Evidence shows us that specialised mood disorder clinics deliver cost savings, better clinical outcomes and improved patient satisfaction. Presented to the Trent Division of the Royal College of Psychiatrists, November 2013, Sheffield.

1. How to set up a
mood disorders clinic
Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire,
Leicestershire Partnership Trust
nstafford@doctors.org.uk
Royal College of Psychiatrists, Trent Division
Sheffield 6 November 2013
W1 Workshop

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
Sutton Coldfield Consulting
Nick Stafford Ltd
Media
BBC Radio 4
BBC World Service
BBC Radio Scotland
Channel 4
CB Films
LOOK
Psychologies
Other
Bipolar UK
UGLE
Wyley Brothers USA
My Mind Books
My Mind Apps

3. Thank you
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Donna Stafford CPN/NMP
Dr. Mark McConnochie ST5
K Gallagher CMHT Manager
Lynn Walters PA
Dr. Mike McHugh,
Consultant in Public Health
Joan Armstrong-Morton, OT
Dr. Julia Kestleman ST6
Dr. David Steadman GP2
Dr. Shahid Hussain ST4
BPE Cymru, Beating Bipolar
PARTNERS
• Leicestershire Partnership
Trust
• LLR PCT
• Astra Zeneca
THIRD SECTOR
• Rethink
• Depression Alliance
• Bipolar UK

4. Specialist services NICE 2006
DoH Guidelines 2007
• All trusts should provide:
– Specialist Mental Health Services
– Access to specialist advice from designated
experienced clinicians
– Referral on to tertiary services
• This has been provided with the Mood
Disorders clinic and provides other benefits

5. Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom, Nick Stafford

6. Public Education/Professional Attitude
Praised by the public for going public
Criticised by psychiatrists for going public

7. The Leicester Model
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A model easily replicated in other adult services
Within a generic CMHT setting
Set up when NWW introduced to LPT
Not commissioned
Within existing time and financial resources
No changes to job plan
Not academic
No research or service development grants (yet)

8. Specialists within specialisms
• What does it mean?
• Increasingly differentiated with medical progress
• In psychiatry
– A need for generalists and specialists
– ADHD, ASD, EDS, CFS / PIER, AOT / CAMHS, MHSOP
• Medicine and surgery
– The norm in all areas

9. Pros and Cons of a Bipolar Clinic
Pros
• Reduce readmissions
• Increase patient satisfaction
• Better continuity of care
• Improved education and
research
• Lower cost
Cons
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Not always more effective
Fragmentation of care
Tertiary setting distance
Gaps in overall care
Could focus less on functional
outcomes
• Need for greater peer support
and expertise

10. Time to hospital readmission for patients treated
in the mood disorder clinic v. standard out-patient care.
N=158
Single manic episode
After 1st, 2nd or 3rd IP admiss
POM = time to readmission
HR = 0.60
95%CI = 0.37 – 0.97
P=0.034
Kessing L V et al. BJP 2013;202:212-219
©2013 by The Royal College of Psychiatrists

11. Economic analysis
Kessing L V et al. BJP 2013;202:212-219

12. Who?
• Patients with
– Bipolar Disorder
– Recurrent depressive disorder
– Depression not responding to treatment >6/12
• This services is yet to be started
• Comorbidity is not an exclusion
• Anyone in adult services (and some MHSOP)

13. Why?
• Specialist clinics work
• They make working life interesting
• Patient satisfaction is high
• Complex phenotype with high external validity
• Requires broad knowledge of
– Psychopathology, Neuropsychology
– (Poly) Psychopharmacology, Psychotherapy
• Better continuity of care
• Improved education and research in the team
• Develop the use of non-medical prescribers

14. Non-medical prescribers
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Supplementary prescribers
MDT model in service
1 hour MDT supervision end of clinic
Focus on BAP & WFSBP guidelines
Regular teaching
Developing 6/12 Mood Disorders Magazine
Advice from Professor Hale’s Kent clinic

15. Integration in South Leicestershire
outpatient clinic services
NMP & CPN
assessment
clinic
Generic OPC
& wellbeing
services
Bipolar
specialised
clinic
CMHT
Outpatient
Clinic
Services
Integrated
depression
clinic

16. The philosophy of the pathway design
Apply what is known
Nothing new
Simple
appliance
of science
Don’t be clever
A model that can be
applied anywhere
Engineer the parts
Feedback to clinicians

17. The diagnosis of bipolar disorder
COMPLEX
DISORDER
COMPLEX
SERVICES

18. Where bipolar is missed
Each element is complex and requires its own solutions
Public
knowledge
Primary
care
CAPTURE MISSED BIPOLAR
PREVENT UNDERDIAGNOSIS
Secondary
psychiatric
care
Other
specialist
care
IMPROVE DIAGNOSTIC ACCURACY
PREVENT OVERDIAGNOSIS
This isn’t possible by just focusing on one element
or designed just by psychiatrists

19. Primary care red flags
Presenting complaint:
• Breast lump
• Blood on toilet paper
• Facial weakness
• Depression
Could it be:
• Breast cancer?
• Bowel cancer?
• CVA?
• Bipolar
disorder?

