Clinical Health Psychology: applications and developments Dr Gary Latchford Joint Course Director Clinical Psychology Training Programme University of Leeds, UK Consultant Clinical Psychologist St James s University Hospital
First hand transplant in UK The clinical psychologist spent more time with recipient before surgery than any other health professional Why? Ensuring a patient is prepared for the mental challenge of living with a hand that is not their own is considered as important as the surgical element of the transplant
First hand transplant in world Clint Hallam Recipient asked for the hand to be removed later.
Plan Why might psychology be important in physical health? Mental health & chronic illness: the cost of co-morbidities Interventions in Clinical Health Psychology: evidence & practice Leeds as an example
Norway and the UK National Health Services with universal coverage Began when economies much poorer Underpinned by shared ideas and values We spend the same too
Percent Health Care Spending as a Percentage of GDP, 1980 2012 * 2011. GDP refers to gross domestic product. Source: OECD Health Data 2014.
OECD review 2014 Norway has an impressive and comprehensive health system High performing High-quality Better performing than peers Denmark & Sweden I m envious!
OECD review 2014 But same challenges as other European nations (and the UK!): Also Ageing population + more chronic illness = changing financial environment changing demographics are putting increased pressure on health services Gap in provision for mild-moderate mental health care In-patient care = largest proportion of expenditure High level of readmissions Response Attention should now turn to developing new structures and services to get the most out of existing services.
Why might psychology be important in physical health? George Engel s Biopsychosocial model a good starting point
The Biopsychosocialmodel Bio: Biochemistry Viruses Bacteria Psycho: Behaviour Beliefs Emotion Stress Experience Illness Social: Poverty Ethnicity Employment Culture Social support
What the Biopsychosocial model means in practice
Social factors affect disease
Social factors affect disease
Leeds Institute of Health Sciences Norway: less inequality than the UK, but still an issue! Kunst et al 1998
Behaviour affects treatment Poor adherence the single biggest reason why therapies fail (Osterberg & Blaschke, 2005)
Psychology affects illness Coronary Heart Disease (CHD): Anxietysymptoms predict CHD 11 years later (Roest et al, 2012; meta analysis of 20 studies, 250,000 people) Depression independent risk factor for: Developing heart disease (X4) (Hippisley-Cox et al 1998; Osborn et al 2007) Death after a heart attack (X2 3.5) (Frasure Smith) Death after bypass surgery (X2) (Blumenthal et al, 2003)
Psychology affects outcome There is no 1:1 relationship between. severity of illness success of treatment/surgery quality of life satisfaction with treatment etc Psychology often the best predictor of outcome e.g. patient beliefs predicts use of health services after a heart attack (Petrie & Weinman)
.including mortality Russ et al (2012) Meta analysis of 10 prospective cohort studies; 68,222 people Dose response relationship between psychological distress and increased risk of mortality Even after adjusting for behavioural and socio-economic factors
Key point Psychology is always involved in health In particular, when mental health and physical health problems co-occur... Things get complicated Needs are often missed And costs go up
The costs of mental health & chronic illness Kings Fund, UK 2012: Long-term conditions and mental health: The cost of comorbidities
Prevalence Increased prevalence of mental health problems in many chronic conditions E.g. Heart disease, Diabetes, Respiratory illness etc.
Prevalence 1 long-term condition = 2 3x more likely to develop depression 3 or more conditions = 7x more likely to have depression
Consequences of poor physical and Poorer quality of life Poorer quality care mental health Poorer self care & adherence Poorer outcomes Higher costs Raises total health care costs by at least45% for each person (Chapman et al 2005; Evans et al 2005; McVeigh et al 2006; Kisely et al 2007; Nuyen et al 2008; Unützer et al 2009)
Mechanisms? Complex and two-way Beliefs about illness & treatment? Behaviour (adherence, lifestyle etc)? Coping & adjustment? Direct or indirect (e.g. immune system)? A lot of useful research How about interventions?
Interventions in Clinical Health Psychology: evidence
A recap: the evidence for Psychotherapy Effect size of all psychotherapies =.85 (Smith, Glass, & Miller, 1980) Average treated patient better off than around 80% untreated in most studies (Asay & Lambert, 1999) No strong evidence that any one psychotherapy produces better outcomes than any other
Psychological interventions in physical health: interactions Mental Health Pre-existing mental health problems Depression, anxiety, distress etc. Physical health Impact of condition Impact of treatment Poorer adherence (medication, rehabilitation etc.) Poorer QoL
Psychological interventions in physical health: evidence Using psychological interventions to address mental health & psychological needs in physical health: Reduced length of stay in hospital Reduced costs Better outcomes (QoL, mortality)
For example Cancer(e.g. Antoni et al, 2009) Pain(e.g. Morley et al, 2009) HIV(e.g. Safren et al, 2009) COPD (e.g. Howard et al, 2010) Diabetes(e.g. van der Felt-Cornelis et al, 2010) Cardiovascular disease (e.g. Moore et al, 2007)
Guidelines Diabetes all diabetes services should have access to a specialist psychologist NHS Diabetes & Diabetes UK (2010) CHD
Evidence -sources Clinical & Health Psychology Liaison Psychiatry (e.g. Rapid Assessment Interface & Discharge RAID study) US & European...
