Can a mental health awareness programme increase the confidence of primary care nurses in managing...

Can a mental health awareness Can a mental health awareness programme increase the confidence of programme increase the confidence of

primary care nurses in managing primary care nurses in managing depression?depression?

Sally Gardner

Nurse Consultant OOH

Trainer /Facilitator Mental Health

DEPRESSIONDEPRESSION

Large Personal, Psychological and Economic Costs

Mental Health Problems = £32 BillionLost Employment = £12 Billion &

Productivity91 Million working days lostTreatment costs = £4.2 Billion

Diminished Quality of LifeExcessive use of Medical Services1 of the 4 most disabling illnesses in the

worldPrimary Care cares for 90% of these

Patients1 Patient in every surgery session suffering

from Depression

Some of the facts:Some of the facts: Depression is common and treatable GPs and nurses are at the “front line” Only 50% is acknowledged Depression is treatable with both drug and non-drug approaches Simply acknowledging depression improves the outcome Over 5000 people commit suicide each year in England …. 1 every 2 hours 9 out of 10 people who commit suicide have some form of mental illness …..

Mostly depression Suicide is 3 times more likely in men than women 66% of people who commit suicide have consulted their doctor within the

past month …. 30% have expressed intent 1 in 20 adults suffer from depression Psychotropic medication is the commonest and highest costing medication

MAJOR DEPRESSIONMAJOR DEPRESSION

Depressed mood and loss of interest and pleasure, plus 4 or more of the following:

Feelings of worthlessness or guiltImpaired concentration

Loss of energy or fatigueThoughts of suicide

Loss or increase in appetiteInsomnia or hypersomniaRetardation or agitation

…… for a minimum of 2 week’s duration

Depressed mood and loss of interest and pleasure, plus 4 or more of the following:

Feelings of worthlessness or guiltImpaired concentration

Loss of energy or fatigueThoughts of suicide

Loss or increase in appetiteInsomnia or hypersomniaRetardation or agitation

…… for a minimum of 2 week’s duration

How common?How common?

Diagnosis Rates per year Practice incidence

Schizophrenia 2-6 4-12 Affective Psychosis

3 6-7

Depression 30-50 60-100 Anxiety 35 70-80 Adjustment 27 50-60 Drugs/Alcohol 2.7 5-6

The Scale of the ProblemThe Scale of the Problem

General population

Consulting GP

Detected by GP

OP

IP

230-315/1000

230 / 1000

100 / 1000

20 / 1000

3 / 1000

THE SIZE OF THE PROBLEMTHE SIZE OF THE PROBLEM

What does this mean?What does this mean?

2.75 million people consult with their GPAverage GP practice of 2,000 pts 218 on

listPrimary care nurses ideally placed

Chronic Disease ManagementChronic Disease Management

AsthmaDiabetesVascular Disease

Depression and Anxiety?

The management of recognised cases of depression often falls short of best practice.

RationaleRationale

Developed mini clinicReduced referrals to CMHT – 60%

reductionBDI scores Mean = 23 at 4/12 Mean= 7

P=0.001High levels pt satisfactionGP workload shared

RationaleRationale

Funding soughtDeveloped training course (steering group) Audit & Evaluation demonstrated increased

knowledge and confidenceFurther evaluation needed

PCT TrainingPCT Training

Level 1 Epidemiology Recognition Medication Risk Assessment SEMI Health Promotion

Level 2,3 Clinical Governance Pharmacology Psychological

Therapies Nurse Intervention Setting up a Service

The StudyThe Study

Postal Questionnaire180 Primary Care NursesTwo Groups generated (training and No

training)Comparisons madeAnalysisOutcomes

AnalysisAnalysis Scales in questionnaire – Cronbachs alpha

Variables – MannWhitney U Test Confidence Attitude Satisfaction

Open ended questions Coded, themes developed and comparisons made

ParticipantsParticipants

0

10

20

30

40

50

60

0

10

20

30

40

50

60

No PCT Training PCT Training

Pe

rc

en

ta

ge

o

f

Pa

rt

ic

ip

a

Training

Comparisons of scoresComparisons of scores

0

10

20

30

40

50

60

70

0

10

20

30

40

50

60

70

Confidence Attitude Satisfaction

Me

an

R

an

k

of

S

co

re

Variable

No training PCT training

Comparisons of levels of Comparisons of levels of training 1 v 2&3training 1 v 2&3

