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  • © Henk Parmentier 2005 © Henk Parmentier 2005

Transcript

  • 1. STEPPED CARE IN DEPRESSION Dr Gabriel Ivbijaro MBBS, FRCGP, FWACPsych, MMedSci, DFFP, MA Family Doctor & Chair, Wonca Working Party on Mental Health
  • 2. AIMS
    • Recognition of depression
    • Use of Evidenced Based intervention
    • Understanding stepped care
    • Able to use the mhGAP Algorithm
  • 3. mhGap Modules
  • 4.
  • 5.
  • 6. Challenges - application of best evidence worldwide
    • How can we best apply principles for the treatment of depression in primary care that:
      • Are compatible with the range of cultural values held across the world’s continents
      • Incorporate patient choice
      • Are compatible with financial constraints faced by individual nations
  • 7. Antidepressants: current controversies
    • Are antidepressants the answer to all problems or has the case been overstated?
    • Should antidepressant be routinely prescribed?
    • What role do they play in the overall treatment of depressive disorder?
  • 8. SSRI’s- what’s new?
    • Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration ( Irving Kirsch, Brett J. Deacon, Tania B. Huedo-Medina, Alan Scoboria, Thomas J. Moore & Blair T. Johnson PLoS Med 5(2) 2008)
    • Looked at data on fluoxetine, venlafaxine, nefazodone, paroxetine
    • Mean change in HDRS compared between placebo & drug: FDA >1.8; UK NICE > 3 to be clinically significant
    • Most trials on severely depressed patients
  • 9. SSRI vs placebo in depression
  • 10. When do they work?
  • 11. Meta-analysis conclusions
    • Exceptionally large placebo response ≈ 80%
    • Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients
    • The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication
  • 12. What do we need?
    • A pragmatic approach that combines best evidence and best practice whilst incorporating the attibutes of the best primary, secondary and tertiary care services
    • The ability to accommodate that patients move between and across services and have different needs at different times
    • As a rehabilitation psychiatrist I straddle a number of services and get a different perspective – what is the way forward?
  • 13. Stepped care in mental health
    • A holistic approach that takes into account the local situation and matches resources to individual patients whilst recommending minimum standards that all should aspire to
    • How might it be conceptualised?
    • (Thornicroft & Kinsella BJP 2004, 185, 283-290)
  • 14. Low level of resources – step A
    • Step A : Primary Care with Specialist Back Up
    • Screening & assessment by primary care staff
    • Talking treatments including counselling and advice
    • Pharmacological treatment
    • Liaison and training with mental health specialist staff when available
    • Limited specialist back-up for
      • Training
      • Consultation for complex cases
      • In-patient assessment & treatment for case that cannot be managed in primary care e.g. in general hospitals
  • 15. Medium level of resources – step A + step B
    • Step B: Mainstream mental health care
    • Out-patient / ambulatory clinics
    • Community mental health teams
    • Acute in-patient care
    • Long-term community based residential care
    • Employment & occupation
  • 16. High level of resources – step A + step B + step C
    • Step C: Specialised/ differentiated mental health services
    • Specialised clinics for specific disorders/patient groups including:
      • eating disorders, dual diagnosis, treatment resistant affective disorders, adolescent services
    • Specialised CMHT’s including:
      • early intervention teams , assertive community Rx
    • Alternatives to acute admission including:
      • Home Rx/crisis resolution, crisis houses, acute day hospital
  • 17. High level of resources – Step A + Step B + Step C
    • Alternatives types of long stay community residential care including:
      • Intensive 24 hr staffed residential provision, less intensively staffed accommodation, independent accommodation
    • Alternative forms of occupation and vocational rehabilitation:
      • Sheltered workshops, supervised work placements, cooperative work schemes, self-help and user groups, club houses/transitional employment programmes, vocational rehabilitation, individual placement and support services
  • 18. Stepped care in depression
    • Primary care has an important role to play in the treatment of depression
    • Antidepressants alone are not the answer
    • A variety of evidence based interventions should be possible whether practising in low, medium or high resource settings and a collaborative approach will need to be taken
  • 19.
  • 20. Risk Assessment
  • 21. Primary Care Tips
  • 22.
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  • 27.
  • 28.
  • 29.
  • 30. LOOK What did you see? LISTEN What did you hear? TEST What has been tested and what needs to be tested?
  • 31.  
  • 32. Case Discussion
    • Use Local cases
    • All
  • 33.
  • 34.
  • 35. LOOK What did you see? LISTEN What did you hear? TEST What has been tested and what needs to be tested?