PRIMARY CARE MENTAL PRIMARY CARE MENTAL HEALTH HEALTH

COLLABORATIVE COLLABORATIVE –– THE THE EVIDENCEEVIDENCE

Dr Gabriel IvbijaroDr Gabriel Ivbijaro MBBS FRCGP FWACPsych MMedSci MAMBBS FRCGP FWACPsych MMedSci MA

Convenor WONCA Special Interest Group in Convenor WONCA Special Interest Group in Psychiatry & NeurologyPsychiatry & Neurology

Medical Director Forest Road Medical Centre Medical Director Forest Road Medical Centre Mental Health PMS PracticeMental Health PMS Practice

2

AIMSAIMS•• To quantify the scale of primary care To quantify the scale of primary care

mental health problemsmental health problems•• To consider the role of To consider the role of ‘‘CollaborativesCollaboratives’’•• To review some of the evidence To review some of the evidence

supporting the use of collaboratives in supporting the use of collaboratives in managing common mental health managing common mental health problems in primary careproblems in primary care

•• To examine the rationale for some of the To examine the rationale for some of the measures chosen by this Collaborativemeasures chosen by this Collaborative

3

WHAT ARE COMMON MENTAL WHAT ARE COMMON MENTAL HEALTH PROBLEMS?HEALTH PROBLEMS?

•• Mental health problems excluding:Mental health problems excluding:–– Schizophrenia, Schizophrenia, –– Bipolar disorderBipolar disorder–– Severe depressionSevere depression–– Severe obsessive compulsive disorderSevere obsessive compulsive disorder

•• The above are all disorders primary care is The above are all disorders primary care is not equipped to deal withnot equipped to deal with

4

WHAT ARE SERIOUS MENTAL WHAT ARE SERIOUS MENTAL HEALTH PROBLEMS (SMI)HEALTH PROBLEMS (SMI)

•• Safety:Safety:–– Unintentional selfUnintentional self--harmharm–– Intentional selfIntentional self--harmharm–– Safety of othersSafety of others–– Abuse by othersAbuse by others

•• Informal & Formal Care:Informal & Formal Care:–– Help from informal carersHelp from informal carers–– Help from formal servicesHelp from formal services

•• Diagnosis:Diagnosis:–– Psychotic illnessPsychotic illness–– DementiaDementia–– Severe neurotic illnessSevere neurotic illness–– Personality disorderPersonality disorder–– Developmental disorderDevelopmental disorder

•• Disability Disability (impaired ability to function (impaired ability to function effectively in community)effectively in community)::–– Employment & recreationEmployment & recreation–– Personal carePersonal care–– Domestic skillsDomestic skills–– Interpersonal relationshipsInterpersonal relationships

•• Duration:Duration:–– 6 months to more than two 6 months to more than two

yearsyears

(Building Bridges (Building Bridges –– DOH 1996)DOH 1996)

WHAT IS THE SCALE WHAT IS THE SCALE OF THE PROBLEM?OF THE PROBLEM?

6

GOLDBERG HUXLEY MODELGOLDBERG HUXLEY MODELLevelLevel FilterFilter Filter descriptionFilter description Rate Rate

(per (per 1000)1000)

11 Community (total)Community (total) 250250

1st Filter Illness BehaviourIllness Behaviour

22 Primary Care (total)Primary Care (total) 230230

2nd Filter Ability to detectAbility to detect

33 Primary CarePrimary Care (identified)(identified) 140140

3rd Filter Willingness to referWillingness to refer

44 Mental Illness Services Mental Illness Services (total)(total)

1717

4th Filter Factors determining Factors determining admissionadmission

55 Mental Illness (admissions)Mental Illness (admissions) 66

7

DEPRESSIONDEPRESSION

•• Common psychiatric problem in primary Common psychiatric problem in primary care worldwidecare worldwide

•• Often underOften under--treatedtreated•• UnderUnder--diagnosed diagnosed (Ballinger et al 2001, Lecrubier 2001, (Ballinger et al 2001, Lecrubier 2001,

WONCA Culturally Sensitive Depression Guideline 2005)WONCA Culturally Sensitive Depression Guideline 2005)

8

EPIDEMIOLOGYEPIDEMIOLOGY

•• Female lifetime prevalence 20Female lifetime prevalence 20--25 %25 %•• Male lifetime prevalence 7Male lifetime prevalence 7--12%12%•• Deliberate self harm 10Deliberate self harm 10--16%16% (Angst 1996, Murphy (Angst 1996, Murphy

et al 1987)et al 1987)

