South London and Maudsley (SLaM) IAPT-SMI Demonstration 3 Site for Psychosis

Transcription

1 South London and Maudsley (SLaM) IAPT-SMI Demonstration 3 Site for Psychosis Dr Louise Johns Consultant Clinical Psychologist IAPT-SMI Project Lead Psychosis Clinical Academic Group (CAG) 1 st July 2015

2 NICE 2009/2014 Offer CBT to all people with schizophrenia Offer family intervention to families who live with or are in close contact with the service user

3 69% of Trusts have funding challenges for providing access to psychological therapies for people with a diagnosis of schizophrenia 94% have encountered obstacles in making psychological therapies available, including insufficient skilled staff

4 Research has led to a range of evidence-based psychological treatments. We know much more about what works than we used to... The committed individuals who went into the mental health profession to improve lives should be helped to do exactly that. Schizophrenia Commission Prof Sir Robin Murray

5 I always asked for some kind of psychological therapy or talking therapy but was told, no, it was too dangerous. I had to wait 20 years for something that was the most beneficial thing. [Therapy] has changed my life basically. Dolly Sen, Service User Consultant Talking to Norman Lamb MP, Minister of State, on 19 December 2012 at SLaM

6 Delays in accessing CBTp in SLaM Peters et al, 2009 (N=74) Mean length of illness was 8 years (range 0-32) Mean of 2.8 in-patient admissions (range 0-20)

7 National Audit of Schizophrenia (2014) It is clear that the numbers of service users having access to, and actually receiving, these types of intervention remain very low. This needs to be addressed and has significant funding implications....this is probably the largest deficit that exists in the treatment services provided by Trusts.

8 National Audit of Schizophrenia (2014) Recommendations for the Department of Health Ensure the Increasing Access to Psychological Therapies (IAPT) for severe mental illness programme has the same level of support as the existing IAPT for anxiety and depression. This should include a national data set, indicators in national frameworks and plans for how this could develop.

9 Barriers to Access Too few therapists Insufficiently trained (lack of clarity on competences) Lack of supervision No time; without specialised role Organisational barriers & lack of support (other interventions prioritised; therapy a luxury ) (Shafran et al., 2009; Berry & Haddock, 2008; Haddock et al., 2014; Lobban & Jones 2010; Prytys et al., 2011)

10 Overcoming obstacles to access in SLaM

11 Core population 4 South London Boroughs 1.3 million; inner city, very high indices of psychosis and social deprivation and ethnic diversity Psychosis Clinical Academic Group which provides services for 7,000 people with psychosis All services for people with psychosis organised in 4 stage specific care pathways Clinical research programme focused on translational research, developing new psychological treatments

12 Predicted new cases: England and Wales Local Authorities: Lowest, mid and SLaM boroughs Source: Kirkbride et al, 2013, Psymaptic

13 Work in SLaM Ten point charter addressing barriers and facilitators: Service user involvement Therapy quality criteria and staff training Data gathering, data systems and outcomes Care pathways, ensuring integrated effective psychological therapies in Early Intervention & Recovery pathways

14 Historical service data

15 Graph 1 Psychotic symptoms reduction [voices (effect size:.52) and delusions (effect size:.75)] following therapy, maintained at follow-up (effect sizes:.44 &.82) (all significant at p<.001)*. *Linear mixed model analyses include mid-therapy scores and are based on 248 individuals for voices; 302 for delusions (but only 25% have follow-up assessment)

16 Graph 2 Emotional problems reduction [anxiety (effect size:.44) and depression (effect size:.51)] maintained at follow-up (effect sizes:.29 &.34) (all significant at p <.001)*. *Linear mixed model analyses include mid-therapy scores and are based on 360 individuals for depression; 362 for anxiety (but only 24% have follow-up assessment)

17 Graph 3 General distress reduction [CORE-10 (effect size:.61) and increase in life satisfaction (effect size:.49)] maintained at follow-up (effect sizes:.47 &.47) (all significant at p <.001)*. *Linear mixed model analyses include mid-therapy scores and are based on 180 individuals for CORE; 361 for MANSA (but only 36% have follow-up assessment for CORE; 23% for MANSA)

18 IAPT-SMI in SLaM

19 Selection of Demonstration Sites by Open Competition: criteria Delivering evidence-based psychological therapies Therapists with appropriate competences Have strategic approach, which is replicable Collecting outcome data routinely and effectively (access to historical data) Provision of training and supervision Overcoming barriers to implementation: e.g. senior management buy-in ; ring-fenced time

20 Our aims Increase access by 50% Pilot outcome measures, including sessional measure Improve completion rates to 95% minimum Provide a clinically and cost-effective service

21 SLaM Psychosis Demonstration site: Increasing access in two care pathways Early Intervention Pathway Promoting Recovery Pathway Promoting Recovery Pathway

