Disclosure Log - Mental Health Inquiry

Summary

The requester asked about FOI publication practices and sought copies of mental health treatment plan templates following a recent inquiry. The authority responded by providing detailed Anxiety and Bipolar Affective Disorder pathway templates based on NICE guidelines, though the response text does not explicitly address the questions regarding publication policies.

Key Facts

• The Department of Health and Social Care provided Anxiety and Bipolar Affective Disorder treatment pathways.
• The pathways are based on NICE Clinical Guidance (QS53, CG113, CG159) and British Association for Psychopharmacology Guidelines.
• The Anxiety pathway outlines interventions across three steps: Primary Care, Community Wellbeing Service, and CMHSA.
• The Bipolar pathway details medication options for manic and depressive episodes and referral criteria.
• The outcome of the request was recorded as 'Some information sent but not all held'.

Data Disclosed

• 2019-09-16
• 2019-10-09
• 22 pages
• 2 documents
• QS53
• CG113
• CG159
• 2014
• 2016
• 14 sessions
• 3-4 months
• 7-14 hours
• 16-20 hours
• 3 hours
• 9 sessions
• 2, 4, 6, 12 months
• 8-12 mth intervals
• 1-2 wks
• 2-4 wks
• 3 or more depressive episodes

Original Request

I recently made a request for information (FOI 906825 Mental Health data) which you replied, however my questions are Question 1 Why was the answer not disclosed in the IOM FOI Disclosure Log for the general public to view? Question 2 How many other FOI's answered by your department have also not been published on line? Question 3 Who in your organisation decides if an FOI will not be published on line (title of person, e.g. manager etc. and grade)? Question 4 In light of the recently published Mental Health Inquiry reported by the media last week, please provide copies of all the patient treatment plans/pathways templates e.g. blank templates. Question 5 Who in Mental Health produced the plans/pathways in question 4 (title of person e.g. head nurse etc. and grade)?

Data Tables (41)

Full Response Text

Anxiety Pathway Based on: NICE Clinical Guidance QS53, CG113, CG159 British Association for Psychopharmacology Guidelines 2014

Step 1: Primary Care Intermittent episodes of panic or anxiety, and taking action to prevent these feelings Over arousal, irritability, poor concentration, poor sleeping and worry about several areas most of the time. Fear of embarrassment causing avoidance of doing things or speaking to people; avoidance of being centre of attention; being embarrassed or looking stupid are among the worst fears. Offer: bibliotherapy, information on support groups, explain & promote the benefits of exercise Panic disorder with or without agoraphobia Generalised anxiety disorder Social Anxiety Disorder SSRIs, (best started at a lower dose), some TCAs (Clomipramine, Imipramine, Lofepramine), Venlafaxine, some Benzodiazepines in emergencies but NICE does not recommend them (clonazepam, diazepam, lorazepam), sodium valproate (an anticonvulsant). SSRI. If no response or judged to be unsuitable, SNRIs & Pregabalin may be considered. SSRIs, venlafaxine, moclobemide, some benzodiazepines in emergencies (bromazepam, clonazepam) and pregabalin (an anticonvulsant) Review at 2, 4, 6, 12 months, then at 8- 12 mth intervals Review at 2, 4, 6, 12 months, then at 8-12 mth intervals Review within 1-2 wks, then every 2-4 wks for the first 3 months. Review monthly thereafter.
Step 2: Community Wellbeing Service Assess Panic disorder with the PDSS Assess Agoraphobia with the MIA. Assess with the GAD-7 Assess with the Social Phobia Inventory (SPIN) Panic Disorder Specific:
- Individual non-facilitated self-help - Individual guided self help
- Group based intervention grounded on CBT principles. - Individual exposure intervention with Occupational Therapist up to 14 sessions over 3-4 months Generalised Anxiety Disorder Specific:
- 1:1 non-facilitated self-help - 1:1 guided self help
- Group based intervention grounded on CBT principles. Social Anxiety Disorder: -1:1 CBT
- 14-15 sessions of 60- 90 minutes' duration - over 4 months Individual weekly sessions with Occupational Therapist up to 14 sessions over 3-4 months CBT weekly sessions of one hour each for a total of 7-14 hours. - Individual desensitisation intervention with Occupational Therapist up to 14 sessions over 3-4 months CBT weekly sessions of one hour each for a total of 16-20 hours over 4 months. Individual weekly sessions with Occupational Therapist up to 14 sessions over 3-4 months If CBT declined, offer CBT-based supported self-help.
- up to 9 sessions with a CBT-based self-help book
- 1:1 or by telephone, for a total of 3 hours - Over 3−4 months Step 3: CMHSA Consider referral if the person has severe anxiety with marked functional impairment in conjunction with:
- a risk of self-harm or suicide or - significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or - self-neglect or - an inadequate response to step 2 interventions Reassess patient, undertake comprehensive risk assessment, do risk management plan.

