Pathway-for-anxiety--and-depression.pptx

About anxiety and depression

1. Structure of questioning a patient about anxiety and depression and related treatment recomendations Virtual Patient Pathways for anxiety and depression assessment Please see attached notes Tara Renton

2. Questionnaires and scores Stepped treatment 1,2,3 and 4 IAPT referral GMP Clinical Psychologist and psychiatric support See See NICE recommended management protocols on subsequent slides What about general life advice and links? Sleep, Diet microbiome, exercise and managing stress Do we need GMP details? What other details do we collect? What will the privacy declaration look like?

3. PHQ4 The 'Patient Health Questionnaire-4' (PHQ-4) is a 4 item inventory rated on a 4 point Likert-type scale. Its items are drawn from the first two items of the 'Generalized Anxiety Disorder–7 scale' (GAD–7) and the 'Patient Health Questionnaire-8' (PHQ-8). Its purpose is to allow for very brief and accurate measurement of depression and anxiety. Kroenke, K., Spitzer, R. L., Williams, J. B. W., Löwe , B. (2009). An ultra-brief screening scale for anxiety and depression: the PHQ-4 Psychosomatics, 50, 613-621.

4. GAD 7

5. PHQ 9 scoring

6. Management mild or subthreshold depression The term 'people with persistent subthreshold depressive symptoms or mild depression' includes all people with persistent subthreshold depressive symptoms or mild depression and a chronic physical health problem . state that antidepressants should not be used routinely for people with persistent subthreshold depressive symptoms or mild depression, but may be considered in cases where there is: a past history of moderate or severe depression  or initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)  or subthreshold depressive symptoms or mild depression that persist(s) after other interventions  or mild depression that complicates the care of a physical health problem (for people with depression and a chronic physical health problem only).

7. Management NICE clinical guideline 91  defines appropriate high-intensity interventions for people with moderate depression and a chronic physical health group-based cognitive behavioural therapy (CBT)  or individual CBT for people who decline group-based CBT or for whom it is not appropriate, or where a group is not available  or behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.

8. Management Patient diagnosed with severe depression (PHQ15 score 15-20): People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care. NICE clinical guideline 91  states that collaborative care should form part of a well-developed stepped-care programme. In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step. Collaborative care requires that the patient and healthcare professional jointly identify problems and agree goals for interventions, and normally comprises: case management which is supervised and supported by a senior mental health professional close collaboration between primary and secondary physical health services and specialist mental health services in the delivery of services the provision of a range of evidence-based interventions the long term coordination of care and follow-up.

9. Action points for management of patient with Severe depression Action points: If the patient screens positive for Probable Major Depression this should be discussed with them during their appointment. Check whether they are already receiving any support for this. Ask the patient if they are already receiving mental health care, e.g. from CMHT. If this is the case it would be better to liaise with their psychiatrist or care-coordinator. For patients with severe depression/suicidal ideation , consider referral team liaison psychiatrist. This guidance does not supersede clinical judgement. Offer and discuss a referral if deemed appropriate by the responsible clinician. A risk assessment should be undertaken for patients who screen positive for suicidal ideation (see below), and if there are immediate concerns about the patient’s safety, contact the duty liaison psychiatrist (bleep 278) for discussion of the patient and advice. If the patient screens positive for mild/moderate depression , explore whether the distress is primarily related to oral health or not. If so, consider a referral to the team psychologist. If not, inform the GP and suggest a referral to IAPT (Improving Access to Psychological Therapies http://www.iapt.nhs.uk/ ). Patients should also be informed about self referral to IAPT services. If any referral is made, the patient’s GP should be informed.

10. Guide for patients who screen positive for suicidal ideation Step 1 Suicide alert : If a patient responds “more than half the days” or “nearly every day” to Item 9 of the PH Q-9: “Have you been bothered by . . . Thoughts that you would be better off dead or of hurting yourself in some way” a suicide alert will appear in the database. This Guide is intended to help in these situations, but is only a guide , and is not intended to replace clinical judgement. Remember a high proportion of people have suicidal ideas. We are asking you to see if there is an issue which raises particular concerns. Check the patient’s response to PHQ-9 Item 9 by asking if they have been having these thoughts in the last 2 weeks ? If no, make a routine referral to team psychiatrist” If yes, move to Step 2 Step 2:   Assess Hopelessness “Do you feel life is not worth living?” “Are you feeling hopeless about the present or future?”   Assess Suicidal Ideation “Have you had any thoughts about taking your own life?” If no, “make a routine referral to team psychiatrist” If answer to any question is yes or there is any ambivalence, move to Step 3   Patients screen positive for Suicidal ideation

11. Patients screen positive for Suicidal ideation   Step 3:   Assess Suicidal Plans “Have you made plans for how you would do it?” “Do you have the means to carry them out?” “Have you considered what might stop you?”   Ask about Previous Attempts “Have you ever tried to end your life before?” Ask about Recent Life Stressors “What has been happening recently...?” (Recent stressors could include e.g. worsening of physical health, untreated pain, bereavement or an important anniversary)   Ask about Mental Health Problems “Have you ever suffered with a mental health problem such as depression?” Assess Social Support / Safety “Is there anyone you can confide in or turn to for some support?”

