- Email: [email protected]
The role of the general practitioner in severe mental illness
The broader picture
The role of the general practitioner in severe mental illness
they still need the help of their GP as well, if only for repeat prescriptions and sickness certificates. Also, a significant number of people with chronic psychoses receive their regular depot neuroleptic injections from general practice nurses rather than from community mental health nurses. It is very important, therefore, that GPs, practice nurses and other members of the primary care team have an understanding of the problems of their patients with SEMI, and know where to seek help when necessary. GPs do have a number of advantages to help them remain involved in the care of their SEMI patients. They have often known their patients as children or young people before the illness developed, and many people who will not attend psychiatric clinics are still happy to go to their own doctor’s surgery for care. Many community mental health teams (CMHTs) do not offer 24-hour care and the practice is often the first port of call for patients’ relatives when problems develop out of hours.
Tony Kendrick
Abstract Around 25% of patients with severe enduring mental illness (SEMI) lose contact with psychiatric services and are looked after entirely in general practice, so it is important that primary care teams understand their problems and know where to seek help. GPs and practice nurses also have a very important role to play in the physical care of patients with SEMI. High rates of smoking and obesity, and the side effects of psychotropic drugs, mean that these patients are at increased risk of developing heart disease, chronic obstructive lung disease and diabetes. Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia. Regular structured assessments of SEMI patients in general practice have been shown to improve the process and outcome of care. The National Service Framework recommended that practices produce a register of patients, to ensure that regular reviews are carried out, including both mental and physical health problems. Since 2003, the UK GP contract has awarded practices money to produce a register and carry out regular reviews of SEMI patients. Practices can set up registers easily, using repeat prescribing data and computer diagnostic labels. Regular reviews should include a check on symptoms, medication, physical health and coordination arrangements with secondary care. In the UK, practice computer systems now provide a template for recording regular reviews, to enable practices to meet their contract targets.
Physical and preventative care GPs and practice nurses have an important role to play in the physical care of patients with SEMI. High rates of smoking and obesity – in part due to the side effects of psychotropic drugs – mean that these patients are at increased risk of developing chronic bronchitis, hypertension and angina.3 Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia, and regular screening for coronary heart disease has been recommended.4 Rates of diabetes are also significantly higher than the general population,5 which may be due in part to the diabetogenic effects of medication, particularly the newer atypical antipsychotics like olanzepine and risperidone. The UK NICE clinical guideline on schizophrenia recommended physical health checks for diabetes, blood pressure, lipids, and smoking.6 The NICE clinical guideline on bipolar disorder recommended an annual physical health check including weight, smoking status, alcohol use, fasting cholesterol in all patients over 40, and fasting plasma glucose level for diabetes.7
Keywords bipolar disorder; family practice; primary care; regular review; schizophrenia; severe enduring mental illness; structured records
The need for a register of patients with SEMI General practice is essentially reactive: GPs and practice nurses wait for patients to come and see them or request a home visit. However, a significant proportion of patients with SEMI need to be sought out for review. GPs and practice nurses need to be aware of those who do not attend for review, in order to alert the CMHT to find out if the patient is experiencing difficulties. This involves reversing the usual assumption in primary care that if a patient does not return it means they are well. To be aware of who is and is not attending for care, the practice ideally needs a register of patients with SEMI. The NSF recommends that agreements should be reached between primary care and specialist mental health services to target care management resources for people with SEMI, and that practices should produce a register of such patients, to ensure that regular reviews are carried out (to include both mental and physical health problems).
Primary care teams and the care of severe mental illness The UK National Service Framework (NSF) for Mental Health urged mental health teams to stay in contact with all people with severe and enduring mental illnesses (SEMI),1 but in reality a significant proportion (25–30% of patients) will lose contact with psychiatric services and be looked after entirely in general practice.2 Even when patients are in contact with specialist services
Tony Kendrick FRCGP FRCPsych is a General Practitioner and Professor of Primary Medical Care at the University of Southampton School of Medicine, UK. His doctoral thesis was a study of improving the care of people with long-term mental illness in general practice. He has written more than 70 papers, 20 book chapters and four books on mental health problems in primary care, including depression, eating disorders, bereavement, and carers’ health, as well as schizophrenia and other severe and enduring mental illnesses. Conflicts of interest: none declared.
