National Institute for Health and Clinical Excellence (NICE)
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New NICE guidance to help millions with common mental health disorders
Common mental health disorders can affect up to 15% of the population at any one time. They account for one in five of all work days lost and cost UK employers £25bn each year. Common mental health disorders include depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and social anxiety disorder.
This new NICE guideline on the identification of and pathways to care for common mental health disorders focuses on primary care. It draws on existing NICE guidelines and makes new recommendations on how patients are assessed, and when and how they are referred to other services for treatment. The guideline also provides clear advice to managers and commissioners on how to develop referral and care pathways in their local area.
Professor Stephen Pilling, Director, National Collaborating Centre for Mental Health, and Director, Centre for Outcomes Research and Effectiveness, University College London, said: "This guideline will ensure that effective treatments are made available to people with depression and a range of anxiety disorders. This is important because, untreated, the outcomes of these conditions are serious. For example, depression is the commonest cause of suicide in this country. But if people receive appropriate treatment, as outlined in this guideline, they get better."
RCGP Chair Dr Clare Gerada said: "GPs can see patients with two, three or four different conditions and while we have a myriad of guidance, it can be difficult to know where to start. The new NICE resource is really helpful as it lists the various common mental health disorders all on one page for easy reference and brings together existing guidelines. It also gives advice on what to treat first, for example, if you have a patient with anxiety as well as depression. We are really pleased that NICE is listening to GPs and producing practical guidance that can be easily adopted for the benefit of patients."
Paul Farmer, Chief Executive of the mental health charity Mind, said: "One in four people will experience a mental health problem every year and yet huge numbers do not receive the help or support they need for their distress, often because their symptoms are not picked up on or the treatment they need is not available. Receiving a diagnosis and following this up with the right type of care can be key in determining whether someone progresses towards recovery or whether their mental health further deteriorates.
"I sincerely hope that healthcare professionals and commissioners put these guidelines to good use as a one stop shop reference tool for primary mental health care. Accurate identification and effective treatment of common mental health problems can minimise the chances of people needing more in depth and costly treatment further down the line."
Recommendations from the new guideline include:
Improving access to services
Primary and secondary care clinicians, managers and commissioners should collaborate to develop local care pathways that promote access to services for people with common mental health disorders by: supporting the integrated delivery of services across primary and secondary care; focusing on entry and not exclusion criteria; having multiple means (including self-referral) to access the service.
Be alert to possible depression (particularly in people with a past history of depression, possible somatic symptoms 1 of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions: 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? If a person answers ‘yes' to either of the above questions, consider depression and follow the recommendations for assessment.
Be alert to possible anxiety disorders (particularly in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or in those who have experienced a recent traumatic event). Consider asking the person about their feelings of anxiety and their ability to stop or control worry, using the 2-item Generalized Anxiety Disorder scale. 2
Developing local care pathways
Primary and secondary care clinicians, managers and commissioners should work together to design local care pathways that promote a stepped-care model of service delivery that: provides the least intrusive, most effective intervention first; does not use single criteria such as symptom severity to determine movement between steps; monitors progress and outcomes to ensure the most effective interventions are delivered and the person moves to a higher step if needed.
Primary and secondary care clinicians, managers and commissioners should work together to ensure effective communication about the functioning of the local care pathway. There should be protocols for: sharing and communicating information with people with common mental health disorders, and where appropriate families and carers, about their care; sharing and communicating information about the care of service users with other professionals (including GPs); communicating information between the services provided within the pathway.
Professor Tony Kendrick, Professor of Primary Care and Dean, Hull York Medical School, and General Practitioner, Hull Primary Care Trust and Chair of the Guideline Development Group (GDG), said: "The costs of common mental health disorders are very high. They are estimated to cause one in five days lost from work in Britain. There are existing problems with identification of people with the disorders and with access to primary and secondary care. At present GPs have to consult several different disorder-specific guidelines when presented with patients with these problems, which makes it difficult to access the relevant information. There is also a need for greater clarity around the indications for treatment and referral and a more systematic approach to organising care pathways, including the consideration of 'stepped care' and 'collaborative care'.
"This new guideline can be used by GPs as a handy guide to initial identification and referral, with quick reference points to the disorder-specific guidelines for details of treatment."
Barbara Compitus, General Practitioner, Southville, Bristol said: "Recognising and treating common mental health disorders is an everyday task for GPs. 90% of common mental health disorders are treated in primary care and over a third of GP time is spent helping people with mental health problems.
"Because patients present in diverse ways GPs need practical and accessible tools to further increase recognition of common mental health disorders. This guideline delivers these tools and will enable GPs to drive up the quality and consistency of care provided."
Mr Terence Lewis, member of the GDG with personal experience of mental health problems, and Deputy Chair of the Commission to Review Mental Health Services in the Northwest of England, said: "Those of us who experience common mental illness do get better, but it can be a devastating experience. We look to our GP to help us make some sense of what's wrong and help us choose the best treatment available that will help us.
