Extracts From and A Link To COMMON MENTAL HEALTH DISORDERS: THE NICE GUIDELINE ON IDENTIFICATION AND PATHWAYS TO CARE, 2011

COMMON MENTAL HEALTH DISORDERS: THE NICE GUIDELINE ON IDENTIFICATION AND PATHWAYS TO CARE, 2011, full text html, full text pdf.

[This post consists of extracts from the above book]

“This guideline is concerned with the care and treatment of people with a common mental health disorder, including depression, generalised anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). It makes recommendations about the delivery of effective identification, assessment and referral for treatment in primary care.”

“A number of treatments exist for common mental health disorders. However, because this guideline is predominantly interested in the identification and assessment of these conditions, the treatments will only be discussed briefly. For more information, please see the relevant guideline (see Section 2.1).”

“In summary, common mental health disorders are associated with a range of symptoms that can lead to significant impairment and disability, and high costs both for the individual with the disorder and for society as a whole.

Effective treatments are available that differ depending on the disorder. As a result, early detection, assessment and intervention are key priorities for any healthcare system. This guideline, which is focused on primary care, will provide recommendations on how to best identify and assess common mental health disorders and the key indicators for treatment in order to help improve and facilitate access to care, and the route through care.”

Please Note:

“This guideline does not cover interventions to treat the disorders and should be used in conjunction with other relevant NICE guidelines, which give evidence of the effectiveness of interventions for the specific disorders, including drug treatments and psychological therapies:

Self-harm: the Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care (NICE, 2004c; NCCMH, 2004b).
Obsessive-compulsive Disorder (NICE, 2005a; NCCMH, 2006).
Post-traumatic Stress Disorder (PTSD) (NICE, 2005b; NCCMH, 2005).
Antenatal and Postnatal Mental Health (NICE, 2007a; NCCMH, 2007).
Depression (NICE, 2009a; NCCMH, 2010b).
Depression in Adults with a Chronic Physical Health Problem (NICE, 2009b; NCCMH, 2010a).
Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults (NICE, 2011a; NCCMH, 2011a).
Self-harm: Longer-Term Management (NICE, 2011c; NCCMH, forthcoming). A NICE guideline on social anxiety disorder is expected in 2013.”
Social anxiety disorder: recognition, assessment and treatment of social anxiety disorder, Web Guideline, Full Text pdf.

1.2.4 The structure of this guideline

“The guideline is divided into chapters, each covering a set of related topics. The first three chapters provide a summary of the clinical practice and research recommendations, a general introduction to guidelines and the topic, and to the methods used to develop this guideline. Chapter 4 to Chapter 7 provide the evidence that underpins the recommendations.”

2.2.2 Incidence and prevalence

“In the US, Kessler and colleagues conducted the National Comorbidity Survey, a representative household interview survey of 9,282 adults aged 18 years and over, to estimate the lifetime (Kessler et al., 2005a) and 12-month (Kessler et al., 2005b) prevalence rates of mental disorders classified using the Diagnostic and Statistical Manual of Mental Disorders (4th text-revision version; DSM-IV-TR) of the American Psychiatric Association (APA, 2000). A summary of their findings can be seen in Table 1. Of the 12-month cases in the US National Comorbidity Survey, 22.3% were classified as serious, 37.3% as moderate and 40.4% as mild. Fifty-five per cent carried only a single diagnosis, 22% two diagnoses and 23% three or more diagnoses. Latent class analysis identified three highly comorbid classes representing 7% of the population, and the authors concluded that, although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of people with high comorbidity (Kessler et al., 2005b).”

“In summary, at any given time common mental health disorders can be found in around one in six people in the community, and around half of these have significant symptoms that would warrant intervention from healthcare professionals. Most have non-specific mixed anxiety and depressive symptoms, but a proportion have more specific depressive disorder or anxiety disorders including panic disorder, phobias, OCD or PTSD.”

