Dr. Justin Shute
Liaison Psychiatry Consultant
Long Term
conditions 30% of the
population of
(c. 15.4m
30% (c. 4.6m) of those
with an LTC have a
mental health problem
Mental health
problems 20% of the
population of
(c. 10.2m
46% (c.4.6m) of those
with a mental health
problem have an LTC
Naylor Parsonage et al 2012 based on Crimpean and Drake 2011
People with LTCs 2-3 X more Likely to
have Mental Illness
 Depression 2-3 X more common in cardiac disease,
coronary artery disease, stroke, angina, congestive
heart failure, or following a heart attack
• Fenton and Stover 2006; Benton et al 2007; Gunn et al 2010; Welch et al
 Prevalence between 20 & 50%
 But 2-3 X increase compared with controls is consistent
across studies
People with LTCs 2-3 X more Likely to
have Mental Illness
 Diabetes 2-3 X more likely to have depression than the
general population
• Fenton and Stover 2006; Simon et al 2007; Vamos et al 2009
 Chronic obstructive pulmonary disease 3 X more mental
illness than general population
• NICE 2009
 Anxiety disorders are very common; panic disorder 10 X
• Livermore et al 2010
 World Health Surveys: 2 or more LCTs 7X more likely to
have depression than people without LCT
• Moussavi et al 2007
Does It Really Matter ?
 Cardiovascular patients with depression experience
50% more acute exacerbations per year and have
higher mortality rates
• Katon 2003
 Depression leads to 2-3 X negative outcomes for
people with acute coronary syndromes
• Barth et al 2004
 Depression increases mortality rates after heart attack
by 3-5 X
• Lesperance et al 2002
Does It Really Matter ?
 2 X mortality after heart bypass surgery over an
average follow-up period of 5 years
• Blumenthal et al 2003
 Chronic heart failure 8 X more likely to die within 30
months if they have depression
• Junger et al 2005
 People with diabetes & depression 36-38% increased
risk of all-cause mortality over a 2 year follow-up period
• Katon et al 2004
 Poorer glycaemic control, more diabetic complications
and lower medication adherence
• Das-Munshi et al 2007
Does It Really Matter ?
 Relationship between LTCs and mental illness is
exacerbated by socio-economic deprivation:
greater proportion of people in poorer areas have
multiple long term conditions
effect of this multi-morbidity on mental health is
stronger when deprivation is also present
Why are Outcomes Worse ?
 Co-morbid mental health problems impair active
 Reduced motivation and energy for selfmanagement leads to poorer adherence to
treatment plans DiMatteo et al 2000
 Cardiac patients, depression increases adverse
health behaviours (eg. physical inactivity) and
decrease adherence to self-care regimens such as
smoking cessation, dietary changes and cardiac
rehabilitation programmes Benton et al 2007; Katon 2003
 Poorer dietary control and adherence to
medication Vamos et al 2009
 Befriending
 Debt advice
 Wellbeing in the workplace initiatives
• Knapp et al 2011
Hampered by “hard wired separation of physical
and mental health care”
Principles for Assessment
• When assessing a patient with a chronic physical
health problem who may have depression,
conduct a comprehensive assessment that does
not rely simply on a symptom count.
• Take into account:
– the degree of functional impairment and/or
disability associated with the possible
depression and
– the duration of the episode.
The stepped-care model
Focus of the
STEP 4: Severe and complex1
depression; risk to life; severe selfneglect
STEP 3: Persistent subthreshold depressive
symptoms or mild to moderate depression with
inadequate response to initial interventions;
moderate and severe depression
STEP 2: Persistent subthreshold depressive
symptoms; mild to moderate depression
STEP 1: All known and suspected presentations of
see slide notes
Nature of the
Medication, high-intensity psychological
interventions, electroconvulsive therapy,
crisis service, combined treatments,
multiprofessional and inpatient care
Medication, high-intensity psychological
interventions, combined treatments, collaborative
care2, and referral for further assessment and
Low-intensity psychosocial interventions, psychological
interventions, medication and referral for further
assessment and interventions
Assessment, support, psycho-education, active monitoring
and referral for further assessment and interventions
Case identification and recognition
• Be alert to possible depression
– Particularly in patients with a past history of
depression or
– a chronic physical health problem with
associated functional impairment.
• Consider asking patients who may have
depression two questions, specifically:
– During the last month, have you often been
bothered by feeling down, depressed or hopeless?
– During the last month, have you often been
bothered by having little interest or pleasure in
doing things?
