By Dr Sarah Wilson, Consultant Psychiatrist, Queen’s Medical Centre, Nottingham

This project was awarded runner up in the Parkinson’s Advanced MasterClass 36A Award, 2019

Background

2017: Discussion with geriatrician looking at mental health issues in Parkinson’s Disease and wanting to improve the links and pathways between Physical and Mental Health.  An audit of 53 PD patients identified the presence of significant Mental Health needs among this group and this was backed up with a survey of PD clinicians.

2018: Attempts to replicate the survey and audit from a MH perspective.  Only 17 patients identified due to poor coding of PD and related conditions in MH records.  Permissions sought to access and compare data across acute and MH Trusts.  224 patients were identified from PD clinic lists (seen by geriatricians between 1/7/2017 and 30/6/2018) and cross-referenced with MHSOP (Mental Health Services for Older People) records, showing 82 were known to MHSOP between 1/1/2017 and 31/10/2018.

2019: Data collected and analysed, report completed and Business Case writing begins…

Audit

PD Clinicians don’t feel confident managing the mental health needs of patients with PD, don’t feel there is adequate time to explore mental health issues during a consultation and don’t feel there is adequate feedback or access to Mental Health records following patient assessment by the Mental Health team.  They do not feel that there is a clear pathway for referring patients with mental health needs for specialist assessment.  Psychiatrists feel that integrated mental and physical healthcare for patients with PD is the way forward and while they are confident in recognizing the symptoms of suspected PD and the mental health symptoms which may be secondary to PD medication, they don’t feel confident in adjusting PD medication.  Like the PD clinicians, they don’t feel that current pathways for referrals and advice from the PD services are as clear as they could be.

Of the 82 patients, 44 were male.  The age range was 67-98 years with a median age of 80.5 years.  167 referrals were generated for the 82 patients, with 64 from primary care, 53 from secondary care (mostly inpatient to liaison psychiatry) and 50 between MH teams.  31 referrals were made by the MDS to MHSOP, but 68% of these came via the GP.  Most referrals were to the Community Mental Health Teams (CMHT) and Liaison Psychiatry, while most contacts were with the CMHTs and the Intensive Recovery Teams, with a surprisingly large number attending MHSOP Day Hospitals.  Most contacts were with nurses or unqualified staff.

As expected, depression, dementia and psychosis were the 3 most common mental health diagnoses.  30/82 had an antidepressant prescribed (Mirtazapine most common, Sertraline second commonest),  9/82 had an antipsychotic prescribed (Usually Quetiapine, occasionally Amisulpride) and 18/82 were prescribed acetylcholinesterase inhibitors (Rivastigmine being the most common).  35/42 patients on Levodopa were also prescribed psychotropic medication to manage mental health symptoms.

The audit was felt to be an underestimate of need as only those whose mental illness was severe enough to require secondary mental health services were identified.  It was notable that 10% of Mental Health contacts were with the day hospital, potentially highlighting this as a need or future service development.  Most contacts were with qualified nurses across all settings, making a nurse-led initiative both appropriate and viable.  Integrating services will ensure accurate diagnoses, information sharing and judicious prescribing across physical and mental healthcare.

An integrated service would benefit patients by preventing unnecessary delays in referrals, duplication and getting “lost in the system”.  Communication between physical and mental healthcare would be vastly improved, with time and cost savings from reduced duplication of assessments.  Early recognition and management of neuropsychiatric complications may reduce the need for intensive recovery and inpatient mental health services, further reducing the burden on already stretched mental health services.

Business Case

There is clear need for integrating Physical and Mental Healthcare for people with Parkinson’s.  Options to consider within the business case include:

  1. Do nothing.  This is the current scenario which nobody is happy with.
  2. Improve communication between services.  This would be a short-term solution, but would still lead to duplicated work, delays in assessment and treatment, and risk overloading already stretched services.
  3. Create a Parkinson’s RMN post.  This is the preferred option. We believe that the post will lead to potential cost and efficiency savings, that outweigh the investment required to fund the new post.
  4. Create a Consultant Psychiatrist for PD post.  Expensive and unnecessary currently, also difficult to fill.

It is expected that the Parkinson’s RMN would:

  • Identify, diagnose and commence first line treatments for common mental illnesses.
  • Facilitate referrals to appropriate MHSOP mental health teams as required.
  • Share information between teams for patients open to both PD and MHSOP services.
  • Provide education on managing common mental health conditions to PD nurses and the rest of the team.
  • Provide mental health support and monitoring for patients with PD and their carers.
  • Seek support from consultant psychiatrist where necessary.

Next Steps The next stage is to complete the business case, with support and agreement from MHSOP, PD services and local PDUK groups, and service improvement and development manager.  Once this is all agreed we can look at sharing this with local commissioners for funding, and aim to get the service up and running by 2021.