Clinical Governance Workshop 10th January 2007 
-Mental Health Issues-

Present ;Drs Sadler, Gallow, Allistone, Mapara, Tipple, Manton, Sharma, Khan, Ormiston, Lang, Craske, Oliver, Stier, Antscherl

Apologies ; Drs. Bulger, Tiwari

Notes
Gratitude was expressed to Stephanie Sadler, Consultant in Community Psychiatry, for substituting at very short notice (2 hours!) for the Beating the Blues manager, who phoned in sick.
The first part of the meeting was to discuss the provision of CBT and other psychological therapies followed by a discussion on the continuing decrease of the mental health service and how patients can be best served. 
The underlying theme was the blurred boundary between primary and secondary care for mental health and how this is continually being exploited by the “Commissioners”
Secondary Care should look after major psychiatric illness- schizophrenia, bipolar disorders and severe OCD and potentially suicidal depressives.

Primary care should do the rest! 

Primary Care Management of Depression

To facilitate this;
1.	Secondary care should be available to see patients where there is uncertainty with the diagnosis or where medication/therapy is not helping.
2.	GPs must be aware of NICE guidance on their role in managing mild to moderate depression with psychological therapies and drugs.
3.	There must be a primary care provision of psychological therapies to refer to 
a.	Counselling should be targeted to depression (scored) or mild OCD
b.	CBT should be offered to patients with negative thoughts causing behaviour problems leading to depression. These tend to be fairly intelligent, motivated patients. Cost effectiveness of computerised CBT v. CB therapist needs to be decided.
c.	Should this be practice based or centralised? This depends on locality need. One computer in a rented room in Dacorum may be enough. Print outs can be brought to the GP follow up appointments for discussions on progress.
d.	Much of eCBT was tested and tried in Australia. Log on and see for your self. If it looks alright pass it on to a patient possibly with an introductory handout.  http://moodgym.anu.edu.au 
4.	There needs to be a Lead GP/Manager to pursue this situation. There is apparently a counselling evaluation project in Dacorum, a primary care psychology service in St Albans and a trial; of this in Watford. This needs to be pursued! (RG to contact Mike Drake for details). RG to identify PCT Lead.

Consultant services

Due to work pressure from cutbacks the service scheme was devised to reflect case priorities and best use of Consultant time.

•	All daytime contact will be received by the Duty team who will pass urgent cases to the CATT. There will be an immediate telephone assessment of the case. Please obtain the patients contact (home or mobile) phone number. 
•	The outcome of the contact with the patient will be faxed back to the referring GP as the most likely way to get an urgent response through.
•	c50% of current Consultant workload is follow ups. These will be stopped and the Consultant used for new referrals and availability for Emergencies. Registrars and SHOs will deal with the rest with the Consultant close by.
•	All letters from the Mental Health will be on a template and coded for diagnosis. They will contain much less detail as a copy has to be sent to the patient and contents may be harmful.
•	Appointment changes are unavoidable due to constantly changing commitments. A copy of the patient’s appt. change letter will not be sent to the GP as well!
•	DNAs- the patient will be written to by the CMHT if alarmed. GPs need to be vigilant for medico-legal reasons!
•	Referral to in-house psychology should be for specialist counselling or CBT but is often for other treatments such as Seymour therapy or EFT.

Medical Management issues
•	Duloxetine is slightly better tolerated than venlafaxine and cheaper at higher doses (60 v 150). However, both are more effective than SSRIs, which should be used in the first instance.
•	The patient still needs an ECG and BP check pre treatment, which can now be started by the GP.
•	Mirtazapine is also a valuable treatment when sedation is needed, but weight gain and sedation is a problem.
•	Bupropion, the commonest used anti depressant in USA is also being used by the Consultant in cases poorly responding to other treatments.

Richard Gallow