For the busy GP, recognising and treating common mental health disorders are everyday tasks. However, despite dealing with these conditions so frequently, there are many barriers for GPs and patients when it comes to case identification and access to appropriate care pathways.
The plethora of national guidelines and the range of local services, with varying exclusion criteria, can be difficult to navigate.
The aim of the new NICE guideline for common mental health disorders, which is written for primary care, is to focus on a number of areas where practical, evidence-based recommendations are needed to help break down these local and national barriers.
The key areas are identification, access, assessment, treatment and pathways to care.
Common mental health dis-orders can present in a variety of ways and consideration should be given to using depression and anxiety screening in certain cases.
GPs should be aware of patients with a past history of common mental health disorders, somatic symptoms and chronic physical health problems.
They should also be aware of the effects of any recent traumatic events in patients who may have an existing anxiety disorder.
The two question tests that are highlighted in this new guideline, the generalised anxiety disorder scale (GAD-2) and the Whooley depression screen, should be used as a priority in such cases.
GPs can use these quick and easy screening tests practically and effectively in a 10-minute consultation. Once a potential case has been identified, further assessment should be arranged.
Local barriers to access should be identified and removed. A focus on entry, rather than exclusion, criteria is recommended. The involvement of GPs in commissioning presents an opportunity for GPs to lead on the development of local, accessible, patient- centred care pathways with a strong primary care base.
This guideline provides a steer to facilitate collaborative working between primary and secondary care clinicians, managers, commissioners and patients, to produce understandable, acceptable access points. A move away from a single point of access and the expansion of access points, including self-referral, is a key recommendation.
Supporting access by understanding factors beyond the common mental health disorders themselves, such as location, opening hours and support services, such as creche facilities, should be considered.
Once a patient has been identified as having a common mental health disorder, they should be referred for further assessment. Assessments should be carried out by a practitioner who is trained to carry out a mental health assessment.
This recommendation should not been seen as a barrier but as an opportunity to increase competency within primary care and to expand the role of practitioners other than GPs to perform these assessments.
There is also a reminder that assessments should include direct questioning about suicidal ideation or intent, with a clear local pathway to access appropriate and timely care for high-risk patients.
GPs should be aware of local services available to their patients.
The guideline includes recommendations on which effective treatment types are advised for all of the common mental health disorders.
Steps 1 to 3 of the stepped care pathway are provided in tabular form in the guideline, to allow GPs a single page reference point where depression, generalised anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder all have specific recommendations.
This guideline presents an opportunity to review services that are available locally.
It also provides a hierarchy for treatments and allows a further step away from psychotropic medication being the most common treatment for common mental health disorders in primary care.
Pathways to care
In line with previous guidance, a stepped care approach is recommended.
The guideline emphasises collaborative working to improve local care pathways, with an understanding that pathways should be easy to navigate and have clear threshold criteria for each step.
Single criteria, such as symptom severity, should not be used to determine movement between steps and more flexibility should be provided to allow treatments to be tailored.
This will avoid situations where patients who do not 'fit the criteria' are denied access to care. Patient choice and past experience should be considered. In the past, overly rigid interpretation of criteria and the use of single entry criteria have led to problems for many patients.
In summary, this guideline provides two key elements for GPs.It pulls together a number of existing NICE guideline recommendations, to provide a relevant, easily used, quick reference point on best care.
It also makes new recommendations that provide tools to enable GPs to drive up the quality and consistency of care and improve the recognition of common mental health disorders.
- The NICE guideline, Common mental health disorders: identification and pathways to care, was published on 25 May 2011 and is available on the NICE website at: www.nice.org.uk/CG123
- Dr Compitus is a member of the NICE guideline development group and a GP in Southville, Bristol.