12. Action points for Patients screen positive for Suicidal ideation “Can you make a commitment that you will keep yourself safe until . . . [offer another appointment within the next week or so]?” In the meantime “arrange an early appointment with team psychiatrist, if possible, or phone the GP” Think with the patient about ways he/she might be able to keep safe e.g. being with people, calling a friend or using other helpful strategies if they are feeling low. Advise patient to attend Accident and Emergency if feeling in crisis. If you have immediate concerns about safety, and the patient presents with any combination of Hopelessness OR Suicidal Ideation AND Detailed Suicidal Plan AND/OR Serious Previous Attempt AND/OR Severe life stressor AND/OR Mental Health Problem AND/OR Social isolation   Discuss these concerns with the team psychiatrist and consider the following according to clinical judgement: Contact liaison psychiatry for discussion of the patient and advice. If liaison psychiatry advises, ask the patient if you can take them to the Accident & Emergency Department (A&E). See Box 1 for guidance on taking a patient to A&E. OR If you have serious concerns about the patient’s suicidal risk you can offer to take them to A&E. If the patient is reluctant to go to A&E you may want to talk to them further about their concerns on this course of action. For example, you tell the patient that they will meet an experienced psychiatric nurse who is used to helping people in this kind of situation. If the patient raises fears about psychiatric admission, let them know that care is provided in the community wherever possible. If the patient still declines the offer to go to A&E, the patient may go home. You should phone the patient’s GP and inform them of the situation. See Box 2 for guidance on communicating with the GP.

13. Somatic disorder identified by PHQ 15 Somatisation assessment based upon PHQ 15 Somatic symptom disorder severity: there are four options. 1) No somatic symptom disorder (PHQ-15 score <=4) 2) Mild somatic symptom disorder (PHQ-15 score 5-9) 3) Moderate somatic symptom disorder (PHQ-15 score 10-14) 4) Severe somatic symptom disorder (PHQ-15 score ≥15) Referral advice: For patients who screen positive for Somatic Symptom Disorder, advice on referral will be displayed according to the following algorithm. Mild to moderate depression (PHQ15 score 5-14):  “Refer to team psychologist if SSD is related to nerve injury. Otherwise alert GP in letter: advise IAPT referral" Severe somatic symptom disorder (PHQ-15 score ≥15):  “Refer to team psychiatrist if SSD is related to nerve injury. Otherwise alert GP in letter: advise IAPT referral" Action points: If the patient screens positive for mild/moderate/severe SSD this should be discussed with them during their consultation. • Explore whether SSD is related to their orofacial pain. If so, offer a referral to the clinical psychologist ( If SSD is severe, referral should be made to psychiatrist and discuss this with the patient. Or referral to IAPT (Improving Access to Psychological Therapies http://www.iapt.nhs.uk/). Additionally, inform the patient about self-referral to IAPT. • If any referral is made, the patient’s GP should be informed.

14. Management for patients with moderate to severe anxiety Step 1 — For all people with generalized anxiety disorder (GAD): Assess the severity of GAD. Ask about: The number, severity, and duration of symptoms. The degree of distress and functional impairment. Consider using validated assessment tools such as the  GAD-7  questionnaire, to help determine GAD severity. Enquire about the following factors which may affect the development, course, and severity of GAD: Comorbid depressive disorder, or other anxiety disorder — if present, treat the disorder which is most severe first, as this is more likely to improve overall functioning. For more information,  see the CKS topics on  Depression ,  Obsessive-compulsive disorder , and  Post-traumatic stress disorder . Comorbid medical conditions — ensure that any comorbid conditions are optimally managed, as this is likely to improve overall functioning. Comorbid substance misuse — bear in mind that substance misuse can be a complication of GAD, that non-harmful substance use should not be a contraindication to the treatment of GAD, and that harmful and dependent substance misuse should be treated first as this may lead to significant improvement in the symptoms of GAD. For more information, see the CKS topics on  Alcohol - problem drinking  and  Opioid dependence . Environmental stressors such as physical or emotional trauma, employment or financial worries, poor living conditions, or problems with interpersonal relationships — discuss practical solutions to stressors contributing to GAD. Note:  If the person is exhibiting marked functional impairment, severe co-morbid depression or other mental health disorder, GAD has been assessed as severe, or other concerns have been raised, consider assessing their  risk of suicide . Consider the person's history of mental health disorders, and past experience of and response to treatments  — this information should guide clinical judgement on what level of intervention may be required. Provide written material about the nature of GAD and its treatment options:   NICE  and the  Royal College of Psychiatrists  have produced information leaflets that include this information. Arrange active  monitoring  of the person's symptoms, functioning, and response to treatment (if applicable) at intervals as detailed below, and/or determined by clinical judgement.

