iapt smi demonstration site for psychosis · 3 south london and maudsley (slam) iapt-smi...

3 South London and Maudsley (SLaM)

IAPT-SMI Demonstration Site for Psychosis

Dr Louise Johns

Consultant Clinical Psychologist

IAPT-SMI Project Lead

Psychosis Clinical Academic Group (CAG)

1st July 2015

NICE 2009/2014

• Offer CBT to all people

with schizophrenia

• Offer family

intervention to families

who live with or are in

close contact with the

service user

69% of Trusts have funding

challenges for providing

access to psychological

therapies for people with a

diagnosis of schizophrenia

94% have encountered obstacles in making psychological therapies available, including insufficient skilled staff

“Research has led to a range of

evidence-based psychological

treatments. We know much more

about ‘what works’ than we used

to. . . The committed individuals

who went into the mental health

profession to improve lives should

be helped to do exactly that.”

Schizophrenia Commission

Prof Sir Robin Murray

“I always asked for some

kind of psychological

therapy or talking therapy

but was told, no, it was too

dangerous. I had to wait 20

years for something that

was the most beneficial

thing. [Therapy] has

changed my life basically.”

Dolly Sen,

Service User Consultant

Talking to Norman Lamb MP, Minister of State, on 19 December 2012 at SLaM

Delays in accessing CBTp in SLaM Peters et al, 2009

(N=74)

• Mean length of illness was 8 years (range 0-32)

• Mean of 2.8 in-patient admissions (range 0-20)

National Audit of Schizophrenia (2014)

‘It is clear that the numbers of service users having

access to, and actually receiving, these types of

intervention remain very low.

This needs to be addressed and has significant

funding implications.

...this is probably the largest deficit that exists in

the treatment services provided by Trusts.’

National Audit of Schizophrenia (2014)

Recommendations for the Department of Health

Ensure the Increasing Access to Psychological

Therapies (IAPT) for severe mental illness

programme has the same level of support as the

existing IAPT for anxiety and depression.

This should include a national data set, indicators in

national frameworks and plans for how this could

develop.

Barriers to Access

• Too few therapists

• Insufficiently trained (lack of clarity on

competences)

• Lack of supervision

• No time; without specialised role

• Organisational barriers & lack of support (other

interventions prioritised; therapy a ‘luxury’)

(Shafran et al., 2009; Berry & Haddock, 2008; Haddock et al., 2014; Lobban & Jones

2010; Prytys et al., 2011)

Overcoming obstacles to access in

SLaM

• Core population – 4 South London Boroughs 1.3 million; inner city, very high indices of psychosis and social deprivation and ethnic diversity

• Psychosis Clinical Academic Group which provides services for 7,000 people with psychosis

• All services for people with psychosis organised in 4 stage specific care pathways

• Clinical research programme focused on translational research, developing new psychological treatments

Predicted new cases: England and Wales

Local Authorities: Lowest, mid and SLaM boroughs

Source: Kirkbride et al, 2013, Psymaptic

Work in SLaM 2003-2012

• Ten point charter addressing barriers and facilitators:

– Service user involvement

– Therapy quality criteria and staff training

– Data gathering, data systems and outcomes

– Care pathways, ensuring integrated effective psychological therapies in Early Intervention & Recovery pathways

Historical service data

Graph 1 Psychotic symptoms reduction [voices (effect size: .52) and delusions

(effect size: .75)] following therapy, maintained at follow-up (effect sizes: .44 & .82)

(all significant at p<.001)*.

*Linear mixed model analyses include mid-therapy

scores and are based on 248 individuals for voices;

302 for delusions (but only 25% have follow-up assessment)

Graph 2 Emotional problems reduction [anxiety (effect size: .44) and depression

(effect size: .51)] maintained at follow-up (effect sizes: .29 & .34) (all significant at

p < .001)*.

