrawal and loss of interest
Information for Professionals People with Learning Disability are likely to have a higher prevalence of mental health problems. Mental health problems are complex in presentation and can present a diagnostic challenge. Therefore, people with Learning Disability are more likely to have unmet mental health needs. Some flexibility is advised with the assessment approach, in that the assessment may need to be done over a period of time (rather than in one setting) and information from carers is very valuable. Caution is advised with diagnoses especially when there are other issues such as diagnostic overshadowing, cognitive distortion in difficult life situations and when there are symptoms related to other developmental disorders. Specific information for the following disorders: Anxiety Obsessive compulsive disorder Depression Bipolar disorder Psychosis
Information for Service Users and Carers Depression Leaflet Anxiety Leaflet Psychosis Leaflet Bipolar Disorder Leaflet
Clinical Assessment Full Psychiatric History Developmental History History of Presenting Illness Consider Co-morbid Illnesses Past Psychiatric History Past Treatment History (Consider Side Effects of Medications) Significant Medical History Family History Drugs and Alcohol Relationship History Forensic History Full MSE Investigations (For baseline and to monitor for side effects of medications) Full Blood Count Vitamin B12 Thyroid Functions Liver Functions U&Es
Anxiety diagnosis (ICD-10 ) Generalized Anxiety Disorder Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is "free-floating"). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed. Panic Disorder [Episodic Paroxysmal Anxiety] The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad. Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression. Social Phobias Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem. Symptoms may progress to panic attacks. Agoraphobia A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes. Panic disorder is a frequent feature of both present and past episodes. Depressive and obsessional symptoms and social phobias are also commonly present as subsidiary features. Avoidance of the phobic situation is often prominent, and some agoraphobics experience little anxiety because they are able to avoid their phobic situations.
OCD Diagnosis (ICD-10) The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.
Depression Diagnosis Depressive Episode In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and selfconfidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. Mild Depressive Episode Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities. Moderate Depressive Episode Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities. Page 1 of 2
Severe Depressive Episode Without Psychotic Symptoms An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present. Severe Depressive Episode With Psychotic Symptoms An episode of depression as described in F32.2, but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent. Recurrent Depressive Disorder A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania). There may, however, be brief episodes of mild mood elevation and overactivity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of recurrent depressive disorder (F33.2 and F33.3) have much in common with earlier concepts such as manic-depressive depression, melancholia, vital depression and endogenous depression. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes have been experienced. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-). Page 2 of 2
Bipolar Disorder Diagnosis Bipolar Affective Disorder A disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar. Bipolar Affective Disorder, Current Episode Hypomanic The patient is currently hypomanic, and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Manic Without Psychotic Symptoms The patient is currently manic, without psychotic symptoms (as in F30.1), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Manic With Psychotic Symptoms The patient is currently manic, with psychotic symptoms (as in F30.2), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Mild Or Moderate Depression The patient is currently depressed, as in a depressive episode of either mild or moderate severity (F32.0 or F32.1), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Page 1 of 2
Bipolar Affective Disorder, Current Episode Severe Depression Without Psychotic Symptoms The patient is currently depressed, as in severe depressive episode without psychotic symptoms (F32.2), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Bipolar Affective Disorder, Current Episode Severe Depression With Psychotic Symptoms The patient is currently depressed, as in severe depressive episode with psychotic symptoms (F32.3), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Bipolar Affective Disorder, Current Episode Mixed The patient has had at least one authenticated hypomanic, manic, depressive, or mixed affective episode in the past, and currently exhibits either a mixture or a rapid alteration of manic and depressive symptoms. Bipolar Affective Disorder, Currently In Remission The patient has had at least one authenticated hypomanic, manic, or mixed affective episode in the past, and at least one other affective episode (hypomanic, manic, depressive, or mixed) in addition, but is not currently suffering from any significant mood disturbance, and has not done so for several months. Periods of remission during prophylactic treatment should be coded here. Page 2 of 2
Psychosis Diagnosis Schizophrenia The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms. The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission. The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedate the affective disturbance. Nor should schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06.2, and those induced by psychoactive substances under F10-F19 with common fourth character.5.
