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
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