Psychological Talking Therapies in

Secondary Care: A Local Report on IAPT

SMI Data by

Clare Carter, Chris Gordon & Jo Gibson

May 2015

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Foreword

We have now been a demonstration site for Improving Access to Psychological Therapies for Personality Disorder for over two years. We have established an effective way of measuring outcomes and providing regular reports to NHS England. This has required a significant cultural change for secondary care mental health services and we have received considerable praise for this achievement where many others have failed. This success is down to you and we thank you for your commitment and efforts.

This report highlights the improvements that people with a diagnosis of personality disorder have made with the therapies and service which you provide. It is a testament to the good work you do and, provides evidence of the effectiveness of psychological therapies for people who in the not too distant past were excluded from services on the basis of this diagnosis. We are currently working on a national report with the other demonstration sites. The initial results are very promising and show significant improvement in clinical outcomes and wellbeing and, highly significant reductions in service use, rates of admission and most importantly the risk of suicide and self harm. The report is due to be finalised and published in autumn 2015. Our next challenge is follow up measures. We know that psychological therapies and interventions provide benefits during treatment and we now need to establish whether these are sustained post treatment. This will require reconfiguration of the demonstration site team to administer these, which is in process. We would like to thank you for your continued efforts in administering the outcome measures and look forward to providing you with a further report in the autumn. Kind regards

Chris Gordon Clinical Manager Personality Disorder Service & Demonstration Site Lead

Liz Fawkes Head of Psychological Therapies & Personality Disorder

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Table of Contents

Executive Summary ....................................................................................... 4

Introduction ..................................................................................................... 5

Objectives & Method ...................................................................................... 6

Findings........................................................................................................... 8

Discussion .................................................................................................... 12

Recommendations ………………………………………………………………...13 Appendix ……………………………………………………………………………15

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Executive Summary

Background Somerset Partnership NHS Foundation Trust is a National demonstration site for personality disorders as part of the Improving Access to Psychological Therapies for Severe Mental Illness project. As part of this, a data outcome booklet and health utilisation questionnaire has been introduced to the Psychological Therapies Service (PTS) in Secondary Care. Aims This report aims to provide a brief summary of the outcomes recorded for people referred to the PTS between 1st November 2012 and 31st December 2014 who have personality disorder diagnosis/ traits.

Method

Data was used from collected patient recorded outcome measures and that recorded on patient electronic records- RIO. The sample includes those completing more than one session of therapy, and have paired outcome scores regarding mood, wellbeing and functioning. Findings There were 1116 referrals to the Psychological Therapy Service (PTS) within the reporting period that attended at least one appointment. Nearly half of all referrals had any completed these outcome measures. Of these, 92% scored above 3 on the Standardised Assessment of Personality – Abbreviated Scale (SAPAS) at their first response. Of this sample, nearly 30% had a Personality Diagnosis recorded on RIO. The results show that overall people who have a diagnosis of a Personality Disorder or who have Personality Disorder traits access psychological therapies and show improvement in outcomes relating to mood, wellbeing and functioning. In relation to primary care IAPT national recovery rates, 33% reached standard recovery in low mood, 32% in generalised anxiety. 42% of people showed ‘reliable improvement’ in low mood, 48% in generalised anxiety. In addition, 28% showed ‘reliable recovery’ in low mood and 30% in generalised anxiety.

