Rationalising treatment for anxiety disorders: Introducing a transdiagnostic group approach

Transcription

1 Rationalising treatment for anxiety disorders: Introducing a transdiagnostic group approach Submission for the 2015 Canterbury DHB Quality Improvement and Innovation Awards Anxiety Disorders Service Specialist Mental Health Service Canterbury District Health Board

2 Table of Contents Project Information Sheet... 2 Abstract... 3 Introduction and Background... 3 Planning and Implementation... 6 Results and Findings Conclusions and Future Direction Glossary Figure 2 GANTT diagram

3 Project Information Sheet Project title Rationalising treatment for anxiety disorders: Introducing a transdiagnostic group approach Name and address of service/department Anxiety Disorders Service Building 9, Hillmorton Hospital, Annex Road, Private Bag 4733, Christchurch 8140 Contact Person Name Job Title Claire Gilbert Clinical Manager claire.gilbert@cdhb.health.nz Address: Anxiety Disorders Service Building 9, Hillmorton Hospital, Annex Road, Private Bag 4733, Christchurch 8140 Telephone: Word Count (limit 3000)

4 Abstract Overview: This project evaluates the efficacy and efficiency of a novel application of transdiagnostic cognitive behavioural therapy (TCBT), adapted by the Anxiety Disorders Service (ADS) for delivery in a group format to patients with a range of anxiety disorders. TCBT refers to the adaptations of standard CBT to treating mixed disorders. Vision/aim: Previously, in line with international best practice, ADS delivered evidenced-based group and individual CBT packages tailored for specific anxiety disorders. Slow recruitment into groups for less common disorders meant long waiting times for already anxious patients, and resultant use of resource intensive individual treatment. Increasing recognition in the anxiety literature of shared psychological processes underlying anxiety disorders and overlapping treatment strategies has led to the development of transdiagnostic approaches to rationalise treatment delivery. Goals/objectives: The goals of this project were to adapt Barlow s Unified Protocol TCBT to a group format: to deliver the group and establish feasibility to evaluate effectiveness to compare outcomes to previously conducted disorder-specific groups for generalised anxiety disorder and for panic disorder. Eleven groups run from were included. Participants were 94 adults with a primary anxiety disorder, with or without depression. Groups met weekly for 9 weeks with one-month follow-up. Measures included diagnostic, self-report symptom measures, and participant treatment ratings. Results: Retention was satisfactory with high patient-rated satisfaction. The TCBT group achieved large pre-post effect sizes in those who completed treatment, comparable to previously conducted disorder-specific (DS) groups The wait time for the TCBT group was considerably less than for the previous DS groups. Conclusions: These analyses indicate that the TCBT group approach is effective and efficient for ADS, is acceptable to patients; and in reducing waiting time will improve quality of life for patients and their families. It has the potential to be implemented in primary settings with less severe symptoms. 3

5 Introduction and Background The health care environment: The Anxiety Disorders Service (ADS) is part of the Specialist Mental Health Service (SMHS) at Canterbury District Health Board (CHDB). ADS is a small specialist team addressing high demand to treat moderate to severe, often coexisting anxiety disorders. The team receives approximately 470 referrals a year ( ) and has seven full-time equivalent clinical staff. When this initiative started the ADS waiting list was around 9 months, although this is now at 3 weeks. Motivating or initiating factors: Previously, as per international best practice in specialist services, the ADS delivered evidenced-based group and individual cognitive behavioural therapy (CBT) packages tailored for specific anxiety disorders. Group treatment is resource efficient, provides social support enhancing motivation, opportunities to learn from others and for behavioural experiments. However, slow recruitment into some DS-CBT groups meant long waiting times for already anxious patients, and resultant use of resource intensive individual treatment. A fishbone analysis (Figure 1) illustrates motivators for this project including high treatment demand, limited resources for treatment and the problem of DS treatment approach affecting wait time and treatment duration. Increasing recognition in the anxiety literature of shared psychological processes underlying anxiety disorders and overlapping treatment strategies led to the relatively recent development of transdiagnostic approaches to rationalise treatment delivery. Barlow s Unified Protocol for emotional disorders (1) is one such transdiagnostic treatment. There is emerging evidence for transdiagnostic approaches but few studies to date on group applications 4

