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Common mental health disorders in primary care

About

What is covered

This pathway covers identifying common mental health disorders in people aged 18 and over in primary care and the principles for treatment and referral.

Updates

Updates to this pathway

5 February 2014 Anxiety disorders (quality standard 53) added.
12 December 2013 Mental wellbeing of older people in care homes (quality standard 50) added.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on identifying and managing common mental health disorders in adults in primary care in an interactive flowchart

What is covered

This pathway covers identifying common mental health disorders in people aged 18 and over in primary care and the principles for treatment and referral.

Updates

Updates to this pathway

5 February 2014 Anxiety disorders (quality standard 53) added.
12 December 2013 Mental wellbeing of older people in care homes (quality standard 50) added.

Sources

NICE guidance and other sources used to create this pathway.
Anxiety disorders (2014) NICE quality standard 53
Mental wellbeing of older people in care homes (2013) NICE quality standard 50
Depression in adults (2011) NICE quality standard 8

Quality standards

Mental wellbeing of older people in care homes

These quality statements are taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice for mental wellbeing of older people in care homes and should be read in full.

Anxiety disorders

These quality statements are taken from the anxiety disorders quality standard. The quality standard defines clinical best practice for anxiety disorders care and should be read in full.

Quality statements

Assessment

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.

Quality measure

Structure: Evidence of an assessment process for people who may have depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Process: Proportion of people who receive an assessment for depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Numerator – the number of people in the denominator receiving an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Denominator – the number of people receiving an assessment for depression.

What the quality statement means for each audience

Service providers ensure that a process is in place for assessing people who may have depression that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Healthcare professionals ensure that people who may have depression are assessed using a process that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
Commissioners ensure they commission services that have an assessment process in place that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.
People who may have depression receive an assessment to find out how severe their symptoms are, how much they are affected by the depression and how long it has lasted for.

Definitions

The term ‘people who may have depression’ includes all people with a chronic physical health problem who may have depression.
For details of the assessment see appendix C of NICE clinical guideline 90 and 91. This should be supported by use of a formal rating scale for symptom severity (for example, Patient Health Questionnaire [PHQ-9], Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI]).
The assessment of functional impairment should include social perspectives of impairment as defined by the World Health Organisation International Classification of Functioning, Disability and Health.

Source guidance

NICE clinical guideline 90 recommendation 1.1.4.1 and NICE clinical guideline 91 recommendation 1.1.3.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection. Information on assessment of severity is collected by Quality and Outcomes Framework (QOF) indicator Depression 2: In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care.

Equality and diversity considerations

Quality statement 1 should be supplemented with recommendation 1.3.1.5 (which is the same in NICE clinical guideline 90 and 91) in cases where the person with depression has significant language or communication difficulties.
Recommendation 1.3.1.5 states: ‘For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer and/or asking a family member or carer about the person’s symptoms to identify possible depression. If a significant level of distress is identified, investigate further.’

Practitioner competence

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.

Quality measure

Structure:
a) Evidence of local arrangements for the regular supervision of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression.
b) Evidence of local arrangements for regular monitoring of compliance with applicable competencies for practitioners delivering pharmacological, psychological or psychosocial interventions.
c) Evidence that services are commissioned to provide pharmacological, psychological or psychosocial interventions of content and duration in accordance with NICE guidance for people with depression.
Process:
a) Proportion of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression who receive regular supervision.
Numerator – the number of practitioners in the denominator receiving regular supervision.
Denominator – the number of practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression.
b) Proportion of people with depression receiving interventions who receive interventions of appropriate content in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving interventions of appropriate content in accordance with NICE guidance.
Denominator – the number of people with depression receiving psychological, psychosocial or pharmacological interventions.
c) Proportion of people with depression receiving interventions who receive interventions of appropriate duration in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving interventions of appropriate duration in accordance with NICE guidance.
Denominator – the number of people with depression receiving psychological, psychosocial or pharmacological interventions.

What the quality statement means for each audience

Service providers ensure systems are in place to regularly supervise practitioners to ensure they are competent in delivering interventions of appropriate content and duration for people with depression in accordance with NICE guidance.
Healthcare professionals ensure they are competent to deliver interventions of appropriate content and duration for people with depression in accordance with NICE guidance.
Commissioners ensure they commission services that supervise practitioners and provide programmes of appropriate content and duration for people with depression in accordance with NICE guidance.
People with depression receive suitable treatment for the right length of time from competent staff.

Definitions

The term ‘people with depression’ includes all people with depression and a chronic physical health problem.
NICE clinical guideline 90 and 91 provide information on the correct content and duration of interventions.
Competencies for practitioners delivering psychological therapies are provided by the Improving Access to Psychological Therapies (IAPT) programme.
A competency based curriculum for specialist training in psychiatry is provided by the Royal College of Psychiatrists.
Regular supervision involves a review and reflection on practice and should be in a format appropriate to the setting, type of practitioner and type of intervention being delivered.

Source guidance

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Recording health outcomes

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust delivery of interventions.

Quality measure

Structure: Evidence of systems in place to monitor health outcomes for people with depression at each appointment and use the findings to adjust delivery of interventions.
Process: Proportion of people with depression receiving pharmacological, psychological or psychosocial interventions who have their health outcomes recorded at initial contact and subsequent review.
Numerator – the number of people in the denominator whose health outcomes are recorded at initial contact and subsequent review.
Denominator – the number of people with depression receiving pharmacological, psychological or psychosocial interventions.
(Suggested audit standard derived from Improving Access to Psychological Therapies [IAPT] performance indicators: Achievement of 90% data completion of health outcomes at initial contact and subsequent review).

What the quality statement means for each audience

Service providers ensure systems are in place to record patient health outcomes.
Healthcare professionals ensure they record patient health outcomes and use findings to adjust delivery of interventions.
Commissioners ensure they commission services that record patient health outcomes at each appointment and use findings to adjust delivery of interventions.
People with depression have their progress checked at each appointment to help decide on how best to continue with treatments.

Source guidance

NICE clinical guideline 90 recommendation 1.1.5.1 and NICE clinical guideline 91 recommendation 1.1.4.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Low-intensity interventions for persistent subthreshold depressive symptoms or mild to moderate depression

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.

