Ivbijaro 02


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  • © Henk Parmentier 2005 © Henk Parmentier 2005
  • Ivbijaro 02

    1. 1. STEPPED CARE IN DEPRESSION Dr Gabriel Ivbijaro MBBS, FRCGP, FWACPsych, MMedSci, DFFP, MA Family Doctor & Chair, Wonca Working Party on Mental Health
    2. 2. AIMS <ul><li>Recognition of depression </li></ul><ul><li>Use of Evidenced Based intervention </li></ul><ul><li>Understanding stepped care </li></ul><ul><li>Able to use the mhGAP Algorithm </li></ul>
    3. 3. mhGap Modules
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    6. 6. Challenges - application of best evidence worldwide <ul><li>How can we best apply principles for the treatment of depression in primary care that: </li></ul><ul><ul><li>Are compatible with the range of cultural values held across the world’s continents </li></ul></ul><ul><ul><li>Incorporate patient choice </li></ul></ul><ul><ul><li>Are compatible with financial constraints faced by individual nations </li></ul></ul>
    7. 7. Antidepressants: current controversies <ul><li>Are antidepressants the answer to all problems or has the case been overstated? </li></ul><ul><li>Should antidepressant be routinely prescribed? </li></ul><ul><li>What role do they play in the overall treatment of depressive disorder? </li></ul>
    8. 8. SSRI’s- what’s new? <ul><li>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) </li></ul><ul><li>Looked at data on fluoxetine, venlafaxine, nefazodone, paroxetine </li></ul><ul><li>Mean change in HDRS compared between placebo & drug: FDA >1.8; UK NICE > 3 to be clinically significant </li></ul><ul><li>Most trials on severely depressed patients </li></ul>
    9. 9. SSRI vs placebo in depression
    10. 10. When do they work?
    11. 11. Meta-analysis conclusions <ul><li>Exceptionally large placebo response ≈ 80% </li></ul><ul><li>Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients </li></ul><ul><li>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 </li></ul>
    12. 12. What do we need? <ul><li>A pragmatic approach that combines best evidence and best practice whilst incorporating the attibutes of the best primary, secondary and tertiary care services </li></ul><ul><li>The ability to accommodate that patients move between and across services and have different needs at different times </li></ul><ul><li>As a rehabilitation psychiatrist I straddle a number of services and get a different perspective – what is the way forward? </li></ul>
    13. 13. Stepped care in mental health <ul><li>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 </li></ul><ul><li>How might it be conceptualised? </li></ul><ul><li>(Thornicroft & Kinsella BJP 2004, 185, 283-290) </li></ul>
    14. 14. Low level of resources – step A <ul><li>Step A : Primary Care with Specialist Back Up </li></ul><ul><li>Screening & assessment by primary care staff </li></ul><ul><li>Talking treatments including counselling and advice </li></ul><ul><li>Pharmacological treatment </li></ul><ul><li>Liaison and training with mental health specialist staff when available </li></ul><ul><li>Limited specialist back-up for </li></ul><ul><ul><li>Training </li></ul></ul><ul><ul><li>Consultation for complex cases </li></ul></ul><ul><ul><li>In-patient assessment & treatment for case that cannot be managed in primary care e.g. in general hospitals </li></ul></ul>
    15. 15. Medium level of resources – step A + step B <ul><li>Step B: Mainstream mental health care </li></ul><ul><li>Out-patient / ambulatory clinics </li></ul><ul><li>Community mental health teams </li></ul><ul><li>Acute in-patient care </li></ul><ul><li>Long-term community based residential care </li></ul><ul><li>Employment & occupation </li></ul>
    16. 16. High level of resources – step A + step B + step C <ul><li>Step C: Specialised/ differentiated mental health services </li></ul><ul><li>Specialised clinics for specific disorders/patient groups including: </li></ul><ul><ul><li>eating disorders, dual diagnosis, treatment resistant affective disorders, adolescent services </li></ul></ul><ul><li>Specialised CMHT’s including: </li></ul><ul><ul><li>early intervention teams , assertive community Rx </li></ul></ul><ul><li>Alternatives to acute admission including: </li></ul><ul><ul><li>Home Rx/crisis resolution, crisis houses, acute day hospital </li></ul></ul>
    17. 17. High level of resources – Step A + Step B + Step C <ul><li>Alternatives types of long stay community residential care including: </li></ul><ul><ul><li>Intensive 24 hr staffed residential provision, less intensively staffed accommodation, independent accommodation </li></ul></ul><ul><li>Alternative forms of occupation and vocational rehabilitation: </li></ul><ul><ul><li>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 </li></ul></ul>
    18. 18. Stepped care in depression <ul><li>Primary care has an important role to play in the treatment of depression </li></ul><ul><li>Antidepressants alone are not the answer </li></ul><ul><li>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 </li></ul>
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    20. 20. Risk Assessment
    21. 21. Primary Care Tips
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    30. 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 <ul><li>Use Local cases </li></ul><ul><li>All </li></ul>
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    34. 35. LOOK What did you see? LISTEN What did you hear? TEST What has been tested and what needs to be tested?