Improving Access to Psychological Therapies (IAPT):

Background, Strengths, Weaknesses and Future

Directions.

David M Clark University of Oxford, UK

New Prospects for Mental Health •  Enormous progress in psychological treatment research

•  NICE recognizes the advance and recommends evidence-based psychological therapies as first line treatments for: –  Depression –  Anxiety related disorders (Generalized anxiety, panic disorder,

obsessive compulsive disorder, social anxiety, agoraphobia, PTSD, health anxiety, specific phobias)

–  Eating Disorders –  Personality Disorders

•  And as adjuncts to medication for –  Schizophrenia & bipolar disorder

NICE Recommended Treatments

Condition Treatments

Depression (mod-severe) CBT & Interpersonal Psychotherapy (IPT)

Depression (mild-moderate) CBT, IPT, Couples, Brief Psychodynamic, Counselling

Depression (relapse prevention)

CBT, Mindfulness

Anxiety Disorders (ALL) Specialized forms of CBT

PTSD Trauma-focused CBT, EMDR

Eating Disorders CBT, IPT

Schizophrenia Family Therapy, CBT

Borderline PD Mentalization*, Dialectical Behaviour Therapy*, Schema-focused CT*

BUT •  Most of the public don’t benefit

•  Surveys show psychological treatment preferred to medication on ratio of 3:1

•  YET in most western countries only a few (less than 10%) of adults with anxiety or depression have an evidence-based psychological therapy

•  AND the position was much worse in psychosis & children

Improving Access to Psychological Therapies (IAPT) in England

For overview see Clark (2011). International Review of Psychiatry, 23, 375-384

What is IAPT? An English 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

•  deploying them in specialized, local services for depression and anxiety disorders

•  measuring and reporting clinical outcomes for ALL patients who receive a course of treatment (public transparency)

How did it come about?

Lobbying and Public Campaign Political Support

Brown Johnson Cameron & Clegg

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Mental  illness  is  38%  of  all  illness  in  rich  countries  

Heart  disease,  stroke,  cancer,  lung  diseases            and  diabetes  

Mental  illness  (mainly  depression,  anxiety  disorders  and  child  disorders)  

Other  physical  illness  

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Mental  illness  is  the  main  health  problem  of  working  age  in  rich  countries  

0"10"20"30"40"50"60"70"80"90"

100"

0,14" 15,29" 30,44" 45,59" 60+"

Percentage)of)morbidity)due)to)mental)illness)

THE ECONOMIC COST

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Depression 50% more disabling than angina, asthma, arthritis or diabetes.

Mental health problems account for:

40% of disability benefits.

40% of absenteeism.

Cost to economy c. £70 billion

Cost to taxpayers c. £35 billion

WHY IAPT HAS ZERO NET COST

• Gross  cost  per  person  treated            £650  

• Savings  on  physical  healthcare          >  £650  • Savings  on  benefits/taxes                    >  £650  

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The National Plan (2008-2020) •  Train at least 9,000 new therapists and employ them in new clinical

services for depression & anxiety disorders.

•  NICE Guidelines (including stepped care).

•  National Curricula (high and low intensity practitioners: PWPs)

•  Published set of competencies for all therapies (Roth, Pilling et al)

•  For CBT (PWP and HI) “in-service” full-time training.

•  Hi 2 days per week in HEI and 3 days in IAPT. 60 HEI days in total.

•  PWP 1 day per week in HEI and 4 days in service.

•  CPD training for other modalities (IPT, DIT, Couples, Counselling for depression. Now also Mindfulness).

The National Plan (2008-2020)

•  Success to be judged by clinical outcomes (50% recovery target)

•  Self-referral & Session by session outcomes measurement

•  Access targets: by 2015 15% of prevalence, by 2020 25% of prevalence

•  Total Investment: around £1.3 billion

IAPT So Far •  Transformed treatment of anxiety & depression •  Stepped care psychological therapy services established

in every area of England. Self-referral. •  Approx 17% of local prevalence (900,000 per year) seen

in services •  Around 60% have course of treatment (approx 540,000

per year) •  Outcomes recorded in 97% of cases (pre-IAPT 38%) •  Very strict (depression & anxiety) recovery criteria •  Nationally 49% recover and further 16% improve. •  55% of CCGs have recovery > 50%, some > 60%. •  Variability must be the next focus.

Why getting complete data matters. (Clark, Layard, Smithies, Richards, Suckling & Wright, 2009, Behav. Res.Ther)

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2

4

6

8

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Depression Anxiety

Impr

ovem

ent

Pre-Post Complete Post Missing

IAPT So Far •  Transformed treatment of anxiety & depression •  Stepped care psychological therapy services established

in every area of England. Self-referral. •  Approx 17% of local prevalence (900,000 per year) seen

in services •  Around 60% have course of treatment (approx 540,000

per year) •  Outcomes recorded in 97% of cases (pre-IAPT 38%) •  Very strict (depression & anxiety) recovery criteria •  Nationally 49% recover and further 16% improve. •  55% of CCGs have recovery > 50%, some > 60%. •  Variability must be the next focus.

What  is  our  current  variability?  