6 This project aimed to rationalise treatment delivery by considering the potential to treat coexisting disorders simultaneously given these shared features of disorders and treatments to deliver more frequent TCBT groups rather previous DS-groups thereby reducing waiting times. The project team: Jennifer Jordan, Clinical Psychologist/Senior Research Fellow, Clinical Research Unit (CDHB and University of Otago, Christchurch,(also worked at ADS 2011-June 2015 Alison Alexander, Senior Clinical Psychologist Ron Chambers, Consultant Clinical Psychologist, Clinical Leader Psychology Helen Colhoun, Senior Clinical Psychologist Caroline Bell, Consultant Psychiatrist Claire Gilbert Clinical Manager / Psychiatric Nurse All except CB have been involved in the development and implementation of the TCBT. JJ, AA and RC have led the dissemination activities and JJ and AA have co-written this report. JJ did the data analyses. CB and JJ have co-written ethics and grant applications. CG has facilitated the team in all aspects of this project. 5

7 Planning and Implementation Site visit Three staff attended a workshop in Wellington in April 2012 where renowned anxiety expert Professor David Barlow from the Centre for Anxiety and Depression at Boston University presented his Unified Protocol transdiagnostic treatment for emotional disorders. Literature The treatment of anxiety disorders Over the past 40 years, more explicit description of diagnostic categories has increased reliability and validity of diagnoses. This led to the development of targeted manualised treatments for these well-defined disorders, particularly within CBT, a dominant evidence-based psychotherapy regarded as the gold standard treatment in this field. there are currently evidenced-based DS-CBT treatment manuals recommended for panic disorder, generalised anxiety disorder, obsessive compulsive disorder and social phobia, as well as for major depressive disorder (see (2-4). Current best-practice is to deliver these disorder specific (DS-CBT) treatment packages in individual or group treatment format, as had been the practice at ADS until this project. This approach has difficulties however and the pendulum has swung back to a more parsimonious approach, where a single treatment is used to treat more than one disorder at the same time. This began with Fairburn s proposal for transdiagnostic treatment for eating disorders (5) which inspired Barlow to develop the transdiagnostic protocol for emotional disorders (6). This paradigm change is reflected in the National Institute of Mental Health (USA) in 2013 calling for research to move from diagnostic to dimensional trait/symptom focussed approaches addressing possible neurobiological mechanisms underlying mental disorders. Transdiagnostic approaches to anxiety recognise the shared underlying features across anxiety disorders and frequently co-occurring depression (e.g. trait anxiety, neuroticism); shared clinical features across anxiety disorders; and that the major difference between anxiety disorders is the content of the threat. CBT treatment principles and strategies are similar across anxiety disorder CBT packages but with different behavioural targets and behavioural experiments for each disorder (6). Transdiagnostic research is growing rapidly with two recent meta-analyses summarising the literature in this area. Reinholt et al (2014) (7) reviewed the literature that included 12 trials of TCBT for anxiety disorders. They concluded that transdiagnostic approaches were effective with moderate effect sizes overall, were more effective than waitlist control and treatment as usual; and changes were maintained at follow-up. A second meta-analysis (8) of 50 studies reported that in uncontrolled studies, large pre-post effect sizes were obtained for anxiety (0.85) and depression (0.91). In 24 trials, transdiagnostic treatments were superior to control conditions on all outcome measures with still large pooled effect sizes for anxiety (0.65) and depression (0.80). In four randomised trials comparing transdiagnostic with DS comparisons, transdiagnostic was equivalent to DS treatments for anxiety although they concluded that transdiagnostic may be better for depression. Two main transdiagnostic research groups in anxiety disorder treatment are those of David Barlow (1) and Peter Norton and colleagues. Norton s group have published several studies of group TCBT, demonstrating that their group TCBT was effective and equivalent to group DS-CBT (9, 10). Barlow and colleagues Unified Protocol distils 6

