Golnar aref - cardiovascular and mental health
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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London
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Golnar aref - cardiovascular and mental health
- 1. Cardiovascular Disease and Mental Health Integrating physical and mental health care pathways
- 2. Case of Need Mental health problems are the largest single source of disability in the United Kingdom Patients with long-term conditions are 2-3 x more likely to experience mental health problems Prevalence of depression in cardiovascular disease is 10 to 20% and this is approximately 3 x more common than in the general population Figure 1: Morbidity among people under age 65 Physical illness (e.g. heart, lung, musculo- skeletal, diabetes) Mental illness (mainly depression, anxiety disorders, and child disorders)
- 3. Case of Need International research shows that mental health co-morbidities are associated with a 45-75% increase in service costs per patient. The LSE report estimates that extra physical healthcare caused by mental illness now costs the NHS at least £10bn a year.
- 4. Meet Jeremy* • 55 year-old male • Had an acute heart event 1 year ago • He experienced another heart attack a month later • He had heart surgery following this and was hospitalised for one month • He has been signed off sick for the past year • He rarely leaves the house and feels low most days • Jeremy has undiagnosed and untreated anxiety and depression *Name changed to protect confidentiality
- 5. Jeremy’s outlook 50 % more acute exacerbations per year Twice as likely to have further cardiac events His anxiety is one of the strongest predictors of in-hospital complications Treating depression and anxiety has the potential to improve; His quality of life Functioning Physical health outcomes
- 6. Screening During the last month have you been feeling down, depressed or hopeless? During the last month have you often been bothered by having little interest or pleasure in doing things? During the last month, have you often been bothered by: Feelings of worthlessness? Poor concentration? Thoughts of death?
- 8. MANAGEMENT
- 9. Treatment options for mild-moderate-severe depression group
- 10. Treatment options for mild-moderate-severe depression group
- 11. Collaborative Care Consider referral to secondary services for: Patients with moderate or severe depression & anxiety who have not responded to initial interventions If the patient is assessed to be at high risk of suicide Self harm or self-neglect Close collaboration is required between physical health services and specialist mental health services for long-term follow-up
- 12. Jeremy Assessed by primary care services Seen by psychiatric team Referred for psychology- CBT Started on Sertraline- after discussion with cardiology team Close liaison with primary care services Jeremy started back at work after 8 months Everyone was so busy treating my heart no one stopped to think about how I was feeling…
- 13. Key Leadership Actions Early screening for depression Patients undergoing heart surgery should receive screening for anxiety and depression Accurate auditing of the numbers of patients with cardiovascular disease screened & treated for depression & anxiety Ensure local expertise for delivery of psychiatric and psychological interventions
- 14. References The Centre for Economic Performance’s Mental Health Policy G. How mental illness loses out in the NHS London: The London School of Economics and Political Science, 2012. http://www.bps.org.uk/news/how-mental-illness-loses-out-nhs. Depression with a chronic physical health problem, NICE Clinical Guideline (October 2009); The treatment and management of depression in adults with chronic physical health problems. No Health without Mental Health: the supporting evidence. www.rcpsych.ac.uk.
Notas del editor
- Good morning- I am an ACF – what that effectively means I am a psychiatrist who also does research. David Osborn is my supervisor unfot couldn’t be here this morning. He is also a clinician who does research. Today I will be speaking about the significant link b/t CVD and mental health- and what we can do to improve and manage those who have both.
- Among people under 65, nearly half of all ill health is mental. In other words, nearly as much ill health is mental illness as all physical illnesses put together. Moreover patients with long-term conditions are 2-3 x more likely to experience mental health problems. Nearly a third of all people with long-term physical conditions have a co-morbid mental health problem like depression or anxiety disorders. And research has demonstrated that mental health illness often increases the scale of physical illness-so it can make existing physical illness worse. If we think about depression specifically 10-20% of those with CVD have depression- 3 x times more than gen pop. Anxiety problems are also common in cardiovascular disease and often co-exists with depression
- This is imp not only because of QOF for the patient but also because of COST. These mental health conditions raise the costs of physical health-care by at least 45% for a wide range of conditions including cardio-vascular disease, diabetes and COPD at each level of severity, . Altogether the extra physical healthcare caused by mental illness now costs the NHS at least £10 billion.
- So what can be done? I wanted to demonstrate the effective mng and treatment of depression and anxiety in cvd by talking about Jeremy. Jeremy was a service user I met whilst work at the recovery centre – which use to be known as psychiatric day hospital. He had a heart attack a year before I met him
- Outcomes from cardiovascular care are poorer for patients with co-morbid mental health problems Cardiovascular patients with depression experience 50 % more acute exacerbations per year. Patients with depression and coronary heart disease are twice as likely to have further cardiac events, compared with patients without depression. Anxiety after heart attacks may lead to more frequent episodes of heart events, even after controlling for confounding factors including depression. Post-heart attack anxiety is one of the strongest predictors of in-hospital complications. Treating depression and anxiety in people with a chronic physical health problem has the potential to improve their quality of life, improve functioning and physical health outcomes.
- As recommended by NICE any patient who may have depression (especially those with a past history of depression or who suffer from a chronic physical illness associated with functional impairment) should be asked the following two questions : During the last month have you been feeling down, depressed or hopeless? During the last month have you often been bothered by having little interest or pleasure in doing things? If patients with a chronic physical illness answer 'yes' to either question, the following three questions should be asked. During the last month, have you often been bothered by: Feelings of worthlessness? Poor concentration? Thoughts of death?
- Conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode. Consider the role of the physical health problem and any prescribed medication in the depression. Patient Health Questionnaire (PHQ-9): this is a nine-item questionnaire which helps both to diagnose depression and to assess severity. It is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual - Fourth Edition (DSM-IV). It takes about three minutes to complete. Hospital Anxiety and Depression (HAD) Scale: despite its name, this has been validated for use in primary care. It is designed to assess both anxiety and depression. It takes about 5 minutes to complete.
- Conventional psychological and antidepressant treatments are effective at improving depression and anxiety in people with cardiovascular disease. When people with physical symptoms receive psychological therapy, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy. So while doing the right thing on mental illness, the NHS costs itself nothing. This applies much less to most other NHS expenditures. This is mainly because the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3.
- The stepped-care model provides a framework in which to organise the provision of services, and supports patients and practitioners in identifying and accessing the most effective interventions. In stepped care the least intrusive, most effective intervention is provided first. If this is not beneficial the next step up should be offered.
- Patients who have cardiovascular disease should be asked about how anxious or depressed they feel to reduce incidence of further cardiac events and improve quality of life. Patients undergoing cardiac surgery should be pre- screened and offered follow-up screening for anxiety and depression to improve overall outcomes. Effective appropriate interventions should be available and offered to those detected as having anxiety and depression in primary care and acute care settings.