LONG TERM CONDITIONS AND MENTAL HEALTH

Dr. Justin ShuteLiaison Psychiatry ConsultantMRCPsych MRCP

Long Term conditions - 30% of the

population of England

(c. 15.4m people)

Mental health problems - 20% of the

population of England

(c. 10.2m people)

46% (c.4.6m) of those with a mental health

problem have an LTC

30% (c. 4.6m) of those with an LTC have a mental health problem

LTCs MH PROBLEMS

Naylor Parsonage et al 2012 based on Crimpean and Drake 2011

People with LTCs 2-3 X more Likely to have Mental Illness

Depression 2-3 X more common in cardiac disease, coronary artery disease, stroke, angina, congestive heart failure, or following a heart attack• Fenton and Stover 2006; Benton et al 2007; Gunn et al 2010; Welch et al

2009

Prevalence between 20 & 50%

But 2-3 X increase compared with controls is consistent across studies

People with LTCs 2-3 X more Likely to have Mental Illness

Diabetes 2-3 X more likely to have depression than the general population• Fenton and Stover 2006; Simon et al 2007; Vamos et al 2009

Chronic obstructive pulmonary disease 3 X more mental illness than general population• NICE 2009

Anxiety disorders are very common; panic disorder 10 X• Livermore et al 2010

World Health Surveys: 2 or more LCTs 7X more likely to have depression than people without LCT • Moussavi et al 2007

Does It Really Matter ?

Cardiovascular patients with depression experience 50% more acute exacerbations per year and have higher mortality rates• Katon 2003

Depression leads to 2-3 X negative outcomes for people with acute coronary syndromes• Barth et al 2004

Depression increases mortality rates after heart attack by 3-5 X• Lesperance et al 2002

Does It Really Matter ?

2 X mortality after heart bypass surgery over an average follow-up period of 5 years• Blumenthal et al 2003

Chronic heart failure 8 X more likely to die within 30 months if they have depression • Junger et al 2005

People with diabetes & depression 36-38% increased risk of all-cause mortality over a 2 year follow-up period • Katon et al 2004

Poorer glycaemic control, more diabetic complications and lower medication adherence• Das-Munshi et al 2007

Does It Really Matter ? Relationship between LTCs and mental illness is

exacerbated by socio-economic deprivation:

greater proportion of people in poorer areas have multiple long term conditions

effect of this multi-morbidity on mental health is stronger when deprivation is also present

Why are Outcomes Worse ? Co-morbid mental health problems impair active

self-management Reduced motivation and energy for self-

management leads to poorer adherence to treatment plans DiMatteo et al 2000

Cardiac patients, depression increases adverse health behaviours (eg. physical inactivity) and decrease adherence to self-care regimens such as smoking cessation, dietary changes and cardiac rehabilitation programmes Benton et al 2007; Katon 2003

Poorer dietary control and adherence to medication Vamos et al 2009

Prevention Befriending Debt advice Wellbeing in the workplace initiatives

• Knapp et al 2011

Hampered by “hard wired separation of physical and mental health care”

• When assessing a patient with a chronic physical health problem who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count.

• Take into account:– the degree of functional impairment and/or

disability associated with the possible depression and

– the duration of the episode.

Principles for Assessment

STEP 1: All known and suspected presentations of depression

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

STEP 4: Severe and complex1 depression; risk to life; severe self-neglect

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Focus of the intervention

Nature of the intervention

Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions

1,2 see slide notes

The stepped-care model

Case identification and recognition

• Be alert to possible depression – Particularly in patients with a past history of

depression or – a chronic physical health problem with

associated functional impairment.• Consider asking patients who may have

depression two questions, specifically: – During the last month, have you often been

bothered by feeling down, depressed or hopeless? – During the last month, have you often been

bothered by having little interest or pleasure in doing things?

Low-intensity psychosocial interventions

For patients with: • persistent sub-threshold depressive symptoms or mild

to moderate depression and a chronic physical health problem

• Sub-threshold depressive symptoms that complicate care of chronic physical health problem

Consider offering one or more of the following interventions, guided by patient preference:

‐ structured group physical activity programme

‐ group-based peer support (self-help) programme

‐ individual guided self-help based on CBT

‐ computerised CBT.

