Improving Access to Psychological Therapies (IAPT): Background, Strengths, Weaknesses and Future Directions. David M Clark

Transcription

1 Improving Access to Psychological Therapies (IAPT): Background, Strengths, Weaknesses and Future Directions. David M Clark University of Oxford, UK

2 New Prospects for Mental Health Enormous progress in psychological treatment research NICE recognizes the advance and recommends evidencebased psychological therapies as first line treatments for: Depression Anxiety related disorders (Generalized anxiety, panic disorder, obsessive compulsive disorder, social anxiety, agoraphobia, PTSD, health anxiety, specific phobias) Eating Disorders Personality Disorders And as adjuncts to medication for Schizophrenia & bipolar disorder

3 NICE Recommended Treatments Condition Depression (mod-severe) Depression (mild-moderate) Depression (relapse prevention) Anxiety Disorders (ALL) PTSD Eating Disorders Treatments CBT & Interpersonal Psychotherapy (IPT) CBT, IPT, Couples, Brief Psychodynamic, Counselling CBT, Mindfulness Specialized forms of CBT Trauma-focused CBT, EMDR CBT, IPT Schizophrenia Borderline PD Family Therapy, CBT Mentalization*, Dialectical Behaviour Therapy*, Schema-focused CT*

4 BUT Most of the public don t benefit Surveys show psychological treatment preferred to medication on ratio of 3:1 YET in most western countries only a few (less than 10%) of adults with anxiety or depression have an evidence-based psychological therapy AND the position was much worse in psychosis & children

5 Improving Access to Psychological Therapies (IAPT) in England For overview see Clark (2011). International Review of Psychiatry, 23,

6 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, local services for depression and anxiety disorders measuring and reporting clinical outcomes for ALL patients who receive a course of treatment (public transparency)

7 How did it come about? Lobbying and Public Campaign Political Support Brown Johnson Cameron & Clegg

8 Mental illness is 38% of all illness in rich countries Heart disease, stroke, cancer, lung diseases and diabetes Other physical illness Mental illness (mainly depression, anxiety disorders and child disorders) 8

9 Mental illness is the main health problem of working age in rich countries Percentage)of) morbidity)due) to)mental) illness) 100" 90" 80" 70" 60" 50" 40" 30" 20" 10" 0" 0,14" 15,29" 30,44" 45,59" 60+" 9

10 THE ECONOMIC COST Depression 50% more disabling than angina, asthma, arthritis or diabetes. Mental health problems account for: 40% of disability benefits. 40% of absenteeism. Cost to economy c. 70 billion Cost to taxpayers c. 35 billion 10

11 WHY IAPT HAS ZERO NET COST Gross cost per person treated 650 Savings on physical healthcare > 650 Savings on benefits/taxes >

12 The National Plan ( ) Train at least 9,000 new therapists and employ them in new clinical services for depression & anxiety disorders. NICE Guidelines (including stepped care). National Curricula (high and low intensity practitioners: PWPs) Published set of competencies for all therapies (Roth, Pilling et al) For CBT (PWP and HI) in-service full-time training. Hi 2 days per week in HEI and 3 days in IAPT. 60 HEI days in total. PWP 1 day per week in HEI and 4 days in service. CPD training for other modalities (IPT, DIT, Couples, Counselling for depression. Now also Mindfulness).

13 The National Plan ( ) Success to be judged by clinical outcomes (50% recovery target) Self-referral & Session by session outcomes measurement Access targets: by % of prevalence, by % of prevalence Total Investment: around 1.3 billion

14 IAPT So Far Transformed treatment of anxiety & depression Stepped care psychological therapy services established in every area of England. Self-referral. Approx 17% of local prevalence (900,000 per year) seen in services Around 60% have course of treatment (approx 540,000 per year) Outcomes recorded in 97% of cases (pre-iapt 38%) Very strict (depression & anxiety) recovery criteria Nationally 49% recover and further 16% improve. 55% of CCGs have recovery > 50%, some > 60%. Variability must be the next focus.

15 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

16 IAPT So Far Transformed treatment of anxiety & depression Stepped care psychological therapy services established in every area of England. Self-referral. Approx 17% of local prevalence (900,000 per year) seen in services Around 60% have course of treatment (approx 540,000 per year) Outcomes recorded in 97% of cases (pre-iapt 38%) Very strict (depression & anxiety) recovery criteria Nationally 49% recover and further 16% improve. 55% of CCGs have recovery > 50%, some > 60%. Variability must be the next focus.