PSYCHIATRY 6:8
Drawing up a register of patients with SEMI Over 90% of patients with SEMI can be quickly identified, especially now that most practices are computerized, by listing all 343
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
those already known to the primary care team and CMHT, combined with searching repeat prescription systems for psychotropic drugs.2 Table 1 lists sources of information that might help in the construction of a register. Having identified the patients, the GP should check their records for current contact with psychiatric services; the GP should have been informed of all patients in receipt of the Care Programme Approach (CPA). Patients who are out of contact may benefit from referral back to secondary care, although a proportion of patients will decline referral, preferring to see their GP for continuing care.
inactivity, a poor self-image, self-neglect and indifference to discomfort) are unlikely to bring problems to their GP’s attention. A number of problems can build up which could lead to a crisis in care if not detected. What is needed, therefore, is a repertoire of specific closed questions to ensure that problems are not missed. Table 2 shows a special record card designed for general practice Lloyd George-size record envelopes. On one side is important summary information which might be needed in an emergency – such as being called to see a partner’s patient on a Friday evening when everyone else has gone home – and on the other is a structured record focusing on important areas of mental and physical health and social functioning. There are now computer templates for paperless practices to use for their structured assessments of their SEMI patients. EMIS, probably the commonest system used in general practice, has a bespoke template.
The need for structured patient assessments Patient contacts in primary care are relatively short: an average of 8 minutes per consultation in the GP’s surgery, perhaps longer on home visits; practice nurse appointments may last only 5 minutes for a depot injection. Therefore GPs and practice nurses need a strategy to identify important problems or changes in their patients with SEMI quickly and efficiently. There is not time to carry out lengthy, comprehensive psychiatric and social assessment of the kind performed in specialist outpatient clinics. Traditionally, GPs have been taught that the most efficient consulting style is to start with an open question and encourage the patient to set the agenda. This ensures that the patient’s concerns are quickly identified and can be addressed in the time available. However, this approach may be inappropriate for many people with SEMI. Those with negative symptoms (including apathy,
The evidence base A randomized controlled trial (RCT) of setting up registers of the long-term mentally ill and teaching GPs to carry out structured assessments of these patients was carried out in 16 group practices in the south of England.8 The assessments were associated with clear changes in the process of patient care over a 2-year period. Changes in psychotropic medication, particularly neuroleptic drugs, and referrals for psychosocial problems, particularly to community mental health nurses, were significantly more frequent in the intervention group. However, most of the GPs in the study, who were self-selected for their interest in mental health, considered that there was not enough time in routine consultations to carry out the structured assessments. It seemed unlikely, therefore, that most GPs would be willing to do it. An alternative approach involved setting up special clinic sessions in practices to assess patients with SEMI, similar to those for asthma and diabetes that are already widespread in general practice. Nazareth and colleagues carried out a controlled trial of such an approach in four inner-London practices and found it to be generally feasible, and to lead to small but measurable improvements in symptoms on the Present State Examination and functioning on the Global Assessment Scale.9 A third approach was an RCT of teaching practice nurses who give depot neuroleptic injections to carry out brief structured assessments during injection appointments and to bring any problems to their GP’s attention.10 The trial found that the practice nurses were generally unsure and anxious about the problems of people with chronic psychosis and keen to learn more about them. However, the impact of training nurses in structured assessments on patient care could not be demonstrated. This seemed to be because problems uncovered by the nurses were not always dealt with by their GPs. It was concluded that joint GP and nurse assessments would be best, in special clinic sessions.
