Plenary Npcmhc Evidence

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  • 1. PRIMARY CARE MENTAL HEALTH COLLABORATIVE – THE EVIDENCE Dr Gabriel Ivbijaro MBBS FRCGP FWACPsych MMedSci MA Convenor WONCA Special Interest Group in Psychiatry & Neurology Medical Director Forest Road Medical Centre Mental Health PMS Practice
  • 2. AIMS • To quantify the scale of primary care mental health problems • To consider the role of ‘Collaboratives’ • To review some of the evidence supporting the use of collaboratives in managing common mental health problems in primary care • To examine the rationale for some of the measures chosen by this Collaborative 2
  • 3. WHAT ARE COMMON MENTAL HEALTH PROBLEMS? • Mental health problems excluding: – Schizophrenia, – Bipolar disorder – Severe depression – Severe obsessive compulsive disorder • The above are all disorders primary care is not equipped to deal with 3
  • 4. WHAT ARE SERIOUS MENTAL HEALTH PROBLEMS (SMI) • Safety: – Unintentional self-harm • Disability – Intentional self-harm (impaired ability to function – Safety of others effectively in community): – Abuse by others – Employment & recreation • Informal & Formal Care: – Personal care – Help from informal carers – Domestic skills – Help from formal services – Interpersonal relationships • Diagnosis: • Duration: – Psychotic illness – 6 months to more than two – Dementia years – Severe neurotic illness – Personality disorder (Building Bridges – DOH 1996) – Developmental disorder 4
  • 5. WHAT IS THE SCALE OF THE PROBLEM?
  • 6. GOLDBERG HUXLEY MODEL Level Filter Filter description Rate (per 1000) 1 Community (total) 250 1st Filter Illness Behaviour 2 Primary Care (total) 230 2nd Filter Ability to detect 3 Primary Care (identified) 140 3rd Filter Willingness to refer 4 Mental Illness Services 17 (total) 4th Filter Factors determining admission 5 Mental Illness (admissions) 6 6
  • 7. DEPRESSION • Common psychiatric problem in primary care worldwide • Often under-treated • Under-diagnosed (Ballinger et al 2001, Lecrubier 2001, WONCA Culturally Sensitive Depression Guideline 2005) 7
  • 8. EPIDEMIOLOGY • Female lifetime prevalence 20-25 % • Male lifetime prevalence 7-12% • Deliberate self harm 10-16% (Angst 1996, Murphy et al 1987) • There may be cultural variation in prevalence – Japan 2.6%, Chile 29.5% (Goldberg & Lecrubier 1995) 8
  • 9. WHO predict that by the year 2020 depression will be the second most important cause of disability after ischaemic heart disease Murray & Lopez 1997
  • 10. ANXIETY SYNDROMES • Many studies have shown high prevalence of anxiety syndromes worldwide (Robinson et al 1984, Angst & Dobler-Mikola 1985, Wittchen et al 1992) • Common disorders: – Generalised anxiety disorder (GAD) – Agoraphobia – Panic disorder • Sufferers are heavy primary care users (Goldberg & Huxley 1980) • Few consult specialist services (Regier et al 1978) • Many other ill-defined anxiety states present in primary care 10
  • 11. PREVALENCE & RECOGNITION OF ANXIETY SYNDROMES IN FIVE EUROPEAN PRIMARY CARE SETTINGS A WHO Study on Psychological Problems in General Health Care E. Weiller, JH Bisserbe, W. Maier & Y. Lecrubier (1998)
  • 12. FINDINGS • A detailed GP community study • Groningen, Mainz, Berlin, Manchester, Paris • Consecutive male & female GP attendees < 65yrs old • Screened with 12 item GHQ (General Health Questionnaire) • Exclusions : too ill, too far away, NFA, language problems • Within one week subjects underwent in-depth testing 12
  • 13. INSTRUMENTS & SAMPLE • Primary Care Version of Composite International Diagnostic Interview (CIDI WHO 1991) • Self –rated health status (5 point scale) • Brief Disability Questionnaire (BDQ) (Stewart et al 1988; Ware & Sherbourne 1992) • 10 359 approached & eligible • 9714 completed GHQ-12 • 1973 interviews in total • Mainz lowest response rate : 36.8% • Manchester highest response rate : 71.1% • These results are relevant to the UK population 13
  • 14. RESULTS • 4.6% ANXIETY RELATED PROBLEMS – 77.8% of these well defined psychiatric problem – 22.2% of these ill defined psychiatric problem – 6.7% : Sub-thresh-hold GAD – 8.5% : GAD – 8.8% : Agoraphobia +/- panic disorder – 3.3% : Panic disorder – 36.8% : Other mainly depression 14
  • 15. SUMMARY • Common mental health problems occur commonly • Primary Care is the first port of call • We need to improve the skills of Primary Care teams to deal with this effectively • Collaboratives may be one way forward 15
