ivbijaro 02
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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?