Table 1 Summary of prevalence rates for common mental health disorders

Disorder	Prevalence estimates	Reference

Major depression	4 to 10% (worldwide)	Waraich and colleagues (2004)
	6.7% (12-month)	Kessler and colleagues (2005b)
	16.6% (lifetime)	Kessler and colleagues (2005a)

Dysthymia	2.5 to 5% (worldwide)	Waraich and colleagues (2004)
	1.5% (12-month)	Kessler and colleagues (2005b)
	2.5% (lifetime)	Kessler and colleagues (2005a)

GAD	3.1% (12-month)	Kessler and colleagues (2005b)
GAD	5.7% (lifetime)	Kessler and colleagues (2005a)

Panic disorder	2.7% (12-month)	Kessler and colleagues (2005b)
Panic disorder	4.7% (lifetime)	Kessler and colleagues (2005a)

Agoraphobia without panic disorder	0.8% (12-month)	Kessler and colleagues (2005b)
Agoraphobia without panic disorder	1.4% (lifetime)	Kessler and colleagues (2005a)

Phobia (specific)	8.7% (12-month)	Kessler and colleagues (2005b)
Phobia (specific)	12.5% (lifetime)	Kessler and colleagues (2005a)

Social anxiety disorder	6.8% (12-month)	Kessler and colleagues (2005b)
Social anxiety disorder	12.1% (lifetime)	Kessler and colleagues (2005a)

OCD	1.0% (12-month)	Kessler and colleagues (2005b)
OCD	1.6% (lifetime)	Kessler and colleagues (2005a)

PTSD	1.5% to 1.8% (1-month)	Andrews and colleagues (1999)
	1.3 to 3.6% (12-month)	Creamer and colleagues (2001) and Narrow and colleagues (2002)
	6.8% (lifetime)	Kessler and colleagues (2005a)

2.3.1 Pharmacological treatments

Depression

There is a wide range of antidepressant drugs available for people with depression. These can be grouped into tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors and a range of other chemically unrelated antidepressants (British National Formulary [BNF] 59; British Medical Association & the Royal Pharmaceutical Society of Great Britain, 2010).

Generalised anxiety disorder

Placebo-controlled trials indicate that a wide range of drugs with differing pharmacological properties can be effective in the treatment of GAD (Baldwin et al., 2005). In recent years, antidepressant medications such as SSRIs have been increasingly used to treat GAD (Baldwin et al., 2005).

Conventional antipsychotic drugs and the newer ‘atypical’ antipsychotic agents have also been used in the treatment in GAD, both as a sole therapy and as an ‘addon’ to SSRI therapy when the latter has proved ineffective (Pies, 2009). However, the greater side-effect burden of antipsychotic drugs means that presently their use is restricted to people with refractory conditions, with prescribing being guided by secondary care physicians.

Panic disorder

There is evidence to support the use of pharmacological intervention in the treatment of panic disorder, in particular with SSRIs. When a person has not responded to an SSRI, other related antidepressants may be of benefit. There is little good evidence to support the use of benzodiazepines. In contrast to a number of other depressive and anxiety disorders, there is little evidence to support the use of pharmacological and psychological interventions in combination.

Obsessive-compulsive disorder

Pharmacological investigations have demonstrated effectiveness in OCD, in particular with SSRIs and related antidepressants (Montgomery et al., 2001; Zohar & Judge, 1996) for moderate to severe presentations, especially if the problem has a chronic course; this may be in combination with psychological interventions.

Post-traumatic stress disorder

At present there is no conclusive evidence that any drug treatment helps as an early intervention for the treatment of PTSD-specific symptoms (NCCMH, 2005). However, for people who are acutely distressed and may be experiencing severe sleep problems, consideration may be given to the use of medication. Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy. Drug treatments should be considered for the treatment of PTSD in adults when a person with the disorder expresses a preference not to engage in a trauma-focused psychological treatment. The SSRI paroxetine is the only drug with a current UK product licence for PTSD.

2.3.2 Psychological treatments

Depression

Effective psychological treatments for depression identified in the NICE Depression guideline (NICE, 2009a) include: cognitive behavioural therapy (CBT), behavioural activation, interpersonal therapy (IPT), behavioural couples therapy and mindfulness-based cognitive therapy. For moderate to severe disorders these are often provided in conjunction with antidepressants. For subthreshold and milder disorders, structured group physical activity programmes, facilitated self-help and CCBT are effective interventions.