8 common principles of CBT present in all evidenced-based protocols for specific emotional disorders. It is designed to be applicable to all anxiety and mood disorders. To date there are only two small studies of group TCBT based on the Unified Protocol (11, 12) they demonstrated feasibility and that group TCBT was superior to medication-only in reducing anxiety and depressive symptoms. Costing and expected benefits The costs of waiting for treatment are difficult to quantify but include reduced wellbeing and prolonged suffering, loss of earnings, disability benefits and resultant burden on the family and community. Service provision benefits to ADS: It was estimated that if TCBT groups were run more frequently then treatment could begin several months sooner, with efficiencies through larger group numbers and by treating disorders concurrently. More frequent groups mean a quicker patient journey. Previously the lengthy wait-list for DS-groups required therapists to deliver case management or as often happened, to offer individual treatment. Group treatment is almost twice as efficient as individual therapy: for example, a TCBT group is 9 sessions at 3 hours each, so 27 therapist hours x 2 therapists = 54 therapist hours to treat 8 patients. Individual therapy based on 12 sessions per client would take 96 therapist hours. Goals and objectives The goals of this project were to adapt Barlow s Unified Protocol TCBT to a group format to be delivered at ADS: to establish feasibility to evaluate effectiveness to compare outcomes to previously conducted DS groups for generalised anxiety disorder and for panic disorder. Ethics: This study was approved by the CDHB SMHS Research Committee. Participants provide informed consent to participate in ongoing evaluation of ADS groups. Consultation with stakeholders: Maori consultation was undertaken for planned research projects (not funded) with Ms Karen Keelan, Research Advisor Maori at the University of Otago, Christchurch. The ADS has regular contact with Anxiety Support. Wider consultation with other stakeholders was not considered necessary since ADS has longstanding expertise in the use of group CBT for anxiety and the TCBT delivery format was new, not the content. Systematic monitoring of progress occurs at every group. Review of progress with each patient following group is standard practice at ADS with further treatment delivered if and when necessary. Our first pilot study evaluated the first five groups (42 participants), using the methodology used here, and indicated preliminary feasibility and effectiveness. Links to CDHB s strategic goals: The TCBT project addresses CDHB strategic goals with improved benefits for patients through: improving efficiency and timelines in the patient journey reducing waiting times 7

9 Innovative aspects: When this project started there was no published research on group applications of transdiagnostic treatment for anxiety disorders, and our adaptation of the protocol for use in this format was novel. This is the largest sample size comparison of TCBT with DS-CBT group treatment to date. IMPLEMENTATION: The time frames and implementation of this project are charted in the Gantt diagram (Figure 2). The project was initiated by ADS and approved through SMS management reporting lines. Methods: Participants were referred by general practitioners to ADS and subsequently referred to TCBT groups during Inclusion criteria: Adults (18-65 years) with a primary disorder of generalised anxiety disorder (GAD), panic and/or agoraphobia, mixed anxiety symptoms or complicated comorbidity, providing informed consenting to the group and the evaluation, able to attend, able to converse in English. Exclusion criteria were declining the group, too busy with work or family commitments to attend, the group was considered unsuitable for them, a primary OCD or social phobia (treated in other groups). Measures: Baseline assessment Mini International Neuropsychiatric Interview (MINI) (13) structured diagnostic assessment assessing current anxiety and mood diagnoses Pre-post self-report measures reported here include: Beck Anxiety Inventory (14) Beck Depression Inventory (15) The Session Rating Scale (16), completed after each session. Statistics: Independent t-tests, general linear models and Cohen s d effect sizes. The TCBT group treatment package: This was adapted from the Unified protocol therapist and client manuals (1).This TCBT group is 9x 3 hour sessions, with follow-up at 1 month to review, consolidate strategies and make plans after discharge. Two clinicians (psychologists, nurses, social workers, occupational therapists, psychiatric registrars) co-facilitate groups. Key treatment modules: 1: Motivation Enhancement 2: Understanding Emotions. Recognising and tracking emotions 3: Emotion Awareness Training: learning to observe experiences 4: Cognitive Appraisal and Reappraisal 5: Emotion Avoidance 6: Awareness and Tolerance of Physical Sensations 7: Emotion and Interoceptive Exposures 8: Reviewing Accomplishments, Maintenance of Change and Relapse Prevention Monitoring progress Patient progress within groups is reviewed in team meetings. Reports are given at annual ADS planning days (minutes available for viewing). ADS has a culture of openness to innovation and there have been no identified barriers to change. The team has all been trained to deliver TCBT. All processes for referral into groups, pre-group 8

