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Improving access to psychological therapy: Initial evaluation of two UK demonstration sites.

Clark DM, Layard R, Smithies R, Richards DA, Suckling R, Wright B - Behav Res Ther (2009)

Bottom Line: Clinical outcomes were broadly in line with expectation. 55-56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status.Outcomes were comparable for the different ethnic groups who access the services.Issues for the further development of IAPT are discussed.

View Article: PubMed Central - PubMed

Affiliation: NIHR Biomedical Research Centre for Mental Health, South London & Maudsley NHS Foundation Trust & Kings College London, UK. david.clark@kcl.ac.uk

ABSTRACT
Recently the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders. Prior to this development, the Department of Health established two pilot projects that aimed to collect valuable information to inform the national roll-out. Doncaster and Newham received additional funds to rapidly increase the availability of CBT-related interventions and to deploy them in new clinical services, operating on stepped-care principles, when appropriate. This article reports an evaluation of the new services (termed 'demonstration sites') during their first thirteen months of operation. A session-by-session outcome monitoring system achieved unusually high levels of pre to post-treatment data completeness. Large numbers of patients were treated, with low-intensity interventions (such as guided self-help) being particularly helpful for achieving high throughput. Clinical outcomes were broadly in line with expectation. 55-56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status. Treatment gains were largely maintained at 10 month follow-up. Opening the services to self-referral appeared to facilitate access for some groups that tend to be underrepresented in general practice referrals. Outcomes were comparable for the different ethnic groups who access the services. Issues for the further development of IAPT are discussed.

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Improvement in PHQ-9 and GAD-7 scores between initial assessment (pre) and last available session (post) in people who either completed the CORE-OM at pre and post or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site.
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fig3: Improvement in PHQ-9 and GAD-7 scores between initial assessment (pre) and last available session (post) in people who either completed the CORE-OM at pre and post or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site.

Mentions: Missing data, particularly at post-treatment, is common in evaluations of the outcomes achieved in routine clinical services. There is controversy about the importance of such missing data (Clark, Fairburn, & Wessely, 2007). Is it reasonable to assume that the clinical outcomes of patients for whom post-treatment data is missing will be as good as those for patients with complete data or is it possible that patients with missing data are likely to have done less well (or better) overall? The Doncaster and Newham data allow us to address this issue empirically. Both sites used two outcome monitoring systems. One was the session-by-session system (using the PHQ-9 & GAD-7) which achieved almost complete pre to post data (99% for Doncaster, 88% in Newham). The other was a more conventional, less frequently sampled, outcome monitoring system that was used with another symptom measure (CORE-OM) and the employment questionnaire. The latter system was associated with much lower pre–post treatment data completeness. To determine whether missing data matters, we compared the pre- and post-treatment scores on the PHQ-9 and GAD-7 in those individuals who did, or did not, provide pre–post treatment data for the CORE-OM or the employment questionnaire. Separate repeated measures anovas were performed on the PHQ-9 and GAD-7 data from each site. For each analysis, the repeated measures factor (time) was pre vs post scores on the PHQ-9 or GAD-7. The between subjects factor (“data completeness”) was whether participants did or did not have complete pre-post data on the CORE-OM or the employment questionnaire. For all but one of the analyses, there was a significant time by data completeness interaction (all p < .001). Inspection of the means indicated that in both sites patients who had complete data on the CORE-OM or the employment questionnaire improved more on their anxiety scores (GAD-7) than patients who had incomplete data. The same pattern was observed for depression (PHQ-9) scores. In Newham, patients who had complete data on the CORE-OM or the employment questionnaire showed greater improvement in depression. In Doncaster, patients who had complete data on the employment questionnaire, but not CORE-OM, showed significantly greater improvement in depression. To obtain an estimate of the extent to which patients with complete data on the conventional outcome monitoring system improved more that those with incomplete data, separate pre-post effects sizes were computed for the two groups. The effect sizes on the PHQ and GAD were on average 1.72 times greater for the data complete group (range 1.09–2.47). Fig. 3 illustrates the data completeness effect.


Improving access to psychological therapy: Initial evaluation of two UK demonstration sites.

