PRIMARY CARE MENTAL
      HEALTH
COLLABORATIVE – THE
     EVIDENCE
  Dr Gabriel Ivbijaro      MBBS FRCGP FWACPsych MMedSci...
AIMS
• To quantify the scale of primary care
  mental health problems
• To consider the role of ‘Collaboratives’
• To revi...
WHAT ARE COMMON MENTAL
    HEALTH PROBLEMS?
• Mental health problems excluding:
  – Schizophrenia,
  – Bipolar disorder
  ...
WHAT ARE SERIOUS MENTAL
     HEALTH PROBLEMS (SMI)
• Safety:
   – Unintentional self-harm     • Disability
   – Intentiona...
WHAT IS THE SCALE
OF THE PROBLEM?
GOLDBERG HUXLEY MODEL
Level         Filter                        Filter description     Rate
                            ...
DEPRESSION

• Common psychiatric problem in primary
  care worldwide
• Often under-treated
• Under-diagnosed (Ballinger et...
EPIDEMIOLOGY

•   Female lifetime prevalence 20-25 %
•   Male lifetime prevalence 7-12%
•   Deliberate self harm 10-16% (A...
WHO predict that by the
year 2020 depression will
   be the second most
   important cause of
disability after ischaemic
 ...
ANXIETY SYNDROMES
• Many studies have shown high prevalence of
  anxiety syndromes worldwide (Robinson et al 1984,
  Angst...
PREVALENCE &
   RECOGNITION OF
ANXIETY SYNDROMES IN
   FIVE EUROPEAN
    PRIMARY CARE
      SETTINGS
  A WHO Study on Psyc...
FINDINGS
• A detailed GP community study
• Groningen, Mainz, Berlin, Manchester, Paris
• Consecutive male & female GP atte...
INSTRUMENTS & SAMPLE
• Primary Care Version of Composite International
  Diagnostic Interview (CIDI WHO 1991)
• Self –rate...
RESULTS
• 4.6% ANXIETY RELATED PROBLEMS
  – 77.8% of these well defined psychiatric problem
  – 22.2% of these ill defined...
SUMMARY
• Common mental health problems
  occur commonly
• Primary Care is the first port of call
• We need to improve the...
NATIONAL PRIMARY CARE
        MENTAL HEALTH
    COLLABORATIVE (PCMHC)
• Aimed at supporting Primary Care in dealing
  with...
KEY PRINCIPLES OF
         COLLABORATIVE
• To create and validate a register for
  proactive care
• To create alternative ...
AIMS OF COLLABORATIVE
• To improve the care of all working age adults
  with mental health problems in Primary Care
• To i...
WHAT WILL THE
  COLLABORATIVE MEASURE?
• GP consultation rates for people with common mental
  health disorder electronic ...
ARE COLLABORATIVES
          EFFECTIVE?
• To answer this question I will review:
  – International literature on collabora...
PCMHC COLLABORATIVES -
       THE PICTURE

• Extensive literature from USA, Australia,
  New Zealand, Canada that this app...
INTERNATIONAL EXAMPLES
          NEW ZEALAND
• A collaborative approach to the delivery of
  mental health services to juv...
INTERNATIONAL EXAMPLES
          CANADA
• Bridging with Primary Care: A shared care
  mental health pilot project (2002 Is...
INTERNATIONAL EXAMPLE
            USA
• Californian adolescent mental health
  collaborative (1999)
• Reduced suicide & pa...
ALL THE EVIDENCE
 SHOWS THAT PRIMARY
CARE COLLABORATIVES
 CAN IMPROVE MENTAL
    HEALTH CARE
    MANAGEMENT
WHY DO THEY WORK?
• Lead to educational initiatives for staff
• Lead to organisational change
• Lead to culture change in ...
RATIONALE BEHIND OUR
      CHOSEN MEASURES
Consultation Rates
• Patients with mental illness use primary
  care services m...
EXTRA CONSULTATION PER
     1000 PATIENTS 1998
                      Figures adjusted to account
                      for...
EFFECT OF REFERRAL TO
     PSYCHIATRIC SERVICES
• Patients prefer to be treated for mental
  health problems by GP (van Bo...
MENTAL ILLNESS AND
         EMPLOYMENT
Monitoring sick notes:
• Very important for long term conditions
• In back pain the...
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Plenary Npcmhc Evidence

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Plenary Npcmhc Evidence

  1. 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. 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. 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. 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. 5. WHAT IS THE SCALE OF THE PROBLEM?
  6. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 25. ALL THE EVIDENCE SHOWS THAT PRIMARY CARE COLLABORATIVES CAN IMPROVE MENTAL HEALTH CARE MANAGEMENT
  26. 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. 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. 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. 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. 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

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