10 individual assessments, symptoms measures and the content of groups are established. A TCBT group working treatment manual is currently in the process of being refined by a working group. The ADS Service Provision Framework has been updated to include the new group. 9

11 % Results and Findings Description of sample: The TCBT sample includes data from 11 groups ranging from 7-10 participants in each. Gender was 69% women and 31% men. Age ranged from with a mean age of 36.6 (SD 12.2). Ethnicity was predominantly European (86%), Maori 2% and of the 19% reporting other ethnicities, 6% were non-new Zealand born Europeans, 3% were European (with English as a second language) and 1% reported Asian ethnicity. Psychiatric comorbidity among anxiety diagnoses and with depression was very common (Figure 3) Figure 3. Number of anxiety and/or depression diagnoses with the Transdiagnostic sample Number of comorbid diagnoses The mean number of anxiety diagnoses was 2.3 (SD 1.4, range 1-6) and if depression was included, the means number of diagnoses was 2.8 (SD 1.6, range 1-6). Only 25% had a single diagnosis. The most frequent diagnosis at 79% was generalised anxiety disorder (Figure 4). Figure 4. Frequency and type of diagnosis within the Transdiagnostic sample Major depression Post traumatic stress dis Obsessive compulsive dis Panic/agoraphobia Social phobia Generalised Anxiety dis % Patient perspectives: Retention in the group was satisfactory and consistent with what would be expected, with 79% completing 75% of the group (at least 6 of 9 sessions). Patients rated the group highly at end treatment with the median rating for 10

12 group processes being the highest possible score ( very much so 5/5) for 6/8 questions, and 4.5 for how helpful for me and 4/5 for progress, compared to the beginning of treatment. Figure 5-7 illustrate the strength of endorsement with regard to helpfulness (Figure 5) of the group at end treatment, rating of group cohesion and support and how much the patients felt heard, understood and respected. Fig.5. How helpful the TCBT group was for me 1=not at all % 4% 14% 5=very much 57% 25% Fig.6. Patient rating of how well the TCBT group worked together 1=not at all well 1 0% 2 5% 3 2% 4 18% 5=extremely well 5 75% 11

13 Effectiveness: The TCBT group was effective in treating participants, with large prepost effect sizes for completers for anxiety (Beck Anxiety Inventory d=0.74) and depression (Beck Depression Inventory d=0.68). Comparison with historical disorders specific groups: Baseline data indicated that the groups differed in severity so direct comparisons of outcome could not be made. The TCBT group had more severe anxiety (means, standard deviations) (26.2 (12.6) vs (9.7), F=4.6, df=2, p<0, 05) and depression scores than the DS-GAD group (26.6 (12.17) vs (9.8) F= 8.9, df=2, p< 0.001), and more severe depression compared to the DS-Panic group (26.6 (12.2 vs 18.5 (12.1), F=8.9, df=2, p<0.001). Effect sizes for anxiety scores (BAI) completers calculated separately for the DS and for those with the respective diagnosis in the TCBT groups indicated similarly large effect sizes for the DS-Panic group (d=0.97) and for the TCBT-Panic participants (d=0.90). For those with GAD, once again, effect sizes were large in the DS-GAD group (d=0.76) and the TCBT GAD group (d=0.65). Waiting time for group treatment: ADS has run TCBT groups more frequently as the numbers needed to start a group are more easily obtained. In 2014 and 2015, there were five and four groups run in respective years. This compared to previous years when due to low numbers, typically only two groups were run for those with GAD and two for those with Panic disorders. Waiting time for TCBT group treatment is dramatically reduced as a result. Outcomes of the project: The goals of this project were to adapt the TCBT to a group format: to deliver the group and establish feasibility This project has demonstrated feasibility Successful delivery of eleven groups High ratings of acceptability from patients Waiting time for groups has more than halved thereby providing earlier symptom relief with reduced impact on quality of life. to evaluate effectiveness Large effect sizes for those who completed are comparable with the international literature to compare outcomes to previously conducted DS groups for generalised anxiety disorder and for panic disorder Symptom outcome effect sizes are comparable to historical DS groups despite the TCBT sample having more severe symptoms 12

