How to set up a
mood disorders clinic
Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire,
Leicestershire Par...
Disclosures
Pharmaceuticals
Astra Zeneca Ltd
Otsuka Ltd
Bristol Myers Squibb Ltd
Glaxo Smith Kline Ltd
Pfizer Ltd
Eli Lill...
Thank you
•
•
•
•
•
•
•
•
•
•

Donna Stafford CPN/NMP
Dr. Mark McConnochie ST5
K Gallagher CMHT Manager
Lynn Walters PA
Dr...
Specialist services NICE 2006
DoH Guidelines 2007
• All trusts should provide:
– Specialist Mental Health Services
– Acces...
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 publ...
The Leicester Model
•
•
•
•
•
•
•
•

A model easily replicated in other adult services
Within a generic CMHT setting
Set u...
Specialists within specialisms
• What does it mean?
• Increasingly differentiated with medical progress
• In psychiatry
– ...
Pros and Cons of a Bipolar Clinic
Pros
• Reduce readmissions
• Increase patient satisfaction
• Better continuity of care
•...
Time to hospital readmission for patients treated
in the mood disorder clinic v. standard out-patient care.

N=158
Single ...
Economic analysis

Kessing L V et al. BJP 2013;202:212-219
Who?
• Patients with
– Bipolar Disorder
– Recurrent depressive disorder
– Depression not responding to treatment >6/12
• T...
Why?
• Specialist clinics work
• They make working life interesting
• Patient satisfaction is high
• Complex phenotype wit...
Non-medical prescribers
•
•
•
•
•
•
•

Supplementary prescribers
MDT model in service
1 hour MDT supervision end of clinic...
Integration in South Leicestershire
outpatient clinic services
NMP & CPN
assessment
clinic
Generic OPC
& wellbeing
service...
The philosophy of the pathway design
Apply what is known
Nothing new

Simple
appliance
of science

Don’t be clever
A model...
The diagnosis of bipolar disorder
COMPLEX
DISORDER

COMPLEX
SERVICES
Where bipolar is missed
Each element is complex and requires its own solutions

Public
knowledge

Primary
care

CAPTURE MI...
Primary care red flags
Presenting complaint:
• Breast lump

• Blood on toilet paper
• Facial weakness
• Depression

Could ...
The goal in primary care
“If a GP sees Depressive Disorder they
should have a reflex consideration of
bipolar disorder eve...
Practical solutions in primary care

Education for
everyone

Screening tool –
choice, is it
used?

Always be alert
(as wit...
Educating Primary Care
Bipolar Disorder
Guidance on recognition in
Primary Care
A pragmatic review and brief
management co...
Primary care education in Leicester
•
•
•
•
•
•
•

Face to face large group seminars (50+)
RCGP meetings
Individual practi...
Primary care screening options
• Ask more questions
– But which? (e.g. BRIDGE)

• Collateral history encouraged
• EMIS / S...
If GP refers to the Clinic
• Standard GP letter (no forms to fill in)
• HCL-32 if appropriate, not mandatory
– MDQ if pref...
Specialised Bipolar Clinic Model
New
assessments

Follow ups
MDT

Tertiary service

Group and
individual BPE
Preparing the clinic setting
• Reducing the outpatient clinic load
• 720 caseload to 250
• Caseload percentages
– New refe...
Utilizing existing resources (caseload)
• There are enough cases of bipolar in a CMHT
caseload to stream them through a si...
Staff (bipolar clinic)
•
•
•
•
•
•
•

Consultant psychiatrist
ST4 Trainee psychiatrist
GP trainee
3 non-medical prescriber...
Staff (depression), (provisional)
• 2 Consultant general adult psychiatrists
• 2 Consultant psychiatrist psychotherapists ...
Elements of the Clinic 1st Assessment
Specialised bipolar clinic model essential to make this work
Pre-Interview
Questionn...
Assessment elements
Comprehensive report
Copied to patient

Multi-dimensional
Co-morbidities managed
Detailed risk assessm...
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-intervi...
Management algorithms
• International Guidelines for bipolar treatment
– BAP
– WFSBP

•
•
•
•

Weekly OPC initially if nec...
New psychoeducation course
•
•
•
•

Traditional syllabus
In addition:
DBT (Interpersonal effectiveness)
Functional remedia...
Survival curve on time to recurrence.

BPE group cf. Control group:
Fewer recurrences
3.86 v. 8.37, F=23.6, P<0.0001
Less ...
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 ...
Prof. Morriss’s RCT and planned
specialised depression model
Private sector developments
• Clinical Partners Ltd
• Nuffield Health
• Joint assessments with psychologist
• Clinics offe...
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 fundi...
Key Conclusions
•
•
•
•
•
•
•
•
•

Specialised bipolar clinic essential and possible
Whole care pathway maximizes impact
E...
Media attention & public education is
possible, even for a small project

nstafford@doctors.org.uk
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How to set up a mood disorders clinic

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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.