Drawing up a register of patients with severe and enduring mental illnesses Patients can be identified from the following sources: Practice data • Computerized prescriptions for patients on: • antipsychotic drugs (oral and depot) • anticholinergics • antidepressants • anxiolytics • Computerized diagnostic records or disease register, where appropriate • Patients being seen for depot injections by the practice nurse, where appropriate • Appointment lists of patients seen in surgery or on home visits in the previous 3 months (as a reminder of patients who are not on medication or seeing the nurse) Mental health services data • Patients of the community psychiatric nurse • Consultant psychiatrists’ case-registers and outpatient records • Day-hospital patients
Targeted payments in general practice
Social services data • Social workers’ caseloads
Initiatives aimed at increasing the quantity and quality of reviews of patients with SEMI in general practice have the potential to change the process and outcome of care. Setting up registers and special review sessions is time-consuming, however, and competes with numerous other obligations in general practice. These
(Source: Kendrick et al., 1994.2)
Table 1
PSYCHIATRY 6:8
344
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
Important elements to be included in regular general practice structured reviews of patients with severe and enduring mental illnesses Side 1
Side 2
Name First diagnosed Hospital admissions Relatives/other carers
DOB Hospital no.
GP Consultant Psychologist Pattern of relapse Important notes
Community psychiatric nurse Social worker Occupational therapist
Date Medication Anxiety Depression Hallucinations Delusions Appearance Behaviour Preventive Physical Housing Finance Daily activities
Table 2
initiatives therefore need to be promoted through targeted remuneration. Burns and Cohen showed that more practices in southwest London would set up joint GP/practice nurse assessments in response to the introduction of trial item-of-service payments for the initiative.11 The new General Medical Services contract for GPs in the UK, agreed in 2003, allowed practices to earn more money if they adopted two quality indicators related to SEMI. Practices could earn points for producing a register of people with SEMI who
require regular follow-up, and points related to the percentage of patients on the register with a review recorded in the preceding 15 months, which included a check on the accuracy of prescribed medication, a review of physical health, and a review of coordination arrangements with secondary care. The contract was revised in 2006 to tighten the definition of SEMI to include only people with long-term functional psychoses (schizophrenia, bipolar affective disorder and other psychoses), using ICD-10 criteria in line with other areas of the contract.12 The previous definition was more generic and allowed some practices to include people with chronic depression or anxiety disorders. However, some people with those non-psychotic diagnoses are nevertheless significantly disabled by their illness and could benefit from a similar structured review. Table 3 shows the recommended elements of the regular review for which practices can earn extra income under the new contract. The revised contract also introduced points for actively following up patients on the register who fail to attend for regular review, within 14 days of their non-attendance.
Recommended elements for the regular review of SEMI patients Physical care • Routine health promotion and prevention advice appropriate to the patient’s age, gender and health status (e.g. weight, blood pressure, cholesterol, cervical cytology, mammography) • Issues relating to alcohol or drug use • Smoking and heart disease (including history suggestive of arrhythmias) • Risk of diabetes (particularly with olanzapine and risperidone)
Conclusion People with severe and enduring mental illnesses are among the most vulnerable members of society. Motivating and rewarding primary care teams for focusing more of their efforts on this group has the potential to make a huge difference to their future health and life expectancy. ◆
Medication • Accuracy of medication which the GP is prescribing Coordination of services • Community mental health nurse involvement • Inclusion of patient in Care Programme Approach • What services are actually being received by the patient and their carers
References 1 Department of Health. National service framework for mental health. London: Department of Health, 1999. 2 Kendrick T, Burns T, Freeling P, et al. Provision of care to general practice patients with disabling long-term mental illnesses: a survey in 16 practices. Br J Gen Pract 1994; 44: 301–05.
(Source: NHS Confederation/BMA, 2003 and revised 2006.)
