Screening for mental health problems and memory impairment for people with long term physical health

conditions

Louise Ross September 2010

The North East Mental Health Development Unit is hosted by NHS County Durham

Executive Summary

At present there are 15.4 million people in England with a Long-Term Condition (LTC) and due to the increasingly ageing population by 2025 this is predicted to reach 18 million (DH, 2010). The costs associated with the treatment and care for those with a LTC account for a significant proportion of health and social care resources and are forecast to rise to 26.4 billion (DH, 2010). This can be explained by the greater use of GP and outpatient appointments and use of inpatient bed days by people with a LTC (DH, 2010). There are high incidences of people with LTCs and co morbid common mental health problems (Stafford et al 2007; Anderson et al, 2001; Barry et al, 2008). Evidence shows that this can negatively impact upon their ability to manage and cope with their LTC (Whiting et al, 2006). The Operating Framework for the NHS in England 2009/10 recognises how important it is to ensure that people with LTCs receive an optimum level of care, stating that Over the next two years, to ensure that those living with long term conditions receive a high quality service and help to manage their condition, everyone with a long term condition should be offered a personalised care plan. (DH, 2008, p15) The DH strategy for LTCs pioneers personalised care planning, which ensures a persons full range of needs are accounted for and puts people with LTCs at the centre of decision making about their own care (DH, 2009). These principles are reflected by those set out in Our Vision, Our Future (NHS NE, 2008) and New Horizons (DH, 2009) whereby early detection and intervention are central to patient outcomes and QIPP savings. This paper will focus on two problems often associated with LTCs, which would limit abilities to manage a LTC and are high on the agenda on current policy drivers: mental health and memory. This will inform a pilot study, in which screening of common mental health (MH) problems and memory impairment will be incorporated into the annual health check for people living with a LTC, within 12 general practices in the North East (NE) of England. This paper will appraise the screening tool options and their applicability to a LTCs client group. The structure will be parallel in both mental health and memory, providing recommendations for a self-administered questionnaire to be completed prior to meeting with the GP, and in cases where this screens as positive, a follow up screening instrument to inform the referral process. The tools that are recommended in this paper for mental health screening for people with LTCs are the PHQ-2 and GAD-2 and the PHQ-9 and GAD-7 as pre-screening and further screening respectively. The TYM test is the recommended tool for memory screening in the LTC pilot.

Contents 1 2 Introduction: Screening for Depression & Anxiety in Primary Care...........4 1.1 NICE guidance & NHS drivers...........................................................4 Review of Screening Tools .......................................................................5 2.1 Patient Health Questionnaire (PHQ)..................................................5 2.1.1 PHQ-2 ........................................................................................5 2.1.2 PHQ-9 ........................................................................................6 2.1.3 GAD-2 and GAD-7......................................................................6 2.1.4 Hospital and Anxiety Depression Scale (HADS) ........................7 2.1.5 Beck Depression Inventory Second Edition (BDI-II) ...............7 2.2 Recommendations for Long Term Conditions (LTC) Pilot .................7 2.3 The Referral Pathway ........................................................................8 2.3.1 IAPT & the Stepped Care Model for Common Mental Health Problems ..................................................................................................8 Introduction: Screening for Memory Problems in Primary Care ..............11 3.1 NICE guidance & NHS drivers.........................................................11 Review of Screening Tools .....................................................................11 4.1.1 The Test Your Memory (TYM)..................................................12 4.2 Recommendations for Long Term Conditions (LTCs) pilot. .............13 4.3 Referral Pathway .............................................................................13 4.3.1 The Stepped Care Model for Memory Impairments..................13 Overview of Recommendations for Long Term Conditions (LTCs) pilot .14 Final Thoughts ........................................................................................14 References .............................................................................................15

3 4

5 6 7

Figure 1: IAPT Stepped Care Model for Common Mental Health Problems ....9 Appendices Appendix 1- Comparative Table: Common MH Screening Tools.19 Appendix 2- Comparative Table: Memory Screening Tools..20 Appendix 3- Table of Common MH Screening Tools evaluated against BPS Criteria...21 Appendix 4- Table of Memory Screening Tools evaluated against BPS Criteria...21 Appendix 5- Comments received from Draft 1.22

1 Introduction: Screening for Depression & Anxiety in Primary Care

It is widely reported that the detection of mental health problems is essential for responsive delivery of appropriate interventions, thus driving the quality of care provided (NICE, 2009; NICE, 2004). There is now strong evidence that the level of symptom severity can be inferred from the implementation of both self-assessment and clinician delivered questionnaires (BMA, 2008). Furthermore, this invites a collaborative discussion with the patient about the relevant treatment interventions and options available to them, as guided by the stepped care model endorsed by NICE (NICE, 2009). Depression is associated with a 50% increase in costs of long term medical care (Katon, 2003). This makes investment in improving the mental health of people with long-term conditions valuable. In particular, improvements need to be made in the identification and treatment of depression and anxiety, as this is likely to lead to financial savings (Michie et al, 2005) and increase the Quality, Innovation, Productivity and Prevention (QIPP) potential.

