This document discusses the evidence supporting primary care mental health collaboratives. It begins by defining common mental health problems and examining their high prevalence rates. It then reviews literature showing that collaboratives have improved mental healthcare management internationally by increasing education, encouraging organizational change, and allowing reflection. The document outlines the aims and measures of the UK's National Primary Care Mental Health Collaborative, such as consultation rates, referrals to psychiatry, and sick leave durations, which aim to improve care for patients and monitor the effects of the collaborative approach.

1. PRIMARY CARE MENTAL
HEALTH
COLLABORATIVE – THE
EVIDENCE
Dr Gabriel Ivbijaro MBBS FRCGP FWACPsych MMedSci MA
Convenor WONCA Special Interest Group in
Psychiatry & Neurology
Medical Director Forest Road Medical Centre
Mental Health PMS Practice

2. AIMS
• To quantify the scale of primary care
mental health problems
• To consider the role of ‘Collaboratives’
• To review some of the evidence
supporting the use of collaboratives in
managing common mental health
problems in primary care
• To examine the rationale for some of the
measures chosen by this Collaborative
2

3. WHAT ARE COMMON MENTAL
HEALTH PROBLEMS?
• Mental health problems excluding:
– Schizophrenia,
– Bipolar disorder
– Severe depression
– Severe obsessive compulsive disorder
• The above are all disorders primary care is
not equipped to deal with
3

4. WHAT ARE SERIOUS MENTAL
HEALTH PROBLEMS (SMI)
• Safety:
– Unintentional self-harm • Disability
– Intentional self-harm (impaired ability to function
– Safety of others effectively in community):
– Abuse by others – Employment & recreation
• Informal & Formal Care: – Personal care
– Help from informal carers – Domestic skills
– Help from formal services – Interpersonal relationships
• Diagnosis: • Duration:
– Psychotic illness – 6 months to more than two
– Dementia years
– Severe neurotic illness
– Personality disorder (Building Bridges – DOH 1996)
– Developmental disorder
4

5. WHAT IS THE SCALE
OF THE PROBLEM?

6. GOLDBERG HUXLEY MODEL
Level Filter Filter description Rate
(per
1000)
1 Community (total) 250
1st Filter Illness Behaviour
2 Primary Care (total) 230
2nd Filter Ability to detect
3 Primary Care (identified) 140
3rd Filter Willingness to refer
4 Mental Illness Services 17
(total)
4th Filter Factors determining
admission
5 Mental Illness (admissions) 6
6

7. DEPRESSION
• Common psychiatric problem in primary
care worldwide
• Often under-treated
• Under-diagnosed (Ballinger et al 2001, Lecrubier 2001,
WONCA Culturally Sensitive Depression Guideline 2005)
7

8. EPIDEMIOLOGY
• Female lifetime prevalence 20-25 %
• Male lifetime prevalence 7-12%
• Deliberate self harm 10-16% (Angst 1996, Murphy
et al 1987)
• There may be cultural variation in
prevalence
– Japan 2.6%, Chile 29.5% (Goldberg & Lecrubier
1995)
8

9. WHO predict that by the
year 2020 depression will
be the second most
important cause of
disability after ischaemic
heart disease
Murray & Lopez 1997

10. ANXIETY SYNDROMES
• Many studies have shown high prevalence of
anxiety syndromes worldwide (Robinson et al 1984,
Angst & Dobler-Mikola 1985, Wittchen et al 1992)
• Common disorders:
– Generalised anxiety disorder (GAD)
– Agoraphobia
– Panic disorder
• Sufferers are heavy primary care users (Goldberg &
Huxley 1980)
• Few consult specialist services (Regier et al 1978)
• Many other ill-defined anxiety states present in
primary care 10

11. PREVALENCE &
RECOGNITION OF
ANXIETY SYNDROMES IN
FIVE EUROPEAN
PRIMARY CARE
SETTINGS
A WHO Study on Psychological
Problems in General Health Care
E. Weiller, JH Bisserbe, W. Maier & Y. Lecrubier
(1998)

12. FINDINGS
• A detailed GP community study
• Groningen, Mainz, Berlin, Manchester, Paris
• Consecutive male & female GP attendees <
65yrs old
• Screened with 12 item GHQ (General Health
Questionnaire)
• Exclusions : too ill, too far away, NFA, language
problems
• Within one week subjects underwent in-depth
testing
12

13. INSTRUMENTS & SAMPLE
• Primary Care Version of Composite International
Diagnostic Interview (CIDI WHO 1991)
• Self –rated health status (5 point scale)
• Brief Disability Questionnaire (BDQ) (Stewart et al
1988; Ware & Sherbourne 1992)
• 10 359 approached & eligible
• 9714 completed GHQ-12
• 1973 interviews in total
• Mainz lowest response rate : 36.8%
• Manchester highest response rate : 71.1%
• These results are relevant to the UK population 13

14. RESULTS
• 4.6% ANXIETY RELATED PROBLEMS
– 77.8% of these well defined psychiatric problem
– 22.2% of these ill defined psychiatric problem
– 6.7% : Sub-thresh-hold GAD
– 8.5% : GAD
– 8.8% : Agoraphobia +/- panic disorder
– 3.3% : Panic disorder
– 36.8% : Other mainly depression
14