Table 3
PSYCHIATRY 6:8
345
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
Further reading Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Pract 1997; 47: 515–20. (Practical, evidence-based guidelines developed by an expert consensus group.) Gask L, Roger A, Roland M, et al. A practical guide to the national service framework for mental health, 30–31, 2nd edn. Manchester: National Primary Care Research and Development Centre, 2003 (www.npcrdc.man.ac.uk). (Includes practical guidance on setting up registers and implementing regular review.) New GMS contract. Investing in general practice. London: NHS Confederation/BMA, 2003. (Includes a separate book of supporting documentation.)
3 Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatry 1996; 169: 733–39. 4 Osborn DPJ, Nazareth I, King MB. Risk for coronary heart disease in people with severe mental illness. Cross-sectional comparative study in primary care. Br J Psychiatry 2006; 188: 271–77. 5 Bushe C, Holt R. Prevalence of diabetes and impaired glucose tolerance in patients with schizophrenia. Br J Psychiatry 2004; 184(suppl 47): s67–s71. 6 National Institute for Clinical Excellence. Clinical guideline 1. Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: National Institute for Clinical Excellence, 2002. 7 National Institute for Health and Clinical Excellence. Clinical guideline 38. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. London: National Institute for Health and Clinical Excellence, 2006. 8 Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. Br Med J 1995; 311: 93–98. 9 Nazareth I, King M, See Tai S. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatry 1996; 169: 482. 10 Burns T, Millar E, Garland C, et al. Randomized controlled trial of teaching practice nurses to carry out structured assessments of patients receiving depot antipsychotic injections. Br J Gen Pract 1998; 48: 1845–48. 11 Burns T, Cohen A. Item-of-service payments for general practitioner care of severely mentally ill persons: does the money matter? Br J Gen Pract 1998; 48: 1415–16. 12 World Health Organization. International classification of diseases. (ICD-10), 10th edn. Geneva: WHO, 1992.
PSYCHIATRY 6:8
Practice points • People with SEMI often do not present for regular review in primary care • Practices can easily set up registers, using repeat prescribing data • Regular structured assessments can improve the process and outcome of care • Practices can now earn extra income for reviewing their SEMI patients
346
© 2007 Elsevier Ltd. All rights reserved.
The role of the general practitioner in severe mental illness
they still need the help of their GP as well, if only for repeat prescriptions and sickness certificates. Also, a significant number of people with chronic psychoses receive their regular depot neuroleptic injections from general practice nurses rather than from community mental health nurses. It is very important, therefore, that GPs, practice nurses and other members of the primary care team have an understanding of the problems of their patients with SEMI, and know where to seek help when necessary. GPs do have a number of advantages to help them remain involved in the care of their SEMI patients. They have often known their patients as children or young people before the illness developed, and many people who will not attend psychiatric clinics are still happy to go to their own doctor’s surgery for care. Many community mental health teams (CMHTs) do not offer 24-hour care and the practice is often the first port of call for patients’ relatives when problems develop out of hours.
Tony Kendrick
Abstract Around 25% of patients with severe enduring mental illness (SEMI) lose contact with psychiatric services and are looked after entirely in general practice, so it is important that primary care teams understand their problems and know where to seek help. GPs and practice nurses also have a very important role to play in the physical care of patients with SEMI. High rates of smoking and obesity, and the side effects of psychotropic drugs, mean that these patients are at increased risk of developing heart disease, chronic obstructive lung disease and diabetes. Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia. Regular structured assessments of SEMI patients in general practice have been shown to improve the process and outcome of care. The National Service Framework recommended that practices produce a register of patients, to ensure that regular reviews are carried out, including both mental and physical health problems. Since 2003, the UK GP contract has awarded practices money to produce a register and carry out regular reviews of SEMI patients. Practices can set up registers easily, using repeat prescribing data and computer diagnostic labels. Regular reviews should include a check on symptoms, medication, physical health and coordination arrangements with secondary care. In the UK, practice computer systems now provide a template for recording regular reviews, to enable practices to meet their contract targets.
