IAPT for Adults: Progress to Date & Next Steps. David M Clark National Clinical & Informatics Advisor University of Oxford

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1 IAPT for Adults: Progress to Date & Next Steps David M Clark National Clinical & Informatics Advisor University of Oxford (david.clark@psy.ox.ac.uk)

2 What is IAPT? An English Programme that aims to vastly increase the availability of effective (NICE recommended) psychological treatments for depression and all anxiety disorders by: training a large number of psychological therapists deploying them in specialized, stepped care local services for depression and anxiety disorders measuring and reporting clinical outcomes for ALL patients who receive a course of treatment (public transparency)

3 IAPT So Far Stepped care psychological therapy services established all 211 CCGs. Self-referral supported Approx 15% of local prevalence seen in services Around 60% have course of treatment (approx 530,000 per year) Outcomes recorded in 97% of cases (pre-iapt 38%)

4 Why getting complete data matters. (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009, Behav. Res.Ther) 10 Improvement Pre-Post Complete Post Missing 0 Depression Anxiety

5 IAPT So Far (3 rd Annual HSCIC Report and latest Quarterly Data) Recovery rate: 45% (range 19%** to 69%) ( A third of CCGs now exceed 50% ) Reliable Improvement: 61% (range 24% to 73%) Reliable deterioration: 6% (range 3% to 11%) Problem descriptor: 68%* (range <1% to 100%) Reducing variability must be one of the next goals. Notes: * up from 62% in 2013/14. ** data completeness issues, true low probably 30%

6 Recovery in some Groups of interest Over 65s: 57.8% recovery & 62% reliable improve Ex-Armed Forces: 47.8% Sexual Orientation: Recover Reliable Improvement Heterosexual 46.0% 62.2% Gay/Lesbian 42.7% 61.4% Bi-sexual 34.5% 56.2% But approx 40% of people do not state their orientation

7 Wait Times to First Treatment Average wait: 32 days Wait less than 4 weeks: 66.9% Wait less than 8 weeks: 85.9% Wait more than 13 weeks: 7.1%

8 Recovery and Number of Sessions by Problem Descriptor (Tables 9e & 4) Problem Descriptor Recovery Rate (%) No of Sessions Specific Phobia GAD Panic Disorder OCD Mixed Anx & Dep Depression Social Phobia PTSD Agoraphobia

9 Reasons for not having course of therapy (Table 7) 1,123,003 referrals* ended in 2014/15, with 654,121 not having a course of treatment (2 or more sessions). Of these: 57% never attended/contacted the service 43% attended at least once, of whom - 74% unsuitable/ referred elsewhere - 26% declined treatment or dropped out So overall only 11% of referrals who do not have a course of treatment were suitable but declined or dropped out. Note: * some individuals have more than one referral

10 Patient Experience Questionnaire (1) Table 17a Post-treatment Questions % Most or All Times Staff listened to you and treated concerns seriously? 96.7 Service helped you better understand and address your difficulties? Felt involved in making choices about your treatment and care? Got the help that mattered to you? 91.4 Have confidence in your therapist and their skills? 95.8 Clearly, very positive but note that PEQ was only completed by 11% (50,937) of patients who had finished a course of treatment

11 Patient Experience Questionnaire (2) Post Assessment Questions YES (%) Given information about options for choosing a treatment? 92.3 Did you have a treatment preference? 77.6 Were you offered your preference? 77.8 (4.2% NO & 14.4% Not applicable) Satisfied with your assessment? 73.7* (23.8% No) Between 57,000 and 74,000 responses, which is less than 10%. * Completely or mostly satisfied

12 Breakdowns by Therapy Type

13 How many NICE recommended high intensity therapies are available? (Table 9c) Number of CCGS HI therapies

14 Which Therapies are available? Therapy Type Number of CCGs CBT 212 Counselling 194 IPT 142 Couples 97 DIT 77 Other Hi % of CCGs offer CBT and Counselling (universal offer) 76% of CCGs offer at least 3 of 5 High intensity therapies 51% of CCGs offer at least 4 of 5 High intensity therapies

15 Number of people who had a course of different IAPT therapies in 2014/15 DIT, 0.3% IPT 1% Psychoeducational peer support 4% Pure self help 9% Other LI 9% Counselling 10% CBT 20% Couples, 0.2% Guided self-help 21% Other HI 4% Employment support, 0.1% CCBT 1% Behaviour activation 4% Not specified 17%

