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NICE Depression (CG90) Audit

           N Peart
           N Nixon
           P Adams
Demographic and Clinical Population
              Data
                Number                        Percentage
Female          48                            60
White British   71                            89
Age 36 - 55     52                            65
Recurrent       69                            86


                Duration of Episode (weeks)   Percentage
                16 +                          88
                24 +                          73
Sample Mean     89                            -
Demographic and Clinical Population
              Data
                                                  Mean Follow-
                                     Percentage
                                                  up in weeks
Some Antidepressant                  98           -
Some change following non-response   80           -
Dose escalation following non-
                                     70           6.8
response
Switch following non-response        50           4.4
Initial assessment
Factor                              Percentage




    GOOD
Psychosocial/personality factors    98


Symptom profile/treatment history   95


Asked about suicidal ideation       93


Diagnosis based on assessment       89
Prescribing and follow up
                           Percentage
Discussion (where appropriate)               Mean Follow-up for cases
                                                   Percentage
Follow-up following anti-
                           meeting NICE      not meeting NICE Target
depressant initiation
                           Target (weeks)    [mean weeks (Range) ]
Side effects of medication                         54
Without suicidal intent    36% (0 – 2)       6.8 (3.3 – 17.4)
Rational for combination treatment                   53
With suicidal intent       47% (0 – 1)       6 (2.2 – 13)
Length of treatment                                  22
                                                            Mean Follow-
                                            Percentage
Potential benefits of escalation/switch             20      up in weeks
Some Antidepressant                         98              -
Some change following
Potential interactions non-response         80       16     -
Dose escalation following non-response      70              6.8
Discontinuation symptoms                             11
Switch following non-response               50              4.4
Psychotherapy
• ‘For people with moderatePercentage Cases depression,
                      Number Cases
                                    or severe    Mean Sessions

    provide a combination of antidepressant
    medication and a high-intensity psychological
All Cases             80           100           -
    intervention’ (CG90: 8.11.3.2)
• ‘For a Discussed 42
Any Therapyperson whose depression has not
                                   53            -
    responded to either pharmacological or
Any Referral Made     28           35            -
    psychological interventions, consider combining
    antidepressant medication with CBT.’ (CG90: 8.11.7.1)
Any Referral Accepted 19           24            7-8
• ‘The duration of treatment should typically be in
    the range of 16 to 20 sessions’ (CG90: 8.11.4.2/3)
NICE high-intensity   11           14            7
Prevention of Recurrence
• CBT, 16 – 20 sessions (CG90: 8.11.9.1)     Percentage

• MBCT, 8 sessions (CG90: 8.11.9.2)
   Recurrent cases                           86%
• ‘There is strong evidence that responders to
  medication, who have had multiple relapses,
   Secondary prevention (identifying
  should stay on medication to avoid relapse…This
   vulnerability and providing strategies or 36%
   advice for staying well)
  effect holds true beyond 12 months.’ (CG90: 12.6.4)
• ‘For people with recurrent severe depression…
   Advanced Statements                       0%
  consider developing advance decisions and
  advance statements.’ (CG90: 14.7.2.1)
Specialist Care
• ‘For a person whose depression has failed toPercentage
   respond to various strategies for
   augmentation and combination treatments,
 Resistant cases                              100%

         CLAHRC ≈ 50%
   consider referral to a practitioner with a
 Specialist Care (collaborative) in treating depression, or to
   specialist interest                        0%
   a specialist service’ (CG90: 12.3.16.5)
Recommendations
1   Improved availability of high-intensity psychological
    therapies for depression
      That can be realistically offered to the often complex
      presentations of this disorder seen in secondary
      psychiatric care
1   Specialist Care
      NICE requirement
      Lead cultural change
         Lead education and support for clinicians in finding optimal
         pharmacotherapy with appropriate follow up
         Showing the value of collaborative care between
         pharmacotherapy and psychotherapy in maximising benefit
         Addressing long term vulnerability rather than just treating
         episodes in isolation (i.e. secondary prevention)

