Common mental health
disorders: identification
and pathways to care
Implementing NICE guidance
within primary care
2011
NICE clinical guideline 123
What this presentation covers
Scope
Background
Key recommendations for implementation
Primary care costs avoided and benefits
Discussion
Find out more
Scope
The guideline aims to improve access to care and the
identification and recognition of common mental health
disorders, and provide advice on principles for local care
pathways.
Advice from existing NICE guidelines has been combined
with new recommendations on access, assessment and
local care pathways.
Common mental health disorders include depression,
panic disorder, generalised anxiety disorder,
obsessive-compulsive disorder, post-traumatic
stress disorder and social anxiety disorder.
Epidemiology
• 15% of the population are
affected by common mental
health disorders
• Women are 1.5 to 2.5 times
more likely to experience
depression than men
• 34% of South Asian women
have a common mental health
disorder compared with
10% of South Asian men
Background
• Depression is a leading cause of disability – and it is
projected to become the second most common cause
of loss of disability-adjusted life years in the world
• Only a small minority of people who experience anxiety
disorders receive treatment
• Recognition of anxiety disorders in primary care is
particularly poor
Abbreviations used
CBT - cognitive behavioural therapy
ERP - exposure and response prevention
EMDR - eye movement desensitisation and reprocessing
GAD - generalised anxiety disorder
OCD - obsessive compulsive disorder
IPT - interpersonal psychotherapy
PTSD - post-traumatic stress disorder
A full glossary of terms used in the guidance can be found
alongside this slide set on the NICE website
Key priorities for implementation
Areas identified as key priorities for implementation:
• Identification
• Improving access to services
• Developing local care pathways
Identification: depression
Be alert for possible depression, particularly in those with
a past history or possible somatic symptoms of
depression, or a chronic physical health problem
Consider asking:
• 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?
Identification: anxiety 1
Be alert to possible anxiety
disorders, particularly in
those with a past history or
possible somatic
symptoms of an anxiety
disorder, or who have
experienced a recent
traumatic event.
Consider asking about
feelings of anxiety and the
ability to stop or control
worry, using the GAD-2
scale.
Identification: anxiety 2
Consider asking:
Over the last two weeks, how often have you been
bothered by the following problems?
• Feeling nervous, anxious or on edge
• Not being able to stop or control worrying
GAD-2 is the first two questions of the GAD-7 scale
The GAD-7 tool was developed by Drs.
Robert L. Spitzer, Janet B.W. Williams,
Kurt Kroenke and colleagues, with an
educational grant from Pfizer Inc.
Identification: anxiety 3
Score of 3 or more consider an anxiety disorder and
follow the recommendations for assessment
Score of less than 3 but you still have concerns that the
person may have an anxiety disorder ask:
Do you find yourself avoiding places or
activities and does this cause you problems?
N.B. The scoring of more or less than 3 applies to the use
of the two GAD-2 questions
Identification
For significant communication difficulties, consider
using the Distress Thermometer and/or asking a family
member or carer about the person’s symptoms
If identification questions indicate
a common mental health disorder,
a competent practitioner should
perform a mental health
assessment
If this professional is not the
person’s GP, inform
the GP of the referral
Assessment
Consider using:
• A diagnostic or problem identification tool, for example
the Improving Access to Psychological Therapies
(IAPT) screening prompts tool
• A validated measure relevant to the disorder to inform
assessment and support evaluation of interventions:
- 9-item Patient Health Questionnaire (PHQ-9)
- Hospital Anxiety and Depression Scale (HADS)
- 7-item Generalized Anxiety Disorder scale (GAD-7)
Ask directly about suicidal ideation and intent
Assessment:
core components
Staff conducting assessments should be able to:
- determine the nature, duration and severity of the
presenting disorder
- take into account symptom severity and associated
functional impairment
- identify appropriate treatment and referral options
in line with relevant NICE guidance
Consider factors that may affect the development,
course and severity of a person’s presenting problem:
- history of mental health disorder or chronic physical health
- past experience and response to treatments
- quality of interpersonal relationships
- living conditions and social isolation
Severity of common mental
health disorders: definitions
Mild relatively few core symptoms, a limited duration and little
impact on day-to-day functioning
Moderate all core symptoms of the disorder plus other related
symptoms, duration beyond that required by minimum diagnostic
criteria, and a clear impact on functioning
Severe most or all symptoms of the disorder, often of long duration
and with very marked impact on functioning
Persistent subthreshold symptoms and associated functional
impairment that do not meet full diagnostic criteria but have a
substantial impact on a person’s life, and which are present
for a significant period of time
Stepped-care model
CMHDs presentation and severity
Recommended interventions
Step 1
All disorders – known and suspected presentations
All disorders: Identification, assessment,
psychoeducation, active monitoring; referral
for further assessment and interventions
Step 2
Persistent subthreshold depressive symptoms or
mild to moderate depression; GAD; mild to moderate
panic disorder; mild to moderate OCD; PTSD
(including mild to moderate)
Depression
GAD and panic disorder
OCD
PTSD
All disorders – Support groups, educational
and employment support services; referral
for further assessment and interventions
Step 3
Persistent subthreshold depressive symptoms; mild
to moderate depression not responded to a lowintensity intervention; moderate or severe
depression; GAD with functional impairment or has
not responded to low-intensity intervention; moderate
to severe panic disorder; OCD with moderate or
severe functional impairment; PTSD
Depression
GAD
Panic disorder
OCD
PTSD
All disorders – Support groups, educational
and employment support services; referral
for further assessment and interventions
Improving access to services
Collaborate to develop local care pathways that:
• support integrated delivery across primary and
secondary care
• have clear and explicit entry criteria
• focus on entry and not exclusion criteria
• have multiple means and points of access,
including self-referral
• have a designated lead to oversee care
• promote access for people from socially
excluded groups
Developing local care
pathways:1
Design local care pathways that promote a stepped-care
model of integrated delivery to:
•
•
•
•
•
•
•
provide least intrusive, most effective interventions first
have explicit criteria for different levels of intervention
not base movement between levels on a single criteria
monitor progress and outcomes
minimise the need for transition between services
establish clear access and entry points
have designated staff responsible for coordination
of care
Developing local care
pathways: 2
Develop protocols for communicating
information:
•
•
•
•
for service users about their care
with other professionals (including GPs)
between services within the pathway
to services outside the pathway
Robust systems should be in place to ensure
routine reporting of outcomes
Primary care costs avoided
and benefits
Due to variation in current practice, it is not possible to quantify the national
cost impact of the NICE recommendations.
