Improving access to psychological therapies

1
Improving access to psychological therapies

• Catherine Hooper Facilitator
• IAPT Project (depression and anxiety) Cognitive
  Behavioural Therapist, Brynmair Clinic, Llanelli
• Chris Jones
• Cognitive Behavioural Psychotherapist
• Myddfai Psychotherapy Centre
• Carmarthen

2
Why improve access?

• NICE guidelines
• Government policies and targets
• Locally- attention and concern within the Trust,
  establishment of the Psychological therapies
  group, Modernisation agenda

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Modernising the provision of Psychological
Therapies

• Report compiled by Chris Jones, Psychotherapy
  Dept
• Aim
• - to determine need for psychological
  therapy within the 3 counties
• - to determine the current capacity to
  provide psychological therapy
• - to develop options to address the gap

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What Need and When?
a Prevalence of mental health problems in GP
registered population. b
Attend GP (1st assessment) c Referral to
Primary Care Team d Referral to Secondary
Care Team e Acceptance onto CPA f Existing
CPA pool
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DIAGNOSTIC CATEGORY INCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Ceredigion (popn 18-65yrs 63,610) INCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Pembrokeshire (popn 18-65yrs 69,187 INCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Carmarthenshire (popn 18-65yrs 106,190
Anxiety Panic Disorder 89/509 96/553 148/850
Anxiety Generalised Anxiety Disorder 2799 3044 4672
Anxiety All phobias 1145 1245 1911
Bipolar Disorder 3/1209 3/1315 4/2018
Depression (incid. Of Major Depn) 191/1336 208/1453 319/2230
Eating Disorders anorexia - bulimea No reliable estimate for adult popn (7/1000 girls 1/1000 boys) 0.5-1 young women c. 477 No reliable estimate for adult popn (7/1000 girls 1/1000 boys) 0.5-1 young women c.519 No reliable estimate for adult popn (7/1000 girls 1/1000 boys) 0.5-1 young women c.796
Obsessive Compulsive Disorder 38/670 42/761 64/1168
Body Dysmorphic Disorder 318-445 346-484 531-743
Personality Disorder 2799 3044 4672
Post-traumatic Stress Disorder 1590 1730 2655
Schizophrenia 7/318 8/346 12/531
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Estimated prevalence of psychiatric diagnoses
in Ceredigion, Carmarthenshire and Pembrokeshire
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Judith Evan-Jones Toolkit assay of caseloads
skillsin Trust CMHTs
Diagnosis Ceredigion CMHTs Pembrokeshire CMHTs Carmarthen CMHTs - projected Total
Anxiety 19 3 18 40
Depression 42 34 76
Anxiety depression 1 112 90 203
Bioplar 30 65 76 171
Eating disorder 4 4 6 14
Anorexia 6 5 11
Psychosis 119 169 230 518
PTSD 3 2 4 9
OCD/BDD 8 4 10 22
PD not specified 1 6 6 13
Borderline PD 23 5 22 50
Totals 256 370 501 1127
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Toolkit Caseload CompositionPembs. Ceredigion
CMHTs
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Casework Projections based on Corporate Data
CMHT Toolkit Responses
Carm. Cered. Pembs. Total
Anxy Depn 358 119 173 650
OCD/BDD 25 15 6 46
BPAD 192 58 98 348
Eating Disorders 22 19 6 47
Psychosis 581 229 254 1064
PTSD 10 6 3 19
PD (NOS) 15 2 9 26
Borderline PD 56 44 8 108
Total 1259 492 557 2308
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Summary of Psychological Treatment per Case by
Dominant Evidence
Modality Hours Duration
Anxiety and depression CBT 8 - 20 4 months
OCD/BDD CBT 10
BPAD CBT 16 6 - 9 months
CBT Family Work 16 6 months
Eating Disorders CBT 20 40 6 12 months
CAT 25 6 months
Psychodynamic 25 6 months
Psychosis CBT 10 6 months
CBT Family Work 10 6 months
PTSD CBT 8 12 3 months
EMDR 8 12 3 months
PD inc Borderline DBT c. 160 12 months
SFT c. 276 36 months
CAT Long
Psychodynamic (TFP) c. 276 36 months

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All P D Adult CMHTs Formal Skills
Skill level Skill level Skill level Skill level Skill level
Skill A A-B B B-C C Total
CAT            
CBT 5     3 1 9
Counselling 1 8 3     12
DBT     9     9
EMDR     2     2
Personal Construct Psychotherapy            
Psychodynamic Therapy            
Psychosocial Interventions for Psychosis   3 10     13
Schema Focused Therapy            
Systemic Therapy            
Transactional Analysis     1   1 2
Total 6 11 25 3 2 47
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Psychological Treatment Hours Estimated per annum
by Modality (for all cases to have minimum
treatment within one year) CMHT caseloads only