Clark DM, Layard R, Smithies R, Richards DA, Suckling R, Wright B - Behav Res Ther (2009)

Improvement in PHQ-9 and GAD-7 scores between initial assessment (pre) and last available session (post) in people who either completed the CORE-OM at pre and post or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3111658&req=5

fig3: Improvement in PHQ-9 and GAD-7 scores between initial assessment (pre) and last available session (post) in people who either completed the CORE-OM at pre and post or who failed to complete the CORE-OM at post. Data from the Newham Demonstration site.
Mentions: Missing data, particularly at post-treatment, is common in evaluations of the outcomes achieved in routine clinical services. There is controversy about the importance of such missing data (Clark, Fairburn, & Wessely, 2007). Is it reasonable to assume that the clinical outcomes of patients for whom post-treatment data is missing will be as good as those for patients with complete data or is it possible that patients with missing data are likely to have done less well (or better) overall? The Doncaster and Newham data allow us to address this issue empirically. Both sites used two outcome monitoring systems. One was the session-by-session system (using the PHQ-9 & GAD-7) which achieved almost complete pre to post data (99% for Doncaster, 88% in Newham). The other was a more conventional, less frequently sampled, outcome monitoring system that was used with another symptom measure (CORE-OM) and the employment questionnaire. The latter system was associated with much lower pre–post treatment data completeness. To determine whether missing data matters, we compared the pre- and post-treatment scores on the PHQ-9 and GAD-7 in those individuals who did, or did not, provide pre–post treatment data for the CORE-OM or the employment questionnaire. Separate repeated measures anovas were performed on the PHQ-9 and GAD-7 data from each site. For each analysis, the repeated measures factor (time) was pre vs post scores on the PHQ-9 or GAD-7. The between subjects factor (“data completeness”) was whether participants did or did not have complete pre-post data on the CORE-OM or the employment questionnaire. For all but one of the analyses, there was a significant time by data completeness interaction (all p < .001). Inspection of the means indicated that in both sites patients who had complete data on the CORE-OM or the employment questionnaire improved more on their anxiety scores (GAD-7) than patients who had incomplete data. The same pattern was observed for depression (PHQ-9) scores. In Newham, patients who had complete data on the CORE-OM or the employment questionnaire showed greater improvement in depression. In Doncaster, patients who had complete data on the employment questionnaire, but not CORE-OM, showed significantly greater improvement in depression. To obtain an estimate of the extent to which patients with complete data on the conventional outcome monitoring system improved more that those with incomplete data, separate pre-post effects sizes were computed for the two groups. The effect sizes on the PHQ and GAD were on average 1.72 times greater for the data complete group (range 1.09–2.47). Fig. 3 illustrates the data completeness effect.

Bottom Line: Clinical outcomes were broadly in line with expectation. 55-56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status.Outcomes were comparable for the different ethnic groups who access the services.Issues for the further development of IAPT are discussed.

View Article: PubMed Central - PubMed

Affiliation: NIHR Biomedical Research Centre for Mental Health, South London & Maudsley NHS Foundation Trust & Kings College London, UK. david.clark@kcl.ac.uk

ABSTRACT
Recently the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders. Prior to this development, the Department of Health established two pilot projects that aimed to collect valuable information to inform the national roll-out. Doncaster and Newham received additional funds to rapidly increase the availability of CBT-related interventions and to deploy them in new clinical services, operating on stepped-care principles, when appropriate. This article reports an evaluation of the new services (termed 'demonstration sites') during their first thirteen months of operation. A session-by-session outcome monitoring system achieved unusually high levels of pre to post-treatment data completeness. Large numbers of patients were treated, with low-intensity interventions (such as guided self-help) being particularly helpful for achieving high throughput. Clinical outcomes were broadly in line with expectation. 55-56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status. Treatment gains were largely maintained at 10 month follow-up. Opening the services to self-referral appeared to facilitate access for some groups that tend to be underrepresented in general practice referrals. Outcomes were comparable for the different ethnic groups who access the services. Issues for the further development of IAPT are discussed.

Show MeSH
Related in: MedlinePlus