Overcoming barriers to implementation of psychological therapies for psychosis

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Overcoming barriers to implementation of
psychological therapies for psychosis
Dr Kathy Greenwood Sussex Psychosis Research
interest Group (SPRiG)
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CBTp RCTs meta-analysis (Wykes et al, 2008,
Schizo Bull, 34, 523-37)
Mean effect size on target symptoms .40 (95
CIs .25 - .55) Rigorous studies only (12
studies) .22 (95 CIs .02 - .43)
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CBTp RCTs meta-analysis (Wykes et al, 2008,
Schizo Bull, 34, 523-37)

• Significant effects (ranging from .35 .44) for
  
• Positive symptoms (32 studies)
• Negative symptoms (23 studies)
• Functioning (15 studies)
• Mood (13 studies)
• Social anxiety (2 studies)

20 from UK, 5 from USA, 2 from Germany,
Australia, Netherlands, 1 from Canada, Italy,
Israel 27 individual CBTp, 7 group CBTp
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Practitioners, people using Services and families
highlighted the interventions most valued
alongside medication. ?. 43 CBT. ?. 34 Peer
support. ?. 22 Exercise prescriptions. ?. 20
Family Therapy (only 10 among service
users). ?. 17 Creative therapies (art/music). ?.
14 Physical health checks. ?. 13 Self-help
strategies. ?. 12 Complementary therapies.
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The most researched therapy is (CBT). Trials have
found that on average, people gain as much
benefit from CBT as from medication. Family
interventions have also been extensively
researched and many people find family meetings
very helpful.
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CBTp is effective

• 1 of the UK population (approximately 600,000
  people) have psychosis
• 40 have persistent distressing symptoms
  (5200-8600 in Sussex alone)
• CBTp is the only NICE recommended individual
  intervention for psychosis
• Multiple RCTs and meta-analyses support its
  effectiveness

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So whats the problem?

• 94 of trusts struggle to provide CBTp.
• Fewer than 20 of service-users receive it
• Of 187 randomly selected service users in NW
  England only 13 (6.9) had been offered CBTp
  Haddock et al. 2013
• Of those offered it, 22-43 refuse or do not
  attend (Freeman et al. 2013 Haddock et al. 2013)

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Implementation research

• Planning
• Educating
• Financing
• Restructuring
• Monitoring Quality
• Policy content
• Powell et al. 2012

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Investment and Access?
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Talking therapy demand vastly outstrips supply
in the NHS. Urgent need for further investment
in psychological approaches to ensure that all
services come up to the standard of the best, and
so that people can be offered choice. Different
approaches suit different people. Not everyone
finds formal psychological therapy helpful, some
find it unhelpful. All staff need to be trained
in the principles of a psychological approach so
that it can inform not only formal therapy but
also the whole culture of services and every
conversation that happens within them.
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Only 1 in 10 of those who could benefit get
access to true CBT (Cognitive Behavioural
Therapy) despite it being recommended by NICE
(National Institute of Health and Clinical
Excellence). ?

• Increase access to psychological therapies in
  line with NICE guidelines.
• Ensure commissioning of
• services in line with NICE

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Improving capacity to meet demand (Garety and
colleagues)

• Mental health, learning disabilities and
  addictions services national specialist
  services large RD portfolio. 4,500 staff
• ?Core population - 4 South London Boroughs
  1.1million inner city, very high indices of
  social deprivation
• ?Substantially raised rates of psychosis,
  especially in ethnic minority populations (x4-9)

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Conclusions (Prytys et al 2011)

• Mapping of need
• 10 point charter
• Named link person in each team
• Screening for CBT/FI eligibility
• Training for staff
• Limited change in implementation

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Conclusions (Prytys et al 2011)

• Audited provision remained low around 10 for
  CBTp and 5 for FIp.
• Barriers to implementation included pessimistic
  staff views (on recovery), misunderstanding of
  who was suitable for psychological therapy, heavy
  caseload, and pressure of other tasks.
• Need for highly trained and supervised staff.
• No funding for implementation

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So whats stopping us? Cost and Access or A war
of words, beliefs and ideologies?
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Words, Beliefs, Ideologies?
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Knowledge and beliefs are important

• NICE - research aimed at behaviour change
  (individuals or population) needs to consider
  knowledge and beliefs
• Theory of planned behaviour - requires
  implementation is desirable, associated with
  positive attitudes and perceived to be within
  behavioural control (Ajzen 1991).