Level B and Above
Disorder CBT Psychod. CAT EMDR DBT SFT
Anx dep 5200-13000
OCD/BDD 460
BPAD 1136
Eating dis. 940-1880 1175 1175
Psychosis 21280
PTSD 152-228 152-228
PD inc Bor Long Long 21440 12328 (assume 1/3 take-up)
Total 29168-37984 1175 1175 152-228 21440 12328
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Therapy Capacity DeficitHours per annum Level
B and Above
CBT Psychod CAT EMDR DBT SFT
Therapy needed (h) 29168-37984 1175 1175 152-228 21440 12328
CMHT 4 0 0 2 9 0
CMHT Cap. (h) 4600 0 0 2300 10350 0
Deficit range 24568-33384 1175 1175 2148-2372 11090 12328
Addnl WTE range (25h/wk 46wk/yr) 21.4-29.0 1.0 1.0 -1.9 to-1.8 9.6 10.7
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Mind the Gap

• Evidence base largely supports and recommends CBT
  for many common disorders
• Effective, accessible, speedy, economic, variety
  of methods
• Not for all, however
• Clinical experience and a less prolific evidence
  base also suggest the utility of other therapies
  (dynamic work, CAT, SFT, art)
• Provides choice of approach highly meaningful
  to clients
• Indicated for specific disorders for some may
  need to be intense and lengthy
• Practice evidence indicates use for long-term and
  sometimes ill-defined (and profound) distress
• Applications for team and organisational
  development
• Basic, psychologically informed engagement skills
  also necessary for majority of work force
• e.g. basic listening and other counselling skills

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Results

• Huge gap between need and provision
• On CMHT caseloads estimated deficits- 29,168
  37,984 of treatment hours per annum for CBT
  alone, 5,200-13,000 deficit of treatment hours
  for people with anxiety\ depression, 21,280
  deficit of treatment hours for people with
  psychosis

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How can we address the gap?

• Improving access to Psychological Therapies
  Project launched in 2009
• Stage one will be concerned with improving access
  for people with anxiety and depression

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Aim of the IAPT (depression and anxiety) Project

• For patients entering our service to receive
  evidence based psychological therapies delivered
  by mental health professionals who are competent
  in their use
• For our service to be NICE compliant
• NICE guidelines (2004) Depression and Anxiety(
  panic disorder with or without agoraphobia and
  generalised anxiety disorder)
• To train a sustainable psychologically skilled
  workforce to provide interventions now and in the
  future

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Progress so far

• 8-day CBT training programme designed
• Curriculum based on the DOH(2007) Report The
  competencies required to deliver CBT to people
  with depression and anxiety
• Aim to train mental health professionals up to
  Level B status

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Level B definition

• A practitioner who is able to deliver formulation
  based or manualised evidence based interventions
  for specific problems, through regular structured
  sessions for an agreed time. Requires training in
  the particular interventions appropriate to the
  particular diagnosed problem, but will only work
  under close consultative supervision

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Why CBT?

• Evidence base largely supports and recommends CBT
  for most mental health problems
• Therefore in most cases CBT should be the first
  psychological intervention that is offered
• However recognised that it certainly does not
  work for everyone and other psychological models
  should continue to be provided and developed

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Who are we training?

• We are providing the training course in all 3
  counties and in all CMHTS both adult and older
  adult
• In some areas ward staff and CRT members have
  been trained
• So far 18 mental health professionals have been
  trained in Llanelli and Pembrokeshire
• With a further 30 in training in Ceridigion
• Updates are also being offered to staff who have
  already done their basic training
• All professions have been represented amongst the
  trainees

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Training is not enough!

• Past experience nationally and locally tells us
  that training without appropriate support and
  supervision is not enough to change practice
• To address this we have set up supervision groups
  across the counties. Supervision starts in
  training and continues thereafter
• The psychological therapies group has formed a
  subgroup which manages and monitors the project

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Measuring competencies

• For trainees we are using the Cognitive Therapy
  Scale- Revised, which is a validated scale used
  nationally by all respected Cognitive Therapy
  training courses
• Practically trainees submit tape recordings for
  scrutiny and have to reach a certain standard
  before being awarded Level B status
• After initial training continuous professional
  development is provided and trainees are expected
  to attend, this programme has started in Llanelli
  and Pembrokeshire

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Competencies for supervisors

• All IAPT supervisors have attended training in
  CBT supervision
• Supervision group for the supervisors set up
• About to introduce validated scale to assess
  competencies of the supervisors-
  Supervisionadherance guidance evaluation (SAGE)
  instrument.

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Will it work?

• Audit to find out
• Have we increased access?
• Were the interventions effective?
• Were the patients satisfied with the service?

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The future

• Stage 2 is planned to begin in next few months
  and will be concerned with increasing access for
  people with established psychosis
• Discussions with Learning Disability services to
  include them in the project
• Discussion with Swansea University, School of
  Health Studies to accredit the training
• Training to become part of induction process for
  all mental health professionals?

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Now you can help us!

• What difficulties do you envisage introducing
  psychological interventions into TAU?
• Groups of 5
• Brainstorm difficulties solutions
• Feedback

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The challenge

• Integrating psychological interventions into
  normal care
• Care coordination and CBT- can they mix ?
• Fitting it all in- giving psychological care
  equal status
• Changing the habits of a lifetime or several
  lifetimes.