Improving Access To Psychological Therapies Research Articles

Views about integrating smoking cessation treatment within psychological services for patients with common mental illness: A multi-perspective qualitative study.

BackgroundTobacco smoking rates are significantly higher in people with common mental illness compared to those without. Smoking cessation treatment could be offered as part of usual outpatient psychological care, but currently is not.ObjectiveTo understand patient and health care professionals' views about integrating smoking cessation treatment into outpatient psychological services for common mental illness.DesignQualitative in‐depth interviews, with thematic analysis.ParticipantsEleven Improving Access to Psychological Therapies (IAPT) psychological wellbeing practitioners (PWPs), six IAPT patients, and six stop smoking advisors were recruited from English smoking cessation, and IAPT services.ResultsPatients reported psychological benefits from smoking, and also described smoking as a form of self‐harm. Stop smoking advisors displayed therapeutic pessimism and stigmatizing attitudes towards helping people with mental illness to quit smoking. PWPs have positive attitudes towards smoking cessation treatment for people with common mental illness. PWPs and patients accept evidence that smoking tobacco may harm mental health, and quitting might benefit mental health. PWPs report expertise in helping people with common mental illness to make behavioural changes in the face of mood disturbances and low motivation. PWPs felt confident in offering smoking cessation treatments to patients, but suggested a caseload reduction may be required to deliver smoking cessation support in IAPT.ConclusionsIAPT appears to be a natural environment for smoking cessation treatment. PWPs may need additional training, and a caseload reduction. Integration of smoking cessation treatment into IAPT services should be tested in a pilot and feasibility study.Patient or public contributionService users and members of the public were involved in study design and interpretation of data.

OP178 Assessing Digitally Enabled Therapies: Challenges And Opportunities

IntroductionIn 2017, the National Institute for Health and Care Excellence (NICE) and the National Health Service England established a program to identify Digitally Enabled Therapies (DET) that increase access to Improving Access to Psychological Therapies (IAPT) services. The aim was to determine whether DETs could improve service efficiency, and whether outcomes are at least as good as those achieved by NICE-recommended non-digital therapies.MethodsAn IAPT assessment briefing (IAB) was developed for each eligible DET. IABs included an assessment of content, technical standards, clinical effectiveness, and cost and resource impact. IABs were reviewed by the NICE IAPT expert panel to decide whether a DET is suitable for evaluation in IAPT services, needs further development, or is not suitable. Suitable DETs were evaluated for up to two years.ResultsOf 154 DETs reviewed by the program, fourteen had IAB assessments. The high dropout rate was due to ineligible products or developer withdrawal. Of the fourteen IABs, five were recommended for evaluation, one was recommended for development, and eight were not recommended.ConclusionsDETs can provide an alternative for patients who may not be able to access treatment. When establishing programs to review DETs, centers must consider the quality of the products submitted and, where necessary, make pragmatic decisions about assessment criteria.

Beyond the barriers: South Asian women’s experience of accessing and receiving psychological therapy in primary care

Purpose A number of initiatives have been developed to ensure easy access to mental health services for Black and Asian Minority Ethnic (BAME) communities. Improving Access to Psychological Therapies (IAPT) is a service that delivers first line interventions for South Asian women; however, little is known about what makes IAPT accessible for this population. This paper aims to explore South Asian women’s experiences of accessing psychological therapy and whether therapy within IAPT helps individuals to re-frame their experiences within their own cultural context. Design/methodology/approach A qualitative approach was used. Semi-structured interviews were carried out with South Asian women who accessed an IAPT service. Ten participants took part in the study and interviews were analysed using thematic analysis. Findings Six themes were identified; access, experience, cultural framework, therapist characteristics, expectations and “sticking with it”. Having a good therapeutic relationship with the therapist was key. While cognitive behavioural therapy (CBT) enabled clients to manage their symptoms, manualised CBT led to a sense of dissatisfaction for some. Clients spoke of having to make a forced choice to either deny their culture or leave their culture at the door to access therapy. Cultural and religious exclusion had a negative impact on therapy particularly for those whose difficulties were related to their cultural or religious context. Practical implications Culture and religion continues to be excluded from psychological therapy for South Asian Women. A cultural shift is required from within IAPT services to maintain engagement for this group. Further clinical implications are discussed. Originality/value While the experiences of Black and Asian ethnic minority groups accessing secondary mental health services has been explored, this study explores and highlights the experiences of South Asian Women accessing therapy in primary care, and uniquely identifies the processes that enable women to engage in therapy.