•• There may be cultural variation in There may be cultural variation in prevalenceprevalence–– Japan 2.6%, Chile 29.5% Japan 2.6%, Chile 29.5% (Goldberg & Lecrubier (Goldberg & Lecrubier

1995)1995)

WHO predict that by the WHO predict that by the year 2020 depression will year 2020 depression will

be the second most be the second most important cause of important cause of

disability after ischaemic disability after ischaemic heart diseaseheart disease

Murray & Lopez 1997 Murray & Lopez 1997

10

ANXIETY SYNDROMESANXIETY SYNDROMES•• Many studies have shown high prevalence of Many studies have shown high prevalence of

anxiety syndromes worldwide anxiety syndromes worldwide (Robinson et al 1984, (Robinson et al 1984, Angst & DoblerAngst & Dobler--Mikola 1985, Wittchen et al 1992)Mikola 1985, Wittchen et al 1992)

•• Common disorders:Common disorders:–– Generalised anxiety disorder (GAD)Generalised anxiety disorder (GAD)–– Agoraphobia Agoraphobia –– Panic disorderPanic disorder

•• Sufferers are heavy primary care users Sufferers are heavy primary care users (Goldberg & (Goldberg & Huxley 1980)Huxley 1980)

•• Few consult specialist services Few consult specialist services (Regier et al 1978)(Regier et al 1978)

•• Many other illMany other ill--defined anxiety states present in defined anxiety states present in primary care primary care

PREVALENCE & PREVALENCE & RECOGNITION OF RECOGNITION OF

ANXIETY SYNDROMES IN ANXIETY SYNDROMES IN FIVE EUROPEAN FIVE EUROPEAN PRIMARY CARE PRIMARY CARE

SETTINGSSETTINGSA WHO Study on Psychological A WHO Study on Psychological

Problems in General Health CareProblems in General Health CareE. Weiller, JH Bisserbe, W. Maier & Y. Lecrubier E. Weiller, JH Bisserbe, W. Maier & Y. Lecrubier

(1998)(1998)

12

FINDINGSFINDINGS•• A detailed GP community study A detailed GP community study •• Groningen, Mainz, Berlin, Manchester, ParisGroningen, Mainz, Berlin, Manchester, Paris•• Consecutive male & female GP attendees < Consecutive male & female GP attendees <

65yrs old65yrs old•• Screened with 12 item GHQ (General Health Screened with 12 item GHQ (General Health

Questionnaire)Questionnaire)•• Exclusions : too ill, too far away, NFA, language Exclusions : too ill, too far away, NFA, language

problemsproblems•• Within one week subjects underwent inWithin one week subjects underwent in--depth depth

testing testing

13

INSTRUMENTS & SAMPLEINSTRUMENTS & SAMPLE•• Primary Care Version of Composite International Primary Care Version of Composite International

Diagnostic Interview Diagnostic Interview (CIDI WHO 1991)(CIDI WHO 1991)

•• Self Self ––rated health status (5 point scale)rated health status (5 point scale)•• Brief Disability Questionnaire (BDQ) Brief Disability Questionnaire (BDQ) (Stewart et al (Stewart et al

1988; Ware & Sherbourne 1992)1988; Ware & Sherbourne 1992)

•• 10 359 approached & eligible 10 359 approached & eligible •• 9714 completed GHQ9714 completed GHQ--12 12 •• 1973 interviews in total1973 interviews in total•• Mainz lowest response rate : 36.8%Mainz lowest response rate : 36.8%•• Manchester highest response rate : 71.1%Manchester highest response rate : 71.1%•• These results are relevant to the UK populationThese results are relevant to the UK population

14

RESULTSRESULTS•• 4.6% ANXIETY RELATED PROBLEMS4.6% ANXIETY RELATED PROBLEMS

–– 77.8% of these well defined psychiatric problem77.8% of these well defined psychiatric problem–– 22.2% of these ill defined psychiatric problem22.2% of these ill defined psychiatric problem

–– 6.7% : Sub6.7% : Sub--threshthresh--hold GADhold GAD–– 8.5% : GAD8.5% : GAD–– 8.8% : Agoraphobia +/8.8% : Agoraphobia +/-- panic disorderpanic disorder–– 3.3% : Panic disorder3.3% : Panic disorder–– 36.8% : Other 36.8% : Other mainly depressionmainly depression

15

SUMMARYSUMMARY

•• Common mental health problems Common mental health problems occur commonlyoccur commonly

