Dual Diagnosis GP link work

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GP NEWSLETTER

Newsletter

August 2014

I am pleased to introduce the latest GP newsletter from Barnet Enfi eld and Haringey Mental Health Trust. Dual diagnoses of substance misuse and other mental disorders present particular challenge in primary and secondary care. Substance misuse often gets in the way of engagement with psychological treatment of common mental disorders, or makes the treatment ineffective. However discharging people from secondary care after a crisis as ‘unsuitable for treatment’ may leave signifi cant needs unaddressed. The use of a linkworker provides a model which can bridge the gap between primary and secondary care, and the pathway is explained in the article. I hope that you also fi nd summaries of treatments for anxiety disorders and for men’s sexual health problems useful and informative. I welcome your suggestions for areas of our services you would like to see covered in future newsletters.

The Primary Care Academy continues to offer its RCGP accredited teaching across all our boroughs, and although I am very aware of the conﬂ icting demands on your CPD time I do hope you will consider making some time for mental health in your programme, as 160 GPs across Barnet ,Enfi eld and Haringey have in the last year.

Dr Jonathan Bindman Medical Director

Joanthan.bindman@beh-mht.

nhs.uk

Dual Diagnosis GP link work

The Dual Diagnosis Network (DDN) has been operating a hub and spoke model in the borough of Haringey for several years, and has recently expanded into Enfi eld. DDN recovery workers are embedded within local mental health teams, including Triage and CRHT. The recovery workers propose to follow-up cases deemed inappropriate for the mental health services because of drug and/or alcohol misuse so are referred back to primary care. The two most common presentations are addressed as follows:

We aim to follow up such cases in primary care, and offer up to 12 weeks of psychosocial interventions. This includes engagement, motivational

in-terventions, active treatment and relapse prevention. We aim to:

• reduce representations to mental health services

• treat substance misuse problem

• Facilitate the pathway back to mental health services if required.

Dr Pardeep Grewal MSc MRCPsych, Consultant Psychiatrist and Clinical Lead for Substance Misuse Services will provide consultant leadership for the project.

The DD workers will sometimes visit the GP surgery with the service user and accompany service users to appointments.

A ﬂ ow chart showing the Dual Diagnosis Network GP link work pathway can be found on page 2.

For further information about the DDN please contact Dr Pardeep Grewal on [email protected]

or Helen Kyriakidou (DDN Operations Manager) on 0208 702 5378 or email at [email protected]

GP refers DD case to Triage:

Joint assessment with Triage and DDN worker.

If service user does not meet threshold for BEHMHT, however there are some low threshold mh issues plus substance use, dual worker to offer short term support (max 12 weeks).

CRHT discharges case back to primary care

DDN follow up (max 12 weeks) to complete substance misuse intervention.

Service user seen at home or GP surgery.

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Dual Diagnosis Network GP Link Work Pathway Dual Diagnosis Network

GP Link Work Pathway Dual Diagnosis Network

GP Link Work Pathway

GP referrals to Triage team of clients with dual diagnosis presentations:

• Joint assessment between Triage team and dual diagnosis (at GP surgeries where appropriate)

• If client meets mh threshold for transfer to CMHTs then dual diagnosis to continue offering interventions in the community - no need for GP link work role

Brief interventions for CRHT cases, discharged back to GPs:

• Client is deemed stable around mental health needs and related risk, and requires a brief follow up (max 12 weeks) from dual diagnosis to complete D&A treatment post discharge from CRHT

• Transfer to GP link/DD senior practitioner for 12 wk (max) DD intervention at local GP surgeries- CHECK SUITABILITY

• If client does not meet threshold for ongoing mh treatment in CMHTs or Acute Care Pathway (CRHT/Wards), however there are minor mh diffi culties with ongoing D&A use, transfer to GP link/DD senior practitioner for 12 wk (max) DD interventions at local GP surgeries - CHECK SUITABILITY

Check Suitability

• Aged 18 and over

• Live in stable environment with some support

• Presents with D&A use problems

• Attend appointments on time/

complying with treatment

• Appear well motivated

• Low threshold support needed, i.e. social services involvement/

mental health issues

• No outstanding housing issues

• No outstanding child Protection

• Identify which GP

• Sign contract with GP and client

• Sign consent to share careplan information with GP

Attend 1st appointment with client, GP and GP link/DD senior practitioner at GP surgery to:

• Discuss any concerns the GP may have from client’s presentation, clinical history, social needs, etc

• Discuss the treatment client can expect and concerns the client may have in a new setting with the GP

• Discuss BBV treatment, run DBS and arrange for HVB vaccinations, negotiate if could be done by GP (?) – DD keyworker to monitor

During 12 wk - DD treatment episode, GP link/DD senior practitioner to:

• Contact GP to arrange joint reviews and inform of careplan following assessment with Triage team or discharge from CRHT

• Fax client information to GP

• Contact GP surgery for handover appointments, changes in clinical picture, risk or treatment, pre-discharge planning, etc

• Help GPs re-direct referrals back to Triage team or CRHT if mh deterioration/crisis

• Exit Review in 12 weeks, at GP Practice with client and GP (ideally) at GP practice.

