Identification and care pathways for common mental health disorders: summary of NICE guidance
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2868 (Published 24 May 2011) Cite this as: BMJ 2011;342:d2868
- Stephen Pilling, professor, director12,
- Craig Whittington, senior systematic reviewer2,
- Clare Taylor, editor3,
- Tony Kendrick, professor of primary care and dean4
- on behalf of the Guideline Development Group
- 1Centre for Outcomes Research and Effectiveness, University College London, WC1E 7HB, UK
- 2National Collaborating Centre for Mental Health, University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
- 3National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA
- 4Hull York Medical School, Hull HU6 7RX, UK
- Correspondence to: S Pilling s.pilling{at}ucl.ac.uk
At any one time, as many as 15% of people in the United Kingdom1 experience common mental health problems such as depression and anxiety disorders, including generalised anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. These may cause considerable impairment and disability, with high costs for both the person and society. Most people who are diagnosed with a common mental health disorder (about 80%) are treated in primary care2; however, there is widespread under-recognition of depression and anxiety disorders.3 4
This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) to improve identification of common mental health disorders, access to services, and pathways to care.5 The guideline also adopted or adapted treatment recommendations from existing NICE guidance on depression,6 7 generalised anxiety disorder and panic disorder,8 post-traumatic stress disorder,9 obsessive-compulsive disorder,10 and antenatal and postnatal mental health11 and organised them into a common stepped care framework.
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com.
Identification of common mental health disorders
Be alert to possible depression (particularly in people with a history 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 past month, have you often been bothered by feeling down, depressed, or hopeless?
-During the past 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 below). [Based on moderate quality validation studies]
Be alert to possible anxiety disorders (particularly in people with a history of depression or those who have possible somatic symptoms of an anxiety disorder or have experienced a recent traumatic event). Consider asking the person about their feelings of anxiety and the ability to stop or control worry using the two item generalized anxiety disorder scale (GAD-212) (box).
-If the person scores three or more on the GAD-2 scale, consider an anxiety disorder and follow the recommendations for assessment
-If the person scores less than 3 on the GAD-2 scale but you are still concerned they may have an anxiety disorder, ask: “Do you find yourself avoiding places or activities and does this cause you problems?” If the person answers “yes” consider an anxiety disorder and follow the recommendations for assessment (see below).
[Based on low quality evidence from validation studies, and the experience and opinion of the Guideline Development Group (GDG)]
Generalized anxiety disorder scales (GAD-212 and GAD-713)*
GAD-2 (short screening tool)
Over the past two weeks how often have you been bothered by the following problems:
Feeling nervous, anxious, or on edge?
Being unable to stop or control worrying?
GAD-7 (seven item)
This comprises the two questions above plus the following questions.
Over the past two weeks, how often have you been bothered by the following problems:
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?
*Scoring for both scales, for each question: not at all=0; several days=1; more than half the days=2; nearly every day=3
Assessment of common mental health disorders
If the identification questions (above) indicate a possible common mental health disorder but you are not competent to perform a mental health assessment, refer the person to an appropriate healthcare professional; if this professional is not the person’s general practitioner, inform the general practitioner of the referral. If you are competent, however, to perform a mental health assessment, you should review the person’s mental state and associated functional, interpersonal, and social difficulties.
When assessing a person with a suspected common mental health disorder, consider using:
-A diagnostic or problem identification tool or algorithm—for example, the screening prompts tool in the data handbook from the Improving Access to Psychological Therapies programme14
-A validated measure relevant to the disorder or problem being assessed—for example, the nine item patient health questionnaire (PHQ-9),15 the hospital anxiety and depression scale (HADS),16 or the seven item generalized anxiety disorder scale (GAD-7)13 (box) to inform the assessment and support the evaluation of any intervention.
As well as 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 or chronic physical health problem
-Any 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, assess the impact of the presenting problem on the care of children and young people and if necessary, follow local safeguarding procedures.
Always ask people 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
-Advise the person to seek further help if the situation deteriorates.
[The recommendations above are adapted from existing NICE guidelines, which were based on evidence from moderate quality randomised controlled trials; validation studies; and the experience and opinion of the GDG]
Treatment and referral for treatment
When discussing treatment options with a person with a common mental health disorder, consider:
-Their past experience of the disorder and their experience of and response to previous treatment
-The trajectory of symptoms
-The diagnosis or problem specification and the severity and duration of the problem
-The extent of any associated functional impairment arising from the disorder itself or any chronic physical health problem
-The presence of any social or personal factors that may have a role in the development or maintenance of the disorder
-The presence of any comorbid disorders.
Provide information about:
-The nature, content and duration of any proposed intervention
-The acceptability and tolerability of any proposed intervention
-Possible interactions with any current interventions
-The implications for the continuing provision of any current interventions.
If the person has:
-Depression that is accompanied by symptoms of anxiety: the first priority should usually be to treat the depressive disorder, in line with the NICE guideline on depression6
-An anxiety disorder and comorbid depression or depressive symptoms: consult the NICE guidelines for the relevant anxiety disorder8 9 10 and consider treating the anxiety disorder first
-Both anxiety and depressive symptoms with functional impairment but no formal diagnosis: discuss with the person the symptoms to treat first and the choice of intervention
-A common mental health disorder and harmful or dependent drinking: refer for treatment of the alcohol misuse17 18 first as this may significantly improve depressive or anxiety symptoms.