17 What is our current variability? Recovery rate: 49% (range 30% to 71%) Reliable Improvement: 64% (range 24% to 73%) Reliable deterioration: 6% (range 3% to 11%) Problem descriptor: 68%* (range <1% to 100%) Average number of sessions: 6.3 (range 2.3 to 9.4) Percent of sessions DNA: 12% (range 5% to 27%) Average wait time: 30 days (range 5 to 154 days)

18 Enhancing Service Recovery rates How? Lessons from analysis of national data Service innovation projects Clinical Leadership Public Health England Fingertips Tool

19 Lessons from analysis of national data (Gyani et al, IAPT Year one) Services with higher recovery rates Higher average number of sessions Use stepped care appropriately Core of experienced staff NICE compliant treatment Self-referral (less sessions to recovery) Initial severity also predicts recovery

20 IAPT Year 7 A government agency (HSCIC) publishes an annual IAPT report that gives a more rounded view of the strengths and weaknesses of IAPT and make sit possible to explore a range of predictors (correlates) of clinical outcomes using multiple regression.

21 Year 7:Which Therapies are available? DIT 0.3% IPT 1% Therapy Type CCG s CBT 211 Counselling 180 IPT 141 Couples 95 DIT 77 Employment Support 59 Other Hi 185 PsychoeducaXonal peer support 4% Employment support 0.1% Pure self help 9% Guided self- help 21% Behaviour acxvaxon 4% Counselling 10% Not specified 17% 85% of CCGs offer CBT and Counselling (universal offer) 96% of CCGs offer at least 2 High intensity therapies, 75% offer at least 3, 48% offer at least 4 of 5 High intensity therapies But capacity for Couples, IPT and DIT needs to increase (plans in place) CCBT 1% Other LI 9% CBT 20% Couples 0.2% Other HI 4%

22 Year 7: PaXent Experience QuesXonnaire Post Assessment Questions Given information about options for choosing a treatment? Did you have a treatment preference? Were you offered your preference? Satisfied with your assessment? YES (%) YES (4.2 NO 14.4 n/a) 73.7* (23.8 NO) Between 57,000 and 74,000 responses, which is less than 10%. * Completely or mostly saxsfied Post-treatment Questions Staff listened to you and treated concerns seriously? 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? % Most or All Times Have confidence in your 95.8 therapist and their skills? Clearly, very posi.ve but note that PEQ was only completed by 11% (50,937) of pa.ents who had finished a course of treatment

23 Recovery Rates are sxll higher when therapists sxck to NICE recommended treatments Self-help treatment for Depression: Guided 50% vs Pure 36% (p <.0001) Generalized anxiety disorder treatment CBT 55% or Guided Self-help 59% vs Counselling 46% (ps<.0001)

24 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

25 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.

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30 Weaknesses of IAPT Many people still don t get treatment Link to employment variable Choice also variable Some unhelpful old practices (arbitrary limits on number of sessions) still persist in some areas. Investment, premises, equipment variable PWP turnover rate (22% pa). Physical and mental health care not joined up. Still only focuses on anxiety & depression. SMI etc deserve same benefits.

31 Plans for further expansion of IAPT in this parliament (up to 2020).

32 Next Steps (by 2020) Increase access to IAPT to at least 25% of prevalence Focus on anxiety & depression in context of long-term physical health conditions & troubling medically unexplained symptoms. Greater use of digital platforms to maximize geographic reach, deliver therapy in people s homes when they have time to work on their problems Internet therapy programmes with asynchronous therapist support Video conferenced therapy sessions Blended care

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34 Advantages of Internet Delivery Realise mass public benefit 80% reduction in therapist time. Treat everyone for current cost of treating 15-20% Patients access treatment anywhere, anytime, less stigma. Advance Psychotherapy Research Large (10,000s) samples allow definitive moderator and mediator analyses. More consistent content delivery New interventions to address identified targets can be rapidly evaluated in online RCTs.

35 Lessons from IAPT Importance of NICE Systematic approach to training Make friends with politicians and economists Try, try and try again Recruit support of patient groups Outcome data on ALL patients Clinicians Opt In to the revolution Deliver on time for politicians Recovery focused clinical leadership Create an innovation environment

36 Thank You