•  Recovery rate: 49% (range 30% to 71%) •  Reliable Improvement: 64% (range 24% to 73%) •  Reliable deterioration: 6% (range 3% to 11%)

•  Problem descriptor: 68%* (range <1% to 100%) •  Average number of sessions: 6.3 (range 2.3 to 9.4) •  Percent of sessions DNA: 12% (range 5% to 27%) •  Average wait time: 30 days (range 5 to 154 days)

Enhancing Service Recovery rates How? •  Lessons from analysis of national data •  Service innovation projects •  Clinical Leadership •  Public Health England Fingertips Tool

Lessons from analysis of national data (Gyani et al, 2013. IAPT Year one)

Services with higher recovery rates •  Higher average number of sessions •  Use stepped care appropriately •  Core of experienced staff •  NICE compliant treatment •  Self-referral (less sessions to recovery)

Initial severity also predicts recovery

IAPT Year 7

•  A government agency (HSCIC) publishes an annual IAPT report that gives a more rounded view of the strengths and weaknesses of IAPT and make sit possible to explore a range of predictors (correlates) of clinical outcomes using multiple regression.

Year 7:Which Therapies are available?

Therapy Type CCGs

CBT 211 Counselling 180 IPT 141 Couples 95 DIT 77 Employment Support

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Other Hi 185 85%  of  CCGs  offer  CBT  and  Counselling  (universal  offer)  96%  of  CCGs  offer  at  least  2  High  intensity  therapies,  75%  offer  at  least  3,  48%  offer  at  least  4  of  5  High  intensity  therapies  But  capacity  for  Couples,  IPT  and  DIT  needs  to  increase  (plans  in  place)    

DIT  0.3%   IPT  1%  

Counselling  10%  

Couples  0.2%  

CBT  20%  

Other  HI  4%  

Not  specified  17%  

Behaviour  acXvaXon  

4%  

CCBT  1%  

Employment  support  0.1%  

Guided  self-­‐help  21%  

PsychoeducaXonal  peer  support  

4%  

Pure  self    help    9%  

Other  LI  9%  

Year  7:  PaXent  Experience  QuesXonnaire  Post-treatment Questions

% Most or All Times

Staff listened to you and treated concerns seriously?

96.7

Service helped you better understand and address your difficulties?

91.5

Felt involved in making choices about your treatment and care?

93.3

Got the help that mattered to you?

91.4

Have confidence in your therapist and their skills?

95.8

Clearly,  very  posi.ve  but  note  that  PEQ  was  only  completed  by  11%  (50,937)  of  pa.ents  who  had  finished  a  course  of  treatment    

Post Assessment Questions

YES (%)

Given information about options for choosing a treatment?

92.3

Did you have a treatment preference?

77.6

Were you offered your preference?

77.8 YES (4.2 NO 14.4 n/a)

Satisfied with your assessment?

73.7* (23.8 NO)

Between  57,000  and  74,000  responses,  which  is  less  than  10%.  *  Completely  or  mostly  saXsfied  

Recovery  Rates  are  sXll  higher  when  therapists  sXck  to  NICE  recommended  

treatments    

Self-help treatment for Depression: Guided 50% vs Pure 36% (p <.0001) Generalized anxiety disorder treatment CBT 55% or Guided Self-help 59% vs Counselling 46% (ps<.0001)

Improving Recovery rates: clinical leadership, staff supervision and CPD

•  NHSEngland workshop with some high recovery rate services

•  A consistent theme –  Leadership focused on recovery and reliable

improvement data in an inquisitive and staff supportive manner

–  Staff get personal feedback benchmarked against service average or other therapists

–  Personalized CPD programmes for staff

Public Transparency

Google “Common Mental Health Disorders Profiles Tool” Website displays multiple indices of IAPT performance by CCG, along with other key variables (social deprivation levels, investment in psychological therapies, etc) Designed to facilitate learning from other CCGs and to empower both commissioners and patients.

Weaknesses of IAPT •  Many people still don’t get treatment •  Link to employment variable •  Choice also variable •  Some unhelpful old practices (arbitrary limits on

number of sessions) still persist in some areas. •  Investment, premises, equipment variable •  PWP turnover rate (22% pa). •  Physical and mental health care not joined up. •  Still only focuses on anxiety & depression. SMI etc

deserve same benefits.

Plans for further expansion of IAPT in this parliament (up to 2020).

Next Steps (by 2020) Increase access to IAPT to at least 25% of prevalence •  Focus on anxiety & depression in context of long-term

physical health conditions & troubling medically unexplained symptoms.

•  Greater use of digital platforms to maximize geographic reach, deliver therapy in people’s homes when they have time to work on their problems –  Internet therapy programmes with asynchronous therapist

support –  Video conferenced therapy sessions –  Blended care

Extend benefits of IAPT to SMI •  Outcome & reporting monitoring for all patients •  Staff trained in latest NICE recommended

treatments Extend CYP IAPT

Advantages of Internet Delivery Realise mass public benefit •  80% reduction in therapist time. •  Treat everyone for current cost of treating 15-20% •  Patients access treatment anywhere, anytime,

less stigma. Advance Psychotherapy Research •  Large (10,000s) samples allow definitive

moderator and mediator analyses. •  More consistent content delivery •  New interventions to address identified targets can

be rapidly evaluated in online RCTs.

Lessons from IAPT •  Importance of NICE •  Systematic approach to training •  Make friends with politicians and economists •  Try, try and try again •  Recruit support of patient groups •  Outcome data on ALL patients •  Clinicians Opt In to the revolution •  Deliver on time for politicians •  Recovery focused clinical leadership •  Create an innovation environment

Thank You