More sensitive identification of psychotic experiences in common mental disorder by primary mental healthcare services - effect on prevalence and recovery: casting the net wider.

Psychotic experiences may emerge in more severe cases of common mental disorders (CMD). Previous work identified that 30% of patients treated by mental health services in primary healthcare, specifically the Improving Access to Psychological Therapies (IAPT) programme in England, reported psychotic experiences, began treatment with more severe CMD and were less likely to reach recovery. To replicate our previous assessment of psychotic experiences in the IAPT programme using a more sensitive threshold and determine its impact on the prevalence of psychotic experience and likelihood of recovery. Additionally, to compare recovery rates between patients with and without psychotic experiences at the end of therapy. The Community Assessment of Psychic Experiences (CAPE-P15) with a cut-off of 1.30 was used to determine the prevalence of psychotic experiences. Recovery rates were determined using measures collected in the IAPT programme for depression (PHQ-9) and anxiety (GAD-7). Multi-group growth models estimated improvement trajectories. In total, 2042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The prevalence of psychotic experiences was 18% higher when using a lower threshold. The recovery rate for patients with psychotic experiences was lower (36%) than for those without (64%). Despite sharing similar improvement trajectories, the higher initial severity of CMD among patients with psychotic experiences impeded likelihood of recovery. As psychotic experiences may be a marker of severity in CMD, the benefits of identifying these in IAPT populations may also apply to patients with milder experiences. Further investigation of the consequential demands on service provision and how this would affect clinical practice is recommended.

Four practice-based preliminary studies on Human Givens Rewind treatment for posttraumatic stress in Great Britain

Background: Human Givens (HG) Rewind is a relatively unknown trauma-focussed treatment. This paper aimed to provide preliminary evidence of the effectiveness of Rewind to treat posttraumatic stress (PTS) in a variety of clinical settings in Great Britain. Methods: An observational prospective design was used in each of the four studies. Standardised questionnaires were administered in every session. Pre- and post-treatment means and effect sizes were calculated for each study, as were ‘recovery rates’ and ‘reliable change’ rates. Results: Across four studies, a total of 274 clients completed treatment and had complete data. The data capture rate ranged from 80-100%. The mean pre-treatment scores were in the severe range. The pre-post treatment effects sizes ranged from 1.90-2.68. The recovery rate, or percentage of clients who were below the clinical cut-off after treatment, ranged from 46-56% for the more conservative lower cut-offs, and ranged between 71-82% for the higher clinical cut-offs as used by Improving Access to Psychological Therapies (IAPT). Across the four studies, 83-96% of clients had ‘reliably improved’ (88-94% on trauma-specific questionnaires), with 4-17% having no reliable change on those questionnaires. There was no ‘reliable deterioration’. The mean number of HG treatment sessions ranged from 5-6.5 sessions (range 1–24 sessions), with between 73% and 84% of participants completing treatment in six sessions or less. Conclusions: These preliminary results indicate that HG Rewind appears to be a promising trauma treatment in a variety of settings. A randomised controlled trial is now required to determine the efficacy of this treatment.

Therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions.

Improving Access to Psychological Therapies (IAPT) services in England have established a long-term condition (LTC) pathway in recent years, meaning that LTC therapies are now delivered via varied modes and by professionals with varied experiences. To gain insight into how this new pathway is functioning in practice, this study aimed to explore therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in LTCs. A qualitative design was employed using semi-structured interviews. Fifteen therapists were recruited from IAPT and physical health care settings. Interviews were first analysed using inductive thematic analysis. A deductive approach was then taken to map themes onto Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflective monitoring) to guide steps towards improving implementation. Four key themes highlighted patient, therapist, and service-level factors related to uptake and engagement: Working flexibly with barriers within the National Health Service context; Acceptability of 'embedded' versus 'separate' psychological care; Confidence in working with people with LTCs; and Navigating implementation of online therapies. Therapists recognized the need for tailored LTC therapies, though opinions about online therapies varied. Therapists expressed commitment to flexibly adapting their practice to suit patient needs, but felt their flexibility was limited by system and service constraints. Barriers to uptake and engagement need to be addressed to optimize LTC pathways. Findings demonstrated the importance of offering flexible, tailored therapy to people with LTCs, and equipping staff and services with adequate training and resources to improve functioning of LTC pathways in practice.