Quality measure

Structure: Evidence of local arrangements to provide appropriate low-intensity psychosocial interventions to people with persistent subthreshold depressive symptoms or mild to moderate depression.
Process: Proportion of people with persistent subthreshold symptoms or mild to moderate depression who receive appropriate low-intensity psychosocial interventions.
Numerator – the number of people in the denominator receiving appropriate low-intensity psychosocial interventions.
Denominator – the number of people with persistent subthreshold depressive symptoms or mild to moderate depression.

What the quality statement means for each audience

Service providers ensure systems are in place for people with persistent subthreshold depressive symptoms or mild to moderate depression to access appropriate low-intensity psychosocial interventions.
Healthcare professionals ensure people with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.
Commissioners ensure they commission services that provide appropriate low-intensity psychosocial interventions to people with persistent subthreshold depressive symptoms or mild to moderate depression.
People with some mild but long-lasting symptoms of depression or with mild or moderate depression__ receive appropriate psychological treatment, for example a self-help programme (undertaken alone or, if the person has a long-term physical health problem, in a group), a group exercise programme, or a treatment using a computer called ‘computerised cognitive behavioural therapy’ (or CCBT for short).

Definitions

The term ‘people with persistent subthreshold depressive symptoms or mild to moderate depression’ includes all people with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem.
NICE clinical guideline 90 and 91 define appropriate low-intensity interventions as:
  • individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
  • a structured group physical activity programme
  • computerised CBT
  • group-based CBT for people with persistent subthreshold depressive symptoms or mild to moderate depression and no existing chronic physical health problem who decline low-intensity psychosocial intervention
  • a group-based peer support (self-help) programme (for people with persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem only).

Source guidance

NICE clinical guideline 90 recommendations 1.4.2.1 and 1.4.3.1, and NICE clinical guideline 91 recommendation 1.4.2.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Equality and diversity considerations

NICE clinical guideline 90 recommendation 1.4.2.1 and NICE clinical guideline 91 recommendation 1.4.2.1 include computerised cognitive behavioural therapy as a recommended intervention, which has been identified as a possible issue for people with learning disabilities and acquired cognitive impairment (although it may improve access for some people with mobility problems). A number of alternative interventions are offered in the recommendations (guided self-help, physical activity, peer support) in order to take this into account.
In addition, people with physical disabilities may experience access issues relating to participation in physical activity interventions. Therefore alternative interventions are provided in recommendation 1.4.2.1. In addition, recommendation 1.4.2.2 (NICE clinical guideline 91) recommends that physical activity programmes are modified to take into account participants’ physical disability.

Antidepressants for persistent subthreshold depressive symptoms or mild depression

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.

Quality measure

Structure: Evidence of local arrangements to support the correct prescribing of antidepressants to people with persistent subthreshold depressive symptoms or mild depression in accordance with the NICE guidance.
Process: Proportion of people with persistent subthreshold depressive symptoms or mild depression prescribed antidepressant medication who meet specific clinical criteria for the prescription of antidepressants in accordance with NICE guidance.
Numerator – the number of people in the denominator meeting the specific clinical criteria for the prescription of antidepressants in accordance with NICE guidance.
Denominator – the number of people with persistent subthreshold depressive symptoms or mild depression prescribed antidepressants.

What the quality statement means for each audience

Service providers ensure policies are in place for the prescription of antidepressants to people with subthreshold depressive symptoms or mild depression only when specific clinical criteria are met in accordance with NICE guidance.
Healthcare professionals ensure they prescribe antidepressants to people with subthreshold depressive symptoms or mild depression only when the person meets the specific clinical criteria in accordance with NICE guidance.
Commissioners ensure they commission services that monitor whether the prescription of antidepressants to people with subthreshold depressive symptoms or mild depression is being carried out in accordance with NICE guidance.
People with some mild but long-lasting symptoms of depression or mild depression are not usually prescribed antidepressants except in particular circumstances (for example, if they have had moderate or severe depression in the past; have depression which has lasted for a long time – usually at least 2 years; still have depression after other treatments; or if treatment of a physical health problem is made more difficult because of mild depression).

Definitions

The term ‘people with persistent subthreshold depressive symptoms or mild depression’ includes all people with persistent subthreshold depressive symptoms or mild depression and a chronic physical health problem.
NICE clinical guideline 90 recommendation 1.4.4.1 and NICE clinical guideline 91 recommendation 1.4.3.1 state that antidepressants should not be used routinely for people with persistent subthreshold depressive symptoms or mild depression, but may be considered in cases where there is:
  • a past history of moderate or severe depression or
  • initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
  • subthreshold depressive symptoms or mild depression that persist(s) after other interventions or
  • mild depression that complicates the care of a physical health problem (for people with depression and a chronic physical health problem only).

Source guidance

NICE clinical guideline 90 recommendation 1.4.4.1 and NICE clinical guideline 91 recommendation 1.4.3.1 (key priorities for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Moderate to severe depression and no existing chronic physical health problem

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.

Quality measure

Structure: Evidence of coordination and cooperation between services delivering pharmacological and psychological interventions.
Process: Proportion of people with moderate or severe depression (and no existing chronic physical health problem) who receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Numerator – the number of people in the denominator receiving a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Denominator – the number of people with moderate or severe depression (and no existing chronic physical health problem).

What the quality statement means for each audience

Service providers ensure systems are in place for the delivery of a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy for people with moderate or severe depression (and no existing chronic physical health problem).
Healthcare professionals ensure people with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.
Commissioners ensure coordination and cooperation between services to enable effective delivery of combined psychological and pharmacological therapy for people with moderate or severe depression and no existing chronic physical health problem.
People with moderate or severe depression and no long-term physical health problems receive antidepressants along with psychological treatments (either a treatment called ‘cognitive behavioural therapy’, or CBT for short, or a treatment called ‘interpersonal therapy’, or IPT for short).

Source guidance

NICE clinical guideline 90 recommendation 1.5.1.2 (key priority for implementation).

Data sources

Structure: Local data collection.
Process: Local data collection.