1.1 NICE guidance & NHS drivers

NICE guidelines on the management of depression in primary and secondary care advocate the use of the International Classification of Diseases (ICD-10) criteria for diagnosing and assessing severity of depression. Although NICE has identified ICD-10 as the recommended diagnostic tool for depression they acknowledge that it is doubtful whether severity can realistically be captured in a single symptom count (NICE, 2004). The Guideline Development Group (GDG), which makes NICE recommendations when evidence is uncertain, advocate that a two stage process of identification and diagnosis would be best practice in primary care and that evidence supported the continued use of the Whooley questions (see Box 1) as part of this initial process. It has been suggested that using an additional question: is this something with which you would like help? (Arroll et al, 2005) may improve the specificity of this initial screening phase. However, in terms of a particular MH screening tool for the rest of this process NICE do not make recommendations but suggest a second step of a more detailed instrument possessing better overall psychometric properties if either of the Whooley screening questions was marked as yes.. Box 1 During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things? Whooley et al (1997)

The Quality and Outcomes Framework (QOF) (BMA, 2008), a NICE-led performance management and payment system for general practitioners (GPs) in the National Health Service (NHS) in England, Wales, and Scotland was introduced in 2004 as part of the General Medical Services Contract. This replaced other fee arrangements and financially rewarded GPs for implementing best practice. It was widely adopted by GPs throughout the UK. Incentives included assessing for depression and/or anxiety, to encourage discussions with the patient with regard to their treatment options. Practices are advised to choose one of the three measures listed below, which are validated for use in primary care settings.

2 Review of Screening Tools

In this section, these tools are reviewed and evaluated in the context of use with people with LTCs. The Patient Health Questionnaire (PHQ-2 and PHQ-9) The Hospital Anxiety and Depression Scale (HADS) Beck Depression Inventory, second edition (BDI-II)

See Appendix 1 for an overview of these tools

2.1 Patient Health Questionnaire (PHQ)

The PHQ was developed from the more detailed PRIME-MD tool (Spitzer et al, 1994). Subsequently there have been three main tools developed from this scale; the PHQ-9 (Spitzer et al, 1999), PHQ-2 (Kroenke et al, 2003) and the Whooley questions (Whooley et al, 1997) see Box 1. Although the PHQ-2 and the Whooley questions use the same items the difference is that the PHQ-2 follows the Likert scale format of the PHQ-9 whereas the Whooley version dichotomises the questions (yes/no). The Whooley questions and the PHQ-2 have a cut-off points of 1 and 3 respectively.

2.1.1 PHQ-2
Increasingly there has been a demand for ultra-short questionnaires, as evidence suggests that even short questionnaires (defined as those with 514 items, taking between 2 and 5 minutes to complete) are not routine in primary or secondary care (Gilbody et al, 2002). This has directly led to the development of ultra-short questionnaires comprising of three, two or even one single-detection question. Mitchell & Coyne (2007) propose that the PHQ2 is the most well known example of this (see Box 1). These are endorsed by NICE guidelines in the process of identifying depression cases. Evidence suggests that a one-question test only identifies three out of every ten patients with depression in primary care and therefore is likely to be an unacceptable screening tool if solely relied upon (Mitchell & Coyne, 2007). However, in support of the use of the PHQ-2, two or three question tests

perform better, identifying eight out of every ten people with depression in primary care. Caution should be taken when interpreting the PHQ-2, as 2 and 3 item questionnaires can often result in false positives (Mitchell & Coyne, 2007). Arroll et al (2005) extended the two question format by adding the additional question: Is this something with which you would like help?, evidencing an improvement in the diagnostic specificity from 78% (two questions alone) to 89% (either screening question plus help question) for depression. The PHQ-2 is proposed to be an effective method for ruling out a diagnosis of depression, rather than having diagnostic capabilities (Mitchell & Coyne, 2007), and is reported to be of equal value to a GPs ability to eliminate depression (Arroll et al, 2005) and should only be used in a screening process whereby there are sufficient resources to administer a second-stage assessment for those who screen positive (Mitchell & Coyne et al, 2007).

