Mental Health Using an EMIS Mental Health Template and a Register of patients to improve the care of those with Anxiety and Depression.

Anxiety and Depression Demographics – a recent report. Audit of Depression reviews Step by step approach to creating an active Anxiety and Depression register Anxiety and Depression Template Depression Pathway

Demographics

Depression is the third most common reason for GP consultations in the UK (Gilbody and others, 2002; Plummer and Gray, 2000). Of all those in England suffering from anxiety or depression in each year, 8.73 per cent and 9.81 per cent entered treatment using the IAPT mental health service in 2011/2012 and 2012/13, respectively. A recent PCT-level analysis found that IAPT had no significant effect on antidepressant prescribing (Sreeharan et al, 2013).

Demographics and Deprivation The relationship between socioeconomic disadvantage and higher psychiatric morbidity is well documented (Ford et al, 2010; Madianos et al, 2011; Paul and Moser, 2009) A number of studies have shown that there is a strong link between depression and unemployment (Payne et al, 1993) The recent recession has had widespread economic implications for the UK population.. Unemployment rates have risen: from roughly 5.5 per cent in 2007 to 7.7 per cent in 2012 (ONS, 2014). A general population study (N = 950) by Huber in 2010 found that 53 per cent of adults had experienced depressive symptoms – four to five times higher than levels recorded among the general population before the recession.

Antidepressant Prescribing in Primary Care The average number of antidepressants prescribed per 1,000 people in England rose from 307 items a year in 1998, to 743 items a year in The factors behind the rise remain poorly understood and antidepressant prescribing has continued to grow despite investment in alternative treatments e.g. IAPTs. It may be linked to longer term use of antidepressants as well as increased prevalence of Depression.

Variance in Antidepressant Prescribing

The rate of antidepressant prescriptions per person varied widely across different PCTs. In quarter 3 of 2012/13, 15 PCTs prescribed between 50 and 100 items per 1,000 people, whereas 20 PCTs prescribed over 250 items per 1,000 people. City and Hackney PCT prescribed 81 items per 1000 people; the third lowest in the country. Overall London PCTs were low prescribers of Antidepressants compared to the UK average.

What causes variance in GP Prescribing of antidepressants? Patient Characteristics: Higher proportions of Female, White patients over 65 led to higher prescribing. GP Characteristics: GPs qualifying in the UK had a higher prescribing rate, and over the age of 55 had a lower prescribing rate. GP Practices with higher antibiotic prescribing rates had a significantly higher antidepressant prescribing rate as did those with greater patient satisfaction, more GPs per head of population and with a higher level of health in general. Socioeconomic factors such as income, education, crime, living environment, unemployment had no significant association with antidepressant prescribing rate at one point in time. Nor did Local IAPT uptake rates. Increases in Unemployment rates in any particular area led, however, to increased prescribing over time.

Prevalence Recorded rates of depression in QOF for adults aged 18 and over were 11.2 per cent in 2010/11 and 11.7 per cent in 2011/12. In 2012/13, the methodology for recording depression in QOF was changed and became more conservative therefore the depression prevalence for 2012/13 was estimated to be much lower, at 5.8 per cent. This change is consistent across all practices in the UK. Previous studies have demonstrated that depression is often under- recognised and under-treated in primary care (Ballenger and others, 2001).

Prevalence in City and Hackney; Depression Coding Audit A search of codes for Depression (not anxiety) produced at least 73 individual codes, many of which are not included in QOF. There appears to be no easy way to identify patients with Depression due to the variance in Coding. A proxy was used - those patients who have received an Issue of an antidepressant in the last 3 months (not amitripyline 10mg or 25mg) An audit of these patients showed that 64% were not being picked up by QOF coding. 19% of the total had a Neurotic Disorder diagnosis e.g. Anxiety, which is not included in QOF Potentially 45% who have Depression are not being picked up by QOF due to coding issues. These figures were confirmed on a CCG-wide analysis of City and Hackney; there were also very similar figures in Tower Hamlets CCG Therefore we may be underdiagnosing and under-prescribing due to factors relating to our population, but also those that we are diagnosing and prescribing for may not be being picked up on through official figures due to coding issues.

Audit of Depression Reviews An audit of 50 patients currently receiving antidepressants (issued in the last 3 months; not amitriptyline 10 or 25) 14 (28%) had not had a review performed by a GP in the last 12 months. 4 patients (8%) were under Private or NHS Psychiatric care. 4 patients (8%) had difficulty coming to the surgery due to their mental health problems or were reluctant to be reviewed. 2 patients were Diabetics with poor Diabetic control; their mental state had been flagged up by the Diabetic Nurse but the patient hadn’t mentioned it to their GP. Of those patients not under Psychiatry f/up, the mean duration of antidepressant use was 8.8 years.

EMIS Template / pop-up Coming soon… A pop-up as a reminder re: annual Depression / Anxiety review in those currently being issued with Antidepressants (not Amitriptyline 10 or 25) (expected July/Aug 2014) This will link through to the new Depression / Anxiety template. This will include up to date QOF prompts It will include links to Big White Wall, WellHappy App, Social Prescribing, SAPAS tool, Depression Pathway.

Big White Wall

WellHappy App (for ages 12-25)

SAPAS

SAPAS Scoring The questions can be read out directly to the patient. Patients are asked whether the description in each question applies to them MOST OF THE TIME and in MOST SITUATIONS. Question 3 (“in general, do you trust people”) is reverse coded- ie a NO answer scores 1 point. Questions 1,2 and 4-8 a YES answer scores 1 point. A total score of 3 or more indicates that further assessment for personality disorder is suggested. Sensitivity= 0.94, Specificity= 0.85 (Moran et al BJPsych 2003)

Step by Step guide to creating your Practice Depression / Anxiety Register. This should take you or your administrator approximately 30 mins. Batch code - Mental Health Care by GP (non QOF) The EMIS template and annual review reminder should be triggered by this code, and/or by a recent Issue of an antidepressant medication. You would then have a list to start identifying those without a QOF code / the code list is there for reference to help. When the pop-up review reminder starts, please check that the patient has a QOF code as part of their first review.

Depression Pathway

Depression Pathway (cont)

Conclusions (1) A recent report on antidepressant prescribing trends identified that we in City and Hackney are low prescribers. This may be due to under-diagnosis ?related to demographic factors. The prevalence of Depression in City and Hackney is significantly under-estimated by QOF figures. An Audit of Depression Coding shows the wide variety of codes used, many of which don’t count for QOF. It may be helpful to use a code not connected to QOF, e.g. ‘Mental Health Care by GP’ which would enable tracking of your patients with Anxiety / Depression as an initial step.

Conclusions (2) Antidepressant usage is rapidly increasing despite investment in, and use of, psychological therapies i.e. IAPTS. It is not clear why but it may be partly linked to long-term usage of antidepressants. An Audit of Patients currently receiving antidepressants suggests that around a quarter have not had a review by a GP for a year; of these (and not under Secondary Care) the average duration of antidepressant use is nearly 9 years. This audit suggests we are not systematically reviewing some of those patients who might most benefit from having their mental health better managed, for example Diabetics or those whose mental health is so poor they struggle to leave the house. We should also focus on those who have been taking antidepressants for many years. The step-by-step guide may enable practices to create their own active Mental Health Registers to facilitate active management of these patients. A system to prompt us to review patients annually opportunistically is an EMIS Template pop-up (due out in July/ August 2014). The Template also includes links to the Depression Pathway, the SAPAS tool, Social Prescribing where appropriate and Big White Wall, and the SPOC form when it has been agreed.

Questions? Feedback, Ideas, Comments?