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Improving access to psychological therapies and older people: findings from the Eastern Region.

ABSTRACT: BACKGROUND:Evaluations of the Improving Access to Psychological Therapies (IAPT) scheme have not yet focused on minority subgroups. This paper aims to evaluate accessibility, waiting times and clinical outcomes of IAPT for older adults. METHODS:All referrals from six Primary Care Trusts (PCT) in the East of England were used in this analysis. During each session, the therapist recorded information on anxiety symptoms using the Generalised Anxiety Disorder Questionnaire (GAD-7) and depressive symptoms with the Patient Health Questionnaire (PHQ-9). Waiting times, type of referrals and reliable recovery rates were investigated. RESULTS:Older adults accounted for only 4% of all the IAPT referrals made between September 2008 and July 2010 in the Eastern Region. Waiting times for both IAPT assessment and treatment were slightly lower for older adult. In all centres, reliable recovery rates were higher in older adults compared to younger adults post-treatment, however these differences were not significant, with the exception of a difference in anxiety scores (?(2)(1) = 18.6, p < 0.001). In multivariate analyses, being an older adult was associated with recovery for depression (OR = 1.30, 95% CI 1.10-1.53), anxiety (OR = 1.42, 95% CI 1.21-1.66), and overall recovery (OR = 1.31, 95% CI 1.10-1.54) after adjustment for gender, PCT region, baseline score, maximum treatment step during treatment, dropping out, and number of sessions. CONCLUSIONS:The IAPT services were shown to be beneficial to older patients, however, access to these services in later life has been lower than expected. The service pathway for older populations needs to be better researched in order to eliminate possible obstacles in accessing services.

SUBMITTER: Prina AM

PROVIDER: S-EPMC4007011 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Improving access to psychological therapies and older people: findings from the Eastern Region.

Prina A Matthew AM Marioni Riccardo E RE Hammond Geoffrey C GC Jones Peter B PB Brayne Carol C Dening Tom T

Behaviour research and therapy 20140328

<h4>Background</h4>Evaluations of the Improving Access to Psychological Therapies (IAPT) scheme have not yet focused on minority subgroups. This paper aims to evaluate accessibility, waiting times and clinical outcomes of IAPT for older adults.<h4>Methods</h4>All referrals from six Primary Care Trusts (PCT) in the East of England were used in this analysis. During each session, the therapist recorded information on anxiety symptoms using the Generalised Anxiety Disorder Questionnaire (GAD-7) and ...[more]

PMID: 24727362

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Project description:BACKGROUND:Prompt 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. METHOD:The 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. RESULTS:Several 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. CONCLUSION:Both 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.

Project description:England's national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective.

Project description:Providing good quality psychiatric services to patients who attend general hospital has been an area that has attracted a lot of interest.(1)(2) We know that more than one quarter of general hospital patients have a mental disorder, mental ill health impedes recovery from physical illness, and mental disorders are often unrecognised in patients with physical illness. By improving the quality of our service we hope that we can achieve better integration with the medical teams and thus tackle the aforementioned problems.(3)(4) In our trust, relevant work has been completed by the clinical health psychology team in Cardiac Rehabilitation wards. Our liaison team provides psychiatric assessment and treatment to inpatients at St Bartholomew's hospital that have been referred to us by our medical colleagues. We first observed that not all the medical teams are fully aware of the referral process and that they were keen on having training sessions and further education on the area of psychological medicine. Another area that we focused on during this process was making sure that we maintained quality of service provision while our service was in transition due to relocation. Ward based information sessions and meetings were held. An introductory session to psychiatry was also provided on medical induction. Information leaflets with referral process and contact numbers were produced for staff at ward level and for administrative support. A liaison psychiatry pathway was created to incorporate the changes that occurred after the relocation of our service. Following these interventions there was significant improvement among the staff in recognising and referring patients with psychiatric issues through the use of liaison psychiatry pathway. There was also increase in satisfaction amongst staff. Education improves understanding and awareness of mental illness and a care pathway focuses attention on this area, improving patient safety and quality of care.(5)(6).

