Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield, Staffs, UK.
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Outlining the early proposal of an integrated care pathway for bipolar disorder in Staffordshire and Shropshire to a group of GPs in Lichfield.
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Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield, Staffs, UK.
- 1. From primary to tertiary care An integrated care pathway for the improved screening, assessment and management of bipolar disorder Dr. Nick Stafford, Consultant Psychiatrist Lichfield, SSSFT
- 2. Disclosures Pharmaceuticals Astra Zenenca Ltd Otsuka Ltd Bristol Myers Squibb Ltd Glaxo Smith Kilne Ltd Pfizer Ltd Eli Lilly Ltd Lundbeck Ltd Servier Laboratories Ltd GW Pharma Ltd Private Healthcare Nuffield Health Sutton Medical Consulting Rooms Full list of business relationships at: www.uk.linkedin.com/pub/nick-stafford/17/7a4/54a/
- 3. Public Education/Professional Attitude Praised by the public for going public Criticised by psychiatrists for going public
- 4. The management of bipolar disorder
- 5. Primary care Secondary psychiatric care Inpatient care Tertiary care CAPTURE MISSED BIPOLAR BEGIN TREATMENT EARLY SHARED CARE AGREEMENTS IMPROVE DIAGNOSTIC ACCURACY BEGIN TREATMENT EARLY ENHANCE SPECIALIST TREATMENT Each element requires its own solutions to improve overall outcomes Aims of the bipolar care pathway
- 6. Project in Leicester Health Care & Pharma Mental Health Trust AstraZenecaPCT/CCGs Charitable Bipolar UK Depression Alliance Rethink
- 7. Elements of the care pathway Primary Care Secondary Care Tertiary / Specialised Care Increase awareness Screening Enhanced assessment Psychosocial interventions Second opinions Comprehensive management plans Pilot sites: Lichfield (CMHT) Stafford (IP)
- 8. Elements of the care pathway Primary Care Secondary Care Tertiary / Specialised Care
- 9. Primary care red flags Presenting complaint: Breast lump Blood on toilet paper Persistent cough Depression Could it be Breast cancer? Bowel cancer? Lung cancer? Bipolar?
- 10. How do we fix it, practically? Education Screening tool not diagnostic Always be alert A few extra questions is effective Low index of suspicion History from someone close
- 11. 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”
- 12. Primary care education in Staffs Large group seminars (50+) Individual practice seminars (3-15) All Primary HCPs (not just GPs) Internet e-Learning programme
- 13. Primary care screening options • Ask more questions – But which? (e.g. BRIDGE) • Collateral history encouraged • EMIS / Systm1 alerts (software templates) – Surprisingly less popular with GPs • Formal screen HCL-32 – How useful is it in practice? – Frequency of use • MDQ preferable?
- 14. HCL-32 • Most validated screen for hypomania • Available in a range of languages • Combines stem questions with screening questions • Distribute packs in primary care
- 15. Dimension and categories Bipolar Depression Borderline Anxiety disorders Addictions HPA axis link?
- 16. Bipolar or unipolar depression
- 17. Borderline more likely if: • Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and sometimes more than a few days) • Identity disturbance: markedly and persistently unstable self-image or sense of self • Chronic feelings of emptiness • Severe dissociative symptoms • Frantic efforts to avoid real or imagined abandonment • Recurrent suicidal threats, gestures or behaviour • Self mutilating behaviour
- 18. Others (not exclusive) • Anxiety • ADHD • PTSD • Other personality disorders • ‘Behavioural’ • Alcohol & substance misuse
- 19. 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 CPN • Patient educated about possible bipolar • Leaflets given (pre- and post-diagnosis) • Mood diary before OPC appointment
- 20. Elements of the care pathway Primary Care Secondary Care Tertiary / Specialised Care
- 21. Specialised Bipolar Clinic And supporting services Psychosocial interventions Tertiary service
- 22. 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 can be provided with a local specialised bipolar disorder clinic
- 23. 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
- 24. Nick Stafford, Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom
- 25. Pros and Cons of a Bipolar Clinic Pros • Reduces readmissions • Increased satisfaction with care • Better continuity of care • Improved education and research Cons • Greater cost (not always) • 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
- 26. Time to hospital readmission for patients treated in the mood disorder clinic v. standard out-patient care. Kessing L V et al. BJP 2013;202:212-219 ©2013 by The Royal College of Psychiatrists 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
- 27. Kessing L V et al. BJP 2013;202:212-219 Economic analysis
- 28. Specialised Bipolar Clinic Model Secondary care assessments and management Second opinions in tertiary service Psychosocial interventions Training and Research MDT
- 29. Elements of the Clinic 1st Assessment Pre-Interview Questionnaire • Lengthy • Patients enjoy completing • Structure similar to semi- structured interview Semi-Structured Interview • Detailed focus on moods • Predominant Polarity • Bipolarity Index • Detailed medication history • Comorbidities identified TO IMPROVE DIAGNOSTIC ACCURACY AND CARE PLAN COMPREHENSIVENESS
- 30. Semi structured assessment • Face to face interview: – 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
- 31. Missed diagnosis of bipolar • Variable figures: >15% RDD in primary care • Impact of untreated episodes are manifold • Relationship breakdown • Occupational breakdown • Increased use of CMHT services • Increased use of inpatient services • Kindling in the untreated worsens prognosis
- 32. MDT Approach MDT Members •Consultants •Higher ST trainees •Non-medical prescribers •Visiting clinicians •CPN •OT (BPE) •Social Worker
- 33. Psychosocial interventions • Training for all IP & CMHT staff – Psychoeducation – Functional remediation – IPSRT (Interpersonal Social Rhythm Therapy) – DBT (Dialectical Behavioural Therapy) – FFT (Family Focused Therapy)
- 34. Bipolar Psychoeducation Survival curve on time to recurrence. Colom F et al. BJP 2009;194:260-265 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
- 35. The philosophy of the pathway design Apply what is known Iterative design The model can be applied anywhere Appliance of science
- 36. If GP/Psychiatrist refers to the Clinic Standard summary letter HCL-32 encouraged if appropriate Patient educated about possible diagnosis Leaflets given (pre- and post-diagnosis) Mood diary from referral to OPC appointment
- 37. Elements of management Comprehensive report Clarity of diagnosis & management Psychoeducation & Evidence-based management plan Multi-axial diagnoses & co-morbidities managed Health advice Quality information Management with GP
- 38. Elements of the care pathway Primary Care Secondary Care Tertiary / Specialised Care
- 39. Management algorithms • International Guidelines for bipolar treatment – BAP – WFSBP • Weekly OPC initially if necessary • Management of comorbidity • Lifestyle advice • Psychoeducation (online and face to face) • MDT approach and enhanced capacity
- 40. Structure of South Leicestershire outpatient clinics now CMHT Outpatient Clinic Services OPC services Assessment clinic Bipolar disorder specialised clinic Integrated depression clinic (at a later date) Generic Specialised
- 41. Training In clinic experience Psychiatry trainees GP trainees NMPs Students Psychosocial interventions Psycho Education IPSRT DBT FFT Medication Workshops Forums NMS skills General training Medical student Psychiatric trainees Nurses Other CMHT/IP members
- 42. Research
- 43. In development • New Psychoeducation Course • Web based support • App development • New manuals for psychosocial interventions • Research
- 44. Media attention & public education Thank you
Editor's Notes
- Time to hospital readmission for patients treated in the mood disorder clinic v. standard out-patient care.