  • 16. NATIONAL PRIMARY CARE MENTAL HEALTH COLLABORATIVE (PCMHC) • Aimed at supporting Primary Care in dealing with common mental health problems • Approx 1 in 3 people consult GP with mental health problems • 80% of these dealt with by Primary Care • 30% of working age people obtain sick notes from GP for some kind of mental illness • Primary Care preferred option for most mental health users and carers 16
  • 17. KEY PRINCIPLES OF COLLABORATIVE • To create and validate a register for proactive care • To create alternative care management and arrangements for common mental health problems • To support the implementation of direct self care 17
  • 18. AIMS OF COLLABORATIVE • To improve the care of all working age adults with mental health problems in Primary Care • To identify innovative, successful mental health practices • To create an opportunity for multiple stakeholders to come together to learn from each others expertise and experience • To adapt care pathways and NICE Guidance to suit local needs 18
  • 19. WHAT WILL THE COLLABORATIVE MEASURE? • GP consultation rates for people with common mental health disorder electronic list • Rates of consultation with other GP staff for common mental health disorder electronic list • Rate of referral to CMHT/ consultant psychiatrists for people on common mental health electronic list • % of people with common mental health disorders electronic list issued Med 3, 4 & 5 totalling longer than 13 weeks • Individual teams will be encouraged to identify and report on local measures that are particular to their sites 19
  • 20. ARE COLLABORATIVES EFFECTIVE? • To answer this question I will review: – International literature on collaboratives – Effect of mental illness on GP consultation – Effect of referral to psychiatric services on the patient – Mental illness and unemployment 20
  • 21. PCMHC COLLABORATIVES - THE PICTURE • Extensive literature from USA, Australia, New Zealand, Canada that this approach is effective • Other Primary Care Collaboratives for long term physical conditions such as CHD, diabetes, patient access in the UK have also been effective 21
  • 22. INTERNATIONAL EXAMPLES NEW ZEALAND • A collaborative approach to the delivery of mental health services to juvenile offenders (2003 Hicks & McCormack) • Lead to service re-design and staff training • Improved levels of user satisfaction • Increase in knowledge and confidence of staff • Challenges encountered: – Client confidentiality – Sustainability – Differing organisational goals – Different organisational philosophies – Tension between medical & social models 22
  • 23. INTERNATIONAL EXAMPLES CANADA • Bridging with Primary Care: A shared care mental health pilot project (2002 Isomura et al) • Enhanced mental health care of patients in British Columbia • Increased GP, patient & carer satisfaction • Addressed a number of problems including: – Lack of access to timely consultation – Limited mental health services capacity 23
  • 24. INTERNATIONAL EXAMPLE USA • Californian adolescent mental health collaborative (1999) • Reduced suicide & parasuicide rates • Reduced teenage pregnancy & STD rates • Reduced alcohol and substance misuse rates 24
  • 25. ALL THE EVIDENCE SHOWS THAT PRIMARY CARE COLLABORATIVES CAN IMPROVE MENTAL HEALTH CARE MANAGEMENT
  • 26. WHY DO THEY WORK? • Lead to educational initiatives for staff • Lead to organisational change • Lead to culture change in individuals & organisations • Support self-reflection • Encourage learning from peers • Allow time out for reflection & refreshment 26
  • 27. RATIONALE BEHIND OUR CHOSEN MEASURES Consultation Rates • Patients with mental illness use primary care services more than those with long term physical conditions • Holistic care & appropriate care planning can reduce usage (Ivbijaro et al 2005) 27
  • 28. EXTRA CONSULTATION PER 1000 PATIENTS 1998 Figures adjusted to account for co-morbidity Condition Doctors Nurses Total Diabetes 14 51 65 Hyper tension 80 56 136 CHD 56 27 83 Ulcer healing drugs 131 12 144 Asthma/COPD 248 61 309 Antidepressants 316 16 332 28
  • 29. EFFECT OF REFERRAL TO PSYCHIATRIC SERVICES • Patients prefer to be treated for mental health problems by GP (van Boeijen et al 2005) • Limited capacity of secondary care settings • Some effective treatments e.g. CBT difficult to provide in primary care • Primary care needs to monitor referral rates to secondary care to better commission appropriate services 29
  • 30. MENTAL ILLNESS AND EMPLOYMENT Monitoring sick notes: • Very important for long term conditions • In back pain the longer you are off sick the more likely that you will not return to work • Mirrored by patients suffering from mental disorder • Useful to monitor this and link with services that can intervene to support people to maintain an occupational status 30