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The CPN liaison service
To provide a seamless mental health
cases who, however, continue to be referred to service across the primary / secondary care
CMHTs by GPs who feel that they do not have thenecessary expertise. Thus, there is a risk that some interface, it is necessary to look at the
patients might find that neither primary nor needs of modern primary care and
secondary care feels able to deal with their problems.
community mental health services. A
theoretical model can then be developed
The advent of new antipsychotic drugs, the trainingof CPNs in advanced psychotherapeutic skills such which integrates services and clarifies the
as cognitive therapy and family therapy, and the resources, both human and training,
adoption of more effective Assertive Outreach needed in such a service.
techniques do make CPNs more effective in dealingwith severe mental illness in the community. Despite It has been suggested that between 20–25% of this, the effective use of the Care Programme consultations carried out by GPs on a day-to-day Approach (CPA) should involve GPs and the PCT in basis concern mental health problems. Yet, a the management of the seriously mentally ill. The large proportion of patients who present with involvement of general practice in the care of the depression to their primary care team (PCT) are not seriously mentally ill (especially when dealing with diagnosed as suffering from the condition. 1,2 In an physical symptoms) has been emphasized by the average practice list of 1900 patients there will be: recent publication of consensus guidelines. 6 Burnsand colleagues have also demonstrated that practice nurses can monitor the progress of the seriously ◆ 60 with moderate to severe depression mentally ill. 7 These advances offer great promise for ◆ 140 with mixed anxiety and depression the improvement of the mental health of our However, most patients who are treated with ◆ Sufficient resources in finance and manpower antidepressants in primary care are not treated for a are available in both primary and secondary care sufficient time according to current guidelines.
◆ Appropriate education is given to enable Furthermore, most patients prescribed tricyclic primary care doctors and nurses to carry out antidepressants by their GPs are prescribed sub- their role in the field of mental health, and education in cognitive and family therapytechniques (such as the Thorn Course) are made Primary care in England must shoulder the major part of the burden of mental healthcare, and manage ◆ A clear structure is established to ensure the most of it without referral to secondary care services.
close relationships and cooperation of PCTs and This task is a great one and GPs need the support of CMHTs is maintained and that this strategy is their team and a programme of ongoing education to enable them to deal adequately with the mentalhealth workload generated by their practice lists.
The first attempts to link PCTs and CMHTs devolvedoutpatient clinics into primary care. However, Within secondary care it has become policy, psychiatrists who run outpatient clinics in general following an Audit Commission report, to assume practice surgeries often fail to integrate into the PCT.
that community psychiatric nurses (CPNs) and Recent articles by Gask and coworkers, 8 and Burns community mental health teams (CMHTs) should and Bale 9 have described consultation-liaison reserve their attention for the care of the seriously attachments of psychiatrists to PCTs. However, the mentally ill. 5 This has led to the withdrawal of CPNs number of psychiatrists available throughout the and CMHTs from involvement with ‘less serious’ country is insufficient to provide such a system forall general practices.
Mark Agius MD
We have recently developed a system which takes Medical Adviser
John Butler MSc
advantage of a third model also described by Gask Lead Community Mental Health Nurse and colleagues. 8 CPNs, who are part of the CMHT, Beds and Luton Community NHS Trust, Charter House are aligned with general practices, and this is developed into a full liaison service between PCTs In addition, health visitors are able to identify Primary Care
Community Mental
postnatal depression and to treat it using cognitive, Health Team
problem-solving or counselling strategies. 14,15 Training the PCT is critical to making the model Creative
work. A team of multidisciplinary trainers trained therapist
after the fashion described by Tylee 16 is based in Luton 17 and visits PCTs to help increase their preparedness to deal with mental health problems.