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Knowledge and beliefs are important

• Conceptual models of implementation require
  change in the adopter needs, motivations,
  values, goals and skills
• perceived relative advantage (compared with other
  approaches),
• compatibility with self (ones own views, health
  and illness perceptions)
• complexity, trialability and observability (i.e.
  seeing it as achievable, watching it in action
  and knowing that it works)

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Barriers to implementationWhat CMHT staff say?
Questions What is your understanding of the
outcomes of people with schizophrenia? How do you
work with people with a diagnosis of
schizophrenia? How would you prioritise which
service users are offered therapy? Are you aware
of the NICE guidelines for schizophrenia
regarding psychological therapies? What are your
views about clinical practice guidelines such as
NICE? Prytys et al. 2010
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What CMHT staff say?
Prytys et al. 2010 (n20) 16 concerned by lack of
time - the focus became more on keeping them
stable with just compliance with medication,
very little support 10 emphasised combined
medication and therapy - They have to be on
their medication obviously. If they dont take
their medication it (therapy) is not going to
work .
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What CMHT staff say?
Prytys et al. 2010 (n20) 7 positive and 6
negative views re. CBTp benefits - thought for
high fx less symptomatic. 10 reported service
user refusal I dont think they would ask for
it 13 thought simple CBT techniques important
e.g psychoeducation, anxiety management, relapse
prevention 11 emphasised importance of
specialist CBT therapist in team or lack of this
as a barrier to intervention.
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What CMHT staff say?

• Beliefs about referral criteria, pathways,
  benefits
• Insight High and Low
• Symptoms High and Low
• Function High and Low

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Uptake?What EYE project service users say..

• Informed choice, holistic approaches,
  availability of talking therapies are
  facilitators to engagement
• Exclusive focus on medication, lack of choice,
  lack of information are barriers
• Uptake/engagement with psychosis interventions
  hampered by beliefs emotional barriers
  (Greenwood et al. in prep Morrison et al. 2012)

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Uptake

• Uptake of interventions/CBTp affected by health,
  illness and treatment perceptions.
• Beliefs that psychosis is transitory led to
  reduced uptake
• Beliefs of limited personal control and
  biological causality (control/cure) led to reduce
  active engagement
• Limited illness beliefs explored

(Freeman et al. 2013 2014 Williams and Steer
2011 Theodore et al. 2012 Lobban et al. 2004).
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Illness Perception (e.g. Rogers 1983)
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Uptake Interventions

• Specific (pre-) interventions, based on illness
  perceptions, have been effective in promoting
  adherence to and outcomes from physical health
  interventions and have emphasised the need to
  tailor the intervention to health beliefs.
• Interventions for medication adherence in
  psychosis are also common, with medication
  adherence relating to beliefs about treatment and
  illness perceptions.
• Cameron et al 2005 Horne and Weinman et al 2002
  McAndrew et al. 2008 Petrie et al. 2002

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Recent key CBTp studies

• Turner et al 2014
• Psychological Interventions for Psychosis A
  Meta-Analysis of Comparative Outcome Studies
• Jauhar et al 2014
• Cognitive-behavioural therapy for the symptoms of
  schizophrenia systematic review and
  meta-analysis with examination of potential bias
• Morrison et al 2014
• Cognitive therapy for people with schizophrenia
  spectrum disorders not taking antipsychotic
  drugs a single-blind randomised controlled trial

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"This house believes that CBT for psychosis has
been oversold"
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Only 1 in 10 of those who could benefit get
access to true CBT despite it being recommended
by NICE (National Institute of Health and
Clinical Excellence).
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The basis of clinical decisionsIsaacs and
Fitzgerald BMJ 1999

• Eminence
• seniority of the protagonist with a faith in
  clinical experience
• Vehemence
• Volume substitutes for evidence
• Eloquence
• Good dress sense and verbal skill
• Confidence
• Only applicable to surgeons
• Evidence
• Randomised controlled trials, meta-analyses

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IAPT for Psychosis
Northwest Sussex Pilot

• Dr Emily Gray, Principal Clinical Psychologist
• Dr Nicola Motton, Clinical Psychologist
• Northern West Sussex Assessment and Treatment
  Service
• Daniel Stevens, Assistant Psychologist
• Education and Training

With thanks to Jenefer Lofty, Art Therapist, and
Esmie Rush, Psychology Intern, Northwest Sussex
Assessment and Treatment Service
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Increase capacity to offer therapy in Northwest
Sussex

• Art Therapy (group format)
• CBT
• Family Intervention (FI)
• Behavioural Activation / Graded Exposure (BA/GE)

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Increase capacity to offer therapyOur approach

• Use existing resource designated psychosis
  spaces on caseloads
• -New training for existing staff to increase
  capacity (FI, BA/GE)
• -Top-up training for CBT practitioners
• -Specialist supervision CBT and FI
• Additional resource - Assistant psychologists
  (BA/GE) and CBT trainees