2.1.2 PHQ-9
The PHQ-9 is a self-administered nine item depression questionnaire developed in the US (Kroenke et al, 2001). There is a wealth of evidence that supports the validity of the PHQ-9 for use in screening for depressive symptoms in primary care (Kroenke et al, 2010; Hansson et al, 2009). The PHQ-9 has been validated against a diagnostic gold standard of depression in the UK (Gilbody et al, 2007). It can be completed in less than two minutes and provides evidence of good levels of sensitivity (91.7%) and specificity (78.3%) for depression. This makes the brief PHQ-9 questionnaire comparable to the screening abilities of more lengthy clinician-administered instruments in detecting depression (Gilbody et al, 2007). Although the PHQ-9 does not detect for anxiety, a recent article published by Kroenke et al (2010) benchmarks the PHQ-9 and GAD-7 as brief, well-validated measures for monitoring depression and anxiety respectively.

2.1.3 GAD-2 and GAD-7

Similar to the PHQ-9, the GAD-7 has an abbreviated two-item version, known as the GAD-2. This consists of the first 2 items on the GAD-7 and representing the core anxiety symptoms. Scores on this GAD-2 subscale ranged from 0 to 6. Both have been shown to be effective in detecting generalised anxiety, panic, social anxiety and post-traumatic stress disorder (Kroenke et al, 2010). However, although there are promising findings for the GAD-2 and GAD-7s validity in screening for Generalised Anxiety Disorder (GAD) (Spitzer et al, 2006) the levels of sensitivity for this tool are not yet definitive (Kroenke et al, 2010). The PHQ-9 and GAD-7 form the main body of the questionnaires as part of the Improving Access to Psychological Therapies (DH, 2008) data set. These form part of the minimum data set for all IAPT sites to collect. There are currently over 100 Primary Care Trusts (PCTs) which have joined the IAPT programme and all PCTs are committed to provide a service by 2011 (DH, 2008). The IAPT programme reports that the IAPT data set was compiled

using the most suitable, free to access tools that were available in other languages and most widely used in practice (DH, 2008).

2.1.4 Hospital and Anxiety Depression Scale (HADS)

The HADS is a self administered questionnaire, which has both an anxiety and depression scale enabling a clinician to establish severity of both anxiety and depression simultaneously, whilst providing separate scores for each of the independent subscales as independent measures. The HADS consists of 14 items with the response format of four options of symptom severity per item in relation to the respondents experiences over the last week. Many studies have supported the validity of HADS (Snaith et al, 2003). A review of 747 studies in which the HADS was administered concluded that it was shown to perform well in the assessment of both anxiety and depression for somatic, psychiatric, primary care patients and the general population (Bjelland et al, 2002). The HADS can be purchased from a reliable publisher of psychometric scales, which has arranged translations into many languages which are available at request.

2.1.5 Beck Depression Inventory Second Edition (BDI-II)

The BDI was originally developed in the 1960s (Beck et al, 1961) and was updated a number of times (Beck et al, 1979; Beck et al, 1996) subsequently. It is a self- report instrument that uses the DSM-IV criteria to categorise the symptom severity of depression. The BDI-II consists of 21 items that will assess the severity of depression in clinical and normal patient samples. Each item has four statements attached to it that are arranged in increasing severity in relation to a symptom of depression. The BDI-II takes around five minutes to complete and can be purchased from the suppliers website. This scale has been widely used as a tool to identify depression severity (Sharp & Lipsky, 2002). The BDI-II has demonstrated reliable, internally consistent and valid scores in primary care medical settings suggesting that it may improve the detection and support the treatment of people with depression (Arnau et al, 2001). It can be used alongside the BDI-fast screen, a shortened version of the full scale which was been developed for use in primary care (Beck et al, 1997).

2.2 Recommendations for Long Term Conditions (LTC) Pilot

As a result of this paper the recommendations for the LTC Pilot are, for the identification of depression, the use of the PHQ-2 as a tool for the patient to self administer prior to meeting with the GP followed by the PHQ-9 if the patient scores 3 or more. The PHQ-9 would be filled in by the patient in the presence of the GP who could aid administration and support its delivery. The GAD-2 and GAD-7 are the equivalent of these measures for the identification of anxiety disorders and, as with PHQ-2 and PHQ-9, their use is recommended within this pilot. These are also widely used nationally and although they have not received as much attention as the PHQ-9, their depression counterpart, they have shown to be an effective and accurate 7

screening tool. The scores of the PHQ-9 and GAD-7 would then be used to inform the referral pathway (see Table 1 and Table 2, p10). The PHQ and GAD scales were deemed as the tool of choice for a number of reasons: they are widely used in the NHS in primary care nationally and in other healthcare systems internationally; the PHQ is endorsed by the QOF as a tool that benchmarks effective depression screening; they are both part of the IAPT minimum data-set and thus scores link directly to the stepped care model providing clear care pathways; and there are no charges associated with their use.

