1. The Primary-Secondary Care Interface Dr Rob Waller Consultant Psychiatrist Bradford District Care Trust rob.waller@bdct.nhs.uk

2. Outline What are you saying to the client? Is a diagnosis the best way to meet their needs? Getting more assistance: Antidepressant medication Secondary care Counselling Are questionnaires any use? How not to get depressed yourself!

3. Clinical Depression ICD-10 Depressive Episode Lowering of mood, reduction of energy, and decrease in activity Little variation Two-weeks Somatic Symptoms – dictates severity

4. Other types of depression Brainstorm: think of as many forms of depression as you can Non-medical depressions: Dysthymia/Cyclothymia/Personality Baby-blues Economic depression Psychodynamic depression The Great Depression

5. Responses to a diagnosis Relief – help is at hand Stigma – people will think… Regression – I am a failure after all Attribution – how can I change things? Anger – how can you know? Anti-medical – I dont want pills Dependant – Its up to you now Reductionism – so thats what it is…

6. Seven levels of understanding One-line Diagnosis – ICD-10 Differential Diagnosis Bio-psycho-social formulation 3x3 Aetiological Grid Cross-sectional formulation:5-Areas Longitudinal formulation: Beliefs/Rules Why has this person developed this illness at this point in their lives?

7. Aetiological Grid BioPsychoSocial Antecedents Behaviour Consequences

8. Cross-sectional Formulation ENVIRONMENTENVIRONMENT Mood Thoughts Biology Behaviour Trigger

9. Longitudinal Formulation Cognitive Biases Mood Thoughts Biology Behaviour Trigger Activating Events Core BeliefsEarly Events ENVIRONMENTENVIRONMENT

10. This person, This illness, This time Genes IUE Perinatal Tabla Rasa? Oral Anal Genital Latent DemandsResources Life

11. The eighth level

12. Do we need a diagnosis? Problem-focussed Bio: medication, diet, exercise Socio: debt, CAB, community groups Psycho: counselling, guided self help Solution-focussed Where do you want to be in six months? What steps are needed to get there? Can you do one before I see you next week?

13. NICE management

14. NICE GPs Watchful Waiting Computerised CBT Guided Self Help Brief Psychological Interventions Two of these !

15. Secondary Care Options Counselling [may well be PCT based] Psychiatry Out-patient - complexity In-patient - risk Therapy Psychotherapy – dynamic factors Psychology – circular factors One Stop Shop?

16. When to Refer Complexity Needs longer than seven minutes Needs more than Counselling Needs careful diagnosis & formulation Risk Risk-spotting [hunches] Risk-assessment [dynamic/static] Risk-management [self + others + residual]

17. Questionnaires - QOF vs Usefulness Group Work In threes: Which ones do you use? How do you use them? Why do you use them? Five mins

18. Feedback

19. Making Questionnaires Work Time: They fill them in Diagnosis vs Change Measure Copyright: the PHQ Discussion: eg BDI item 9 Symptom Targeting: eg sleep

20. Depressed GPs Doctors on the Edge: General Practitioners, Health and Learning in the Inner-City Linden West Gritty realism, observational style, vastly helpful but also depressing http://www.bmj.com/cgi/content/full/322/7294/1128

21. How not to become depressed Groups of five What ways do you personally use to stop yourself from becoming depressed? Do these work? What can we learn from this how we talk to clients?

22. Feedback What is mental HEALTH? And what can we do to increase it? Work-life balance? Or should we go for integration? Research findings for mental health Static: supportive upbringing, education, etc Dynamic: Marriage / confiding relationship Intrinsic faith Personal development opportunities

23. The Primary-Secondary Care Interface Dr Rob Waller Consultant Psychiatrist Bradford District Care Trust rob.waller@bdct.nhs.uk