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Introduction

In 2008 the Department of Health launched the Improving Access to Psychological Therapies Programme (IAPT) to help increase public access to a range of psychological treatments for depression and anxiety that have been recommended by the National Institute for Health and Clinical Excellence (NICE). The IAPT programme, with the continued support of the Department of Health, is looking at how it can extend the benefits of improving access to psychological treatments to those with a severe mental illness. The programme’s long term aim is to ensure that all people with a psychosis, bi-polar and personality disorder, who could benefit from evidence based therapies, have access to them. To support this ambition the IAPT programme has set up the Severe Mental Illness (SMI) Project. Somerset Partnership NHS Foundation Trust has become a National Demonstration Site for improving access to psychological therapies for people with Personality Disorder. This involves working with the Department of Health and two other Trusts in central London in improving access to evidenced based psychological interventions for Personality Disorder. Somerset is unique in its development and provision of a whole systems approach to working psychologically with people with personality disorder across primary and secondary care, as well as providing traditional psychological therapies in both settings within limited resources. As part of the demonstration site work we have provided a series of open days to share our practice. We are publishing a manual which includes the implementation of the relational recovery model and the training we have provided to all community and inpatient teams. We have set up a user forum and in collaboration with service users we have developed a website that includes information on local services, the national demonstration site work and personality disorder more generally. The Department of Health is keen for all demonstration sites to collect data and provide evidence and information regarding the impact on people’s health and wellbeing as a result of the treatment they have received. This has meant the introduction of data outcome and health utilisation booklets to the Personality Disorder Service and Psychological Therapies Departments in Secondary Care, and the expansion of the data set collected within Primary Care. Primary and secondary care psychological therapies services are now equipped to work with people with personality disorders and those who have traits of PD, which makes the Trust one of very few able to work with some consistency across both elements of service delivery. We aim to ensure access to high quality and appropriate talking therapies, and interventions that are psychologically informed, for people with personality disorder or personality disorder traits at any point along their whole care pathway. As a demonstration site, we have been asked to share our good practice on how we currently work with people in secondary care and how we have used this work to improve access to talking therapies and support for people experiencing emotional difficulties in primary care.

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Objectives

The aim of this report is to provide a brief local report looking at data from 1st November 2012 to 31st December 2014. Only data relating to individuals who were referred to and seen at least once by the Psychological Therapy Service (PTS) in 2013 will be included. Within the report we hope to:

1. Identify the number of people within general secondary care PTS who have personality disorder traits and/ or diagnosis.

2. Identify outcomes for this group, to include those completing more than one session of therapy across mood, wellbeing, and functioning.

Please note individuals that were included in this sample may have also been receiving at the same time, other services as well as psychological therapy, such as Personality Disorder service involvement, care co-ordination, medical interventions etc.

Method

The data used to complete this report was from information recorded on RIO and data recorded on outcome data booklets completed by service users. The data included is in line with IAPT SMI data reporting period from 1st November 2012 to 31st December 2014. The results include people that attended the range of therapeutic modalities including: CAT, DBT Skills Group 1 and 2, CAT Men’s Group, CBT, Psychodynamic Therapy, Art Therapy. The outcomes of SAPAS questionnaires were used to define the sample of those with personality disorder traits. The Standardised Assessment of Personality – Abbreviated Scale (SAPAS) is an 8 item measure used as a screen for personality disorder. It identifies areas such as difficulties in trusting others, forming relationships, understanding oneself and experiencing sudden changes in emotions (see Appendix for a copy). The SAPAS can be used to screen for personality disorder with reasonable specificity (80% in secondary care with a cut off score of 3 and above). Diagnosis as recorded on RIO was also used to identify those of the sample with a Personality Disorder diagnosis. The results regarding outcomes for individuals was derived from completed outcome questionnaires by service users. It includes all people who completed at least two questionnaires, in order to be able to assess any change. Change was measured as the percentage of difference between pre and post scores. The outcome measures used include measures in low mood and anxiety (PHQ9, GAD7), wellbeing (WEMWBS) and functioning (WASAS and EQ5DL5).

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In addition, the outcomes for IAPT definitions for standard recovery, ‘reliable improvement’ and ‘reliable recovery’ are included for reference. It only includes people whose first scores reach ‘caseness’ (PHQ9: >/=10, GAD7: >/=8). IAPT standard recovery includes all people who move below ‘caseness’. Reliable improvement counts the number of people where both scores exceed the measurement error of the questionnaire. This currently only applies to the measures of PHQ9 (decrease by 6+ points) and GAD7 (decrease by 4+ points). IAPT reliable recovery counts the number of people where both scores exceed the measurement error of the questionnaire and their score moves below the clinical cut-off. Currently this only applies to the measures of PHQ9 (score <10) and GAD7 (score <8).

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Findings

As Graph 1 below denotes, there were a total of 1116 referrals to the Psychological Therapy Service (PTS) between 1st November 2012 and 31st December 2014 (inclusive) where the client attended at least one appointment. This includes 116 people that were referred twice within this time. Of these, nearly half of all referrals completed at least one SAPAS questionnaire, and the majority of these (92%) scored above the cut off of 3 at their first score, with nearly 30% having a Personality Disorder diagnosis recorded on RIO. The average number of appointments attended for the sample of people scoring above 3 on SAPAS is 17, with a range of 1-76 appointments. Graph 1. Referrals to PTS.

