The Primary-Secondary Care Interface

Dr Rob WallerConsultant Psychiatrist

Bradford District Care Trustrob.waller@bdct.nhs.uk

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!

Clinical Depression

ICD-10 Depressive Episode Lowering of mood, reduction of energy, and

decrease in activity Little variation Two-weeks

Somatic Symptoms – dictates severity

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

Responses to a diagnosis

Relief – help is at handStigma – people will think…Regression – I am a failure after allAttribution – how can I change things?Anger – how can you know?Anti-medical – I don’t want pillsDependant – It’s up to you nowReductionism – so that’s what it is…

Seven levels of understanding

One-line Diagnosis – ICD-10Differential DiagnosisBio-psycho-social formulation3x3 Aetiological GridCross-sectional formulation:5-AreasLongitudinal formulation: Beliefs/RulesWhy has this person developed this illness

at this point in their lives?

Aetiological Grid

Bio Psycho Social

Antecedents

Behaviour

Consequences

Cross-sectional Formulation

ENVI

RONMENT

Mood

Thoughts

BiologyBehaviour

Trigger

Longitudinal Formulation

Cognitive Biases

Mood

Thoughts

BiologyBehaviour

Trigger

Activating Events

Core Beliefs Early Events

ENVI

RONMENT

This person, This illness, This time

Genes

IUE

Perinatal

Tabla Rasa?

Oral

Anal

Genital

Latent

Demands Resources

Life

The eighth level

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?

NICE management

NICE GPs

Watchful WaitingComputerised CBTGuided Self HelpBrief Psychological Interventions

Two of these !

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?

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]

Questionnaires - QOF vs Usefulness

Group WorkIn threes:

Which ones do you use? How do you use them? Why do you use them?

Five mins

Feedback

Making Questionnaires Work

Time: They fill them inDiagnosis vs Change MeasureCopyright: the PHQDiscussion: eg BDI item 9Symptom Targeting: eg sleep

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

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?

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

The Primary-Secondary Care Interface

Dr Rob WallerConsultant Psychiatrist

Bradford District Care Trustrob.waller@bdct.nhs.uk