Anxiety Management and Treatment Broad Approach To Treatment In Anxiety Disorders Consider the full range of possible co-morbidities when planning treatment Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Psychoeducation Return to baseline level of functioning Anxiety Management and Treatment Guidelines for Treatment with Medication The Frith algorithms Panic Disorder Generalised Anxiety Disorder NICE Guidelines
Panic disorders Algorithm 15.2 Treatment of panic disorders in adults with LD Try cognitive behaviour therapy or anxiety management Continue treatment Partial or poor response Try an SSRI or SNRI eg paroxetine, sertaline, escitalopram or venlafaxine Continue treatment Partial or poor response Try imipramine Continue treatment Partial or poor response Try propranolol Continue treatment Partial or poor response Try benzodiazepines Continue treatment but limit to 4 weeks
Algorithm 15.3 Treatment of generalised anxiety disorder in adults with LD Generalised anxiety disorder Cognitive behavioural therapy or anxiety management training where applicable continue Poor or partial response Predominantly somatic symptoms Minimal somatic symptoms Propranolol up to 120mg/day [Note 1] Poor response or side effects Continue treatment Stop propanolol Start an SSRI (preferably with a long half-life) or venlafaxine or pregabalin Poor response Continue treatment [Note 3] Try another SSRI or a tricyclic antidepressant or a small dose of antipsychotc or buspirone or a benzodiazepine [Note 2]
OCD Management and Treatment Broad Approach To Treatment In OCD Consider the full range of possible co-morbidities when planning treatment. Consider pervasive developmental disorders in the differential diagnosis, or as a co-morbidity. Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Consider exposure response prevention as part of the CBT approach. Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication o o The Frith Algorithms NICE Guidelines
Algorithm 15.1 Treatment of obsessive compulsive disorder (OCD) in adults with LD OCD Not associated with autistic spectrum disorder Associated with autistic spectrum disorder Try psychological approaches Try psychological approaches Poor response Poor response Continue treatment Try an antidepressant eg paroxetine or fluoxetine or sertraline a high dose if required upto BNF limits Try a small dose of antipsychotic eg haloperidol or risperidone or olanzapine Continue treatment Poor response or side effects Withdraw antipsychotic Try high dose of antidepressant if required upto BNF limits eg paroxetine or fluoxetine or sertraline or clomipramine Continue treatment Poor response or side effects Try a combination of small doses of an atypical antipsychotic and SSRI eg risperidone and paroxetine Continue treatment
Depression Management and Treatment Broad Approach To Treatment In Depressive Disorders Consider the full range of possible co-morbidities when planning treatment Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Consider whether part of a recurrent depressive disorder or bipolar disorder Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Consider prophylaxis if recurrent depression or bipolar disorder Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication The Frith Algorithms NICE Guidelines
Algorithm 17.1 Treatment of depression in adults with LD Depression [Note 1] Try a tricyclic antidepressant if previous history of successful treatment with this medication Severe psychotic depression or serious suicide risk. Consider ECT with concomitant antidepressant treatment ± antipsychotic Newer antidepressants eg SSRIs at therapeutic dose or for at least 4 weeks Effective, well tolerated Ineffective Ineffective Continue treatment for 6-9 months if first episode; 2-5 years if recurrent Increase dose. Re-assess after 4 weeks Review diagnosis Change antidepressant Change antidepressant consider SNRIs, NARIs, or a NASSA Continue treatment for 6-9 months if first episode; 2-5 years if recurrent Ineffective, poorly tolerated Effective, well tolerated Ineffective, poorly tolerated Change class of antidepressant Ineffective, poorly tolerated Consider lithium augmentation or ECT Monitor thyroid function tests 6-9 months Effective, well tolerated Effective Ineffective, poorly tolerated Augmentation with T3 Try reversible MAOIs [Note 2] Ineffective Effective, well tolerated. Maintain dietary restriction Ineffective Putative treatments [Note 3]
Bipolar Disorder Management and Treatment Broad Approach To Treatment In Bpad Consider whether part of a recurrent depressive disorder or bipolar disorder. Due consideration to prophylaxis Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase. Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication The Frith Algorithms NICE Guidelines
Algorithm 17.3 Treatment of mania/hypomania associated with bipolar affective disorder in adults with LD Continue mood stabiliser. In not already on one consider prophylaxis with lithium or carbamazepine or sodium valproate [Notes 3,4,5,6] Rapid tranquillisation [Note 8] Commence antimanic medication, one of the following eg olanzapine, quetiapine, divalproex sodium, sodium valproate, carbamazepine or risperidone [Note 2] Poor response With aggression Poor response/not on lithium or other mood stabiliser Add benzodiazepine [Note 7] Mania/ hypomania Without aggression Continue If already on lithium/other mood stabiliser augment the dose if permissible [Note 1] Poor response Commence mood stabiliser/ antipsychotic if not already started Attempt to withdraw antipsychotic drug Poor response Consider combination of mood stabilisers eg lithium+sodium valproate+/-antipsychotic drug Continue Consider other drugs such as clozapine, lamotrigine or topiramate NB Committee on Safety in Medicine warning
Psychosis Management and Treatment Broad Approach To Treatment In Psychotic Disorders Focus on containing risks Consider joint working with teams like PIER Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase. Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication NICE Guidelines
Approach to Treatment Resistant Conditions o o o o o Review history Review diagnosis Review doses of medication Review compliance to treatment Consider undiagnosed co-morbidites Review investigations: consider neuro-imaging Consider exploring for other developmental disorders o o o Consider influence of environmental factors Consider other classes of drugs, augmentation strategies Consider a period of assessment in the inpatient unit
Discharge Planning Ensure global outcomes achieved Agree on discharge with service user/carer Letter to GP Reason for referral Outcome of assessment Outcome of intervention Advice on management of condition in primary care Advice on early symptoms/signs of recurrence Advice on re-referral