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What Is the Future of Primary Mental Health Care?: A Post COVID-19 Service Evaluation
- Ahmad Zarif, Imaduldin Nazir, Azad Mahmod, Hajira Bibi, Reshma Rasheed, Anjali Patel, Yathorshan Shanthakumaran
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S143
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Aims
During the COVID-19 pandemic, many service lines needed to be transformed to enable more telemedicine and virtual consultations. This enabled seamless care across many service boundaries as all services adapted to operate virtually. During COVID-19, the mental health of many patients deteriorated. With easing of restrictions, we wanted the patient voice to be heard and to ensure our service was patient-centred. We undertook a service evaluation to understand our patients preferences. Our cross-sectional study evaluated patient preferences for their care which we felt was important as earlier during pandemic, patients did not have the choice to choose between virtual vs face-to-face consultations. We felt this was important to our patients so they could exercise choice of consultation and this would enable the patient voice to be heard.
Methods591 patients across three practices in primary care were identified from the Serious Mental Illness (SMI) and on the depression register. They were asked about their preference of care: telemedicine vs face-to-face consultations. Using a simple questionnaire, in order to record their preference on the patient screen. Of these a total of 495 patients (83%) participated in the study.
ResultsOf the 495 respondents, 308 (52%) declined virtual telemedicine consultations and 175 (29%) patients were content with virtual consultations. Of the 175 patients who wanted telemedicine were 20 to 40 years of age. Reasons given included convenience (allows family and work commitment) and overall time management (reluctancy to travel). The 308 patients (52%) wanted face-to-face consultations because they wanted human contact, validation of their mental health problems, reassurance and were uncomfortable about discussions on the phone. They also had poor mobility especially the elderly who chose traditional models of care.
ConclusionAs services are restored to the new norm of patient care, patient choice should remain paramount if services are to remain patient centric. During the COVID-19 pandemic, many services transformed to virtual consultation of necessity without recognising the impact on patients themselves. Patients with serious mental health and depression are inherently vulnerable and our evaluation goes to show that despite the popularity of telemedicine. Patient choice should enable patients to access face-to-face care for greater patient satisfaction.
An Observational Study of the Mental Health Burden in Frail and Elderly Patients
- Yathorshan Shanthakumaran, Reshma Rasheed, Anjali Patel
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S66
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Aims
Psychiatric illnesses are common among older adults and are associated with increased mortality and physical comorbidities. It is suggested that patients with frailty have a higher prevalence of depressive symptoms. (1) The eFI (electronic Frailty Index) is a tool used to assess the severity of frailty in elderly frail patients using a cumulative deficit model based on routine interactions with their GP.
MethodsPatients were selected for annual frailty assessments by searching the electronic clinical system (SystmOne) using the eFI tool. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) framework. In addition, all patients were screened for coexisting anxiety and depression using the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) questionnaire.
ResultsOf the 118 patients who ranged from mild to severe frailty, we found there was a positive correlation of the frailty severity eFI scores with increased rates of anxiety and depression evidenced by higher scores on the PHQ-9 and GAD-7 scoring tools. We found a positive correlation of the eFI with the PHQ-9 depression scores of (r = 0.819 p < 0.001). Within the same data set, we found correlation coefficients of eFI and anxiety GAD-7 scores (r = 0.651 p < 0.001). Increasing frailty was found to be associated with a higher rate of depression and anxiety.
ConclusionWe found in this study higher (eFI) electronic frailty indices are associated with higher rates of anxiety and depression. We would recommend annual frailty assessments in patients with high electronic frailty indices and this should include screening for mental health deterioration. Early detection of deterioration will enable patient centered supportive measures and targeted treatment strategies. Health maintenance programs should ensure patient centered holistic assessment of both physical and mental health needs for early identification to avoid deterioration of both physical and mental health.
