An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder


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Presented to a workshop on the challenges of detecting and diagnosing bipolar disorder at the Royal College of Psychiatrists International Conference, Edinburgh 2013.

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An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder

  1. 1. From primary to secondary care An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire Royal College of Psychiatrists International Conference Edinburgh July 2013 W4 Improving the diagnosis and management of bipolar disorder: screening, integrated care pathways and specialised clinics
  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 BMI Healthcare Clinics in: London, Leicester, Sutton Coldfield Previously Vice Chair Bipolar UK
  3. 3. Thank you • Donna Stafford CPN/NMP • Dr. Mark McConnochie ST5 • Kate Gallagher CMHT Manager • Lynn Walters PA • Dr. Mike McHugh, Consultant in Public Health • Dr. Shahid Hussain ST4 • Dr. Julia Kestleman ST6 • BPE Cymru & Beating Bipolar PARTNERS • Leicestershire Partnership Trust • LLR PCT • Astra Zeneca THIRD SECTOR • Rethink • Depression Alliance • Bipolar UK
  4. 4. The diagnosis of bipolar disorder COMPLEX DISORDER COMPLEX SERVICES
  5. 5. Where bipolar is missed Public knowledge Primary care Secondary psychiatric care Other specialist care Each element is complex and requires its own solutions CAPTURE MISSED BIPOLAR PREVENT UNDERDIAGNOSIS IMPROVE DIAGNOSTIC ACCURACY PREVENT OVERDIAGNOSIS This isn’t possible by just focusing on one element or designed just by psychiatrists
  6. 6. Public Education/Professional Attitude Praised by the public for going public Criticised by psychiatrists for going public • Image of Angelina Jolie • Image of Catherine Zeta Jones
  7. 7. The philosophy of the pathway design Apply what is known Nothing new Engineer the parts Feedback to clinicians Don’t be clever A model that can be applied anywhere Simple appliance of science
  8. 8. 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
  9. 9. Primary care red flags Presenting complaint: Could it be: • Breast lump • Blood on toilet paper • Facial weakness • Depression • Breast cancer? • Bowel cancer? • CVA? • Bipolar disorder?
  10. 10. 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?
  11. 11. 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
  12. 12. 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?
  13. 13. 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
  14. 14. Specialised Bipolar Clinic Model New assessments Follow ups Tertiary service Group and individual BPE MDT
  15. 15. Elements of the Clinic 1st Assessment Pre-Interview Questionnaire •Lengthy (up to 3 hrs.) •Patients enjoy completing •Structure similar to semi-structured interview •Question based around DSM-IV criteria Semi-Structured Interview •Detailed focus on moods •Predominant Polarity •Bipolarity Index •Detailed medication history •Comorbidities examined •PD screening (IPDE) •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 Specialised bipolar clinic model essential to make this work Soon to commence a parallel specialised depression clinic
  16. 16. Assessment elements Comprehensive report Copied to patient Holistic management plan Tx - Medical, Psychological Health advice, Quality information Multi-dimensional Co-morbidities managed Detailed risk assessment Health & Wellbeing group Metabolic screening Managed with GP
  17. 17. Structure of South Leicestershire outpatient clinics CMHT Outpatient Clinic Services Generic OPC services NMP & CPN assessment clinic Bipolar specialised clinic Integrated depression clinic
  18. 18. 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
  19. 19. 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
  20. 20. Media attention & public education is possible, even for a small project