Mental Health (Adult) Referral

Scott McLaughlin All Referrals, General Practice Referrals

Access to service by General Practitioner

The following is a description of tiered services within mental health to guide decision making and appropriate referral and signposting. In this context a tier refers to a service requirement with appropriate training and skills for delivery of patient care and is based on patient need, increasing complexity and risk assessments. It is based on the premise that patients will need to access a variety of health services dependent on their need throughout their lives, from those at primary care to those that are more specialised, and that a strategic approach to identify needs will best inform delivery of services and support evidenced based care.

Although it is anticipated the majority of GP colleagues will deal with Tier 1, Tier 2, Tier 3 and that they will treat and manage the majority of mental health problems in primary care, it is important to have information as to how best to use the services, to understand the range of treatments and interventions available and the need to ensure there are appropriate links with primary care as regards decision making at secondary care. Although GP colleagues may have less contact with Tier 4 their role will also be important in terms of sharing information and guiding secondary care on primary care interventions and treatments as part of multidisciplinary risk assessments and planning of care.

For the sake of completion Tier 0 refers to community, public health and strategic approaches to promote the general health and well being of patients and is not included here.

Currently and to allow the service to further develop we have combined the existing structures within psychology and how it would link with psychiatry services for the purposes of facilitating a referral system that is seamless from primary to secondary care , this will be reviewed and may be subject to further revision as services further evolve.

Tier 4: Specialist community teams, specialist inpatient units and regional health services

In Tier 4 highly specialist services provide aspects of Mental Health Care (mainly Forensic and Rehabilitation services) that may not be able to be provided within community secondary care services (of Tier 2 and 3). Currently there is no direct referral into this service from primary care but future developments of service may consider this.

Tier 3: Moderate to Severe Presentations

CMHTs (Community Mental Health Teams) are at the heart of secondary care services in Tier 3 and provide services to patients aged 16-65 and who have left school.
Patients aged 16-18 years who are still at school are the remit of Child and adolescent mental health services.
CMHTS also provide an emergency response to patients who are suffering a mental health crisis and require to be seen the same day, consequently each CMHT has a duty worker system and referrals can be taken 08:30-18:30 Monday to Friday and at weekends 10:00-16:30.

General guidance as to patients who would benefit from the Service includes:

  • Patients with severe depression not responsive to primary care interventions, this includes watchful waiting, psycho education prescription of antidepressants at appropriate doses as per SIGN guidelines.
  • Psychoses or suspected psychoses including Bipolar Disorder and Schizophrenia/Psychotic Depression.
  • Obsessive Compulsive Disorders and severe Anxiety Disorders, including suspected Somatoform Disorders which include Body Dysmorphic Disorder, somatisation disorder, Conversion Disorder, pain disorder and Hypochondriasis.
  • Eating Disorder with the exception of when this is deemed severe and the individual therefore has complex needs (i.e. acute clinically significant effects on physical health; or the presence of some acute physical effects with incapacitating Eating Disorder symptomatology which pose significant threat to functioning in several domains): refer to TESS a tier 3 specialist Eating Disorder Service in Coatbridge – see Firstport.
  • Assessment of cognitive functioning in patients to aid management plans and to develop strategies for improving functioning, including those patients suspected of having early onset dementia.
  • Assessment of suspected or confirmed pervasive developmental disorders including Autistic spectrum disorder, Asperger’s and Attention deficit hyperactivity Disorder.
    PTSD (at least three months post-trauma).
  • Survivors of Sexual abuse with significant psychological sequelae that have not responded to or not been able to attend other services including EVA (see the Gender Based Violence section on FirstPort) and MASA (Men Against Sexual Abuse contact 07896 839415, available on Tuesday evenings only) and who are at risk of developing severe depression and /or anxiety or trauma symptoms.
  • Suspected Borderline Personality Disorders or suspected personality-related difficulties and may include those patients whose mental health problems and/or whose level of functioning has deteriorated to warrant repeated hospital presentations (usually with repeated self harm attempts or Adult support and Protection referrals) and or brief admissions to a mental health unit.
  • Provision of intensive home treatment, home visits, outpatient appointments by CMHTs in available community bases (as alternatives to hospital admission) as well as the ability to further step up care to acute inpatient care if the needs and risk assessments of the patient cannot be safely provided for in the community.

Tier 2: Mild to Moderate Presentations

Assessment/treatment of mild to moderate common mental health problems (including Specific Phobias, Panic Disorder, Generalised Anxiety Disorder, Social Phobias, Health Anxiety, complicated or prolonged grief reactions, psycho-sexual difficulties, Habit Disorders and includes mild and moderate depression.

For the purposes of clarity as regards the definition of depression it includes the following:

  • Mild depression. This doesn’t usually stop you living your daily life, but you may find it difficult to concentrate at work or do things that you normally enjoy.
  • Moderate depression. This has a significant impact on your daily life e.g. unable to work, withdrawing from friends and family, incurring negative thoughts, anxiety and or panic symptoms and you may have more symptoms than people with mild depression.

Treatment/Support Options:

(A) Community Support Options:

  • NHS 24 (Guided Self Help/Telephone CBT)
  • Well Connected (self referral) including STRESS CONTROL, healthy working lives for employees in organisation less than 250 people: Health Working Lives
  • Counselling (self referral to Workplace Employee Assistance Programmes/University and College Health Services)

(B) Specialist Mental Health Support:

  • Counselling (NHS) both individual and groups available as appropriate
  • CBT (NHS) both individual and groups available as appropriate

Tier 1: Pre-Treatment Presentations

The identification, assessment and treatment of mild common mental health problems, such as anxiety and depression.
Although it is recognised that the majority of patients with mental health problems are treated in primary care, and effective treatment is available. As part of ongoing work in NHSL to standardise treatments it is important that patients are offered choices for treatment that follow evidence based guidelines.

As a consequence, it is expected that as part of the GPs repertoire of choices for patients, it is assumed that there has been an attempt to offer and inform the patient of self help, telephone help lines, website based CBT and NHS 24 CBT, or specific counselling including:

CRUSE for bereavement – www.cruse.org.uk
RELATE for marriage or relationship difficulties – www.relate.org.uk
PETAL for patients experiencing trauma and loss after a murder or suicide – www.petalsupport.com

and that the patients have been unable to or it has not been possible to engage with these interventions before referral to the secondary care services.

Pre treatment presentations will include the identification, assessment and treatment of mild common mental health problems, such as anxiety and depression. For patients who have been unable to access or unable to engage with common interventions that include:

Treatment/Support Options:

  • Watchful Waiting
  • Well Connected (self referral including STRESS CONTROL classes)
  • Voluntary Organisation (CRUSE, etc.) (self-referral)
  • Statutory sector support services.
  • Mainstream leisure, education and recreational services.

A Helpful guide includes SIGN Guideline 114 for depression, that concentrates on the non pharmaceutical management of depression.

Exclusion Criteria

  • Understandable and time limited Psychological difficulties that exist in the context of recent life events and which can be understood as a normal reaction to adverse life events (uncomplicated bereavement; recent trauma).
  • Anger in the absence of significant other mental health difficulties
  • Substance Abuse as Primary Condition as the Lanarkshire Alcohol and Drug service may be more appropriate see first port
  • Chronic Pain (refer to the Chronic Pain Team)
  • Those patients with a definite diagnosis of Traumatic Brain Injury as their needs may be better met by the Traumatic Brain Injury Team based in Blantyre Health Centre see FirstPort
  • Learning Disability as the Learning Disability team may be more appropriate Community Learning Disability Team see Firstport