How to set up amood disorders clinic

Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire,Leicestershire Partnership Trust

nstafford@doctors.org.uk

Royal College of Psychiatrists, Trent DivisionSheffield 6 November 2013

W1 Workshop

DisclosuresPharmaceuticalsAstra Zeneca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kline LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd

Private PracticeClinical Partners LtdNuffield HealthSutton Coldfield ConsultingNick Stafford Ltd

MediaBBC Radio 4BBC World ServiceBBC Radio ScotlandChannel 4CB FilmsLOOKPsychologies

OtherBipolar UKUGLEWyley Brothers USAMy Mind BooksMy Mind Apps

Thank you

• Donna Stafford CPN/NMP• Dr. Mark McConnochie ST5• K Gallagher CMHT Manager• Lynn Walters PA• Dr. Mike McHugh, Consultant

in Public Health• Joan Armstrong-Morton, OT• Dr. Julia Kestleman ST6• Dr. David Steadman GP2• Dr. Shahid Hussain ST4• BPE Cymru, Beating Bipolar

PARTNERS• Leicestershire

Partnership Trust• LLR PCT• Astra Zeneca

THIRD SECTOR• Rethink• Depression Alliance• Bipolar UK

Specialist services NICE 2006DoH Guidelines 2007

• All trusts should provide:– Specialist Mental Health Services– Access to specialist advice from designated

experienced clinicians– Referral on to tertiary services

• This has been provided with the Mood Disorders clinic and provides other benefits

Allan Young, Tony Hale, Heinz Grunze, Daniel Smith, Francesc Colom, Nick Stafford

Public Education/Professional Attitude

Praised by the public for going public Criticised by psychiatrists for going public

The Leicester Model

• A model easily replicated in other adult services• Within a generic CMHT setting• Set up when NWW introduced to LPT• Not commissioned• Within existing time and financial resources• No changes to job plan• Not academic• No research or service development grants (yet)

Specialists within specialisms

• What does it mean?• Increasingly differentiated with medical progress

• In psychiatry– A need for generalists and specialists– ADHD, ASD, EDS, CFS / PIER, AOT / CAMHS, MHSOP

• Medicine and surgery– The norm in all areas

Pros and Cons of a Bipolar Clinic

Pros• Reduce readmissions• Increase patient satisfaction• Better continuity of care• Improved education and

research• Lower cost

Cons• Not always more effective• Fragmentation of care• Tertiary setting distance• Gaps in overall care• Could focus less on functional

outcomes

• Need for greater peer support and expertise

Time to hospital readmission for patients treatedin the mood disorder clinic v. standard out-patient care.

Kessing L V et al. BJP 2013;202:212-219

©2013 by The Royal College of Psychiatrists

N=158Single manic episodeAfter 1st, 2nd or 3rd IP admissPOM = time to readmission

HR = 0.6095%CI = 0.37 – 0.97P=0.034

Kessing L V et al. BJP 2013;202:212-219

Economic analysis

Who?

• Patients with– Bipolar Disorder– Recurrent depressive disorder– Depression not responding to treatment >6/12

• This services is yet to be started

• Comorbidity is not an exclusion

• Anyone in adult services (and some MHSOP)

Why?• Specialist clinics work• They make working life interesting• Patient satisfaction is high

• Complex phenotype with high external validity• Requires broad knowledge of

– Psychopathology, Neuropsychology– (Poly) Psychopharmacology, Psychotherapy

• Better continuity of care• Improved education and research in the team

• Develop the use of non-medical prescribers

Non-medical prescribers

• Supplementary prescribers• MDT model in service• 1 hour MDT supervision end of clinic• Focus on BAP & WFSBP guidelines• Regular teaching• Developing 6/12 Mood Disorders Magazine• Advice from Professor Hale’s Kent clinic

Integration in South Leicestershire outpatient clinic services

CMHT Outpatient

Clinic Services

Generic OPC & wellbeing

services

NMP & CPN assessment

clinic

Bipolar specialised

clinic

Integrated depression

clinic

The philosophy of the pathway design

Apply what is known Nothing new

Engineer the parts Feedback to clinicians

Don’t be cleverA model that can be

applied anywhere

Simple appliance of science

The diagnosis of bipolar disorder

Whole systems problems

Whole systems solutions

COMPLEXDISORDER

COMPLEXSERVICES

Where bipolar is missed

Public knowledge

Primary care

Secondary psychiatric

care

Other specialist

care

Each element is complex and requires its own solutions

CAPTURE MISSED BIPOLARPREVENT UNDERDIAGNOSIS

IMPROVE DIAGNOSTIC ACCURACYPREVENT OVERDIAGNOSIS

This isn’t possible by just focusing on one elementor designed just by psychiatrists

Primary care red flags

Presenting complaint: Could it be:• Breast lump

• Blood on toilet paper

• Facial weakness

• Depression

• Breast cancer?• Bowel cancer?• CVA?• Bipolar

disorder?

The goal in primary care

“If a GP sees Depressive Disorder they should have a reflex consideration of bipolar disorder every time and ask relevant questions to probe for it”

• How do we make this happen?

Practical solutions in primary care

Education for everyone

Screening tool – choice, is it

used?