14 Conclusions and Future Direction This TCBT project has demonstrated feasibility and equivalent effectiveness to evidence-based DS treatment previously delivered at ADS. The high comorbidity and impact on mood and anxiety symptoms confirms the applicability of this model. High levels of patient satisfaction align with the CDHB statement that quality of patient experience is important along with effectiveness. The service delivery efficiencies for ADS positively impact on speed of the patient journey to treatment, with reduced wait times (CDHB initiative Less time spent waiting ). This is another measure adopted by ADS to improve efficient delivery in the face of ongoing large demand to treat this high prevalence disorder. TCBT is now an established feature of the ADS service delivery. Ongoing monitoring will occur as part of the ADS routine evaluation of treatment outcomes. Future research is planned including examination of predictors of outcome ( who benefits the most/least and from which aspect?) to further refine the TCBT group. Other outcomes: This TCBT project has attracted considerable attention locally and our team has undertaken dissemination activities, delivering four presentations including an invited afternoon workshop for the Canterbury branch of the New Zealand College of Clinical Psychologists (17-20). It has also generated considerable interest from other services and has generated a planned collaborative pilot study of a brief TCBT group to be delivered in primary care. Partners include ADS, the Canterbury Initiative, Pegasus Health Brief Intervention Counselling service and the Clinical Research Unit (a collaboration of the CDHB and the University of Otago, Christchurch). This new project promises greater collaboration with primary care, sharing of ADS expertise with primary health services to offer faster access to clinically effective and cost effective cost treatment in the community. Early community treatment may prevent the anxiety disorder becoming severe or chronic, thus reducing the psychosocial impact for patients and their whanau and downstream secondary care service delivery costs. This forthcoming initiative (a direct result of the current project) addresses the CDHB The Canterbury Way: A whole system approach model. If successful, it is the brief TCBT will be rolled out, with training provided to community agencies in Canterbury at that stage. We anticipate publishing several papers from this project in peer review journals. Entering this TCBT project for the Quality Award aims to highlight this innovative change to ADS service delivery. 13

15 Glossary of abbreviations ADS = Anxiety Disorders Service CBT = Cognitive Behavioural Therapy DS = Disorder specific GAD = generalized anxiety disorder MINI = Mini International Psychiatric Interview OCD = Obsessive Compulsive Disorder PTSD = Posttraumatic Stress Disorder SMHS = Specialist Mental Health Service TCBT = Transdiagnostic Cognitive Behavioural Therapy 14

