Common mental health disorders affect as many as one in six people in the community. The 2007 ONS household survey of adult psychiatric morbidity in England found that 16.2% of 16-64 year olds were suffering from an anxiety or depressive disorder.¹ Of those 4.4% were diagnosed with generalised anxiety disorder (GAD); 3.0% with post-traumatic stress disorder (PTSD); 2.3% with major depression; 1.4% with phobias; 1.1% obsessive compulsive disorder (OCD); and 1.1% with panic disorder. The conditions are not mutually exclusive and the most common problem was mixed anxiety and depression, found in 9% of patients.¹ The diagnoses were established through diagnostic psychiatric interviews with subjects screening positive in the survey.

These disorders are even more common in primary care. The New Zealand Magpie Study found that 20.7% of people presenting to primary care had suffered a common mental health disorder over a 12-month period, compared with 14.8% in the community.²

Many patients with common mental health disorders go undetected by GPs, and can suffer disabling symptoms for years as a result, yet treatment is usually successful.

Most sufferers do not consult their GP - only 38% of people with disorders in the ONS survey had asked their doctor for help. Even when patients do present with symptoms they are often not diagnosed. As a consequence, a minority of patients get help in primary care. Only 24% of sufferers in the ONS survey were receiving treatment: 14% medication; 5% counselling or therapy; and 5% both.¹

GPs often fail to identify cases of anxiety and depression among the patients presenting to them. Kessler and colleagues screened patients attending practices to identify cases and followed them up for three years to see if, and when, they were diagnosed by their GP.3 As many as 30% of the cases of anxiety and depression remained undetected at three years’ follow-up, of which 14% were severe cases significantly disabled by their problems.³

NICE has produced a range of guidelines on the management of common mental health disorders covering: depression in adults,⁴ depression with chronic physical health problems,⁵ anxiety (GAD and panic),⁶ antenatal and postnatal mental health,⁷ OCD,⁸ and PTSD.⁹

These guidelines on the individual disorders cover treatment very well, but vary in their coverage of identification, assessment, and appropriate referral. GPs have to consult several different guidelines when presented with common mental health disorders. A major driver for the development of the latest guideline Common mental health disorders: Identification and pathways to care, published in May 2011,¹⁰ was to bring together recommendations on identification, assessment and referral in one place, for easy reference.

Improving identification

The NICE depression guidelines ^{4, 5} recommend that GPs are alert for depression in those with a past history of depression, and in patients with a chronic physical health problem.

The two Whooley questions for depression will be familiar to GPs and practice nurses who have used them to screen patients with diabetes and coronary heart disease for the QOF (see box 1, below):

• During the last month have you often been bothered by feeling down, depressed or hopeless?

• During the last month have you been bothered by having little interest or pleasure in doing things?

The GAD and panic guideline6 also recommends that practitioners look for anxiety disorders in people with chronic physical disorders, plus frequent attenders with multiple functional somatic symptoms, and in patients with excessive alcohol consumption. The new guideline recommends using a brief screening tool for anxiety disorders, the two item screen for generalised anxiety disorder, or GAD-2.11 GAD-2 consists of the first two questions of GAD-7 (see table 1, above). The tool asks:

• Over the last two weeks, how often have you been bothered by the following problems?

1 Feeling nervous, anxious or on edge

2 Not being able to stop or control worrying

If the GAD-2 is positive (GAD score ≥3) the guideline recommends that the practitioner asks patients the other five questions of the GAD-7 tool for generalised anxiety disorder12 (see table 1, above) to make a provisional diagnosis of a significant anxiety disorder.

If the GAD score is ≤ 2 but you still have concerns about anxiety, then ask:

• Do you find yourself avoiding places or activities and does this cause you problems?

If the response is positive, then consider an anxiety disorder.

The GAD is useful among patients with anxiety symptoms within the past two weeks, but some patients with panic, phobias, PTSD, or OCD may not come into this category if they have been avoiding the situations or cues that make them anxious. So the guideline recommends the use of the avoidance question above. If the response is positive it should lead on to further enquiry about situation-specific anxiety. For those with language difficulties, it may be preferable to use the distress thermometer, ¹³ an analogue scale which asks the patient to rate their distress between 0 and 100, with scores above 40 suggesting further assessment should be arranged.

The patient’s mental state

The use of the depression screening and assessment questionnaires in implementing the QOF has been criticised as some practitioners have made decisions on the basis of these scores alone, without carrying out a fuller assessment. The new guideline emphasises that practitioners should go on to:

• characterise the patient’s mental state

• assess the degree to which it interferes with their daily lives

• explore interpersonal and social difficulties with relationships, living conditions, money and family worries which may be causing the problem

It also recommends taking into account previous treatment and considering using further standardised assessments to make specific diagnoses. These would include the PHQ-9¹⁴ or HADS¹⁵ for depression, as currently recommended in the QOF.

Referral

In considering whether referral for specialist psychological or psychiatric treatment is necessary, the guideline recommends that practitioners take into account:

• the patient’s past experience of their disorder, including their experience of, and response to, previous treatments

• the trajectory of their symptoms, their severity and duration

• the degree of associated functional impairment

• comorbid mental or physical disorders complicating the presentation

Psychological wellbeing practitioners receiving referrals from GPs or practice nurses, or self-referrals by the patients themselves, could use the Improving Access to Psychological Therapies (IAPT) screening prompts tool16 to identify specific diagnoses when considering whether patients referred to them should be treated with brief low-intensity therapy initially, or referred straight on to clinical psychologists for high-intensity CBT-based interventions.

Access to care

There are significant barriers to access to both primary care and secondary care for mental health problems, which particularly affect the elderly, black and minority ethnic patients, especially if English is not their first language.

The guideline recommends that GPs and specialists agree explicit criteria for entry to the mental health service, and provide information about services in the care pathway in a range of languages and formats (visual and aural).

Access should be possible from different settings throughout the community, through multiple means of access, including self-referral. The evidence suggests that access is reduced rather than enhanced by restricting entry to a single point of access.

The guideline also recommends that mental health services should be provided in a variety of settings, including the community rather than hospital outpatients, patients’ homes, and outside working hours. A healthcare professional should be designated to oversee the whole of the patient’s journey through the care pathway. It also suggests that crèches, assistance with travel, and advocacy services should be provided to assist patients in accessing treatment.

Text messages, email, the telephone, and internet have all been shown to improve communication with patients, and encourage them to attend for follow-up. Translators should be readily available, and therapists should use culturally sensitive methods of assessment.

A stepped care approach

The guideline recommends that treatment should follow a stepped care approach, such that patients receive the least intrusive treatments first, unless the severity of their problems, or previous non-response to low-intensity treatment, means they should be referred directly on for high-intensity treatment.

The quick reference guide (see useful information box, p32) contains an algorithm summarising the treatment recommendations for all the anxiety disorders and depression, across steps 1, 2, and 3 of the stepped care model.

It is striking that antidepressants are not usually recommended as treatment until step 3, yet in practice most patients receive antidepressants as a first response in general practice.

This algorithm might be a useful resource for practitioners in suggesting treatments they should request from their local psychological services and, if not available already, consider commissioning through the GP consortium. These include newer treatments such as eye movement desensitisation and reprocessing for PTSD, and exposure and response prevention for OCD.