Moderate depression and a chronic physical health problem

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with moderate depression and a chronic physical health problem receive an appropriate high-intensity psychological intervention.

Quality measure

Structure: Evidence of local arrangements to provide appropriate high-intensity psychological interventions for people with moderate depression and a chronic physical health problem.
Process: Proportion of people with moderate depression and a chronic physical health problem who receive an appropriate high-intensity psychological intervention.
Numerator – the number of people in the denominator receiving an appropriate high-intensity psychological intervention.
Denominator – the number of people with moderate depression and a chronic physical health problem.

What the quality statement means for each audience

Service providers ensure systems are in place for the delivery of appropriate high-intensity psychological interventions for people with moderate depression and a chronic physical health problem.
Healthcare professionals ensure people with moderate depression and a chronic physical health problem receive appropriate high-intensity psychological interventions.
Commissioners ensure they commission services to provide appropriate high-intensity psychological interventions to people with moderate depression and a chronic physical health problem.
People with moderate depression and a long-term physical health problem receive appropriate psychological treatment (for example, group or one-to-one CBT, or a treatment for people with a regular partner called behavioural couples therapy, if appropriate).

Definitions

NICE clinical guideline 91 defines appropriate high-intensity interventions for people with moderate depression and a chronic physical health problem as:
  • group-based cognitive behavioural therapy (CBT) or
  • individual CBT for people who decline group-based CBT or for whom it is not appropriate, or where a group is not available or
  • behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit.

Source guidance

NICE clinical guideline 91 recommendation 1.5.1.2 (key priority for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Severe depression and a chronic physical health problem

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual cognitive behavioural therapy.

Quality measure

Structure: Evidence of local arrangements to provide a combination of antidepressant medication and individual cognitive behavioural therapy (CBT) to people with severe depression and a chronic physical health problem.
Process: Proportion of people with severe depression and a chronic physical health problem who receive a combination of antidepressant medication and individual CBT.
Numerator – the number of people in the denominator receiving a combination of antidepressant medication and individual CBT.
Denominator – the number of people with severe depression and a chronic physical health problem.

What the quality statement means for each audience

Service providers ensure systems are in place to provide people with severe depression and a chronic physical health problem with a combination of antidepressant medication and individual CBT.
Healthcare professionals ensure people with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual CBT.
Commissioners ensure they commission services to provide a combination of antidepressant medication and individual CBT to people with severe depression and a chronic physical health problem.
People with severe depression and a long-term physical health problem receive antidepressants along with one-to-one CBT.

Source guidance

NICE clinical guideline 91 recommendation 1.5.1.3

Data source

Structure: Local data collection.
Process: Local data collection.

Collaborative care

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.

Quality measure

Structure: Evidence of local arrangements to provide collaborative care to people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Process: Proportion of people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, who receive collaborative care.
Numerator – the number of people in the denominator receiving collaborative care.
Denominator – the number of people with a chronic physical health problem and moderate to severe depression with associated functional impairment whose symptoms are not responding to initial interventions.

What the quality statement means for each audience

Service providers ensure systems are in place for providing collaborative care to people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Healthcare professionals ensure collaborative care is provided to all people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
Commissioners ensure they commission services that provide collaborative care for people with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions.
People with moderate to severe depression and a long-term physical health problem affecting their everyday life, whose symptoms have not improved after early treatments, receive ‘collaborative care’, which means that a dedicated team of healthcare professionals work together to treat the depression and the physical health problem.

Definitions

NICE clinical guideline 91 states that collaborative care should form part of a well-developed stepped-care programme. In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.
Collaborative care requires that the patient and healthcare professional jointly identify problems and agree goals for interventions, and normally comprises:
  • case management which is supervised and supported by a senior mental health professional
  • close collaboration between primary and secondary physical health services and specialist mental health services in the delivery of services
  • the provision of a range of evidence-based interventions
  • the long term coordination of care and follow-up.

Source guidance

NICE clinical guideline 91 recommendation 1.5.4.1 and 1.5.4.2.

Data source

Structure: Local data collection.
Process: Local data collection.

Continuing antidepressants

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for people at risk of relapse.

Quality measure

Structure: Evidence of local arrangements for monitoring and reviewing people prescribed antidepressants.
Process:
a) Proportion of people with depression benefiting from antidepressants who remain on them at least 6 months after remission.
Numerator – the number of people in the denominator remaining on antidepressants at least 6 months after remission.
Denominator – the number of people with depression benefiting from antidepressants.
b) Proportion of people with depression benefiting from antidepressants and at risk of relapse who remain on them 2 years after remission.
Numerator – the number of people in the denominator remaining on antidepressants 2 years after remission.
Denominator – the number of people with depression benefiting from antidepressants and at risk of relapse.

What the quality statement means for each audience

Service providers ensure systems are in place for monitoring and reviewing all people with depression prescribed antidepressants.
Healthcare professionals ensure people with depression benefiting from antidepressants are advised to continue with treatment for at least 6 months, extending to at least 2 years for people at risk of relapse.
Commissioners ensure they commission services that monitor compliance with antidepressant medication.
People with depression who are feeling better after taking antidepressants are advised to keep taking them for at least 6 months, and for up to at least 2 years if their symptoms are likely to return.

Definitions

The term ‘people with depression’ includes all people with depression and a chronic physical health problem.
The level of medication at which acute treatment was effective should be maintained for at least 2 years (unless there is good reason to reduce the dose, such as unacceptable adverse effects) if:
  • they have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
  • they have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
  • the consequences of relapse are likely to be severe (for example, suicide attempts, loss of functioning, severe life disruption and inability to work).

Source guidance

NICE clinical guideline 90 recommendations 1.9.1.1 (key priority for implementation) and 1.9.1.4.

Data source

Structure: Local data collection.
Process: Local data collection.

Reassessing people prescribed antidepressants

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first 3 months of treatment.

Quality measure

Structure: Evidence of procedures to regularly reassess people with depression whose treatment consists solely of antidepressants.
Process: Proportion of people with depression treated solely with antidepressants who are reassessed at least every 4 weeks for the first 3 months of treatment.
Numerator – the number of people in the denominator reassessed at least every 4 weeks for the first 3 months of treatment.
Denominator – the number of people with depression treated solely with antidepressants.