Anxiety Pathway Based on: NICE Clinical Guidance QS53, CG113, CG159 British Association for Psychopharmacology Guidelines 2014

Bipolar Affective Disorder Pathway

The development of this pathway has been guided by the published recommendations of the National Institute for Health and Care Excellence (NICE, 2014) and British Association for Psychopharmacology 2016 Step 1: Primary Care Primary care should consider referring to secondary care patients with:

• Mania or severe depression who are a danger to themselves or others
• Overactive, disturbed behaviour
• Three or more depressive episodes and history of overactive, disinhibited behaviour For those already diagnosed, follow the crisis plans developed within Step 3
• Review treatment and care, including medication, at least annually and more often if the person, carer or healthcare professional has any concerns. Step 3: CMHSA Full psychiatric & physical health assessment and review medication and side effects, including weight gain. Manic Episode: Dopamine antagonists, Valproate, Lithium (for those with strong and sustained suicidal risk as determined by their actions, or persistent thought of suicide)

Depressive Episode: Quetiapine Olanzapine, Olanzapine plus Fluoxetine Antidepressants Lurasidone Lamotrigine as combination Use the Mood Disorder Questionnaire to inform diagnosis and monitoring thereafter Follow the physical health monitoring policy. For pregnant women with acute symptoms consider pharmacological therapy Carefully consider drug options, rapid cycling, risk, behaviour disturbance For those with persistent depressive symptoms and no recent history of rapid cycling consider structured psychological therapy Consider Psychological interventions specifically developed for adults with bipolar disorder such as: individual CBT, group or family intervention and WRAP. Also provide information about structured exercise, activity scheduling, engaging in pleasurable and socially directed activities, ensuring adequate diet and sleep and social support. Offer a combined healthy eating and physical activity programme If there co-morbid condition e.g. Personality Disorder/substance misuse - treat as per associated pathway Long-term management of Bipolar Disorder - Lithium (Mania, depression, suicide) - Dopamine antagonists and partial agonists, valproate (mainly mania) - Lamotrigine (depression) Consider offering befriending

Consider joint working:
CRHTT - suicidal patients DAT- substance abuse Consider focused family intervention Promotion of healthy lifestyle, extra support at times of crisis Consider individual structured psychological interventions, such as CBT, in addition to prophylactic medication for people who are relatively stable but may have mild to moderate affective symptoms, 16 sessions over 6-9 months. 6-9 months covering psychoeducation and ways to improve communication and problem solving Step 4: Inpatient Severe and complex depression who are at significant risk of suicide, self-harm or self- neglect. For patients with treatment resistant depression and a chronic physical health problem work closely with physical health services and be aware of possible additional drug interactions. For patients with severe or resistant depression: continue to offer high-intensity psychological interventions with increase of intensity and duration. Consider ECT within in-patient treatment for severe, life-threatening depression and when a rapid response is required, or when other treatments have failed. Bipolar Affective Disorder Pathway

The development of this pathway has been guided by the published recommendations of the National Institute for Health and Care Excellence (NICE, 2014) and British Association for Psychopharmacology 2016

Mental Health Service

Care Plan and Review
Date printed: 18 September 2019

Client Name:
Client Date of Birth:
Client Post Code:
Client RIO Number:
Client NHS Number:
Client CPA Level:
Client Address:
Client Contact:

Next Of Kin
Client Next of Kin Relationship

Your Care Co-Ordinator is

Client GP:

This is / these are who to contact, and how, when During Office Hours:
Outside Office Hours (evenings, night-time, weekends):

Problem Intervention / Action and Frequency Anticipated Outcome and Clients View Planned / Actual Start Date Main Person Responsible

Risk Management Plan

Additional history - recent or historic

Date CPA Review Held

Agreed CPA Review Date

Review of Unmet Needs

Client View

Carers View

Other Notes - What Worked well Other Notes - What did not work well

Additional Information

Other Comments - of user, carer(s), assessor, other agency. Include any outstanding difference of view.