Generalised anxiety disorder

Cognitive and behavioural approaches are the treatments of choice for GAD. People who have moderate to severe disorder, particularly if the problem is long-standing, should be offered CBT or applied relaxation. For those with milder and more recent onset disorders, two options are available: facilitated or non-facilitated self-help based on CBT principles and psychoeducational groupsalso based on CBT principles.

Panic disorder

Cognitive and behavioural approaches are again the treatments of choice for panic disorder. People who have a moderate to severe GAD, particularly if it is longstanding, should receive between 7 and 14 hours of therapist-provided treatment over a 4-month period. For those with milder and more recent onset GAD, facilitated or non-facilitated self-help based on CBT principle are efficacious treatments.

Obsessive-compulsive disorder

CBT is the most widely used psychological treatment for OCD in adults (Roth & Fonagy, 2004). The main CBT interventions that have been used in the treatment of OCD are exposure and response prevention (ERP) (for example, Foa & Kozak, 1996; Marks, 1997), different variants of cognitive therapy (Clark, 2004; Freeston et al., 1996; Frost & Steketee, 1999; Krochmalik et al., 2001;Rachman, 1998, 2002 and 2004; Salkovskis et al., 1999; van Oppen & Arntz, 1994; Wells, 2000), and a combination of ERP and cognitive therapy (see Kobak et al., 1998; Roth & Fonagy, 2004). ERP and cognitive therapy have different theoretical underpinnings, but may be used together in a coherent package.

Post-traumatic stress disorder

General practical and social support and guidance about the immediate distress and likely course of symptoms should be given to anyone following a traumatic incident. Trauma-focused psychological treatments are effective for the treatment of PTSD, either trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR). These treatments are normally provided on an individual outpatient basis and are effective even when considerable time has elapsed since the traumatic event(s).

2.4 IDENTIFICATION, ASSESSMENT AND PATHWAYS TO CARE

Figure 1Levels and filters model of the pathway to psychiatric care (adapted from Goldberg & Huxley, 1992)

Case identification

The fact that common mental health disorders often go undiagnosed among primary care attenders has led to suggestions that clinicians should systematically screen for hidden disorders. However, general screening is not without its problems and is currently not recommended in most countries, including the UK. Instead, targeted case identification, which involves screening a smaller group of people known to be at higher risk based on the presence of particular risk factors, may be a more useful method of improving recognition of psychological disorders in primary care.

Whooley and colleagues (1997) found that two questions were particularly sensitive in identifying depression:

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?

The current NICE Depression guideline (NICE, 2009a) recommends that GPs be alert to possible depression in at-risk patients and consider asking the above Whooley questions when depression is suspected. If the person screens positive, further follow-up assessments should then be considered. Currently, no equivalent Whooley questions have been recommended for anxiety.

The view of the GDG for this guideline was that the development of separate case identification questions for each type of anxiety disorder would very likely be impractical and have no utility for routine use in primary care. The preference was to explore the possibility of a small number of case identification questions with general applicability for a range of anxiety disorders. A potentially positive response would then prompt a further assessment. This is dealt with in Chapter 5.

Assessing severity of common mental health disorders: definitions

Assessing the severity of common mental health disorders is determined by three factors: symptom severity, duration of symptoms and associated functional impairment (for example, impairment of vocational, educational, social or other functioning).

Mild

generally refers to relatively few core symptoms (although sufficient to achieve a diagnosis), a limited duration and little impact on day-to-day functioning.

Moderate

refers to the presence of all core symptoms of the disorder plus several other related symptoms, duration beyond that required by minimum diagnostic criteria, and a clear impact on functioning.

Severe

refers to the presence of most or all symptoms of the disorder, often of long duration and with very marked impact on functioning (for example, an inability to participate in work-related activities and withdrawal from interpersonal activities).

Persistent subthreshold

refers to symptoms and associated functional impairment that do not meet full diagnostic criteria but have a substantial impact on a person’s life, and which are present for a significant period of time (usually no less than 6 months and up to several years).5 CASE IDENTIFICATION AND FORMAL ASSESSMENT

5.2.11 Recommendations

5.2.11.1.

Be alert to possible depression (particularly in people with a past history of depression, possible somatic symptoms of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions, specifically:

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 (see Section 5.3.8)15.

5.2.11.2.

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 (GAD-2; see Appendix 13).

