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