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Management of depression in a primary care clinic

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VOL: 103, ISSUE: 27, PAGE NO: 28-29

Val Ward, PGDip, BSc (Hons) nursing studies, RMN; Nicola Walpole, BSc (Hons) nursing studies, RMN;Claire Glover, BSc (Hons) accounting and finance

Val Ward is CPN; Nicola Walpole is CPN; Claire Glover, BSc (Hons) is clinical governance coordinator; all at Northamptonshire Healthcare NHS Trust

Abstract Ward, V. et al (2007) Managing depression in a primary care mental health clinic. nursingtimes.net

Abstract Ward, V. et al (2007) Managing depression in a primary care mental health clinic. nursingtimes.net

This article describes a pilot to establish a mental health clinic in primary care, aimed at the early recognition and management of depression and associated disorders. Referrals of clients presenting with symptoms of anxiety and depression to the community mental health team (CMHT) decreased by almost 50% during the pilot. Closer working relationships between primary and secondary care were established and clients' experiences of mental health services enhanced.

Introduction
The literature was reviewed to emphasise the scale of the problemand put it in context of current policy. One in four GP consultations are for mental health problems (Department of Health, 2000). Depression is the third most common reason for consultation in UK general practice (Gilbody et al, 2002; Plummer and Gray,2000) and while depressive episodes are common, they may go unrecognised or be sub-optimally managed (Gillam, 2004; Gilbody et al, 2002). Guidance on identifying mental health problems in primary care has been published (Goldberg and Huxley, 1980).

The World Health Organization estimates that next to heart disease, major depression will be the world's most debilitating disease by 2020 (WHO, 2002).

Rationale

In addition to this existing information, standard two of the National Service Framework for Mental Health (DH, 1999) recommended that services should aim 'to deliver better primary mental health care and ensure consistent advice and help for people with mental health needs'. It added: 'All service users who have a primary mental health problem should: have their mental health needs identified and assessed; be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it.'

NICE (2004) guidance stated: 'Where trained mental health professionals are working in primary care, specialised treatments may be available in this setting.'

The primary care mental health clinic (PCMHC) was piloted to improve and promote closer working relationships with primary care, enhance the user's experience of mental health services, and reduce the high number of referrals of people with common mental health problems from GPs to secondary care.

Similar studies have been conducted that can be drawn on for comparison, such as that by Gilbert et al (2005) and Richardson and Paxton (2004).

The PCMHC, staffed by two community psychiatric nurses, used the Hospital Anxiety and Depression Scale, which is an evidence-based assessment tool. HADS was designed as a simple yet reliable tool for use in medical practice. The term 'hospital' in its title may suggest that it is only valid in such a setting, but many studies conducted worldwide have confirmed that it is valid when used in community settings including primary care medical practice (Snaith, 2003).

A local GP practice that provides general medical services to a population of 8,500 people was willing to participate and so the PCMHC pilot began. The service was made available predominately for clients aged 16-65 years.

Aims of the project

The objective was to evaluate a 12-month project that involved holding a mental health clinic in a GP practice. The PCMHC was aimed at the early recognition and management of depression, anxiety and associated disorders and would complement the identification of depression - a role undertaken by heath visitors - by providing an additional resource.

The primary aims of the service were to:

  • Reduce the number of referrals to the community mental health team (CMHT) as well as duty calls and referrals to outpatients;
  • Enhance clients' experience of mental health care and treatment;
  • Provide a simple route of access to mental health care;
  • Promote societal acceptance of mental health services in order to reduce associated stigma;
  • Improve communication between GP practices and secondary care;
  • Reduce the costs of unnecessary prescribing.

The service was audited against one of its primary aims. A comparison was made between the number of referrals received by the CMHT for anxiety and depression during the 12-month pilot and the number of referrals for anxiety and depression the year before the pilot was carried out.

Audit method

The population for this study was composed of clients referred to the PCMHC based on the following criteria:

  • Mild to moderate depression; mixed anxiety and depression; and anxiety disorders including post-traumatic stress disorder, obsessive compulsive disorder, phobias, panic disorder and generalised anxiety disorder;
  • Aged 16-65 years.

