Step 3 - Radboud Universitair Medisch Centrum voor Mindfulness

Report
TalkingSpace & TalkingHealth
The IAPT service, Oxfordshire and Buckinghamshire
NHS Foundation Trust
Christina Surawy: Oxford Mindfulness Centre, Oxford University
Department of Psychiatry
With thanks to: Emma Evans, Clinical Supervisor and Clinical Psychologist
Outline of the session
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Overview of TalkingSpace
TalkingHealth: Services for people with longterm health conditions
MBCT within IAPT
Questions and answers
Referrals to TalkingSpace
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TS receives 6500 referrals a year
Primarily self-referral
The service is meeting nationally agreed
recovery rates (40-50%)
The stepped care model
Step 4 – Secondary Care (e.g. CMHT)
Eating Disorders, Drug and Alcohol addictions, Severe OCD, Severe depression, Bipolar disorder,
Psychosis
Step 3 – Primary Care (High Intensity Therapy)
Moderate to severe depression, mild to moderate anxiety, including GAD and health anxiety, OCD,
social phobia, PTSD
Step 2 – Primary Care (Low Intensity Therapy)
Mild to moderate depression or anxiety
Step 1 – Active monitoring (often GP)
Psychological problem identified
PHQ-9 and GAD-7 completed at least 5 weeks apart
Patient direct to self-help materials
Typical patient journey
ROUTE A: Patient consults GP and mental health concerns are raised
GP:
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Discuss and assess patient suitability for IAPT.
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GP gives patient TalkingSpace leaflet
Patient:Calls in to book initial telephone assessment (or sends in brief form)
ROUTE B: Self-referral
Typical patient journey
Route C: Mental health concerns identified during consultation with other
health professional
Health professional:
 Discuss and assess patient suitability for IAPT.
 Gives patient TalkingHealth leaflet OR recommends further assessment
with GP
Patient:
 Calls in to book initial telephone assessment (or sends in brief form) OR
sees GP
Patient journey continued
Patient booked for initial brief telephone assessment (20-30 minutes maximum)
If appears appropriate for TalkingSpace:
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Step 2 class
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Step 2 guided self help for anxiety and depression or computerised CBT for
depression
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Step 3 High Intensity CBT assessment
BUT IF Primarily seeking help with adjustment/transition/loss/relationship
issues AND/OR prefers a non-structured treatment
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Referral to GP practice-based counselling (PML)
If referral appears inappropriate or unclear:
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May involve: liaison with GP,CMHT/Psychological Therapies (Step 4)
Treatments offered
Step 2 (LI)
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Psychoeducation courses – anxiety, depression,
insomnia, emotional well being in diabetes
Information giving
Bibliotherapy & Guided-self help
Computerised CBT (Beating the Blues)
3-month follow ups as standard
Psychoeducation courses
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Offered in various locations throughout
Oxfordshire
Depression, anxiety or insomnia
Four sessions (five for insomnia)
Stand-alone treatment or an introduction to CBT
skills
1 month follow up call
Psychoeducation classes:
patient comments
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It would do a majority of people good.
It’s really helpful/reassuring to meet other people
suffering from the same thing.
It’s nice to talk within a group and not just one to
one which is quite intense.
Excellent and friendly presentation.
Useful and informative. Has certainly helped me
to overcome some of my problems.
Treatments offered
Step 3 (High Intensity)
 Groups – depression, OCD, anxiety (transdiagnostic),
carers’ groups for people caring for people with dementia
 Individual CBT
 Mindfulness Based CT group for depression (relapse
prevention)
 Mindfulness Based CT group for long-term conditions
 IPT (Interpersonal therapy)
 DIPT (Brief Dynamic Interpersonal Therapy)
Additional interventions and services
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Employment support (Restore) to liaise, provide
signposting and support for people struggling to
stay in employment
Who can’t we see?
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Children (under 18)
Acute mental health crisis/ high risk to self or others
Previous unsuccessful treatment at Step 3
Severe depression/anxiety
Severe OCD
Eating disorder
Psychosis/Bipolar disorder
Personality disorder
Significant substance misuse
Currently seen by another mental health service/
already receiving psychological therapy or counselling
Not registered with Oxfordshire GP
TalkingHealth: A service for
people with long-term physical
health conditions
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Part of TalkingSpace
Initially developing services for people living
with:
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Diabetes
Cardiac rehab and heart failure
CFS
Long term conditions (including MS and MUS)
TalkingHealth
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Higher rates of depression and anxiety when
living with a long-term health condition
People do not access services at the
expected rates – possible reasons:
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Focus on physical health?
Mental health symptoms considered ‘inevitable’?
Interaction between physical health and mental
health difficulties results in typical mental health
treatments not seen as relevant/appropriate?
Priorities
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Self-referral or referral from any health
professional
Work flexibly (telephone, GP practices and
other settings)
Aim to work closely with those involved in
physical health care
Cardiac services
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Input to classes run by nursing staff
(psychoeducation)
Guided self help (step 2)
Individual CBT and staff supervision groups
(step 3)
TalkingHealth: Diabetes
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The number of people recorded as having diabetes
accessing the service has doubled over the last year
Emotional well-being in diabetes
course
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Four session psychoeducation group for people with
diabetes and depression.
CBT based
Adapted from step 2 class ‘Managing your mood’
Looks at interaction between physical and mental health
Topics covers:
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Behavioural activation
Problem solving
Goal setting
Cognitive challenging
Evidence to support a course
Initial outcomes suggest:
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Greater improvements in mood (PHQ-9) than in standard class
Improvements in physical health (HBA1c)
MBCT in TalkingSpace and TalkingHealth
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OMC have undertaken to train step 3 IAPT
practitioners to deliver MBCT for recurrent
depression and anxiety (TS) and LTC’s including
MUS). Also a specific MBCT course for CFS
Hoffman et al. (2011) showed that MBCT reduces
anxiety and depression across a range of physical
diagnoses
So far 8 courses have run
Average no. of participants in TS= 16
Fewer in talking health
MBCT for LTC’s
Open to all patients with
anxiety and depression (or
previous anxiety and
depression) as a result of
any physical health
condition, and including
carers.
 Some data:
Spring 2013 course, mean pre
post change in PHQ9=
11.25 – 6.75 with >50%
moving from clinical to non
clinical range
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12
10
8
6
4
2
0
pre
post
MBCT for LTC’s
For GAD 7, the change was from
9.12 to 5.5 with 50% moving from
clinical to non clinical range
10
9
8
7
6
5
4
3
2
1
0
pre
post
Case example – Bill
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66 year old male
Physical health: Multiple sclerosis (diagnosed 25
years), neuropathic pain, referred by pain clinic
Mental health: Low mood, self-critical, frustration,
tense, restless, body/pain the enemy (constant battle)
Treatment: Mindfulness based cognitive therapy
group (8 week programme)
Outcome: improved mood, more relaxed, not fighting
pain/body, reduced scores on PHQ-9 & GAD-7
Future directions
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Continue to adapt and develop MBCT for
LTC’s and MUS
Individualised measures
Developing links with pain services
Questions?

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