Meeting the mental health indicators will be a challenge for GPs but should bring great benefit to a vulnerable group of patients, says Dr Jill Murie


The emphasis of the new GMS quality framework for mental health is on addressing the needs of individuals with severe longterm mental illness, primarily, although not exclusively, schizophrenia and bipolar affective disorder.

Around 70% of individuals with schizophrenia have a relapsing disease and 10% follow a chronic progressive course.1 In bipolar disorder, the lives of some 10 to 15% of patients are disrupted by more than three recurrent episodes annually.2

These individuals are not only disabled but disadvantaged, discriminated against and at high risk of suicide. Around 40% of them are not in contact with specialist services.3

The mental health indicators

A total of 41 points is available for achieving the mental health quality indicators in the new GMS contract (Table 1, below). The recommended Read codes can be found at www.doh.gov.uk/ipu/whatnew/qspec.pdf.

Table 1: Clinical indicators for mental health
Disease/ indicator no Clinical indicator
Points
Qualifier Preferred Read code Exception reporting and suggested Read code Payment stages
MH 1 A register of patients with severe long-term mental illness who require and have agreed to regular follow up
7
  Register 9H8. Removed from register 9H7.  
MH 2 % patients with severe long-term mental illness with a review of accuracy of prescribed medication, physical health and coordination arrangements with secondary care
23
Recorded in preceding 15 months Review 6A6. Medication review 8B3S   25-90%
For patients on lithium
MH 3 % patients with lithium levels recorded
3
Measured in preceding 6 months Lithium level 44W8%   25-90%
MH 4 % patients with serum creatinine and TSH recorded
3
Measured in preceding 15 months Creatinine 44J3%
TSH 442W
  25-90%
MH 5 % patients with serum lithium in therapeutic range
5
Measured in preceding 6 months Numeric value   25-70%

The indicators are supported by the National Service Framework for Mental Health 4 and the best available research evidence for the diagnosis, treatment, review and integrated care of patients with severe long-term mental illness.1,2,5 The first and fundamental step towards a needs-based service is a register of personal details.6,7

It is also vital to carry out a risk assessment of patients’ compliance with medication to reduce serious adverse health outcomes. Two-thirds of individuals with schizophrenia readmitted to hospital are not taking their medication as prescribed.8 Around 50% of individuals prescribed mood stabilisers fail to take them correctly, and 10 to 20% of people with bipolar disorder commit suicide.9

Co-morbidity in schizophrenia accounts for 60% of premature deaths that are not suicides.10 Individuals with schizophrenia are four times more likely than average to die from coronary heart disease. They are also more vulnerable to respiratory disease and flu and have high rates of diabetes and hepatitis. Lifestyle factors such as smoking, heavy alcohol use and a lack of exercise contribute significantly to the increased mortality rates.11

Effective social care is at least as important as medication in preventing relapse and admission to hospital.12 It is recommended that social measures such as employment, benefits and housing are addressed as part of a ‘holistic package’ of care.12

Disease register – mental health 1

The value of each quality point is based on expected disease prevalence, which is influenced by local factors such as mental health hostels in the practice area. Although registers have been set up by specialist services, definitions of severe long-term mental illness vary and local prevalence figures are not robust. Published estimates for life-time prevalence are around 1% for schizophrenia 5 and between 1.3 and 1.6% for bipolar disorder.2

Inclusion criteria: The principle of inclusion is pragmatically defined as "the construction of a register based on patient need”. Practices can therefore decide which patients to include.

While severe disability can arise from a range of depressive and neurotic illnesses, accuracy and consistency in recording are crucial to the effectiveness of the register.

Limiting the register to schizophrenia and bipolar disorder prioritises individuals with the greatest needs. This approach reduces variability between practices and creates better public health intelligence to inform allocation of resources.

Enduring or ‘long term’ implies that the condition has lasted or is likely to last more than 2 years including remissions and relapses. Restricting the register to those aged 16 to 64 years focuses attention on the provision of adult mental health services. Inevitably, there will be overlap with paediatric and old age psychiatry.

Estimates of need based on contact with mental health services alone will seriously underestimate the true prevalence in the practice population. Homeless people and illicit drug users are often not registered with a GP. In Lanarkshire, individuals with severe long-term mental illness have been identified from primary care information systems, hospital discharge statistics (Table 2, below) and key informant data provided by local statutory and non-statutory mental health services.