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Clahrc audit 16_10_12

  • 1. NICE Depression (CG90) Audit N Peart N Nixon P Adams
  • 2. Demographic and Clinical Population Data Number Percentage Female 48 60 White British 71 89 Age 36 - 55 52 65 Recurrent 69 86 Duration of Episode (weeks) Percentage 16 + 88 24 + 73 Sample Mean 89 -
  • 3. Demographic and Clinical Population Data Mean Follow- Percentage up in weeks Some Antidepressant 98 - Some change following non-response 80 - Dose escalation following non- 70 6.8 response Switch following non-response 50 4.4
  • 4. Initial assessment Factor Percentage GOOD Psychosocial/personality factors 98 Symptom profile/treatment history 95 Asked about suicidal ideation 93 Diagnosis based on assessment 89
  • 5. Prescribing and follow up Percentage Discussion (where appropriate) Mean Follow-up for cases Percentage Follow-up following anti- meeting NICE not meeting NICE Target depressant initiation Target (weeks) [mean weeks (Range) ] Side effects of medication 54 Without suicidal intent 36% (0 – 2) 6.8 (3.3 – 17.4) Rational for combination treatment 53 With suicidal intent 47% (0 – 1) 6 (2.2 – 13) Length of treatment 22 Mean Follow- Percentage Potential benefits of escalation/switch 20 up in weeks Some Antidepressant 98 - Some change following Potential interactions non-response 80 16 - Dose escalation following non-response 70 6.8 Discontinuation symptoms 11 Switch following non-response 50 4.4
  • 6. Psychotherapy • ‘For people with moderatePercentage Cases depression, Number Cases or severe Mean Sessions provide a combination of antidepressant medication and a high-intensity psychological All Cases 80 100 - intervention’ (CG90: 8.11.3.2) • ‘For a Discussed 42 Any Therapyperson whose depression has not 53 - responded to either pharmacological or Any Referral Made 28 35 - psychological interventions, consider combining antidepressant medication with CBT.’ (CG90: 8.11.7.1) Any Referral Accepted 19 24 7-8 • ‘The duration of treatment should typically be in the range of 16 to 20 sessions’ (CG90: 8.11.4.2/3) NICE high-intensity 11 14 7
  • 7. Prevention of Recurrence • CBT, 16 – 20 sessions (CG90: 8.11.9.1) Percentage • MBCT, 8 sessions (CG90: 8.11.9.2) Recurrent cases 86% • ‘There is strong evidence that responders to medication, who have had multiple relapses, Secondary prevention (identifying should stay on medication to avoid relapse…This vulnerability and providing strategies or 36% advice for staying well) effect holds true beyond 12 months.’ (CG90: 12.6.4) • ‘For people with recurrent severe depression… Advanced Statements 0% consider developing advance decisions and advance statements.’ (CG90: 14.7.2.1)
  • 8. Specialist Care • ‘For a person whose depression has failed toPercentage respond to various strategies for augmentation and combination treatments, Resistant cases 100% CLAHRC ≈ 50% consider referral to a practitioner with a Specialist Care (collaborative) in treating depression, or to specialist interest 0% a specialist service’ (CG90: 12.3.16.5)
  • 9.
  • 10. Recommendations 1 Improved availability of high-intensity psychological therapies for depression That can be realistically offered to the often complex presentations of this disorder seen in secondary psychiatric care 1 Specialist Care NICE requirement Lead cultural change Lead education and support for clinicians in finding optimal pharmacotherapy with appropriate follow up Showing the value of collaborative care between pharmacotherapy and psychotherapy in maximising benefit Addressing long term vulnerability rather than just treating episodes in isolation (i.e. secondary prevention)

Editor's Notes

  1. 80% had at least one of escalation or switching
  2. Mention collaborative cf distant approach in general secondary care.
  3. PROXIMAL MECHANISMS OF ACTION: AD – anterior network for example blocking serotonin transporters in the striatum; reduce response to anxious faces, improve to happy at a largely preconscious level Therapist – dorsal network; for example helping people to re-appraise at a largely conscious level At a human level these 2 processes are interlinked (like it or not!). And so antidepressants have effects on enabling people to concentrate and plan better – to make better use of therapy; and therapy by helping people to re-think things makes the antidepressants more effective. And the 50% of people in the audit who got into the specialist team got this type of care