Project description:BACKGROUND:The innovative treatment model Improving Access to Psychological Therapies (IAPT) and its Norwegian adaptation, Prompt Mental Health Care (PMHC), have been evaluated by cohort studies only. Albeit yielding promising results, the extent to which these are attributable to the treatment thus remains unsettled. OBJECTIVE:To investigate the effectiveness of the PMHC treatment compared to treatment as usual (TAU) at 6-month follow-up. METHODS:A randomized controlled trial with parallel assignment was performed in two PMHC sites (Sandnes and Kristiansand) and enrolled clients between November 9, 2015 and August 31, 2017. Participants were 681 adults (aged ?18 years) considered for admission to PMHC due to anxiety and/or mild to moderate depression (Patient Health Questionnaire [PHQ-9]/Generalized Anxiety Disorder scale [GAD-7] scores above cutoff). These were randomly assigned (70:30 ratio; n = 463 to PMHC, n = 218 to TAU) with simple randomization within each site with no further constraints. The main outcomes were recovery rates and changes in symptoms of depression (PHQ-9) and anxiety (GAD-7) between baseline and follow-up. Primary outcome data were available for 73/67% in PMHC/TAU. Sensitivity analyses based on observed patterns of missingness were also conducted. Secondary outcomes were work participation, functional status, health-related quality of life, and mental well-being. RESULTS:A reliable recovery rate of 58.5% was observed in the PMHC group and of 31.9% in the TAU group, equaling a between-group effect size of 0.61 (95% CI 0.37 to 0.85, p < 0.001). The differences in degree of improvement between PMHC and TAU yielded an effect size of -0.88 (95% CI -1.23 to -0.43, p < 0.001) for PHQ-9 and -0.60 (95% CI -0.90 to -0.30, p < 0.001) for GAD-7 in favor of PMHC. All sensitivity analyses pointed in the same direction, with small variations in point estimates. Findings were slightly more robust for depressive than anxiety symptoms. PMHC was also more effective than TAU in improving all secondary outcomes, except for work participation (z = 0.415, p = 0.69). CONCLUSIONS:The PMHC treatment was substantially more effective than TAU in alleviating the burden of anxiety and depression. This adaptation of IAPT is considered a viable supplement to existing health services to increase access to effective treatment for adults who suffer from anxiety and mild to moderate depression. A potential effect on work participation needs further examination.

Project description:BackgroundPsychological treatment delivered by telephone is recommended by the National Institute for Health and Care Excellence (NICE) for mild to moderate depression and anxiety, and forms a key part of the Improving Access to Psychological Therapy (IAPT) programme in the UK. Despite evidence of clinical effectiveness, patient engagement is often not maintained and psychological wellbeing practitioners (PWPs) report lacking confidence and training to deliver treatment by telephone. This study aimed to explore the perspectives of professional decision makers (both local and national) on the barriers and facilitators to the implementation of telephone treatment in IAPT.MethodsSixteen semi-structured qualitative telephone interviews and one focus group were carried out with decision makers (n?=?21) who were involved locally and nationally in policy, practice and research. The interviews and focus group were coded thematically, and then mapped onto the four core constructs of Normalisation Process Theory (NPT).ResultsThe use of telephone for psychological treatment was universally recognised amongst participants as beneficial for improving patient choice and access to treatment. However, at service level, motives for the implementation of telephone treatments are often misaligned with national objectives. Pressure to meet performance targets has become a key driver for the use of telephone treatment, with promises of increased efficiency and cost savings. These service-focussed objectives challenge the integration of telephone treatments, and PWP acceptance of telephone treatments as non-inferior to face-to-face. Ambivalence among a workforce often lacking the confidence to deliver telephone treatments leads to reluctance among PWPs to 'sell' treatments to a patient population who are not generally expecting treatment in this form.ConclusionsPerceptions of a need to 'sell' telephone treatment in IAPT persist from top-level decision makers down to frontline practitioners, despite their conflicting motives for the use of telephone. The need for advocacy to highlight the clinical benefit of telephone treatment, along with adequate workforce support and guidance on best practice for implementation is critical to the ongoing success and sustainability of telephone treatment in primary care mental health programmes.

Project description:BACKGROUND:Social prescribing is encouraged to promote well-being, reduce isolation and loneliness. Traditional, generalist day centres for older people could be suggested by social prescribing, but little is known about their clientele or their outcomes. As part of a larger study of the role, outcomes and commissioning of generalist English day centres for older people, the characteristics of attenders at 4 day centres, their reasons for attendance and outcomes were explored. METHODS:This mixed-methods study used qualitative interviews and standardised tools within an embedded multiple-case study design. Semi-structured interviews with older day centre attenders (n = 23, 62% of eligible attenders) of 4 day centres in south-east England, recruited purposively to reflect organisational differences, were analysed. RESULTS:Participants reported non-elective withdrawal from socialisation following health or mobility decline, or losses. Apart from living arrangements and marital status, attenders' profiles differed between centres. Access had been mostly facilitated by others. Day centre attendance enhanced quality of life for this group of socially isolated people with mobility restrictions and at risk of declining independence and wellbeing. The positive impact on attenders' social participation and involvement and on meaningful occupation was significant (p-value < 0.001, 99% CI), with an average ASCOT gain score of 0.18. Ten outcome themes were identified. CONCLUSION:Outcomes of day centre attendance are those targeted by social care and health policy. Centres were communities that 'enabled' and offset loss or isolation, thus supporting ageing in place through wellbeing and contributed something unique to their attenders' lives. By monitoring attenders' health and wellbeing and providing practical support, information and facilitating access to other services, centres offered added value. Attendance needs to be set in the context of other social engagement and care provision which may not overlap or duplicate centre support. Professionals may wish to explore the benefits of social prescriptions to day centres but should map local centres' provision, engage with their organisers, and seek information on attenders, who may differ from those in this study.

Dataset Information

Improving access to psychological therapies and older people: findings from the Eastern Region.

Publications

Improving access to psychological therapies and older people: findings from the Eastern Region.

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