NICE guidelines update 2013
Katie Simpson
South Central SHA
IAPT GP Clinical Lead
Mental Health Lead Berks East PCT
Primary Care Mental Health
• 281 million consultations in Primary Care
annually
• 30% of all GP consultations have a Mental
Health component
• 90% Mental Health Problems managed by
Primary Care
CG90 NICE Depression guidance
• Depression: review of assessment
• Emphasis on psychological interventions
• Pharmacological interventions
new information
efficacy and cost effectiveness
augmenting
• Relapse prevention
• GP key role
Principles for assessment
The guidelines discourage over reliance on the number
of symptoms. Instead:
• Distress
• Duration
• Disability
If the patient’s symptoms have been distressing and
have been present for 2 weeks or more at a level
where they have affected their ability to function
normally then it is likely that they are significant
Identification and assessment
• Be alert to possible depression
– Particularly in people with a past history of depression
or a chronic physical health problem with associated functional
impairment.
• Consider asking people 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?
(PHQ2)
• “Is this something with which you would like help”?
Role of the General Practitioner
• GPs ideally placed to detect depression
• “Watchful waiting” vs GP involvement in all steps of
the model
CG 90 not so explicit about boundaries primary care/
specialist care
• But: dangers of false diagnosis and medicalisation of
distress
Some evidence of diagnosis and prescription in pts. not
actually depressed
Key points for intervention
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Step 1
Identification
Risk assessment
Active monitoring
Step 2
Advice on sleep hygiene and activity
Low intensity psychological interventions
Step 3
High intensity psychological interventions
Referral
Steps 2, 3, and 4
Antidepressants
Steps 2, 3 and 4
Provision of service delivery system
The Characteristics of IAPT
• Implements NICE Guidelines
– Not only CBT
• Stepped care
• Outcome focused
• Self referral
Stepped Care
Referral Criteria
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Problems suitable for Talking Therapies
Depression
Generalised anxiety disorder
Psychological problems arising from long term medical conditions
Panic disorder
Social phobia
Specific phobias
OCD Obsessive compulsive disorder
PTSD Post- traumatic stress disorder –moderate/single trauma e.g. RTA
Health anxiety
Medically Unexplained Physical Symptoms
Post natal depression (mild/moderate)
Employment stress, support required to stay in or obtain work.
Not suitable:
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Children
Psychosis
Actively suicidal
Complex problems eg PD, Severe
PTSD, Moderate/Severe Eating
disorders
• Drug/Alcohol problems
• Under Secondary Care Services
NICE conclusions on
antidepressant medication
• When prescribing, should normally be
SSRI (Selective Serotonin Receptor
Inhibitors) in generic form
• Avoid using routinely for subthreshold
depressive symptoms
• Discuss options, consider side effects,
discontinuation, potential interactions,
physical health, previous experience
Starting antidepressant
treatment
Obtain patient’s agreement that they have a depressive illness, then:
• Address patient concerns, views on tablets and antidepressants,
and discuss common myths
 Gradual effects and need to persevere
 Side effects and drug interactions
 Previous experience of efficacy/side effects
 Discontinuation symptoms
 Not addictive
 Ask about St. John’s Wort
• Review after 2 weeks, then at least monthly
• If suicide risk or <30years review after 1 week, then frequently
Mode of action: SSRI (Selective
Serotonin Receptor Inhibitors)
Common Side Effects of SSRIs
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Nausea
Diarrhoea
Headache
Anxiety
Insomnia/drowsiness- adapt time of taking
Weight loss/gain
Sexual difficulties: lack of orgasm
Short term rx (<2 weeks) with a benzodiazepine
Care in people at risk of falls
Generic SSRIs: Fluoxetine, Citalopram,
Sertraline, Paroxetine
• Sertraline & Citalopram are safer in
patients with Long term conditions as
less interactions with other medication
• Paroxetine more discontinuation
symptoms
• Fluoxetine can increase anxiety in
approx 10%
Escitalopram
• Isomer of citalopram
• Cochrane report supported it BUT
• Small no’s of patients, short term follow
up, Pharmaceutically sponsored trials
• Not enough information to recommend it
above other treatments as much more
expensive.
SNRIs (Serotonin & Noradrenaline
Reuptake Inhibitors)
• Venlafaxine: can increase blood
pressure, more toxic in overdose.
