Improving Access to Psychological Therapies in England Dr Alan Cohen FRCGP Director 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 This slide could be combined with the previous slide.

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

Performance management Organisationally Performance management Policy DH SHA PCTs GPs and Hospitals

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 - Improving A - Access to P - Psychological T – Therapies A commissioner led, outcome focused programme to deliver improved access to psychological therapies, through the implementation of NICE guidelines What is a commissioner?

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 Engage professional bodies Voluntary sector campaign Regional and local management structure Clinical Networks Clinical Leadership

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

We will have this in the participant’s packet We will have this in the participant’s packet. This slide is probably enough at this point with a little explanation from you and an indication that you are going to review the guidelines in depth later.

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 About what %% of GPs used to have counsellors in their practices? The methods for “monitoring and measuring” would be useful to explore in more depth later in the presentation.

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 Engage professional bodies 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 What did you do to get the 3,600 therapists/counselors trained and placed. Explain the competency based training including who was trained (credentials type of training and supervision, placement ….more about the structure and content of the national training effort.

Therapists Low Intensity – 2nd Step High Intensity – 3rd 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 23

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

The MDS Clinical Choice and satisfaction Employment PHQ-9, GAD-7, anxiety disorder specific measures Choice and satisfaction Employment Quality of life (WHODAS) I don’t understand this slide?

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 Can you get into more detail with this and next slide. The population prevalence, data collection, outcomes (data). Thanks

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 Certainly the first statement supports the reasons for using scientifically rigorous tx recommendations (NICE)

Challenges… Validity of NICE guidelines Tribal politics Money Training new staff Engaging primary care What do you mean by the “validity of NICE guidelines”? I am concerned that based on the next slide you (or others) don’t support the evidence based guidelines. I understand that the implementation of guidelines must be tempered somewhat by clinical judgment but the consistent use of evidence based guidelines is one of the major reasons for our interest in the IAPT. Certainly there is always some resistance and that is a legitimate challenge. Please let me know. Also is the item “training new staff” necessary?

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 See previous slide

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) FYI ..we call this professional “cultural differences”

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 What has been done about this? Also how have patients been engaged?

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

Thank you More information Alan Cohen: doctoralancohen@mac.com www.iapt.nhs.uk Thank you

NICE GUIDELINES Breakout Session MeHAF Integrated Care Learning Community November 4, 2011 Bangor, Maine

Stepped Care

Step 1 Be 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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11

Step 3 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 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 Enter content into the left-hand text box only. This should include summary highlights of the main points of the document and also any relevant exclusions. These main points may become the title of subsequent pages within Basic Principles as the source is further reported on and the main facts are expanded upon. Please use font Tahoma and text size 11