Data returns

The next set of results regards the outcomes for those scoring above 3 on SAPAS, including those with a PD diagnosis and have completed at least two outcome measures. As Table 1 below highlights, the highest number of paired scores on any of the outcome measures is 323 (for PHQ9 and GAD7). This equates to about 30% of all referrals returning at least two data booklets, with a small proportion returning just one and a significant proportion returning none at all. Table 1. Summary of data returns and outcomes.

Outcome Measure Total no. in sample with paired scores

% of people with improvement in scores.

PHQ9 323 68%

GAD7 323 64%

WASAS 307 64%

WEMWBS 304 70%

EQ5DL 179 62%

1116

528 486

158

0

200

400

600

800

1000

1200

Total Completed SAPAS SAPAS >3 PD Diagnosis

No

. of

refe

rral

s

Referrals

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Results of Individual Outcomes Measures

PHQ9. The PHQ9 is a 9 item measure used to indicate symptoms relating to low mood/ depression. The total number of paired outcome scores for this sample was 323. The percentage of people with improvement in scores was 68%. As the graph below denotes the majority of improvement was between 1-25%. In regard to IAPT national recovery rates, 33% of people reached standard recovery in relation to their PHQ9 scores, 42% of people showed reliable improvement and 28% showed reliable recovery. Graph 2. PHQ9 Percentage Improvement.

GAD7. The Generalised Anxiety Disorder measure (GAD7) is a 7 item measure used to indicate symptoms relating to Generalised Anxiety. The total number of paired outcome scores for GAD7 was 323, with 64% showing improvement in scores. Similarly to PHQ9 scores the majority of these improving between 1-25%. In regard to IAPT national recovery rates, 32% reached standard recovery on the GAD7, 48% of people showed reliable improvement and 30% showed reliable recovery. Graph 3. GAD7 Percentage Improvement.

0

20

40

60

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120

1 - 25% 26 - 50% 51 - 75% 76 - 100%

No

. of

Peo

ple

Percentage Improvement

PHQ9 Percentage Improvement

0

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120

1 - 25% 26 - 50% 51 - 75% 76 - 100%

No

. of

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ple

Percentage Improvement

GAD7 Percentage Improvement

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Wellbeing & functioning

WASAS The Work & Social Adjustment Scale consists of 5 items relating to someone’s everyday level of functioning across different domains. The total number of paired outcome scores was 307, 64% achieving improvement in scores. The majority of improvement was in the 1-25% range, no one showing improvement in the 76-100% range. Graph 4. Work & Social Adjustment Scale Percentage Improvement.

WEMWBS The Warwick & Edinburgh Mental Wellbeing Scale (WEMWBS) is a 14 item scale to measure someone’s general wellbeing. There were a total of 304 paired outcome scores for the WEMWBS, 70% of which showing some improvement in scores. Graph 5. Warwick & Edinburgh Mental Wellbeing Scale Improvement Scores.

0

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40

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120

140

1 - 25% 26 - 50% 51 - 75% 76 - 100%

No

. of

Peo

ple

Percentage Improvement

WASAS Percentage Improvement

0

50

100

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200

1 - 25% 26 - 50% 51 - 75% 76 - 100%

No

. of

Peo

ple

Percentage Improvement

WEMWBS Percentage Improvement

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EQ 5D 5L This 6 item scale aims to measure the level of functioning for an individual. The total number of paired outcome scores was 179, 62% reaching improvement in scores. Graph 6. EQ5DL5 Percentage Improvement

Summary of Results

There were 1116 referrals to the Psychological Therapy Service (PTS) between 1st November 2012 and 31st Dec 2014 that attended at least one appointment. Only about half of these completed a SAPAS questionnaire, with 486 people (92%) scoring above the cut off of 3 on the Standardised Assessment of Personality – Abbreviated Scale (SAPAS) at their first response. Of which, nearly 30% of people had a Personality Disorder diagnosis recorded on RIO. For those that had paired outcomes (about 30% of all referrals), most people showed at least some improvement in scores, and this was similar across all measures, with 62% minimum (EQ5DL5) to 70% showing some improvement in the measure of wellbeing (WEMWBS). In relation to primary care IAPT national recovery rates, 33% reached standard recovery in low mood, 32% in generalised anxiety. 42% of people showed ‘reliable improvement’ in low mood, 48% in generalised anxiety. In addition, 28% showed ‘reliable recovery’ in low mood and 30% in generalised anxiety.