*Linear mixed model analyses include mid-therapy

scores and are based on 360 individuals for depression;

362 for anxiety (but only 24% have follow-up assessment)

Graph 3 General distress reduction [CORE-10 (effect size: .61) and increase in life

satisfaction (effect size: .49)] maintained at follow-up (effect sizes: .47 & .47) (all

significant at p < .001)*.

*Linear mixed model analyses include mid-therapy scores and

are based on 180 individuals for CORE; 361 for MANSA (but only

36% have follow-up assessment for CORE; 23% for MANSA)

IAPT-SMI in SLaM

Selection of Demonstration Sites by

Open Competition: criteria

• Delivering evidence-based psychological therapies

• Therapists with appropriate competences

• Have strategic approach, which is replicable

• Collecting outcome data routinely and effectively

(access to historical data)

• Provision of training and supervision

• Overcoming barriers to implementation: e.g. senior

management ‘buy-in’; ring-fenced time

Our aims

• Increase access by 50%

• Pilot outcome measures, including sessional

measure

• Improve completion rates to 95% minimum

• Provide a clinically and cost-effective service

SLaM Psychosis Demonstration site:

Increasing access in two care pathways

Promoting Recovery Pathway Promoting Recovery Pathway

Early Intervention Pathway

What IAPT-SMI offers: CBTp CBT for psychosis:

• Weekly or fortnightly individual 1 hour sessions

• 6-9 months therapy

• Therapists receive weekly-fortnightly group supervision Suitability criteria:

• F20 diagnosis (schizophrenia spectrum)

• distressing positive symptoms of psychosis OR

• secondary emotional disturbances / sense-making & recovery

work

• not predominantly negative symptoms

• motivated to attend

What IAPT-SMI offers: FIp FI for psychosis:

• Fortnightly 1 hour sessions with client and carer(s)

• Up to ten sessions, over a period of 3-9 months

• Therapy delivered by two trained therapists

• Usually delivered at home

• Therapists receive weekly-fortnightly group supervision Suitability criteria:

• F20 spectrum diagnosis

• In close contact with an ‘informal caregiver’ (approx. 10 plus

hours face to face or living with)

• Need carer and service user agreement

Pre

PSYRATS – Voices & Beliefs

WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

3-month

PSYRATS – Voices & Beliefs

WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

Satisfaction with therapy & PEQ

Post

PSYRATS – Voices & Beliefs

WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

Satisfaction with therapy & PEQ

Short CHOICE weekly

IAPT-SMI:

CBT assessments

Pre

Experience of caregiving inventory

WEMWBS

DASS-21

CORE-10

IPQ carer version

Confidant question

Measures Feedback

Post

Experience of caregiving inventory

WEMWBS

DASS-21

CORE-10

IPQ carer version

Confidant question

Measures Feedback

Satisfaction with therapy

Sessional satisfaction measure

IAPT-SMI:

Carer assessments

• Overall, perceived as helpful (Mean 6.7-7.0, SD 2.0-2.3)

• Perceived more positively by older clients, but

unrelated to symptom severity, gender or ethnicity

• Majority (>90%) rated as neutral or helpful; length,

emotional content & repetition identified as less helpful

• Comments: ‘used my brain’; ‘made me think’; ‘helped

explain’; ‘helped identify an area to work on’; ‘good to

get things off my chest’

Satisfaction with Measures

Therapy was life-changing and empowering. I have a better understanding of my problems, particularly the triggers and contributions to them.

Therapy has helped me to deal with my anxiety and paranoid thoughts. I am confident I can cope if I have any negative thoughts in the future. I now feel able to move forward with my life

Therapy has been a fantastic experience. I now have a better understanding of why I hear voices and how to cope with them. I now feel less stressed and much happier in myself.

It was helpful to learn about

my thinking, considering

alternative perspectives and

seeing the positive sides of a

situation.