Community
midwife
Psychiatrist
After visiting the practice and assessing the currentpractice, the team writes a report giving advice and expertise. It runs workshops for PCGs offering evidence-based guidelines to deal with common Counsellor
Psychologist
mental health problems. The team also runsworkshops to train practice nurses in theidentification and management of depressionanxiety. The full implementation of this model is a Figure 1: CPN Liaison Model
challenging task which will take many years ofeducation and innovation, with regular audit.
However, there seems little doubt that the fullintegration of PCTs and CMHTs, using the CPN as and CMHTs (see Figure 1). The CPN belongs to both the link worker, presents the best chance of taking the CMHT and the PCT, and in this way, can fulfill psychiatry of recent years and achieving a fullyintegrated community psychiatric service.
◆ Acting as liaison link with the CMHT, giving advice to GPs on the management of mentalhealth problems, and referring to the consultant References
1. Paykel ES, Priest RG. Recognition and management of depression in
general practice: Consensus statement. BMJ 1992;305:1198–202 ◆ Giving cognitive therapy and family therapy to 2. Kessler D, Lloyd K, Lewis G, et al. Cross sectional study of symptom the seriously mentally ill within the setting of the attribution and recognition of depression and anxiety in primary care.
BMJ 1999;318:436–9 3. Onyett, Pidd, Cohen, et al. Mental health service provision and the ◆ Ensuring the full involvement of the practice in primary health care team. Mental Health Rev 1996;1(3):8–16 4. Tylee A, Donaghue JM. The treatment of depression: Prescribing the CPA, acting as a keyworker, and encouraging patterns of antidepressants in primary care in the UK. Brit J Psychiatry ◆ Offering clinical supervision to practice nurses, 5. Audit Commission. Funding a place: A review of mental health services.
district nurses, health visitors and counsellors.
6. Burns T, Kendrick T. The primary care of patients with schizophrenia: A search for good practice. Brit J Gen Pract 1997;47:515–20 It is clear that for this liaison role to be implemented, 7. Burns T, Millar E, Garland C, et al. Randomized controlled trial of teaching practice nurses to carry out structured assessment of patients there must be sufficient number of CPNs available to receiving depot antipsychotic injections. Brit J Gen Pract cover all the practices in an area. CPN attachments to practices should be for an indefinite time and only 8. Gask L, Sibbald B, Creed F. Evaluating models of working at the interface between mental health services and primary care. Brit J be changed rarely, in order to ensure continuity of care. The value of this form of CPN liaison is 9. Burns T, Bale. Establishing a mental health liaison attachment with primary care. Adv Psychiatr Treatment 1997;3:219–44 graphically illustrated in the interim report of IRIS, 11 which suggests that in cases of early psychosis, the 11. Goldberg, Gourney. The general practitioner, the psychiatrist and the attached CPN is probably the one person in the burden of mental health care. Maudsley Discussion Paper No. 1 12. Mann AH, Blizard R, Murray J, et al. An evaluation of practice nurses practice who is able to collate all of the available working with general practitioners to treat people with depression. Brit J 13. Mynors-Wallace L, Davies I, Gray F, et al. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders Given proper medical supervision by the practice given by community nurses in primary care. Brit J Psychiatry CPN, it is possible to mobilise all types of primary 14. Holden, et al. Counselling in a general practice setting: Controlled study care nurses to help in the management of common of health visitor intervention in treatment of postnatal depression. BMJ mental health problems (advocated by Goldberg and Gournay). 16 Mann and colleagues 12 have shown that 15. Appleby L, Warner R, Whitton A, et al. A controlled study of fluoxetine and cognitive behavioural counselling in the treatment of postnatal practice nurses can monitor depressed patients and encourage compliance with treatment. Mynors- 16. Tylee A. RCGP mental health management course. J Primary Care Wallace and coworkers 13 have shown that practice 17. Agius M, Butler J. The management of mental health in primary care: nurses can be trained in basic cognitive skills, such The development of a training and facilitation initiative. RCGP Beds as problem-solving, to use with depressed patients.
and Herts Faculty News 1999;91:6–7

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