Professor Tony Kendrick outlines how access and use of services for common mental health disorders could be improved through commissioning and support for patients

Common mental health disorders affect as many as one in six people in the community. The 2007 Office for National Statistics (ONS) household survey of adult psychiatric morbidity in England found that 16.2% of working-age adults had an anxiety or depressive disorder (1-week prevalence). Of these:1

  • 9.0% had mixed anxiety and depressive disorder
  • 4.4% were diagnosed with generalised anxiety disorder (GAD)
  • 3.0% with post-traumatic stress disorder (PTSD)
  • 2.3% with major depression
  • 1.4% with phobias
  • 1.1% with obsessive-compulsive disorder (OCD)
  • 1.1% with panic disorder.

NB the above total is over 16% because patients can have more than one disorder.

Mental health disorders are even more common among patients attending general practices. The New Zealand Magpie Study in 2003 found a similar prevalence in the community to the ONS study (15%), but a higher prevalence (21%) in primary care (12-month prevalence).2 However, only 38% of people with disorders in the ONS survey had asked their doctor for help,1 which is one reason why common mental health disorders are missed.

Even when patients do present with symptoms of common mental health disorders, they are often not diagnosed by their GPs. Kessler et al screened attendees in general practice to identify cases of anxiety and depression, and followed them up over 3 years, monitoring the time taken for diagnosis by their GPs.3 This research found that 32% of anxiety and depression cases remained undetected by their GPs at 3-years’ follow up, of which 14% had severe symptoms resulting in disability.3 As a consequence, only a minority of patients obtain help in primary care.

The ONS survey also found that only 24% of people with a common mental health disorder were being given treatment, with:1

  • 14% being prescribed medication
  • 5% undergoing counselling or therapy
  • 5% receiving both counselling and therapy.

Guidance on mental health disorders

NICE has previously released the following guidelines on mental health:

  • Depression in adults (Clinical Guideline [CG] 90)4
  • Depression with chronic physical health problems (CG91)5
  • Anxiety (GAD and panic disorder) (CG113)6
  • Antenatal and postnatal mental health (CG45)7
  • OCD (CG31)8
  • PTSD (CG26).9

However, the above guidelines vary in their coverage of identification, assessment, and referral. One of the main reasons for developing the new NICE guideline on Common mental health disorders: identification and pathways to care10 was to combine the recommendations on identification, assessment, and referral in one place, thereby allowing for easy reference by busy GPs and practice nurses.

Identification

The NICE guideline provides very practical advice to aid identification, suggesting questions for brief enquiry in the first instance (Figure 1, below).10

Depression

In line with its guidelines on depression,4,5 NICE recommends that GPs be alert for a diagnosis of depression in people with a past history of this disorder and in those with a chronic physical health disorder. The two ‘Whooley’ questions for depression have been used by GPs and practice nurses since 2006 to screen patients with diabetes and coronary heart disease for the QOF:10,11

  • ‘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?’

Anxiety disorders
General practitioners should also be alert to possible anxiety disorders in their patients.10 The NICE guideline on GAD (CG113) recommends that practitioners look for anxiety disorders in people presenting with anxiety or significant worry, and in people who attend primary care frequently and:6

  • have a chronic physical disorder
  • have somatic symptoms
  • who are repeatedly worrying about a wide range of different issues
  • who misuse alcohol.

The guideline on common mental health disorders recommends considering the use of the 2-item screen, GAD-2,12 (see Figure 1, below), as a screen for anxiety in the first instance. The tool asks:10

  • ‘Over the last 2 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?’

If the person scores three or more on the GAD-2 scale (for scoring, see Figure 2, below), an anxiety disorder should be considered and recommendations for assessment should be followed (such as using GAD-713, see Figure 2, below) to make a provisional diagnosis of significant anxiety.10

The GAD-2 tool will help detect patients with anxiety within the last 2 weeks, but some patients with panic, phobias, PTSD, or OCD may not have experienced symptoms within this period if they have been avoiding the situations that bring on their anxiety. Therefore the guideline recommends the use of a question about avoidance:10

  • ‘Do you find yourself avoiding places or activities and does this cause you problems?’