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How to set up a mood disorders clinic

  1. 1. How to set up a mood disorders clinic Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire, Leicestershire Partnership Trust nstafford@doctors.org.uk Royal College of Psychiatrists, Trent Division Sheffield 6 November 2013 W1 Workshop
  2. 2. Disclosures Pharmaceuticals Astra Zeneca Ltd Otsuka Ltd Bristol Myers Squibb Ltd Glaxo Smith Kline Ltd Pfizer Ltd Eli Lilly Ltd Lundbeck Ltd Servier Laboratories Ltd GW Pharma Ltd Private Practice Clinical Partners Ltd Nuffield Health Sutton Coldfield Consulting Nick Stafford Ltd Media BBC Radio 4 BBC World Service BBC Radio Scotland Channel 4 CB Films LOOK Psychologies Other Bipolar UK UGLE Wyley Brothers USA My Mind Books My Mind Apps
  3. 3. 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
  4. 4. Specialist services NICE 2006 DoH 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
  5. 5. Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom, Nick Stafford
  6. 6. Public Education/Professional Attitude Praised by the public for going public Criticised by psychiatrists for going public
  7. 7. 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)
  8. 8. 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
  9. 9. 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
  10. 10. Time to hospital readmission for patients treated in the mood disorder clinic v. standard out-patient care. N=158 Single manic episode After 1st, 2nd or 3rd IP admiss POM = time to readmission HR = 0.60 95%CI = 0.37 – 0.97 P=0.034 Kessing L V et al. BJP 2013;202:212-219 ©2013 by The Royal College of Psychiatrists
  11. 11. Economic analysis Kessing L V et al. BJP 2013;202:212-219
  12. 12. 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)
  13. 13. 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
  14. 14. 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
  15. 15. Integration in South Leicestershire outpatient clinic services NMP & CPN assessment clinic Generic OPC & wellbeing services Bipolar specialised clinic CMHT Outpatient Clinic Services Integrated depression clinic
  16. 16. The philosophy of the pathway design Apply what is known Nothing new Simple appliance of science Don’t be clever A model that can be applied anywhere Engineer the parts Feedback to clinicians
  17. 17. The diagnosis of bipolar disorder COMPLEX DISORDER COMPLEX SERVICES
  18. 18. Where bipolar is missed Each element is complex and requires its own solutions Public knowledge Primary care CAPTURE MISSED BIPOLAR PREVENT UNDERDIAGNOSIS Secondary psychiatric care Other specialist care IMPROVE DIAGNOSTIC ACCURACY PREVENT OVERDIAGNOSIS This isn’t possible by just focusing on one element or designed just by psychiatrists
  19. 19. Primary care red flags Presenting complaint: • Breast lump • Blood on toilet paper • Facial weakness • Depression Could it be: • Breast cancer? • Bowel cancer? • CVA? • Bipolar disorder?
  20. 20. 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?
  21. 21. 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
  22. 22. Educating Primary Care Bipolar Disorder Guidance on recognition in Primary Care A pragmatic review and brief management commentary Daniel Dietsch, Nick Stafford, Daniel Mann, Daniel Smith, Carolyn Chew-Graham
  23. 23. 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
  24. 24. 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?
  25. 25. 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
  26. 26. Specialised Bipolar Clinic Model New assessments Follow ups MDT Tertiary service Group and individual BPE
  27. 27. 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
  28. 28. 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%
  29. 29. Staff (bipolar clinic) • • • • • • • Consultant psychiatrist ST4 Trainee psychiatrist GP trainee 3 non-medical prescribers Visiting clinicians Occupational therapist Administrative staff
  30. 30. 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
  31. 31. Elements of the Clinic 1st Assessment Specialised bipolar clinic model essential to make this work Pre-Interview Questionnaire Semi-Structured Interview • Lengthy (up to 3 hrs.) • Patients enjoy completing • Structure similar to semi-structured interview • Question based around DSM-IV criteria • 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 Soon to commence a parallel specialised depression clinic
  32. 32. Assessment elements Comprehensive report Copied to patient Multi-dimensional Co-morbidities managed Detailed risk assessment Holistic management plan Tx - Medical, Psychological Health advice, Quality information Health & Wellbeing group Metabolic screening Managed with GP
  33. 33. Pre-assessment questionnaire • Video of questionnaire removed due to size
  34. 34. ISBD Taskforce BD/UD
  35. 35. 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
  36. 36. 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
  37. 37. 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)
  38. 38. Survival curve on time to recurrence. BPE group cf. Control group: Fewer recurrences 3.86 v. 8.37, F=23.6, P<0.0001 Less time acutely ill 154 v. 586 days, F=31.66, P=0.0001 Less hospitalised days (median) 45 v. 30, F=4.26, P=0.047 Colom F et al. BJP 2009;194:260-265
  39. 39. In development • New Psychoeducation Course • Web based support • App development
  40. 40. MDT Benefits • Weekly case based discussions • Monthly teaching seminars • Updates on current research
  41. 41. 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
  42. 42. Prof. Morriss’s RCT and planned specialised depression model
  43. 43. Private sector developments • Clinical Partners Ltd • Nuffield Health • Joint assessments with psychologist • Clinics offer same services (except groups) • Clinics in – London – Leicester – West Midlands
  44. 44. Improved interfaces • • • • Primary care Psychological therapies Personality Disorder services Etc…
  45. 45. 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
  46. 46. 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
  47. 47. Media attention & public education is possible, even for a small project nstafford@doctors.org.uk
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