Table 2: Identification of patients with severe long-term mental illness
Primary care information systems

Read code

  • E10.. (schizophrenic disorders)
  • E11.. (affective psychoses)

or subcode

  • Eu30. (manic episode)
  • E1160 (mixed bipolar affective disorder)

Repeat prescribing e.g. by BNF code

  • 402010 (oral antipsychotic drugs)
  • 402020 (antipsychotic depot injections)
  • 402030 (antimania drugs)
  • 403010 (tricyclic and related antidepressants)
  • 403020 (monoamine oxidase inhibitors)
  • 403030 (selective serotonin reuptake inhibitors)
  • 403040 (other antidepressants)

and/or by drug (including proprietary preparations)

  • Neuroleptic antipsychotics (chlorpromazine, flupentixol, pimozide, sulpiride, fluphenazine, haloperidol, trifluoperazine, thioridazine, loxapine)
  • Atypical antipsychotics (amisulpride, clozapine, olanzapine, quetiapine, risperidone, sertindole, zotepine)
  • Lithium by drug (lithium carbonate, lithium citrate)
  • Other mood stabilisers (carbamazepine, sodium valproate)

Referrals and clinic lists

  • Psychiatry
  • Community mental health team

Hospital discharge data

  • Three or more psychiatric admissions within the past 3 years
  • An inpatient psychiatric admission of more than 90 days within the past 3 years
  • A formal psychiatric admission in the past 3 years
  • Discharged with a principal diagnosis of schizophrenia (ICD9: 295; ICD10: F20)
  • Discharged with a principal diagnosis of bipolar disorder (ICD9: 296; ICD10: F30, F31)
  • Discharged with a principal diagnosis of other psychotic illness (ICD9: 297-299, excluding 298.0; ICD10: F21, F22, F24-F29)
  • Discharged with a principal diagnosis of severe psychotic depression (ICD9: 298.0; ICD10: F32.3)

Exception reporting: Exception reporting may need to be invoked for new diagnoses, new patients and patients for whom it is not appropriate to review the condition because of particular circumstances, for example terminal disease. In schizophrenia, 20% of patients recover 1 and some patients with bipolar disorder achieve partial or full remission.2

However, exception reporting raises ethical issues, particularly relating to informed dissent, where the patient does not agree to receiving care. Compulsory treatment is also highly controversial. In these situations, the patient’s carer should be involved. Refusal to involve the carer must be reviewed on an ongoing basis and recorded in the case notes.6

Exclusion: Although individuals with learning disabilities, dementia, alcohol or substance misuse problems also experience severe long-term mental illness, they should be included on the register only when a dual diagnosis is made. It is important that patients with chronic depression and those who misuse alcohol and/or illicit drugs are entered onto separate registers for practices wishing to provide enhanced care for these conditions.

Confidentiality: In England, section 60 of the Health and Social Care Act 2001 allows registers to hold information about individuals without their knowledge or consent.13 However, patients need to know they are consenting to more than inclusion on a register. They are agreeing to proactive physical, psychological and social interventions.

Patients should therefore understand how the information will be used locally, what benefits are anticipated, who will have access to the information and which security measures and privacy enhancing technologies are being used.14 An alternative to identifiable data is a register of patients known only to the practice and mental health services and unidentifiable in terms of names, addresses, age and sex. This enables the anonymous recording of needs and service use to inform local planning.

The disease register must be entirely confidential to reassure patients that possible stigma is not an issue. Access to information should be on a strict ‘need to know’ basis. The approaches used must comply with the Data Protection Act 15 and NHS Caldicott guidelines.16

Review – mental health 2

Each practice needs a reliable system for reviewing the clinical progress, risk factors and co-morbidities of individuals with severe long-term mental illness. In addition, multidisciplinary team involvement and out-of-hours arrangements for patients on a care programme approach – a package of care based on the assessment of need – should be recorded to anticipate crisis and prevent suicide 24 hours a day. This will be difficult to achieve without a clinical information system shared by social workers and GPs.

Prescribed medication: Patients’ willingness to take prescribed medication varies with the illness, from first-onset psychosis where drop-out rates are highest, to long-term follow-up when patients are feeling better and perhaps reluctant to continue treatment. The patient and his or her carer should be involved in shared decision making about the treatment options after an informed discussion of the relative benefits of the drugs and their side-effect profiles.

Individuals with newly diagnosed schizophrenia and those on older neuroleptic agents are most likely to experience side-effects (Box 1, below). Side-effects have serious consequences for compliance. Consequently, once a patient’s symptoms are controlled, the dose should be adjusted to the minimum effective dose.