IAPT-SMI Family feedback

‘For the family therapy, I think it was to have

a space. Where {my son} and I could

actually verbalise our concerns… in a space

where it wasn’t, it wouldn’t lead to an

argument, or hurt or upset, because it was

a, I am saying this so I can, so we can find a

solution to it.’

My experience of therapy

Progress and 24-month outcomes

Further detail in:

Jolley S et al (2015), Behaviour Research and Therapy, 64, 24-30

Increased access - referrals

2011 Projected Achieved per annum

Total Increase Total %inc PA %inc PA

CBT 106 50 156 47% 288 172%

FI 15 10 25 67% 38 153%

Both 121 60 181 50% 326 169%

Speed of access

Mean waiting times (days)

Months Referred to

assessed

Assessed to

offered

therapy

Total

%

reduction

in waiting

times

6 45 38 83 40%

12 43 49 92 33%

24 38 48 86 38%

Male BME

Female BME

0%

20%

40%

60%

80%

100%

EI ≤35 PR TOTAL

Male BME 93% 87% 89%

Male non-BME 86% 94% 92%

Female BME 88% 89% 89%

Female non-BME 100% 88% 91%

% co

mpl

etin

g

Treatment completers (n=211) by age and demographics

Equity of access

Completion of measures

• Paired completion – 96% for 5+ sessions; 78% for

drop-out (<5 sessions)

• DH minimum dataset – feasible & acceptable

• FI assessments – feasible & acceptable

• Completion regime: Pre, Mid, Post, no Mid for FI

• Sessional CHOICE: feasible, acceptable and

essential for paired completion rates

EI (n=58) PR (n=145)

PRE 5.00 4.21

POST 6.70 5.81

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Service user-reported wellbeing: CHOICE (p<.001; ES 0.8, 0.7)

EI (n=46) PR (n=134)

PRE 42.43 36.77

POST 51.70 44.99

0.00

10.00

20.00

30.00

40.00

50.00

60.00

Service user-reported wellbeing: WEMWBS (p<.001; ES 0.8, 0.7)

EI (n=44) PR (n=125)

PRE 16.90 21.22

POST 12.10 16.83

0.00

5.00

10.00

15.00

20.00

25.00

Service user-reported impact on functioning: WSAS

(EI: p=.002, ES 0.5; PR: p<.001, ES 0.5)

EI (n=47) PR (n=128)

PRE 15.81 17.92

POST 10.34 13.16

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

Service user-reported distress:CORE-10 (p<.001; ES 0.6)

EI (n=13) PR (n=60)

PRE 21.38 23.98

POST 11.54 19.28

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Service user-reported voices: PSYRATS (EI: p=.007, ES 1.1; PR: p<.001; ES 0.5)

EI (n=13) PR (n=70)

PRE 13.92 13.63

POST 7.10 8.30

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Service user-reported beliefs: PSYRATS(EI: p=.002, ES 1.4; PR: p<.001; ES 0.85)

IAPT-SMI Demonstration Site for

Psychosis: Cost-Effectiveness Analyses

Prof Paul McCrone Professor of Health Economics

Centre for the Economics of Mental and Physical Health

(CEMPH)

King's College London

Institute of Psychiatry, Psychology & Neuroscience

Methods • Therapy costs estimated using PSSRU figures (Curtis,

2013)

• Bed days and crisis team episodes recorded over

therapy period and for estimated for period of same

length before therapy

• Costs based on NHS Reference Costs

• Health-related quality of life measured with EQ5D

before, during and after therapy

• Change in employment status recorded

Crisis Team Costs

Bed Costs

Total Costs by Pathway

Health-Related Quality of Life

Employment and Activity

Economic summary

• Increased costs of therapy offset by

reduced inpatient and crisis team costs

• Improvements in quality of life

• Improvements in employment status

• Indications of cost-effectiveness

• Future controlled studies required

Competence,

Training and

Supervision

IAPT-SMI: Competence Framework for Psychological Interventions for people with Psychosis / Bipolar Disorder (Roth & Pilling, 2013)

• Modular training outline

• From awareness supervision & service change

• www.ucl.ac.uk/CORE

• Individualised and formulation based, but adheres to

published manuals and the CORE CBTp competence

framework (Roth and Pilling, 2013).