All clients attending the clinic were included in the audit. Data was collected for each client in relation to the following:

  • GP;
  • Marital status;
  • Age;
  • Ethnic origin;
  • Referring agent;
  • Presenting problem;
  • Current medication;
  • Outcome;
  • Number of appointments made and attended;
  • Feedback from primary care professional.

In addition, referral and episode of care details were recorded by the primary care mental health workers, as were HADS scores.

Key findings

The service received 88 referralsfrom 12 April 2005 to 12 April 2006. Table 1 summarises the characteristics of the referred population. The majority of the clients seen (69%) were female. Over half of the client group (54%) were between the ages of 25 and 44 years. The reason for referral was coded according to the reason identified by the referrer, the most common being depression.

Ethnicity was recorded for all clients referred: the majority of clients (97%) were White British. The geographical area where the pilot was conducted has a very small percentage of people from minority ethnic backgrounds compared with the national average: 96% of the population are from a White British background (Office of National Statistics, 2001).

Some 9% of the clients seen had co-morbidities, including diabetes, multiple sclerosis and epilepsy. Data on the use of medication was available for all clients referred. In total, 47% of those using the PCMHC service were also taking psychotropic medication.

Of the 88 people referred to the service, 17 did not attend the initial appointment; of those who did attend, 54 were offered further appointments. Fifteen participants were signposted to other services following the initial assessment appointment.

In the year of the pilot, the CMHT received 14 referrals for clients with anxiety and depression from the pilot practice. This included referrals from the mental health assessment team who were not aware of our service so would refer straight to the CMHT as protocol states. In the same period of the previous year, the CMHT received 27 referrals for anxiety and depression symptoms from the practice.

From 1 April 2006, the clinic stopped taking new referrals; in the following three months, 12 referrals for anxiety/depression were received by the CMHT from the pilot practice.

Feedback

The GPs reported client satisfaction to be 'excellent' 71% of the time, with no negative responses. Feedback from the referrers identified that clients liked being seen in the GP surgery and valued the ease of access to the clinic. They also found the appointment system and short waiting times very reassuring, providing continuity of care. The clients had also commented on the motivation and support offered by the CPNs, finding the interventions they provided beneficial. This was thought to be better than signposting elsewhere, for example, through support groups.

In terms of the effectiveness of the service from a service-user perspective, all responses from GPs were positive: 86% of responses were rated 'excellent'. Overall, comments demonstrated that this was a beneficial service that effectively integrated with primary care.

Referrers supported the feedback from clients on the ease of access, appointment systems and interventions. The referrers also commented that the interventions offered an alternative treatment pathway to that of medication and helped prevent crises. They also appreciated having in-house CPNs as this enhanced communication and offered a quick and positive link that enabled primary care staff to discuss mental health issues with an appropriate professional. They considered that the project had increased the understanding of each other's roles and methods of practice.

We asked referrers to score the overall project on a scale of 1-10 (1 being low). The results showed an average score of 9.4. Comments on how this service could improve suggested that it should continue with more hours offered.

Our experience

Direct collaborative working enhanced the understanding of the roles and responsibilities of all professionals and also gave the opportunity to offer explanations and develop a greater understanding of the scope and constraints of the mental health trust governance arrangements. We felt trusted and valued in our professional roles as CPNs and worked autonomously within a supportive team.

The CMHT criteria are now focused on severe and enduring mental illness, which screens out people with mild/moderate mental health problems. The short-term work undertaken in primary care, in most cases, prevented deterioration to such a degree that referral to CMHT was not required. Due to early intervention it was possible to introduce cognitive behavioural therapy principles and self-help strategies as a first-line treatment and an alternative to offering medication in the initial treatment stages.

The appointment system worked well, the time allocated to each individual client was adhered to and was considered appropriate.

Clients appeared more willing to accept and use self-help strategies, and as such required fewer sessions. This may have been a result of being seen in a less stigmatised environment as opposed to a specialist mental health unit. We felt our interventions were beneficial to clients, as only three were re-referred.

More responsibility was left with the clients and we were encouraged to embrace positive risk-taking, which meant we did not foster dependency. This was helped by easy access to communication systems and working alongside other members of staff in the practice, as well the use of a 'paper free' electronic patient record system that we found to be less bureaucratic and time-consuming.

In short, we found this a very rewarding and enlightening experience, which was further enhanced by positive client feedback.