15. Step 2 — For people without marked functional impairment who have not improved following step 1 interventions, offer low-intensity psychological interventions based on cognitive behavioural therapy (CBT) principles, such as : Individual non-facilitated self-help — should include suitable written or electronic materials that the person works through systematically over a period of at least 6 weeks. Minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes, is required. Individual guided self-help — should include suitable written or electronic materials, and be supported by a trained practitioner who facilitates the programme and reviews progress and outcome. This usually consists of five to seven weekly or fortnightly face-to-face or telephone sessions, each lasting 20–30 minutes Psychoeducational groups — should have an interactive design and encourage observational learning through presentations and self-help manuals. They should have a ratio of approximately one trained practitioner to 12 participants and usually consist of six weekly 2 hour sessions.  Management for patients with moderate to severe anxiety

16. Step 3 — For people with marked functional impairment  or  GAD that has not improved following step 2 interventions, offer either: An individual high-intensity psychological intervention such as CBT or applied relaxation,  or  drug treatment.  Note: the choice between psychological intervention or drug treatment should be guided by the person's preference, as there is no evidence that one is more effective than the other in the treatment of GAD. Psychological interventions  — Inform the person that response to psychological treatment is not immediate and that a prolonged course is usually needed to maintain an initial response. Drug treatment  — first-line treatment is usually with a selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine,  or escitalopram. A selective serotonin-noradrenaline reuptake inhibitor (SNRI), such as duloxetine or venlafaxine is a possible alternative. Pregabalin can be offered if SSRIs or SNRIs are contraindicated or not tolerated. For more information, see the relevant sections in  Prescribing information . Discuss the potential for adverse effects and withdrawal symptoms before drug treatment is initiated. Explain that adverse effects early in treatment with an SSRI or SNRI may include increased anxiety, agitation, and sleeping problems. Review  the effectiveness and adverse effects of the drug every 2 to 4 weeks during the first 3 months of treatment and every 3 months thereafter. Dose adjustment may be required. Bear in mind that an absence of clinical benefit within four weeks suggests that a response to unchanged treatment is unlikely and that the full efficacy of the drug may take up to 12 weeks to be realised. Be aware that in a minority of people aged under 30 years of age, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm.  Anyone in this age group receiving an SSRI or SNRI should therefore be seen within 1 week of first prescribing, and the risk of  suicidal thinking  and self-harm should be monitored weekly for the first month.  Benzodiazepines should  not  be offered for the treatment of GAD in primary care, except as a short-term measure during crises. For more information, see the section on Prescribing information. Do  not  offer an antipsychotic for the treatment of GAD in primary care. If a pregnant woman with GAD requires step 3 management: Ideally, a high-intensity psychological intervention should be offered first. If drug treatment is considered necessary in the first trimester (such as in a women for whom psychological intervention has proved ineffective), the potential risks and benefits should be discussed. For example, it is still unclear whether SSRIs (and SNRIs) used in the first trimester may slightly increase the risk of infant congenital heart defects above the background rate of approximately 1 in 100. There are insufficient data to permit an evidence-based assessment of the fetal safety profile of pregabalin. This must be balanced against the risks to both mother and fetus if the maternal condition is not optimally controlled. Consider discussion with a specialist in obstetrics for women who may require SSRI or SNRI medication in pregnancy.  If a woman with GAD who is stabilised on current treatment reports a pregnancy, the risk of relapse must be taken into account when considering discontinuing Management for patients with moderate to severe anxiety

17. Step 4 — Refer for specialist treatment (including complex drug and/or psychological interventions, possibly administered on an inpatient basis, or via multi-agency teams), people with severe anxiety and marked functional impairment,  and/or  GAD that has not improved following step 3 interventions,  and/or  those exhibiting, or at risk of: Self-harm.  Self-neglect. A significant comorbidity such as substance misuse, personality disorder, or complex physical health problem. Suicide — refer urgently (same day) to the crisis resolution and home treatment team if the person is at high risk of suicide. For more information see the section on managing risk of suicide in the CKS topic on  Depression . Note: For information on what action to take if admission is thought to be necessary but the person refuses, see the 'compulsory admission' section in the CKS topic on  Depression . Follow local policy when referring to specialist mental health services. For all people with GAD being managed in primary care, also consider providing self-care advice relating to: Sleep hygiene — such as going to bed and waking up at the same time each day, eliminating alcohol after 6 pm, avoiding caffeine after 3 pm, and getting out of bed if unable to fall asleep to avoid negative associations with the sleep environment. For more information, see the CKS topic on  Insomnia . The benefits of regular exercise — can improve overall health and has been shown to improve anxiety symptoms. Management for patients with moderate to severe anxiety

18. Action points for patients with moderate to severe anxiety Action points for anxiety: If the patient screens positive for probable Generalised Anxiety Disorder this should be discussed with them during their consultation. Explore whether the patient’s anxiety is related to their orofacial pain. If so consider offering a referral to the team psychologist and discuss this with the patient. If the anxiety is not related to their orofacial pain, a referral to the GP should be considered and recommend a referral to IAPT (Improving Access to Psychological Therapies http://www.iapt.nhs.uk/ ). Additionally, inform the patient about self-referral to IAPT. If any referral is made, the patient’s GP should be informed