STEPPED CARE IN DEPRESSIONDr Gabriel Ivbijaro MBBS, FRCGP, FWACPsych, MMedSci, DFFP, MA Family Doctor & Chair, Wonca Working Party on Mental Health

AIMS

Recognition of depression Use of Evidenced Based intervention Understanding stepped care Able to use the mhGAP Algorithm

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mhGap Modules3

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Challenges - application of best evidence worldwide

How can we best apply principles for the treatment of depression in primary care that:Are compatible with the range of cultural values

held across the world’s continents Incorporate patient choiceAre compatible with financial constraints faced

by individual nations

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Antidepressants: current controversies

Are antidepressants the answer to all problems or has the case been overstated?

Should antidepressant be routinely prescribed?

What role do they play in the overall treatment of depressive disorder?

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SSRI’s- what’s new?

Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration (Irving Kirsch, Brett J. Deacon, Tania B. Huedo-Medina, Alan Scoboria, Thomas J. Moore & Blair T. Johnson PLoS Med 5(2) 2008)

Looked at data on fluoxetine, venlafaxine, nefazodone, paroxetine

Mean change in HDRS compared between placebo & drug: FDA >1.8; UK NICE > 3 to be clinically significant

Most trials on severely depressed patients

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SSRI vs placebo in depression9

When do they work?10

Meta-analysis conclusions

Exceptionally large placebo response ≈ 80% Drug–placebo differences in antidepressant

efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients

The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication

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What do we need?

A pragmatic approach that combines best evidence and best practice whilst incorporating the attibutes of the best primary, secondary and tertiary care services

The ability to accommodate that patients move between and across services and have different needs at different times

As a rehabilitation psychiatrist I straddle a number of services and get a different perspective – what is the way forward?

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Stepped care in mental health

A holistic approach that takes into account the local situation and matches resources to individual patients whilst recommending minimum standards that all should aspire to

How might it be conceptualised? (Thornicroft & Kinsella BJP 2004, 185, 283-290)

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Low level of resources – step A

Step A : Primary Care with Specialist Back Up Screening & assessment by primary care staff Talking treatments including counselling and advice Pharmacological treatment Liaison and training with mental health specialist staff

when available Limited specialist back-up for

Training Consultation for complex cases In-patient assessment & treatment for case that cannot

be managed in primary care e.g. in general hospitals

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Medium level of resources – step A + step B

Step B: Mainstream mental health care Out-patient / ambulatory clinics Community mental health teams Acute in-patient care Long-term community based residential care Employment & occupation

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High level of resources – step A + step B + step C

Step C: Specialised/ differentiated mental health servicesSpecialised clinics for specific disorders/patient groups including:

eating disorders, dual diagnosis, treatment resistant affective disorders, adolescent services

Specialised CMHT’s including: early intervention teams , assertive community Rx

Alternatives to acute admission including:Home Rx/crisis resolution, crisis houses, acute day hospital

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High level of resources – Step A + Step B + Step C Alternatives types of long stay community

residential care including: Intensive 24 hr staffed residential provision, less

intensively staffed accommodation, independent accommodation

Alternative forms of occupation and vocational rehabilitation: Sheltered workshops, supervised work placements,

cooperative work schemes, self-help and user groups, club houses/transitional employment programmes, vocational rehabilitation, individual placement and support services

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Stepped care in depression

Primary care has an important role to play in the treatment of depression

Antidepressants alone are not the answer A variety of evidence based interventions

should be possible whether practising in low, medium or high resource settings and a collaborative approach will need to be taken

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Risk Assessment20

Primary Care Tips21

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LOOK

What did you see?

LISTEN

What did you hear?

TEST

What has been tested and what needs to be tested?

Case Discussion

Use Local cases All

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LOOK

What did you see?

LISTEN

What did you hear?

TEST

What has been tested and what needs to be tested?