2.3 The Referral Pathway

2.3.1 IAPT & the Stepped Care Model for Common Mental Health Problems
NICE recommends a range of psychological therapies to treat people who are experiencing depression and/or anxiety. The stepped care model provides a system of care in line with the levels of severity associated with mental health problems. The IAPT service functions to support the delivery of the stepped care model in relation to common mental health problems, such as depression and anxiety. Figure 1 outlines the IAPT stepped care model. The stepped care model has two main principles: Treatment should always have the best chance of delivering positive outcomes while burdening the patient as little as possible. A system of scheduled reviews to detect and act on non-improvement must be in place to enable stepping up to more intensive treatments, stepping down where a less intensive treatment becomes appropriate and stepping out when an alternative treatment or no treatment become appropriate.

Derived from the IAPT website www.iapt.org.uk NICE guidelines advocate the treatment of depression if the patient presents with depression as the primary diagnosis. Only in cases where anxiety is the primary diagnosis should this be treated first (NICE, 2009; NICE, 2004).

Figure 1: IAPT Stepped Care Model for Common Mental Health Problems

NICE promotes the stepped care framework in the MH guidelines in the delivery of effective services. This also includes a Step 4, which in this case would correspond with severe and complex depression where there may also be a risk to life and/ or severe self-neglect. This is not incorporated into the IAPT stepped care model as this level of mental ill health would not constitute input at a primary care level. Mental Health has been prominent in policy drivers for some time due to the overt health and cost implications attached to it. This has resulted in the development of clear referral pathways to ensure smooth and effective delivery of psychological services. The majority of psychological therapies provided by the IAPT programme are Cognitive Behavioural Therapy (CBT) based interventions. CBT has been shown to improve mental health problems in people who have long term physical conditions, such as CHD, diabetes and COPD. IAPT recommends that people are referred to the IAPT service if they screen positive on the two questions recommended by the QOF (also known as the Whooley questions) The PHQ-2 would ideally be administered before meeting with the GP and 9

could be sent out prior to the meeting. The further PHQ-9 questionnaire can then be administered in primary care and the score from this can be used to inform the referral process within the Stepped Care Model. If a patient was referred to the IAPT service they would continue to complete the PHQ-9 as part of the IAPT Data Set and this continuity would make worthwhile links between primary care services. The tables below outline the range of scores mapped onto the IAPT stepped care model (see IAPT Stepped Care Model for Common Mental Health Problems (Figure 1)). Table 1 PHQ-9 Score Step in Stepped Care Model Recognition, assessment and Initial Step 1 management Persistent sub threshold depressive symptoms (PHQ-9= 1-4), mild (PHQ9= 5-9) or moderate depression (PHQ-9= 10-14) Step 2

Persistent sub threshold depressive Step 3 symptoms (PHQ-9= 1-4) or mild (PHQ-9= 5-9) to moderate depression (PHQ-9= 10-14) with inadequate response to initial interventions, and moderate (PHQ-9=15-19) and severe depression (PHQ-9=20-27) Developed in line with NICE, 2009. Table 2 GAD-7 Score Step 1: All known and suspected presentations of GAD Step 2: Diagnosed GAD that has not improved after education and active monitoring in step 1 Step 3: GAD with marked functional impairment or that has not improved after step 2 Step in Stepped Care Model Step 1 Step 2

Step 3

Developed in line with NICE, 2011 (Still in development) The IAPT service would use the information provided by a referrer and the PHQ-9/GAD-7 questionnaires to allocate an individual to a low or high intensity practitioner who would initially offer an appointment to the patient. The IAPT service provides a smooth care pathway, as there is the flexibility to move up or down the stepped care model in accordance with progress made at any given level.

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3 Introduction: Screening for Memory Problems in Primary Care

The average consultation time in UK primary care is 7.5 minutes. For this reason cognitive testing is often deemed as too time consuming by primary care teams (Brooke & Bullock, 1999). Traditionally the Mini-Mental State Exam (MMSE) has been labelled as the gold standard cognitive test. However more recently, with the increased pressure to manage the growing number of people with cognitive impairments as our population ages (Brodaty et al, 2006), there has been a surge of development of alternative brief tests in response to this need.