CPA Review Name Signature Date Care Co-Coordinator

Client

Carer

CPA Next Review

CPA Distribution List
Name Role Location Telephone Number

Depression Pathway The development of this pathway has been guided by the published recommendations of the National Institute for Health and Care Excellence (NICE, 2017) Step 1: Primary Care Screening patients in primary care with a history of past depression or other mental health problems such as dementia and chronic physical health problems with associated functional impairment. Watchful waiting by GP, offering a follow-up appointment within two weeks. Discuss the presenting problem(s) and any concerns and provide advice on sleep hygiene, anxiety management and the benefits of exercise. - If depression is accompanied by symptoms of anxiety, prioritise treatment of anxiety first.
- If comorbid Anxiety Disorder and Depression/depressive symptoms treat the anxiety disorder first (since effective treatment of the anxiety disorder will often improve the depression or the depressive symptoms). Consider use of an anti-depressant (if history of moderate or severe depression) Step 2: Community Wellbeing Services Persistent sub threshold depressive symptoms or mild to moderate/severe depression Use the PHQ-9 to inform diagnosis and monitoring thereafter.
Low-intensity psychosocial interventions or group-based: - Individual guided self-help based on CBT principles (and including behavioural activation and problem-solving techniques) 6–8 sessions (face-to-face and by telephone) over 9–12 weeks, including follow-up; - Physical activity programme (group based, 45-60 minutes, 3 sessions per week for 12 weeks); - Individual CBT: CBT 16-20 sessions over 3-4 months. - Individual Occupational Therapy 14 sessions over 3-4 months - Consider individual counselling if you think the patient may benefit or they request it: offer 6–10 sessions over 8–12 weeks. Step 3: CMHSA Persistent moderate depression with inadequate response Step 2 provision, and severe depression in adults Provide a combination of antidepressant medication (SSRI, Venlafaxine a TCA or an MAOI) and a high-intensity psychological intervention: - Individual CBT: 16-20 sessions over 3-4 months. 3-4 follow-up sessions over the next 3-6 months. For moderate or severe depression, consider 2 sessions per week for the first 2–3 weeks. - Behavioural activation: 16–20 sessions over 3–4 months. 3–4 follow-up sessions over the next 3–6 months. For moderate or severe depression, consider 2 sessions per week for the first 3–4 weeks. Step 3 Relapse Prevention

• At remission: continue medication for at least 6 months and then review
• Risk of relapse: advise use of antidepressants for at least 2 years and then review
• Individual CBT if relapse despite antidepressants and for people with a significant history of depression and residual symptoms despite treatment - 16–20 sessions over 3–4 months.
• If more are needed to achieve remission, deliver 2 sessions per week for the first 2–3 weeks; also include 4–6 follow-up sessions in the next 6 months or
• WRAP Step 4: Inpatient management & treatment Severe and complex depression who are at significant risk of suicide, self-harm or self- neglect. For patients with treatment resistant depression and a chronic physical health problem work closely with physical health services and be aware of possible additional drug interactions. For patients with severe or resistant depression, including inpatient care:
• High-intensity psychological interventions with increase of intensity and duration. Consider ECT within in-patient treatment for severe, life-threatening depression and when a rapid response is required, or when other treatments have failed. Depression Pathway The development of this pathway has been guided by the published recommendations of the National Institute for Health and Care Excellence (NICE, 2017)

Eating Disorders Pathway The development of this pathway has been guided by the published recommendations of the National Institute for Health and Care Excellence (NICE, 2017), The Royal College of Psychiatrists, Royal College of Physicians (2010) and Joint Commissioning Panel for Mental Health (2013).

Step 1: Primary Care Target Groups: Young people with low BMI compared to age norms, physical signs of starvation, academic related stress, depression and/or self harm, women with gastrointestinal problems/repeated vomiting/Type 1 Diabetes/women reporting erratic periods or amenorrhoea, adults who exercise compulsively and children with poor growth, Assessment: Use the SCOFF (appendix 1) and assess physical (diabetes/osteoporosis/pregnant/growth & BMI), psychological & social needs, risk to self and indicators of abuse (in children). Low/moderate risk: Age 8-17: refer to the CAMHS

Referral upon discharge from CAMHS ≥18 High risk: severe emancipation, serious risk of self- harm, severe deterioration, poor response to treatment. Consider prompt assessment from endocrinologist at Noble’s Hospital and urgent referral to specialist inpatient service via the OATS panel. Age 8-18: refer to the CAMHS (transition to CMHSA at 18) Age ≥18: refer to the CMHSA Step 3: CMHSA Use the EDE 17.0 to measure of eating disorder psychopathology or the EDE-Q when it is impracticable or undesirable to complete the EDE. Use the CIA immediately after the EDE-Q to monitor severity (repeat as outcome measure). Complete Assessment form for ED-MH. Bulimia Nervosa Binge Eating Disorder OSFED Anorexia Nervosa If appropriate consider encouraging family/significant others to support through treatment.

Guided self-help programme Treat for most closely resembled disorder. BAM - to improve motivation for change

Consider SSRI Fluoxetine increase gradually to 60mg One of the following 3:
1. CBT-ED – 40 sessions/40 weeks 2. MANTRA – 20 sessions (+10 if complex) 3. SSCM - ≥20 sessions

If inappropriate consider: Focal Psychodynamic Therapy 40 sessions/40 weeks

CBT-ED: 20 sessions over 20 weeks; twice weekly appointments in first phase. CBT-ED: 16 weekly 90 minute group session over 4 months. CBT-ED: 16-20 sessions
If vomiting or using laxatives frequently assess fluid and electrolyte balance Consider ECG if: rapid weight loss, excessive exercise, severe purging behaviours, bradycardia, hypotension, excessive caffeine, prescribed or non-prescribed medications, muscular weakness, electrolyte imbalance, previous abnormal heart rhythm. Step 4: Inpatient Management Psychological treatment, structured symptom focused treatment regimen, focus on eating behaviour and individual psychosocial issues. If the patient requires refeeding refer to

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