What the quality statement means for each audience

Service providers ensure systems are in place to ensure people treated solely with antidepressants are reassessed at least every 2 to 4 weeks for at least the first 3 months of treatment.
Healthcare professionals ensure they reassess people treated solely with antidepressants at least every 2 to 4 weeks for at least the first 3 months of treatment.
Commissioners ensure they commission services that reassess people treated solely with antidepressants at least every 2 to 4 weeks for at least the first 3 months of treatment.
People with depression treated only with antidepressants are checked at least every 2 to 4 weeks for the first 3 months of treatment or longer.

Definitions

The term ‘people with depression’ includes all people with depression and a chronic physical health problem.

Source guidance

NICE clinical guideline 90 recommendation 1.5.2.6 and NICE clinical guideline 91 recommendation 1.5.2.19.

Data source

Structure: Local data collection.
Process: Local data collection.

Lack of response to initial treatment within 6 to 8 weeks

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.

Quality measure

Structure: Evidence of local arrangements to identify people with depression that has not responded adequately to initial treatment within 6 to 8 weeks and to review treatment plans.
Process: Proportion of people with depression that has not responded adequately to initial treatment within 8 weeks who have their treatment plan reviewed.
Numerator – the number of people in the denominator receiving a review of their treatment plan.
Denominator – the number of people with depression that has not responded adequately to initial treatment within 8 weeks.

What the quality statement means for each audience

Service providers ensure systems are in place for reviewing treatment plans for people with depression that has not responded adequately to initial treatment within 6 to 8 weeks.
Healthcare professionals ensure people with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.
Commissioners ensure they commission services that review the treatment plans for people with depression that has not responded adequately to initial treatment within 6 to 8 weeks.
People with depression whose symptoms have not much improved 6 to 8 weeks after starting treatment have their treatment plan reviewed.

Definitions

The term ‘people with depression’ includes all people with depression and a chronic physical health problem.

Source guidance

Recommendations on sequencing of treatments after initial inadequate response are contained within section 1.8 of NICE clinical guideline 90.

Data source

Structure: Local data collection.
Process: Local data collection.

Residual symptoms or risk of relapse

This quality statement is taken from the Depression in adults quality standard. The quality standard defines clinical best practice for depression in adults and should be read in full.

Quality statement

People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.

Quality measure

Structure: Evidence of local arrangements to provide appropriate psychological interventions to people who have been treated for depression who have residual symptoms or are at significant risk of relapse.
Process: Proportion of people who have been treated for depression who have residual symptoms or are at significant risk of relapse who receive appropriate psychological interventions.
Numerator – the number of people in the denominator receiving appropriate psychological interventions.
Denominator – the number of people who have been treated for depression who have residual symptoms or are at significant risk of relapse.

What the quality statement means for each audience

Service providers ensure systems are in place to provide appropriate psychological interventions for people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse.
Healthcare professionals ensure people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.
Commissioners ensure they commission services that provide appropriate psychological interventions for people who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse.
People who have been treated for depression who have remaining symptoms or whose symptoms are likely to return receive further suitable psychological treatment.

Definitions

The term ‘people who have been treated for depression’ includes all people with a chronic physical health problem who have been treated for depression.
The term ‘at significant risk of relapse’ includes those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment.
People with depression are at risk of relapse if:
  • they have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
  • they have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
Appropriate psychological interventions for people at significant risk of relapse are:
  • individual cognitive behavioural therapy for people who have relapsed despite antidepressant medication and for people with a significant history of depression and residual symptoms despite treatment
  • mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression.

Source guidance

NICE clinical guideline 90 recommendation 1.9.1.8 (key priority for implementation).

Data source

Structure: Local data collection.
Process: Local data collection.

Participation in meaningful activity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.

Rationale

It is important that older people in care homes have the opportunity to take part in activity, including activities of daily living, that helps to maintain or improve their health and mental wellbeing. They should be encouraged to take an active role in choosing and defining activities that are meaningful to them. Whenever possible, and if the person wishes, family, friends and carers should be involved in these activities. This will help to ensure that activity is meaningful and that relationships are developed and maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.
Data source: Local data collection.
Outcome
a) Feedback from older people in care homes that they are offered opportunities to take part in activity during their day.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.
b) Feedback from older people in care homes that they have taken part in activity during their day that is meaningful to them.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that opportunities for activity are available and that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them and that promotes their health and mental wellbeing.
Social care, health and public health practitioners ensure that they offer older people in care homes opportunities during their day to participate in spontaneous and planned activity that is meaningful to them and that promotes their health and mental wellbeing.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of activities that are undertaken within the care home and can demonstrate that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them.

What the quality statement means for service users, family, friends and carers

Older people in care homes have opportunities during their day to take part in activities of their choice that help them stay well and feel satisfied with life. Their family, friends and carers have opportunities to be involved in activities with them when the older person wishes.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Meaningful activity
Meaningful activity includes physical, social and leisure activities that are tailored to the person’s needs and preferences. Activity can range from activities of daily living such as dressing, eating and washing, to leisure activities such as reading, gardening, arts and crafts, conversation, and singing. It can be structured or spontaneous, for groups or for individuals, and may involve family, friends and carers, or the wider community. Activity may provide emotional, creative, intellectual and spiritual stimulation. It should take place in an environment that is appropriate to the person’s needs and preferences, which may include using outdoor spaces or making adaptations to the person’s environment. [Adapted from SCIE guide 15, Choice and Control, Living well through activity in care homes: the toolkit (College of Occupational Therapists) and expert consensus]
Mental wellbeing
Mental wellbeing includes areas that are key to optimum functioning and independence, such as life satisfaction, optimism, self-esteem, feeling in control, having a purpose in life, and a sense of belonging and support. [Adapted from the Mental health improvement programme, background and policy context (NHS Health Scotland)]

Equality and diversity considerations

Staff working with older people in care homes should identify and address the specific needs of older people arising from diversity, including gender and gender identity, sexuality, ethnicity, age and religion.
When tailoring activities to the needs and preferences of older people, staff should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should have the necessary skills to include people with cognitive or communication difficulties in decision-making (from Dignity in care [SCIE guide 15]: Choice and control). Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been offered opportunities for meaningful activity, staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person, such as family members, carers, or an advocate.