• Duloxetine: Also used in diabetic
neuropathy (& stress incontinence)
• Side effects similar to SSRI
MIRTAZEPINE
Mirtazepine
• Works by increasing noradrenaline and
serotonin in unique way (blocking alpha
adrenergic receptors)
• Weight gain
• Sedation- some times useful
• Often used to augment other
antidepressants
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TCADS (Tricylic Anti Depressants) e.g
amitriptyline, clomipramine, dothiepin
• Work on serotonin and noradrenaline
• Side effects: dry mouth, constipation,
blurred vision, palpitations, urinary
retention
• Very toxic in over dose (especially
dothiepine) except lofepramine
Starting Treatment
• Response by 2-4 weeks
• Switch or increase dose if:
– Inadequate response
– Side effects
– Patient prefers
Risk
• Assess, not just
using a symptom
count
• Assess social
support
• Arrange appropriate
help
• Advise how to seek
help
• GP’s are used to
living in a very risky
world
• We can each expect
a suicide every 5
years
Suicide risk
• Review after 1 week
• Consider other forms of support e.g. More
frequent direct or telephone contact
• Consider referral to crisis team
• Advise and monitor potential for increased
agitation, anxiety and suicidal ideation
• Take into account toxicity in overdose
 Venlafaxine associated with increased risk
 TCAs increased risk (except lofepramine)
Augmenting antidepressants
If person is informed and prepared to
accept additional side effects, consider
augmenting with:
• Lithium
• An antipsychotic such as aripiprazole,
olanzapine, quetiapine, risperidone
• Another antidepressant, such as
mirtazapine or venlafaxine
Relapse prevention
Need to continue treatment for at least 6/12 from
recovery
 Continue medication for at least 2 years
(If 2+ recent episodes, other risk factors, relapse
consequences severe e.g occupation)
 Psychological interventions: For recurrent depression
Individual CBT (16-20 sessions over 3-4 months)
OR
Mindfulness based cognitive therapy (8 week group)
Discontinuation
When stopping antidepressants, gradually reduce
dosage over a 4 week period
• Some people may require longer, esp. With e.g.
paroxetine, venlafaxine
• Exception is fluoxetine
• Warn about discontinuation symptoms – usually
settle within a week
• If symptoms mild: reassure and monitor
• If symptoms severe: reintroduce original dose or
another with longer half life and reduce gradually
Subthreshold and mild
depression
• Do not routinely use drugs
• Consider them for:
– Those with a PMH of moderate/severe
depression
– H/O 2y + subthreshold symptoms
– Subthreshold / mild depression persisting
after other interventions
Key points
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GPs should be alert to possible signs of depression in patients, but
should not medicalise distress
Assessment and management should be carried out according to the
stepped-care model
Patients should be supported by the GP throughout the management
process
GPs should use active monitoring for patients as appropriate
GPs should have knowledge of:
– low-intensity psychological interventions
– locally available services
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Pharmacological treatment choices should be tailored to the individual
patient
The use of St John’s wort is not recommended
High-intensity psychological interventions should be offered to patients
with moderate to severe depression
How to manage anxiety disorders
in general practice
Katie Simpson
South Central SHA
IAPT GP Clinical Lead
Mental Health Lead Berks East PCT
Subtypes of anxiety disorders
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GAD
Panic disorder
PTSD
OCD
Social phobia
Specific phobias (e.g. spiders)
Acute stress disorder
Generalised anxiety disorder
• GAD (5% of GP patients)
• DSM IV:
‘excessive worry and heightened tension
majority of days’
‘difficulty controlling the worry’
‘plus additional symptoms’
‘should cause clinically significant distress or
impairment of function’
‘6 months’
Who has GAD?
chronic physical health problems
OR
people seeking reassurance about somatic
symptoms (particularly the elderly and those
from minority ethnic groups)
OR
repeatedly worrying about a range of issues
Stepped care in GAD
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Step 1 – identification and assessment, education and active monitoring
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Step 2 – individual pure self help, individual guided self help or psychoeducational groups.
Books: ‘Living with fear’ by Marks IM,
‘Mastery of your anxiety and panic’ by Barlow DH
‘Overcoming anxiety’ by Kennerley H.
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Step 3 – high-intensity psychological interventions (CBT or applied relaxation)
OR
drug treatment (Sertraline).
See them within 1 week of starting rx
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Full anxiolytic effect takes 1 week or more.
Important to cont rx after remission to prevent relapse (at least 1 year).
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Step 4 – consider referral to secondary care
SSRI/SNRI at step 3
• Sertraline 1st line
• If ineffective/ not tolerated then another SSRI
or SNRI
• Consider: withdrawal syndrome/ side effect
profile/ risk of suicide/self harm-toxicity in
OD/previous experience of drug rx
Pregabalin
• If pt cannot tolerate SSRIs then offer
pregabalin or SNRI
• Also used in neuropathic pain & epilepsy
• Side effects : dizziness, drowsiness, dry
mouth, ankle swelling , blurred vision,
poor concentration, weight gain
Benzodiazepines
• Do not offer BDZs for Rx of GAD apart from
short-term measures during a crisis. Advice in
BNF - not be used as sole rx for chronic
anxiety.
• Avoid driving- even the next morning
• Can become habit forming after 2 weeks
• In long term can cause rebound insomnia and
anxiety
Beta Blockers
• B blockers help with palpitations and
tremor NOT psychological
symptoms/muscle tension
• Side effects: cold extremities, tiredness
• NOT with asthma
Anti- psychotics
• Do not use antipsychotics for rx of GAD
in primary care e.g chlorpromazine,
haloperidol, risperidone, aripiprazole
• Risks out weigh benefits
• Weight gain, increased risk of Diabetes,
Cardio vascular disease including stroke
Principles of care in GAD
• Provide contact numbers and info about what to do and who to
contact in a crisis
• Comorbid anxiety or physical disorder? Treat the primary
disorder first (the one that is more severe)
• Non-harmful alcohol misuse not a contraindication to rx of GAD.
However with harmful and dependent alcohol misuse rx this first
as alone it may lead to a significant improvement in GAD
Thank you
Dr Katie Simpson
South Central SHA
IAPT GP Clinical Lead
Mental Health Lead Berks East PCT
katiesimpson2@nhs.net