Central and North West London Central London Community Healthcare
NHS Foundation Trust NHS Trust
Central and North West London NHS Foundation Trust, Central London Community Healthcare NHS Trust and
Depression Alliance working together.
INCLUSION CRITERIA
A.
AGE
All patients seen by the service must be 18 years or older.
B.
GP REGISTRATION
All patients seen by the service must be registered with a Kensington and Chelsea GP. Where a patient is resident in Kensington and Chelsea but not registered with a GP we will encourage the patient to register with a Kensington and Chelsea GP.
The service is not available for patients who are residents of Kensington and Chelsea but registered with a GP outside Kensington and Chelsea. In these cases the patient will receive primary care mental health services which have been commissioned for the area outside Kensington and Chelsea.
C.
DIAGNOSIS
C1) Patients with mild, moderate or severe depression and/or anxiety disorders. This includes the following groups of patients:

Patients with mild to moderate depression and/or anxiety (PHQ-9 and /or GAD-7 <15)

Patients with more severe levels of depression and/or anxiety (PHQ-9 and GAD-7 >15) and significant impairment of social and occupational functioning

Patients with long term conditions who are also suffering from depression and anxiety
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Patients with adjustment disorders
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Patients with significant life stresses who do not have a diagnosable mental health condition who may benefit from referral to the counselling stream of the service or may be signposted to other voluntary and community services
C2) The anxiety disorders include patients with the following diagnoses:

Phobic anxiety disorders including agoraphobia, social phobia and specific phobias e.g., blood and injury phobias, heights, closed spaces, etc

Panic disorder
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Generalised anxiety disorder
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Obsessive compulsive disorder

Post-traumatic stress disorder

Health anxiety
C3) Patients with mild eating disorders (BMI>17.5) who do not meet the criteria for referral to specialist eating disorder services. The service does not provide treatment for morbid obesity.
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C4) Patients with medically unexplained symptoms with no currently known physical pathological cause, where there is evidence that the symptoms may be related to a psychiatric disorder or other emotional difficulties.
C5) Patients presenting with insomnia or sleep related problems
C6) Patients on the SMI register currently under GP care alone who have a stable illness but require increased support due to a recent change of circumstances or inter current stress (for example, bereavement, homelessness, debt, change of medication, new physical health diagnosis)
C7) All those on GP SMI registers under primary or secondary care, who require help engaging with
Annual Physical Health Reviews and recommended blood monitoring. Where the patient is care coordinated this should involve appropriate liaison with the care co-ordinator rather than direct liaison with the patient.
EXCLUSION CRITERIA
A. AGE
All patients under the age of 18 years.
B. RISK
B1) Patients who are at immediate significant risk to themselves e.g. high suicide risk, high levels of self neglect or self-harm.
B2) Patients at significant risk to other people e.g. risk of neglect of children or vulnerable adults, expressions of high levels of violence or aggression.
C. COMPLEXITY/CO-MORBIDITY
Complex presentation with mental health and social problems in multiple domains which are unlikely to respond to a brief recovery model.
D. PERSONALITY DISORDER
The team does not provide a service for patients with personality disorders, where the primary aim of treatment is to treat long-term maladaptive behaviour patterns and persistent interpersonal problems.
In certain cases, patients with personality disorder with an additional diagnosis of depression or anxiety, may be offered targeted interventions for these latter conditions, where there is evidence that personality factors would not interfere with effective treatment of these conditions
E. PATIENTS UNDER THE CARE OF THE MENTAL HEALTH TRUST
Patients currently registered under the care of Mental Health Trust services.
As stated above PCLNs will support GP practices in ensuring that patients on the practices SMI register do receive, as a minimum, an annual physical health check and monitoring. Other than this specific work the service will not see patients who are under the care of the Mental Health Trust.
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F. PATIENTS RECENTLY DISCHARGED FROM MENTAL HEALTH TRUST
Patients discharged within the past six months from MH Trust services. After six months and where appropriate the assessment process will determine whether patients previously treated by the Mental
Health Trust can be safely and effectively treated with the Primary Care Mental Health Team or require re-referral to the Mental Health Trust
G. THOSE REQUIRING SPECIALIST MENTAL HEALTH SERVICES FROM CNWL
G1) Patients with an established psychotic or manic illness who are acutely unwell and those who are diagnosed for the first time with a psychotic or manic illness.
G2) Patients with severe eating disorders (BMI 17.5 or less).
G3) Patients with drug and alcohol misuse problems as the primary issue, will only be seen once these problems has been assessed and treated by an appropriate drug and alcohol agency.
G4) Patients with a significant forensic history involving threatened or actual violence to others.
G5) Patients requiring treatment for offending behaviour which may include: o Sex offenders o Shop lifting o Actual bodily harm o Grievous bodily harm
G6) Patients with body dysmorphic syndrome.
G7) Patients with gender identity problems.
G8) Patients with severe learning difficulties.
G9) Patients with ADHD
G10) Patients with autistic spectrum disorders.
G11) Patients requiring treatment for addictions as the primary issue including non substance addictions such as shopping, gambling, over eating.
H. PATIENTS REQUIRING REFERRAL TO ANOTHER PROVIDER FOR SPECIALIST SERVICES
Those who by individual negotiation, after triage or assessment, have their needs best met by another service due to past history including:
H1) Patients with pain, where the primary reason for the referral is pain management.
H2) Patients with anger management problems with no evidence of a co-morbid mental health condition.
H3) Patients requiring treatment for sexual dysfunction in the absence of a co-morbid mental health condition.
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H4) Patient with chronic fatigue syndrome who require an integrated multi-disciplinary specialist service.
H5) Patients who are morbidly obese.
H6) Marital or couple therapy in the absence of concurrent mental health problems in one or more of the partners.
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