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23 What IAPT-SMI offers: CBTp CBT for psychosis: Weekly or fortnightly individual 1 hour sessions 6-9 months therapy Therapists receive weekly-fortnightly group supervision Suitability criteria: F20 diagnosis (schizophrenia spectrum) distressing positive symptoms of psychosis OR secondary emotional disturbances / sense-making & recovery work not predominantly negative symptoms motivated to attend

24 What IAPT-SMI offers: FIp FI for psychosis: Fortnightly 1 hour sessions with client and carer(s) Up to ten sessions, over a period of 3-9 months Therapy delivered by two trained therapists Usually delivered at home Therapists receive weekly-fortnightly group supervision Suitability criteria: F20 spectrum diagnosis In close contact with an informal caregiver (approx. 10 plus hours face to face or living with) Need carer and service user agreement

25 IAPT-SMI: CBT assessments Pre PSYRATS Voices & Beliefs WEMWBS 3-month PSYRATS Voices & Beliefs WEMWBS Post PSYRATS Voices & Beliefs WEMWBS WSAS WSAS WSAS EQ-5D EQ-5D EQ-5D Short CHOICE Short CHOICE Short CHOICE CORE-10 CORE-10 CORE-10 Brief IPQ Brief IPQ Brief IPQ Measures Feedback Measures Feedback Measures Feedback Satisfaction with therapy & PEQ Satisfaction with therapy & PEQ Short CHOICE weekly

26 IAPT-SMI: Carer assessments Pre Experience of caregiving inventory WEMWBS DASS-21 Post Experience of caregiving inventory WEMWBS DASS-21 CORE-10 CORE-10 IPQ carer version IPQ carer version Confidant question Confidant question Measures Feedback Measures Feedback Satisfaction with therapy Sessional satisfaction measure

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28 Satisfaction with Measures Overall, perceived as helpful (Mean , SD ) Perceived more positively by older clients, but unrelated to symptom severity, gender or ethnicity Majority (>90%) rated as neutral or helpful; length, emotional content & repetition identified as less helpful Comments: used my brain ; made me think ; helped explain ; helped identify an area to work on ; good to get things off my chest

29 Therapy was life-changing and empowering. I have a better understanding of my problems, particularly the triggers and contributions to them. Therapy has helped me to deal with my anxiety and paranoid thoughts. I am confident I can cope if I have any negative thoughts in the future. I now feel able to move forward with my life Therapy has been a fantastic experience. I now have a better understanding of why I hear voices and how to cope with them. I now feel less stressed and much happier in myself. It was helpful to learn about my thinking, considering alternative perspectives and seeing the positive sides of a situation.

30 IAPT-SMI Family feedback For the family therapy, I think it was to have a space. Where {my son} and I could actually verbalise our concerns in a space where it wasn t, it wouldn t lead to an argument, or hurt or upset, because it was a, I am saying this so I can, so we can find a solution to it.

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33 My experience of therapy

34 Progress and 24-month outcomes Further detail in: Jolley S et al (2015), Behaviour Research and Therapy, 64, 24-30

35 Increased access - referrals 2011 Projected Achieved per annum Total Increase Total %inc PA %inc PA CBT % % FI % % Both % %

36 Months Speed of access Mean waiting times (days) Referred to assessed Assessed to offered therapy Total % reduction in waiting times % % %

37 % completing Equity of access Treatment completers (n=211) by age and demographics 100% 80% 60% 40% 20% 0% EI 35 PR TOTAL Male BME 93% 87% 89% Male non-bme 86% 94% 92% Female BME 88% 89% 89% Female non-bme 100% 88% 91% Male BME Female BME

38 Completion of measures Paired completion 96% for 5+ sessions; 78% for drop-out (<5 sessions) DH minimum dataset feasible & acceptable FI assessments feasible & acceptable Completion regime: Pre, Mid, Post, no Mid for FI Sessional CHOICE: feasible, acceptable and essential for paired completion rates

39 Service user-reported wellbeing: CHOICE (p<.001; ES 0.8, 0.7) EI (n=58) PR (n=145) PRE POST

40 Service user-reported wellbeing: WEMWBS (p<.001; ES 0.8, 0.7) EI (n=46) PR (n=134) PRE POST

41 Service user-reported impact on functioning: WSAS (EI: p=.002, ES 0.5; PR: p<.001, ES 0.5) EI (n=44) PR (n=125) PRE POST

