Everything you need to know about Mental Health in 60 minutes…

1. Everything you need to know about Mental Health in 60 minutes… Dr Tom Tasker GP with Special Interest in Mental Health NHS Salford

2. Overview • Antidepressants • New NICE guidance • Improving Access To Psychological Therapies (IAPT) • Stepped Care Model • Physical health in SMI • Case Studies

3. When – Depression • Mild (PHQ-9: < 10) • Avoid • Unless: • Past h/o severe depression • Not responding to other interventions • Moderate(PHQ-9: 10 – 19) • Consider • Discuss with patient • Severe (PHQ-9: 20+) • Encourage to take • Evidence best for comb’n of AD + Psychological therapy

4. When – Anxiety Disorders • Mild/moderate • Avoid • Psychological Therapy 1st line (NICE) • Moderate/severe • Consider if loss of function • Should be an adjunct to Psychological therapies

5. When – Depression/anxiety • If depression is accompanied by marked anxiety…. • TREAT DEPRESSION FIRST • Consider AD as appropriate

6. Draft NICE guidance re ADs • Generic SSRI 1st line • Efficacy • Better tolerated • Favourable risk-benefit ratio • Less likely to be discontinued because of side effects • Low acquisition-cost • (Paroxetine: higher rate of discontinuation symptoms)

7. Draft NICE Guidance for ADs • 2nd line: • Different SSRI • Better tolerated newer generation AD • Combining ADs • Remit of GPSI/psychiatrist • SSRI plus mirtazapine • Do not initiate dosulepin • Increased cardiac risk • Toxicity in OD

8. Draft NICE guidance for ADS • What is the best strategy following 6-8 weeks of adequate treatment? • Suggest RCT to assess: • Continuing same/increasing dose of SSRI • Switch to another SSRI • Switch to AD of different class

9. Which – Depression (Salford) • 1st line: • Sertraline • 2nd line • Change class • Mirtazapine • Venlafaxine • Duloxetine

10. Which – Anxiety (Salford) • 1st Line • Citalopram • 2nd line • Escitalopram • Venlafaxine

11. Cost per monthly prescriptions • Fluoxetine 20mg 69p • Citalopram 20mg £1.24 • Sertraline 50mg £1.37 • Escitalopram 10/20mg £15/£25 • Mirtazapine 30/45mg £3.28 - £19 • Duloxetine 60mg £27.72 • Venaxx/venlalic 75–225mg £10 - £30

12. Good prescribing tips • Considerations • Length of initial prescription • Toxicity in overdose • When to review • Careful in < 30 years old

13. Good prescribing tips • How often to review? • (1) week • 2 weeks • 4 or 5 weeks • 8 weeks • 12 weeks • 1 – 2 monthly thereafter

14. Good prescribing tips • When to consider increasing dose? • No response – 2-3 weeks • Partial response – 4 – 6 weeks • Switch after 4-6w if unsatisfactory response

15. Good prescribing tips • How long to treat for? • At least 6 months after remission • If recurrent consider 1 – 2 years • Consider acute v repeat prescriptions • Try to avoid ADs in bereavement (except in past h/o depression)

16. Good prescribing tips • Tricyclics • Avoid subtherapeutic doses • Helps anxiety symptoms but not depression • Avoid dosulepin altogether • No new initiations • Consider switching

18. How much is being invested in the Improving Access to Psychological Therapies programme in the next 3 years? • A £173,000 • C £ 17.3million • B £1.73 million • D £173 million

19. How much is being invested in the Improving Access to Psychological Therapies programme in the next 3 years? • D £173 million

20. Improving Access to Psychological Therapies (IAPT) • Comprehensive Spending Review 2007 • £30 million in 2008/9 • £70 million in 2009/10 • £70 million in 2010/11

21. 1st wave - IAPT 2008/9 • 35 pilot sites in 2008/9 • 5 sites in NW SHA • Salford – 26 new trainees • 11 Low Intensity (Graduate Workers) • 15 High intensity (CBT workers)

22. IAPT • NICE-compliant (Stepped care model) • Step up/down as necessary • Step 2 • Low Intensity Interventions • Step 3 • High Intensity Interventions (CBT, IPT) • Step 4 • Non-IAPT (Psychology Services)

23. Low Intensity Workers • Low intensity interventions - Medication management • Behavioural activation • Problem-solving • Guided self-management • Brief CBT • Signposting • 4 – 6 sessions x 30 minutes

25. Stepped Care Model • Framework in which to organise services • Aim is to provide the least intrusive, most effective intervention first • Patients should enter at the step that is appropriate to them but generally the least intensive • Patients can be stepped up or down as necessary

27. Physical Health & SMI • Life expectancy • Reduced by 10 – 15 years • Younger patients at very high risk compared with general population • Cardiovascular Disease • Mortality in excess of 2x that of general population • Diabetes • Up to 5x that of general population

28. Other health related issues • Health inequalities • Lifestyle • Smoking • 61% schizophrenia, 46% BPD • (Social Exclusion Unit Report - Mental health and social exclusion) 2004 • Alcohol & Drug Misuse • Obesity • Metabolic Syndrome • Hyperprolactinaemia

29. Cardiovascular Risk Factors and Schizophrenia 1Davidson et al. Aust NZ J Psychiatry. 2001;35:196–202;2Herran et al. Schizophr Res. 2000;4:373–381; 3Dixon et al. Schizophr Bull. 2000;26:903–912;4Kato et al. PrimCare Companion J Clin Psychiatry. 2005;7:115–118

