IAPT Progress and Lessons from Year One

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IAPT Progress and Lessons from Year One
David M Clark National Clinical Advisor for
IAPT (david.clark_at_kcl.ac.uk)
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Evidence base for IAPT

• RCTs demonstrating efficacy of CBT in depression
  and all anxiety disorders
• Generalization studies demonstrating similar
  effectiveness in routine samples (if same
  treatments highly trained therapists).
• Studies showing that training therapists in
  evidence based treatments leads to improved
  outcomes for patients.

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Can brief therapist training improve patient
outcomes?
Ref Grey et al. (2008) Behavioural and Cognitive
Psychotherapy, 36, 509-520
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Mean improvement rates before and after a
psychology training clinic adopted ESTs
Source Cukrowicz et al (2005). J. Consult. Clin
Psychol, 36, 330-337
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Evidence base for IAPT

• RCTs demonstrating efficacy of CBT in depression
  and all anxiety disorders
• Generalization studies demonstrating similar
  effectiveness in routine samples (if same
  treatments highly trained therapists).
• Studies showing that training therapists in
  evidence based treatments leads to improved
  outcomes for patients.
• Doncaster Newham (52 recovery) and 11
  Pathfinder sites (49 recovery).

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Demonstration Sites Newham Doncaster

• Excellent data completeness (99 in Doncaster,
  88 Newham).
• 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.
• When compared with GP referrals, self- referrals
  were as severe, tended to have had their anxiety
  disorder or depression for longer, and had BME
  rates that were more representative of the
  community. Ditto social phobia and PTSD.
• Outcome does not differ by ethnic status or
  referral route
• White 50
• Black 54
• Asian 67

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National Year One What happened?

• Excellent choice of training providers
• Strong support from SHAs (despite almost
  impossibly tight timetable)
• Over-achievement in sites (35 PCTs versus 20)
• Over-achievement in trainee numbers ( gt 1000
  versus 730)
• London trainees 25 from BME groups
• 43,000 patients accessed services in first 6
  months (on target)

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Lessons from Year One (Courses)

• Trainee selection
• Advertise well in advance (? twice)
• Band 6 band 7 (high intensity trainees)
• KSA requirements made clear at start
• Link to IAPT sites
• Close liaison with services starting with joint
  selection
• Clarity over role qualifications of supervisors
  in the services
• Agreement over recording sessions for supervision
• Clarity about study time
• Appreciation of high stress levels for students
• Teaching
• Revisit and elaborate basics.
• Adequate experiential work.

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Lessons from Year One (services)

• Importance of qualified workforce to
• Treat patients
• Model service for trainees
• Provide supervision for trainees
• Minimum of 1 wte CBT trained therapist for every
  two trainees
• Top - Up training for qualified staff.
• Accommodation for qualified staff trainees (mix
  GP practice community/central location)
• IT system in place and tested before trainees
  arrive.

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Lessons from Year One (services)

• Getting the right case and person mix
• Equity by clinical condition and person
  characteristics (BME, age, gender)
• Avoid being overwhelmed by inappropriate cases
  (personality disorders, all secondary
  services/CMHT wait list).
• Solutions
• Self-referral (improves access for BME, PTSD and
  Social Phobia)
• GP education
• Coherent care pathways for non-IAPT cases
• Monitor equity with early review (ocean liner)

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Rates of Anxiety Disorders in Pathfinders vs
Primary Care
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Lessons from Year One (services)

• Delivering treatment in line with NICE Guidance
• In vivo work with anxiety disorders (i.e
  treatment cannot be all office based)
• Appropriate dose and frequency of treatment
• Not fixed number of sessions
• Sometimes twice a week (severe depression, OCD)

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Lessons from Year One (services)

• Right training experiences for trainees
• Opportunity to sit in on work of experienced CBT
  staff (high and low)
• Full range of disorders ( depression and 7
  anxiety disorders including PTSD)
• Appropriate training cases
• Services need to deliver the treatments trainees
  are being trained to deliver (low)

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Lessons from Year One (services)

• Service Structure
• Integrating high intensity, low intensity and
  employment advisor work
• Promoting a multi-disciplinary workforce
• GP leads
• Developing CPD and an innovative environment that
  people want to be part of.