If the person scores three or more on the GAD-2 scale, consider an anxiety disorder and follow the recommendations for assessment (see Section 5.3.8).
If the person scores less than three on the GAD-2 scale, but you are still concerned they may have an anxiety disorder, ask the following: ‘Do you find yourself avoiding places or activities and does this cause you problems?’. If the person answers ‘yes’ to this question consider an anxiety disorder and follow the recommendations for assessment (see Section 5.3.8).

5.2.11.3.

For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer16 and/or asking a family member or carer about the person’s symptoms to identify a possible common mental health disorder. If a significant level of distress is identified, offer further assessment or seek the advice of a specialist.156 FURTHER ASSESSMENT OF RISK AND NEED FOR TREATMENT, AND ROUTINE OUTCOME MONITORING6.1 INTRODUCTIONThis chapter is focused on the further assessment and decision making that follows on from an initial assessment, the primary purpose of which is to identify and characterise the nature of the presenting problem, as discussed in Chapter 5. A further task of this chapter is to advise on how the information gained from the assessment can be used to inform the choice of appropriate treatment.

Finally, this chapter considers ROM (Routine Outcome Monitoring) and the role it has to play in the delivery of effective interventions for people with common mental health disorders.

6.3.8 Recommendations

Table 35 Step 2 treatment and referral advice

Disorder	Psychological interventions	Pharmacological interventions	Psychosocial interventions
Depression – persistent subthreshold symptoms or mild to moderate depression	Offer or refer for one or more of the following low-intensity interventions: individual facilitated self-help based on the principles of CBT CCBT a structured groupphysical activity programme a group-based peer support (self-help) programme (for those who also have a chronic physical health problem) non-directive counsellingdelivered at home (listening visits) (for women during pregnancy or the postnatal period)a,b,c.	Do not offer antidepressants routinely but consider them for, or refer for an assessment, people with: initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)or subthreshold depressive symptoms or mild depression that persist(s) after other interventionsor a past history of moderate or severe depression or mild depression that complicates the care of a physical health problema,b.	Consider: informing people about self-help groups, support groups and other local and national resources educational and employment support servicesa.
GAD – that has not improved after psychoeducation and active monitoring in Step 1	Offer or refer for one of the following low-intensity interventions: individual non-facilitated self-help individual facilitated self-help psychoeducational groups d.	N/A
Panic disorder – mild to moderate	Offer or refer for one of the following low-intensity interventions: individual non-facilitated self-help individual facilitated self-help.	N/A
OCD – mild to moderate	Offer or refer for individual CBT including ERP of limited duration (typically up to 10 hours), which could be provided using self-help materials or by telephone or Refer for group CBT (including ERP)e,f.	N/A
PTSD – including mild to moderate PTSD	Refer for a formal psychological intervention (trauma-focused CBTor EMDR)g.	N/A	Consider: informing people about support groups and other local and national resources educational and employment support servicesa.
All disorders – women planning a pregnancy, during pregnancy or following pregnancy who have subthreshold symptoms that significantly interfere with personal and social functioning	For women who have had a previous episode of depression or anxiety, consider providing or referring for individual brief psychological treatment (four to six sessions), such as IPT or CBTc. Women requiring psychological interventions during pregnancy or the postnatal period should be seen for treatment within 1 month of (and no longer than 3 months from) initial assessmentc.	When considering drug treatments for women who are pregnant, breastfeeding or planning a pregnancy, consult Antenatal and Postnatal Mental Health (NICE, 2007a) for advice on prescribing.	For women who have not had a previous episode of depression or anxiety, consider providing or referring for social support during pregnancy and the postnatal period; such support may consist of regular informal individual or group-based supportc.

a Adapted from Depression (NICE, 2009a).
b Adapted from Depression in Adults with a Chronic Physical Health Problem (NICE, 2009b).
c Adapted from Antenatal and Postnatal Mental Health (NICE, 2007a).
d Adapted from Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults (NICE, 2011a).
e Adapted from Obsessive-compulsive Disorder (NICE, 2005a).
f Group formats may deliver more than 10 hours of therapy.
g Adapted from Post-traumatic Stress Disorder (NICE, 2005b).