If the patient’s response is positive, this should also lead on to further enquiry about the nature of their situation-specific anxiety.

For patients with relatively less well developed English language skills, it may be possible to use the ‘Distress thermometer’,14 an analogue scale, which asks the patient to rate their distress between 0 and 10, with scores above 4 suggesting further assessment should be arranged.10

Figure 1: Brief questions for identifying common mental health disorders10

graph

GAD-2=generalised anxiety disorder scale—2 items; GAD-7=generalised anxiety disorder scale—7 items; IAPT=improving access to psychological therapies; PHQ-9=9-item Patient Health Questionnaire; HADS=Hospital Anxiety and Depression Scale

Adapted from National Institute for Health and Care Excellence (NICE) (2011) CG123. Common mental health disorders: identification and pathways to care. Quick Reference Guide. London: NICE. Available at: www.nice.org.uk/guidance/CG123

Further assessment for treatment and referral

The NICE guideline on common mental health disorders emphasises that practitioners should go on to characterise the patient’s mental state, assess the degree to which it interferes with their daily lives, and explore interpersonal and social difficulties, with relationships, living conditions, money and family worries, which may be causing the problem.10 It also recommends taking into account previous treatment and considering the use of further standardised assessments to make specific diagnoses. These could include use of the 9-item Patient Health Questionnaire [PHQ-9]15 or Hospital Anxiety and Depression Scale (HADS)16 for depression, as currently incentivised through the QOF.11

However, it is important that practitioners do not make decisions about treatment or referral on the basis of scores from a questionnaire alone, but take into account the person’s social situation and past history, including their previous responses to treatment, and assess the importance of their symptoms in context. When considering whether referral for specialist psychological or psychiatric treatment is necessary, the guideline recommends that GPs take these issues into account, as well as:10

  • the trajectory of their symptoms
  • severity and duration of symptoms
  • degree of associated functional impairment
  • co-morbid mental or physical disorders complicating the presentation.

Psychological wellbeing practitioners receiving referrals from GPs or practice nurses, or self-referrals by the patients themselves, could use the improving access to psychological therapies (IAPT) service’s screening prompts tool;17 this will help to identify specific diagnoses when considering whether referred patients should be treated with brief low-intensity therapy initially, or referred straight on to clinical psychologists for high-intensity cognitive behavioural therapy (CBT) based interventions.

Figure 2: Anxiety identification—GAD-7 and GAD-2 tools*10
Over the last 2 weeks, how often have you been bothered by the following problems (Use 3 to indicate your answer) Not at all Several days More than half the days Nearly every day
1. Feeling nervous, anxious, or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3
(For office coding: Total Score T _ = _ + _ + _ )

*Questions 1 to 7 form the GAD-7 tool; questions 1 and 2 form GAD-2
Developed by Drs Spitzer R, Williams J, Kroenke K et al with an educational grant from Pfizer Inc.
No permission required to reproduce, translate, display, or distribute.
GAD-7=generalised anxiety disorder scale—7 items; GAD-2=generalised anxiety disorder scale—2 items

Stepped-care approach

It is recommended that the treatment of common mental health disorders should follow a ‘stepped-care’ approach, such that patients receive the least intrusive treatments first, unless the severity of their problems, or previous non-response to low-intensity treatment, means they should be referred directly on for high-intensity treatment.

The treatment recommendations for all the anxiety disorders and depression, across steps 1, 2, and 3 of the stepped-care model are summarised in Figure 3 (below).10 It is striking that antidepressants are not usually recommended as a treatment option until step 3, yet in practice most patients receive antidepressants as a first response in general practice.

Figure 3 (below) will be a useful resource for commissioners when negotiating the best deal they can get from their local psychological services. Newer treatments such as eye movement desensitisation and reprocessing (EMDR) for PTSD, and exposure and response prevention (ERP) for OCD, should ideally be available in all geographical areas.