15. SUMMARY
• Common mental health problems
occur commonly
• Primary Care is the first port of call
• We need to improve the skills of
Primary Care teams to deal with this
effectively
• Collaboratives may be one way
forward
15

16. NATIONAL PRIMARY CARE
MENTAL HEALTH
COLLABORATIVE (PCMHC)
• Aimed at supporting Primary Care in dealing
with common mental health problems
• Approx 1 in 3 people consult GP with mental
health problems
• 80% of these dealt with by Primary Care
• 30% of working age people obtain sick notes
from GP for some kind of mental illness
• Primary Care preferred option for most mental
health users and carers
16

17. KEY PRINCIPLES OF
COLLABORATIVE
• To create and validate a register for
proactive care
• To create alternative care management
and arrangements for common mental
health problems
• To support the implementation of direct
self care
17

18. AIMS OF COLLABORATIVE
• To improve the care of all working age adults
with mental health problems in Primary Care
• To identify innovative, successful mental health
practices
• To create an opportunity for multiple
stakeholders to come together to learn from
each others expertise and experience
• To adapt care pathways and NICE Guidance to
suit local needs
18

19. WHAT WILL THE
COLLABORATIVE MEASURE?
• GP consultation rates for people with common mental
health disorder electronic list
• Rates of consultation with other GP staff for common
mental health disorder electronic list
• Rate of referral to CMHT/ consultant psychiatrists for
people on common mental health electronic list
• % of people with common mental health disorders
electronic list issued Med 3, 4 & 5 totalling longer than
13 weeks
• Individual teams will be encouraged to identify and report
on local measures that are particular to their sites
19

20. ARE COLLABORATIVES
EFFECTIVE?
• To answer this question I will review:
– International literature on collaboratives
– Effect of mental illness on GP
consultation
– Effect of referral to psychiatric services
on the patient
– Mental illness and unemployment
20

21. PCMHC COLLABORATIVES -
THE PICTURE
• Extensive literature from USA, Australia,
New Zealand, Canada that this approach
is effective
• Other Primary Care Collaboratives for long
term physical conditions such as CHD,
diabetes, patient access in the UK have
also been effective
21

22. INTERNATIONAL EXAMPLES
NEW ZEALAND
• A collaborative approach to the delivery of
mental health services to juvenile offenders (2003
Hicks & McCormack)
• Lead to service re-design and staff training
• Improved levels of user satisfaction
• Increase in knowledge and confidence of staff
• Challenges encountered:
– Client confidentiality
– Sustainability
– Differing organisational goals
– Different organisational philosophies
– Tension between medical & social models
22

23. INTERNATIONAL EXAMPLES
CANADA
• Bridging with Primary Care: A shared care
mental health pilot project (2002 Isomura et al)
• Enhanced mental health care of patients in
British Columbia
• Increased GP, patient & carer satisfaction
• Addressed a number of problems
including:
– Lack of access to timely consultation
– Limited mental health services capacity
23

24. INTERNATIONAL EXAMPLE
USA
• Californian adolescent mental health
collaborative (1999)
• Reduced suicide & parasuicide rates
• Reduced teenage pregnancy & STD rates
• Reduced alcohol and substance misuse
rates
24

25. ALL THE EVIDENCE
SHOWS THAT PRIMARY
CARE COLLABORATIVES
CAN IMPROVE MENTAL
HEALTH CARE
MANAGEMENT

26. WHY DO THEY WORK?
• Lead to educational initiatives for staff
• Lead to organisational change
• Lead to culture change in individuals &
organisations
• Support self-reflection
• Encourage learning from peers
• Allow time out for reflection & refreshment
26

27. RATIONALE BEHIND OUR
CHOSEN MEASURES
Consultation Rates
• Patients with mental illness use primary
care services more than those with long
term physical conditions
• Holistic care & appropriate care planning
can reduce usage (Ivbijaro et al 2005)
27

28. EXTRA CONSULTATION PER
1000 PATIENTS 1998
Figures adjusted to account
for co-morbidity
Condition Doctors Nurses Total
Diabetes 14 51 65
Hyper tension 80 56 136
CHD 56 27 83
Ulcer healing drugs 131 12 144
Asthma/COPD 248 61 309
Antidepressants 316 16 332
28

29. EFFECT OF REFERRAL TO
PSYCHIATRIC SERVICES
• Patients prefer to be treated for mental
health problems by GP (van Boeijen et al 2005)
• Limited capacity of secondary care
settings
• Some effective treatments e.g. CBT
difficult to provide in primary care
• Primary care needs to monitor referral
rates to secondary care to better
commission appropriate services
29

30. MENTAL ILLNESS AND
EMPLOYMENT
Monitoring sick notes:
• Very important for long term conditions
• In back pain the longer you are off sick the
more likely that you will not return to work
• Mirrored by patients suffering from mental
disorder
• Useful to monitor this and link with
services that can intervene to support
people to maintain an occupational status
30