Some contributions on the experience and therapy of depression published in the Italian journal Psicoterapia e Scienze Umane («Psychotherapy and the Human Sciences»)

The author reflects about a psychoanalytic interpretation of The Tale of Genji (Genji monogatari), considered by many to be the greatest novel of the ancient Japanese literature. It was composed by Murasaki Shikibu (about 1.000 A.D.), a lady-in-waiting for the Empress Akiko at the imperial court in Heian, now Kyoto. The tale is mostly full of poetical explorations about themes of love, affection, friendship, loyalty, into the social political Heian’s world and in conformity with Buddhist conviction in the vanity of the world. A comprehensive reading of the text including Murasaki’s life and her background, gives us the possibility to catch the human attempt to cure depression through narration. Kirsch et al. in 2002 studied all 47 randomized clinical trials (RCT) submitted by pharmaceutical companies to the U.S. Food and Drug Administration (FDA) for approval of the six most prescribed Selective Serotonin Reuptake Inhibitors (SSRI) antidepressants. The mean difference between drug and placebo was less than 2 points on the 21-item (62-point) Hamilton Depression Scale (which is the version used in many of the these RTCs). This superiority to placebo, although statistically significant, was not clinically significant. Furthermore, 57% of the trials funded by the pharmaceutical industry failed to show a significant difference between drug and placebo. Most of these negative data were not published and were accessible only by gaining access, thanks to the Freedom of Information Act, to FDA documents. This research is discussed in light of the wider problem of the roles of medications and interpersonal relationship in psychiatric practice. The polarity of relatedness and self-definition («anaclitic» and «introjective»), fundamental to the development of psychoanalytic theory and consistent with a number of other approaches to personality theory, provides the basis for articulating aspects of personality development, variations in normal personality organization, the explanation of a wide-range of psychopathology, and aspects of the therapeutic process in both short and long-term treatments. The contributions of this fundamental polarity to these aspects of personality theory speak to the validity of this theoretical model and the importance of the fundamental polarity of relatedness and self-definition. The formulations and findings discussed in this paper indicate that there is much to be gained by going beyond the symptom focus of contemporary diagnostic nosology presented in DSM-III and DSM-IV, and seeking instead to identify underlying principles of personality organization. Empirical evidence shows that empirically supported treatments are helpful for many mental disorders. However, in most countries the great majority of people do not have access to psychological therapies. The English Improving Access to Psychological Therapies (IAPT) program aims to improve the access to psychological therapies by training over 10,500 new therapists in empirically supported treatments and deploying them for the treatment of depression and anxiety disorders. IAPT treats over 560,000 patients per year, obtains clinical outcome data on 98.5% of them, and this information is in the public domain. Around half of these patients recover and about two thirds of them show benefits. The clinical and economic arguments on which IAPT is based are presented, along with details on the service model, how the program is implemented, and findings updated to July 2017. Limitations and future directions are discussed.

Personality difficulties and response to community-based psychological treatment for anxiety and depression

BackgroundPrevious research suggests that comorbid personality disorder may be associated with a less favourable treatment outcome for individuals with depression and anxiety disorder. However, little is known about whether personality difficulties are associated with treatment outcomes within Improving Access to Psychological Therapies (IAPT) services-the largest platform for treating depression and anxiety in England, UK. Secondary aims were to investigate i) whether individual personality difficulties are associated with treatment outcome and ii) whether findings are moderated by treatment type. MethodsThe sample included 3,689 adults who accessed community-based psychological treatment (cognitive behavioural therapy, emotional skills training, or other psychological therapy) for depression and/or anxiety disorder. Associations between personality difficulties (assessed with the Standardised Assessment of Personality–Abbreviated Scale (SAPAS)) and treatment outcomes (recovery and reliable improvement in depression/anxiety symptom scores, assessed using questionnaire-based measures) were investigated using logistic/linear regression. ResultsPersonality difficulties were associated with a reduced likelihood of recovery (adjusted OR per unit increase on SAPAS: depression=0.87, 95%CI 0.84, 0.91; anxiety=0.86, 95%CI 0.82, 0.90) and reliable improvement (adjusted OR per unit increase on SAPAS: depression=0.88, 95%CI 0.84, 0.92; anxiety=0.85, 95%CI 0.82, 0.89). Those with three or more difficulties were over 30% less likely to recover/reliably improve. LimitationsPersonality difficulties data were collected via self-report and were not available for all participants. ConclusionPatients with personality difficulties have a less favourable response to psychological treatment for depression/anxiety disorder. If replicated, the findings highlight a major challenge to the way community-based psychological therapy services in England (IAPT services) are presently constituted.