•GP link/DD Senior Practitioner to complete Start, 6 wks and Dx TOPs and produce a TOPs tracker tool for every case, to facilitate annual audit of role effectiveness

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Anxiety Disorders and the

Treatment for Them

Recent newspaper headlines referring to “the age of anxiety” and “Britain’s silent anxiety epidemic” will have confirmed what many GPs knew already: anxiety disorders are very common. Although they have generally attracted less attention than mood disorders and psychosis the research re-veals people diagnosed with such problems expe-rience high levels of distress, are highly disabled and score low on quality of life measures.

These disorders also contribute to increased mor-bidity and mortality.

A recent survey by the Mental Health Foundation found that 1 in 5 people reported that they feel anxious “nearly all the time” or “a lot of the time”.

Anxiety disorders seem to be under-reported too, which is unfortunate, as they seem to follow a chronic or recurring course without treatment. Anxiety disorders entail a huge economic cost to society aside from the personal misery involved for the sufferer. The most disabling anxiety disor-ders include panic disorder, obsessive- compulsive disorder (OCD), social anxiety disorder (SAD), post-traumatic stress

disorder (PTSD) and gener-alized anxiety disorder (GAD).

The same study by the Mental Health Foundation reveled that while GAD affects between 2 and 5% of the population people with this disorder account for as much as 30% of the mental health problems seen by GPs.

The treatment for anxiety disorders includes pharmacological and psychological interventions. The first line medical intervention is the SSRI group of anti- depressants. These are not considered a cure and are most effective in the long term when com-bined with psychological therapies. Benzodiaze-pines, once very popular in the treatment of anxiety problems, have largely fallen into disfavor apart from use as a short- term treatment of acute anxious states. Not only can they give rise to dependency but by suppressing symptoms they can also interfere with the application of

psychological therapy.

The best supported psychological treatments for anxiety disorders are the CBT. These range from anxiety management approaches incorporating relaxation methods, cognitive restructuring and exposure to newer, more conceptually sophisticated, cognitive and metacognitive interventions.

The developments in theory point to the role of worry as a key trans-diagnostic ingredient in the anxiety disorders. Worry has been defined as long chains of predominantly verbal thought in which the person seeks to answer “What if…?” questions. People prone to these conditions seem to employ worry along with threat monitoring as their dominant approach to managing themselves. Typically sufferers hold positive beliefs about their worry e.g. “If I worry I will be

prepared” “Focusing on danger can keep me safe”

and these metacognitive beliefs are a driver for this style of thinking.

In some disorders, for instance GAD, worry is also appraised as dangerous and out of control and this “worry about worry”

is a central feature of this disorder. Newer treatments targeting positive and negative beliefs about worry and teaching strategies to disengage from worry intrusions rather than elaborate upon them seems to be driving much improved outcomes.

At Barnet, Enfield & Haringey there is a stepped-care approach to anxiety treatment. Our IAPT service, provided jointly with Whittington Health, offers guided self-help programmes, small group work and individual therapy. The Complex Care Service at St Ann’s Hospital offers a comprehen-sive package of care for individuals with more en-during and complex presentations and includes individual and group approaches that aim to normalize anxiety through psych-education, improve coping and meaningful living and alleviate symptoms.

There is a specialist post-traumatic stress treatment track for complex trauma and a specialist group for chronic OCD. The Trust is also endeavoring to form closer links with user-led groups in the community.

This article is written by Gerry McCarron, Clinical Specialist in CBT

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Number of selected STI diagnoses among MSM: England, 2012

31 Public Health England: 2012 STI Slide Set

• Data from routine GUM clinic returns.

• * First episode; ** Non -Specific Genital Infection

• *** Includes diagnoses of primary, secondary and early latent syphilis

• Data type: service data

Rateofgonorrhoeadiagnosesbygender & age:

England,2012

• Excludes diagnoses where gender was reported as ‘unknown’

NumberofselectedSTIdiagnosesamong MSM:England,2012

Rate of gonorrhoea diagnoses by gender & age:

England, 2012

NumberofselectedSTIdiagnosesamong MSM:England,2012

Rateofgonorrhoeadiagnosesbygender & age:

England,2012

Update on

men’s sexual health

Men are less likely to attend health services than women and sexual health services are no

exception. Young men aged 20-24 and men who have sex with men (MSM) are disproportionately affected by sexual infections.

According to PHE gonorrhoea diagnoses had been in a decline 2003 -2008 but have since risen steadily among men. Diagnoses increased by 21%

(23% among men and 17% among women) between 2011 and 2012 although this can partly be attributed to the increased use of nucleic amplifi cation tests (NAATs) and increased testing.

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Explaining about men’s sexual

health

In 2012 beyond age 21, the diagnoses rate of Chlamydia for males were higher than for females.