Mental health services

There are significant barriers to accessing services for mental health problems in both primary and secondary care, which particularly affect the elderly, and black and minority ethnic patients, especially those for whom English is not their first language.

The guideline recommends that explicit criteria should be specified for referral to mental health services, and information about services provided should be made readily available in a range of formats (visual and aural) and languages. Entry to services should be possible from a range of settings including the community, accident and emergency departments, and hospital clinics, through multiple means of access, including self-referral. Equality of provision tends to be reduced by restricting entry to a single point of access.

The guideline recommends that mental health services should be provided in a variety of settings, including the community as well as outpatients, in patients’ homes, and out of hours. A healthcare professional should be designated to oversee the whole of the patient’s journey through the care pathway. A range of support services (e.g. crèche facilities, assistance with travel, advocacy services) should be considered to facilitate access and use of services.

General practitioners involved in commissioning should consider negotiating these access arrangements for their patient populations, and discuss newer methods of communicating with patients too. Texting, email, and the internet have all been shown to improve communication with patients and the telephone can be used to monitor patients’ progress, and encourage them to persist with treatment. Translation services should of course be readily available, but psychiatrists and psychological therapists should also use culturally sensitive methods of assessment.

Conclusion

General practitioners and their teams should consider what they need to do to implement the new guidance on improving access, identification, and referral pathways for their patients, particularly for anxiety disorders, as less work has been done for them than for depression.

Figure 3: Stepped-care model: a combined summary for common mental health disorders10

graph

*Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression.
†For people with depression and a chronic physical health problem.
‡For women during pregnancy or the postnatal period.
GAD=generalised anxiety disorder; OCD=obsessive compulsive disorder; PTSD=post-traumatic syndrome disorder; CBT=cognitive behavioural therapy; IPT=interpersonal therapy; ERP=exposure and response prevention; EMDR= eye movement desensitisation and reprocessing

National Institute for Health and Care Excellence (NICE) (2011) CG123. Common mental health disorders: identification and pathways to care. Quick Reference Guide. London: NICE. Available at: www.nice.org.uk/guidance/CG123 Reproduced with permission.


Implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 123 on Common mental health disorders: identification and pathways to care. The tools are now available to download from the NICE website: www.nice.org.uk/CG123

Baseline assessment tool

The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Costing tools

A costing report and local cost template for the guideline have been produced:

  • Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline
  • Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Podcasts

A podcast is available in which a member of the Guideline Development Group discusses the guidance.

Slide set

The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.

  1. National Centre for Social Research and the Department of Health Sciences, University of Leicester. Adult psychiatric morbidity in England, 2007: results of a household survey. NHS Information Centre for Health and Social Care, 2009. Available at: www.ic.nhs.uk/pubs/psychiatricmorbidity07
  2. Magpie Research Group. The nature and prevalence of psychological problems in New Zealand primary healthcare: a report on mental health and general practice investigation (MaGPIe). New Zealand Med J 2003; 116 (1171): U379.
  3. Kessler D, Bennewith O, Lewis G, Sharp D. Detection of depression and anxiety in primary care: follow up study. BMJ 2002; 325: 1016–1017.
  4. National Institute for Health and Care Excellence. Depression: the treatment and management of depression in adults (update). Clinical Guideline 90. London: NICE, 2009.Available at: www.nice.org.uk/guidance/CG90 nhs_accreditation
  5. National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: treatment and management. Clinical Guideline 91. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG91 nhs_accreditation
  6. National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care. Clinical Guideline 113. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG113 nhs_accreditation
  7. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical Guideline 45. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG45
  8. National Institute for Health and Care Excellence. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical Guideline 31. London: NICE, 2005. Available at: www.nice.org.uk/guidance/CG31
  9. National Institute for Health and Care Excellence. Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26. London: NICE, 2005. Available at: www.nice.org.uk/guidance/CG26
  10. National Institute for Health and Care Excellence. Common mental health disorders: identification and pathways to care. Clinical Guideline 123. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG123 nhs_accreditation
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