0

5

10

15

20

25

0

5

10

15

20

25

Confidence Attitude Satisfaction

Me

an

R

an

k

of

S

co

re

s

Variable

level 1 level 2 + 3

ResultsResults

Response rate 47.8%Training group scored higher on

Confidence Attitude and Knowledge when compared to no training group

Level 1 training improved attitude but did not statistically increase knowledge or confidence when compared to level 2&3 training

QualitativeQualitative

51 comments were coded into positive, negative and neutral

50% were positive ( “training is greatly needed”)

35% were negative (“not sure short courses provide necessary skills”)

Neutral (“ protected time in short supply”)

Future Training Future Training

Interest in Training

strongly agree

agree

neutraldisagree

Training CoursesTraining Courses

0

10

20

30

40

50

60

70

0

10

20

30

40

50

60

70

half day full day lunchtime self-directed

Pe

rc

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ta

ge

i

nd

ic

at

in

g

pr

ef

Training Format

Options regarding role of Options regarding role of nursesnurses

Role One – deliver enhanced recognition referral for assessment

Role two – deliver a service in the assessment and monitoring of patients with depression

Role three – development of depression mini clinics

What this study addsWhat this study adds• A training programme designed to increase confidence, improve attitudes towards depression and increase satisfaction with knowledge and training is effective

   Primary care nurses are motivated to participate in future training in the management of depression.

   Future courses should resemble the PCT training course

 Depression “mini clinics” may require more organisation within primary care for them to be viable

Setting up a ServiceSetting up a Service

ProcessProcess

Involve the whole teamState clear AimWhat are the objectivesWhere are we nowWhere do we want to beHow do we know when we have got there

WhoWho

Who needs to be involved?

Who will referrals come from?

Who will have overall responsibility?

WhatWhat

What needs to be in place………Job descriptionProtocolsGuidelinesReferral guidelinesPatient pathwaysSupervision

Setting up a clinicSetting up a clinicLevel 1,2,3Level 1,2,3

Decide on service model

Level 1 – All members of team Mental health awareness Mental health Promotion G/P implements evidence based guidelines

Setting up a clinicSetting up a clinicLevel 2Level 2

Level 2 includes criteria from level 1 plus……

G/P diagnose a mental health problemRefers to Nurse clinicWorks collaboratively with G/P (case

reviews)

Setting up a clinicSetting up a clinicLevel 2Level 2

Telephone support 1-2 weeksNurse review 2-4 weeks Holistic assessmentNurse monitors mood and compliance to

medicationRisk assessment

Setting up a clinicSetting up a clinicLevel 3Level 3

Level 3 Includes criteria from level 1&2 plus

Identifies and differentially diagnose own patients Holistic assessment Arranges tests and investigations Diagnosis Decides on medical management Supplementary prescribing

Setting up a clinicSetting up a clinicLevel 3Level 3

Liase with other members teamCase ManagementAccountableResponsibleAutonomousRefersDischarge

ImplementationImplementation

Team meetingDecide on service modelSet realistic timescalesAudit trail in placeRegular reviews (team)Ongoing auditPatient satisfaction tools

EvaluationEvaluation

SWOT Analysis

Forcefield Analysis

Audit against standards

What needs to change??

Make changes

Implement and review

ConclusionConclusion

Primary Care Nurses have an important role in managing depression

Pilot study identified improved outcomesEvaluation study identified increased

satisfaction with knowledge confidence and attitude.

ConclusionConclusion

Training is effectiveTraining is requestedShort courses are the preferred optionThere are different options regarding

management of depressionThree models identified

ConclusionConclusion

Training primary care nurses in depression management and delivering a service in primary care is posssible

It can only be hypothesied that this will improve outcomes

There is a need for a RCT comparing patient outcomes delivered by nurses with training and usual primary care.

THANKYOUTHANKYOU

QUESTIONS ?

Sally GardnerNurse ConsultantTake Care Now

Sally.gardner@takecarenow.co.uk