Table 36 Step 3 treatment and referral

Disorder	Psychological or pharmacological interventions	Combined and complex interventions	Psychosocial interventions
Depression – persistent subthreshold depressive symptoms or mild to moderate depression that has not responded to a low-intensity intervention	Offer or refer for: antidepressant medication or a psychological intervention (CBT, IPT,behavioural activation or behavioural couples therapy)a. For people who decline the interventions above, consider providing or referring for: counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression short-term psychodynamic psychotherapyfor people with mild to moderate depressiona. Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depressiona.	N/A	Consider: informing people about self-help groups, support groups and other local and national resources befriending or a rehabilitation programme for people with long-standing moderate or severe disorders educational and employment support servicesa.
Depression – moderate or severe (first presentation)	See combined and complex interventions column	Offer or refer for a psychological intervention (CBT or IPT) in combination with an antidepressanta.
Depression – moderate to severe depression and a chronic physical health problem	See combined and complex interventions column	For people with no, or only a limited, response to psychological or drug treatment alone or combined in the current or in a past episode, consider referral to collaborative care b.
GAD – with marked functional impairment or non-response to a low-intensity intervention	Offer or refer for one of the following: CBT or applied relaxation or if the person prefers, drug treatmentc.	N/A
Panic disorder – moderate to severe (with or without agoraphobia)	Consider referral for: CBT or an antidepressant if the disorder is long-standing or the person has not benefitted from or has declined psychological interventionsc.	N/A	Consider: informing people about self-help groups, support groups and other local and national resources befriending or a rehabilitation programme for people with long-standing moderate or severe disorders educational and employment support servicesa.
OCD – moderate or severe functional impairment, and in particular where there is significant comorbidity with other common mental health disordersd	For moderate impairment, offer or refer for: CBT (including ERP) or antidepressant medicatione.	For severe impairment, offer or refer for: CBT (including ERP) combined with antidepressant medication and case managemente,f.
	Offer home-based treatment where the person is unable or reluctant to attend a clinic or has specific problems (for example, hoarding)e.
PTSD	Offer or refer for a psychological intervention (trauma-focused CBT or EMDR). Do not delay the intervention or referral, particularly for people with severe and escalating symptoms in the first month after the traumatic eventg. Offer or refer for drug treatment only if a person declines an offer of a psychological intervention or expresses a preference for drug treatmentg.	N/A	Consider: informing people about support groups and other local and national resources befriending or a rehabilitation programme for people with long-standing moderate or severe disorders educational and employment support servicesa.

a Adapted from Depression (NICE, 2009a).
b Adapted from Depression in Adults with a Chronic Physical Health Problem (NICE, 2009b).
c Adapted from Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults (NICE, 2001a).
d For people with long-standing OCD or with symptoms that are severely disabling and restrict their life, consider referral to a specialist mental health service.
e Adapted from Obsessive-compulsive Disorder (NICE, 2005a).
f For people with OCD who have not benefitted from two courses of CBT (including ERP) combined with antidepressant medication, refer to a service with specialist expertise in OCD.
g Adapted from Post-traumatic Stress Disorder (NICE, 2005b).

6.4 ROUTINE OUTCOME MONITORING

6.4.1 Introduction

ROM has increasingly become a part of mental healthcare. Within the field of psychological therapies, recent developments in the IAPT programme led by the Department of Health (CSIP [Care Services Improvement Partnership] Choice and Access Team, 2007) have placed considerable emphasis on ROM.

Table 37 Principles and benefits of outcome measurement (IAPT, 2010)

