Brighton & Hove Wellbeing Service

1. Brighton & Hove Wellbeing Service Update for Localities July 2012

2. What’s going well What’s going less well how it’s going so far…

3. New organisation of mental health services Triage clinicians will advise on treatment options Primary Care Practitioners will advise on treatment options

4. Primary Care Referrals - Quick Reference Guide

5. Primary Care Referrals - Quick Reference Guide

6. Primary Care Referrals - Quick Reference Guide

7. Primary Care Referral Guidelines - Depression

8. Case Study 1 Karimis a 42 year old man from an Asian background who has been suffering from depressed mood, poor concentration and early morning wakening for approximately two months and he has come to see you, his GP, wanting to access some form of psychological support. His PHQ score is 12 and his GAD score is 8. Karim feels that work stress, as well as difficulties in his current relationship, are contributing to his low mood and he is keen to get help to help him feel better. He says that he is not keen to consider medication. He has no previous mental health history and no previous experience of psychological therapy.

9. Case Study 1 In the Wellbeing Service, most people with a PHQ score of 14 or below, and where there is no risk or significant complexity to the presentation, will be assessed by a Psychological Wellbeing Practitioner (PWP). They provide IAPT step 2 help and support. Interventions they offer include: signposting, guided self help, 1:1 behavioural interventions, workshops etc Alternatively, it may also be appropriate for the GP to offer simple supportive counselling and watchful waiting

10. Case Study 1 During the assessment, the PWP finds that it is the couple’s relationship difficulties that are a key cause of Karim’s depression. The relationship has become extremely difficult and tense over the last three months, following the death of his mother in law. The couple are committed to staying together but are struggling to work through their difficulties. This is leaving Karim, in particular, feeling very low and stressed. His PHQ score has increased to 19 although no risk issues are evident. The PWP explored whether Karim might consider IAPT Couple Therapy for Depression and Karim agreed to go home and discuss this option with his wife. His wife agreed and the PWP referred the couple on for couple therapy.

11. Case Study 1 Key learning: We offer an IAPT stepped care model so PWP assessment and interventions are offered first unless otherwise indicated.

12. Case Study 2 Angela is a 52 year old women who has a long history of bipolar disorder which has been managed by you, her GP, for the last two years. She came to the surgery last week, and was clearly much more anxious than the last time you saw her. She felt that her anxiety and agitation had started following the recent loss of her job although it was now affecting all areas of her life. She wondered whether she might be getting depressed again or whether this anxiety was specifically related to losing her job. Her GAD and PHQ scores were both 18.

13. Case Study 2 As her GP, you are unsure about whether Angela should be referred to the Wellbeing Service or the ATS. In this case, the usual course of action would be to refer Angela to your Primary Care Mental Health Practitioner for further assessment. The Practitioner conducts an assessment. As part of this assessment, the practitioner reviews Angela’s relapse prevention plan from her previous bipolar episode. From this review, it becomes clear that Angela is suffering from many of the symptoms that previously preceded a relapse in her bipolar condition. Given this, the Practitioner feels that it is appropriate to refer Angela to the ATS for assessment and review.

14. Case Study 2 Key learning: Primary Care Practitioners are your first port of call where further assessment is required. Their assessment of the person is designed to inform your decision making about the best service and intervention for the person, whether it’s within Wellbeing or within the Assessment and Treatment Service.

15. Case Study 3 Michael is a 24 year old veteran who has been suffering from acute anxiety, flashbacks to traumas in the military and significant depression for some six to eight months since his discharge from the military. He also regularly admits to binge drinking as a way of coping with his symptoms. He also describes significant obsessional behaviours and rituals that he also follows to help him to feel less anxious. A quick exploration of his history reveals a difficult and disruptive early childhood where he was taken into care at the age of six. He says his early childhood was ‘very difficult’. He is currently sleeping on a friend’s floor and has no fixed abode. He describes having thoughts of suicide (‘I’d probably hang myself’ he said) although he had no current intent to act on this plan. ‘I think about it more when drunk’ he said. He admitted to sometimes getting himself into trouble when he binged. He said he felt desperate now and that he couldn’t carry on in this way for much longer.

16. Criteria for the Assessment and Treatment Service Patients should be referred directly to the Assessment and Treatment Service ATS) when one or more of the following criteria are met: Severe and complex mental health presentations For example, this could be someone who is experiencing a relapse of their psychosis, someone with several coexisting mental health conditions requiring psychiatric assessment and multi-disciplinary treatment, or someone with multiple health, mental health and social care needs. A high PHQ9 / GAD score is not in isolation a reason to refer to the ATS. Significant impact on functioning requiring the support of a multi-disciplinary team The patient will be significantly disabled by their condition (for example loss of work, social isolation or risk of self neglect) and would benefit from a review by a multi-disciplinary mental health team.

17. Criteria for the Assessment and Treatment Service Significant risk The patient is at significant risk of hurting themselves or other people, or at severe risk of self neglect or neglect of dependents. Where suicidal ideation is present, patients would have a specific plan of action and an intention to act on that plan, or be at risk of impulsive actions that could result in a suicidal act. Requiring assessment for dementia Patients require a specific assessment for suspected dementia or memory difficulties that may be associated with dementia.

18. Case Study 4 Jane presents with moderate symptoms of depression (PHQ 18, GAD 9). She describes the onset of her depression as being linked to a recent period of heightened conflict with her partner which led to the eventual breakdown of the relationship and to their eventual separation. Jane adds that she has been in a same sex relationship and that issues around her sexuality had been very distressing for her whilst she were growing up. Jane has been depressed before and is willing to begin a course of medication as this has been helpful in the past. However, she also wants to access some psychological therapy as she did not access this last time and she thinks it might be helpful. Jane seems able to reflect openly on her difficulties and appears psychologically minded.

19. Case Study 4 Learning point: The nature of the referral, Jane’s expressed wish for therapy, her psychological mindedness and the fact that she has a PHQ score above 15, means that a direct referral to the talking therapies service is appropriate.

20. Key Messages • Talk to your Practitioner and to ATS triage clinicians when you are unsure • The new configuration of mental health services is designed to deliver the IAPT stepped care model to a greater proportion of Brighton and Hove patients • ………….