Psychological Therapies: Effectiveness, Efficiency and Large Scale Dissemination David M Clark University of Oxford, UK 23 rd October 2013
Outline of Talk How effective are psychological therapies? Novel ways of delivering them How to make them more widely available to the public (IAPT case example)
How effective are psychological therapies?
How can we tell whether a psychological treatment is effective? Randomized controlled trial (RCT) Measure symptoms etc pre & post Broad based measures. Independent assessor Wait-list control (does treatment work?) Psychosocial control (is there a specific effect) Summarize RCTs in a meta-analysis conducted by independent body and issue guidance
Debriefing After Trauma Study
Debriefing After Trauma Study
NICE mental health guidelines positive recommendations Psychological Therapies Cognitive Behaviour Therapy (Depression, OCD, APMH, PTSD, PD, SAD, GAD, Child Depression, Eating Disorders, Antisocial Personality Disorder) Guided Self Help (Depression, GAD, PD, SAD, OCD) Interpersonal Therapy (Depression, Eating Disorders) Parent training (ADHD, Antisocial Personality Disorder) Behavioural Couples Therapy (Depression; Substance Misuse) Analytic Therapy (Depression, SAD, Childhood Depression) Family Interventions (Eating Disorders) Eye Movement Desensitisation and Reprocessing (PTSD) Counselling (Depression) Motivational Interviewing (Substance Misuse) Contingency Management (Substance Misuse)
NICE mental health guidelines negative /no recommendations Psychological Therapies Individual debriefing (PTSD) Family Interventions (Substance Misuse) Interpersonal Therapy (BD, DCHP) Analytic Therapy (OCD, PTSD, BPD, ASPD, APMH) Counselling (GAD, PD, OCD) Cognitive Behavioural Therapy (Substance Misuse) Cognitive Remediation Therapy (Schizophrenia) Facilitated mourning (APMH)
Specificity/ uniqueness of effect? CT for Social anxiety disorder (strong) 60-80% recover. Individual CT superior to group CBT, exposure therapy, interpersonal psychotherapy, psychodynamic psychotherapy, SSRIs, TAU, pill placebo. CBT for Depression (moderate) 50% recover. Superior to pill placebo but not interpersonal psychotherapy Counselling, couples therapy & brief psychodynamic also recommended by NICE for mild to moderate. BUT CBT reduces re-occurence
The Allegiance Argument Wampold argues that all bone fide treatments are equally effective and when results appear to deviate from this rule it is because of experimenter allegiance. Evidence: Post-hoc correlation between outcome and inferred allegiance of sites. Need prospective experimental test
Testing Allegiance Social Phobia Treatment Responders at post-rx (Stangier et al, 2011, Arch Gen Psychiat, 68, 692-700) CT IPT p >.05 p >.05
Do RCTs generalize to real world? YES, if you use similarly trained therapists with regular supervision and adequate sessions BUT training, competence and supervision really matter.
Improvement in PTSD symptoms (Gillespie, Duffy,Hackmann & Clark, 2002, Behav Res Ther) Cases 18 16 14 12 10 8 6 4 2 0-20 -10 0 10 20 30 40 50 60 70 80 90 100 Percent Improvement
Do RCTs generalize to real world? YES, if you use similarly trained therapists with regular supervision and adequate sessions BUT training, competence and supervision really matter.
Pre-Post Improvement in social phobia as a function of initial severity (n = 420) Improvement on LSAS 60 50 40 30 20 10 0 * * Mild Moderate Severe * Trainee Staff (CADAT) Pre-Treatment Symtoms
Therapist Competence and Outcome (Ginzburg, Bonn, Weck, Clark & Stangier, 2012) Independent assessors rate competence in delivery of CT for social anxiety disorder from session video tapes. Competence predicts outcome r =.68, p <.001 Controlled for patient difficulty
Novel ways of delivering psychological therapies
One week intensive treatment for PTSD (Ehlers et al, in press, Am J Psych)
Self-study assisted CT Standard CT involves 14 sessions of 90 mins (21 therapist hours) Self-study assisted CT involves 7 sessions of 90 mins (11.5 hours). Patient complete self-study modules covering all key steps in therapy between sessions. Therapist focuses on misunderstandings, difficulties and in session experiments.
Making Psychological Treatments more widely available (IAPT as a case example)
A 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 (High intensity and PWP) deploying them in specialized, local services for depression and anxiety disorders stepped care, session by session outcome monitoring, regular supervision
How did it come about?
