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Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study.

ABSTRACT: BACKGROUND:Prompt mental health care (PMHC) is a Norwegian initiative, inspired by the English 'Improving Access to Psychological Therapy' (IAPT), aimed to provide low-threshold access to primary care treatment for persons with symptoms of anxiety and depression. The objectives of the present study are to describe the PMHC service, to examine changes in symptoms of anxiety and depression following treatment and to identify predictors of change, using data from the 12 first pilot sites. METHODS:A prospective cohort design was used. All participants were asked to complete questionnaires at baseline, before each treatment session and at the end of treatment. Effect sizes (ES) for pre-post changes and recovery rates were calculated based on the Patient Health Questionnaire and the Generalized Anxiety Disorder scale. Multiple imputation (MI) was used in order to handle missing data. We examined predictors through latent difference score models and reported the contribution of each predictor level in terms of ES. RESULTS:In total, N =?2512 clients received treatment at PMHC between October 2014 and December 2016, whereof 61% consented to participate. The changes from pre- to post-treatment were large for symptoms of both depression (ES?=?1.1) and anxiety (ES?=?1.0), with an MI-based reliable recovery rate of 58%. The reliable recovery rate comparable to IAPT based on last-observation-carried-forward was 48%. The strongest predictors for less improvement were having immigrant background (ES change depression -?0.27, ES change anxiety -?0.26), being out of work at baseline (ES change depression -?0.18, ES change anxiety -?0.35), taking antidepressants (ES change anxiety -?0.36) and reporting bullying as cause of problems (ES change depression -?0.29). Taking sleep medication did on the other hand predict more improvement (ES change depression 0.23, ES change anxiety 0.45). CONCLUSIONS:Results in terms of clinical outcomes were promising, compared to both the IAPT pilots and other benchmark samples. Though all groups of clients showed substantial improvements, having immigrant background, being out of work, taking antidepressant medication and reporting bullying as cause stood out as predictors of poorer treatment response. Altogether, PMHC was successfully implemented in Norway. Areas for improvement of the service are discussed.

SUBMITTER: Knapstad M

PROVIDER: S-EPMC6097447 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study.

Knapstad Marit M Nordgreen Tine T Smith Otto R F ORF

BMC psychiatry 20180816 1

<h4>Background</h4>Prompt mental health care (PMHC) is a Norwegian initiative, inspired by the English 'Improving Access to Psychological Therapy' (IAPT), aimed to provide low-threshold access to primary care treatment for persons with symptoms of anxiety and depression. The objectives of the present study are to describe the PMHC service, to examine changes in symptoms of anxiety and depression following treatment and to identify predictors of change, using data from the 12 first pilot sites.<h ...[more]

PMID: 30115041

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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: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:Background: No studies have examined the underlying structure or predictive validity of the Cognitive Therapy Adherence and Competence Scale (CTACS). Examining the structure of the CTACS is of great relevance because it could provide information on what constitutes competence in CBT, and whether some underlying factors are more important for predicting treatment outcomes than others. This study investigates the psychometric properties of the Norwegian version of CTACS and its associations with treatment outcomes in a sample of primary care clients who received CBT for anxiety and/or depression. Method: Independent assessors rated audiotaped therapy sessions (early, mid and late in treatment) in a sample of 132 primary care clients (mean [SD] age = 34.8 [11.8], 63.6% women), participating in the Prompt Mental Health Care trial. Outcomes were symptoms of anxiety and depression assessed by patient self-report questionnaires. Structural validity was examined by means of confirmatory and exploratory factor analyses (CFA/EFA), whereas longitudinal associations with treatment outcome were explored by adopting multilevel modeling. Results: No evidence was found for the divergent validity of the constructs competence and adherence as indicated by a very high correlation between these two subscales in CTACS (0.97). Regarding reliability, ICCs for the mean score of the full competence scale and its associated subscales were generally good to excellent (0.70-0.80), although the subscale measuring the quality of the therapeutic relationship was relatively low (0.44). Internal consistency was overall acceptable, but our CFA models did not provide an acceptable fit for the pre-specified one-factor and four-factor solutions. EFA results were difficult to interpret, with a sub-optimal three-factor solution providing best model fit and only two meaningful factors [CBT specific skills (? = 0.82) and session structure (? = 0.59)]. Overall, the results indicated no evidence for the scales' predictive validity. Conclusion: Our findings point to several psychometric problems of the CTACS that may limit both its research and clinical utility. The importance of providing empirical evidence for both reliability and validity aspects of scales are discussed and suggestions for future research are provided.

Project description:BackgroundInternationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites.MethodsWe used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014-15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014-15 and 2015-16.FindingsFive service organisation features predicted clinical outcomes in 2014-15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11-42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors.InterpretationTraditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes.FundingWellcome Trust.

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Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study.

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Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study.

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