An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder
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From primary to secondary care An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder Dr. Nick Stafford, Consultant Psychiatrist, South Leicestershire [email protected] Royal College of Psychiatrists International Conference Edinburgh July 2013 g the diagnosis and management of bipolar disorder: screening, integrated care pathways and specialise
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Presented to a workshop on the challenges of detecting and diagnosing bipolar disorder at the Royal College of Psychiatrists International Conference, Edinburgh 2013.
Transcript of An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder
From primary to secondary care
An integrated care pathway for the screening, assessment and diagnosis of bipolar disorder
Dr. Nick Stafford, Consultant Psychiatrist, South [email protected]
Royal College of PsychiatristsInternational Conference
Edinburgh July 2013
W4 Improving the diagnosis and management of bipolar disorder: screening, integrated care pathways and specialised clinics
DisclosuresPharmaceuticalsAstra Zeneca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kline LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd
Private PracticeClinical Partners LtdNuffield HealthBMI HealthcareClinics in:London, Leicester, Sutton Coldfield
Previously Vice Chair Bipolar UK
Thank you
• Donna Stafford CPN/NMP• Dr. Mark McConnochie ST5• Kate Gallagher CMHT
Manager• Lynn Walters PA• Dr. Mike McHugh,
Consultant in Public Health• Dr. Shahid Hussain ST4• Dr. Julia Kestleman ST6• BPE Cymru & Beating
Bipolar
PARTNERS• Leicestershire
Partnership Trust• LLR PCT• Astra Zeneca
THIRD SECTOR• Rethink• Depression Alliance• Bipolar UK
The diagnosis of bipolar disorder
Whole systems problems
Whole systems solutions
COMPLEXDISORDER
COMPLEXSERVICES
Where bipolar is missed
Public knowledge
Primary care
Secondary psychiatric
care
Other specialist
care
Each element is complex and requires its own solutions
CAPTURE MISSED BIPOLARPREVENT UNDERDIAGNOSIS
IMPROVE DIAGNOSTIC ACCURACYPREVENT OVERDIAGNOSIS
This isn’t possible by just focusing on one elementor designed just by psychiatrists
Public Education/Professional Attitude
Praised by the public for going public Criticised by psychiatrists for going public
• Image of Angelina Jolie • Image of Catherine Zeta Jones
The philosophy of the pathway design
Apply what is known Nothing new
Engineer the parts Feedback to clinicians
Don’t be cleverA model that can be
applied anywhere
Simple appliance of science
Practical solutions in primary care
Education for everyone
Screening tool – choice, is it
used?
Always be alert (as with cancer)
Asking just a few questions
can be effective
Low level of suspicion
Collateral history from
someone close
Primary care red flags
Presenting complaint: Could it be:• Breast lump
• Blood on toilet paper
• Facial weakness
• Depression
• Breast cancer?• Bowel cancer?• CVA?• Bipolar
disorder?
The goal in primary care
“If a GP sees Depressive Disorder they should have a reflex consideration of bipolar disorder every time and ask relevant questions to probe for it”
• How do we make this happen?
Primary care education in Leicester
• Face to face large group seminars (50+)• RCGP meetings• Individual practice seminars (3-15)• All Primary HCPs invited (not just GPs)• Learn and discuss the diagnosis of bipolar• Complex case examples• How to make it work in their practice– Bespoke to their needs
Primary care screening options
• Ask more questions – But which? (e.g. BRIDGE)
• Collateral history encouraged• EMIS / Systm1 alerts– Surprisingly less popular with GPs
• Formal screen HCL-32– How useful is it in practice?– Frequency of use
• MDQ preferable?
If GP refers to the Clinic
• Standard GP letter (no forms to fill in)• HCL-32 if appropriate, not mandatory– MDQ if preferred
• Option to use the Mental Health Facilitator• Patient educated about possible bipolar• Leaflets given (pre- and post-diagnosis)• Mood diary before OPC appointment
Specialised Bipolar Clinic Model
New assessments Follow ups
Tertiary service Group and individual BPE
MDT
Elements of the Clinic 1st Assessment
Pre-Interview Questionnaire• Lengthy (up to 3 hrs.)• Patients enjoy
completing• Structure similar to
semi-structured interview
• Question based around DSM-IV criteria
Semi-Structured Interview• Detailed focus on
moods• Predominant Polarity• Bipolarity Index• Detailed medication
history• Comorbidities examined• PD screening (IPDE)
• Multi-axial DSM-IV diagnosis (DSM-5 July)
MDT• Consultant• ST4• Non-medical prescriber
• Visiting clinicians• CPN• OT (BPE)• Social Worker
• Adequate time built in for assessments and follow ups
Specialised bipolar clinic model essential to make this work
Soon to commence a parallel specialised depression clinic
Assessment elements
Comprehensive reportCopied to patient
Holistic management planTx - Medical, Psychological
Health advice, Quality information
Multi-dimensionalCo-morbidities managedDetailed risk assessment
Health & Wellbeing groupMetabolic screening
Managed with GP
Structure of South Leicestershire outpatient clinics
CMHT Outpatient
Clinic Services
Generic OPC services
NMP & CPN assessment
clinic
Bipolar specialised
clinic
Integrated depression
clinic
Funding
• Partial funding for set up from Astra-Zeneca• AZ dissolved partnership with Seroquel 2012
• No additional funding received since• ‘Verbal’ support by Trust and PCT / CCG
• Operates within resources of the CMHT• Plan to introduce into other Leicester localities
Key Conclusions
• Specialised bipolar clinic essential and possible• Whole care pathway maximizes impact• Education of primary HCPs• Structured pre-interview questionnaire• Semi-structured interview• Follow treatment guidelines (WFSBP & BAP)• Integrate into existing OPC structure• MDT approach• Continually engineer pathways and components
Media attention & public education is possible, even for a small project
