NICE guidelines update 2013 Katie Simpson South Central SHA IAPT GP Clinical Lead Mental Health Lead Berks East PCT

281 million consultations in Primary Care annually 30% of all GP consultations have a Mental Health component 90% Mental Health Problems managed by Primary Care Primary Care Mental Health

Depression: review of assessment Emphasis on psychological interventions Pharmacological interventions new information efficacy and cost effectiveness augmenting Relapse prevention GP key role CG90 NICE Depression guidance

Principles for assessment The guidelines discourage over reliance on the number of symptoms. Instead: Distress Duration Disability If the patient’s symptoms have been distressing and have been present for 2 weeks or more at a level where they have affected their ability to function normally then it is likely that they are significant

Be alert to possible depression –Particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment. Consider asking people who may have depression two questions, specifically: –During the last month, have you often been bothered by feeling down, depressed or hopeless? –During the last month, have you often been bothered by having little interest or pleasure in doing things? (PHQ2) “Is this something with which you would like help”? Identification and assessment

Role of the General Practitioner GPs ideally placed to detect depression “Watchful waiting” vs GP involvement in all steps of the model CG 90 not so explicit about boundaries primary care/ specialist care But: dangers of false diagnosis and medicalisation of distress Some evidence of diagnosis and prescription in pts. not actually depressed

Key points for intervention Step 1 Identification Risk assessment Active monitoring Step 2 Advice on sleep hygiene and activity Low intensity psychological interventions Step 3 High intensity psychological interventions Referral Steps 2, 3, and 4 Antidepressants Steps 2, 3 and 4 Provision of service delivery system

The Characteristics of IAPT Implements NICE Guidelines –Not only CBT Stepped care Outcome focused Self referral

Stepped Care

Referral Criteria Problems suitable for Talking Therapies Depression Generalised anxiety disorder Psychological problems arising from long term medical conditions Panic disorder Social phobia Specific phobias OCD Obsessive compulsive disorder PTSD Post- traumatic stress disorder –moderate/single trauma e.g. RTA Health anxiety Medically Unexplained Physical Symptoms Post natal depression (mild/moderate) Employment stress, support required to stay in or obtain work.

Not suitable: Children Psychosis Actively suicidal Complex problems eg PD, Severe PTSD, Moderate/Severe Eating disorders Drug/Alcohol problems Under Secondary Care Services

NICE conclusions on antidepressant medication When prescribing, should normally be SSRI (Selective Serotonin Receptor Inhibitors) in generic form Avoid using routinely for subthreshold depressive symptoms Discuss options, consider side effects, discontinuation, potential interactions, physical health, previous experience

Starting antidepressant treatment Obtain patient’s agreement that they have a depressive illness, then: Address patient concerns, views on tablets and antidepressants, and discuss common myths  Gradual effects and need to persevere  Side effects and drug interactions  Previous experience of efficacy/side effects  Discontinuation symptoms  Not addictive  Ask about St. John’s Wort Review after 2 weeks, then at least monthly If suicide risk or <30years review after 1 week, then frequently

Mode of action: SSRI (Selective Serotonin Receptor Inhibitors)

Common Side Effects of SSRIs Nausea Diarrhoea Headache Anxiety Insomnia/drowsiness- adapt time of taking Weight loss/gain Sexual difficulties: lack of orgasm Short term rx (<2 weeks) with a benzodiazepine Care in people at risk of falls

Generic SSRIs: Fluoxetine, Citalopram, Sertraline, Paroxetine Sertraline & Citalopram are safer in patients with Long term conditions as less interactions with other medication Paroxetine more discontinuation symptoms Fluoxetine can increase anxiety in approx 10%

Escitalopram Isomer of citalopram Cochrane report supported it BUT Small no’s of patients, short term follow up, Pharmaceutically sponsored trials Not enough information to recommend it above other treatments as much more expensive.

SNRIs (Serotonin & Noradrenaline Reuptake Inhibitors) Venlafaxine: can increase blood pressure, more toxic in overdose. Duloxetine: Also used in diabetic neuropathy (& stress incontinence) Side effects similar to SSRI

MIRTAZEPINE

Mirtazepine Works by increasing noradrenaline and serotonin in unique way (blocking alpha adrenergic receptors) Weight gain Sedation- some times useful Often used to augment other antidepressants

TCADS (Tricylic Anti Depressants) e.g amitriptyline, clomipramine, dothiepin Work on serotonin and noradrenaline Side effects: dry mouth, constipation, blurred vision, palpitations, urinary retention Very toxic in over dose (especially dothiepine) except lofepramine

Starting Treatment Response by 2-4 weeks Switch or increase dose if: –Inadequate response –Side effects –Patient prefers

Risk Assess, not just using a symptom count Assess social support Arrange appropriate help Advise how to seek help GP’s are used to living in a very risky world We can each expect a suicide every 5 years