Physical and preventative care GPs and practice nurses have an important role to play in the physical care of patients with SEMI. High rates of smoking and obesity – in part due to the side effects of psychotropic drugs – mean that these patients are at increased risk of developing chronic bronchitis, hypertension and angina.3 Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia, and regular screening for coronary heart disease has been recommended.4 Rates of diabetes are also significantly higher than the general population,5 which may be due in part to the diabetogenic effects of medication, particularly the newer atypical antipsychotics like olanzepine and risperidone. The UK NICE clinical guideline on schizophrenia recommended physical health checks for diabetes, blood pressure, lipids, and smoking.6 The NICE clinical guideline on bipolar disorder recommended an annual physical health check including weight, smoking status, alcohol use, fasting cholesterol in all patients over 40, and fasting plasma glucose level for diabetes.7
Keywords bipolar disorder; family practice; primary care; regular review; schizophrenia; severe enduring mental illness; structured records
The need for a register of patients with SEMI General practice is essentially reactive: GPs and practice nurses wait for patients to come and see them or request a home visit. However, a significant proportion of patients with SEMI need to be sought out for review. GPs and practice nurses need to be aware of those who do not attend for review, in order to alert the CMHT to find out if the patient is experiencing difficulties. This involves reversing the usual assumption in primary care that if a patient does not return it means they are well. To be aware of who is and is not attending for care, the practice ideally needs a register of patients with SEMI. The NSF recommends that agreements should be reached between primary care and specialist mental health services to target care management resources for people with SEMI, and that practices should produce a register of such patients, to ensure that regular reviews are carried out (to include both mental and physical health problems).
Primary care teams and the care of severe mental illness The UK National Service Framework (NSF) for Mental Health urged mental health teams to stay in contact with all people with severe and enduring mental illnesses (SEMI),1 but in reality a significant proportion (25–30% of patients) will lose contact with psychiatric services and be looked after entirely in general practice.2 Even when patients are in contact with specialist services
Tony Kendrick FRCGP FRCPsych is a General Practitioner and Professor of Primary Medical Care at the University of Southampton School of Medicine, UK. His doctoral thesis was a study of improving the care of people with long-term mental illness in general practice. He has written more than 70 papers, 20 book chapters and four books on mental health problems in primary care, including depression, eating disorders, bereavement, and carers’ health, as well as schizophrenia and other severe and enduring mental illnesses. Conflicts of interest: none declared.
PSYCHIATRY 6:8
Drawing up a register of patients with SEMI Over 90% of patients with SEMI can be quickly identified, especially now that most practices are computerized, by listing all 343
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
those already known to the primary care team and CMHT, combined with searching repeat prescription systems for psychotropic drugs.2 Table 1 lists sources of information that might help in the construction of a register. Having identified the patients, the GP should check their records for current contact with psychiatric services; the GP should have been informed of all patients in receipt of the Care Programme Approach (CPA). Patients who are out of contact may benefit from referral back to secondary care, although a proportion of patients will decline referral, preferring to see their GP for continuing care.
inactivity, a poor self-image, self-neglect and indifference to discomfort) are unlikely to bring problems to their GP’s attention. A number of problems can build up which could lead to a crisis in care if not detected. What is needed, therefore, is a repertoire of specific closed questions to ensure that problems are not missed. Table 2 shows a special record card designed for general practice Lloyd George-size record envelopes. On one side is important summary information which might be needed in an emergency – such as being called to see a partner’s patient on a Friday evening when everyone else has gone home – and on the other is a structured record focusing on important areas of mental and physical health and social functioning. There are now computer templates for paperless practices to use for their structured assessments of their SEMI patients. EMIS, probably the commonest system used in general practice, has a bespoke template.
