Improving Access to Psychological Therapies in England

Dr Alan Cohen FRCGPDirector of Primary Care

West London Mental Health Trust

What I am going to cover

• Why IAPT evolved– What it is– Implementation issues– Engaging primary care

• NICE guidelines, and its relation to IAPT– Treatment guidelines

What I am not going to cover

• Why the NHS is better (or worse) than the U.S. system

• Whether socialism is better than capitalism for health care

• Whether the health care reforms in the U.S. (or UK) are a good thing

• Anything else even vaguely political!

How the NHS works

• Health care free at the point of delivery• Funded by central taxation• Primary Care

– 30,000 GPs (and teams) working from 10,000 practices

• There are 350 hospitals providing about 160,000 beds

Organisationally

DH

SHA

PCTs

GPs and Hospitals

Policy Performance management

Translating the Special Relationship

• The NHS works on the principle of a purchaser:provider split– Purchaser of health care = commissioner– Provider of health care = GP or Trust

• The local purchaser commissions for the local population

• There is considerable variation in provision of services throughout England – there is no single immutable care pathway for anything

What is IAPT?

I - ImprovingA - Access toP - PsychologicalT – TherapiesA commissioner led, outcome focused programme

to deliver improved access to psychological therapies, through the implementation of NICE

guidelines

This is the man responsible…

The IAPT Programme

• 2004: 10 Downing Street seminar on worklessness

• 2005: Manifesto commitment to improving access

• 2005: 2 Demonstration sites in Doncaster and Newham

• 2007: 10 Pathfinder sites

The IAPT Programme

• 10th Oct 2007 – World Mental Health Day• New Funding over 3 years

– $53m in 2008– $166m in 2009– $279m in 2010

• To deliver– Treatment for 900,000 people– 3,500 new therapists

• New Government committed to continue support– In total $1,200m programme

System Transformation

DH

SHA

PCTs

GPs and Hospitals

Policy Imperative

Key Performance Indicators

Regional and local management structure

Clinical Leadership

Clinical Networks

Voluntary sector campaign

Engage professional bodies

What is NICE?

NICE

• 2004: Produced guidelines on the management of depression and the management of anxiety

• 2009: reviewed and updated guidelines

NICE Guidelines

• IAPT implements NICE guidelines for depression and anxiety disorders

• Only evidence based approaches included in NICE guidelines are intended to be implemented through IAPT teams

• Stepped care essential

The way it used to be…

• Some GP practices had counsellors• No referral guidelines• No treatment guidelines• No way of monitoring use of evidence based

interventions• No way of measuring success of treatment

The Vision

• Everybody has access to high quality therapists

• Use evidence based referral and treatment guidelines

• Monitor outcomes

What we came up with …

Characteristics of the IAPT service

• Commissioner led• Commissioned against outcomes• A team approach to management of people with common

mental health problems– Low intensity therapists– High intensity therapists– GP champions– Others as needed

• A team per 250,000 population– 40 therapists per team– 60:40 split between high and low intensity therapists

Implementation

• New Staff– New ways of working

• Engage professional bodies• Clinical leaders locally, and local networks• Dissemination of information• Develop evidence based outcomes

“New Ways of Working”

• Focus on care pathway, and what is required by the patient, not what professionals choose to offer

• Requires the review of traditional professional roles, and creation of new roles if neccessary

A Care Pathway

Training New Staff

• A need to recruit and train new staff– Not re-allocate current staff

• Competency based (new ways of working)• Develop a curriculum• Identify educational establishments to deliver

the training• Quality Assure the training• Deliver the training

Therapists

• Low Intensity – 2nd Step – Up to 4 – 5 sessions– Face to face, or telephone contacts– Skilled to deliver a variety of evidence based interventions– Delivers high volume contact

• High Intensity – 3rd Step– Usually 12 – 20 sessions – Face to face therapy– Skilled to deliver CBT and other evidence based interventions

How many staff are needed?

• An excel spreadsheet [check link] that calculated the number of new staff needed for a given population

• Worked on assumptions– Population, morbidity, response to treatment etc– Number of sessions needed to treat a disorder

• Add in cost of staff (national pay scales)• Used to estimate cost of a new service

How did the teams work?