Impact of pilot scheme on the trust

Unfortunately, the pilot scheme was not adopted by the trust due to budget constraints and other developments at the time. However, it is commendable that the audit of the pilot was completed. This means the results are available and can be used to make future decisions. Additionally, the information can be shared with other organisations that might be able to implement similar practices with the same successes and benefits.

Conclusion

The service provided access to treatment for clients with mild to moderate mental health problems. Implementation of the PCMHC service resulted in a reduction in referrals to the CMHT for depression and anxiety-related problems.

Waiting times averaged between 2-4 weeks and referrers and service users were satisfied with this. The findings indicate that brief interventions (1-3 sessions) can be effective in primary care. This was asserted from working in partnership with clients, their feedback and the paucity of re-referrals or subsequent referrals to the CMHT.

We would have liked enough time before implementing the service to have developed a satisfaction questionnaire to gain direct users' views of the service, as the feedback received was only from a secondary source. However, clients were asked to complete the HADS tool during the initial assessment and then at the end of sessions. In total, 100% of clients showed improvement following sessions with the PCMH workers as measured using the HADS tool.

In the early stage of the pilot a referrer to the service did not adhere to age criteria. This was possibly due to a communication problem in that the mental health nurses did not make the age group clear. This 16-65 year age criteria was initially established by the mental health nurses due to the existing working practices with this age group in the adult CMHT. On reflection the upper age limit could have been lifted as those over 65 years that were seen were found to have the same difficulties and needs as those in the 16-65-year age group.

Development implications for nurses

  • PCTs and the NHS trust should ensure that the PCMHC service continuesand that service capacity (including staff to support it) is increased to ensure equity of access across the area.
  • PCMHC staff should hold collaborative meetings with PCTstaff in order to increase awareness of the service and develop greater integration with the PCT. Opportunities for joint training with PCT staff should be maximised.
  • PCMH workers should develop a range of strategies to maintain continuity of the service during staff absences or sickness.

There was a low rate of non-attendance for first appointments (19% did not attend or cancelled the appointment), but this was costly in terms of clinical time. PCMH workers should implement strategies to minimise non-attendance and reduce administrative and clinical time spent on patient referrals not engaging with the service. This could include telephone follow-up of those clients referred before offering them an appointment.

Information should be given to clients before their assessment via the referrer to make clear the possible outcomes of assessment including signposting to other services.

A service-user feedback questionnaire should be developed.

Initially it was proposed that both practitioners would work together for half a day in the clinic and use a further half-day for administrative work. After four weeks, it was agreed that this was not the most appropriate use of resources and the decision was made to change the hours. Each practitioner would hold a clinic, one in the morning and one in the afternoon, which offered a more flexible service to the clients and was a more appropriate use of clinician time. However, due to the pressures of work within the CMHT, the half-day allocated for administrative and follow-up work was lost. It is recommended that this time be retained in the future.

References

Department Of Health (1999)The National Service Framework for Mental Health. London: DH.

Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: DH.

Gilbody, S. et al (2002) Improving the recognition and management of depression in primary care Effective Health Care Bulletin 7 (5).

Gilbert, N. et al (2005) The effectiveness of a primary care mental health service delivering brief psychological interventions: a benchmarking study using the CORE system. Primary Care Mental Health;3: 4, 241-251.

Gillam, T. (2004) Managing depression: an overview. Mental Health Practice; 7: 9, 33-37.

Goldberg, D., Huxley, P. (1980) Mental Health in the Community. The pathway to psychiatric care. London: Tavistock Publications

NICE (2004) Depression: management of depression in primary and secondary care - NICE Guidance. London: NICE.

Office of National Statistics (2001) National Census 2001[online] Available from:http://www.statistics.gov.uk/

Plummer, S., Gray, R. (2000) Community mental health nurses, primary care and the National Service Framework for Mental Health. Mental Health Practice; 4: 1, 32-36.

Richardson, N., Paxton, R. (2004) Open clinics: a pilot initiative to improve access to mental health services. Mental Health Practice; 7: 8, 17-18.

Snaith, P. (2003) The Hospital Anxiety & Depression scale. Health & Equality of Life Outcomes; 1: 29.

World Health Organization (2002) Innovative Care for Chronic Conditions: Building Blocks for action: Global report. Geneva: WHO.

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