The need for structured patient assessments Patient contacts in primary care are relatively short: an average of 8 minutes per consultation in the GP’s surgery, perhaps longer on home visits; practice nurse appointments may last only 5 minutes for a depot injection. Therefore GPs and practice nurses need a strategy to identify important problems or changes in their patients with SEMI quickly and efficiently. There is not time to carry out lengthy, comprehensive psychiatric and social assessment of the kind performed in specialist outpatient clinics. Traditionally, GPs have been taught that the most efficient consulting style is to start with an open question and encourage the patient to set the agenda. This ensures that the patient’s concerns are quickly identified and can be addressed in the time available. However, this approach may be inappropriate for many people with SEMI. Those with negative symptoms (including apathy,
The evidence base A randomized controlled trial (RCT) of setting up registers of the long-term mentally ill and teaching GPs to carry out structured assessments of these patients was carried out in 16 group practices in the south of England.8 The assessments were associated with clear changes in the process of patient care over a 2-year period. Changes in psychotropic medication, particularly neuroleptic drugs, and referrals for psychosocial problems, particularly to community mental health nurses, were significantly more frequent in the intervention group. However, most of the GPs in the study, who were self-selected for their interest in mental health, considered that there was not enough time in routine consultations to carry out the structured assessments. It seemed unlikely, therefore, that most GPs would be willing to do it. An alternative approach involved setting up special clinic sessions in practices to assess patients with SEMI, similar to those for asthma and diabetes that are already widespread in general practice. Nazareth and colleagues carried out a controlled trial of such an approach in four inner-London practices and found it to be generally feasible, and to lead to small but measurable improvements in symptoms on the Present State Examination and functioning on the Global Assessment Scale.9 A third approach was an RCT of teaching practice nurses who give depot neuroleptic injections to carry out brief structured assessments during injection appointments and to bring any problems to their GP’s attention.10 The trial found that the practice nurses were generally unsure and anxious about the problems of people with chronic psychosis and keen to learn more about them. However, the impact of training nurses in structured assessments on patient care could not be demonstrated. This seemed to be because problems uncovered by the nurses were not always dealt with by their GPs. It was concluded that joint GP and nurse assessments would be best, in special clinic sessions.
Drawing up a register of patients with severe and enduring mental illnesses Patients can be identified from the following sources: Practice data • Computerized prescriptions for patients on: • antipsychotic drugs (oral and depot) • anticholinergics • antidepressants • anxiolytics • Computerized diagnostic records or disease register, where appropriate • Patients being seen for depot injections by the practice nurse, where appropriate • Appointment lists of patients seen in surgery or on home visits in the previous 3 months (as a reminder of patients who are not on medication or seeing the nurse) Mental health services data • Patients of the community psychiatric nurse • Consultant psychiatrists’ case-registers and outpatient records • Day-hospital patients
Targeted payments in general practice
Social services data • Social workers’ caseloads
Initiatives aimed at increasing the quantity and quality of reviews of patients with SEMI in general practice have the potential to change the process and outcome of care. Setting up registers and special review sessions is time-consuming, however, and competes with numerous other obligations in general practice. These
(Source: Kendrick et al., 1994.2)
Table 1
PSYCHIATRY 6:8
344
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
Important elements to be included in regular general practice structured reviews of patients with severe and enduring mental illnesses Side 1
Side 2
Name First diagnosed Hospital admissions Relatives/other carers
DOB Hospital no.
GP Consultant Psychologist Pattern of relapse Important notes
Community psychiatric nurse Social worker Occupational therapist
Date Medication Anxiety Depression Hallucinations Delusions Appearance Behaviour Preventive Physical Housing Finance Daily activities
Table 2
initiatives therefore need to be promoted through targeted remuneration. Burns and Cohen showed that more practices in southwest London would set up joint GP/practice nurse assessments in response to the introduction of trial item-of-service payments for the initiative.11 The new General Medical Services contract for GPs in the UK, agreed in 2003, allowed practices to earn more money if they adopted two quality indicators related to SEMI. Practices could earn points for producing a register of people with SEMI who
require regular follow-up, and points related to the percentage of patients on the register with a review recorded in the preceding 15 months, which included a check on the accuracy of prescribed medication, a review of physical health, and a review of coordination arrangements with secondary care. The contract was revised in 2006 to tighten the definition of SEMI to include only people with long-term functional psychoses (schizophrenia, bipolar affective disorder and other psychoses), using ICD-10 criteria in line with other areas of the contract.12 The previous definition was more generic and allowed some practices to include people with chronic depression or anxiety disorders. However, some people with those non-psychotic diagnoses are nevertheless significantly disabled by their illness and could benefit from a similar structured review. Table 3 shows the recommended elements of the regular review for which practices can earn extra income under the new contract. The revised contract also introduced points for actively following up patients on the register who fail to attend for regular review, within 14 days of their non-attendance.