Principles
The primary purpose of outcome measurement is to improve people’s experience and benefits from the service and is part of ongoing, collaborative service evaluation, with feedback from patients at its heart. Outcomes feedback to clinicians helps improve the quality of their interventions. Outcomes feedback to supervisors supports case reviews and collaborative treatment planning. Routinely collected outcomes data helps managers and commissioners of services to respond to diverse needs, and monitor and improve overall service performance. Intelligent use of aggregate outcomes data aims to define best practice models of service delivery. The requirement for data collection should be proportionate to the treatment being offered, and integrated with clinical priorities.
Benefits
People chart their progress towards recovery and see at what point their psychometric score falls within the normal range. Therapists and supervisors, and the clinical team, can chart progress and adjust treatment plans, if the feedback indicates the current plan is not working. Clinicians can check performance against their peers to keep their skills up to date. Service managers can use an outcomes framework to manage performance and improve quality, helping commissioners ensure contracts are providing good value for money. Local, regional and national leads will benefit from having accurate, comprehensive outcomes data being fed in to the policy-making system, helping drive up standards by setting benchmarks as well as improving whole system care pathways and future resource planning. 6.4.5 Clinical evidence summary The evidence shows that across a range of methods used to monitor outcomes, frequent ROM can have benefits (albeit of a limited size) on the short-term mental health outcomes for service users. There is, however, limited evidence on the long-term impact on mental health outcomes. There was also evidence that feedback could not only improve a mental health outcome for individual service users but also might do so through an impact on healthcare professional behaviour. This is in line with emerging evidence from the IAPT programme (Clark et al., 2009). 6.4.7 From evidence to recommendations The primary aim of the use of ROM in healthcare is to improve outcomes for service users. The studies reviewed in this section clearly demonstrated that ROM and feedback to clinicians resulted in improved outcomes for services users in both RCTs and high-quality observational studies. The GDG in developing its recommendations was also mindful of current developments in the NHS, for example in the QOF (British Medical Association and NHS Employers, 2006) and the National Quality Standards46 that are in development for secondary care for mental health services. Both of these programmes promote the use of measures, such as the PHQ-9, HADS and GAD-7, which by their structure and design lend themselves to ROM. These measures also have the advantage of reasonable psychometric properties, are free to use and are feasible for everyday use. With this in mind, and also taking into consideration the impact of routine feedback, the GDG decided to support ROM, for the benefits it may bring both to the individual patients and to the information it may supply about the overall effectiveness of local care pathways. Therefore, the GDG recommended the adoption of sessional ROM using measures already in place in the NHS, but with flexibility for individual practitioners to draw on a range of other formal assessment measures that have good psychometric properties and are feasible for routine use. 6.4.8 Recommendations 6.4.8.1. Primary and secondary care clinicians, managers and commissioners should work together to design local care pathways that have robust systems for outcome measurement in place, which should be used to inform all involved in a pathway about its effectiveness. This should include providing: * individual routine outcome measurement systems effective electronic systems for the routine reporting and aggregation of outcome measures effective systems for the audit and review of the overall clinical and cost effectiveness of the pathway. 6.4.9 Research recommendations 6.4.9.1. In people with a common mental health disorder, what is the clinical utility of routine outcome measurement and is it cost effective compared with standard care? (See Appendix 11 for further details.) 7 SYSTEMS FOR ORGANISING AND DEVELOPING LOCAL CARE PATHWAYS: 7.1 INTRODUCTION It has long been argued that the effective and efficient organisation of healthcare systems is associated with better outcomes, and much of the effort of managers and funders of healthcare is focused on the re-organisation of healthcare systems. Unfortunately, few of these re-organisations have been subject to formal evaluation so the benefits that may have followed from this process have been difficult to quantify and, in the absence of accurate description, difficult to replicate. Although this has led to considerable uncertainty about the best methods by which to organise healthcare systems, in recent years a consensus has emerged to support the development of clinical care pathways as one model for doing this (Vanhaecht et al., 2007; Whittle & Hewison, 2007), including interest in the field of mental health (Evans-Lacko et al., 2008). 8.2 STEPPED CARE 8.2 STEPPED CARE A stepped-care model (shown below in Figure 12) is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. The model presents an integrated overview of the key assessment and treatment interventions from this guideline. Figure 12. Stepped-care model: a combined summary for common mental health disorders. Figure 12 Stepped-care model: a combined summary for common mental health disorders. * Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression. ** For people with depression and a chronic (more…) Recommendations focused solely on specialist mental health services are not included (these can be found in related guidance). Recommendation 8.5.1.3 sets out the components of a stepped-care model of service delivery, which should be included in the design of local care pathways for people with common mental health disorders. 