Personal identity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are enabled to maintain and develop their personal identity.

Rationale

It is important that staff working with older people in care homes are aware of the personal history of the people they care for and respect their interests, beliefs and the importance of their personal possessions. Older people should be involved in decision-making and supported and enabled to express who they are as an individual and what they want. They should be able to make their own choices whenever possible. Enabling older people to maintain and develop their personal identity during and after their move to a care home promotes dignity and has a positive impact on their sense of identity and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are enabled to maintain and develop their personal identity.
Data source: Local data collection.
Outcome
Feedback from older people in care homes that their personal identity is respected.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, personal cleanliness and comfort, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care work to embed a culture built on dignity and choice in care homes and ensure that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.
Social care, health and public health practitioners work with older people in care homes to tailor support and opportunities to their needs and preferences, with the aim of maintaining and developing their personal identity.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of the actions they have taken to embed a culture of dignity and choice, and that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.

What the quality statement means for service users

Older people in care homes are given support and opportunities to express themselves as individuals and maintain and develop their sense of who they are.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]

Enabled

‘Enabled’ refers to actions taken by staff working with older people in care homes to ensure that older people can maintain and develop their personal identity. This may include using life history to tailor support and opportunities to the needs and preferences of the individual. Staff should ensure that older people are able to choose their own clothes, have their most valued possessions with them and choose where to sit while they are eating. It may be necessary to adapt the older person’s environment and provide access to outdoor spaces. Staff should facilitate social inclusion by promoting and supporting social interactions and access to social networks, involvement with the community, and existing and new relationships. [Adapted from Dignity in care (SCIE guide 15), Choice and control and Social inclusion, and expert consensus]
Personal identity
This refers to a person’s individuality, including their needs and preferences, and involvement in decision-making in all aspects of their life. Maintaining a sense of personal identity can involve using life history to maintain and build a meaningful and satisfying life, as defined by the person themselves. Central to personal identity is the feeling of having a purpose in life, feeling valued, having a sense of belonging and a feeling of worth. Relationships, including those with family, carers and friends, are an important aspect of a person’s identity and can have a significant impact on mental wellbeing. An individual’s personal identity may change as their circumstances alter. [Adapted from Personalisation: a rough guide (SCIE guide 47), My Home Life: Promoting quality of life in care homes, ‘Voice, choice and control’ in care homes (Joseph Rowntree Foundation); and expert consensus]

Equality and diversity considerations

Staff working with older people in care homes should identify the specific needs arising from diversity, including gender and gender identity, sexuality, ethnicity, spirituality, culture, age and religion.
When ensuring that older people are enabled to maintain and develop their personal identity be aware of any learning disabilities, acquired cognitive impairments, communication or language barriers or cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been enabled to maintain and develop their personal identity staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person such as family members, carers, or an advocate.

Recognition of mental health conditions

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of mental health conditions recognised and recorded as part of their care plan.

Rationale

Mental health conditions are highly prevalent among older people in care homes, but are often not recognised, diagnosed or treated. Ageing with good mental health can make a key difference in ensuring that life is enjoyable and fulfilling. The recognition and recording of symptoms and signs of mental health conditions by staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of mental health conditions in older people, and record them in their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of mental health conditions and record them in the older person’s care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of mental health conditions (such as depression and anxiety) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Mental health conditions
These include common mental health conditions such as depression, generalised anxiety disorder and social anxiety disorder, and may also include dementia and delirium. People may have more than one mental health condition at a given time. (See the NICE guidelines on dementia (NICE clinical guideline 42), depression in adults (NICE clinical guideline 90), depression in adults with a chronic physical health problem (NICE clinical guideline 91), delirium (NICE clinical guideline 103), common mental health disorders (NICE clinical guideline 123) and social anxiety disorder (NICE clinical guideline 159) for more information.)
Recognised
Recognised in this context relates to staff observing and recognising the symptoms and signs of mental health conditions, and sharing information and concerns with healthcare professionals, including GPs. Staff should be continually alert to new or worsening symptoms and signs. Observation of behaviour should happen on an ongoing basis and in response to the presentation of relevant symptoms. [Expert consensus]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of mental health conditions when caring for older people. Staff should be alert to the presentation of new symptoms and signs and aware of existing conditions. Staff should also be competent in recognising when older people need a referral for assessment and management of the mental health condition. [Expert consensus]

Equality and diversity considerations

When looking for symptoms and signs of mental health conditions, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of sensory impairment

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes who have specific needs arising from sensory impairment have these recognised and recorded as part of their care plan.

Rationale

Mild but progressive sight and hearing losses are a common feature of ageing and may go unnoticed for some time, but can have a serious effect on a person’s communication, confidence and independence. The recognition and recording of needs arising from sensory impairment by staff who are alert to the symptoms and signs and aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. For older people in care homes this is essential to improve their quality of life and avoid isolation, which can have a detrimental effect on mental wellbeing.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise specific needs arising from sensory impairment in older people, and record these needs as part of their care plan.
Data source: Local data collection.
Process
Proportion of older people in care homes who have regular sight tests.
Numerator – the number of people in the denominator who have had a sight test within the past 2 years.
Denominator – the number of older people in care homes.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners are alert to and recognise specific needs arising from sensory impairment in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise needs that occur because of sight or hearing problems and record these as part of their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of the needs arising from sensory impairment and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new and existing needs. This should involve monitoring of existing impairments and recognition of new sensory impairments. This is likely to include ensuring regular sight and hearing checks are arranged, cleaning glasses, and changing hearing aid batteries, or referral to an appropriately trained professional. [SCIE research briefing 21 and expert consensus]
Regular sight test
Adults are normally advised to have a sight test every 2 years. However, in some circumstances, the ophthalmic practitioner may recommend more frequent sight tests, for example in people who:
  • have diabetes
  • are aged 40 or over and have a family history of glaucoma
  • are aged 70 or over. [NHS Choices]
Sensory impairment
Sensory impairment most commonly refers to sight or hearing loss. It includes combined sight and hearing loss, which is frequently referred to as dual sensory impairment or deafblindness. [Adapted from Basic Sensory Impairment Awareness (NHS Education for Scotland) and Social care for deafblind children and adults (Department of Health)]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of sensory impairment when caring for older people. Staff should be aware that there are many different types of sight and hearing loss, with a large variation in the degree of impairment. Staff should also be competent in recognising when older people need a referral for assessment and management of the sensory impairment. [Expert consensus]

Equality and diversity considerations

Sensory impairment is common in older people. It is frequently perceived as an expected feature of ageing rather than as potentially disabling. It is important that sensory impairment is not considered as acceptable for older people in care homes. This may need to be emphasised during training to increase awareness and recognition of sensory impairments.
When looking for signs or symptoms of sensory impairment, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of physical problems

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of physical problems recognised and recorded as part of their care plan.