42 Service user-reported distress: CORE-10 (p<.001; ES 0.6) EI (n=47) PR (n=128) PRE POST

43 Service user-reported voices: PSYRATS (EI: p=.007, ES 1.1; PR: p<.001; ES 0.5) EI (n=13) PR (n=60) PRE POST

44 Service user-reported beliefs: PSYRATS (EI: p=.002, ES 1.4; PR: p<.001; ES 0.85) EI (n=13) PR (n=70) PRE POST

45 IAPT-SMI Demonstration Site for Psychosis: Cost-Effectiveness Analyses Prof Paul McCrone Professor of Health Economics Centre for the Economics of Mental and Physical Health (CEMPH) King's College London Institute of Psychiatry, Psychology & Neuroscience

46 Methods Therapy costs estimated using PSSRU figures (Curtis, 2013) Bed days and crisis team episodes recorded over therapy period and for estimated for period of same length before therapy Costs based on NHS Reference Costs Health-related quality of life measured with EQ5D before, during and after therapy Change in employment status recorded

47 Crisis Team Costs

48 Bed Costs

49 Total Costs by Pathway

50 Health-Related Quality of Life

51 Employment and Activity

52 Economic summary Increased costs of therapy offset by reduced inpatient and crisis team costs Improvements in quality of life Improvements in employment status Indications of cost-effectiveness Future controlled studies required

53 Competence, Training and Supervision

54 IAPT-SMI: Competence Framework for Psychological Interventions for people with Psychosis / Bipolar Disorder (Roth & Pilling, 2013) Modular training outline From awareness supervision & service change CORE

55 CBTp in SLaM Demonstration Site Individualised and formulation based, but adheres to published manuals and the CORE CBTp competence framework (Roth and Pilling, 2013). Therapists are trained to competence, using assessments of adherence and competence. Supervision provided weekly to fortnightly in groups of 3-6 therapists for 1.5 hours, with fortnightly to monthly individual supervision. Supervisors are senior clinicians with experience of training therapists and of providing therapy within RCTs.

56 Training and competence summary Portfolio of training opportunities in psychological therapies for psychosis, in partnership with KCL Span the workforce from non-clinical to managerial/supervisory Academically accredited training and in-service courses Short courses and modules build to an award Supervised practice strongly emphasised Supervision and support for supervisors

57 What has the SLaM IAPT-SMI pilot demonstrated?

58 We requested: Initial investment Additional therapist time Supervision & management time Dedicated assessment resource Administrative support We selected therapists with specific competences, or trained them to competence, and provided close and frequent supervision

59 Embedded in the service In the PR pathway, therapy provision closely aligned with, but separate from the MDT In the EI pathway, psychological therapy embedded within the specialist MDT Representative PR client group, selected for potential to engage with stand-alone therapy: fits evidence base Specialised assessors: flexible but persistent follow up to maintain engagement and keep attrition down

60 The site has been able to: Exceed targets for increased access to therapy Provide equity of access that reflects the diversity of our local population Achieve excellent completion rates on outcome measures, with positive feedback about the assessment process Show significant within group pre-post improvements on the outcome measures and high satisfaction rates Provide health economic evidence indicating cost effectiveness

61 What we have learnt: NICE-recommended individual psychological therapy can be successfully delivered in routine services In the SLaM demonstration site, primary facilitators were: ring-fenced investment in competent therapy provision ring-fenced time for therapists to deliver therapies adequate supervision, training and CPD trained independent assessors established service pathways & governance structures strong clinical leadership & management Our framework is replicable to inform implementation in other services and is now informing the Early Intervention in Psychosis Access and Waiting Time initiative

62 Rolling this out... Requires a therapist champion to lead service development and facilitate organisational change this should be the initial investment Ready organisations will be able to use further investment to work towards a critical mass of supervisors and therapists Can then support further workforce development innovations (such as low intensity approaches) Dedicated assessment and administrative resources makes more efficient use of therapist time and maintains completion rates for outcomes

63 Thanks to the IAPT-SMI Project Team Operational Group: Dr Louise Johns, Consultant clinical psychologist, Project lead Dr Suzanne Jolley, Data Lead, Lambeth Recovery Psychology lead Dr Miriam Fornells-Ambrojo, Clinical Psychologist, STEP, IAPT-SMI EI lead Dr Juliana Onwumere, FI lead, service user and carer involvement lead Craig Milosh, Clinical Psychologist, SHARP Devon Elliott, Business Intelligence Analyst, Psychosis Management Team Bina Sharma, Rosanna Michalczuk, Zara Kanji, Annabel Broyd and Suzanne Law, Psychology Assistants Steering group: Prof Philippa Garety, Psychosis CAG Clinical Director Angela Morford and Garry Ellison, Service User consultants Roger Oliver, Carer consultant Dr Emmanuelle Peters, PICuP Director Adrian Webster, CAG Psychological Therapies lead Sarah Dilks, Lead Psychologist, Promoting Recovery pathway Dorothy Abrahams and Marlise Marshall, administrators

64 Thank you for listening