16 Are IAPT Therapies being deployed in line with NICE Guidance? (Table 5b) Problem descriptors are missing for 33% of cases When problem descriptors are specified most therapy types are being deployed in line with NICE Guidance Full range of high intensity therapies used when depression is a problem (depression & mixed anxiety & depression codes) Mostly CBT for anxiety disorders BUT there are two deviations from NICE Pure self-help given to 14,284 people, but not recommended. In GAD Counselling given to 2,517 people, but not recommended

17 Recovery Rates for LAST Therapy Type For the first time HSCIC report a breakdown of recovery rates by therapy type NOT A RANDOMIZED COMPARISON, SO PATIENTS WHO RECEIVE DIFFERENT THERAPIES MAY DIFFER IN OTHER IMPORTANT WAYS. IAPT is a stepped care system so many people get more than one therapy HSCIC only reports breakdown by LAST therapy in the sequence. Will tend to overestimate recovery when a therapy is also first in the sequence (low intensity therapies in general, some people with high intensity therapy). Therapies (IPT & CBT) that are predominantly used after a failed course of low intensity therapy may have less placebo responders, ETC, ETC Nevertheless, the data gives a rough indication of whether the different therapies as currently deployed in IAPT are are associated with reasonable recovery rates.

18 Depression Recovery Rates & Sessions for Last Therapy Type (Tables 5a & 4) Last Therapy Type Recovery (%) Computerized Cognitive-Behavior Therapy (ccbt) Interpersonal Psychotherapy (IPT) Couples Therapy Guided Self-help Brief Psychodynamic Therapy (DIT) Counselling Cognitive-Behaviour Therapy (CBT) Not specified Pure Self-Help Other low intensity Average sessions

19 Are deviations from NICE guidance associated with lower recovery rates? (Tables 5a & 5b) Self-help: GAD: Guided 50% vs Pure 36% (p <.0001) CBT 54.7% or Guided Self-help 59.9% vs Counselling 45.7% (ps<.0001)

20 Enhancing Service Recovery rates How? Lessons from analysis of national data Service innovation projects (Bucks) Local collaborative networks (Oxford AHSN) Clinical Leadership Public Health England Fingertips Tool.

21 Lessons from analysis of national data (Gyani et al, 2013 & internal analyses) Services with higher recovery rates Higher average number of sessions Use stepped care appropriately Core of experienced staff NICE compliant treatment High problem descriptor (ICD-10 code) completeness High paired outcome completeness rates Low DNA rates Shorter wait times

22 No simple relationship between the number of HI therapies available in a CCG and overall recovery rates Correlations Recovery r = -.08 p =.231 Reliable Improvement r = p =.960 ANOVAs Same uninformative null result

23 Improving Recovery rates: a local innovation example Bucks IAPT service (John Pimm) Recovery consistently around 45% & reliable improvement at around 65% Review ALL discharged cases that had failed to recover (one month exercise) Look for themes. Implement changes Now recovery 64%, reliable improvement 76%

24 Recovery Rates Nov 2013 Dec 2014

25 Local Collaborative Networks Oxford AHSN Anxiety & Depression Network covers 5 IAPT services, 12 CCGs. treat >20,000 per year formed in Jan 2014 Aim to increase overall recovery rate by 5% achieved 10% increase (46% to 56%) while national rate stayed constant at 45% Quarterly workshops sharing knowledge & planning innovations.

26 Improving Recovery rates: clinical leadership, staff supervision and CPD NHSEngland workshop with some high recovery rate services A consistent theme Leadership focused on recovery and reliable improvement data in an inquisitive and staff supportive manner Staff get personal feedback benchmarked against service average or other therapists Personalized CPD programmes for staff

27 Public Transparency Google Common Mental Health Disorders Profiles Tool Website displays multiple indices of IAPT performance by CCG, along with other key variables (social deprivation levels, investment in psychological therapies, etc) Designed to facilitate learning from other CCGs and to empower both commissioners and patients.

28 Next Steps Additional funding announced in Autumn Statement to ensure that: significantly more people will have access to talking therapies every year to Increase access to IAPT to at least 25% of prevalence Focus on anxiety & depression in context of long-term conditions. Create co-located physical and mental health services. Continue to expand choice of therapies. Greater use of digital platforms. Expansion of employment advisors Extend benefits of IAPT to SMI Outcome & reporting monitoring for all patients Staff trained in latest NICE recommended treatments

Enhancing Recovery Rates in IAPT Services and the LTC/MUS Expansion Programme.

Enhancing Recovery Rates in IAPT Services and the LTC/MUS Expansion Programme. David M Clark National Clinical and Informatics Advisor (davidmclark@nhs.net) IAPT So Far Transformed treatment of anxiety