When offering treatment for a common mental health disorder or making a referral, follow the stepped care approach, usually offering or referring for the least intrusive, most effective intervention first (figure⇓).
[All recommendations above are adapted from existing NICE guidelines, which were supported by moderate quality randomised controlled trials and validation studies and based on the experience and opinion of the GDG]
Stepped care model for common mental health disorders, showing treatments that should be offered at each step and guidance on referral (for further details see the NICE guideline5)
Improving access to services and developing local care pathways
Primary and secondary care clinicians, managers, and commissioners should work together to develop local care pathways that promote access and care that are integrated across primary and secondary care services; access to services should be possible via various routes (including self referral) and entry points.
Ensure effective communication, with protocols for sharing information about patients’ care (a) with service users and their families and carers where appropriate; (b) with other professionals (including general practitioners); and (c) with the services in the care pathway and services outside the pathway.
[All recommendations above are based on low to moderate quality evidence from systematic reviews of randomised controlled trials and validation studies and on the experience and opinion of the GDG]
Overcoming barriers
Under-recognition of common mental disorders remains a problem,3 4 although use of the quality and outcomes framework (QOF) (a voluntary annual incentive programme for general practices in England to achieve specific results19) may improve the recognition and assessment of depression. Similar incentives for anxiety disorders do not exist, and their adoption might be considered to promote recognition. Developing effective and efficient local care pathways can improve the quality of care but requires collaboration between professionals and managers in both primary and secondary care services.
Such collaboration needs to reach beyond healthcare professionals and traditional healthcare settings if it is to improve poor service access for some groups, such as older people and those from black and minority ethnic groups. This means working with a broad range of community based organisations in developing methods to improve access and settings in which to deliver services. The guideline provides clear advice about the criteria on which to base referrals for various psychological treatments, but access to such treatment remains limited,1 and clinicians may be over-using medication, particularly in milder disorders. Thus the continued roll-out of programmes supporting evidence based psychological interventions, such as the Improving Access to Psychological Therapies programme (to train over 3000 new psychological therapists in the English NHS to provide such interventions in line with NICE guidance)20 21 will be important.
Further information on the guidance
Although most NICE guidelines on common mental health disorders provide some advice on case recognition and referral pathways, the advice varied in scope and was not provided in a common format. In addition, healthcare professionals had to obtain it from several different guidelines. These factors, combined with the lack of a consistent approach to the development and implementation of care pathways for common mental disorders, have led to inconsistency in the delivery of interventions and in the coordination of care for people with common mental health disorders.
This is the first guideline specifically aimed at primary care practitioners, managers, and commissioners. It recommends that they should work together to develop local care pathways that:
Promote access to services, focusing on entry (and not exclusion) criteria that are clear and explicit and on having various entry points to access the service, which also facilitate links with the wider healthcare system and community
Promote a stepped care approach providing the least intrusive, most effective intervention first and clear and explicit criteria for access to and movement between different pathway levels
Monitor progress and outcomes to ensure that the most effective interventions are delivered and the person moves to a higher step if necessary
Provide an integrated programme of care across both primary and secondary care services that:
-Minimises the need for transition between different services or providers
-Allows services to be built around the pathway and not the pathway around the services
-Establishes clear links (including access and entry points) to other pathways (including those for physical healthcare needs)
-Has designated staff responsible for the coordination of care.
Methods
This guideline used standard NICE methods22 and a new approach to adapting existing NICE recommendations to provide advice suitable for primary care and related settings (for example, guidance on referral for treatment). When adapting recommendations, NICE preserved the meaning and intent of the original recommendations but changed the wording and structure where necessary. The Guideline Development Group decided that it was reasonable and appropriate to adapt recommendations from several existing guidelines and bring them together into a clear, coherent, and comprehensible format to facilitate understanding and uptake. Furthermore, these recommendations were adapted within the same stepped care framework used by existing NICE guidelines on the assessment and treatment of common mental health disorders.
Future research
The clinical and cost effectiveness of using a comprehensive assessment (conducted by a mental health professional) versus a brief assessment (conducted by a paraprofessional)
What method should be used to allow comparison of assessment instruments for common mental health disorders (to establish the equivalence of scores on different scales measuring the same outcome)
The clinical utility of using the GAD-2 assessment tool in people with suspected anxiety disorders, compared with routine case identification, to accurately identify different anxiety disorders and whether an avoidance question needs to be added to improve case identification
The clinical utility of routine outcome measurement and whether it is cost effective compared with standard care
Whether the use of a simple algorithm (based on factors associated with treatment response) is more clinically and cost effective than a standard clinical assessment
Notes
Cite this as: BMJ 2011;342:d2868
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Contributors: All authors drafted the summary, reviewed the draft, and approved the final version for publication. SP is the guarantor.
Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: SP, CW, and CT had support from the National Collaborating Centre for Mental Health (NCCMH) for the submitted work; CW and CT have been employed by the NCCMH in the previous three years; SP receives funding from NICE to support guideline development at the NCCMH; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.