A Quality Improvement of the Identification of Obesity in Patients With Mental Health Morbidity and Referral to Weight Management Services
- Anjali Patel, Reshma Rasheed, Yathorshan Shanthakumaran
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S107-S108
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A quality improvement project was undertaken to counteract obesity in patients with mental health morbidity. The exponential trend of increased antidepressant prescribing (SSRI, SNRI and anti-psychotic medication) has created a trend towards weight gain in patients. An audit of the Serious Mental Illness (SMI) register and depression registers was conducted in a population of 591 patients. Those patients identified as obese were offered referral to the local authority weight management services.
MethodsPatients have a body weight and BMI calculation with their twice yearly mental health and medication review and those whose BMI met the obesity criteria were offered referral to the local authority for 12 weeks weight management services.
ResultsOf the SMI and depression register 189 (32%) patients met the criteria for referral to the weight management program. Of these 154 (81%) patients accepted the local NHS weight management program, 35 (18%) of patients declined the NHS weight management program.
ConclusionWeight gain is a known side effect of antidepressant medication SSRI and SNRIs and Anti psychotic medication resulting in increased risk of obesity and cardiovascular and metabolic disease. The QI program was undertaken to counteract these changes with referral to weight management services to address the weight gain the patients were experiencing.
This quality improvement service was done to help patients across three surgeries lose weight in an effective and educational manner. We found a high rate of acceptability of referral to weight management services when offered as patients themselves were aware of the weight gain. A review of positive changes in the BMI after referral to the weight management program will be undertaken at 6 and 12 months to evaluate its acceptability and effectiveness. We advocate sensitive counselling of the risks of weight gain and regular monitoring of body weight throughout the span of the prescribing of these weight gaining agents.
Metabolic Effects of Antidepressants; Is It Time to Change the Conversation?
- Anjali Patel, Yathorshan Shanthakumaran, Reshma Rasheed, Imaduldin Nazir
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S66
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- Article
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Aims
The incidence of depression has risen both nationally and internationally. The mainstay of management remains referral to IAPT and treatment with SSRI and SNRIs and the rates of prescribing are rising exponentially. During the COVID-19 pandemic, more people faced mental health challenges. In the last ten years, the incidence of SSRI prescribing rose from 6.8% to 100%. A known side effect of antidepressant medication is weight gain, dyslipidemia, increasing risk of impaired fasting glycaemia and diabetes. Our study was conducted to assess the actual risk incurred in our population from the point of starting therapy till date.
MethodsPatients were identified from the GP clinical system (SystmOne) to identify those with a current prescription of antidepressants and antipsychotics. A retrospective analysis of 591 patients' case records was undertaken. Body weight, BMI, fasting glucose, HbA1c, fasting lipids and Q risk were analysed at the time of prescription initiation, post treatment and any rise in cardiovascular risk over a period of years. The data were analysed to see the trajectory of deterioration in metabolic risk. All patients were assessed to ensure they had been signposted and referred to weight management services.
ResultsThe data show a positive correlation between the onset of antidepressant and antipsychotic prescribing, worsening of BMI, increase of cardiovascular and metabolic risk. The data show an exponential rise in BMI and metabolic risk (cardiovascular Q risk, dyslipidemia, imparied fasting glycaemia, diabetes and ischaemic heart disease) for patients taking SSRI and SNRI within 12 months. This effect continues for the length of the prescribing interval. We also found that with the rise of BMI dose, escalation was common due to reduced effectiveness. The average rise in cardiovascular Q risk average was 14.05% over three years. Patients need careful counselling at the outset and need regular reassessment of metabolic risks at each medication review. Informed consent must be obtained - risks of SSRI, SNRI and antipsychotic risk should be stated.
ConclusionA known iatrogenic risk of antidepressant medication is weight gain, dyslipidemia, increasing risk of impaired fasting glycaemia and diabetes. Careful counselling and metabolic risk assessment is required when initiating these medications. Throughout the length of prescribing patients need re-assessment of their cardiovascular and diabetes risk with timely referral to weight management services to counterbalance metabolic risks.