Mood Clinic

Seeks opportunity for improving daily function and quality of life when sustained remission is elusive [1].
Multi-dimensional: examines patient, illness and treatment related factors that could be addressed/acted on with active intervention.

Outcome optimisation is patient defined, e.g. using goals based outcomes such as optimism and self confidence; return to pre-morbid state and restoration of usual  functioning [4,5].

Emphasises shared decision making reflecting patient preferences and historical experience with treatment.

Treatment Resistant Depression (TRD)

Inadequate symptom response (< 25% on a standardised instrument) [2,3] after two consecutive trials of medication.  

TRD focuses on medication at adequate minimum effective dose and duration (4 weeks) and does not consider intolerance to be treatment failure [3].

Treatment success is often clinician defined, e.g. response [2] defined as a 50% reduction in pre and post-intervention on HAM-D (HRDS), MADRS or PHQ9. 

Emphasises research, clinical trials and consideration of revising or augmenting pharmacological/biological treatments.

[1] McAllister-Williams, et al. (2020) ‘The Identification, Assessment and Management of Difficult to Treat Depression: An International Consensus Statement’. Journal of Affective Disorders 267 (April 2020): 264–82.

[2] Rush, et al. (2006) ‘Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder’. Neuropsychopharmacology 31, no. 9: 1841–53.

[3] Sforzini, et al. (2022) ‘A Delphi Method Based Consensus Guideline for Definition of Treatment Resistant Depression for Clinical Trials’. Molecular Psychiatry 27, no. 3: 1286–99. https://doi.org/10.1038/s41380-021-01381-x.

[4] Zimmerman, et al. (2006) ‘How Should Remission From Depression Be Defined? The Depressed Patient’s Perspective’. American Journal of Psychiatry 163, no. 1: 148–50.

[5] Zimmerman, et al. (2012) ‘Symptom Differences between Depressed Outpatients Who Are in Remission According to the Hamilton Depression Rating Scale Who Do and Do Not Consider Themselves to Be in Remission’. Journal of Affective Disorders 142, no. 1: 77–81.

Referrals are encouraged and informal enquiries regarding eligibility of patients can be made by emailing the Mood Clinic.

Eligible patients include:

• Those who have tried at least two NICE recommended treatments (e.g. one course of psychotherapy and one trial of an antidepressant; or two trials of different antidepressants) for depression and have not had satisfactory improvement in symptom control, quality of life or functioning
• Those who have had difficulties that have persisted for longer than six months after trying at least two treatments
• Those who have complicating factors (for example, intolerance of previous medications or adverse experiences with previous therapies)
• Those with co-morbid diagnoses provided these are stable and the focus of the referral is management of mood difficulty
• Those who are help seeking, able to give informed consent and able to tolerate a series of assessments over an extended period of time.

Patients may be declined:

• If a patient has yet to trial two approved treatments
• If a co-morbid diagnosis or symptom – for example, a psychotic disorder - requires treatment first, or where there is an expectation that revision of their treatment for a comorbidity would be expected to improve mood symptoms.

Referrals will be reviewed and discussed by the multidisciplinary, that includes psychiatrists, research nurses and allied health professionals. There are three potential outcomes from each referral:

• Accepted: The patient is accepted into the Clinic and will be contacted by the team
• More information required: The referral did not include enough information to decide whether to accept or decline. The referrer will be contacted directly for further, specific information.
• Declined: The patient is not suitable for the Clinic. Any declined referral will include a rationale for this decision, and if appropriate, written advice on interventions and avenues for further treatment, that may address their mood disorder.

We are a specialist service designed to support people aged 18 or over where first line treatments from their GP or mental health team have not helped.

Referrals are accepted from community mental health teams and from primary care via simple ‘free text’ email submission of this form to referrals.mood.clinic@merseycare.nhs.uk     

Professionals advice service

We offer a limited advice service via email or phone. GPs, mental health practitioners or psychiatrists can seek advice on:

• Suitability of a patient referral to the Mood Clinic
• Next steps for patients where referral to Mood Clinic is uncertain; for example, if considering changing or titrating a medication or when a previous treatment is being considered for re-starting/re-trial.

Please be aware that:

• This facility cannot provide diagnoses for patients, emergency advice or provide crisis services
• Emails will be answered Monday to Friday, 9am to 3pm (unavailable outside of these times)
• Phone support, with calls made to 0151 351 8837, will be answered on Friday between 9am and 12 noon.

We offer an outpatient multidisciplinary team assessment that delivers a psychological, occupational and psychiatric formulation with bespoke recommendations for treatment, in collaboration with the patient’s “home” team to implement and monitor plans, where appropriate. Management recommendations consider patients’ treatment preferences, previous experiences and goals alongside their home team’s clinical perspective. We will employ a transdiagnostic approach, focusing on clinical complexity rather than e.g. diagnosis based exclusions.

The flow chart outlines the patient’s journey through the Mood Clinic, from referral to transfer back to their referring team. Throughout, collaboration with their referring team is emphasised in: early information gathering stages, designing the tentative treatment plan and ensuring recommendations from Mood Clinic, including prescribing, are enacted.

The service will actively use and trial new technologies for implementing measurement based care, monitoring patients’ clinical state as well as capturing registry grade data to enable novel treatments (including equitable access to clinical trials) to be targeted to those most likely to benefit.

Patients who progress through the Mood Clinic will be part of a confidential, pseudonymised regional Mood Clinic Data Registry, governed by Mersey Care (with the level of participation dependent on patient consent) providing detailed, clinical trial standard phenotyping and will be available to access future research and trials of new treatments. Consent for participation in Mood Clinic Data Registry is in addition to the patient’s preferences for the Trust’s Count Me In scheme and patients can choose for their data to be used for their clinical care only, then additionally consent to its use for improving care nationally and/or to take part in research.

Mental health Research for Innovation Centre (M-RIC)

In June 2023, Mersey Care NHS Foundation Trust and the University of Liverpool launched the Mental health Research for Innovation Centre (M-RIC). Mood Disorders Care Innovation work focuses on new ways for treating mood disorders and we are establishing a service aligned with the Mental Health Mission Translational Research Collaboration’s (MHM TRC) Mood Disorders theme, learning and borrowing from best practices in other regional and national services. More information can be found on the M-RIC website.