•• Primary Care is the first port of callPrimary Care is the first port of call•• We need to improve the skills of We need to improve the skills of

Primary Care teams to deal with this Primary Care teams to deal with this effectivelyeffectively

•• Collaboratives may be one way Collaboratives may be one way forwardforward

16

NATIONAL PRIMARY CARE NATIONAL PRIMARY CARE MENTAL HEALTH MENTAL HEALTH

COLLABORATIVE (PCMHC)COLLABORATIVE (PCMHC)•• Aimed at supporting Primary Care in dealing Aimed at supporting Primary Care in dealing

with common mental health problemswith common mental health problems•• Approx 1 in 3 people consult GP with mental Approx 1 in 3 people consult GP with mental

health problemshealth problems•• 80% of these dealt with by Primary Care80% of these dealt with by Primary Care•• 30% of working age people obtain sick notes 30% of working age people obtain sick notes

from GP for some kind of mental illnessfrom GP for some kind of mental illness•• Primary Care preferred option for most mental Primary Care preferred option for most mental

health users and carershealth users and carers

17

KEY PRINCIPLES OF KEY PRINCIPLES OF COLLABORATIVECOLLABORATIVE

•• To create and validate a register for To create and validate a register for proactive careproactive care

•• To create alternative care management To create alternative care management and arrangements for common mental and arrangements for common mental health problemshealth problems

•• To support the implementation of direct To support the implementation of direct self careself care

18

AIMS OF COLLABORATIVEAIMS OF COLLABORATIVE•• To improve the care of all working age adults To improve the care of all working age adults

with mental health problems in Primary Carewith mental health problems in Primary Care•• To identify innovative, successful mental health To identify innovative, successful mental health

practicespractices•• To create an opportunity for multiple To create an opportunity for multiple

stakeholders to come together to learn from stakeholders to come together to learn from each others expertise and experienceeach others expertise and experience

•• To adapt care pathways and NICE Guidance to To adapt care pathways and NICE Guidance to suit local needs suit local needs

19

WHAT WILL THE WHAT WILL THE COLLABORATIVE MEASURE?COLLABORATIVE MEASURE?

•• GP consultation rates for people with common mental GP consultation rates for people with common mental health disorder electronic listhealth disorder electronic list

•• Rates of consultation with other GP staff for common Rates of consultation with other GP staff for common mental health disorder electronic listmental health disorder electronic list

•• Rate of referral to CMHT/ consultant psychiatrists for Rate of referral to CMHT/ consultant psychiatrists for people on common mental health electronic listpeople on common mental health electronic list

•• % of people with common mental health disorders % of people with common mental health disorders electronic list issued Med 3, 4 & 5 totalling longer than electronic list issued Med 3, 4 & 5 totalling longer than 13 weeks13 weeks

•• Individual teams will be encouraged to identify and report Individual teams will be encouraged to identify and report on local measures that are particular to their siteson local measures that are particular to their sites

20

ARE COLLABORATIVES ARE COLLABORATIVES EFFECTIVE?EFFECTIVE?

•• To answer this question I will review:To answer this question I will review:–– International literature on collaborativesInternational literature on collaboratives–– Effect of mental illness on GP Effect of mental illness on GP

consultationconsultation–– Effect of referral to psychiatric services Effect of referral to psychiatric services

on the patienton the patient–– Mental illness and unemploymentMental illness and unemployment

21

PCMHC COLLABORATIVES PCMHC COLLABORATIVES --THE PICTURETHE PICTURE

•• Extensive literature from USA, Australia, Extensive literature from USA, Australia, New Zealand, Canada that this approach New Zealand, Canada that this approach is effectiveis effective

•• Other Primary Care Collaboratives for long Other Primary Care Collaboratives for long term physical conditions such as CHD, term physical conditions such as CHD, diabetes, patient access in the UK have diabetes, patient access in the UK have also been effectivealso been effective

22

INTERNATIONAL EXAMPLESINTERNATIONAL EXAMPLESNEW ZEALANDNEW ZEALAND

•• A A collaborative approach to the delivery of collaborative approach to the delivery of mental health services to juvenile offenders mental health services to juvenile offenders (2003 (2003 Hicks & McCormack) Hicks & McCormack)

•• Lead to service reLead to service re--design and staff trainingdesign and staff training•• Improved levels of user satisfactionImproved levels of user satisfaction•• Increase in knowledge and confidence of staffIncrease in knowledge and confidence of staff•• Challenges encountered:Challenges encountered:

