In my last Mental Elf blog, I reviewed a study which showed that patients with comorbid Personality Disorders had poorer recovery from depression and anxiety when treated with psychological therapies in an IAPT (Improving Access to Psychological Therapies) service. In the blog I explored the possibility that IAPT services are increasingly receiving referrals for patients who are markedly more complex than the intended “mild-moderate anxiety and depression” presentations the services were set up to treat. I was really pleased therefore to be asked to report on a new study that set out to further explore and test this hypothesis.
This blog briefly looks at the initial findings of the PROMPT project in which a multidisciplinary team of academics from King’s College London collaborated with a London based IAPT provider (South London and Maudsley NHS Foundation Trust, Southwark Psychological Therapies Service) to assess clinical characteristics of patients assessed in the IAPT service over a 12-month period. It reports on the patients recruited to a study which will go on to explore the impact that the patient characteristics has on the efficacy of the IAPT treatment that the patients go onto to receive. The authors’ long-term goal is to use clinical characteristics to predict the outcome of therapy:
The predicting outcome following psychological therapy in IAPT (PROMPT) project provides an infrastructure to allow for the systematic collection of data geared towards understanding the predictors of treatment outcomes.
Additionally, they hope to be able to use their study to identify subgroups of IAPT patients who do not respond to existing treatments in order to devise experimental studies for the identification of new treatments.
Once again, as an IAPT practitioner, academic and blogger, I am excited to see such research projects start to dissect the enormous IAPT data pool with a view of improving and optimising psychological therapy provision. Sometimes for me it feels that the data is only being used for financial reasons (e.g.“Payment-by-Results”) and here again I am encouraged to see that the emphasis is on improving not only access to psychological therapies, but also on the relevance and quality of the therapy to the patient.
This naturalistic cohort study reports on the characteristics of patients referred (either self-referrals or GP-referrals) to the Southwark Psychological Therapies Service (SPTS) between February 2014 and February 2015. They collected and analysed a wide range of demographic and clinical data. The latter included:
- Treatment factors (such as the number of previous IAPT episodes and whether or not the participant was due to receive high intensity or low intensity IAPT therapy)
- Diagnoses and symptomatology
- The Mini International Neuropsychiatric Interview (MINI) was used to assess current and lifetime diagnoses;
- Borderline personality was assessed using subsection of the Structured Clinical Interview for DSMIV Personality Disorders (SCID-II);
- The Hypomania Checklist (HCL-16) used to assess bipolar disorders;
- Depression and anxiety symptoms were further assessed using the Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder assessment (GAD-7) respectively;
- Stressful life events were assessed using the List of Threatening Events Questionnaire;
- Traumatic events during childhood were assessed using the Childhood Trauma Questionnaire;
- The Standardised Assessment of Personality Abbreviated Scale (SAPAS) was used to screen for personality disorder.
All data were analysed using IBM SPSS statistical software version 20. Continuous variables are presented as mean ± SEM.
The study recruited 187 participants and data for these was further analysed.
Socio-demographic characteristics showed they recruited more females (64%) than men; that the majority were white (83%); that those recruited were mainly (80%) not classed as unemployed and that participants had a wide range of income.
More than half of the participants (55%) had experienced at least one stressful life event and 67% reported experiencing at least one form of childhood trauma.
In terms of the current diagnosed presenting issue(s), the study found:
- Generalised Anxiety Disorder (GAD): 66%
- Depression: 53%
- Agoraphobia: 48%
- Social Phobia: 33%
- PTSD: 21%
- Alcohol Dependence: 18%
- OCD: 18%
- Dysthymia: 10%
Less than 10% of this cohort were diagnosed with substance dependence, mood disorder with psychotic symptoms, hypomania, mania, bulimia or psychosis.
The vast majority of those recruited had more than one current diagnosis (72%), with 58% having 3 or more current conditions at assessment.
It was also noteworthy that the study identified that 28% of the participants had a history of (hypo)mania and that 61% of participants scored above the cut-off on the HCL-16, suggesting a large proportion of the patients with depression seen within the IAPT service fell within the bipolar spectrum at assessment.
Looking at the severity of both depression and GAD showed the following:
|Depression (PHQ9 score)||GAD (GAD7 score)|
And therefore high percentages of patients were above the initial “mild-moderate” original IAPT remit.
The authors’ concluded that their study demonstrated that it was possible to collect meaningful data using their study protocol.
They go on to state that:
…the results have revealed the complex nature of the patients seen within an urban IAPT service…
going on to emphasise:
…the high rates (presenting in an urban IAPT service) of psychiatric comorbidity, bipolarity, childhood trauma and traits of personality disorder.
Strengths and limitations
It is great to see these data published at the outset of the longer-term PROMPT study and in general these findings are very much in keeping with published data and qualitative/anecdotal evidence that IAPT services are seeing complex presentations.
Personally, I was really surprised and somewhat disappointed that they were only able to recruit and report upon such a small number of participants, as this is surely a small percentage of patients referred to the IAPT service in the 12 months of recruitment.
Perhaps the most powerful and (for me at least) interesting and worrying aspect of this study is the authors’ inclusion of, analysis and evaluation of the data on the prevalence rates of childhood trauma; in this study 48% had suffered emotional abuse, 20% physical abuse, 35% sexual abuse, 57% emotional neglect and 36% physical neglect. The authors correctly emphasise the link between such trauma and complex long-term psychological disorders.
IAPT was set up to treat people with mild-moderate depression and/or anxiety disorders by applying evidence-based psychological therapies (the stepped care models outlined in current NICE guidance). I continue to worry that “we” are going to struggle to help patients who present with complex and severe issues; given the limitations IAPT places on duration and type of therapy offered.