16 References 1. Barlow DH, Ellard KK, Fairholme CP, Farchione TJ, Boisseau CL, Allen LB, et al. Unified protocol for transdiagnostic treatment of emotional disorders. Barlow DH, editor. New York: Oxford University Press; Barlow DH. Clinical handbook of psychological disorders: A step-by-step treatment manual: Guilford publications; Wells A. Cognitive therapy of anxiety disorders: A practice manual and conceptual guide: John Wiley & Sons; Beck JS. Cognitive therapy: basics and beyond. New York: The Guilford Press; Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. Behav Res Ther. 2003;41: Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behav Ther. 2004;35(2): Reinholt N, Krogh J. Efficacy of Transdiagnostic Cognitive Behaviour Therapy for Anxiety Disorders: A Systematic Review and Meta-Analysis of Published Outcome Studies. Cognitive Behaviour Therapy. 2014;43(3): Newby JM, McKinnon A, Kuyken W, Gilbody S, Dalgleish T. Systematic review and metaanalysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clin Psychol Rev. 2015;40(0): Norton PJ. Group Cognitive-Behavioural Therapy of Anxiety: A Transdiagnostic Treatment Manual New York: The Guilford Press,; Norton PJ, Barrera TL. Transdiagnostic versus diagnosis-specific cbt for anxiety disorders: a preliminary randomized controlled noninferiority trial. Depress Anxiety. 2012;29(10): de Ornelas Maia ACC, Nardi AE, Cardoso A. The utilization of unified protocols in behavioral cognitive therapy in transdiagnostic group subjects: A clinical trial. J Affect Disord. 2015;172: de Ornelas Maia ACC, Braga AA, Nunes CA, Nardi AE, Silva AC. Transdiagnostic treatment using a unified protocol: Application for patients with a range of comorbid mood and anxiety disorders Trends in Psychiatry and Psychotherapy. 35 (2) (pp ), Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan KH, et al. The Mini International Neuropsychiatric Interview (MINI): A short diagnostic structured interview: Reliability and validity according to the CIDI. Eur Psychiatry. 1997;12(5): Beck AT, Steer RA. Beck Anxiety Inventory Manual. San Antonio, TX: Psychological Corporation.; Beck AT, Steer RA, Brown GK. Beck depression inventory-ii. San Antonio Duncan BL, Miller SD, Sparks JA, Claud DA, Reynolds LR, Brown J, et al. The Session Rating Scale: Preliminary Psychometric Properties of a Working Alliance Measure. Journal of Brief Therapy. 2003;3(1): Jordan J, Alexander A, Chambers R. Transdiagnostic group cognitive behaviour therapy for emotional disorders. Aotearoa New Zealand Association for Cognitive and Behavioural Therapies; ; Christchurch Jordan J, Alexander A, Chambers R, Blampied M, Colhoun H, Gilbert C. Transdiagnostic Group Cognitive Behaviour Therapy for Emotional disorders (esp. Anxiety and Mood). Psychology Forum Day, Canterbury District Health Board; Christchurch Jordan J, Alexander A, Chambers R. Transdiagnostic vs. Disorder-specific treatment for anxiety disorder- a step forward? Grand Round, Clinical Meeting of the Canterbury District Health Board and the University of Otago, Christchurch; 18 September 2013; Christchurch Jordan J, Alexander A, Chambers R. Transdiagnostic group cognitive behaviour therapy for emotional disorders. New Zealand College of Clinical Psychologists (Canterbury Branch Education session); 3 July 2015; Christchurch

17 Figure 2. Gantt diagram showing timelines for Transdiagnostic cognitive behaviour group (TCBT) project April 2012 May 2012 June 2012 July-Aug 2012 Jul-Aug 2013 Oct mid 2013 Nov mid 13 Aug 2013 Sept 2013 Nov 2013 March- May 2014 Oct 2014 Nov 2014 Dec June 2015 Feb-// July 2015 Wellington Conference: Barlow on TCBT feedback to Anxiety team /discussion & ideas generating Review of literature - ongoing Decision to design a TCBT group treatment Working party for group Ethics discussion and approval Pilot TCBT treatment groups Planning day Nov 2012-discussion of group so far Presentation to Grand Round, Clinical Meeting CDHB Dissemination of treatment protocol to other staff Planning Day Nov 2013-review of group Preliminary evaluation of data TCBT Group Treatment Protocol working party Presentation to ANZACBT national conference Service review including TCBT treatment and processes Workshop to Canterbury Branch Education Session NZCCP 16 Further review, data analysis, review success of changes