30. Metabolic Syndrome (IDF Definition 2005) • Metabolic syndrome defined as criterion one plus any two of next four criteria: IDF = International Diabetes Federation; HDL = High-density Lipoprotein; Available at www.idf.org

31. The core problem...?

32. 70 59.6 60 50 50 40 Prevalence (%) 28.1 30 22.4 20 10 6.2 4.6 0 Overweight Obese Healthy Overweight Obese Healthy BMI 25–29.9 BMI ≥30 BMI <25 BMI 25–29.9 BMI ≥30 BMI <25 Men Women Prevalence of Metabolic Syndrome According to BMI n=12,363 BMI = Body Mass Index Park et al. Arch Intern Med. 2003;163:427–436

33. Prevalence of Obesity is Increased in Schizophrenia Schizophrenia No schizophrenia 30 Normal weight 25 Overweight Obese 20 Percentage 15 10 5 0 <20 20–22 >22–25 >28–30 >30–33 >33–35 >35 >26–28 >24–26 BMI category BMI = Body Mass Index Allison et al. J Clin Psychiatry. 1999;60:215–220

34. Metabolic Syndrome Increases Total and Cardiovascular Mortality *** 20 Metabolic syndrome present 18.0 Metabolic syndrome absent 18 16 *** 14 12.0 12 10 Mortality (%) 8 6 4.6 4 2.2 2 0 Total mortality CV mortality Median follow-up: 6.9 years ***p<0.001 vs. patients without metabolic syndrome CV = Cardiovascular Isomaa et al. Diabetes Care. 2001;24:683–689

35. Prevalence of Diabetes in Schizophrenia vs. General Population Prevalence (%) 15–35 25–35 35–45 45–55 55–65 Age range (years) n=415 patients with schizophrenia De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14

36. Osborn et al, Arch Gen Psychiatry Vol 64 Feb 2007 • 46 136 people with SMI • 300 426 without SMI were selected for the study • Hazard ratios (HRs) in people with SMI compared with controls were: for CHD mortality • 3.22 (95% CI, 1.99-5.21) for people 18 - 49 yrs • 1.86 (95% CI, 1.63-2.12) for those 50 - 75 yrs • 1.05 (95% CI, 0.92-1.19) for those > 75 yrs

37. Osborn et al, Arch Gen Psychiatry Feb 2007 • For stroke deaths, the HRs were: • 2.53 (95% CI, 0.99-6.47) for those < 50 yrs • 1.89 (95% CI, 1.50-2.38) for 50 - 75 yrs • 1.34 (95% CI, 1.17-1.54) for > 75 yrs

38. Further Findings from Osborn et al, 2007 • Increased HRs for CHD mortality occurred irrespective of: • sex • SMI diagnosis • Or prescription of antipsychotic medication • However a higher prescribed dose of antipsychotics predicted greater risk of mortality from CHD and stroke

39. Other Common Physical Health Problems • People with schizophrenia are also at increased risk for: • Hyperprolactinaemia • Particularly associated with conventional antipsychotics, risperidone, amisulpride • Sexual dysfunction • May also be a consequence of conventional antipsychotic therapy; the causal link with atypical antipsychotics is less clear

40. Mental Health Indicator 9 -Annual Physical Health Check • Alcohol & drug misuse • Smoking • BMI/waist circumference • BP • Diabetes screening • Lipid profiles in patients • > 40 years • Those on atypical antipsychotics

41. Mental Health Indicator 9 -Other issues to consider • Cervical Screening • Dental & Eye Care • Imms & Vaccs • Medication compliance & side effects

42. Mental Health Indicator 6 - Psychiatry Care Plan • Check contact details for: • Main Carer • Care Co-coordinator & all key people involved in care • Check follow up arrangements with specialist mental health services • Check patient awareness of early signs of relapse • Check patient’s preferred course of action in event of relapse • Social situation • CAB, Welfare, Benefits

43. Salford Initiatives • Shared Care Protocol for Atypical Antipsychotics • Tackling DNA rates for physical health checks

44. SCP for Atypical Antipsychotics • Incentivised scheme • 3 visits: • – baseline to be done by specialist MHS • 3m & 6m checks to be done in Primary Care • Annually thereafter as part of QOF • At each visit: • BMI/waist • BP • Fasting BS • Fasting lipids (not at 3m visit)

45. Salford CMHT Initiatives • Care Programme Approach • Current CPA amended • Physical Illness Domain to be extended to include physical health check • Care coordinator role • Pivotal • Responsibility to ensure health check has been done

46. Follow up of DNA’s • If patient DNAs their annual physical health check: • Requirement under QuOF (MH 7) • GP to cc DNA letter to care coordinator • Care coordinator to follow up

48. “Hard to reach” SMI patients • CHUG (Cromwell House User group meeting): • No previous dialogue re physical health • Interested in physical health • Education, awareness • Prefer to undergo check in CMHT • Don’t like attending GP surgeries • Don’t like environment • Stigmatised • Physical symptoms attributed to SMI • Not listened to

49. Survey • Service User Representative: • Wider report to looked at: • How to deliver promotional campaign: • raise awareness • education • Check out why they won’t attend GP • How to facilitate attendance at GP surgeries • Types of interventions they want to see at CMHT level

50. Results of Survey • 48 responses: • Education – want to talk to Care co-ordinator (rather than leaflets/posters) • 70% had a physical health check in past 15m • >90% of checks done at GP surgery • Reassured – GP knows about physical health • Barriers: • Getting appointment • GP running late