Treatment for moderate depression

For patients with initial presentation of moderate depression and a chronic physical health problem:• offer the following choice of high intensity

psychological interventions:– group-based CBT or– individual CBT or– behavioural couples therapy.

•Do not use antidepressants routinely for sub-threshold depressive symptoms or mild depression in patients with a chronic physical health problem•Consider antidepressants for people with: – a past history of moderate or severe depression or– mild depression that complicates the care of the

physical health problem or– Sub-threshold depressive symptoms present for a

long time or– Sub-threshold depressive symptoms or mild

depression that persist(s) after other interventions.

Antidepressant drugs (1)

• When an antidepressant is to be prescribed, tailor it to the patient, and take into account: – additional physical health disorders– side effects, which may impact on the

underlying physical disease– lack of evidence supporting the use of

specific antidepressants for people with particular chronic physical health problems

– interactions with other medications.

Antidepressant drugs (2)

What is collaborative care?

Four essential elementscollaborative definition of problemsobjectives based around specific

problemsself-management training and

support servicesactive and sustained follow up

Consider collaborative care for patients with:• moderate to severe depression • a chronic physical health problem with associated

functional impairment whose depression has not responded to: – initial high-intensity psychological interventions

or– pharmacological treatment or– a combination of psychological and

pharmacological interventions.

Collaborative Care

Detection > 90% of people with depression alone were diagnosed

in primary care Depression detected < 25%among people with LTC

• Bridges and Goldberg 1985

Majority of cases of depression among people with physical illnesses go undetected and untreated• Cepoiu et al 2008; Katon 2003

Active case-finding in people with LTCs needed• NICE 2010

TreatmentStandard interventions eg. antidepressants or

CBT are effective• Fenton & Stover 2006; Yohannes et al 2010, Ciechanowski et al 2000

Psychological therapy was associated with reduced emergency department attendance • De Lusigman et al 2011

Treating co-morbid mental illness by itself doesn’t always translate into improved physical symptoms• Cimpean & Drake 2011; Benton et al 2007; Perez-Prada 2011

Integration Integrating treatment for mental health and physical

better than overlaying mental health interventions• Fenton & Stover 2006; Yohannes et al 2010

Adding a psychological component to COPD rehab programmes: improved completion rates and reduced re-admissions for COPD• Abell et al 2008

CBT-based disease management programme for angina = 33% fewer hospital admissions in following year, saving £1,337 per person• Moore et al 2007

Stepped Care

Secondary Services

1:1 or group CBT

Self help, coping skills, psycho-ed courses, CCBT, behavioural programmes

What Can GPs Do ? Identify patients with co-morbidity Help patients recognise mental health problems Help patients understand links between LTC and mental

health problems• “hard-wired separation of physical and mental care”

Monitor uptake of psychological services by people with LTCs

Identify successful and unsuccessful referral pathways Build relationships between physical and mental

healthcare professionals

Monitoring and Follow Up See patients started on antidepressants not at

risk of suicide ‐ after 2 wks, ‐ every 2 - 4 wks for next 3 mths ‐ less frequently if response is good.

If < 30 yrs (increased risk on anti depressants) see‐ after 1 wk‐ less frequently thereafter until no longer risk

If at increased suicide risk, refer

Side Effects

If side effects develop: monitor symptoms closely and stop anti depressant

if patient finds side effects unacceptable or change if the patient prefers; or

If mild anxiety/insomnia/agitation consider benzodiazepine for 2 wks max.

Caution for those ‐ at risk of falls; or ‐ with chronic anxiety

When to refer

Concerns about risk Inadequate response to psychological

interventions Inadequate response to 1 or 2

antidepressantsAtypical / complicated presentation“Gut feeling”Severity and risk will determine urgent or

routine referral

Where can I find out more?

Pack for good practice and recovery information

BEHMHT GP Intranet site – includes our more detailed treatment guidelines

PCA web resources – in developmentNICE GuidanceRCPsych website