• Different teams discovered their own ways of working– Innovation– ownership

• Team location• Supervision essential to high quality care• Links to other providers, primary care, and specialist

mental health trusts• A requirement that the MDS was recorded on an

approved database

Evidence Based Outcomes

• Reviewed what questionnaires were available already

• Identified those that were free to use• Agreed when the questionnaires were to be

used• Agreed cut off scales

– Recovery vs improvement• Plan to “Pay by Outcome” in 2012/2013

• Clinical– PHQ-9, GAD-7, anxiety disorder specific measures

• Choice and satisfaction• Employment• Quality of life (WHODAS)

The MDS

Benefits of an MDS

• Patient benefits• Therapist benefits• Supervisor benefits• Commissioning benefits

Findings from Wave 1 sites

• IAPT services appear to be beneficial to patients with clinical presentations that vary from mild to severe– Recovery vs improvement

• Self referred patients were as severe as referred by GPs, but recovered in less sessions

• Services that made good use of stepped care have higher recovery rates. – Patients were more likely to recover if they were seen

in services that saw more patients

Findings from Wave 1 Sites

• Compliance with NICE treatment recommendations associated with better outcomes

• Provisional diagnoses are important to ensure patients receive NICE recommended treatments

• Services that had a higher proportion of experienced therapists, had overall recovery rates

Challenges…

• Validity of NICE guidelines• Tribal politics• Money• Training new staff• Engaging primary care

NICE guidelines

• Guideline structure is “rigid”• Dependence on a hierarchy of published

research• Philosophical approach to “mental illness”• Why we had to use NICE guidelines

Tribal politics

• Psychologists/Therapists– Some interventions were not included in NICE

guidelines– Enormous educational agenda

• Mental health vs. physical health – GPs were skeptical (this was a mental health

intervention)

Money

• Lots of new money• How to allocate that resource

– Equality vs innovation

Engage Primary Care

• General practitioners were seen as crucial to success of programme

• Mental health staff thought that primary care are “not interested” in mental health problems

• Relationship with physical health, and medically unexplained symptoms

Professional Engagement

• A public statement from the leaders of ALL the primary care organisations that they supported this programme

• Each team HAD to have a local GP leader• Provide training and support to the local

leaders• Identify learning needs

Clinical Engagement

• Help mental health staff realise that managing depression/anxiety had a significant impact on physical long term conditions

• Develop work on savings accrued by providing psychological support to people with LTC/MUS

• Educate mental health commissioners • Develop a national special interest group in

psychological management of LTC/MUS

LTC/MUS

• Ground breaking research – linked databases– Improved clinical outcomes– significant savings possible

• Engaged primary care clinicians not “interested” in mental health

• Engaged acute hospital colleagues not “interested” in mental health

• Introduction of collaborative care• Part of national policy

Next session

• What is the stepped care approach?• Savings and clinical pathways for people with

LTC/MUS• Proposed changes to the NHS?

In memoriam

Prof John C Nemiah

Emeritus Professor of Psychiatry, Dartmouth Medical School

1919 - 2009

More information

• Alan Cohen: doctoralancohen@mac.com• www.iapt.nhs.uk

Thank you

NICE GUIDELINES

Breakout SessionMeHAF Integrated Care Learning CommunityNovember 4, 2011Bangor, Maine

Stepped Care

Step 1Be alert to possible depression

(particularly in those with previous depression or a chronic physical health problem).

Consider asking “During the last month have you often been bothered by:

Feeling down, depressed or hopeless?Having little interest or pleasure in

doing things?”

If the person also has a chronic physical health problem, consider asking three further questions

“During the last month have you often been bothered by:

Feelings of worthlessness?Poor concentration?Thoughts of death?”

Step 1b

Conduct a comprehensive assessment that does NOT rely simply on a symptom count.

Consider • The degree of functional

impairment• The duration of the episode

Explore the following:• History of depression or co-

morbid mental/physical health problems

• Past history of mood elevation• Response to previous

treatments• Quality of interpersonal

relationships• Social history including

employment

If the person has a learning disability or cognitive impairment consider seeking advice from a specialist when developing a treatment plan.