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Training outcomes

• 10 members of staff trained in BA/GE to date
• 2 currently in training
• 6 members of staff trained in FI to date
• 2 currently in training

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Increasing offers of therapy

• So through increasing capacity as described
  above, did the number of offers of therapy
  increase?
• A target of 82 offers of therapy was set (half of
  the caseload at baseline who were identified as
  having schizophrenia-spectrum disorders)
• Criteria for identifying appropriate clients to
  different interventions were circulated,
  clinicians attended team meetings, circulated
  emails advertising psychosis spaces

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Offers of therapy made

• There have been 67 new offers of therapy since
  Dec 2012 (approx 42 of those with schizophrenia
  spectrum disorders on caseloads)
• 82 towards our target of making 82 new offers of
  therapy within 2 year period

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What helped increase offers?

• Use of groups enabled a greater number of clients
  to receive art therapy
• Positive experience of interventions from staff
  perspective more referrals
• Staff valued opportunities to discuss potential
  referrals, availability of therapy staff and
  approachability
• Increased conversations between clinicians, and
  between clinicians and clients about
  interventions

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Challenges

• Movement of staff
• Competing time demands
• Competing clinical demands (complex trauma/PD
  also CBT slots are only 2.5 of case load)
• Difficulty identifying appropriate clients
  (insight, medication, stability)
• Clinicians perceptions of capacity and referral
  process
• Clinicians knowledge of treatment options,
  benefits, pathways

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Ideas going forwards

• Improve information for clients and staff on
  interventions available
• Rolling training programme, whole-team training
• Awareness-raising event(s) for staff, carers,
  clients, GPs, commissioners, etc
• Psychosis-specific roles / protected time for
  psychosis work
• Exploration of group interventions
• Assertive-outreach approach to seeking out
  clients / families
• Research study on barriers to intervention

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Developing the evidence base to improve
implementation and uptake of CBT for psychosis
K Greenwood, K Cavanagh, A Field, R deVisser, R
Chandler, D Fowler, E Peters, M Hayward, P Garety
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Research Questions

• What are the knowledge, beliefs and behaviours of
  service-users and clinicians towards uptake and
  implementation of CBT for psychosis?
• Can a pre-CBTp informed choice intervention
  improve
• (i) knowledge, beliefs and behaviours
• (ii) empowerment, QoL, Hope

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Aims

• The study aims to do this by
• Identifying the knowledge, beliefs and behaviours
  associated with current provision and use of
  CBTp in service users and clinicians, and using
  this information to develop two new outcome
  measures.
• Developing two pre-CBT informed choice
  interventions, based on implementation science,
  health perceptions and phase 1 outcomes
• Developing and assessing the feasibility of the
  interventions in two preliminary small-scale
  randomised controlled trials (RCTs) for
  Clinicians and Service-users

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Method - Phase 1

• a) Qualitative focus groups to explore
  barriers/facilitators to uptake/implementation in
  
• Clinicians and
• Service users
• Who support or who do not value CBTp
• b) Large-scale investigation of
  barriers/facilitators using questionnaire in 400
  service users and clinicians to clarify nature of
  problem to be addressed.

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Method - Phase 2

• Consultation to reach consensus on interventions
• Content (modules)
• Format (e-learning, website, booklet, video pack)
• Intervention likely to include
• (i) a knowledge component
• (ii) an experiential component
• (iii) a motivational behaviour
  change component
• (iv) a health perceptions behaviour
  change component
• (v) a decision aid component.

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Method - Phase 3

• Design A feasibility RCTs comparing the
  informed choice interventions (pre-CBT-IC) with
  treatment as usual (TAU) in two distinct groups
  of 40 clinicians and 40 service- users.
• Measures at baseline post intervention and
  3-month follow-up
• the new personal knowledge/beliefs questionnaires
  and measures of mental health and well-being,
  self-efficacy and empowerment
• log of CBTp-related behaviour
• Feasibility data to assess the acceptability and
  applicability of the interventions and the
  pragmatic applicability and validity of the trial
  protocol.

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From your own experience, what are the knowledge
beliefs, attitudinal barriers to
uptake/implementation?
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In addition, a study we are supporting in Sussex
(Staff Attitudes Towards Guided Self-Help CBT for
Distressing Voices) will be closing shortly.
All mental health clinical staff are invited to
take part.You will be asked for your opinions
on a new psychological intervention for people
who hear voices To take part just visit the
website www.survey.bris.ac.uk/sussex/staffsurvey
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Sussex Psychosis Research interest
Group www.sussex.ac.uk/spriglab