3.1 NICE guidance & NHS drivers

The importance of early detection is emphasised in the National Dementia Strategy (DH, 2009). This stresses the importance of early diagnosis, as late detection limits the extent a person has over their treatment choices. More recently, assessment of a patients cognition has moved towards being deemed as a crucial component of medical consultation (Brown et al, 2009). This is reflected in the Department of Health Operating Framework for 2008/2009 (DoH, 2007), which summarised the situation as: providing people with dementia and their carers the best life possible is a growing challenge, and one that is becoming increasingly costly for the NHS. Research shows that early intervention in cases of dementia is cost effective and can improve quality of life for people with dementia and their families. The National Dementia Strategy (DH, 2009) places primary care at the heart of this initial identification process. The Strategy has set out the development of specialist services, such as memory clinics, which would support primary care by providing explicit referral pathways.

4 Review of Screening Tools

This paper will define and critically appraise a number of cognitive screening tests in line with their appropriateness for use in GP consultations with people with long term conditions (LTCs). This will include tools highlighted in NICE guidance (NICE, 2006): MMSE, General Practitioner Assessment of Cognition (GP COG) and the 6-Item Cognitive Impairment Test (6CIT) and a number of tools, some which have not been outlined by NICE but which have been specifically validated for use in primary care with a good evidence base. This includes the Mini-Cog and Memory Impairment Screen (MIS). Finally, a new NHS recognised, brief, self-administered test for dementia known as the Test Your Memory (TYM) assessment is discussed. Sperlinger et al (2004) utilised work by The British Psychological Society (BPS) on outcome measures to produce a set of criteria which clinical

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measures could be scored against. Milne et al (2008) further adapted these in line with the target population of people with cognitive impairments. The Sixteen criteria were grouped into four key domains Practicality (Time implications for clinician, cost and availability of tool). Feasibility (acceptability to patients and clinicians, ease of administration and scoring, time taken to complete). Range of applicability (applicability to wide age range and different dementia types, sensitivity to education level, language and culture). Psychometric Properties (validity, reliability, specificity and sensitivity).

The four key domains have been used in this paper to evaluate the Memory Screening Tools available at present. These criteria have also been utilised to evaluate the MH screening tools (see section 2), as they provide a parallel system for ensuring the screening tools for the LTC pilot meet BPS standards of best practice (See Appendices 3 and 4). Milne et al (2008) reviewed eight instruments that met the inclusion criteria, including those presented as options in the opening section of this paper (with the exception of the TYM, which was still in development at the time the study was underway). The three screening measures that were rated as best overall for implementation in primary care using this point system were the GP COG, the Mini-Cog and the MIS (see Appendix 2 for an overview of these tools). Despite the above three tools being advocated as best practice, Brown et al (2009) stress that these do not fully meet three essential requirements for widespread use by non-specialists: that it takes minimal operator time to administer tests, that is covers a reasonable range of cognitive functions and that it is sensitive to mild Alzheimers disease. They propose that the TYM test fulfils these three essential requirements.

4.1.1 The Test Your Memory (TYM)

The TYM is quick to use, examines 10 cognitive skills, and detects 93% of cases of Alzheimers disease in comparison to 53% by the MMSE (Brown et al, 2009). It has been referred to as the simple test that can spot Alzheimers in five minutes and this has been publicised by NHS choices. Using the cut off point of 42 to indicate a possible diagnosis of Alzheimers in a group of people where 10% had Alzheimers gave a negative predictive value of 99% and a positive predictive value of 42% (Brown et al, 2009). Furthermore, the TYM is completed by the patient and scored using a rigid scoring sheet. This means that it is unlikely that the patient or scorer will have an influence on the score thus securing the TYM as a valid and robust memory tool. The TYM shows equivalent screening abilities to the original and revised Addenbrookes examinations in the diagnosis of dementia (Mioshi et al, 2006; Mathuranath et al, 2000), covering similar cognitive domains in its testing and also being sensitive to mild dementia. The TYM has the advantage over the Addenbrookes examinations and other substantial instruments, such as the

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MMSE due to its simplicity in delivery and accessibility and ease for training implementation.

4.2 Recommendations for Long Term Conditions (LTCs) pilot.

As a result of this paper the recommendations for the LTC pilot are the use of the TYM test. This has a strong advantage over current cognitive tests in that it has a brief but rigorous scoring system and as a result of this a strong interrater agreement that is described as a level of excellence (Brown et al, 2009). For example, a combination of ten minutes and presence of the scoring sheet enabled a nurse to score the TYM sheets as accurately as a specialist. This provides assurance that the TYM test will avoid the pitfalls of other cognitive screening tools regarding to confusing scoring and interpretation systems. The simplicity of the implementation of this tool aligns with the need for people to be trained quickly in response to what is described as a huge challenge to society, both now and increasingly in the future (DH, 2009, p9).