• Therapists are trained to competence, using assessments

of adherence and competence.

• Supervision provided weekly to fortnightly in groups of 3-6

therapists for 1.5 hours, with fortnightly to monthly

individual supervision.

• Supervisors are senior clinicians with experience of

training therapists and of providing therapy within RCTs.

CBTp in SLaM Demonstration Site

Training and competence summary

• Portfolio of training opportunities in psychological

therapies for psychosis, in partnership with KCL

• Span the workforce from non-clinical to

managerial/supervisory

• Academically accredited training and in-service

courses

• Short courses and modules build to an award

• Supervised practice strongly emphasised

• Supervision and support for supervisors

What has the SLaM IAPT-SMI pilot demonstrated?

Initial investment We requested:

• Additional therapist time

• Supervision & management time

• Dedicated assessment resource

• Administrative support

We selected therapists with specific competences, or

trained them to competence, and provided close

and frequent supervision

Embedded in the service • In the PR pathway, therapy provision closely

aligned with, but separate from the MDT

• In the EI pathway, psychological therapy embedded

within the specialist MDT

• Representative PR client group, selected for

potential to engage with stand-alone therapy: fits

evidence base

• Specialised assessors: flexible but persistent follow

up to maintain engagement and keep attrition down

The site has been able to:

• Exceed targets for increased access to therapy • Provide equity of access that reflects the diversity of

our local population • Achieve excellent completion rates on outcome

measures, with positive feedback about the assessment process

• Show significant within group pre-post improvements on the outcome measures and high satisfaction rates

• Provide health economic evidence indicating cost effectiveness

What we have learnt: • NICE-recommended individual psychological therapy can

be successfully delivered in routine services

• In the SLaM demonstration site, primary facilitators were: – ring-fenced investment in competent therapy provision

– ring-fenced time for therapists to deliver therapies

– adequate supervision, training and CPD

– trained independent assessors

– established service pathways & governance structures

– strong clinical leadership & management

• Our framework is replicable to inform implementation in

other services and is now informing the Early Intervention

in Psychosis Access and Waiting Time initiative

• Requires a therapist champion to lead service

development and facilitate organisational change – this

should be the initial investment

• ‘Ready’ organisations will be able to use further

investment to work towards a critical mass of supervisors

and therapists

• Can then support further workforce development

innovations (such as low intensity approaches)

• Dedicated assessment and administrative resources

makes more efficient use of therapist time and maintains

completion rates for outcomes

Rolling this out...

Thanks to the IAPT-SMI Project Team

Operational Group:

• Dr Louise Johns, Consultant clinical psychologist, Project lead

• Dr Suzanne Jolley, Data Lead, Lambeth Recovery Psychology lead

• Dr Miriam Fornells-Ambrojo, Clinical Psychologist, STEP, IAPT-SMI EI lead

• Dr Juliana Onwumere, FI lead, service user and carer involvement lead

• Craig Milosh, Clinical Psychologist, SHARP

• Devon Elliott, Business Intelligence Analyst, Psychosis Management Team

• Bina Sharma, Rosanna Michalczuk, Zara Kanji, Annabel Broyd and Suzanne Law, Psychology Assistants

Steering group:

• Prof Philippa Garety, Psychosis CAG Clinical Director

• Angela Morford and Garry Ellison, Service User consultants

• Roger Oliver, Carer consultant

• Dr Emmanuelle Peters, PICuP Director

• Adrian Webster, CAG Psychological Therapies lead

• Sarah Dilks, Lead Psychologist, Promoting Recovery pathway

• Dorothy Abrahams and Marlise Marshall, administrators

Thank you for listening

louise.johns@kcl.ac.uk