Prof Dan Joyce

M-RIC stories – A different approach to difficult-to-treat depression 

By Professor Dan Joyce, M-RIC Lead for innovative therapies for mood disorders; and mental health avatar.

When I was a junior doctor one of my standard jobs was to examine a new patient on a ward and come up with a formulation for why they are in hospital.

My slightly cynical observation was 80 per cent of data stored on their electronic health record (EHR) was just noise, admin such as how many times an appointment letter was sent. Only 20 per cent was data that I could zoom in on and say, ah, now I understand that this person has been unwell for at least a decade; I can see they lost their job and have become homeless.

The next thing I observed was I had a patient who had a relapsing bipolar affective disorder and he would frequently end up in hospital when he had manic relapses. One hypothesis was, it was because he wasn’t sleeping, so we designed a personalised little template for monitoring him, recording how many cups of coffee he had at night and how often he would drop off and then fight sleep.

The nurses didn’t have the time to sit there and monitor a patient in this way. The other thing that occurred to me was what I really want is a quantified measurement, a clinical global impression, not just the opinion of one nurse who happens to be available during a ward round.

“I wanted a way of capturing all those little nuggets of information that we carry around in our heads about the people that we’re caring for, but in a time-efficient, quantitative way.”

We routinely take people’s blood pressure when they’re an inpatient but we don’t have the same device that measures temperament. That, collectively sampled by a number of professionals would actually give us a better triangulation of what’s going on for that patient. We all do it implicitly, but we don’t capture it explicitly.

So that’s how where these ideas came from, about creating a digital avatar and about a different way of monitoring, assessing and treating mood disorders. It has been my singular mission ever since to try and get some of these ideas implemented. M-RIC is giving me the opportunity to do just that.

The people we are targeting are those who’ve had treatment for depression, but it never really went away. They are still somewhat disabled by it and they’ve just learned to live with that lower quality of life. These are not the patients who end up in emergency departments, they’re not the patients who end up being referred in because they’re at high risk of ending their lives. It’s the ones who haven’t really recovered and aren’t doing brilliantly, they’re the sort of hidden majority and they tend to languish in primary care or outside the NHS.

At the same time, we know that the rate of antidepressant medication prescribing has shot up.

There’s a sort of model of care which is, did that work? Well, it’s not brilliant, but I feel a bit better – so let’s not rock that boat, let’s stay on that medication because you’re better than you were.

Now what if you flip the problem around and instead of just focusing on whether you have depression or not, what if we assessed your current treatment for depression, your current difficulties, and asked what is disabling you, what would you like to be better.

What we’re trying to do at the moment is understand what technology we could use to share the process of designing treatment. The sort of model in my head is with the clinician and the patient sat in front of a computer together, with the clinician saying what are the things that bother you most and what do we know about how to measure them, is there a particular instrument or questionnaire we could use.

We want to find a way to do that which isn’t just giving the same patient reported outcome measure every time, with the same questionnaire every two weeks. It’s much more about instantaneous measurement that the patient and the clinician both agree will provide useful data and both agree is not too burdensome.

We are borrowing the expertise that has been developed in other regional mood disorder services, taking it as a gold standard of best practice and then modifying it.

We will create the first mood disorder service for the North West and we will take this rounded approach using different tools, which we think isn’t happening elsewhere at the moment.

The win-win will be a new pathway of care, aimed at people who don’t get better after treatment with medication and/or cognitive behavioural therapy (CBT).  A GP will be able to ask us to see a patient who isn’t responding after six months – or six years – of treatment and we would carry out a more complex, more rounded assessment which might include revising the diagnosis.

The quietly suffering depression patient probably won’t be referred into an acute specialist team because those teams are too overwhelmed with patients at risk of suicide.

We are now designing the service model and the interface with existing NHS processes; and we are looking at different technology platforms. We will start with a small group of patients who have had a hard time getting the right treatment. We will test out our ideas with them and invite them to help us debug what we’re proposing to do in our assessments and treatment recommendations.

Even skilled clinicians struggle a little bit to understand what we’re proposing and why it is different. I tell them to imagine that we have the luxury of treating each patient as a mini research project. Instead of sending these patients back to the GP, you can send the patient to our clinic where we will have the space and time to try something else.

We are working towards launching the mood disorder clinic during 2024.

Other roles held by Professor Dan Joyce
Honorary Consultant Psychiatrist, Mersey Care NHS Foundation Trust
Professor of Connected Mental Health, Institute of Population Health, University of Liverpool
Oxford Health NHS Foundation Trust – lead for cognitive health clinical research facility;
Biomedical Research Centre Core Group Lead for artificial intelligence and digital innovation, University of Oxford, Department of Psychiatry

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