The following areas may incur savings through drug costs avoided
by meeting additional demand with treatments such as talking therapies.
People with mild panic
disorder.
People with mild depression
or anxiety or both.
People who have mild moderate OCD.
Estimated reduction
in need - GP
services and
medications
60%
Saving in GP visits
and drug costs
£ 471 per
person
Estimated reduction
in need of
medications
53%
Saving in drug
costs
£202 per person
Interventions for anxiety:
potential costs
Intervention
Cost of intervention
Identification and assessment
Minimal
Low-intensity psychological interventions
(LIPI)
£540 for 6 sessions or £45 per person
based on a group of 12
Drug treatment
From £189 to £449
High-intensity psychological interventions
(HIPI)
£1125 per person for 15 sessions
Highly specialist treatment
As shown for drug treatment & HIPI but
combined.
Inpatient episode £6496
Interventions for depression:
potential costs
Intervention stages
Potential additional costs
Principles for assessment, coordination of
care and treatment choice
It is estimated these recommendations will
not incur any additional costs
Step 2: recognised depression – persistent
subthreshold depressive symptoms or mild
to moderate depression
Consideration should be given to the
resourcing of group-based peer support
(self-help) programmes
Step 3: persistent subthreshold depressive
symptoms or mild to moderate depression
with inadequate response to initial
interventions, and moderate and severe
depression
Any costs or savings resulting from these
recommendations are likely to be based on
local practice
Discussion
• How are diagnostic or problem identification tools
used in primary care?
What audit activity reviews their use?
• How do our care pathways compare with the NICE
guidance?
• What methods are used to review service user
treatment outcomes?
•
How can we address cases where there is
persistent subthreshold CMHD symptoms?
Find out more
Visit www.nice.org.uk/guidance/CG123 for:
•
•
•
•
•
•
•
the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
baseline assessment
Resource for primary care
online educational tools
Presenter notes
The previous slide marks the end of the presentation;
slides from this point on are for use by the presenter.
For information, the stepped-care table on slide 16
contains action buttons that link to more detailed
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is in slide show view. The presenter will need to click on
a hyperlink to access the further detail.
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Stepped care: depression
Step 2 interventions
Individual facilitated self-help
Computerised CBT
Structured physical activity
Group-based peer support (self-help) programmes
Non-directive counselling delivered at home*
Antidepressants
Self-help groups
* for women during pregnancy or the postnatal period
Step 3 interventions
Back to
stepped care
table
CBT
IPT
Behavioural activation
Behavioural couples therapy
Counselling
Short-term psychodynamic psychotherapy
Antidepressants
Combined interventions
Collaborative care (if chronic physical health problem)
Befriending
Rehabilitation programmes
Self-help groups
Stepped care:
GAD and panic disorder
Step 2 interventions
GAD and Panic disorder
Step 3 interventions
GAD
Step 3 interventions
Panic disorder
Back to
stepped care
table
Individual non-facilitated self-help
Facilitated self-help
Psychoeducational groups
Self-help groups
CBT
Applied relaxation
Drug treatment
Combined interventions
Self-help groups
CBT
Antidepressants
Self-help groups
Stepped care:
obsessive-compulsive disorder
Step 2 interventions
Individual CBT
Group CBT (including ERP)
Self-help groups
Step 3 interventions
CBT (including ERP)
Antidepressants
Combined interventions and
case management
Self-help groups
Back to
stepped care
table
Stepped care:
post-traumatic stress disorder
Step 2 interventions
Trauma-focused CBT
EMDR
Step 3 interventions
Trauma-focused CBT
EMDR
Drug treatment
Back to
stepped care
table