A new guideline offers advice on identification, assessment and care pathways for people with mild to moderate psychiatric symptoms
Bessant M, Ekers D (2011) Common mental health disorders. Nursing Times; 107: early online publication.
Most depressive and anxiety disorders are identified and treated in primary care without referral to specialist mental health services. Yet significant issues persist around recognising and treating people presenting with these disorders, particularly those at a sub-threshold level.
Despite progress to reduce the stigma around mental illness, many people feel reluctant to seek help for emotional and psychological problems.
Of those who do present in primary care, it is estimated only 30% will be diagnosed and offered treatment because health professionals fail to recognise their problems and lack of awareness of care pathways for these conditions (National Institute for Health and Clinical Excellence, 2009).
In 2009, NICE updated its depression guideline, which has been followed by an update of its anxiety guideline (NICE, 2011a).
The depression guideline specificially refers to “severity”, in recognition that milder depressive symptoms can – despite falling below the DSM-IV and ICD-10 thresholds for diagnosis – be “distressing and impairing if persistent” (NICE 2011a; 2009; Masterson et al, 2010).
With this in mind, NICE approached the National Collaborating Centre for Mental Health – one of four centres it commissions to develop clinical guidelines for the NHS – to devise new guidance focused on primary care.
The aim was to improve “access to services (including primary care services themselves), enhancing identification and recognition, and providing advice on the principles that need to be adopted to develop appropriate referral and local care pathways for common mental health disorders” (NICE, 2011b).
Implications for practice
The resulting guideline is particularly relevant to nurses working in primary care as it is concerned with patients with “mild to moderate” symptoms. This is a group nurses often come into regular contact with, and they are well-placed to provide first-level assessment and/or intervention.
While focused mainly on primary care in the NHS, the guideline is also relevant to non-NHS services such as social services and independent or third-sector providers.
The guideline advocates a “stepped care” model to help people with common mental health disorders and their families, carers and professionals to receive the most effective interventions. The model is based upon the principle of offering the least intrusive, most effective intervention first, with an emphasis on patient need and preference.
The guideline also supports using simple yet robust assessment tools to help staff identify common mental health problems in primary care.
Two specific questions are recommended with regard to depression:
- During the past month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
Similarly, with regard to assessing anxiety, the guideline recommends using a two-item, short screening tool:
Over the last two weeks how often have you been bothered by:
- Feeling nervous anxious or on edge?
- Not being able to stop or control worrying? (Spitzer et al, 2006).
In the case of anxiety symptoms, the guideline recommends that, if a low score is achieved but the assessor is still concerned the person may have an anxiety disorder, a third question may be used to identify people with anxiety or phobic disorders who adopt strategies to limit their exposure to the thing that makes them anxious:
- Do you find yourself avoiding places or activities and does this cause you problems?
Using these simple case identification tools gives primary care staff the potential to close the treatment gap – estimated to be more than 50% for depression and anxiety disorders – by identifying a much larger proportion of people who might otherwise fall beneath the radar and fail to get help at a level appropriate to their mental health needs (Kohn et al, 2004).
The guideline emphasises promoting access and developing local care pathways with good integration between primary and acute services.
It also supports “multiple means of access (including self-referral)” to services, rather than the traditional single point of entry model that has characterised many services (NICE, 2011b).
Overall, this new guideline represents an important step on the path towards improving the nation’s mental health.
The guideline,Common Mental Health Disorders: Identification and Pathways to Careis available for download atwww.nice.org.uk/guidance/CG123
Mike Bessant is mental health nurse and regional mental health lead, NHS Direct, Bristol; David Ekers is nurse consultant, primary care mental health, Tees Esk and Wear Valleys Foundation Trust, and honorary clinical lecturer, Centre for Mental Health Research, Durham University
Kohn R et al (2004) The treatment gap in mental health care. Bulletin of the World Health Organization; 82: 858-866.
Masterson B et al (2010) Depression 1: identifying the condition and offering initial treatment for adults.Nursing Times; 106: 31.
National Institute for Health and Clinical Excellence (2011a) Generalised Anxiety Disorder and Panic Disorder (With or Without Agoraphobia) in Adults. London: NICE. www.guidance.nice.org/ukCG113
National Institute for Health and Clinical Excellence (2011b) Common Mental Health Disorders: Identification and Pathways to Care. London: NICE. www.nice.org.uk/CG123
National Institute for Health and Clinical Excellence (2009) Depression: the Treatment and Management of Depression in Adults (Update). London: NICE. www.nice.org.uk/CG90
Spitzer et al (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine; 166: 1092-1097.