MENTAL HEALTH AS A HOT TOPIC

MENTAL HEALTH NATIONAL SERVICE FRAMEWORK

•	Sets national standards for mental health services
•	Based on clinical evidence and sets out best practice for promoting mental health

7 standards of care including:

•	To promote mental health for all
•	Combat discrimination against those with mental health problems
•	Anyone who needs to should have their mental health needs identified and assessed and be offered effective treatments, including referral
•	Should be able to contact local services ‘round the clock’
•	Timely access to an appropriate hospital bed

Has been criticised as having far-fetched targets within a short time period

DEPRESSION

•	Much of the published research in primary care revolves around the poor detection of depression and therefore lack of treatment
•	Many studies look at short questionnaires that screen for depression

Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project: RCT. Lancet 2000; 355:185-91

•	Large RCT
•	Assessed the effectiveness of an education programme on recognition and out come of primary care depression
•	No increase in recognition of depression
•	Findings herald the need for a major change improving management of depression in primary care
•	Results conflict with positive findings of other studies

Antidepressant drugs and generic counseling for treatment of major depression in primary care. BMJ 2001;322:772-5

•	Compared efficacy of antidepressants and counseling for treating mild to moderate depression
•	No difference - counseling may be as effective as drugs in mild-moderate depression
•	Patients on medication may recover more quickly

Effectiveness of exercise as an intervention in the management of depression. BMJ 2001;322:763-7

•	Systematic review of RCTs to determine effectiveness of exercise in management of depression
•	Studies flawed as hard to blind exercise!
•	Need further research

SELF HARM

General practice based intervention to prevent repeat episodes of deliberate self harm: cluster RCT. BMJ 2002;324:1254-7

•	Does GP intervention reduced incidence of self-harm?
•	2/3 of patients consult with GP after an episode of self-harm
•	Intervention-letter from GP inviting consultation/ guidelines on assessment and management of self-harm
•	Outcome - occurrence of repeat episode - no significant difference between groups
•	More research needed - nobody knows what the most effective management of self-harm is
•	GP role important as more than half receive no psychiatric follow up

SUICIDE

Suicide rate in young men in Scotland is twice that in England/ Wales

•	Poverty/ unemployment important factors in Scotland
•	Practical suggestions include making popular sites for suicide less accessible
•	Telephone helpline/ referral service

Familial, psychiatric and socioeconomic risk factors for suicide in young people: nested case-control study. BMJ 325: 74-77

•	Mental illness the strongest risk factor
•	Also parental influence: suicide, early death, unemployment, divorce, poor schooling
•	Recognising mental illness in young people and treating it could help prevent suicides

Burden of illness and suicide in elderly people: case-control study. BMJ 324: 1355-57

•	Most older people who commit suicide in later life suffer from depression
•	Role of somatic illness is less clear 
•	Study showed that visual impairment, neurological disorders and malignant disease were associated with increased risk of suicide in elderly people

BEREAVEMENT

Spiritual beliefs may affect outcome of bereavement: prospective study. BMJ 324:1551

•	Can spirituality affect bereavement?
•	Prospective cohort study of people about to be bereaved
•	People who profess stronger spiritual beliefs seem to resolve grief more rapidly and completely
•	However small sample size as difficult to recruit large numbers at emotive time

POST-NATAL DEPRESSION

•	Common, 13% of deliveries
•	Distinguish from ‘blues’ - emotional lability - peak days 3-5 and over by day 10
•	Depression more likely if previous history
•	Many recover spontaneously
•	50% still depressed at 6 months
•	One third go on to develop a chronic, recurrent mood disorder
•	Treatments include
	Counselling by health visitor
	CBT
	Antidepressants
		TCAs safe with breast feeding
		SSRIs secreted in small amounts in breast milk
•	Refer to mother/ baby unit if psychotic/ suicidal

EATING DISORDERS

•	1/2000 anorexia,    20/2000 bulimia
•	CBT/ SSRIs effective treatment options
•	Early intervention produces better outcome

Anorexia - diagnostic criteria

•	Overconcern with shape and weight, intense fear of becoming fat
•	Active maintenance of low weight (BMI<17.5) with dieting, exercise, vomiting
•	Amenorrhoea for a minimum of three months

Bulimia nervosa - diagnostic criteria

•	Overconcern with shape and weight
•	Frequent binges (bulimic episodes)
•	Extreme behaviour to prevent weight gain - vomiting, diuretic abuse, fasting

SCOFF questionnaire

1.	Do you ever make you Sick because you feel uncomfortably full?
2.	Do you ever worry you have lost Control over how much you eat?
3.	Have you ever lost more than One stone over a month period
4.	Do you believe yourself to be Fat when others say you are thin?
5.	Would you say Food dominates your life?