The next phase of the PROMPT study will help to highlight any gaps in the current IAPT model and hopefully add weight to the growing demand and need to expand the remit of the IAPT programme beyond its current time and therapy choice limitations.
Hepgul N, King S, Amarasinghe M, Breen G, Grant N, Grey N, Hotopf M, Moran P, Pariante CM, Tylee A, Wingrove J, Young AH, Cleare AJ. (2016) Clinical characteristics of patients assessed within an Improving Access to Psychological Therapies (IAPT) service: results from a naturalistic cohort study (Predicting Outcome Following Psychological Therapy; PROMPT). BMC Psychiatry 2016 16:52 DOI: 10.1186/s12888-016-0736-6
Personality disorders, IAPT treatment and recovery from depression and anxiety
IAPT: does improved access lead to increased complexity? https://t.co/X4kCq8Jn6r #MentalHealth https://t.co/adwPGHsZuR
@Mental_Elf interesting, eagerly awaiting the forthcoming #IAPTSMI report
#psychosocial interventions #IAPT: does improved access lead to increased complexity? https://t.co/eUUrHgycFX via @sharethis
Today @121Therapy on early #PROMPT study findings about clinical characteristics of IAPT patients https://t.co/IIkr0l2N1q
IAPT: does improved access lead to increased complexity? https://t.co/Jf213D5y3V via @sharethis
Excellent summary of our paper by @Mental_Elf IAPT: does improved access lead to increased complexity? https://t.co/3MENkGPsKA @MaudsleyNHS
Are people receiving IAPT care suffering from “mild-moderate” conditions or more severe illnesses? https://t.co/IIkr0l2N1q
@Mental_Elf My service sees 90% of our clients meeting caseness at referral stage in either GAD7 or PHQ9. 47% severe GAD7 25% severe PHQ9
@Mental_Elf Maybe more severe but likely to be only help they get or like me get none. I’m in the ‘complex needs box’ so get nothing
Urban IAPT study finds high rates of psychiatric comorbidity, personality disorder, bipolarity & childhood trauma https://t.co/IIkr0l2N1q
@Mental_Elf Wasn’t a component of IAPT meant to be initial triaging, referring the more severe/complex elsewhere?
@dnacked @Mental_Elf where though?
@IStocious @Mental_Elf Well indeed. But as I recall they did claim to have trained a load of psych grads etc to supposedly triage.
@dnacked @Mental_Elf even so, where would they triage people to?
@IStocious @Mental_Elf I know but the point here is they weren’t supposed to be setting people up to fail with overly brief/simple IAPT
@dnacked @Mental_Elf true, and they didn’t set up an alternative to IAPT for those who don’t fit the model. You and I are on the same page
@dnacked @IStocious @Mental_Elf was in meeting once where we were told to start everyone at Step 1.More staff available at that level.Truly!
@Mental_Elf are we surprised??
Doctors can only refer patients to services that are commissioned; complexity in IAPT reflects lack of alternatives. https://t.co/Avu4oU1A55
In the 5 years since discharge from psych section, the only NHS talking therapy I’ve had is 8 sessions of IAPT CBT. https://t.co/Avu4oU1A55
@Mental_Elf Yes. You could just call it “Psychological Therapy” and then have a leaflet or something saying how best to access it.
New research finds majority of IAPT patients have 3 or more mental health conditions at assessment https://t.co/IIkr0kLc9S #comorbidity
@Mental_Elf brilliant & punchy blog @121Therapy good to see substance use attended to but surprised at low incidence in these participants
IAPT: does improved access lead to increased complexity? https://t.co/t0X5YTiGJz via @theoldreader
Article on demand/capacity of IAPT (psychological therapy) services: (https://t.co/IbvGev8jEw) @NIHRMaudsleyBRC https://t.co/7ifEBR2LnB
@Mental_Elf I have an NIHR funded CDRF & in final few months of PhD. qual ints with staff (N=28) and pts (N=22) SAPAS+3 watch this space!
@Mental_Elf PhD entitled -the development of a feasible and acceptable psychological intervention for people with PD traits in IAPT services
@Mental_Elf also keen to link up with those working on prompt study firstname.lastname@example.org
If you want a good half time read, try my latest @Mental_Elf blog on the complexity of IAPT referrals https://t.co/qq6pvDoUKm
No surprises. But good that the research has been done. People come with a range of needs and need a variety of different support. Interesting read.
RT @Mental_Elf: Should IAPT evolve to provide appropriate care for ppl w severe mental illness? https://t.co/FKHKyVo6I3 #iaptsmi https://t.…
Interesting study on the type and severity of issues clients present with at IAPT services –
Don’t miss – IAPT: does improved access lead to increased complexity? https://t.co/IIkr0kLc9S #EBP
@Mental_Elf CBT is contra-indicated for PD and severe mental illnesses. IAPT is one treatment path, it’s not full-spectrum Primary Care MH
@Mental_Elf Secondary Care services should provide psycotherapy to bridge the gap between them and IAPT.
@Mental_Elf IAPT doesn’t lead to increased complexity, it just doesn’t address it, and it highlights the gap in provision of MH services
@Mental_Elf great article on IAPT. Expanding access&type of therapy is a must4those who fall just outside remit of CMHT
Waiting times are still a huge factor here in Hampshire and therefore a lot of patients drop out even before they have been assessed.
Most popular blog this week? It’s @121Therapy IAPT: does improved access lead to increased complexity? https://t.co/IIkr0kLc9S
¿Está el IAPT tratando cada vez casos más graves y complejos? https://t.co/iahoFQVWu1
IAPT: does improved access lead to increased complexity? https://t.co/HQATLRYkPW via @sharethis
IAPT: does improved access lead to increased complexity? https://t.co/h6P5noH1A8