'So just to go through the options…': patient choice in the telephone delivery of the NHS Improving Access to Psychological Therapies services.

This article considers patient choice in mental healthcare services, specifically the ways that choice is enabled or constrained in patient-practitioner spoken interaction. Using the method of conversation analysis (CA), we examine the language used by practitioners when presenting treatment delivery options to patients entering the NHS Improving Access to Psychological Therapies (IAPT) service. Analysis of 66 recordings of telephone-delivered IAPT assessment sessions revealed three patterns through which choice of treatment delivery mode was presented to patients: presenting a single delivery mode; incrementally presenting alternative delivery modes, in response to patient resistance; and parallel presentation of multiple delivery mode options. We show that a distinction should be made between (i) a choice to accept or reject the offer of a single option and (ii) a choice that is a selection from a range of options. We show that the three patterns identified are ordered in terms of patient-centredness and shared decision-making. Our findings contribute to sociological work on healthcare interactions that has identified variability in, and variable consequences for, the ways that patients and practitioners negotiate choice and shared decision-making. Findings are discussed in relation to tensions between the political ideology of patient choice and practical service delivery constraints.

Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin.

Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin.

A pragmatic patient preference trial of cognitive behavioural versus cognitive analytic guided self-help for anxiety disorders

AbstractAims:To outline the methods of a pragmatic patient preference trial in the Improving Access to Psychological Therapies (IAPT) programme comparing cognitive behavioural therapy guided self-help (CBT-GSH) with cognitive analytic therapy guided self-help (CAT-GSH).Method:A partially randomised patient preference trial (PRPPT) methodology. Participants will be assessed with the MINI to ascertain a diagnosis of an anxiety disorder. Treatment will be six to eight 35-minute sessions in each arm. The primary outcome measure is the Beck Anxiety Inventory (BAI), with secondary outcome measures of the IAPT minimum dataset and indices of service utilisation. Participants will be followed up at 8 and 24 weeks.Planned analyses:Choice, treatment completion, drop-out and step-up rates will be summarised via a CONSORT diagram. If there are no differences between randomised and preference participants within each form of GSH, then these groups will be collapsed to form a two-arm trial. The primary analysis will compare between-arm standardised effect sizes on the BAI measure, using Cohen’s d+ at 8- and 24-week follow-up. The proportions in each arm achieving reliable and clinical change on the BAI will be established, with interviews exploring the change process with participants achieving a reliable pre–post change on the GAD-7.Conclusions:The utility of patient preference trials in mental health services are discussed and the necessary further development of robust evidence concerning low-intensity interventions is highlighted.

What influences practitioners\u2019 readiness to deliver psychological interventions by telephone? A qualitative study of behaviour change using the Theoretical Domains Framework