4.3 Referral Pathway

4.3.1 The Stepped Care Model for Memory Impairments
There is no clear nationwide referral process or stepped care model at present for memory impairment. This gap is identified in the National Dementia Strategy (DH, 2009), a five-year strategy which is funding the development of services that are fit for the 21st century for people with dementia and their carers. In the future it is likely that through the development of memory services there will be a clearer framework for GPs to follow in response to detection of memory impairment. A three step model is used in this paper to structure the care pathway process. This consists of: 1. Memory complaints at a primary care level. 2. Assessment of global functioning by a GP. 3. Specific cognitive testing in a specialised setting. Palmer (2003) showed that this three-step framework resulted in a high positive predictive value for Alzheimers disease (85-100%). One drawback of Palmers (2003) three step procedure was that it was not very good at identifying people with mild dementia due to the low sensitivity of the MMSE, the tool he had used with this client group. The TYM test has shown good sensitivity to mild dementia (Brown et al 2009) and is likely to fit well in place of the MMSE in Palmers (2003) referral framework.

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5 Overview of Recommendations for Long Term Conditions (LTCs) pilot

For a more detailed overview of the rationale for the recommended mental health and memory screening tools see 2.2 and 4.2 respectively. The PHQ-2 and the PHQ-9 (screening for depression) and the GAD-2 and GAD-7 (screening for anxiety) were recommended as the mental health screening tools for the LTC pilot. The PHQ-2 and GAD-2 provide a pre-screening process, whereby they could be completed prior to meeting with the GP to inform whether further screening using the PHQ-9 and GAD-7 was required. The TYM test was recommended as the memory screening tool of choice for the LTC pilot. One area that requires further research is the validity of the recommended cut off points with a LTCs client group (Stafford et al, 2007). Although this is an area that is still in development it is suggested that lowering the cut off scores substantially improves the sensitivity of mental health screening tools due to the presence of physical complaints as a result of the presence of a LTC (Stafford et al, 2007). All tools recommended, for both mental health and memory screening, have a good evidence base for use in primary care, have promising findings for detection and are already in use on a national scale in projects or as part of NHS policy drivers.

6 Final Thoughts
This paper was intended to be comprehensive but not exhaustive in providing an overview of the evidence for mental health and memory screening tools and the associated referral pathways in line with NHS policy. The added value of detecting and managing co-morbidity for people with LTCs reflects the importance of screening for mental health and memory problems in this client group.

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7 References
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Brown, J., Pengas, G., Dawson, K., et al. (2009) Self administered cognitive screening test (TYM) for detection of Alzheimers disease: cross sectional study. BMJ, 338. BMA (2008) Quality and outcomes framework guidance: Depression. London: British Medical Association. BMA (2008) Quality and Outcomes Framework guidance for GMS contract 2008/9. Delivering investment in general practice. London: British Medical Association. Department of Health (2010) Improving the health and well-being of people with long term conditions. World class services for people with long term conditions: information tool for commissioners. London: Department of Health. Department of Health (2008) The Operating Framework for the NHS in England 2008/2009. London: Department of Health. Department of Health (2009) Living well with dementia: A national dementia strategy. London: Department of Health. Department of Health (2009) New Horizons: Towards a shared vision for mental health: Consultation. London: Department of Health. Department of Health (2008) Improving Access to Psychological Therapies (IAPT) Commissioning Toolkit. London: Department of Health. Department of Health (2007) The Operating Framework for the NHS in England 2008/2009. London: Department of Health. Gilbody, S., Richards, D. & Barkham, M. (2007) Diagnosing depression in primary care using self completed instruments: UK validation of PHQ-9 and CORE-OM. British Journal of General Practice, 57, 650-652. Gilbody, S., Whitty, P., Grimshaw, J., et al. (2002) Improving the recognition and management of depression in primary care. Effective Health Care Bulletin, 7. Hansson, M., Bodlund, O., & Chotai, J. (2009) Patient education and group counselling to improve the treatment of depression in primary care: a randomized controlled trial. J Affect Disord, 105, 235-240. Katon, W. J. (2003) Clinical and Health Services Relationships between Major Depression, Depressive Symptoms, and General Medical Illness. Society of Biological Psychiatry, 54, 216226. Kroenke et al (2010) The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. General Hospital Psychiatry, 32, 345-359.