Recommended elements for the regular review of SEMI patients Physical care • Routine health promotion and prevention advice appropriate to the patient’s age, gender and health status (e.g. weight, blood pressure, cholesterol, cervical cytology, mammography) • Issues relating to alcohol or drug use • Smoking and heart disease (including history suggestive of arrhythmias) • Risk of diabetes (particularly with olanzapine and risperidone)
Conclusion People with severe and enduring mental illnesses are among the most vulnerable members of society. Motivating and rewarding primary care teams for focusing more of their efforts on this group has the potential to make a huge difference to their future health and life expectancy. ◆
Medication • Accuracy of medication which the GP is prescribing Coordination of services • Community mental health nurse involvement • Inclusion of patient in Care Programme Approach • What services are actually being received by the patient and their carers
References 1 Department of Health. National service framework for mental health. London: Department of Health, 1999. 2 Kendrick T, Burns T, Freeling P, et al. Provision of care to general practice patients with disabling long-term mental illnesses: a survey in 16 practices. Br J Gen Pract 1994; 44: 301–05.
(Source: NHS Confederation/BMA, 2003 and revised 2006.)
Table 3
PSYCHIATRY 6:8
345
© 2007 Elsevier Ltd. All rights reserved.
The broader picture
Further reading Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Pract 1997; 47: 515–20. (Practical, evidence-based guidelines developed by an expert consensus group.) Gask L, Roger A, Roland M, et al. A practical guide to the national service framework for mental health, 30–31, 2nd edn. Manchester: National Primary Care Research and Development Centre, 2003 (www.npcrdc.man.ac.uk). (Includes practical guidance on setting up registers and implementing regular review.) New GMS contract. Investing in general practice. London: NHS Confederation/BMA, 2003. (Includes a separate book of supporting documentation.)
3 Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatry 1996; 169: 733–39. 4 Osborn DPJ, Nazareth I, King MB. Risk for coronary heart disease in people with severe mental illness. Cross-sectional comparative study in primary care. Br J Psychiatry 2006; 188: 271–77. 5 Bushe C, Holt R. Prevalence of diabetes and impaired glucose tolerance in patients with schizophrenia. Br J Psychiatry 2004; 184(suppl 47): s67–s71. 6 National Institute for Clinical Excellence. Clinical guideline 1. Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: National Institute for Clinical Excellence, 2002. 7 National Institute for Health and Clinical Excellence. Clinical guideline 38. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. London: National Institute for Health and Clinical Excellence, 2006. 8 Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. Br Med J 1995; 311: 93–98. 9 Nazareth I, King M, See Tai S. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatry 1996; 169: 482. 10 Burns T, Millar E, Garland C, et al. Randomized controlled trial of teaching practice nurses to carry out structured assessments of patients receiving depot antipsychotic injections. Br J Gen Pract 1998; 48: 1845–48. 11 Burns T, Cohen A. Item-of-service payments for general practitioner care of severely mentally ill persons: does the money matter? Br J Gen Pract 1998; 48: 1415–16. 12 World Health Organization. International classification of diseases. (ICD-10), 10th edn. Geneva: WHO, 1992.
PSYCHIATRY 6:8
Practice points • People with SEMI often do not present for regular review in primary care • Practices can easily set up registers, using repeat prescribing data • Regular structured assessments can improve the process and outcome of care • Practices can now earn extra income for reviewing their SEMI patients
346
© 2007 Elsevier Ltd. All rights reserved.