Always ask a person with depression about suicidal ideation and intent.

If there is a risk of self harm or suicide:

• Assess whether they have adequate social support

• Arrange help appropriate to the risk

• Advise them to seek help if the situation deteriorates

Step 1c

If the person presents with considerable immediate risk to themselves or others, refer them urgently to specialist mental health services

Advise the person and their carers, of the following:

• The potential for increased agitation and suicidal ideation early in treatment

• The need to be aware of mood changes particularly when changing treatments

If the person is assessed to be at risk of suicide, consider:

• Providing increased support• Referral to mental health

specialists

Step 2

Treatment options for people with sub-threshold or mild/moderate depression include:

• General measures– Sleep hygiene– Active monitoring

• Drug Treatment– For people without physical

health problems– For people with physical

health problems

• Psychological interventions

Step 2

General Measures:

Sleep Hygiene: offer advice including:• Establishing regular

sleep and wake times• Avoiding excessive

alcohol, eating or smoking before bedtime

• Creating a proper environment for sleep

• Taking regular physical exercise

General Measures:

Active monitoring: for those people who do not want an intervention, who may recover spontaneously, or those with sub-threshold symptoms who request an intervention

• Discuss the presenting problem

• Arrange a further assessment in two weeks

• Provide information about depression

• Make contact if the person does not attend appointments

Step 2

Drug Treatment

Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with:

• A past history of moderate/severe depression

• Initial presentation of sub-threshold depression for two years

• Symptoms that persist after other interventions

Drug Treatment for people with a chronic physical health problem

Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with:

• A past history of moderate/severe depression

• Initial presentation of sub-threshold depression for two years

• Symptoms that persist after other interventions

• Mild depression that complicates the care of the physical health problem

Step 2

Psychological and psychosocial interventions.

For people WITHOUT a chronic physical health problem

Offer one or more of the following interventions:

• Individual guided self help• Computerised CBT• Structured group physical health

activity

For those who decline any of the above, offer group based CBT

Step 2

Psychological and psychosocial interventions.

For people WITH a chronic physical health problem

Offer one or more of the following:• A structured physical activity

programme• A group based peer support

programme• Individual guided self help

based on CBT principles• Computerised CBT

The above interventions are modified to reflect the physical health needs of the person, and the inter-relationship between depression and the physical disorder

Step 3

Treatment Options for people WITHOUT a chronic physical health problem:

For people who have not benefitted from a low intensity intervention (see Step 2) offer

• An SSRI OR• A high intensity intervention

i.e.– Cognitive behaviour therapy

(CBT)– Interpersonal therapy (IPT)– Behavioural activation– Behavioural couples therapy

For people who decline the above consider counselling or short term psychodynamic psychotherapy

For people with moderate or severe symptoms combine CBT/IPT with drug treatment

Step 3

Treatment Options for people WITH a chronic physical health problem:

For people who have not benefitted from a low intensity intervention (see Step 2) offer

• An SSRI OR• A high intensity intervention

i.e.– Cognitive behaviour therapy

(CBT)– Group based CBT– Behavioural couples therapy

For people with severe symptoms combine CBT with drug treatment

Step 3

Choosing an antidepressant:Discuss choice covering:• Anticipated side effects• Potential interactions• Persons perception of likely

efficacy

Normally choose an SSRI; consider that:

• SSRIs are associated with increased bleeding – consider gastro-protection measures

• Fluoxetine, Fluoxetine, and Paroxetine have a higher propensity for drug interactions

• Consider Citalopram or Sertraline as they have a lower propensity for interactions

• Paroxetine is associated with higher incidence of discontinuation symptoms

Take into account risk of overdose:

• Compared with other equally effective antidepressants Venlfaxine is associated with greater risk of death in overdose

• Greatest risk of death in overdose associated with Tricyclics (except Lofepramine)

When prescribing other than SSRIs consider:

• Increased likelihood of side effects

• MAOIs, and Lithium should only be prescribed by specialists

• Dosulepin should not be prescribed

Prescribing for older adults:• Prescribe age-appropriate

doses• Monitor carefully for side

effects

• Dosulepin is NOT recommended