MEDICALLY UNEXPLAINED SYMPTOMS THE IAPT NATIONAL PATHFINDER PROJECT

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1 MEDICALLY UNEXPLAINED SYMPTOMS THE IAPT NATIONAL PATHFINDER PROJECT Rona Moss-Morris Professor of Psychology as Applied to Medicine National Clinical Advisor to IAPT NHS England Institute of Psychiatry, Psychology and Neuroscience Section of Health Psychology

2 OUTLINE BACKGROUND TO IAPT WHAT PATHFINDER SITES TAUGHT US EVIDENCE BASED TREATMENTS DEVELOPING CLINICAL COMPETENCES AND TRAINING PATHWAYS TO CARE BETTER INTEGRATION

3 The IAPT Programme and Services Delivery of evidenced based talking therapies NICE approved interventions Treating mild to severe (without significant comorbidities) anxiety and depression Easy access GP and self referral

4 Treatment Recovery Focus Initial focus CBT but now includes a wider range of NICE recommended evidenced based interventions High and low intensity therapy and therapists Stepped Care

5 NICE-recommended therapies should be delivered by properly trained practitioners. Practitioners should receive regular (weekly) case supervision led by appropriate experts. All outcomes recorded and service-level outcomes published. Treatment should be delivered in the most cost-efficient manner, including stepped care when appropriate.

6 IAPT for depression and anxiety

7 IAPT LTC/MUS Project 2011 Aim The IAPT LTC/MUS Project aims to extend the benefits of improved access to psychological therapies for anxiety and depression in people with long-term physical conditions and/or medically unexplained symptoms.

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9 Phase Two pathfinders Pathfinder Target Population Intervention & Setting Type of IAPT Service LTC (T2DM) Therapy and Training Bespoke MUS Therapy (Primary Care) & Training Bespoke LTC (COPD) Therapy (Primary Care and Community Settings) & Training Bespoke with Respiratory Services LTC & MUS Therapy and Training (Integrated Care Clinic) Generic IAPT LTC & MUS Therapy Primary Care Model Bespoke LTC & MUS Bespoke MUS (CFS) Therapy (Primary Care and Community Settings) & Training Bespoke with Chronic Fatigue Service LTC (COPD) & MUS Therapy and Tele-health Service Bespoke LTC (Cardiac) Therapy (Primary & Secondary Services) Bespoke LTC & MUS Therapy (Primary Care) & Training Generic IAPT LTC & MUS Therapy (Group Interventions, Guided Self Help, High Intensity) Generic IAPT LTC & MUS Bespoke LTC & All MUS Therapy & Training Generic IAPT

10 Generic versus bespoke GENERIC Staff received training on LTC and/or MUS but treatment protocol used standard IAPT for depression and anxiety BESPOKE Closer integration with physical healthcare services. Incorporated manuals and self-management materials into the standard stepped care model treatment. Greater coordination and continuity of care upon discharge from the IAPT service.

11 Referrals and Treatment Pathways Most referrals from primary care Some bespoke services had links and referral pathways from secondary care and community services Self referral (including sign posting form other health care professionals) The majority of patients received low-intensity interventions (mostly groups) Some bespoke sites referring patients to Step 3 (IAPT) and Step 4 interventions (mostly one-to-one)

12 Which groups treated Unspecified pain (20%) CFS (10%) Fibromyalgia (9%) IBS (8%) Small numbers of Non-cardiac Chest Pain, Hyperventilation Syndrome, Multiple Chemical Sensitivity, and MUS Not Recorded

13 Recovery rates: PHQ % Recovery 90.00% 80.00% 70.00% 68% 68% 68% 60.00% 50.00% 40.00% 30.00% 47% 45% 36% 55% 38% 25% 52% 40% 35% 30% 43% 20.00% 10.00% 0.00% 1* 2* 3* 4 5* 6* 7* 8* 9* * 13 All Recovery Caseness: 10 or higher

14 Recovery rates: GAD % Recovery 90.00% 80.00% 70.00% 60.00% 70% 55% 56% 66% 62% 50.00% 40.00% 30.00% 50% 25% 36% 31% 46% 40% 43% 31% 43% 20.00% 10.00% 0.00% 1* 2* 3* 4 5* 6* 7* 8* 9* * 13 All Recovery Caseness: 8 or higher

15 Pathfinder sites Logistic regression of odds of recovery from depression and anxiety (n=2376) *Controlling for gender and ethnicity Variable Intervention: Standard IAPT (Reference category: tailored) PHQ-9 GAD-7 (Anxiety) (Depression) Odds ratio (CI) P value Odds ratio (CI) P value 0.39 ( ) < ( ) <0.00

16 Reported Challenges Many staff reported a lack of expertise and confidence when working with the LTC/MUS client group. Engaging with clients and maintaining engagement throughout treatment was challenging. Bespoke services reported better engagement when interventions were tailored to the physical condition Psychological dimension should be framed within the specific context of the physical condition MUS patients particularly hard to engage

17 Conclusions from pathfinder data Generic IAPT versus bespoke services Best outcomes for bespoke (integrated) services Best outcomes for condition specific services Worse outcomes for MUS Are GAD and PHQ best outcomes? Disability measure, WSAS may be better Global rating of improvement

18 Why does standard CBT for depression and anxiety protocols not work for MUS? Anxiety and depression in the context of MUS Somatisation of distress Somatic symptoms are caused by underlying distress Reattribution therapy limited efficacy (Kleinstäuber, Witthöft, & Hiller, 2011)

19 Predictors of IBS, CFS and PCS at 6 months Higher levels of: -Anxiety and depression -Perfectionism -Negative illness/ symptoms beliefs - Symptoms long lasting - uncontrollable - distressing - serious consequences -All-or-nothing behaviour Spence & Moss-Morris. GUT. 2007, 56, (8), Moss-Morris et al. Psychological Medicine, 2011, 41, (5), Hou et al (2012). Journal of Neurology, Neurosurgery and Psychiatry.

20 Mediators of Symptom Reduction in CBT for IBS Mediators of change in CBT based interventions for IBS (Reme et al., 2011, Lackner et al., 2007; Chilcott & Moss- Morris) CBT has a direct effect on IBS symptom improvement and related impairment independent of changes in distress Inness behaviours and cognitions mediate the improvement.

21 Illness

22 Cognitive Behavioural Explanatory Models Predisposing factors Precipitating factors Perpetuating factors

23 Precipitants Stress Infection Fatigue Biology Poor sleep, Physiological arousal, Deconditioning Cognition I must not let this get the better of me I don t want to let the children down Emotion Anxious Depressed Emotion Anxious Cognition I have no control over my symptoms, can t do anything like I used to it must be the virus Behaviour All-or-nothing behaviour

24 Development of framework led by Anthony D. Roth and Stephen Pilling

25 Expert Reference group

26 a) find the right trials Methodology identify exemplar trials of evidenced based interventions, based on: NICE and SIGN reviews of the literature oversight by an Expert Reference Group b) find the manuals associated with these trials locate the manuals used in these trials (both published and unpublished) c) extract the competences

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28 New IAPT training curriculum Top up training 5 day PWP training focus on LTC 5-10 day High Intensity IAPT training on LTC and MUS Pathfinders to assess clinical outcomes and cost-effectiveness.

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30 Move to integrated care Physical and mental healthcare provision should be colocated. Mental healthcare provision should be integrated into existing medical pathways and services either primary or secondary care services e.g. oncology, community mental health teams, liaison psychiatry/ psychology services

31 THANK YOU TO NHS ENGLAND IAPT AND NHS SCOTLAND FOR FUNDING THE COMPETENCES WORK