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Bridging the depression gap: nurses lead the way

Lesley Harvey and
Andy Tovey
GP Liaison Nurses (Mental Health)
North Glamorgan NHS Trust Seymour Berry Centre
Dowlais
T:01685 721671

The Seymour Berry Centre in Merthyr Tydfil has recently been announced as the overall UK winner of the Lundbeck Awards for Best Practice in Depression 2003. The UK-wide award was developed by the Depression Alliance to recognise excellence in the management of depression in primary care and to reward outstanding achievement. This feature takes a closer look at the award-winning work of the team, whose service covers 14 practices and a total population of 67,000, and reveals ways in which other primary care teams can improve their services to patients with depression.

Background
Depression is a chronic, recurrent illness carrying a heavy burden for the health service and the community.(1) Depression affects one in five of the UK population at some point in their life(2) and accounts for at least 3,000 of the 4,000 people who commit suicide in England and Wales each year (Department of Health 2003). People with depression suffer from intense feelings of persistent sadness, helplessness and hopelessness that are often accompanied by physical effects such as sleeplessness, a loss of energy or physical aches and pains.
Several specific types of depression have been identified: reactive, endogenous, manic (bipolar depression), seasonal affective disorder and postnatal depression.  Depression can exist by itself, but it can also result from ischaemic heart disease, diabetes, hypertension, pain, rheumatoid arthritis, cancer and osteoporosis.  Psychological issues also permeate every consultation.
The new National Enhanced Services include depression, meaning that primary care teams can now achieve significant and financially rewarded success for the holistic care of a condition that is responsible for every third consultation in primary care. It is also hoped that depression will soon be the first condition to be added to the quality framework within the new GMS contract, as the evidence accumulates for the effectiveness of treating it positively in primary care.
In January 2002, two GP liaison nurses were appointed in Merthyr Tydfil. This was in response to research carried out among GP practices by the Merthyr Community Mental Health Team (CMHT) in conjunction with Neurolink. This research identified the need for support to primary care teams in their management of people with mild-to-moderate mental health problems. In line with Welsh Office recommendations, the CMHT had previously been focusing their resources on providing a service for people with severe mental health needs.
Almost 90% of mental health illnesses are treated in primary care.(3) Up to a quarter of the population has a diagnosable problem, but research suggests that less than 10% of those diagnosed are referred to specialist mental health services.(4) Armstrong (1995) and Gask et al (1997) identified a gap in service provision due to changes in government policies designed to shift care from hospitals into the community.(5,6) As GP liaison nurses, we aim to examine ways to bridge this gap.

Needs and aims
Our initial aim was to develop a good working relationship with the primary care teams to enable us to work in collaboration. We wanted to take an evidence-based research approach and carried out a literature search to this end. A questionnaire was sent to all 14 practices in our catchment area to provide a baseline assessment of the current services available. Seven were returned. The results revealed that no existing arrangements were in place to discuss referrals. There also proved to be a total lack of educative support, and there were no systems in place for members of the CMHT to provide specific input to clinics. The existing referral system was felt to be inadequate for the needs of the population, and waiting times for treatment too long. It was also felt that communication could be improved, and the use of email was suggested to provide rapid feedback on assessment outcomes. Practices wanted, and asked for, regular meetings with a member of the CMHT. These meetings were arranged to suit the needs of each practice and are now part of everyday practice.

Model of practice
A number of models of practice have been developed for primary and secondary care to work effectively together. "Evaluating models of working at the interface between mental health services and primary care" provides examples of this.(6) The model we favour is the consultation-liaison (CL) model. It has numerous advantages over other models. The model advocates that referrals to secondary care should be limited to those most in need of this level of expertise and that GP management skills should improve, so targeting the service best suited to the clients needs. This model also provides the most cost-effective service provision.
The key feature of the CL model is regular face-to-face contact between the psychiatrist, GP and other members of the primary care team.(7) Meetings can vary in frequency from weekly to monthly. Referrals are discussed and a decision is taken to manage the client either in primary or secondary care. The primary care teams are given advice and feedback on management as required. In Merthyr, this model has been adapted so that the GP liaison nurse acts as the practice consultant and signposts patients to other services, such as counselling, as needed. We also have direct access to a consultant psychiatrist if required.

Educational needs
Another area where we offer support is education. A survey was sent to primary care team staff in July 2003 asking them to suggest topics to be discussed and times, locations and teaching methods to best suit their needs. It was thought that teaching sessions after morning surgery in the practice would be most convenient. A list of topics was identified and a teaching package devised for each participant, including a feedback form to monitor response. To date feedback has been very positive.

Service developments
As the posts have developed we have also become involved in a number of service development projects.  Work is taking place with health visitors and midwives to provide a support group for mothers with postnatal depression; steering groups have been developed to produce an assessment tool for the care programme approach, and another to provide a service delivering computerised cognitive behavioural therapy for people with depression. Research is underway into the development of referral pathways and treatment protocols for GPs, and time is dedicated to the provision of advice and support to a number of voluntary agencies. In July 2002 we were part of a team that delivered a course on stress management in Merthyr College, and we expect to be involved in future courses there.  
The service fills the gap between primary and secondary care, has been extremely well received and has helped to reduce GP workload. Importantly, it has considerably reduced distress and the number of people who would have progressed in their illness to need formal psychiatric assessment, therefore contributing to cost savings within the healthcare system.      

The future
Team commitment to the development of mental health services in Merthyr Tydfil will continue as we endeavour to further bridge the gap between primary and secondary care teams and strive to improve the service. The service has been built up from nothing, and the £10,000 prize money from the Lundbeck Awards will be used to further expand and improve the service. Work is to be undertaken to help increase public awareness and understanding of depression, expand our library of self-help literature to include videos and tapes, and further develop care pathways for the treatment of depression by GPs.

References

  1. Manning C, Marr J. "Real-life burden of ­depression" surveys - GP and patient ­perspectives on treatment and management of recurrent ­depression. Curr Med Res Opin 2003;19:526-31.
  2. Depression Alliance. Everything you need to know about depression. London: Depression Alliance; 2002.
  3. Mann A. Depression and anxiety in primary care: the ­epidemiological evidence. In: Jenkins R, et al, editors. The prevention of depression and anxiety: the role of the primary care team. London: HMSO; 1992.
  4. Goldberg D, Huxley P. Mental illness in the community: the pathway to psychiatric care. London: Tavistock; 1992.
  5. Armstrong E. Do practice nurses want to learn about depression? Practice Nursing 1997;8:21-6.
  6. Gask L, et al. Evaluating models of working at the interface between mental health services and primary care. Br J Psychiatry 1997;170:6-11.
  7. Creed F, Marks B. Liaison ­psychiatry in general practice: a comparison of the liaison ­attachment scheme of ­practitioners. J R Coll Gen Pract 1989;39:514-7.