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AIS Annual Report 2009

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The Dundee Advanced Interventions (Neurosurgery for Mental Disorder) Service was first designated as a National Specialist Service in April 2006, and became fully staffed in the first quarter of 2007. We are therefore reporting on the second full year of service activity.

 

	Actual	Planned
Assessments	26	24
Vagus Nerve Stimulation	4	7
Anterior Cingulotomy	3	5
Follow-up	11	12

 

Twenty-five referrals were received during 2008/09. Twenty-two (88%) came from Scotland, 2 (8%) came from England, and 1 (4%) came from Northern Ireland.

Twenty-six assessments were performed. One patient did not attend for initial assessment. The source of assessments mirrored that of referrals, with 3 assessments being conducted outwith the Service Level Agreement (SLA) and was funded by referring NHS Trust in England/ Ireland).

Approximately 60% of assessments had a primary diagnosis of unipolar major depression. Approximately 20% had a diagnosis of Obsessive-Compulsive Disorder. Bipolar disorder, organic disorders, personality disorder, and other anxiety disorders made up the remaining diagnoses.

During 2008/09, 7 procedures (3 cingulotomies and 4 Vagus Nerve Stimulator implantations) were performed. Five procedures were funded outwith the SLA.

There were no deaths, no post-operative infections and no significant adverse events during the current year.

The average (±SD) waiting time (from referral to assessment) for Scottish patients was 10.7 ± 6 weeks. Where patients had to wait longer than 15 weeks, this could be accounted for by reasons such as rescheduled appointments at the request of the patient.

There were no formal complaints.

Patient satisfaction for both outpatient assessment and inpatient admission was consistently high, with the majority of patients rating their experience positively. The service was rated highly for quality of assessment. Inpatient experience was uniformly positive.

In the patients reviewed during 2008/09, six had undergone ACING (four as their second procedure) and five had undergone VNS. Response rates for VNS were 20%. This is believed to reflect the high levels of chronicity, disability and treatment-resistance within the patient group treated in Dundee. With respect to these clinical features, the VNS patients treated in Dundee were not comparable to those typically included in published studies where higher response rates have been described. Two out of 4 (50%) patients undergoing a second ACING for major depression achieved clinical remission.

Staff have delivered a range of presentations at national and regional meetings throughout the year. Invited presentations have also been given at postgraduate psychiatry meetings in Scotland.

The service continues to publish academic papers on NMD and related topics  and a number of AIS staff have been awarded grants for further research.

Dundee AIS continues to build links with local mental health services and a variety of third-sector organisations. In the last year, members of the team have visited tertiary-level inpatient OCD treatment services in London.

The service is optimistic about the possibilities for participation in international multi-centre trials of Deep Brain Stimulation (DBS) for both depression and OCD.

Although of the referral rate for assessments was lower this year than last, we continue to exceed our SLA recommended activity level. This reporting year has been busier with respect to neurosurgical activity and our engagement in post-operative care planning with referring services has continued to build and evolve.

New members of the team bring with them exciting possibilities for the service to build on its existing research portfolio and to ensure the delivery of best clinical practise in the delivery of complex and advanced interventions for chronic, refractory psychiatric illness.

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Please note, some of the following tables duplicate information that is presented in greater detail later in this report. All headings in this summary reflect condensed information that is presented elsewhere.

Dundee Advanced Interventions Service was designated as a National Service in April 2006. The service comprises a small, highly skilled, multi-professional team offering multi-disciplinary assessment and treatment for severe, chronic, and treatment-refractory depression (TRD) and Obsessive-Compulsive Disorder (OCD).

Some of the specialist treatments provided include ablative neurosurgery – Anterior Cingulotomy, and non-ablative stimulation techniques – Vagus Nerve Stimulation (VNS).

Overall activity for the year is shown below. Forty referrals were received during this reporting year, of which six will be seen in the subsequent year. The actual number of assessments exceeded the planned number by 46%. The number of follow-ups conducted was 92% of planned, but the number of follow-ups is, of course, determined by procedures performed in previous years.

Numbers of procedures performed was within the limits of the SLA. However, it should be noted that these have always been aspirational figures and the numbers of patients proceeding to neurosurgical intervention is critically dependent upon pre-referral treatment ‘adequacy’ and, crucially, patient choice.

 

	Actual	Planned
Assessments	35	24
Vagus Nerve Stimulation	1	7
Anterior Cingulotomy	2	5
Follow-up	11	12

 

Of the forty referrals received, 33 referrals (82.5%) originated from Scotland; five referrals (12.5%) from England; and 2 (5.0%) from Northern Ireland.