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Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2003) The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care, 41, 1284-1292 Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001) The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med, 16, 606-613. Mathuranath, P. S., Nestor, P. J., Berrios, G. E., et al. (2000) A brief cognitive battery test battery to differentiate AD and frontotemporal dementia. Neurology, 55, 1613-1620. Michie, S., OConnor, D., Bath, G. et al. (2005) Cardiac rehabilitation; the psychological changes that predict health outcomes and healthy behaviour, Health & Medicine, 10, 88-95. Milne, A., Culverwell, A., Guss, R., et al. (2008) Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr, 20, 911-926. Mioshi, E., Dawson, K., Mitchell, J., et al. (2006) The Addenbrookes cognitive examination revised (ACE-R). A brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry, 21, 1078-1085. Mitchell, A. J., & Coyne, J. C. (2007) Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and metaanalysis of 22 studies. British Journal of General Practice, 57, 144-151. NHS North East (2008) Our vision, our future Our North East NHS: a strategic vision for transforming health and healthcare services within the North East of England. Newcastle upon Tyne: North East Strategic Health Authority. NICE (2011) Common mental health disorders: identification and pathways to care (Guideline in development). NICE (2009) DepressionTreatment and management of depression in adults, including adults with a chronic physical health problem. NICE clinical guideline 23. London: TSO. NICE (2006) Supporting People with Dementia and their Carers in health and social care. NICE Clinical Guideline 42. London: TSO. NICE (2004) Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. NICE Clinical Guidance 22. London: TSO. NICE (2004) Depression: Management of Depression in Primary and Secondary Care. NICE Clinical Guideline 23. London: TSO. Palmer, K., Backman, L., Winbald, B., et al. (2003) Detection of Alzheimers disease and dementia in the preclinical phase: population based cohort study. British Medical Journal, 326, 245-247.

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Appendix 1- Comparative Table: Common MH Screening Tools

Tool PHQ-2 Description Ultra-short questionnaire consisting of two items to screen for depression Scoring System - Score of 3 or more indicates further screening is required. Delivery Time 1m Advantages - Effective method to rule out a diagnosis of depression - Equal value to GPs ability in elimination of depression - Beneficial to add the help question. Shown to improve specificity from 78% to 89% -Based directly on diagnostic criteria for major depressive disorder in the DSM-IV - Free -Part of IAPT minimum data-set -Scores directly map onto stepped-care model and referral pathways -Validated for use in primary care -Greater sensitivity in the detection of depression in comparison to HADS. - Part of the GAD-7, a well known and endorsed screening tool for the IAPT service. - Good reliability - Based on DSM-IV criteria Disadvantages - Can often result in false positives - Only of use when there are sufficient resources to administer a second stage assessment - Relatively new screening tool

PHQ-9

Aids diagnosis of depression and measures symptom severity.

Nine-item questionnaire with a maximum score of 27. 1-4 (minimal) 5-9 (mild) 10-14 (moderate) 15-19 (moderate/severe) 20-27 (severe) First two items on GAD-7 representing core anxiety symptoms. Scores on this subscale ranges from 0-6 to inform further use of GAD-7 7 item questionnaire with the maximum score of 21. 0-4 (normal) 5-9 (mild) 10-14 (moderate) 15-21 (severe) 7-item questionnaire with a maximum score of 21. 0-7 (normal) 8-10 (mild) 11-14 (moderate) 15-21 (severe) 21-item questionnaire with a maximum score of 36. 0-13 (minimal) 14-19 (mild 20-28 (moderate) 29-36 (severe)

3m

GAD-2 GAD-7

Ultra-short questionnaire consisting of two items to screen for anxiety Aids diagnosis of generalised anxiety and measures symptom severity

1m

-Relatively new screening tool -Redundant without a follow up questionnaire - Not as much evidence for different client groups

HADS

Designed to assess both anxiety and depression

5m

- Assesses both anxiety and depression -Validated for use in primary care -Likely to require little training due to being a well- established tool - Based on DSM-IV criteria - Has an abbreviated fast-screen for use in screening for primary care

- Not free to use -Not based on DSM-IV criteria

BDI-II

Assesses severity of depression

5m

- Not free to use - Training practitioners to use the tool would be time consuming

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Appendix 2: Comparative Table: Memory Screening Tools

Tool MMSE Description Measures Orientation, registration (immediate memory), short term (ST) memory and language functioning. Scoring System Scores out of 30 25/30 (normal range) 10/20 (moderate) <10 /9 (severe) Scores >8 or <5 on CA indicate cognitively intact or impaired (CI) respectively. Score of 5-8 (inclusive) requires the further IQ. A score of >3 on this indicates CI. Assess the test as suggestive of dementia if the total score is 8 or more. Delivery Time 10m Advantages -NICE endorsed -Validated in number of populations - Regarded as gold standard. Disadvantages -Does not detect subtle memory loss particularly in well-educated patients -Not free ($1 Per use) -at least 1 of the instruments from which the GPCOG was derived (the CAMCOG [39]) is significantly biased by sociodemographic factors, urging caution when interpreting scores. -Further validation in larger populations required - Complex scoring system

GP COG

Two components: cognitive assessment (CA) and informant questionnaire (IQ). CA includes time orientation, clock drawing, recent event report and word recall. IQ asks about changes over last few years.

