Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield,...

From primary to tertiary care

An integrated care pathway for the improved screening, assessment and management of bipolar disorder

Dr. Nick Stafford, Consultant PsychiatristLichfield, SSSFT

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

Private HealthcareNuffield HealthSutton Medical Consulting Rooms

Full list of business relationships at: www.uk.linkedin.com/pub/nick-stafford/17/7a4/54a/

Public Education/Professional Attitude

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

The management of bipolar disorder

Whole systems proble

m

Whole systems solution

s

Primary care

Secondary psychiatric

care

Inpatient care

Tertiarycare

CAPTURE MISSED BIPOLARBEGIN TREATMENT EARLY

SHARED CARE AGREEMENTS

IMPROVE DIAGNOSTIC ACCURACYBEGIN TREATMENT EARLY

ENHANCE SPECIALIST TREATMENT

Each element requires its own solutionsto improve overall outcomes

Aims of the bipolar care pathway

Project in Leicester

Health Care & Pharma

Mental Health Trust

AstraZenecaPCT/CCGs

Charitable

Bipolar UK

Depression AllianceRethink

Elements of the care pathway

Primary Care Secondary Care

Tertiary / Specialised

Care

Increase awareness

Screening

Enhanced assessment

Psychosocial interventions

Second opinions

Comprehensive management plans

Pilot sites:Lichfield (CMHT)

Stafford (IP)




Care

Primary care red flags

Presenting complaint:

Breast lump

Blood on toilet paper

Persistent cough

Depression

Could it be

Breast cancer?

Bowel cancer?

Lung cancer?

Bipolar?

How do we fix it, practically?

Education Screening tool not diagnostic

Always be alert

A few extra questions is

effective

Low index of suspicion

History from someone

close

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”

Primary care education in Staffs

Large group seminars (50+)

Individual practice seminars (3-15)

All Primary HCPs (not just GPs)

Internet e-Learning programme

Primary care screening options

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

• Collateral history encouraged• EMIS / Systm1 alerts (software templates)

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

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

• MDQ preferable?

HCL-32

• Most validated screen for hypomania• Available in a range of languages• Combines stem questions with screening

questions

• Distribute packs in primary care

Dimension and categories

BipolarDepression

Borderline Anxiety disorders

Addictions

HPA axis link?

Bipolar or unipolar depression

Borderline more likely if:

• Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and sometimes more than a few days)

• Identity disturbance: markedly and persistently unstable self-image or sense of self

• Chronic feelings of emptiness• Severe dissociative symptoms• Frantic efforts to avoid real or imagined abandonment• Recurrent suicidal threats, gestures or behaviour• Self mutilating behaviour

Others (not exclusive)

• Anxiety• ADHD• PTSD• Other personality disorders• ‘Behavioural’• Alcohol & substance misuse

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 CPN• Patient educated about possible bipolar• Leaflets given (pre- and post-diagnosis)• Mood diary before OPC appointment




Care

Specialised Bipolar Clinic

And supporting servicesPsychosocial interventions

Tertiary service

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 can be provided with a local specialised bipolar disorder clinic

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

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

Pros and Cons of a Bipolar Clinic

Pros• Reduces readmissions• Increased satisfaction with

care• Better continuity of care• Improved education and

research

Cons• Greater cost (not always)• 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

Specialised Bipolar Clinic Model

Secondary care assessments and

management

Second opinions in tertiary service


Training and Research

MDT

Elements of the Clinic 1st Assessment

Pre-Interview Questionnaire• Lengthy

• Patients enjoy completing

• Structure similar to semi-structured interview

Semi-Structured Interview• Detailed focus on moods

• Predominant Polarity

• Bipolarity Index

• Detailed medication history

• Comorbidities identified

TO IMPROVE DIAGNOSTIC ACCURACY AND CARE PLAN COMPREHENSIVENESS

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

Missed diagnosis of bipolar

• Variable figures: >15% RDD in primary care• Impact of untreated episodes are manifold• Relationship breakdown• Occupational breakdown• Increased use of CMHT services• Increased use of inpatient services• Kindling in the untreated worsens prognosis

MDT Approach

MDT Members• Consultants

• Higher ST trainees

• Non-medical prescribers

• Visiting clinicians

• CPN

• OT (BPE)

• Social Worker


• Training for all IP & CMHT staff– Psychoeducation– Functional remediation– IPSRT (Interpersonal Social Rhythm Therapy)– DBT (Dialectical Behavioural Therapy)– FFT (Family Focused Therapy)

Bipolar PsychoeducationSurvival 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

The philosophy of the pathway design

Apply what is known

Iterative designThe model can

be applied anywhere

Appliance of science

If GP/Psychiatrist refers to the Clinic

Standard summary letter

HCL-32 encouraged if appropriate

Patient educated about possible diagnosis

Leaflets given (pre- and post-diagnosis)

Mood diary from referral to OPC appointment

Elements of management

Comprehensive reportClarity of diagnosis &

management

Psychoeducation &Evidence-based

management plan

Multi-axial diagnoses& co-morbidities managed

Health adviceQuality information

Management with GP




Care

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

Structure of South Leicestershire outpatient clinics now

CMHT Outpatient

Clinic Services

OPC services

Assessment clinic

Bipolar disorder specialised

clinic

Integrated depression

clinic(at a later date)

Generic Specialised

Training

In clinic experience

Psychiatry trainees

GP trainees

NMPs

Students


Psycho Education

IPSRT

DBT

FFT

Medication

Workshops

Forums

NMS skills

General training

Medical student

Psychiatric trainees

Nurses

Other CMHT/IP members

Research

Evaluation of

SSSFT bipolar services

Portfolio income

generating

external research

In development

• New Psychoeducation Course• Web based support• App development• New manuals for psychosocial interventions

• Research

Media attention & public education

Thank you

Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield,...

Documents

Transcript of Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Practice, Lichfield,...