Rationale

Physical problems can cause discomfort and affect activities of daily living, participation in social activities and independence, and therefore mental wellbeing. The recognition and recording of the symptoms and signs of physical problems by trained staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. This is essential to improve the quality of life and mental wellbeing of older people in care homes.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of physical problems in older people in care homes, and record them as part of their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to symptoms and signs of physical problems in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of physical problems in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of physical problems in older people in care homes and to record them in care plans.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of physical problems (such as pain, dizziness, problems with walking, constipation and continence problems) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Physical problems
Examples of physical problems that could potentially affect a person’s wellbeing include, but are not limited to:
  • joint and muscular pain
  • undiagnosed pain
  • incontinence
  • dizziness
  • constipation
  • urinary tract infection
  • reduced ability to move without support
  • unsteady gait. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of physical problems and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new physical problems and should monitor existing physical problems. [Expert consensus]
Trained staff
Trained staff refers to staff who have been trained to recognise and record the symptoms and signs of physical problems when caring for older people. Staff should be alert to the presentation of new symptoms and competent in recognising when older people need a referral for assessment and management of physical problems. [Expert consensus]

Equality and diversity considerations

When identifying an older person’s needs arising from physical problems, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Access to healthcare services

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have access to the full range of healthcare services when they need them.

Rationale

Older people in care homes typically have greater and more complex health needs than those living in the community, and these needs can affect their wellbeing if they are not addressed. Many care home residents experience problems accessing NHS primary and secondary healthcare services, including GPs. It is important that care homes have good links with GPs and referral arrangements, so that services can be accessed easily and without delay when they are needed. This is essential to prevent unmet healthcare needs from having a negative impact on mental wellbeing.

Quality measures

Structure
Evidence of referral arrangements to ensure that older people in care homes are given access to the full range of healthcare services when they need them.
Data source: Local data collection.
Outcome
Feedback from older people in care homes and from their family, friends and/or carers that they are satisfied with the care they have received.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that they work in partnership with healthcare organisations to implement effective arrangements for access to primary, secondary, specialist and mental health services for older people in care homes.
Social care, health and public health practitioners facilitate access to primary, secondary, specialist and mental health services for older people in care homes by referring the person to the required service when they need it.
Local authorities and other commissioning services commission services from providers that can produce evidence of arrangements with local healthcare organisations which facilitate access to primary, secondary, specialist and mental health services for older people in care homes.

What the quality statement means for service users

Older people in care homes can see their GP and use hospital services when they need them.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Healthcare services
These include primary care, and acute and specialist physical and mental health services. [GP services for older people living in residential care: a guide for care home managers. (SCIE guide 52)]

Equality and diversity considerations

When deciding if access to healthcare services is needed, staff working with older people in care homes should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Assessment of suspected anxiety disorders

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.

Rationale

Accurate diagnosis of a person’s specific anxiety disorder can help them understand their condition and ensure that they are offered the most appropriate treatment at the earliest opportunity.

Quality measures

Structure
a) Evidence of local arrangements for people with a suspected anxiety disorder to receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that healthcare professionals receive training to perform assessments of anxiety disorders.
Data source: Local data collection.
Process
Proportion of people with a suspected anxiety disorder who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Numerator – the number of people in the denominator who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Denominator – the number of people with a suspected anxiety disorder.
Data source: Local data collection

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure they provide services for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, and that the assessment services are delivered by fully trained healthcare professionals.
Healthcare professionals carry out an assessment for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, or refer to a practitioner who is trained to carry out such an assessment.
Commissioners ensure that they commission services that carry out assessments for people with a suspected anxiety disorder to diagnose specific anxiety disorders.

What the quality statement means for service users and carers

People who may have an anxiety disorder are offered an assessment to find out whether they do have an anxiety disorder, what type of disorder it is and the effect it may have on their everyday life.

Source guidance

Definitions of terms used in this quality statement

Anxiety disorder
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Assessment of anxiety disorders
Assessment of anxiety disorders includes the nature, duration and severity of the presenting disorder and associated functional impairment. It also includes consideration of the ways in which the following factors may have affected the development, course and severity of the disorder:
  • a history of any mental health disorder
  • a history of a chronic physical health problem
  • any past experience of, and response to, treatments
  • the quality of interpersonal relationships
  • living conditions and social isolation
  • a family history of mental illness
  • a history of domestic violence or sexual abuse
  • employment and immigration status.
[NICE clinical guideline 123, recommendations 1.3.2.4 and 1.3.2.6]
A diagnostic or problem identification tool or algorithm may be used to inform the assessment. [NICE clinical guideline 123, recommendation 1.3.2.3, NICE clinical guideline 159, recommendations 1.2.7 and 1.4.9 to 1.4.12]
Assessment of social anxiety disorder
The assessment of social anxiety disorder is slightly different from the assessment of other anxiety disorders. It includes consideration of fear, avoidance, distress and functional impairment. It takes into account comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism. A detailed description of the person’s current social anxiety and associated problems and circumstances is obtained, including:
  • feared and avoided social situations
  • what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)
  • anxiety symptoms
  • view of self
  • content of self-image
  • safety-seeking behaviours
  • focus of attention in social situations
  • anticipatory and post-event processing
  • occupational, educational, financial and social circumstances
  • family circumstances and support (for children and young people)
  • friendships and peer groups (for children and young people)
  • medication, alcohol and recreational drug use.
[NICE clinical guideline 159, recommendations 1.2.5 to 1.2.9 and 1.4.5 to 1.4.8]
Suspected anxiety disorder
An anxiety disorder may be suspected in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or recent experience of a traumatic event, and in people who avoid social situations. It may be suspected because of the person’s responses to initial questions about their symptoms. The 2-item Generalized Anxiety Disorder scale may be used to ask the person about their feelings of anxiety and their ability to stop or control worry. [NICE clinical guideline 123, recommendation 1.3.1]