The IAPT Argument (Depression Report 2006) Much current service provision focuses on psychosis which deserves attention but affects 1% of population at any one time. Many more people suffer from anxiety and depression (approx.15% at any one time. 6 million people). Economic cost is huge (lost output 17 billion pa, of which 9 billion is a direct cost to the Exchequer). Effective psychological treatments exist. NICE Guidance recommends CBT for depression and ALL anxiety disorders plus some other treatments for individual conditions (EMDR for PTSD, Interpersonal Psychotherapy, Couples therapy, Counselling & Brief Psychodynamic Therapy for some levels of depression). Less than 5% of people with anxiety disorders or depression receive an evidence based psychological treatment. Patients show a 2:1 preference for psychological therapies versus medication Increased provision would largely pay for itself
The Economic Case Layard, Clark, Knapp & Mayraz (2007) National Institute Economic Review, 202, 1-9. Cost (per patient in ) 750 Benefits to Society Extra output 1,100 Medical costs saved 300 Extra QALYs 3,300 Total 4,700 Benefits to Exchequer Benefits & taxes 900 Medical costs saved 300 Total 1,200
Demonstration Sites:Newham & Doncaster. Awarded extra funds to increase access to psychological treatments. Stepped care * Least burden principle * Psychological Well-Being Practitioners, HI intensity therapists & employment advisers Session by session outcome monitoring Experiment with self-referral
Demonstration Sites: First Year Results (see Clark, Layard,Smithies, Richards et al. (2009) Behav. Res & Ther) Excellent data completeness (99% in Doncaster). Large numbers treated (approx 3,500 in first year). Use of Low intensity important. Outcomes broadly in line with NICE Guidance for those who engaged with treatment (52% recover). Employment benefits. Maintenance of gains. Self-referrals as severe as GP referrals but tended to have had the problem longer & were more representative of ethnic mix of the local community
Why getting complete data matters. (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009, Behav. Res.Ther) 10 Improvem ment 8 6 4 2 Pre-Post Complete Post Missing 0 Depression Anxiety
Why specific measures matter Grey et al (2008) Behav. Cog. Psychotherapy,36, 509-520. Panic related distress/disability (0-8) patient rated 7 6 5 4 3 2 treatment as usual cognitive therapy CT Clark et al (1994) 1 0 end weekly sessions
Agoraphobic avoidance (0-15) 8 7 6 5 4 3 treatment as usual cognitive therapy CT Clark et al (1994) 2 1 0 pre-treatment end weekly sessions
The Roll-out Plan A 7 year plan. Train at least 6,000 new therapists and employ them in new clinical services for depression & anxiety disorders. Initial focus on CBT. Now being expanded to other NICE approved therapies Services follow NICE Guidelines (including stepped care). National Training Curricula (high and low intensity practitioners: PWPs) Published set of competencies for all therapies (Roth, Pilling et al) Success to be judged by clinical outcomes (50% recovery target, with many others showing some benefit) Self-referral & Session by session outcomes measurement
What has been achieved so far?
Adult IAPT for Depression & Anxiety Disorders IAPT services established in 100% of health areas (PCTs) Approx 4,000 (of 6,000) new High intensity CBT therapists and PWPs trained. Approx 30% of high intensity therapists in IAPT services can deliver non-cbt therapies At March 2013 programme is on target Over 1.5 million people seen in services Over 56,000 moved off sick pay & benefits 46% recovery rate Current access rate approx 600,000 pa (10% prevalence)
Some lessons from the early phases of the programme
Variability in Recovery Rates Gyani, Shafran, Layard & Clark (2013) In Year One average 42% recovery rate: but ranges from 27% to 58% in different sites Site ID 33 30 27 25 23 21 19 17 15 13 11 9 7 5 3 0% 10% 20% 30% 40% 50% 60% 70% Recovery Rates
Importance of NICE compliance Most patients received NICE compliant treatment However, a substantial number of patients with GAD received counselling, which is not recommended by NICE and a substantial number of patients who had low intensity interventions had pure self-help, rather than guided self-help Recovery rates suggest deviation from NICE was detrimental: For Depression CBT = Counselling For GAD recovery CBT > Counselling For MADD recovery CBT > Counselling For Recovery at LI Guided Self-Help >Pure Self-Help
Stepped Care The greater the proportion of patients stepped up at a site, the more likely: patients at the site recovered unemployed patients at the site gained employment
Self Referral Self referred patients had similar PHQ-9 and GAD-7 scores to GP referrals, but slightly higher WSAS scores Self referred patients recovered in significantly fewer sessions
Number of Therapy Sessions Sites which gave a larger average number of therapy sessions had higher recovery Issues with IT systems suggest mean number of sessions may be higher than recorded Site Recovery Ra ates 70% 60% 50% 40% 30% 20% 10% 0% 0 2 4 6 8 Median Number of Sessions
Importance of a core of experienced therapists IAPT model specified that at least 30% of staff in a new service should be experienced, fully trained therapists Advice NOT always followed Services with larger number of sessions given by AfC 7 or above better overall outcomes
Is psycholgical therapy as effective in older adults? USA studies of CBT for GAD suggest NO (Wetherell et al., in press) BUT UK CBT is often less prescriptive & may suit older people better IAPT Year One recovery rates for GAD Working age 53.4% Older 57.4%
Talking Therapies: plan of action (2011-15) Talking Therapies 2011-2015 Complete roll-out of services for adults Improve access to psychological therapies for people with Psychosis, Bipolar Disorder, Personality Disorder Initiate stand alone programme for children and young people Improve access for older people and BME communities Develop models of care for: Long Term Conditions Medically Unexplained Symptoms
Public Transparency: A Revolution for Up to now Mental Health Services Commissioners submit to DH aggregate data on number of people seen and average recovery rates for the service (simplistic). Public access (www.ic.nhs.uk). Soon IAPT services submit 50 data items per patient covering demographics, diagnosis, type of treatment and pre & post treatment scores. Much more nuanced reporting.
Thank You