Always be alert (as with cancer)

Asking just a few questions

can be effective

Low level of suspicion

Collateral history from

someone close

Educating Primary Care

Bipolar DisorderGuidance on recognition in

Primary CareA pragmatic review and brief management commentary

Daniel Dietsch, Nick Stafford, Daniel Mann, Daniel Smith, Carolyn Chew-Graham

Primary care education in Leicester

• Face to face large group seminars (50+)• RCGP meetings• Individual practice seminars (3-15)• All Primary HCPs invited (not just GPs)• Learn and discuss the diagnosis of bipolar• Complex case examples• How to make it work in their practice

– Bespoke to their needs

Primary care screening options

• Ask more questions – But which? (e.g. BRIDGE)

• Collateral history encouraged• EMIS / Systm1 alerts

– Surprisingly less popular with GPs• Formal screen HCL-32

– How useful is it in practice?– Frequency of use

• MDQ preferable?

If GP refers to the Clinic

• Standard GP letter (no forms to fill in)• HCL-32 if appropriate, not mandatory

– MDQ if preferred• Option to use the Mental Health Facilitator• Patient educated about possible bipolar• Leaflets given (pre- and post-diagnosis)• Mood diary before OPC appointment

Specialised Bipolar Clinic Model

New assessments Follow ups

Tertiary service Group and individual BPE

MDT

Preparing the clinic setting

• Reducing the outpatient clinic load• 720 caseload to 250• Caseload percentages

– New referrals– Existing mood disorders– 30% total caseload managed in specialised clinic

• Initially half day/week (first 18 months)• Now one day a week• Preparing additional specialist depression clinic

Utilizing existing resources (caseload)

• There are enough cases of bipolar in a CMHT caseload to stream them through a single weekly clinic– Bipolar = 25%

• We are now beginning to do the same with more difficult to treat depression cases– Depression = 30-40%

Staff (bipolar clinic)

• Consultant psychiatrist• ST4 Trainee psychiatrist• GP trainee• 3 non-medical prescribers• Visiting clinicians• Occupational therapist• Administrative staff

Staff (depression), (provisional)

• 2 Consultant general adult psychiatrists• 2 Consultant psychiatrist psychotherapists CBT

• ST4 psychiatrist & GP trainee• Non-medical prescribers (two)

• Improve initial care pathway• Specialize difficult to treat cases

• Overlap with bipolar clinic

Elements of the Clinic 1st Assessment

Pre-Interview Questionnaire• Lengthy (up to 3 hrs.)• Patients enjoy

completing• Structure similar to

semi-structured interview

• Question based around DSM-IV criteria

Semi-Structured Interview• Detailed focus on

moods• Predominant Polarity• Bipolarity Index• Detailed medication

history• Comorbidities examined• PD screening (IPDE)• Occupational therapy• Multi-axial DSM-IV

diagnosis (DSM-5 July)

MDT• Consultant• ST4• Non-medical prescriber

• Visiting clinicians• CPN• OT (BPE)• Social Worker

• Adequate time built in for assessments and follow ups

Specialised bipolar clinic model essential to make this work

Soon to commence a parallel specialised depression clinic

Assessment elements

Comprehensive reportCopied to patient

Holistic management planTx - Medical, Psychological

Health advice, Quality information

Multi-dimensionalCo-morbidities managedDetailed risk assessment

Health & Wellbeing groupMetabolic screening

Managed with GP

Pre-assessment questionnaire

• Video of questionnaire removed due to size

ISBD Taskforce BD/UD

Semi structured assessment

• Face to face interview:– Questionnaire structure maintained– Clarify pre-interview questionnaire– Extra detail were needed– Are diagnostic criteria met? Listed in conclusion.– Bipolar I, II etc…– Predominant Polarity & Polarity Index– Review of comorbidity

• Axis I + addictions• Axis II – IPDE

– Occupational therapy assessment & intervention

Management algorithms

• International Guidelines for bipolar treatment– BAP– WFSBP

• Weekly OPC initially if necessary• Management of comorbidity• Lifestyle advice• Psychoeducation (online and face to face)

• MDT approach and enhanced capacity

New psychoeducation course

• Traditional syllabus• In addition:• DBT (Interpersonal effectiveness)• Functional remediation

– Cognitive remediation– Occupational therapy

• Family Focused Treatment• Interpersonal Social Rhythm Therapy• New manuals (patient, carer, professional)

Survival curve on time to recurrence.

Colom F et al. BJP 2009;194:260-265

BPE group cf. Control group:

Fewer recurrences3.86 v. 8.37, F=23.6, P<0.0001

Less time acutely ill154 v. 586 days, F=31.66, P=0.0001

Less hospitalised days (median)45 v. 30, F=4.26, P=0.047

In development

• New Psychoeducation Course• Web based support• App development

MDT Benefits

• Weekly case based discussions• Monthly teaching seminars• Updates on current research

Specialised commissioned/Embedded in 2ry care

• Simpler models that can fit into any secondary care unit

• Cedars Centre vs. Maudsley specialised centre

• List specialised centres

Prof. Morriss’s RCT and planned specialised depression model

Private sector developments

• Clinical Partners Ltd• Nuffield Health

• Joint assessments with psychologist• Clinics offer same services (except groups)

• Clinics in– London– Leicester– West Midlands

Improved interfaces

• Primary care• Psychological therapies• Personality Disorder services• Etc…

Funding

• Partial funding for set up from Astra-Zeneca• AZ dissolved partnership with Seroquel 2012

• No additional funding received since• ‘Verbal’ support by Trust and PCT / CCG

• Operates within resources of the CMHT• Plan to introduce into other Leicester localities

Key Conclusions

• Specialised bipolar clinic essential and possible• Whole care pathway maximizes impact• Education of primary HCPs• Structured pre-interview questionnaire• Semi-structured interview• Follow treatment guidelines (WFSBP & BAP)• Integrate into existing OPC structure• MDT approach• Continually engineer pathways and components

Media attention & public education is possible, even for a small project

nstafford@doctors.org.uk