Equality and diversity considerations

Consideration should be given to modifying the method and mode of delivery of assessment according to the needs of the person with a suspected anxiety disorder. Technology should be considered for people who may find it difficult to, or choose not to, attend a specific service, for example people with social anxiety who are anxious about attending a healthcare service. Communication needs should be considered for people who do not have English as their first language, for example by providing bilingual therapists or independent translators.
For people with sensory impairment or a learning disability, use of the distress thermometer and asking a family member or carer about the person’s symptoms should be considered.
When assessing people with a suspected anxiety disorder and a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consideration should be given to consulting a relevant specialist.
Assessments should be culturally sensitive, using suitable explanatory models of common mental health disorders and addressing any cultural and ethnic needs. Relevant information, including cultural or other individual characteristics that may be important in subsequent care, should be identified during assessment. For example, if the boundary between religious or cultural practice and obsessive–compulsive symptoms is unclear, healthcare professionals should, with the service user’s consent, consider seeking the advice and support of an appropriate religious or community leader to support the therapeutic process.

Pharmacological treatment

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated.

Rationale

NICE guidance provides recommendations on pharmacological therapies for anxiety disorders. Benzodiazepines are associated with tolerance and dependence, and antipsychotics are associated with a number of adverse effects. Therefore they should not be used routinely to treat anxiety disorders.
Healthcare professionals should be aware of circumstances in which benzodiazepines and antipsychotics may be appropriate, such as short-term care and anxiety disorder crises.

Quality measures

Structure
Evidence of local monitoring arrangements to ensure that people with an anxiety disorder are not prescribed a benzodiazepine or an antipsychotic to treat their disorder unless specifically indicated.
Data source: Local data collection.
Process
a) Proportion of people who have an anxiety disorder and are prescribed a benzodiazepine that is not specifically indicated.
Numerator – the number of people in the denominator for whom a benzodiazepine is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed a benzodiazepine.
b) Proportion of people who have an anxiety disorder and are prescribed an antipsychotic that is not specifically indicated.
Numerator – the number of people in the denominator for whom an antipsychotic is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed an antipsychotic.
Data source: Local data collection.
Outcome
a) Rates of prescribing benzodiazepines.
b) Rates of prescribing antipsychotics.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are procedures and protocols in place to monitor the prescribing of pharmacological treatment for people with anxiety disorders to ensure that benzodiazepines and antipsychotics are not offered to treat that disorder unless specifically indicated.
Healthcare professionals ensure that people with anxiety disorders are not offered benzodiazepines or antipsychotics to treat that disorder unless specifically indicated.
Commissioners ensure that they monitor rates of prescribing of benzodiazepines and antipsychotics to treat anxiety disorders and only commission services from providers who can demonstrate they have procedures and protocols in place to monitor this prescribing.

What the quality statement means for service users and carers

People with an anxiety disorder are not offered benzodiazepines (medication used to help people sleep or act as a sedative) or antipsychotics (medication used mainly to treat psychotic conditions such as schizophrenia) for that disorder unless there are specific clinical reasons why these treatments may be of short-term benefit.

Source guidance

  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.3.21, 1.5.3.22 and 1.5.6.21.
  • Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults (NICE clinical guideline 113), recommendations 1.2.25 (key priority for implementation), 1.4.7 and 1.4.8.
  • Social anxiety disorder (NICE clinical guideline 159), recommendation 1.6.2.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.

Psychological interventions

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are offered evidence-based psychological interventions.

Rationale

Evidence-based psychological interventions can be effective treatments for anxiety disorders. They are recommended first-line treatments in preference to pharmacological treatment. Healthcare professionals should usually offer or refer for the least intrusive, most effective intervention first, in line with the stepped-care approach set out in the NICE guidance.

Quality measures

Structure
Evidence of local arrangements to ensure that people with an anxiety disorder are offered evidence-based psychological interventions.
Data source: Local data collection.
Process
Proportion of people with an anxiety disorder who receive evidence-based psychological interventions.
Numerator – the number of people in the denominator who receive evidence-based psychological interventions.
Denominator – the number of people with an anxiety disorder.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they are able to provide evidence-based psychological interventions to people who are referred to them with anxiety disorders.
Healthcare professionals ensure that they offer evidence-based psychological interventions to people with anxiety disorders.
Commissioners ensure that they commission services from providers that are able to deliver evidence-based psychological interventions to meet the needs of people with anxiety disorders.

What the quality statement means for service users and carers

People with an anxiety disorder are offered psychological treatments (sometimes called ‘talking treatments’) that have been shown by evidence to be helpful for their disorder.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendation 1.4.1.4.
  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.1.8, 1.5.1.9 (key priority for implementation) and 1.5.1.10 (key priority for implementation).
  • Post-traumatic stress disorder (NICE clinical guideline 26), recommendations 1.9.5.1 and 1.9.5.2 (key priorities for implementation).
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.2 (key priority for implementation), 1.3.4 (key priority for implementation), 1.3.7, 1.3.12, 1.5.3 (key priority for implementation) and 1.5.6.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Evidence-based psychological interventions
Evidence-based psychological interventions include both low-intensity interventions incorporating self-help approaches and high-intensity psychological therapies.
For adults with generalised anxiety disorder, panic disorder, post-traumatic stress disorder, obsessive–compulsive disorder or body dysmorphic disorder psychological interventions are offered based on the stepped-care approach. [NICE clinical guideline 123, recommendation 1.4.1.4]
Cognitive behavioural therapy has been specifically developed to treat social anxiety disorder in adults, children and young people [NICE clinical guideline 159, recommendations 1.3.2 and 1.5.3]
Psychological therapies have been specifically developed to treat obsessive–compulsive disorder, body dysmorphic disorder and post-traumatic stress disorder in children and young people. [NICE clinical guideline 31, recommendations 1.5.1.9 and 1.5.1.10; NICE clinical guideline 26, recommendation 1.9.5]

Equality and diversity considerations

For people with generalised anxiety disorder who have a learning disability or cognitive impairment, methods of delivering treatment and treatment duration should be adjusted if necessary to take account of the disability or impairment, with consideration given to consulting a relevant specialist.
It is important that healthcare professionals familiarise themselves with the cultural background of the person with an anxiety disorder. They should pay particular attention to identifying people with post-traumatic stress disorder whose work or home culture is resistant to recognising the psychological consequences of trauma.