BackgroundContemporary health policy is shifting towards remotely delivered care. A growing need to provide effective and accessible services, with maximal population reach has stimulated demand for flexible and efficient service models. The implementation of evidence-based practice has been slow, leaving many services ill equipped to respond to requests for non-face-to-face delivery. To address this translation gap, and provide empirically derived evidence to support large-scale practice change, our study aimed to explore practitioners’ perspectives of the factors that enhance the delivery of a NICE-recommended psychological intervention, i.e. guided self-help by telephone (GSH-T), in routine care. We used the Theoretical Domains Framework (TDF) to analyse our data, identify essential behaviour change processes and encourage the successful implementation of remote working in clinical practice.MethodThirty-four psychological wellbeing practitioners (PWPs) from the UK NHS Improving Access to Psychological Therapies (IAPT) services were interviewed. Data were first analysed inductively, with codes cross-matched deductively to the TDF.ResultsAnalysis identified barriers to the delivery, engagement and implementation of GSH-T, within eight domains from the TDF: (i) Deficits in practitioner knowledge, (ii) Sub-optimal practitioner telephone skills, (iii) Practitioners’ lack of beliefs in telephone capabilities and self-confidence, (iv) Practitioners’ negative beliefs about consequences, (v) Negative emotions, (vi) Professional role expectations (vii) Negative social influences, and (viii) Challenges in the environmental context and resources. A degree of interdependence was observed between the TDF domains, such that improvements in one domain were often reported to confer secondary advantages in another.ConclusionsMultiple TDF domains emerge as relevant to improve delivery of GSH-T; and these domains are theoretically and practically interlinked. A multicomponent approach is recommended to facilitate the shift from in-person to telephone-based service delivery models, and prompt behaviour change at practitioner, patient and service levels. At a minimum, the development of practitioners’ telephone skills, an increase in clients’ awareness of telephone-based treatment, dilution of negative preconceptions about telephone treatment, and robust service level guidance and standards for implementation are required. This is the first study that provides clear direction on how to improve telephone delivery and optimise implementation, aligning with current mental health policy and service improvement.

Improving Access to Psychological Therapies (IAPT) in the United Kingdom: A systematic review and meta-analysis of 10-years of practice-based evidence.

Improving Access to Psychological Therapies (IAPT) is a national-level dissemination programme for provision of evidence-based psychological treatments for anxiety and depression in the United Kingdom. This paper sought to review and meta-analyse practice-based evidence arising from the programme. A pre-registered (CRD42018114796) systematic review and meta-analysis. A random effects meta-analysis was performed only on the practice-based IAPT studies (i.e. excluding the clinical trials). Subgroup analyses examined the potential influence of particular methodologies, treatments, populations, and target conditions. Sensitivity analyses investigated potential sources of heterogeneity and bias. The systematic review identified N=60 studies, with N=47 studies suitable for meta-analysis. The primary meta-analysis showed large pre-post treatment effect sizes for depression (d = 0.87, 95% CI [0.78-0.96], p<.0001) and anxiety (d = 0.88, 95% CI [0.79-0.97], p<.0001), and a moderate effect on functional impairment (d = 0.55, 95% CI [0.48-0.61], p<.0001). The methodological features of studies influenced ESs (e.g., such as whether intention-to-treat or completer analyses were employed). Current evidence suggests that IAPT enables access to broadly effective evidence-based psychological therapies for large numbers of patients. The limitations of the review and the clinical and methodological implications are discussed. IAPT interventions are associated with large pre-post treatment effect sizes in depression and anxiety measures. IAPT interventions are associated with moderate treatment effect sizes with regards to work and social adjustment. A reduction in dropout and also the prevention of post-treatment relapse via the offer of follow-up support are important areas for future development.

A pragmatic randomized waitlist-controlled effectiveness and cost-effectiveness trial of digital interventions for depression and anxiety

Utilization of internet-delivered cognitive behavioural therapy (iCBT) for treating depression and anxiety disorders in stepped-care models, such as the UK’s Improving Access to Psychological Therapies (IAPT), is a potential solution for addressing the treatment gap in mental health. We investigated the effectiveness and cost-effectiveness of iCBT when fully integrated within IAPT stepped-care settings. We conducted an 8-week pragmatic randomized controlled trial with a 2:1 (iCBT intervention: waiting-list) allocation, for participants referred to an IAPT Step 2 service with depression and anxiety symptoms (Trial registration: ISRCTN91967124). The primary outcomes measures were PHQ-9 (depressive symptoms) and GAD-7 (anxiety symptoms) and WSAS (functional impairment) as a secondary outcome. The cost-effectiveness analysis was based on EQ-5D-5L (preference-based health status) to elicit the quality-adjust life year (QALY) and a modified-Client Service Receipt Inventory (care resource-use). Diagnostic interviews were administered at baseline and 3 months. Three-hundred and sixty-one participants were randomized (iCBT, 241; waiting-list, 120). Intention-to-treat analyses showed significant interaction effects for the PHQ-9 (b = −2.75, 95% CI −4.00, −1.50) and GAD-7 (b = −2.79, 95% CI −4.00, −1.58) in favour of iCBT at 8-week and further improvements observed up to 12-months. Over 8-weeks the probability of cost-effectiveness was 46.6% if decision makers are willing to pay £30,000 per QALY, increasing to 91.2% when the control-arm’s outcomes and costs were extrapolated over 12-months. Results indicate that iCBT for depression and anxiety is effective and potentially cost-effective in the long-term within IAPT. Upscaling the use of iCBT as part of stepped care could help to enhance IAPT outcomes. The pragmatic trial design supports the ecological validity of the findings.