20. 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?

21. 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

22. Educating Primary Care
Bipolar Disorder
Guidance on recognition in
Primary Care
A pragmatic review and brief
management commentary
Daniel Dietsch, Nick Stafford, Daniel Mann,
Daniel Smith, Carolyn Chew-Graham

23. Primary care education in Leicester
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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

24. 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?

25. If GP refers to the Clinic
• Standard GP letter (no forms to fill in)
• HCL-32 if appropriate, not mandatory
– MDQ if preferred
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Option to use the Mental Health Facilitator
Patient educated about possible bipolar
Leaflets given (pre- and post-diagnosis)
Mood diary before OPC appointment

26. Specialised Bipolar Clinic Model
New
assessments
Follow ups
MDT
Tertiary service
Group and
individual BPE

27. Preparing the clinic setting
• Reducing the outpatient clinic load
• 720 caseload to 250
• Caseload percentages
– New referrals
– Existing mood disorders
– 30% total caseload managed in specialised clinic
• Initially half day/week (first 18 months)
• Now one day a week
• Preparing additional specialist depression clinic

28. Utilizing existing resources (caseload)
• There are enough cases of bipolar in a CMHT
caseload to stream them through a single
weekly clinic
– Bipolar = 25%
• We are now beginning to do the same with
more difficult to treat depression cases
– Depression = 30-40%

29. Staff (bipolar clinic)
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Consultant psychiatrist
ST4 Trainee psychiatrist
GP trainee
3 non-medical prescribers
Visiting clinicians
Occupational therapist
Administrative staff

30. Staff (depression), (provisional)
• 2 Consultant general adult psychiatrists
• 2 Consultant psychiatrist psychotherapists CBT
• ST4 psychiatrist & GP trainee
• Non-medical prescribers (two)
• Improve initial care pathway
• Specialize difficult to treat cases
• Overlap with bipolar clinic

31. Elements of the Clinic 1st Assessment
Specialised bipolar clinic model essential to make this work
Pre-Interview
Questionnaire
Semi-Structured
Interview
• Lengthy (up to 3 hrs.)
• Patients enjoy
completing
• Structure similar to
semi-structured
interview
• Question based around
DSM-IV criteria
• Detailed focus on
moods
• Predominant Polarity
• Bipolarity Index
• Detailed medication
history
• Comorbidities examined
• PD screening (IPDE)
• Occupational therapy
• 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
Soon to commence a parallel specialised depression clinic

32. Assessment elements
Comprehensive report
Copied to patient
Multi-dimensional
Co-morbidities managed
Detailed risk assessment
Holistic management plan
Tx - Medical, Psychological
Health advice, Quality
information
Health & Wellbeing group
Metabolic screening
Managed with GP

33. Pre-assessment questionnaire
• Video of questionnaire removed due to size

34. ISBD Taskforce BD/UD

35. Semi structured assessment
• Face to face interview:
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Questionnaire structure maintained
Clarify pre-interview questionnaire
Extra detail were needed
Are diagnostic criteria met? Listed in conclusion.
Bipolar I, II etc…
Predominant Polarity & Polarity Index
Review of comorbidity
• Axis I + addictions
• Axis II – IPDE
– Occupational therapy assessment & intervention

36. Management algorithms
• International Guidelines for bipolar treatment
– BAP
– WFSBP
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Weekly OPC initially if necessary
Management of comorbidity
Lifestyle advice
Psychoeducation (online and face to face)
• MDT approach and enhanced capacity

37. New psychoeducation course
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Traditional syllabus
In addition:
DBT (Interpersonal effectiveness)
Functional remediation
– Cognitive remediation
– Occupational therapy
• Family Focused Treatment
• Interpersonal Social Rhythm Therapy
• New manuals (patient, carer, professional)

38. Survival curve on time to recurrence.
BPE group cf. Control group:
Fewer recurrences
3.86 v. 8.37, F=23.6, P<0.0001
Less time acutely ill
154 v. 586 days, F=31.66, P=0.0001
Less hospitalised days (median)
45 v. 30, F=4.26, P=0.047
Colom F et al. BJP 2009;194:260-265

39. In development
• New Psychoeducation Course
• Web based support
• App development

40. MDT Benefits
• Weekly case based discussions
• Monthly teaching seminars
• Updates on current research

41. Specialised commissioned/
Embedded in 2ry care
• Simpler models that can fit into any secondary
care unit
• Cedars Centre vs. Maudsley specialised centre
• List specialised centres

42. Prof. Morriss’s RCT and planned
specialised depression model

43. Private sector developments
• Clinical Partners Ltd
• Nuffield Health
• Joint assessments with psychologist
• Clinics offer same services (except groups)
• Clinics in
– London
– Leicester
– West Midlands

44. Improved interfaces
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Primary care
Psychological therapies
Personality Disorder services
Etc…

45. 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

46. Key Conclusions
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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

47. Media attention & public education is
possible, even for a small project
nstafford@doctors.org.uk