8.3 STEP 1: IDENTIFICATION AND ASSESSMENT 8.3.1 Identification 8.2 STEPPED CARE A stepped-care model (shown below in Figure 12) is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. The model presents an integrated overview of the key assessment and treatment interventions from this guideline. Figure 12 Stepped-care model: a combined summary for common mental health disorders. * Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression. ** For people with depression and a chronic (more…) Recommendations focused solely on specialist mental health services are not included (these can be found in related guidance). Recommendation 8.5.1.3 sets out the components of a stepped-care model of service delivery, which should be included in the design of local care pathways for people with common mental health disorders. Go to: 8.3 STEP 1: IDENTIFICATION AND ASSESSMENT 8.3.1 Identification 8.3.1.1. Be alert to possible depression (particularly in people with a past history of depression, possible somatic symptoms of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions, specifically: 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 (see Section 8.3.2)54. 8.3.1.2. 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 (GAD-2; see Appendix 13). If the person scores three or more on the GAD-2 scale, consider an anxiety disorder and follow the recommendations for assessment (see Section 8.3.2). If the person scores less than three on the GAD-2 scale, but you are still concerned they may have an anxiety disorder, ask the following: ‘Do you find yourself avoiding places or activities and does this cause you problems?’. If the person answers ‘yes’ to this question consider an anxiety disorder and follow the recommendations for assessment (see Section 8.3.2). 8.3.1.3. For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer55 and/or asking a family member or carer about the person’s symptoms to identify a possible common mental health disorder. If a significant level of distress is identified, offer further assessment or seek the advice of a specialist56. 8.3.2 Assessment 8.3.2.1. If the identification questions (see Section 8.3.1) indicate a possible common mental health disorder, but the practitioner is not competent to perform a mental health assessment, refer the person to an appropriate healthcare professional. If this professional is not the person’s GP, inform the GP of the referral56. 8.3.2.2. If the identification questions (see Section 8.3.1) indicate a possible common mental health disorder, a practitioner who is competent to perform a mental health assessment should review the person’s mental state and associated functional, interpersonal and social difficulties56. 8.3.2.3. When assessing a person with a suspected common mental health disorder, consider using: a diagnostic or problem identification tool or algorithm, for example, the Improving Access to Psychological Therapies (IAPT) screening prompts tool57 a validated measure relevant to the disorder or problem being assessed, for example, the 9-item Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale (HADS) or the 7-item Generalized Anxiety Disorder scale (GAD-7) to inform the assessment and support the evaluation of any intervention. 8.3.2.4. All staff carrying out the assessment of suspected common mental health disorders should be competent to perform an assessment of the presenting problem in line with the service setting in which they work, and be able to: determine the nature, duration and severity of the presenting disorder take into account not only symptom severity but also the associated functional impairment identify appropriate treatment and referral options in line with relevant NICE guidance. 8.3.2.5. All staff carrying out the assessment of common mental health disorders should be competent in: relevant verbal and non-verbal communication skills, including the ability to elicit problems, the perception of the problem(s) and their impact, tailoring information, supporting participation in decision-making and discussing treatment options the use of formal assessment measures and routine outcome measures in a variety of settings and environments. 8.3.2.6. In addition to assessing symptoms and associated functional impairment, consider how the following factors may have affected the development, course and severity of a person’s presenting problem: a history of any mental health disorder a history of a chronic physical health problem any past experience of, and response to, treatments the quality of interpersonal relationships living conditions and social isolation a family history of mental illness a history of domestic violence or sexual abuse employment and immigration status. If appropriate, the impact of the presenting problem on the care of children and young people should also be assessed, and if necessary local safeguarding procedures followed58. 8.3.2.7. When assessing a person with a suspected common mental health disorder, be aware of any learning disabilities or acquired cognitive impairments, and if necessary consider consulting with a relevant specialist when developing treatment plans and strategies58. 8.3.2.8. If the presentation and history of a common mental health disorder suggest that it may be mild and self-limiting (that is, symptoms are improving) and the disorder is of recent onset, consider providing psychoeducation and active monitoringbefore offering or referring for further assessment or treatment. These approaches may improve less severe presentations and avoid the need for further interventions. 8.3.2.9. Always ask people with a common mental health disorder directly about suicidal ideation and intent. If there is a risk of self-harm or suicide: assess whether the person has adequate social support and is aware of sources of help arrange help appropriate to the level of risk (see Section 8.3.3) advise the person to seek further help if the situation deteriorates59.