Doncaster Improving Access to Psychological Therapies (IAPT) Nurse Target September 2018 Dennis Convery

Doncaster Improving Access to Psychological Therapies (IAPT) Nurse Target September 2018 Dennis Convery

Aims of the session To introduce the role and function of Doncaster IAPT (improving access to psychological therapies) To understand how to refer into services appropriately To identify depression and anxiety presentations in primary care

Doncaster IAPT Doncaster IAPT service was one of the two original national IAPT demonstration sites in 2006. IAPT was set up to: Improve access to psychological therapies for patients with mild to moderate common mental health problems Provide access to evidenced based psychological therapies Provide predominately high volume low intensity interventions Provide community based clinics Provide a range of psychological therapies through face-to-face, telephone, e-clinic and group interventions. In 2006/07 Doncaster developed a comprehensive stepped care model of psychological therapy provision supporting over 4,500 people.

Doncaster IAPT Nationally there are now IAPT sites, with approximately 900,000 referrals per year. IAPT is a primary care service: August 2018 waiting times: 60.7% enter treatment in 0-4 weeks 86.7% enter treatment in 0-6 weeks 100% enter treatment in 0-18 weeks All above KPIs

Doncaster IAPT outcomes In Doncaster from April 2017 to March 2018: 9733 total referrals 5768 patients entered treatment 52.18% achieved recovery 67.34% achieved reliable improvement

Stepped Care Model Step 4 Secondary Care Step 3 High Intensity Step 2 Low Intensity Step 1: Active Monitoring / Watchful Waiting Recurrent, atypical and those at significant risk Severe and enduring mental health with complex needs Depression Mild, moderate and Severe Panic Disorder Generalised Anxiety Disorder (GAD) Mild to moderate Social Phobia Post-Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD) Depression Mild to Moderate Panic Disorder Mild to Moderate Generalised Anxiety Disorder (GAD) Mild to Moderate Obsessive Compulsive Disorder (OCD) Mild to Moderate Recognition of Problem Medication, complex psychological interventions, combined treatments CBT, Interpersonal Therapy, behavioural activation, couples therapy for depression (mild-moderate), counselling for depression CBT CBT CBT CBT, eye movement desensitisation and reprocessing (EMDR) CBT Computerised CBT (ccbt), guided self-help, behavioural activation, exercise Computerised CBT (ccbt), guided self-help, pure self-help Computerised CBT (ccbt), guided self-help, pure self-help and psycho-educational group Guided self-help Assessment / Watchful Waiting / Signposting

IAPT Referral Criteria Patients 18 years and over with no risk to self or others PHQ9 score of 10 or above GAD7 score of 8 or above Mild to moderate mental health problems, disorders include: Depression, General anxiety, Stress, Panic, Phobia, Social anxiety, Low self esteem, Health anxiety, Obsessive compulsive disorder (OCD), Post Traumatic Stress Disorder (PTSD), Bereavement (resulting in depression/ anxiety) Mild eating disorders (not anorexia nervosa)

Exclusion Criteria Patients with risk to self or others Access / Crisis team Under 18 years old CAMHS / YAMHS PHQ9 score of 9 or below Active Monitoring GAD7 score of 7 or below Active Monitoring Drug or Alcohol Misuse (unless stable or on a treatment programme) Doncaster Drug and Alcohol Service Severe & enduring mental health problems. Organic mental health problems Access Team / Older Peoples Mental Health service

Referral Pathways GP/Healthcare Professional Active Monitoring (Watchful Waiting) Refer to IAPT (assessment & treatment) Access Team and Secondary Services GP to refer direct not through IAPT Practice PWP for low intensity CBT Brief interventions including: Step 2 Groups Goal setting and psycho-education, Inc: Problem solving, Behavioural Stress Control Class activation, graded exposure, Mindfulness Thought challenging, Relaxation / Low self esteem stress management, Sleep Hygiene, Signposting to appropriate services. Group therapy Counselling CBT Traditional counselling, Counselling for Depression, Interpersonal Therapy (IPT), Couples Therapy for Depression. Traditional CBT, Eye Movement Desensitisation and Reprocessing (EMDR), Cognitive Behavioural Analysis System of Psychotherapy (CBASP) Key PWP - Psychological Wellbeing Practitioner CBT - Cognitive Behavioural Therapist

Method 1: Self referral Method 2: GP, practitioner referral Process 1. Patient contacts the service via telephone and referral is processed Advantages The patient can access the next available appointment Motivation to engage is demonstrated Less admin lower non-attendance rates Disadvantages Difficulties taking the first step Process 1. GP / Nurse/ GP Practice Admin send referral to IAPT (fax, post, telephone) 2. IAPT contact patient to book first appointment Advantages Practitioner ensures referral is made Disadvantages Slower as further steps to the process Patient motivation to engage is less clear Higher non-attendance rates

Step 2 - Low Intensity Interventions

Psychological Wellbeing Practitioner s (PWP) Assess and treat people with common mental health problems such as depression and anxiety for up to 8, 30 minute sessions Assist people to help themselves See clients face-to-face in the GP practice (or local venues if no room in local surgery) Utilise telephone and internet contact methods Provide a collaborative care approach Receive regular supervision Provide high volume low intensity evidence-based short-term psychological interventions

SilverCloud Online therapy package supported remotely by clinicians Flexible modules covering: Anxiety Depression Chronic illness Wellbeing Stress Excellent alternative to face-to-face or telephone sessions

Specialist PWP working with the Deaf Community in Doncaster, Rotherham and North Lincolnshire areas. Note: capital D as in deaf : Deaf BSL Users use British Sign Language as their first or preferred language and communication method. Deaf BSL users are recognised as members of the Deaf Community and have a strong Deaf identity. (http://www.nwppn.nhs.uk/index.php/our-work/supporting-clinical-excellence/mental-health-deafness)