Monitoring treatment response

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.

Rationale

Regular monitoring of psychological and pharmacological treatment response ensures that the effectiveness of treatment can be assessed and treatment adjusted if needed. It also provides an opportunity for healthcare professionals to monitor other outcomes such as effects on any long-term conditions and the person’s ability to continue or return to employment.

Quality measures

Structure
Evidence of local arrangements to monitor response to treatment for people being treated for an anxiety disorder at each treatment session and use the findings to adjust delivery of interventions.
Data source: Local data collection.
Process
Proportion of people receiving treatment for an anxiety disorder who have their response to treatment recorded at initial contact and each subsequent treatment session.
Numerator – the number of people in the denominator whose response to treatment is recorded at initial contact and each subsequent treatment session.
Denominator – the number of people receiving treatment for an anxiety disorder.
Outcome
Evidence from feedback that people receiving treatment for an anxiety disorder are aware of their progress.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to record response to treatment at each treatment session for people receiving treatment for anxiety disorders.
Healthcare professionals ensure that they record response to treatment at each treatment session for people receiving treatment for anxiety disorders and adjust treatment if needed.
Commissioners ensure that they commission services that record response to treatment at each treatment session for people receiving treatment for anxiety disorders.

What the quality statement means for service users and carers

People who are receiving treatment for an anxiety disorder have a check at each treatment session to find out how well their treatment is working and help decide how best to continue with their treatment.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendations 1.5.1.3 (key priority for implementation) and 1.5.1.10.
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.1 (key priority for implementation) and 1.5.1.

Definitions

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Monitoring
This includes individual routine outcome measurement, which can be made available for routine reporting and aggregation of outcome measures, as well as audit and review of effectiveness. Specific monitoring tools and routine outcome measures are used. [Adapted from NICE clinical guideline 123 and NICE clinical guideline 159]
Treatment for an anxiety disorder
Treatments for which responses are monitored include psychological interventions and pharmacological treatment.

Equality and diversity considerations

The method of collecting self-reported treatment responses should be tailored to the person with an anxiety disorder, according to their communication needs and preferences. It should be culturally appropriate, accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with anxiety disorders should have access to an interpreter or advocate if needed.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

GAD-2 scale

The GAD-2 screening tool consists of the first 2 questions of the GAD-7 scale.
GAD-7
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several days
More than half the days
Nearly every day
Score
1. Feeling nervous, anxious or on edge
0
1
2
3
2. Not being able to stop or control worrying
0
1
2
3
3. Worrying too much about different things
0
1
2
3
4. Trouble relaxing
0
1
2
3
5. Being so restless that it is hard to sit still
0
1
2
3
6. Becoming easily annoyed or irritable
0
1
2
3
7. Feeling afraid as if something awful might happen
0
1
2
3
Total score
Developed by Drs Robert L Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

Stepped-care model: a combined summary for common mental health disorders

Focus of the intervention
Nature of the intervention
Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression that has not responded to a low-intensity intervention; initial presentation of moderate or severe depression; GAD with marked functional impairment or that has not responded to a low-intensity intervention; moderate to severe panic disorder; OCD with moderate or severe functional impairment; PTSD.
Depression: CBT, IPT, behavioural activation, behavioural couples therapy, antidepressants, combined interventions, collaborative care (for people with depression and a chronic physical health problem), self-help groups, counselling, short-term psychodynamic psychotherapy (discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression).
GAD: CBT, applied relaxation, drug treatment, combined interventions, self-help groups.
Panic disorder: CBT, antidepressants, self-help groups.
OCD: CBT (including ERP), antidepressants, combined interventions and case management, self-help groups.
PTSD: Trauma-focused CBT, EMDR, drug treatment.
All disorders: Support groups, befriending, rehabilitation programmes, educational and employment support services; referral for further assessment and interventions.
Step 2: Persistent subthreshold depressive symptoms or mild to moderate depression; GAD; mild to moderate panic disorder; mild to moderate OCD; PTSD (including people with mild to moderate PTSD).
Depression: Individual facilitated self-help, computerised CBT, structured physical activity, group-based peer support (self-help) programmes (for people with depression and a chronic physical health problem), non-directive counselling delivered at home (for women during pregnancy or the postnatal period), antidepressants, self-help groups.
GAD and panic disorder: Individual non-facilitated and facilitated self-help, psychoeducational groups, self-help groups.
OCD: Individual or group CBT (including ERP), self-help groups.
PTSD: Trauma-focused CBT or EMDR.
All disorders: Support groups, educational and employment support services; referral for further assessment and interventions.
Step 1: All disorders – known and suspected presentations of common mental health disorders.
All disorders: Identification, assessment, psychoeducation, active monitoring; referral for further assessment and interventions.

Glossary

cognitive behavioural therapy
eye movement desensitisation and reprocessing
exposure and response prevention
generalised anxiety disorder
a single-item question screen to identify distress by asking the person to mark on a scale of 0 to 10 how distressed they have been during the past week
2-item generalised anxiety disorder scale
hospital anxiety and depression scale
7-item generalised anxiety disorder scale
improving access to psychological therapies
interpersonal therapy
when applied to common mental health disorders, mild generally refers to relatively few core symptoms (although sufficient to achieve a diagnosis), a limited duration and little impact on day-to-day functioning
obsessive compulsive disorder
9-item patient health questionnaire
post-traumatic stress disorder

Paths in this pathway

Pathway created: November 2013 Last updated: November 2016

© NICE 2016

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