Process evaluation of Prompt Mental Health Care (PMHC): the Norwegian version of Improving Access to Psychological Therapies

BackgroundPrompt Mental Health Care (PMHC) is the Norwegian adaptation of Improving Access to Psychological Therapies (IAPT). Thus far, evaluations of PMHC have mostly focused on the effectiveness, rather than on contextual and implementation processes. Therefore, the objective of this study was to do a process evaluation and examine: 1) To what extent do the services follow guidelines provided by the Norwegian Directorate of Health (NDH), 2) what the therapists experienced as important barriers and facilitators in implementing the service, and 3) client treatment satisfaction and its associations with baseline variables.MethodThe present study uses data from 526 clients who received PMHC treatment in the municipalities of Sandnes and Kristiansand. The therapists completed questionnaires about each client’s course of treatment. We conducted semi-structured interviews with the therapists and analysed them using thematic analysis. Data from client questionnaires were used to report descriptive sample statistics including symptom severity and treatment satisfaction. Linear regression was adopted to examine the associations between client treatment satisfaction and baseline characteristics.ResultsSeveral aspects of PMHC were implemented in line with the guidelines provided by NDH. Importantly, both services reached out to the intended target group, and could further be characterized as low-threshold with relatively short waiting times (median waiting time between initial contact and treatment start was 27 days, IQR 18–39), no waiting lists, and frequent use of self-referral (33.3%). From the client perspective, results indicated a high degree of treatment satisfaction (Mean = 3.93 (SD = .71, range 1–5)), and this was true across demographic characteristics and symptom severity at baseline (all p > .05). Most notable challenges that came forward were; the low provision of guided self-help (received by only 1.0% of clients), the lack of focus on work participation (low to some degree of focus in 70.8% among sick-listed clients), the collaboration with other services (no collaboration in 85.3% of the clients), and some aspects regarding future development of the service.ConclusionBoth sites managed to implement key aspects of PMHC in line with the guidelines, but further development of the program is warranted. Discussion of challenges and future recommendations are presented.