Score of 2 or more suggests anorexia/ bulimia

For part 2 - see ‘Depression in General Practice’ from Mental Health session

DEPRESSION IN GENERAL PRACTICE

10-20% of patients consult in general practice suffering from some form of depression
90% of depressive illness dealt with in general practice

Cause 	- 	Major life changes (birth of  a baby, losing job)
	 	No obvious cause
		Physical changes in the brain
		Social factors - reduction in interest/ activities

Treatments -	Physical -		antidepressants
		Psychological -	cognitive behavioural therapy
		Social -		increased activity/ befriending

Drug Treatment  
	
•	Greatest benefit is in moderate/ severe depression
•	37% of patients relapse within one year of remission
•	Therefore continue treatment after recovery to reduce risk of relapse - for 4-6 	months after first episode
•	In recurrent cases i.e. 2/3 or more attacks within 5 years - long term treatment 	needed and treatment should not be stopped for 2 years after symptoms have resolved

Non Drug Treatments

•	Non directive counseling - no long term effect on outcome
•	Problem solving skills training -  identify and solve inter-personal and social problems
•	Interpersonal therapy - brief supportive therapy linking recent problems in inter-personal relations to mood
•	Cognitive Behavioural Therapy

Adapting and Recovering from Depression

Need support from family, friends, colleagues, health professionals
Discussion to deal with the stigma of depression
Support groups
Back to work/ social activity

CLASSIFICATION OF DEPRESSION (ICD-10)

F33 Recurrent Depressive Disorder

Repeated episodes of depression as specified in depressive episode (mild, moderate, severe)

F32 Depressive Episode

A	Depressed mood				
	Loss of interest and enjoyment
	Reduced energy leading to fatigability

B	Reduced concentration and attention
	Reduced self-esteem and self-confidence
	Ideas of guilt and unworthiness
	Bleak and pessimistic views of the future
	Ideas or acts of self-harm or suicide
	Disturbed sleep
	Diminished appetite

F32.0 	Mild 	- At least 2 A symptoms plus at least 2 B symptoms

F32.1	Moderate - At least 2 A symptoms plus at least 3 B symptoms

F32.2	Severe (without psychotic symptoms)- All 3 A symptoms plus at least 4 B symptoms

F32.3	Severe Depressive Episode (with psychotic symptoms)

Cognitive Behavioural Therapy

•	Not widely available in primary care
•	Basis that emotional problems are due to maladaptive thoughts and beliefs and self-defeating behaviors
•	6 to 16 sessions
•	Aims to change the way the patient thinks about themselves or their situation
•	Some trials show it effective in primary care, others show short term benefits only
•	Evidence that adding this to drug treatment is more effective than either alone in severe depression only

All you need is CBT? J. Holmes. BMJ 324:288-294

•	National Service Framework cites CBT as the first line treatment for depression, eating disorders, panic disorder, obsessive-compulsive disorder and deliberate self harm
•	In its’ favour - efficient, easy to learn and often produces good results

Limitations:

•	The National Institute of Mental Health study of depression - 20 years old - CBT fared less well than interpersonal therapy/ anti-depressants
•	No long term comparative studies to show benefit
•	Leading CBT therapists are recognizing some of its’ limitations
•	Danger of imposing CBT in general practice just as secondary care is moving beyond it

‘CBT seems so far ahead of the field in part because of its’ research and marketing strategy rather than because it is intrinsically superior to other therapies.’

Until the limitations of the evidence for CBT are recognized, there is a risk that psychological treatments in the NHS will be guided by research that is not relevant to actual clinical practice and is less robust than claimed.

Effectiveness of teaching GPs skills in brief CBT to treat patients with depression: randomized controlled trial. M King BMJ  324:947-950

‘CBT is as effective as pharmacotherapy for treating depression with the benefit of reduced rates of relapse’
‘CBT is effective when delivered by GPs who have received extensive instruction’

This study showed brief training has little effect and that GPs require much more training if they are to change their attitudes and acquire skills that have a positive impact on their patients

The clinical and cost-effectiveness of self help treatments for anxiety and depressive disorders in primary care: a systematic review. P Bower BJGP October 2001, 838-845

•	Self help e.g. CBT - requires work to be done by patients between sessions
•	Previous reviews suggested that self-help treatments are more effective than no care
•	However, self-help trials are limited in quality and quantity
•	Further evidence is needed concerning clinical and cost effectiveness to evaluate properly the place of these treatments in mental health in primary care

A qualitative study of patients’ views on anxiety and depression. U Kadam BJGP May 2001, 375-380

•	Anxiety and depression often co-exist
•	Patients viewed their GP as an independent and key resource
•	Patients skeptical about benefits of drug treatment while open to the value of reflexology/ hypnotherapy
•	Several studies have shown that GPs fail to detect a significant proportion of cases with psychological and psychiatric distress
•	GPs find such consultations difficult to address in routine consultation times

Depression in children: may go unnoticed and untreated. P Hazell BMJ 325:229-230

•	Children with depression - lack interest, criticise themselves
•	Some adults find it hard to accept that children may experience depression
•	Australian study: 4% of boys and 2% of girls aged 6-12 had a depressive episode in the preceding 12 months
•	70% chance of relapse in next 5 years
•	Continuity between childhood and adult depression
•	Evidence for the efficacy of treatment is scarce
•	Some trials of CBT have included pre-pubertal children
•	CBT is limited by the number of therapists - may prove more useful as a preventive measure against depression

Food and Drug Administration has taken steps to stimulate research in children - in response there has been a wave of sentiment against the use of medication to treat depression

Children are less likely than adults to receive adequate analgesia for physical pain. There is a danger that because of limited research and antagonism to drug treatment, the same thing may happen with depression.