Of note, between 2008 -2010, there was a steady increase in the number of diagnoses made at community sites, with a decrease observed in 2011.

The prevalence of diagnosed HIV infection in Enfi eld per 1000 population aged 15-59

years is 4.14. Guidelines recommend that routine testing for HIV is offered by GPs for newly registered patients in areas where the rate of HIV is >2/1000 population. Early diagnosis of HIV dramatically improves patients outcomes and prevents onward transmission. There has beensome improvement in the rate of undiagnosed HIV infection for MSM but this is still 18% and for heterosexual men this is higher at 30%. HIV in the United Kingdom: 2013 Report. In the UK MSM remain the group most affected by HIV with 47 per 1000 living with the infection. This is equivalent to an estimated 41,000 (37,300-46,000) MSM living with HIV in 2012, of whom 7,300 (18%; 3,700- 12,300) were unaware of their infection (18%).

Observing the trends of sexual infections in recent years, some infections have proved to be a challenge for those working to control them. Infections once thought to be uncommon in the UK previously such as lymphogranuloma venereum (LGV) and syphilis have in the last decade seen an increase. The fi rst cases of LGV in MSM were seen in 2004 and after a period when rates reached a plateau, again soared in 2009, reaching a hyperendemic phase now in this evolving epidemic. There are currently outbreaks of hepatitis C and shigellosis that are sexually transmitted. Control of gonorrhoea infection in the population now hinges on our ability to prevent further development of resistance to antibiotics. In the past this was treated with a single dose of amoxicillin or quinolone. We now use a combination treatment of an injectable cephalo-sporin with a dose of azithromycin to try to pre-serve this treatment option as there are few left. The changing epidemiology of sexual infections mean that all health care professionals need to be vigilant in order to respond effectively. Along with changes in infection trends, there are also changes in how people meet and fi nd sexual partners. The use of internet and mobile apps mean that sexual networks and sexual behaviours are changing. Understanding these phenomena may help bring about effective interventions to control the spread of infections.

From a public health perspective, good access to diagnosis and treatment of STIs is vital. Sexual health clinics such as ours can only reach some people.

Some men have the impression that we provide mainly contraception while others prefer to see their general practitioner. We would like to work together with GPs to improve care for men’s sexual health.

Dr Wai Ching Loke, is a Consultant in GU medicine in Enfi eld

New base for the

Haringey drug and alcohol service

DASH – the drug and alcohol service is now working in partnership with the charity Belenheim to run the Grove Drug Treatment Service.

The Grove is a free and confi dential service in the London Borough of Haringey. It accepts referrals from individuals, family members and friends experiencing problems with substance mis-use. Referrals are also accepted from other professionals. We are open to anyone living in the borough of Haringey who is over 18.

The Grove offers a range of

recovery focused services including:

• 1:1 support and groups;

• Substitute prescribing;

• Needle Exchange;

• Support in accessing funded treatment for detox;

• BBV testing and vaccinations;

• Club Drug Clinic (GBL, Mephedrone, Crystal Meth, Ketamine and Legal Highs)

• Employment, training and education, bene-fi ts and welfare support;

• Support for carers, families and friends; Complementary therapies.

The Grove also works closely with other Haringey agencies, including the Alcohol Treatment Service and the Recovery Service, so can refer to these agencies for further support.

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Primary Care

Academy update

The Academy continues to go from strength to strength.

Thanks to funding from Health Education NC & E London elearning is to be added to its RCGP accredited face to face programme. Feedback continues to be good, with 95% of session learners willing to recommend it to a colleague.

Academy sessions on dementia (behavioural and psychological symptoms), are being scheduled for the autumn and dates will be published shortly. We have now agreed to open sessions to practice nurses as well as GPs.

To have your say on the topics we cover next year and in the elearning, please complete our short survey on the website.

We are very grateful to the many practices collaborating with us by hosting sessions, including the following who have already done so (in some cases more than once):

Barnet - Lane End, Millway, Langstone Way, Ravenscroft and Torrington Speedwell

Enfield - Carlton House, Forest Rd and Freezywater Haringey – Highgate Group, Somerset Gardens and The Vale

Many thanks also to Barnet CCG Education lead Dr Barry Subel who permitted us to run an Academy session on mental health and long term conditions within the Barnet GP Luncheon Club.

Further details are available at www.beh-mht.nhs.uk/pca

Honorary Professor

role for Trust Director

Mary Sexton, the Trust’s Executive Director of Nursing, Quality and Governance, has become a Honorary clinical Professor to Middlesex University, School of Health and Education.

The year-long appointment will build upon the existing partnership between the two organisations by Mary working closely with the school of Health and Education to ensure an effective learning experience for students on programmes related to mental health and community services.

Speaking about the role, Mary said: “I am very honoured to have been invited to become a Honorary Clinical Professor.

As a nurse leader it is a great opportunity to be involved in developing the nurses of tomorrow and to contribute to University research activity. I am looking forward to working closely with the university over the coming months.”