–– Client confidentialityClient confidentiality–– SustainabilitySustainability–– Differing organisational goalsDiffering organisational goals–– Different organisational philosophiesDifferent organisational philosophies–– Tension between medical & social modelsTension between medical & social models

23

INTERNATIONAL EXAMPLESINTERNATIONAL EXAMPLESCANADACANADA

•• Bridging with Primary Care: A shared care Bridging with Primary Care: A shared care mental health pilot project mental health pilot project (2002 Isomura et al)(2002 Isomura et al)

•• Enhanced mental health care of patients in Enhanced mental health care of patients in British ColumbiaBritish Columbia

•• Increased GP, patient & carer satisfactionIncreased GP, patient & carer satisfaction•• Addressed a number of problems Addressed a number of problems

including:including:–– Lack of access to timely consultationLack of access to timely consultation–– Limited mental health services capacityLimited mental health services capacity

24

INTERNATIONAL EXAMPLEINTERNATIONAL EXAMPLEUSAUSA

•• Californian adolescent mental health Californian adolescent mental health collaborative collaborative (1999)(1999)

•• Reduced suicide & parasuicide ratesReduced suicide & parasuicide rates•• Reduced teenage pregnancy & STD rates Reduced teenage pregnancy & STD rates •• Reduced alcohol and substance misuse Reduced alcohol and substance misuse

ratesrates

ALL THE EVIDENCE ALL THE EVIDENCE SHOWS THAT PRIMARY SHOWS THAT PRIMARY

CARE COLLABORATIVES CARE COLLABORATIVES CAN IMPROVE MENTAL CAN IMPROVE MENTAL

HEALTH CARE HEALTH CARE MANAGEMENTMANAGEMENT

26

WHY DO THEY WORK?WHY DO THEY WORK?

•• Lead to educational initiatives for staffLead to educational initiatives for staff•• Lead to organisational changeLead to organisational change•• Lead to culture change in individuals & Lead to culture change in individuals &

organisationsorganisations•• Support selfSupport self--reflectionreflection•• Encourage learning from peersEncourage learning from peers•• Allow time out for reflection & refreshmentAllow time out for reflection & refreshment

27

RATIONALE BEHIND OUR RATIONALE BEHIND OUR CHOSEN MEASURESCHOSEN MEASURES

Consultation RatesConsultation Rates•• Patients with mental illness use primary Patients with mental illness use primary

care services more than those with long care services more than those with long term physical conditionsterm physical conditions

•• Holistic care & appropriate care planning Holistic care & appropriate care planning can reduce usage can reduce usage (Ivbijaro et al 2005)(Ivbijaro et al 2005)

28

EXTRA CONSULTATION PER EXTRA CONSULTATION PER 1000 PATIENTS 19981000 PATIENTS 1998

Figures adjusted to account Figures adjusted to account for cofor co--morbiditymorbidity

ConditionCondition DoctorsDoctors NursesNurses TotalTotalDiabetesDiabetes 1414 5151 6565Hyper tensionHyper tension 8080 5656 136136CHDCHD 5656 2727 8383Ulcer healing drugsUlcer healing drugs 131131 1212 144144Asthma/COPDAsthma/COPD 248248 6161 309309AntidepressantsAntidepressants 316316 1616 332332

29

EFFECT OF REFERRAL TO EFFECT OF REFERRAL TO PSYCHIATRIC SERVICESPSYCHIATRIC SERVICES

•• Patients prefer to be treated for mental Patients prefer to be treated for mental health problems by GP health problems by GP (van Boeijen et al 2005)(van Boeijen et al 2005)

•• Limited capacity of secondary care Limited capacity of secondary care settingssettings

•• Some effective treatments e.g. CBT Some effective treatments e.g. CBT difficult to provide in primary caredifficult to provide in primary care

•• Primary care needs to monitor referral Primary care needs to monitor referral rates to secondary care to better rates to secondary care to better commission appropriate services commission appropriate services

30

MENTAL ILLNESS AND MENTAL ILLNESS AND EMPLOYMENTEMPLOYMENT

Monitoring sick notes:Monitoring sick notes:•• Very important for long term conditionsVery important for long term conditions•• In back pain the longer you are off sick the In back pain the longer you are off sick the

more likely that you will not return to workmore likely that you will not return to work•• Mirrored by patients suffering from mental Mirrored by patients suffering from mental

disorderdisorder•• Useful to monitor this and link with Useful to monitor this and link with

services that can intervene to support services that can intervene to support people to maintain an occupational statuspeople to maintain an occupational status