O3.6. PREVALENCE OF AND RECOVERY FROM COMMON MENTAL DISORDERS INCLUDING PSYCHOTIC EXPERIENCES

BackgroundSystematic reviews indicate that approximately one third of people with at-risk mental states for psychosis (ARMS) will transition to a psychotic disorder. Research in non-specialised services, such as primary care settings, has shown that far fewer make such a conversion. Nonetheless, psychotic experiences (PE) may also be linked to common mental disorders (CMD), particularly depression and anxiety, and still predict poor outcomes. Population studies modelling the co-occurrence of CMD and PE have found an underlying unitary psychopathological factor, with PE emerging towards its more severe end.We know little about the prevalence of and recovery from PE in primary mental health care, where most CMD are treated. One example of primary mental health care setting in England is the Improving Access to Psychological Therapies (IAPT) programme (https://www.england.nhs.uk/mental-health/adults/iapt/). The IAPT programme provides evidence-based psychological therapies for mild to moderate CMD across the UK National Health Service (NHS). IAPT services adhere to current diagnostic paradigms and, therefore, do not either measure or treat PE.We aimed to establish the prevalence of PE in a large sample of patients with CMD from the IAPT programme and compare recovery rates between patients with CMD and PE (CMD-P) and those without PE.MethodsWe used the Community Assessment of Psychic Experiences - Positive 15-item Scale (CAPE-P15) to determine the prevalence of PE in patients with CMD receiving treatment from IAPT services across England. We employed the CAPE-P15 threshold score of 1.47, which identifies individuals with ARMS, and also a lower threshold of 1.30, chosen as within one standard error of measurement, in order to explore threshold effects in the association between PE and recovery.Patient-reported measures of depression (PHQ-9) and anxiety (GAD-7) are routinely collected in IAPT services and determine ‘caseness’ before, during and after therapy. Using recovery rates (moving from ‘caseness’ to recovery) monitored nationally in the IAPT programme, we stratified patients according to the absence and presence of PE. Multi-group growth models estimated improvement trajectories for each group.Results2,042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The overall prevalence of CMD-P was 29.68% at CAPE-P15 threshold score for ARMS, i.e. 1.47, and 48.09% at threshold score 1.30.The overall recovery rate at threshold of 1.47 was 27.87% and 36.3% at 1.30. Recovery rates for those without PE were 58.92% and 62.43% for thresholds 1.47 and 1.30, respectively. Although patients with or without PE shared similar improvement trajectories, the initial severity of patients with CMD-P impeded their likelihood of recovery during treatment.DiscussionAt least one in four patients receiving treatment from IAPT services in primary care experience CMD-P. This significant group of people experience a lower recovery rate, with adverse implications not only for them but also for efficiency of services. Although recovery trajectories for this group showed improvement over therapy sessions, remittance of symptoms was insufficient to meet national IAPT standards of recovery. This patient group is not well-served by current interventions in primary care.This work forms part of a nation-wide NIHR research programme (TYPPEX; https://www.nihr.ac.uk/news/innovative-mental-health-study-launchesin-eastern-region) aiming to develop innovative therapies for people with CMD-P in primary care. Preliminary results related to feasibility and effectiveness of new therapeutic approaches will also be presented.

Improving access to cognitive behavioural therapy groups for postnatal women following partnership work: a service evaluation

ABSTRACT Objective: Postnatal depression (PND) can adversely impact the wellbeing of the mother and child. However, accessing mental health support is a challenge for the perinatal population. While most studies have focused on the effectiveness of stand-alone interventions in treating PND, recent studies have highlighted the need for collaboration and inter-agency working. This study evaluated the impact of partnership working on the effectiveness of cognitive behavioural therapy (CBT) groups for women with PND and anxiety in an Improving Access to Psychological Therapies (IAPT) service. Method: This study is a service evaluation conducted within a primary care setting. It compares engagement and outcomes from pre-partnership groups that were delivered before the development of local partnership working arrangements with post-partnership groups developed in collaboration with a secondary care perinatal mental health service (PNMHS). Participants attended either pre-partnership (N = 26) or post-partnership (N = 19) CBT groups. Results: Following developments in partnership working arrangements, the diversity and number of referrals to CBT groups significantly increased, with a 50% increase in self-referrals. Retention from referral to start of treatment was high, with an increase to 100% following partnership working arrangements (88.5% vs. 100%). Completion rates were also higher following partnership working arrangements (84.2% vs. 61.5%). However, these differences and differences in recovery outcomes did not reach statistical significance. Discussion: Overall this study has found promising results for the effectiveness of partnership working on perinatal care, particularly when improving access to mental health services for women with PND and anxiety.

The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess

Background: The United Kingdom IAPT (Improving Access to Psychological Therapies) approach of delivering low intensity therapies for symptoms of depression and anxiety was adapted for Australia and named NewAccess. Clinical outcomes of the service were evaluated in three sites between October 2013 and 2016.Aims: This paper describes the clinical outcomes in the Australian health setting.Methods: Prospective cohort study with repeated measures. Both intent-to-treat and per protocol analyses were conducted for primary outcomes measures Patient Health Questionnaire-9 (nine item), and Generalised Anxiety Disorder (seven item). Secondary measures were Phobia Scale and Work and Social Adjustment Scale.Results: Three thousand nine hundred and forty-six individuals were assessed, and 3269 attended at least two treatment sessions. Forty percent were males. There was a clinically meaningful reduction (improvement) shown by reliable recovery rates in both depression and anxiety symptoms at post-treatment assessment (68%; 95% CI: 66–70%) with large effect sizes (1.23 for depression and 1.25 for anxiety). Outcomes in PHQ-9 and GAD-7 were not influenced by age or sex, but recovery rates were significantly reduced by relationship status (single or separated). Unemployment reduced PHQ-9 outcomes but not GAD-7 outcomes.Conclusion: NewAccess demonstrated positive clinical outcomes in Australia, that compared favourably with international studies with the same methodology.