Box 1: Adverse effects of antipsychotic drugs

Neurological

Extrapyramidal

  • Parkinsonism (including tremor)
  • Dystonia (abnormal face and body movements)
  • Akathisia (restlessness)
  • Tardive dyskinesia (rhythmic, involuntary movements of tongue, face and jaw)

Autonomic

  • Blurring of vision, increased intra-ocular pressure, dry mouth and eyes, urinary retention, constipation

Other

  • Seizures
  • Drowsiness, apathy
  • Insomnia

Increased prolactin levels

  • Gynaecomastia
  • Sexual dysfunction
  • Menstrual disorders

Cardiovascular

  • Sudden death
  • Hypotension
  • Ventricular dysrhythmias

Haematological

  • Neutropenia and agranulocytosis (clozapine)

Dermatological

  • Skin rashes
  • Photosensitisation

Ophthalmological

  • Corneal and lens opacities
  • Purplish pigmentation of cornea, conjunctiva and retina

Other

  • Weight gain
  • Jaundice

Approaches to monitoring sideeffects vary and there is little regular audit of prescribing practice.6 National criteria and standardised methods for auditing the use of antipsychotic drugs are recommended.1,6

Review of physical health: Identifying and managing co-existing disease in individuals with severe long-term mental illness is made more difficult by barriers related to the patient, the illness, the attitudes of clinicians, and the structure of healthcare delivery services. GPs, in conjunction with other healthcare specialists, must learn to manage these obstacles to prevention.

Clinical areas for annual review are summarised in Box 2 (below). A protocol for conducting the review and agreed management guidelines will make this process easier.

Box 2: Components of the annual review

Personal details

  • Change of address/homelessness (phone/mobile number)
  • Next of kin/carer/keyworker/advocate (phone/mobile number)

Clinical

  • Confirmation of diagnosis
  • Frequency of relapse
  • Episodes of hospitalisation
  • Suicide risk assessment

Medication review

  • Clinical improvement/control of symptoms
  • Adverse effects of treatment
  • Concordance with medication
  • Involvement of the individual/carer/advocate in treatment decisions
  • Advanced directive in the event of an acute psychotic episode
  • Analysis of cost effectiveness of treatment options

Monitoring

  • Full blood count (clozapine)
  • Serum levels (lithium)
  • Creatinine and thyroid function tests (lithium)

Physical

  • Cardiovascular check including blood pressure, cholesterol
  • Urinalysis to exclude the presence of glucose
  • Protection against influenza by vaccination
  • Peak flow assessment and advice about reducing smoking
  • Lifestyle advice: diet, exercise, alcohol and illicit drugs
  • Women: contraception, cervical cytology

Coordination arrangements

  • Written care plan
  • Annual review by psychiatrist
  • Named keyworker and/or community nurse
  • Psychology assessment
  • Occupational therapy assessment (hygiene, dressing, home management)
  • Social work assessment (accommodation, employment, benefits)

Empowerment

  • Information
  • Self-help group/voluntary agencies

Exception reporting

  • The patient has chosen not to be in contact with specialist mental health services
  • Involvement of carer/independent advocate

Review of co-ordination arrangements: The new contract provides an opportunity for an integrated care pathway between primary and secondary care, and community specialist mental health services. However, many people with severe long-term mental illness have complex medical, social and psychological needs, which cannot be addressed by the health services alone.

A multidisciplinary approach involving statutory and voluntary agencies, including those for social work and housing, plays a key role in providing continuity along the patient journey.

Many practices will be assessed on care that is being delivered outside their practice by community mental health teams. Liaison mental health specialist-led clinics working to protocols, with clinical leads for mental health and practice-based quality coordinators, have the potential to maximise collaboration between agencies.

Ideally, users of the services contribute to the planning of their own care. Where this is not possible, independent advocacy services have a valuable role.

Lithium therapy – mental health 3, 4 and 5

Lithium is an effective, but often poorly supervised, mood stabilising agent for bipolar disorder and unipolar depression. Practices require effective systems for monitoring common adverse effects such as polyuria, weight gain and thyroid disorders and toxicity, which may present as ataxia, dysarthria, tremor or convulsions.17

The BNF states that serum lithium concentrations should be measured every 3 months and thyroid function tests carried out every 6-12 months on stabilised regimes.18 Recommended lithium levels are summarised in Box 3 (below). The new GMS contract’s qualifiers (6-15 months) accommodate unpredictable factors such as hospitalisation.

Box 3: Recommended lithium levels

Treatment
Maintain serum lithium levels in the range 0.6-1.0 mmol/l

Prophylaxis
Maintain serum lithium levels in range 0.4-0.8 mmol/l

See data sheet: EMIMs December 2003 (www.emims.net)

Conclusion

The mental health indicators have been described as the "most unattractive” of the 10 clinical domains in the new GMS contract.19 However rewarding the potential benefits, financially they comprise only 7.5% of the total clinical points available.

