A long-term retrospective evaluation of service use by patients with chronic depression

1. A long-term retrospective evaluation of service use by patients with chronic depression Richard Moore Clinical Psychologist Cambridge Specialist Depression Service Cambridgeshire and Peterborough NHS Foundation Trust

2. Lack of response to treatment in depression • Significant minority of patients fail to respond, respond and relapse or become chronic (eg 15% over 23 year FU, Eaton et al, 2008) • No agreed treatment approach or service provision • CPFT has not kept data on depression, response or service use across time

3. RCT of the clinical and cost effectiveness of a specialist mood disorders team for refractory unipolar depressive disorder • Funded by CLAHRC • Collaboration of CP with NDL • Patients with major depression • Treated for > 6 months in secondary care • Still have HRSD > 16 • Randomised to 12 months of treatment as usual vs specialist service

4. Fellowship Project • Small sample of patients in local pathways with chronic depression • Gather data over long-term retrospective period on • Use of mental health services • Costs of MH service use • Aims: • Provide contextual information for cost of trial and future service implementation • Inform further information requirements

5. Thanks to: • CLAHRC and Murali • My colleagues in Cambridge Specialist Depression Service • Rajini Ramana, Consultant Psychiatrist • Joy Hodgkinson, CPN • Julie McKeown, Admin

6. Patients • Depression persisting despite combined intervention (medication + therapy) • Patients from own caseload • receiving multidisciplinary input • could not be discharged despite strong directives • N=6

7. Data gathering • Client Service Receipt Inventory (Beecham & Knapp, 2001) • Adapted for retrospective use with clinical records over 10 years • Mental health contacts • Discipline • Number • Duration • Medication • Psychotropic • Name • Dose • Duration

8. Sources of information • Clinical contacts • 3 x electronic datasets (CRS, CDL, ECL) • Paper notes • Information sketchy, inconsistent • Essential to cross refer • Medication • CDL, paper notes, GP printouts • Information even patchier, less reliable

9. Costing information • No agreed local data • Standard costings: PSSRU (Curtis, 2011) • Many assumptions about gradings, overheads, chargeable activity levels, training costs etc • Medication costs from BNF (2012)

10. Nature of patients

11. Staff contacts

12. Staff costs

13. Medication

14. Outcomes • Patient 1: transferred to R&R with CRHTT input • Patient 2: discharged to voluntary sector • Patient 3: monthly relapse prevention group • Patient 4: happily discharged • Patient 5: monthly relapse prevention group • Patient 6: unhappily discharged…re-referred!

15. Summary • Contacts vastly exceed acute pathway boundaries • Great variability due to high cost of hospitalisation • Yearly community cost approx £3000 (cf IAPT £750)

16. Implications for services • Patients WILL • obtain long-term input • incur significant costs • Need to make as economical as possible • To be prevented: • Hospitalisation • Re-referral and re-assessment • Through consistency/maintenance treatments

17. Implementation Tools • New information system • Implementation of NICE Guidelines • PPI for chronic depression • Potential influence on pathway design

18. Can we afford to offer high quality maintenance treatment for patients with chronic depression? No! • Can we afford NOT to offer high quality maintenance treatment for patients with chronic depression? • NO!

19. Practical difficulties of Fellowship • Time, time, time • Competing demands • Organisational change • Time, time, time • Sensitivity • Difficulties -> implementation ‘spin offs’