0

20

40

60

80

100

120

140

1 - 25% 26 - 50% 51 - 75% 76 - 100%

No

. of

Peo

ple

Percentage Improvement

EQ5D5L Percentage Improvement

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Discussion Over half of people referred to Psychological Therapies have recorded outcomes for the IAPT SMI project. Considering this is in addition to the standard CORE outcomes already recorded within service this can be seen as positive result. Due to the current financial efficiencies services are faced with, it is going to become increasingly important for services to demonstrate outcomes for people who use the services. It is therefore important that we can find an effective and efficient way of recording meaningful outcomes for people and to demonstrate service effectiveness. Looking into how outcome booklets are administered may also provide some insight into the slight discrepancy of recording for the different measures. The PHQ9 and GAD7 seem to be completed slightly more often than the other measures. It is important to remember the data only relates to paired outcomes, so not necessarily first and last measures of treatment. It is not clear what the different reporting time points are beyond “earlier in treatment” vs. “later in treatment”, for example, rather than start and end it is possible that paired scores are between the mid and end or start and mid points, depending on when data booklets were completed. For future analysis it may be worth trying to identify scores from start to end of treatment if possible. To enable this to be meaningful, a higher number of people will need to complete the outcome measures. The results show some improvement in scores for people, across the range of measures, slightly better results for wellbeing (WEMWEBS) and less for overall health (EQ5D5L). Interpretation of the results is difficult as there is no clarity on what proportion of improvement would be expected and no clear benchmarks for what changes might be considered “usual” in this population. It may be useful for future analysis to include those that received psychological therapy who had a SAPAS score of less than 3, for comparison. This will require more people to complete the SAPAS, as in this sample 92% of those that completed the SAPAS scored over 3. The results in relation to general IAPT recovery rates look promising. Considering the recovery rates are based upon a primary care population only. In this sample of people, 42% reached ‘reliable improvement’ in low mood and 48% improvement in generalised anxiety. In regard to ‘reliable recovery’, 28% reached this threshold for low mood and 30% for generalised anxiety. This could be seen as a positive outcome for this group of people who potentially have more complex and complicated problems than may be seen in primary care. This is positive in relation to The IAPT Year 1 results (Gyani et al 2013) who reported reliable recovery rate at 40% and the reliable improvement at 64%. As PEQ returns for 2013 have already been presented in another report these were not duplicated here. A copy of this additional report can be provided via email by Jo Gibson upon request.

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Conclusions

The results show that overall people who have a diagnosis of a Personality Disorder or who have Personality Disorder traits access psychological therapies and show some improvement in outcomes relating to mood, wellbeing and functioning. Further investigation is required to help understand and improve the completion of outcome measures, which will aid understanding of the results.

Recommendations

Disseminate findings to Psychological Therapy Teams.

Present report to Personality Disorder, Affective Disorders and Psychological Therapies Best Practice Group

Consider ways to improve completion of outcome booklets.

Compare outcomes to those people who receive psychological therapy who do not have Personality Disorder traits/ diagnosis.

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References

Clark, D., & Oates, M. (2014). Improving Access to Psychological Therapies. Measuring recovery in IAPT services. Version 2. NHS England. Gyani, A., Shafrana, R., Layard, R., & Clark, D. (2013). Enhancing recovery rates: Lessons from year one of IAPT. Behaviour Research and Therapy. Vol 51, 9, pg 597–606.

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Appendix

Standardised Assessment of Personality – Abbreviated Scale (SAPAS)

SAPAS

Only circle Yes if the description applies most of the time and in most situations.

Yes No

1 In general, do you have difficulty making and keeping friends? 1 0

2 Would you normally describe yourself as a loner? 1 0

3 In general, do you trust other people? 0 1

4 Do you normally lose your temper easily? 1 0

5 Are you normally an impulsive sort of person? 1 0

6 Are you normally a worrier? 1 0

7 In general, do you depend on others a lot? 1 0

8 In general, are you a perfectionist? 1 0

SAPAS Total Score