Low-Intensity Guided Help Through Mindfulness (LIGHTMIND): study protocol for a randomised controlled trial comparing supported mindfulness-based cognitive therapy self-help to supported cognitive behavioural therapy self-help for adults experiencing depression

BackgroundDepression has serious personal, family and economic consequences. It is estimated that it will cost £12.15 billion to the economy each year in England by 2026. Improving access to psychological therapies (IAPT) is the National Health Service talking therapies service in England for adults experiencing anxiety or depression. Over 1 million people are referred to IAPT every year, over half experiencing depression. Where symptoms of depression are mild to moderate, people are typically offered cognitive behavioural therapy (CBT) self-help (CBT-SH) supported by a psychological well-being practitioner. The problem is that over half of people who complete treatment for depression in IAPT remain depressed despite receiving National Institute of Health and Care Excellent recommended treatment. Furthermore, less than half of IAPT service users complete treatment. This study seeks to investigate the effectiveness of an alternative to CBT-SH. Mindfulness-based cognitive therapy (MBCT) differs from CBT in focus, approach and practice, and may be more effective with a higher number of treatment completions.Methods/designThis is a definitive randomised controlled trial comparing supported MBCT self-help (MBCT-SH) with CBT-SH for adults experiencing mild to moderate depression being treated in IAPT services. We will recruit 410 participants experiencing mild to moderate depression from IAPT services and randomise these to receive either an MBCT-based self-help workbook or a CBT-based self-help workbook. Participants will be asked to complete their workbook within 16 weeks, with six support sessions with a psychological well-being practitioner. The primary outcome is depression symptom severity on treatment completion. Secondary outcomes are treatment completion rates and measures of generalized anxiety, well-being, functioning and mindfulness. An exploratory non-inferiority analysis will be conducted in the event the primary hypothesis is not supported. A semi-structured interview with participants will guide understanding of change processes.DiscussionIf the findings from this randomised controlled trial demonstrate that MBCT-SH is more effective than CBT-SH for adults experiencing depression, this will provide evidence for policy makers and lead to changes to clinical practice in IAPT services, leading to greater choice of self-help treatment options and better outcomes for service users. If the exploratory non-inferiority analysis is conducted and this indicates non-inferiority of MBCT-SH in comparison to CBT-SH this will also be of interest to policy makers when seeking to increase service user choice of self-help treatment options for depression.Trial registrationCurrent Controlled Trial registration number: ISRCTN 13495752. Registered on 31 August 2017 (www.isrctn.com/ISRCTN13495752).

Prevalence of and recovery from common mental disorder including psychotic experiences in the UK Primary Care Improving Access to Psychological Therapies (IAPT) Programme

BackgroundPsychotic experiences (PE) may co-occur with common mental disorders (CMD), such as depression and anxiety. However, we know very little about the prevalence of and recovery from PE in primary mental health care settings, such as the Improving Access to Psychological Therapies (IAPT) services in the UK National Health Service (NHS), where most CMD are treated. MethodsWe used the Community Assessment of Psychic Experiences - Positive 15-item Scale (CAPE-P15) to determine the prevalence of PE in patients receiving treatment from IAPT services. Patient-reported measures of depression (PHQ-9) and anxiety (GAD-7) are routinely collected and establish recovery in IAPT services. We studied recovery rates according to the absence and presence of PE. Multi-group growth models estimated improvement trajectories for each group. ResultsA total of 2,042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The overall prevalence of PE was 29.68%. The recovery rate was 27.43% compared to 62.08% for those without PE. Although patients with or without PE shared similar improvement trajectories, the initial severity of patients with PE impeded their likelihood of recovery. LimitationsWe mirrored routine data collection in IAPT services, including self-report questionnaires that may affect valid reporting of symptoms. Missing data in the calculation of improvement trajectories may reduce generalisability. ConclusionsAt least one in four patients receiving treatment from IAPT services in primary care experience CMD and PE. This significant group of people experience a lower recovery rate, with adverse implications not only for them but also for efficiency of services.