Step 3 High Intensity Interventions

Counselling Approaches in IAPT Person Centred Where the sessions focus on the patients thoughts, feelings and emotions and how it links into depression. It focuses on growth and development and dissolves conditions of worth. Offering between 6 8 sessions Step 3 High Intensity Interpersonal Therapy - IPT An evidenced based model of therapy Breaks down into addressing the following areas: Role Transition, Role Dispute and Interpersonal Sensitivity, Grief, Utilises 16-20 structured sessions - Step 3 High Intensity

Counselling for Depression Counselling for Depression is a new and integrative evidence based model as recommended by NICE and focusses entirely on the depressive symptoms. This therapy is suitable for patients presenting with depression linked to Bereavement, Divorce, Redundancy and Long term medical problems. Up to 20 session Step 3 High Intensity Couples Therapy for Depression This is an evidenced based intervention suitable when one or both or the couples partnership is or are suffering from mild to moderate depression. This therapy is dependant on both of the partnership wanting to remain together, a willingness to consider and change existing behaviours and an ability to instigate and maintain positive change. This model is not suitable for couples considering divorce, where there is any evidence of violence or where neither of the partnership is suffering from depression. Up to 20 session Step 3 High Intensity.

Cognitive Behavioural Therapy CBT is offered at Step 3 within IAPT Up to 20 sessions face to face or e-clinic Therapists based around the borough Understanding the process of how the disorder was developed, what maintains it Collaborative treatment based on evidence Significant focus on managing relapse

Eye Movement Desensitisation Reprocessing (EMDR) CBT therapists in IAPT are trained in EMDR EMDR is a psychological treatment based on principles of neuroscience EMDR is used to treat: Trauma Phobias Complex Grief Pain

Depression signs and symptoms Very common the common cold of psychopathology Associated with significant dysfunction Under diagnosed Often chronic or recurrent Commonly present with other general medical condition or other psychological disorder Multiple safe and effective treatments are available

What do clinicians look for? The common symptoms - Changes in sleep pattern - Changes in interests or activity - Feelings of guilt or increased worry - Changes in energy - Changes in concentration - Changes in appetite - Psychomotor disturbances - Suicidal ideation

Depression a simple CBT cycle Thoughts What s the point I m useless Emotions Low Numb Sad Physical sensations Tired Lethargic Behaviours Withdraw/ isolate Sleep more Do less

Anxiety Signs and symptoms One in four people likely to experience an anxiety disorder Associated with avoidance, fear, worry and impact on functioning Physical symptoms often perceived as difficult to manage Commonly present with another psychological disorder or general medical condition Multiple safe and effective treatments are available

What do clinicians look for? The common symptoms - Changes in sleep pattern - Avoidance of triggering situations - Feelings of fear or increased worry - Acute physical changes such as palpitations, sweating, difficulties catching breath - Changes in concentration - Changes in appetite - Suicidal ideation

Why do we feel anxious? Trigger situation Perceived: likelihood of threat, awfulness of threat, inability to cope, limited rescue or mitigating factors STRESS CHEMICALS: adrenaline cortisol norepinephrine [and others] distressing thoughts and feelings Avoidance and dysfunctional behaviours

Anxiety a simple cycle Thoughts What if I have a panic attack? what if I can t breath and choke to death? What if I pass out? What if I have a heart attack? Emotions Fear, nervousness, stress, sense of dread Physical sensations Palpitations, muscle tension, butterflies in the stomach Behaviours Escape, avoidance of stressors, performing actions or thoughts that are perceived to mitigate risks

Common anxiety problems Common anxiety disorders Generalized anxiety disorder Specific phobias (e.g., flying, needles, certain animals) Social anxiety disorder Panic disorder Agoraphobia Post-traumatic stress disorder Obsessive-compulsive disorder ICD10 and DSMV have exhaustive explanations of these presentations

Quick assessment tools Patient Health Questionnaire 9 (PHQ9) First two questions If answer is more than half the days to one or both then likely depression General Anxiety Disorder 7 (GAD7) First two questions If answer is more than half the days to one or both then likely anxiety

Physical health Approximately 2/3 of patients with a mental health problem have a physical health condition Physical health and psychological health have a reciprocal relationship = problems with one can create/ exacerbate problems with the other Mental health problems can severely impact engagement with physical health care and long term condition management.

Asking the questions Use normal conversational language Ask: How have you been feeling/ coping recently? Do you feel low, anxious, sad, worried, on edge, tense, down, stressed? Is this impacting on your life? Would you like some support to manage this? Do this over a number of appointments if needed

Responding to the answers Be empathic Listen attentively and actively Try to stay outwardly calm Instil hope there are services that can help Manage risk immediately

Case Studies Four case studies per table Please discuss and identify the referral pathway best suited to the case study with any treatment that may be useful: Watchful waiting, IAPT, Secondary care services your facilitator will advise Think about how you would like to assess or respond to the patient in your clinic any helpful questions, your interpersonal style etc Feedback to the larger group.

Contact details: Doncaster IAPT self referrals/ referrals/ enquiries The talking Shop, 63 Hallgate, Doncaster DN13PB Telephone (01302) 565650, Fax (01302) 385207 (available Monday to Friday 9am 5pm) Secondary care/ crisis referrals Single point of access: Opal Centre, Tickhill Road Site, Weston Road, Balby, Doncaster DN4 8QN Telephone: (01302) 566999, Fax (01302) 566789 (available 7 days per week, 24 hours)

Questions

Feedback Anything that was helpful about the session? Anything you will do differently? Anything you will go away and research further?