Thirty-five multidisciplinary clinical assessments were conducted. All patients either were seen on an outpatient / day patient or inpatient basis in Dundee, or were assessed at their local hospital. Four (11.4%) of theses assessments were for patients originating from England; two (5.7%) were from Northern Ireland; one (2.9%) was from Eire; and 28 (80%) were from Scotland. Seven patients (20%) were seen (and financed) out with the Service Level Agreement.

The largest number of Scottish referrals came from NHS Boards with the closest geographical relationship to Tayside. This is commonly seen in National Services, but causes us to be aware that the largest NHS Boards (e.g. NHS Greater Glasgow and Clyde) are not necessarily the largest referrers.

The mean age of patients assessed was 50.3. The male to female ratio was 1:1.7, reflecting, perhaps, that the majority of patients had a primary diagnosis of depression, which is more prevalent in women. A majority of patients (57.1%) were married.

The ethnicity of assessed patients closely mirrored the ethnic distribution of the Scottish population, with 82.1% of individuals being ‘White Scottish’, and 10.7% being ‘Other White British’.

The mean DEPCAT score (an index of socioeconomic deprivation) of Scottish patients assessed over the last two years was 3.2. This suggests that patients referred tend to originate from a slightly more affluent population than might be predicted. Those populations with the estimated highest prevalence rates of depression tend to have higher DEPCAT scores.

 The primary diagnoses of patients seen by the service were as follows: Depression (60.0%); Obsessive-Compulsive Disorder (17.1%); Bipolar Disorder (5.7%); other anxiety disorders (5.7%); organic disorder (5.7%); and Personality Disorder (5.7%). Twenty of patients seen within the reporting period had their primary diagnosis revised after detailed assessment by Dundee AIS, evidencing the utility of detailed clinical review and independent ‘second’ opinions for patients with chronic mental health problems.

For those patients seen with depression (n=17), the average duration of the current episode was 8.4 years, with the average duration of lifetime illness being over 11.5 years. The average duration of inpatient stay was 16 weeks, with some having been hospitalised for over two years during their lifetime. These data confirm the chronicity and disability associated with the presenting illness.

Severity of depressive symptoms was generally within the high ‘moderate’ range and quality of life ratings were low. Indeed, our referred patients rated their health-related quality of life as being worse than those awaiting a liver transplant, or suffering from the neurological disorder Parkinsons’s disease. Three patients actually rated their quality of life as being worse than death.

Patients referred with chronic refractory depression had had an average of 8.1 ‘adequate’ antidepressant drug trials at the time of assessment, but adequacy of psychological treatment was considered to be evidenced for only one third of referred patients.

Patients with OCD scored within the ‘severe’ range of the spectrum, with two patients scoring in the ‘extreme’ range. Health-related quality of life was poor and comparable with the patient referred with depression. The average duration of OCD illness was approximately 16 years. The majority of patients with OCD had not been exposed to robust trials of anti-obsessional medication, with 50% of patients not having had a trial of the ‘gold standard’ medication, Clomipramine. Only 8% of referred patients had experienced an ‘adequate’ previous trial of the ‘gold standard’ psychological treatment for OCD, namely Exposure and Response Prevention (ERP). This is disappointing and raises important questions about the general availability of appropriate and effective psychological services for patients with OCD.

During 2007/08, Dundee AIS performed two ablative procedures – Anterior Cingulotomy (ACING) – and one non-ablative electrical stimulation procedure – Vagus Nerve Stimulation (VNS). Patient demographics are shown in Table 17 below (p. 45). Patients had been unwell continuously for 5-10 years, with a lifetime duration of illness of 8-10 years.

During 2007/08, other notable clinical activities included two inpatient admissions for patients with OCD to deliver intensive, targeted psychological therapy (ERP) which resulted in significant symptom improvement for both. A further patient (having undergone neurosurgery many years previously) was reviewed whilst profoundly depressed and suicidal and was subsequently admitted at the request of the referring team. Following inpatient treatment by the Dundee service, the patient was discharged in full clinical remission.

No deaths have occurred during the lifetime of the NMD service (1992-current) and there have been no completed suicides of patients who have previously received neurosurgical treatment in Dundee. Therefore, there were no deaths during the reporting period.

The mean waiting time for Scottish patients was 9.5 weeks (target = 18 weeks). No referred patient had to wait longer than 16 weeks from referral to assessment.

Patients from out with Scotland (and funded by their local health authority/ Primary Care Trust) did, however, have to wait longer to be seen. In some cases, patients from England had to wait over six months before being appointed. This was due to delays associated with the relevant PCTs providing authorisation of funding for the assessment to proceed.

