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Pathways to care

KEY MESSAGES

  1. The clinical pathway is represented by a number of steps (Figure 2). Each step defines a certain type and intensity of treatment. Patients may enter the clinical pathway at different steps depending on their initial presentation or previous history, and may be stepped up at various points during the course of their illness, depending on progress.
  2. Many patients will enter the pathway at the first or second step, and may access higher steps in order, depending on clinical need.
  3. Within steps, there are some choices patients can make about the type of treatment that suits them best.

As noted earlier, the key idea underpinning stepped care is that patients receive the least intensive intervention that is still expected to provide significant benefit to their health. This model is designed to ensure that the resources available for mental health care are able to be used to manage as many people in need as possible.

Figure 2 shows an overview of the stepped care model. There are a number of important issues to note. First, step 1 is for patients who do not require or want a specific intervention. The other steps are for increasing levels of symptoms, distress and problem complexity. It is appropriate for patients to bypass previous steps if their symptoms are severe enough, or if they had previously tried a step, but did not benefit.

However, it should be noted that the greatest benefit will be gained from stepped care if a significant proportion of patients are successfully managed at step 2. Therefore, although some patients with more moderate disorders may go direct to step 3, some may first try interventions at step 2, and only move to step 3 if they fail to benefit. The exact decision making will depend on the needs of the patient and the available resources. Nevertheless, the advantage of stepped care is that patients who fail to benefit from a more modest intervention at step 2 are identified and encouraged to try other treatments.

The main treatments used in the steps are as follows. Some of these recommendations are from published drafts of the forthcoming NICE guidance, others are based on research evidence of effectiveness, and some relate to service developments that are of particular relevance to the NES (such as the deployment of new graduate workers). It is not expected that all services will necessarily have all the proposed treatments available. Rather, this list should serve as a guide to possible treatment deliv-ery at each step.

STEP 1

Watchful waiting.
According to NICE, watchful waiting can be used with:
(a) patients who do not wish to have an intervention
(b) patients who the health professional thinks will recover without an intervention.

STEP 2

Guided self-help.
According to NICE, this involves a CBT-based self-help resource and limited support from a health care professional who:
(a) introduces the self-help programme
(b) reviews progress and outcome. Much guided self-help involves books and other written materials.

Computerised cognitive-behaviour therapy.
This might involve provision of internet or CD-Rom based materials. Some packages may function best within a guided self-help model above, while others may work without significant guidance from a health professional.

Group psycho-education. This involves a group treatment, providing information about depression, and strategies for managing it (e.g. goal planning and relaxation).

Exercise on prescription. Being physically active can assist in the recovery of depression. Exercise on prescription schemes establish links with local leisure centres to allow patients to access equipment and receive regular advice and monitoring from qualified professionals.

Signposting. This involves assessing a patient and assisting them to find an appropriate local or national voluntary organisations eg RELATE, CRUSE.

Further details of these treatments are provided in Appendix 7.

STEP 3

Brief psychological therapy. There are a number of relevant psychological therapies, including CBT and counselling. The recommended treatment is 6-8 sessions over 10-12 weeks.

Medication. Antidepressants are not generally recommended for patients in steps 1-3 because the risk/benefit ratio is poor. Medication is more commonly used from step 4 onwards. Exceptions may be made when patients have failed to benefit from other interventions at step 3 or lower steps, or where patients have a previous history of moderate to severe depression.

STEP 4

Depression case management. This involves the application of chronic disease management principles to depression. The key facets of the model are as follows:

  1. Assigning a case manager to a patient, who is supported by a specialist mental health professional, and collaborates with the GP in the care of the patient.
  2. Provision of medication and/or brief psychosocial interventions.
  3. Proactive management of the patient led by the case manager, including regular follow up (face to face contact, or by phone), and monitoring of progress.
  4. Feedback of information about treatment and progress from the case manager to the GP and mental health specialist to assist in treatment decision making in patients who fail to improve.

Given that it takes time to train and employ practice nurses or graduate workers to undertake the case management role, it is possible that this role could be undertaken by the GP in the interim. This would be acceptable as a short-term solution, but over the longer term it is necessary that a new professional take up this role, as it may not be the best use of a GPs expertise.

Most of the published studies using depression case management have involved medication, and it is expected that a significant proportion of patients at this step will be on medication. However, all patients will receive additional psychosocial support from the case manager, and it is possible for the case management approach to be used with psychosocial interventions alone, if patients do not wish to use medication. For example, a patient with a moderate to severe depression who does not wish to take medication may receive case management, with psychosocial support offered in the form of facilitated self-help or signposting to other services, as appropriate.

Appendix 8 details a number of websites with relevant resources for use in the case management approach.

Longer term CBT or IPT. For patients with more severe depression longer term specialist psychological therapy may be required. Either cognitive-behavioural therapy or interpersonal therapy may be used. NICE guidelines suggest a treatment length of 16-20 sessions.

STEP 5

Specialist treatment resistant services. A small proportion of patients will fail to improve after treatment in steps 1-4, or the severity of their problem and/or level of risk will make treatment at these steps inappropriate. In these cases there should be the option to refer to specialist/tertiary mental health services for appropriate treatment. Interventions in this step may include: medication; complex psychological treatments or ECT.

As the GP may remain actively involved in the mental health treatment (through the prescribing of medication), good working relations and protocols for regular feedback on patient progress must be developed between the GP and specialist services to aid communication.

When patients have completed their intervention in Step 5, patients should be proactively followed up in order to assess progress and make decisions about the need for further treatments. This issue is dealt with in more detail in the next chapter.