Interventions in Clinical Health Psychology: practice
It works psychological interventions in hospitals and other settings reduced length of stay by 2.5 days and overall health care costs per patient by about 20 per cent Chiles et al, 1999
Organisation more significant effects can be gained by integrating treatment for mental health and physical health needs, rather than overlaying mental health interventions on top
Clinical Health Psychology in action: Leeds as an example Population: 751,500
Leeds Teaching Hospitals 14,000 staff In 2013-14, treated: 957,922 Outpatients 30,126 inpatients Budget around 800m
Department of Clinical & Health Psychology 45 clinicians: Clinical psychologists & counsellors Four sections: Adult Paediatric Neuropsychology Staff counselling Areas include: Renal, Pain, HIV, cancer, Cystic Fibrosis, Accident & Emergency, neurology etc.
Work Individual patient work: Therapy Consultancy Teaching Trust wide work: e.g. communication skills training Research Close links to local clinical psychology training programme
Key features Based together but work into different teams in the hospital Department has hospital wide responsibilities for issues around mental health (of patients and staff) Very close working relationship with Liaison Psychiatry (smaller service, more specialised remit, some overlap)
Our aims Broadly... To reduce psychological distress To increase effectiveness of medical treatment
but remember resilience A really important point The majority of people with chronic illness do not have problems But its important to have services available for those who do, where they need them, when they need them.
Five examples of our work 1. Psychological distress interfering with treatment or recovery 2. Psychological & physical complications in stressful medical procedures 3. Poor uptake or adherence in medical treatment 4. Inappropriate uptake of medical treatment 5. Problems in the delivery of healthcare
1. Psychological distress interfering with treatment or recovery Psychological distress more common in chronic illness Can interfere with treatment & recovery e.g. anxiety & avoidance
Psychotherapy in physical health Many models from psychological therapy relevant, e.g. Cognitive Behavior Therapy Differences? Content & context Appreciation of impact of physical illness Focus on better physical health as well as psychological health
e.g. CBT in Diabetes Assessment & formulationincludes beliefs that impact on diabetic control (e.g. I always fail, I will never get control etc.) Treatmentuses familiar therapeutic techniques (e.g. activity schedules; behavioural experiments etc) but sometimes different focus e.g. diabetic control (White, C. A., 2001. Cognitive behaviour therapy for chronic medical problems: A guide to assessment and treatment in practice)
Case examples 18 year old woman, Type 1 diabetes Anxiety & avoidance, poor adherence, repeated admissions if I avoid thinking about it I feel normal for a while Increased confidence & adaptation 38 year old woman, Type 1 diabetes History of eating disorder, Renal failure, unsure about transplant listing Therapeutic work and acceptance of transplant
2. Psychological & physical complications in stressful medical procedures Medical procedures are stressful and preparation can be important Psychological assessment for some types of surgery is crucial if complications are to be avoided.
e.g. Assessment for surgery Cosmetic Body Dysmorphic Disorder, expectations etc Transplant Recipient (e.g. Lung, Kidney, spinal cord stimulator) Donor (e.g. Altruistic kidney donor programme) Other E.g. epilepsy surgery (e.g. Neuropsychological and psychological assessment)
3. Poor uptake or adherence in medical treatment Adherence is a major problem Role of psychology: Interventions with patients Training & support for staff
e.g. training teams in motivational interviewing (MI) MI for behaviour change Excellent evidence base (Lundahl et al, 2010) We use it with patients We train teams in it: Renal, Cardiology, Cystic Fibrosis E.g. CF teams across UK & Ireland
4. Inappropriate uptake of medical treatment Diverse group: Medically unexplained symptoms (MUS) Somatic complaints Health anxiety Also present in people with diagnosed physical illness (e.g. repeat admissions for angina)
e.g. Medically Unexplained Symptoms Major problem in adult and paediatric work E.g. Non Epileptic Attack Disorder Cost Outpatient costs 20-50% higher Current work with Liaison Psychiatry on developing pathway
5. Problems in the delivery of healthcare Training needs of staff Stress in staff Topical: Francis report into Mid- Staffordshire hospital... Shocking failures of care & compassion
Examples of our work Run staff counselling Staff training Leading on communication skills training for entire workforce Important role in response to Francis report E.g. Schwartz rounds
Final thoughts Recent changes in the UK
NHS Mental Health Strategy (2011) One element in improving efficiency: Physical and mental health Co-morbid mental and physical health problems are an important focus Even less severe mental health problems can have major consequences
NHS 5 year forward view (October 2014) Over the next five years the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together.
improving the management of longterm conditions represents one of the best opportunities to improve productivity in the NHS (Appleby et al, 2010)
The future? Financial challenges But addressing underlying mental health/ psychological needs can reduce costs (Naylor & Bell, 2010) And it s the right thing to do! This requires coordinated services between: primary & secondary care mental & physical health and specialist knowledge Such as Clinical Health Psychology & Liaison Psychiatry
Takk!