"This guidance will help GPs do their job - and it's not an easy job. It will also ensure patients can discuss the help they may need, and choose from a proven range of options, including talking therapies, exercise regimes and medication."
Val Moore, Implementation Programme Director at NICE, said:"NICE guidance aims to promote good health and equal access to healthcare across the country, which is why it is so important that the recommendations made are put into practice to benefit everyone.
"Our implementation team works with the NHS, local authorities, private and voluntary sectors, and the wider public to produce both generic implementation advice and tailored implementation tools to accompany each new set of NICE guidance to help ensure NICE guidance is put into practice. NICE has developed a range of tools for our full suite of mental health guidance, which are all available on the NICE website."
Notes to Editors
1 Somatic symptoms are physical symptoms of common mental health disorders, which form part of the cluster of symptoms that are necessary for achieving a diagnosis. They may include palpitations or muscular tension in an anxiety disorder or lethargy and sleep disturbance in depression. In some cases they may be the main symptom with which a person first presents; they do not constitute a separate diagnosis and should be distinguished from somatoform disorders and medically unexplained symptoms.
2 The GAD-2 is a short screening tool used to assess anxiety
About the guidance
1. The guidance will be available on the NICE website (www.nice.org.uk/guidance/CG123) from 25 May, 2011.
2. Further information about the NICE implementation team can be found on the website at www.nice.org.uk/usingguidance/.
3. Further comments supporting this guideline can be found below.
4. Generalised anxiety disorder (GAD) is a common condition that can be recognised by chronic, excessive worry about a number of different events associated with heightened tension. GAD can vary in its severity and complexity for each person, and for this reason it is very important to consider how each patient should be treated individually.
5. Social phobia or social anxiety disorder is a fear of social situations, such as weddings, or performing in social situations, such as public speaking. People with a social phobia have a fear of embarrassing themselves or of being humiliated in public.
6. Since 2004, NICE has produced a series of guidelines on the care and treatment of common mental health disorders:
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) www.nice.org.uk/guidance/CG115
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults (2011). www.nice.org.uk/guidance/CG113
Depression in adults with a chronic physical health problem: treatment and management (2009). www.nice.org.uk/guidance/CG91
Depression: the treatment and management of depression in adults (2009). www.nice.org.uk/guidance/CG90
Promoting mental wellbeing through productive and healthy working conditions: guidance for employers (2009). www.nice.org.uk/guidance/PH22
Drug misuse: psychosocial interventions (2007) www.nice.org.uk/guidance/CG51
Drug misuse: opioid detoxification (2007). www.nice.org.uk/guidance/CG52
Antenatal and postnatal mental health (2007) www.nice.org.uk/guidance/CG45
Computerised cognitive behaviour therapy for depression and anxiety (2006). www.nice.org.uk/guidance/TA97
Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (2005). www.nice.org.uk/guidance/CG31
Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care (2005). www.nice.org.uk/guidance/CG26
Quality standard on depression in adults: http://www.nice.org.uk/guidance/qualitystandards/depressioninadults/home.jsp
NICE Pathway on depression: http://pathways.nice.org.uk/pathways/depression
Under development: Social anxiety disorder: diagnosis and treatment. NICE clinical guideline. Publication expected 2013.
Further support for the NICE clinical guideline on Common mental health disorders
Marjorie Wallace, chief executive of the mental health charity SANE said: "It is so easy to neglect mental health problems which, if they go unrecognised and untreated, can become serious illness. For the first time doctors, mental health workers and the general public will be able to find information, direction and the most effective ways we currently have available to understand, accept and treat conditions which may have been underplayed in the past, but nevertheless in our experience can cause great and often hidden distress."
Nicky Lidbetter, Anxiety UK CEO, said: "Anxiety UK applauds the new clinical guideline on the identification and pathways to care for common mental health disorders. Our experience, and that of our members, has taught us that it is imperative conditions such as anxiety and depression are detected early to ensure access to timely and appropriate treatment interventions to give people the best possible chance of managing their condition long-term."
Professor Dinesh Bhugra, President of the Royal College of Psychiatrists, said: "We welcome this much-needed new guideline on common mental health disorders, and are very pleased to have been part of its development. Common mental health disorders will affect 1 in 6 of us at some point in our lives, and the vast majority of people will be treated in primary care. Based on the most recent evidence, this guidance provides both primary care professionals and psychiatrists with the information they need to provide the best possible care."
Dr Olivia Carlton, President of the Society of Occupational Medicine said: "Mental health problems such as stress, anxiety and depression are the biggest cause of sickness absence in the UK. We need to remove the stigma associated with these conditions. They are very common and many people will experience one or more periods of this type of illness during their life or live and work with others who are affected. By following this new guidance we can reduce the economic cost and and personal suffering that these conditions cause."