No formal complaints were made during 2007/08.

During the reporting period, we initiated a formal Patient Satisfaction feedback programme. Please see Section 7.2 below (p. 54) for a detailed report. A negative response rate (to questions on a comprehensive questionnaire) of 3% indicates that patients rate the quality of care as being high.

Overall satisfaction is between ‘Agree’ and ‘Strongly Agree’ with statements reflecting high quality of service. There were no negative responses to questions about quality of care. Seventy-one percent of respondents strongly agreed with the statement, “Overall, I am satisfied with the care I received”.

As with the majority of surgical interventions, and comparable with other national specialist services, the clinical outcomes for psychiatric neurosurgical procedures are reported and assessed in terms of detailed prospective clinical audit.

Please see Section 9 below for a detailed analysis of outcomes from NMD Procedures. At the most recent follow-up period occurring during 2007/08, 4/6 (66.6%) of cingulotomy patients[1] met stringent criteria to be deemed ‘responders’. With regards to VNS patients, overall, 4/9 (44.4%) of patients were ‘responders’ at 12-months.

A preliminary cost-utility analysis (CUA) was conducted for Anterior Cingulotomy and Vagus Nerve Stimulation using data generated by our service. Quality-Adjusted Life Years (QALYs) were calculated for patients having undergone each procedure. The cost-per-QALY for Anterior Cingulotomy was just under £35,000, which compares favourably with many other interventions in mental health, particularly in this refractory population. The cost-per-QALY for VNS was £102,000 at 12-months, but follow-up is shorter compared to ACING patients, and other cost benefits (such as admission to hospital) were not incorporated into the calculation.

Patient outcomes are reviewed on a constant basis, and the results of these processes have recently been published in peer-reviewed journals. Surgical outcomes are monitored closely by proactive departmental audit.

There have been no critical incidents or significant adverse events during the lifetime of the Advanced Interventions Service.

The ‘survival’ rate is 100% at all follow-up points. No patient has undergone a subsequent procedure during the same inpatient stay, as clinical practice precludes further procedures prior to one year. There has been one infection occurring in the operative wound in the weeks following surgery. It is not possible to state that this was hospital-acquired. Eventual management involved regular review by the neurosurgical team.

In the last 12-months, Dundee AIS presented seminars at the Royal College of Psychiatrists Scottish Division Autumn Meeting, and a presentation was given at the ‘Joint Annual Scientific Meeting of Great Britain and Ireland and the British Stereotactic and Functional Neurosurgery Group’. Presentations were also made to postgraduate meetings, from Inverness to Glasgow.

The team have also collaborated with specialist regional affective disorders services in England, and a successful application has been made to participate in a Clinical Research Group on the management of treatment-refractory unipolar depression.

Members of the team have published research in peer-reviewed journals, and have contributed to the drafting of clinical guidelines by the National Institute for Health and Clinical Excellence (NICE) and the British Association for Psychopharmacology (BAP). We have also recently authored a chapter on Neurosurgery for Mental Disorder in the Oxford Textbook of Psychiatry and have been commissioned to provide an on-line Consultant CPD Module by the Royal College of Psychiatrists

In the last year, the service has established a website that provides information on the service, as well as making a variety of assessment tools available to clinicians. Website activity has increased steadily over the last six months. We are perhaps unique among services in publishing our waiting times online.

We are looking to watch the development of deep brain stimulation (DBS) in depression and OCD and continue to review the outcome of published data as it become available so that we may continue to develop the service to an international standard. We also intend to participate in any sound scientific translational research that we feel likely to benefit patients.

Dundee AIS is exploring the possibilities offered by ‘telehealth’, and is using developments in Information Technology to deliver high quality patient care to more remote locations, aiding continuity of care.

We are exploring the potential of a Managed Clinical Network for OCD in Scotland, and look forward to working with key stakeholders to take this forward.

We have established initial links with ‘Third Sector’ (voluntary) organisations, which have well-established networks and connections within Scotland, and can play a vital role as partners in ensuring that high quality clinical services are accessible to all.

Dundee Advanced Interventions Service continues to provide specialist interventions for a small number of individuals with chronic and treatment-refractory mental disorder. All patients entering the neurosurgical treatment stream are subject to a detailed prospective clinical audit, with comprehensive assessment of outcomes in domains relating to symptoms, social functioning, quality of life, and neuropsychological performance.

Closely allied to the University of Dundee, the service has a strong research focus and continues to publish research at an international standard. Perhaps uniquely placed to guide developments in the treatment of depression and OCD throughout Scotland, Dundee AIS looks forward to working with stakeholders to continue to improve patient care and outcomes.