Christina Fairhead, RGN, RHV, NEBSM, ENB 950, ENB 970.
Primary Care Mental Health Nurse, Leicester Terrace Health Care Centre, Northampton Primary Care Trust
Leicester Terrace Health Care Centre in Northampton demonstrates the progress that general practices can make through a comprehensive and extensive mental health service, and the impact that involving nurses can make in improving the management of depression. The practice’s work in depression was recently recognised after it was judged overall UK winner of a national award.
One area highlighted by the judges as evidence of best practice was the pivotal role of the primary care mental health nurse. The role provides the opportunity for nurses working in a primary care setting to play a part in implementing an effective and efficient mental health service, particularly in depression.
The scale of depression
Depression is a major public health issue that impacts socially and economically on individuals, families, businesses, the NHS and social services (Armstrong, 2002). It is the most common chronic condition in primary care, exceeding rates of asthma, diabetes and hypertension, with major depression expected to be the world’s most debilitating illness by 2020 (Armstrong, 2002).
At least 80% of patients experiencing depression are treated entirely in primary care (Goldberg and Huxley, 1992) and they will have nearly three times the consultation rates of their non-depressed counterparts (Mann et al, 1998). Of all GP consultations, 50% have a psychological component, with research showing that at least one patient with mild depression or worse is likely to present at each surgery session (Paykel and Priest, 1992). One study found that people with persistent depression suffer, in terms of quality of life, more than those with persistent physical conditions such as arthritis, diabetes or back pain (Hayes, 1995). The cost and burden of depression should not be underestimated.
Developing an integral role for nurses
The whole process of the care of people with depression needs to be enhanced, involving changes in the organisation and function of health-care teams, such as those already being used to improve outcomes in other chronic diseases (Goldberg and Von Korff, 2001). In many conditions, such as asthma and diabetes, the practice nurse’s role in chronic disease management is already accepted. Their role now needs to be integrated into managing depression. Research suggests that, with only brief special training, practice nurses can achieve excellent patient outcomes when working alongside GPs in assessing and managing depression (Mann et al, 1998).
The principle aim of the mental health nurse is to provide practices with a nurse who can dedicate time to managing patients with depression, aiding the work of the whole practice team (Box 1). Very positive patient outcomes are achieved through meeting the aims of the nurse.
The definition of a primary care mental health nurse has been open to discussion, with some people believing they should be a trained mental health nurse, while others believe it is more appropriate that they should be a general nurse who has undergone some extra training. Armstrong (2002) believes: ‘Primary care is a setting for generalists and the use of trained mental health nurses at this level may divert scarce specialist skills from the care of people with serious and enduring mental illness.’
At Leicester Terrace Health Care Centre the primary care mental health nurse provides a generalist role, based largely on the work of Sally Gardner, a practice nurse in Ipswich, who pioneered the role of the practice nurse in the management of depression, without having a mental health nursing qualification (Gardner and McCullagh, 1998).
The role at Leicester Terrace Health Care Centre originally involved 20 hours a week of mental health work, with the remaining hours devoted to general practice nurse duties. After 15 months the proportion of mental health work changed to 10 hours per week. It consists of face-to-face patient contact, clinical supervision, planning meetings, role development, communication and dissemination with the rest of the primary health-care team, and preparation of materials for patient use.
Managing depression through the nurse
Initially the first couple of months as primary care mental health nurse at Leicester Terrace involved planning evidence-based care and interventions that included the referral process, development of a care pathway, assessment process, review, follow-up, risk assessment and management of risk for patients experiencing depression. Throughout this planning process it was intended to normalise and de-stigmatise the care of depression, using a model of chronic disease management. In dividing the role between mental health and generic practice nurse duties, the nurse is still very much part of the practice team. This way of working allows the nurse to see patients for a variety of reasons rather than just depression, and ensures patients identify them as a practice nurse.
Integral to the role is the principle of case management, involving responsibility for monitoring and active follow up (Goldberg and Von Korff, 2001). At Leicester Terrace this responsibility extends to include systematic assessments, continuity of care, a more accurate needs assessment, improved patient education and a holistic approach, with heightened awareness of the effects of co-morbidity.
There is often an artificial dichotomy in primary care, in which the physical needs of patients with depression are not met, and the mental health needs of patients with physical health problems are not recognised. There is an increasing body of evidence that clearly illustrates the damaging effects of depression in the presence of co-existing physical disease (Hayes et al, 1995).