There are many potential difficulties, including issues of clarity of definition, consistency in recording, consent, confidentiality and security of information and, not least, professional accountability.

Financial pressures on communityand primary care-based mental health services may mean that practices lack the capacity to develop collaborative and proactive health and social care for this vulnerable group.20,21

The mental health quality indicators are largely aspirational as in many areas a fully integrated infrastructure will not be in place. At national level, practices will require strategic guidance with well-defined priorities and realistic time-scales within a robust legal framework. Locally, education and training, and adequately resourced community services with excellent communication will be necessary to achieve the mental health targets.

Acknowledgements

I thank Kevin O’Neill, Lanarkshire Mental Health Needs Assessment Project, Julian Hodgson, Alistair MacKenzie Library, Wishaw General Hospital, NHS Lanarkshire and Alistair Philp, Improving Mental Health Information Programme and Rod Muir, Programme Clinical Director and Caldicott Guardian, Information and Statistics Division, NHS Scotland, for information and advice.

References

  1. National Institute for Clinical Excellence. Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia. Technology Appraisal Guidance No 43. NICE, June 2002. www.nice.org.uk
  2. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. American Psychiatric Association. Am J Psychiatry 1994; 151(Suppl 12): 1-36.
  3. The Sainsbury Centre for Mental Health, NHS Alliance. Primary Solutions: an independent policy review on the development of primary care mental health services. London: Sainsbury Centre for Mental Health, 2002. www.scmh.org.uk/8025694D00337EF1/vWeb/fsCPIR4PDJ8T
  4. Department of Health. National Service Framework for Mental Health. London: Department of Health, 1999.www.doh.gov.uk/nsf/mentalhealth.htm
  5. Clinical Standards Board for Scotland (CSBS). Schizophrenia: national overview. Edinburgh: CSBS, 2002.
  6. Kingdon D. Focus on psychiatry. Supervision of registers: caring or controlling? Br J Hosp Med 1996; 56: 470-2.
  7. Slade M, Powell R, Strathdee G. Current approaches to identifying the severe mentally ill. Social Psychiatry and Psychiatr Epidemiol 1997; 32: 177-84.
  8. Adam SG Jr, Howe JT. Predicting medication compliance in a psychotic population. J Nerv Ment Dis 1993; 181: 558-60.
  9. Lewis CF, Tandon R, Shipley JE et al. Biological predictors of suicidality in schizophrenia. Acta Psychiatr Scand 1996; 94: 416-20.
  10. Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003; 178(Suppl): S67-70.
  11. Cohen A, Hove M. Physical health of the severe and enduring mentally ill. A training pack for GP educators. London: Sainsbury Centre for Mental Health, 2001. www.scmh.org.uk/8025694D00337EF1/vWeb/fsCPIR4PDJ8T
  12. Shooter M.The patient’s perspective on medicines in mental illness. Br Med J 2003; 327: 824-6.
  13. House of Commons. Health and Social Care (Community Health and Standards) Act. London: HMSO, 2003. http://www.hmso.gov.uk/acts/acts2001/10015—g.htm#60
  14. The Confidentiality & Security Advisory Group for Scotland. Protecting Patient Confidentiality: Final Report. Edinburgh: Scottish Executive Health Department,2002. www.show.scot.nhs.uk/sehd/publications/ppcr/ppcr-11.htm
  15. House of Commons. Data Protection Act 1998. London:HMSO, 1998. www.hmso.gov.uk/acts/acts1998/19980029.htm
  16. Department of Health, the Caldicott Committee. Report on the review of patient-identifiable information. London: Department of Health, 1997. www.doh.gov.uk/ipu/confiden/report/caldrep.pdf
  17. Murie J. Lithium monitoring audit highlights need for regular review. Guidelines in Practice 2002; 5(3): 81-9.
  18. British Medical Association,Royal Pharmaceutical Society of Great Britain. British National Formulary (BNF). March 2003, p. 186.
  19. Lamb A. Getting to grips with the quality framework. Pulse, 8 December 2003 pp26-8.
  20. Sainsbury Centre for Mental Health. Money for Mental Health: a review of public spending on mental health care. London: Sainsbury Centre for Mental Health, 2003. www.scmh.org.uk/8025694D00337EF1/vWeb/fsCPIR4PDJ8T
  21. Levenson R, Greatley A, Robinson J. London’s State of Mind: King’s Fund mental health inquiry 2003. London: King’s Fund, 2003.

Guidelines in Practice, March 2004, Volume 7(3)
© 2004 MGP Ltd
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