Session 7 - NICE Guidelines and Mood Disorders

Question 1

Briefly describe what the Layard Report (Dec 2004) was about.

Answer 1

Richard Layard (an economist) recognised that Mental health was britain’s biggest social problem. Total economic cost was £25 billion (2% GDP). To solve the issue, it described how 5000 extra therapists needed to be trained in CBT or IPT, and to double the number of psychiatrists in the next 10 yrs.

Question 2

Using evidence from Layard (2004), and Patricia Hewitt (2006) led to the start of IAPT - improving access to psychological therapies (2008). What sort of things did this scheme lead to?

Answer 2

3,600 newly trained psychological therapists.
450,000 patients likely to be completely cures as expected with NICE guidelines.
25,000 fewer people with mental health problems on sick pay and benefits.
All GP practices having access to psychological therapies as the programme rolled out.

Question 3

State the ‘initial’ stepped care model, and what each step meant. (2004 - as part of NICE guidelines for depression)

Answer 3

Step 1: RECOGNITION. recognition in primary care and hospital settings.
Step 2: MILD DEPRESSION. treatment of mild depression in primary care.
Step 3: MODERATE OR SEVERE DEPRESSION. treatment of moderate to severe depression in primary care.
Step 4: TREATMENT RESISTANT. treatment of depression by mental health specialists. Patients are treatment resistant, recurrent, atypical, psychotic or significant risk.
Step 5: RISK TO LIFE. inpatient treatment for depression. Patient is a risk to life, severe self neglect.

Question 4

Describe Step 1 in the Stepped Care pathway.

Answer 4

Recognition - many people with depression do not present to their GP. If they do, many present with physical or somatic symptoms. Depression may be caused by medication. There may be biological, psychological or social causation behind Step 1.

Screen patients if: past history of depression, disabled, has other mental health issues.
Screening should include questions such as ‘changes in mood in last month’ and ‘lost pleasure in things’.

Question 5

Describe Step 2 in the Stepped Care pathway.

Answer 5

You use watchful waiting, sleep and anxiety management, exercise, guided self help and computerised CBT, and psychological intervention s such as problem solving, brief CBT and counselling.

Antidepressants are NOT recommended for initial treatment for mild depression. May consider if past history of depression.

Question 6

Describe Step 3 in the Stepped care pathway.

Answer 6

Moderate - Severe depression. An SSRI is the treatment of choice. If not response after 1 month, then consider alternative anti-depressants.
Use a generic form SSRI (Citalopram & fluoxetine). Setraline safest in CVD.
CBT is the psychological treatment of choice, but consider IPT if patient prefers. 16-20 sessions over a 6-9month period. Patients with severe depression should be given 2 sessions per week for first month.
Combination of CBT and antidepressants should be considered.

Question 7

Describe Step 4 in the Stepped care pathway.

Answer 7

Specialist mental health treatment. Treatment resistant depression. Combination of antidepressants and CBT, lithium augmentation, venlafaxine, augmentation of an antidepressants with another one. Consider mindfulness- based CBT.

Question 8

Describe Step 5 in the Stepped care pathway.

Answer 8

In patient care. Should be considered for people with a significant suicide risk. Electroconvulsive therapy (ECT)

Question 9

Describe 4 key priorities for implantation

Answer 9

1. Screening in primary care and general hospital settings.
2. Watchful waiting
3. Antidepressants in mild depression.
4. Guided self help.
5. Short term psychological treatment.
6. Prescription of an SSRI
7. Tolerance and craving discontinuation/ withdrawal symptoms.
8. Initial presentation of severe depression.
9. Maintenance treatment with anti-depressants.
10. Combination treatment for treatment resistant depression.
11. CBT for recurrent depression.

Question 10

The NICE CG23 was updated back in October 2009 to CG 90. What was introduced and/or updated?

Answer 10

Uses DSM IV (not ICD - 10) as a diagnostic tool.
Covers ‘sub-threshold depressive symptoms’
Recommends some drugs without UK marketing authorisation.
Stepped care model remains (but reduced to only 4 steps).
Group CBT considered in mild-mod depression. First 3 steps are primary care, with the 4th step being secondary care: CBT, IPT, behavioural activation. 16-20 sessions over 3-4 months.
Don’t use Dosulepin