Therefore, while patients with depression are an integral part of the primary care clientele, a large number also experience chronic physical disease. Depressed patients are not the ‘worried well’, they are the ‘worried sick’ (Armstrong, 2002). Many of these people may be seriously disabled by their symptoms of depression, but most do not require referral to specialist services. Research shows the effect of co-morbid depression on patients with asthma, as follows (Mancuso et al, 2000):
- 45%-55% of asthma patients were also found to be depressed
- The depressed patients reported worse health-related quality of life
- They had lower scores on many measures of functional capacity.
Other examples of illustrative research on the effects of co-morbid depression include myocardial infarction (Jones, 2000), diabetes (Anderson et al, 2001), stroke/cerebral vascular accident (House, 1999).
Any member of the primary health-care team can initially identify the possibility of depression. The Hospital Anxiety and Depression Scale (HADs) questionnaire (Snaith and Zigmond, 1994) may be used or the patient may be asked to take a completed HADs questionnaire along to an appointment with his or her usual GP. The GP would then assess the patient’s state of mind and suitability for referral to the primary care mental health nurse against previously determined criteria for referral.
An initial consultation with the nurse takes 40 minutes, as it is felt important to invest the time for a full patient needs assessment. Armstrong (2002) highlights that the ability to make a comprehensive assessment of the person’s health-care needs is a key skill required by professional providers of a first contact service. The objectives for this initial consultation are set out in Box 2.
Occasionally, due to the patient’s condition, it may not be possible to meet all of the objectives in the first consultation. However, some of the objectives should be met at that point, such as the suicide risk assessment and ensuring the patient’s questions are answered.
Active follow-up consultations are allocated 20 minutes and include assessing the patient’s response to treatment, suicide risk assessment, patient information, education, and self-help techniques. In addition, and if appropriate, the primary care mental health nurse determines whether patients are taking the prescribed medication, with advice, support and guidance when encountering problems related to the medication itself (Goldberg and Von Korff, 2001).
At first, patients need to be seen regularly to assess whether their depression is improving. Action must be taken when they do not attend appointments that were agreed during discussion of their care pathway. The patient is told that any action, such as informing the referring GP of failure to attend, is not an attempt to compromise their choice of care, but a bid to aid and engage them through what is accepted as a difficult time.
During care under the nurse, patients are informed of the care pathway and that it is their decision to continue to work with the practice nurse and the GP. Patients are aware that the nurse can refer them back to the GP sooner than originally planned or to the practice counsellor if this is felt to be the appropriate intervention within the care pathway. All relevant information is noted in the patient’s computer record using a depression template, developed with the nurse.
In promoting patient empowerment, the nurse lends out audiocassettes about depression, which patients have reported finding reassuring and informative.
If the patient’s condition allows, they are usually given small tasks to complete between appointments. This has two purposes: first, to help clinicians assess the patient’s motivation and, second, to enable the patient to become actively involved in his or her treatment and take a greater level of personal responsibility.
Patients have also reported experiencing benefits from carrying out the tasks themselves, such as completing a mood chart, therapeutic letter writing, relaxation breathing exercises, and using depression workbooks.
The value of primary care mental health nurses
Some of the outcomes measured throughout the primary care mental health nurse role at Leicester Terrace indicate the following:
Patient satisfaction Patients were given a patient satisfaction questionnaire usually at the first or second nurse consultation. They were asked to complete it at home and return by pre-paid post. A significant number of patients expressed a very high degree of satisfaction with the care they received, with 97% finding the session with the primary care mental health nurse useful.
GP satisfaction Each of the six GPs and the GP registrar were asked to complete a questionnaire, to convey their views regarding the progress of the nurse and the effect on their patients’ care and condition. All of the GPs were positive, with the overall response being that the service was beneficial to both patients and GPs.
Patient concordance with medication For patients receiving antidepressant medication as part of their treatment, information, support and regular contact in the early stages are crucial to improving levels of concordance. Patients’ lack of knowledge is thought to play a part in the high rate at which they abandon drug therapy (Paykel and Priest, 1992). Inadequate treatment with medication, in the first six months in controlled trials, resulted in relapse rates as high as 50%, compared with 20% when treatment was continued at adequate levels (Prien, 1992). For patients who were taking antidepressants and under the care of the primary care mental health nurse, the level of concordance was high compared with previous studies.
To provide a comprehensive service for patients with depression, primary health care should follow a team approach, and acknowledge that all team members are likely to encounter such patients in the course of a normal day. All have a constructive part to play in managing depression according to their individual skills and training. Practice nurses have the skills to manage depression, which they have demonstrated through chronic disease management of conditions such as asthma, diabetes and hypertension. They can make a valuable contribution with only brief special training (Mann et al, 1998) and within the framework of a practice protocol and clinical guidelines.
The Lundbeck Award for Best Practice in Depression 2003
This work was the winner of the Lundbeck Award for Best Practice in Depression 2002.
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