CA:4m IQ: 2m

6CIT

All items verbally based. Measures orientation, ST memory and attention.

4-6m

Mini-Cog

Mini-Cog measures only two areas of cognition: shortdrawing. Verbal memory task with specific encoding procedure Series of 10 tasks including scoring on: orientation, ability to complete a sentence, semantic knowledge, calculation, verbal fluency, similarities, naming, visuospatial abilities, recall of copied sentence and ability to do the test.

MIS TYM

Recall of none of the three words, or recall one or two of the three words an abnormal clock is suggestive. The MIS score is calculated as [2X (free recall)]+[cued recall] Each component is allocated a number of points giving a possible total of 50 points. The cut-off point for Alzheimers is 42 or less

2-4m

>5m

- NICE endorsed -Two stage method has good sensitivity and specificity in detecting dementia -Evidence suggests it is reliable and may be superior to MMSE -Misclassification rate less than MMSE -Free -Correlates well with MMSE and outperforms MMSE in detecting milder dementia -Free to use -Used as part of a large European tool (Easycare) -Computerised versions in use -Misclassification rate less than MMSE -Simple scoring system -Scores not influenced by education level or language abilities. -Misclassification rate less than MMSE -Can be self-administered -More sensitive in detection of Alzheimers disease than MMSE (93% versus 52% respectively) -Accurately detects mild cognitive impairments - Brief but vigorous scoring system -10 m required to train nurse as specialist scorer -Free

-Only measures two areas of cognition. -Scoring of clock drawing is open to bias. -Test requires further validation in primary care. -No current evidence of its validity in primary care.

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Appendix 3- Table of Common MH Screening Tools evaluated against criteria adapted from BPS Guidelines Practicality Feasibility MEASURE A. Depression PHQ-9 BDI-II HADS-D B. Anxiety GAD-7 HADS-A Range of Psychometric applicability Properties

X X X

Appendix 4- Table of Memory Screening tools evaluated against criteria adapted from BPS Guidelines Practicality MMSE GP COG 6CIT Mini-Cog MIS TYM Feasibility Range of Psychometric applicability Properties

? ?

X ?

? ?

? ? ?

Screening Tools shaded in Grey highlight common MH and memory screening tools recommended by this paper for implementation in the LTC pilot

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Appendix 4- Comments received from Draft 1 The first draft of this paper was circulated to a number of health professionals working in a variety of settings in both primary and secondary care. The comments received were very useful in shaping the document and provided the paper with valuable input from clinicians and mental health leads in the region. The completed paper was developed in line with the comments but could not incorporate all suggestions of additional tools in its content. The comments below therefore serve to show the suggestions made in the papers development. General comments: An IAPT Lead for the region commented positively on the links the paper makes with IAPT and the commonality of the tools used within primary care. He stated how the paper ties up some of the activities already being developed and cements the way forward in line with them. A lead Consultant Psychiatrist & Psychotherapist in the region, specialising in CBT, commented upon the value of the scales being cost free and having data for use in primary care. He recommended the additional use of the WHO-5 wellbeing questionnaire, as WHO recommends it as a measure of positive mental health. Mental Health screening tool comments: A Public Health Lead for the region recommended the inclusion of the WEMWBS scale (Warwick Edinburgh Mental Wellbeing Scale). He suggested it has added value in that it is beginning to be used more widely in the region. The shortened version of this scale was highlighted as being the preferred version, as in evaluation of some projects in County Durham they have found that service users preferred this shorter scale as they found it less invasive than the longer version. Memory screening tool comments: The TYM test was recommended by a Consultant Clinical Psychologist Older Adults specialist working for NTW, as Probably the best self report memory test stressing how it is relatively new and not used in the north east at present. He also confirmed that the MMSE is the routine measure at present although it tends to miss mild problems. He highlighted how importance it was to build in additional checks into the system for a LTCs client group, which is something the paper outlined in the Overview of Recommendations for Long Term Conditions (LTCs) pilot section. A Regional GP Advisor for IAPT reported how the paper had made some really sensible suggestions endorsing the use of PHQ-9 due to it's established use in Primary Care. She also commented how she was really interested to see how the TYM performs in primary care as it looks very promising.

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Supporting better mental health

The North East Mental Health Development Unit Hosted by NHS County Durham The Greenhouse Greencroft Industrial Park Stanley County Durham DH9 7XN Tel: 01207 523655 www.nemhdu.org.uk

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