Suicide risk Review after 1 week Consider other forms of support e.g. More frequent direct or telephone contact Consider referral to crisis team Advise and monitor potential for increased agitation, anxiety and suicidal ideation Take into account toxicity in overdose  Venlafaxine associated with increased risk  TCAs increased risk (except lofepramine)

Augmenting antidepressants If person is informed and prepared to accept additional side effects, consider augmenting with: Lithium An antipsychotic such as aripiprazole, olanzapine, quetiapine, risperidone Another antidepressant, such as mirtazapine or venlafaxine

Relapse prevention Need to continue treatment for at least 6/12 from recovery  Continue medication for at least 2 years (If 2+ recent episodes, other risk factors, relapse consequences severe e.g occupation)  Psychological interventions: For recurrent depression Individual CBT (16-20 sessions over 3-4 months) OR Mindfulness based cognitive therapy (8 week group)

Discontinuation When stopping antidepressants, gradually reduce dosage over a 4 week period Some people may require longer, esp. With e.g. paroxetine, venlafaxine Exception is fluoxetine Warn about discontinuation symptoms – usually settle within a week If symptoms mild: reassure and monitor If symptoms severe: reintroduce original dose or another with longer half life and reduce gradually

Subthreshold and mild depression Do not routinely use drugs Consider them for: –Those with a PMH of moderate/severe depression –H/O 2y + subthreshold symptoms –Subthreshold / mild depression persisting after other interventions

Key points GPs should be alert to possible signs of depression in patients, but should not medicalise distress Assessment and management should be carried out according to the stepped-care model Patients should be supported by the GP throughout the management process GPs should use active monitoring for patients as appropriate GPs should have knowledge of: –low-intensity psychological interventions –locally available services Pharmacological treatment choices should be tailored to the individual patient The use of St John’s wort is not recommended High-intensity psychological interventions should be offered to patients with moderate to severe depression

How to manage anxiety disorders in general practice Katie Simpson South Central SHA IAPT GP Clinical Lead Mental Health Lead Berks East PCT

GAD Panic disorder PTSD OCD Social phobia Specific phobias (e.g. spiders) Acute stress disorder Subtypes of anxiety disorders

GAD (5% of GP patients) DSM IV: ‘excessive worry and heightened tension majority of days’ ‘difficulty controlling the worry’ ‘plus additional symptoms’ ‘should cause clinically significant distress or impairment of function’ ‘6 months’ Generalised anxiety disorder

chronic physical health problems OR people seeking reassurance about somatic symptoms (particularly the elderly and those from minority ethnic groups) OR repeatedly worrying about a range of issues Who has GAD?

Step 1 – identification and assessment, education and active monitoring Step 2 – individual pure self help, individual guided self help or psycho- educational groups. Books: ‘Living with fear’ by Marks IM, ‘Mastery of your anxiety and panic’ by Barlow DH ‘Overcoming anxiety’ by Kennerley H. Step 3 – high-intensity psychological interventions (CBT or applied relaxation) OR drug treatment (Sertraline). See them within 1 week of starting rx Full anxiolytic effect takes 1 week or more. Important to cont rx after remission to prevent relapse (at least 1 year). Step 4 – consider referral to secondary care Stepped care in GAD

Sertraline 1 st line If ineffective/ not tolerated then another SSRI or SNRI Consider: withdrawal syndrome/ side effect profile/ risk of suicide/self harm-toxicity in OD/previous experience of drug rx SSRI/SNRI at step 3

Pregabalin If pt cannot tolerate SSRIs then offer pregabalin or SNRI Also used in neuropathic pain & epilepsy Side effects : dizziness, drowsiness, dry mouth, ankle swelling, blurred vision, poor concentration, weight gain

Do not offer BDZs for Rx of GAD apart from short-term measures during a crisis. Advice in BNF - not be used as sole rx for chronic anxiety. Avoid driving- even the next morning Can become habit forming after 2 weeks In long term can cause rebound insomnia and anxiety Benzodiazepines

Beta Blockers B blockers help with palpitations and tremor NOT psychological symptoms/muscle tension Side effects: cold extremities, tiredness NOT with asthma

Anti- psychotics Do not use antipsychotics for rx of GAD in primary care e.g chlorpromazine, haloperidol, risperidone, aripiprazole Risks out weigh benefits Weight gain, increased risk of Diabetes, Cardio vascular disease including stroke

Provide contact numbers and info about what to do and who to contact in a crisis Comorbid anxiety or physical disorder? Treat the primary disorder first (the one that is more severe) Non-harmful alcohol misuse not a contraindication to rx of GAD. However with harmful and dependent alcohol misuse rx this first as alone it may lead to a significant improvement in GAD Principles of care in GAD

Dr Katie Simpson South Central SHA IAPT GP Clinical Lead Mental Health Lead Berks East PCT Thank you