Low-intensity psychosocial interventions
For patients with:
• persistent sub-threshold depressive symptoms or
mild to moderate depression and a chronic physical
health problem
• Sub-threshold depressive symptoms that complicate
care of chronic physical health problem
Consider offering one or more of the following
interventions, guided by patient preference:
‐ structured group physical activity programme
‐ group-based peer support (self-help) programme
‐ individual guided self-help based on CBT
‐ computerised CBT.
Treatment for moderate
For patients with initial presentation of
moderate depression and a chronic physical
health problem:
• offer the following choice of high intensity
psychological interventions:
– group-based CBT or
– individual CBT or
– behavioural couples therapy.
Antidepressant drugs (1)
• Do not use antidepressants routinely for subthreshold depressive symptoms or mild depression
in patients with a chronic physical health problem
• Consider antidepressants for people with:
– a past history of moderate or severe depression or
– mild depression that complicates the care of the
physical health problem or
– Sub-threshold depressive symptoms present for a
long time or
– Sub-threshold depressive symptoms or mild
depression that persist(s) after other interventions.
Antidepressant drugs (2)
• When an antidepressant is to be prescribed,
tailor it to the patient, and take into account:
– additional physical health disorders
– side effects, which may impact on the
underlying physical disease
– lack of evidence supporting the use of
specific antidepressants for people with
particular chronic physical health problems
– interactions with other medications.
What is collaborative care?
Four essential elements
collaborative definition of problems
objectives based around specific
self-management training and
support services
active and sustained follow up
Collaborative Care
Consider collaborative care for patients with:
• moderate to severe depression
• a chronic physical health problem with associated
functional impairment whose depression has not
responded to:
– initial high-intensity psychological
interventions or
– pharmacological treatment or
– a combination of psychological and
pharmacological interventions.
 > 90% of people with depression alone were diagnosed
in primary care
 Depression detected < 25%among people with LTC
• Bridges and Goldberg 1985
 Majority of cases of depression among people with
physical illnesses go undetected and untreated
• Cepoiu et al 2008; Katon 2003
 Active case-finding in people with LTCs needed
• NICE 2010
 Standard interventions eg. antidepressants or
CBT are effective
• Fenton & Stover 2006; Yohannes et al 2010, Ciechanowski et al 2000
 Psychological therapy was associated with
reduced emergency department attendance
• De Lusigman et al 2011
 Treating co-morbid mental illness by itself
doesn’t always translate into improved physical
• Cimpean & Drake 2011; Benton et al 2007; Perez-Prada 2011
 Integrating treatment for mental health and physical
better than overlaying mental health interventions
• Fenton & Stover 2006; Yohannes et al 2010
 Adding a psychological component to COPD rehab
programmes: improved completion rates and reduced
re-admissions for COPD
• Abell et al 2008
 CBT-based disease management programme for
angina = 33% fewer hospital admissions in following
year, saving £1,337 per person
• Moore et al 2007
Stepped Care
1:1 or group CBT
Self help, coping skills, psycho-ed courses,
CCBT, behavioural programmes
What Can GPs Do ?
 Identify patients with co-morbidity
 Help patients recognise mental health problems
 Help patients understand links between LTC and mental
health problems
• “hard-wired separation of physical and mental care”
 Monitor uptake of psychological services by people with
 Identify successful and unsuccessful referral pathways
 Build relationships between physical and mental
healthcare professionals
Monitoring and Follow Up
 See patients started on antidepressants not at
risk of suicide
‐ after 2 wks,
‐ every 2 - 4 wks for next 3 mths
‐ less frequently if response is good.
 If < 30 yrs (increased risk on anti depressants) see
‐ after 1 wk
‐ less frequently thereafter until no longer risk
 If at increased suicide risk, refer
Side Effects
If side effects develop:
 monitor symptoms closely and stop anti depressant
if patient finds side effects unacceptable or change
if the patient prefers; or
 If mild anxiety/insomnia/agitation consider
benzodiazepine for 2 wks max.
 Caution for those
‐ at risk of falls; or
‐ with chronic anxiety
When to refer
 Concerns about risk
 Inadequate response to psychological
 Inadequate response to 1 or 2
 Atypical / complicated presentation
 “Gut feeling”
 Severity and risk will determine urgent or
routine referral
Where can I find out more?
 Pack for good practice and recovery
 BEHMHT GP Intranet site – includes our
more detailed treatment guidelines
 PCA web resources – in development
 NICE Guidance
 RCPsych website

Presentation Long Term Conditions and Mental Health