1 Basic rationale of behavioural activation and other low intensity treatments Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 12th May 2021 Lecture plan 1. Basic rationale of behavioural activation and other low intensity treatments 2. The practical methodology of behavioural activation and other low-intensity skills 3. Evaluating efficacy and areas of clinical application 4. Implementation and dissemination, challenges and solutions 5. Discussion, Q&A with a Psychological Wellbeing Practitioner from the UK Assignments 1. Before each lecture block, reading your assigned publication, taking notes and preparing to discuss it in class 2. End of the course: short essay about what you found most interesting (450-500 words) 3. Active participation in class + Please fill in feedback forms after each class! Format 45min lecture 5min break 10min Q&A Assumptions... • It is useful to conduct experiments on psychotherapy, with the golden standard being randomised controlled trials • It is useful to measure efficacy of psychotherapy with quantitative (as well as qualitative) methods • Cognitive behavioural therapy is one of the most experimentally supported treatments, particularly for common mental health problems, i.e. depression and anxiety Mental health problems in the Czech Republic (in 2017) • 22% experienced mental health disorder • 5% mood disorder • 7% anxiety disorder •11% alcohol use disorder • 5% suicide risk Formanek et al. (2020) Mental health problems in the Czech Republic (in 2020) • 30% experienced mental health disorder • 12% mood disorder • 13% anxiety disorder • 10% alcohol use disorder • 12% suicide risk Winkler et al. (2020) Treatment gap in the Czech Republic (in 2017) • 60% mood disorders • 70% anxiety disorders • 90% alcohol use disorders ... don't receive treatment Kagstrom et al. (2020) Barriers to seeking mental health care * stigma (self & public) * not identifying as having a mental health problem * too expensive (therapist qualification, insurance policies) * too far * too impractical "Mental health care worldwide is at the start of a revolution that will change the shape of health care practice in the next two decades. We are at the birth of a new era—in the development of evidence-based therapies, in the delivery of mental health services, a new era oriented towards the promotion of psychological wellbeing on a community-wide basis." - Oxford guide to low intensity CBT interventions Low intensity mental health treatments = effective treatments that require less time on the side of the specialist, use specialist time in a more cost-effective way (e.g. in a group context) or can be administered by a non-specialist = still require substantial time on the side of the user, but may be accessed more flexibly = significantly reduce financial costs and/or practical burden Possible examples of low intensity treatments? Group therapy Possible examples of low intensity treatments? Group therapy Possible examples of low intensity treatments? Web-based counselling Group therapy Brief school-based Web-based counselling Group therapy Brief school-based Web-based counselling Group therapy Self-help books f Possible examples ( of low intensity V treatments? Brief school-based counselling Peer support Web-based counselling Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based counselling il therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based counselling Email therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based Mental health apps counselling il therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Psychological assistants Peer support Web-based Mental health apps counselling Email therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Psychological assistants Peer support Community therapy by GPs, nurses, teachers? counselling Web-based Mental health apps Guided self-help Group therapy Email therapy Therapy through phone calls / texts Self-help books I Possible examples ( of low intensity V treatments? Brief school-based counselling Psychological assistants Peer support Community therapy by GPs, nurses, teachers? counselling Web-based Mental health apps Guided self-help Group therapy Email therapy Therapy through phone calls / texts Self-help books f Possible examples ( of low intensity V treatments? Therapist robots?! (OpJ 5tfl Brief school-based counselling Psychological assistants Peer support Community therapy by GPs, nurses, teachers? counsellin9 Web-based Mental health apps Guided self-help Group therapy Email therapy Therapist robots?! (OpJ 5tfl Brief school-based counselling Therapy through phone calls / texts New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Self-help books Psychological assistants Peer support Community therapy by GPs, nurses, teachers? counsellin9 Web-based Mental health apps New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Higher cost-effectiveness Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments Lower divorce rate? New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments Lower divorce rate? New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating World peace? Greater choice Higher cost-effectiveness Service flexibility How have low intensity treatments come about? • Treatment becoming shorter, effective and evidence-based • But not nearly in enough provision to meet demand 1978 - first ever self help book? CBT can be delivered as effectively by mental health nurses (Marks et al., 1985) OVER 1,250,000 Copies Sold in 23 Languages VER MOOD SECOND EDITIO Change How You Feel by Changing the Way You Think Dennis Greenberger, PhD I Christine A. Padesky, PhD SECOND EDITION Over 100,000 in Print! The Clinician's Guide to CBT Using MIND OVER MOOD 'I Christine A. Padesky erger 1995 How have low intensity treatments come about? • Treatment becoming shorter, effective and evidence-based • But not nearly in enough provision to meet demand • Mechanistic research - psychotherapy component studies Group 1 paper Jacobson et al. (1996) A component analysis of cognitive-behavioural treatment for depression. Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) * Stable negative cognitive Schemas about the self, the future and the world * Lead to automatic negative thoughts (interpretations of life events) * Leads to depressive behaviour (avoidance) Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) * Stable negative cognitive Schemas about the self, the future and the world * Lead to automatic negative thoughts (interpretations of life events) * Leads to depressive behaviour (avoidance) * Cognitive treatment was assumed to be the main ingredient •Rush et al. (1977) schema: "I am unlovable jj ' biased information processing: - pays more attention to signs of rejection - more likely to remember examples of rejection than acceptance automatic negative thought: "He takes too long to text me back because he doesn't really love me. This always happens to me." x 3 cot*?* cognitive distortions y/^All or nothings, thinking Jumping to conclusions 2 + 2 = 5 "If he doesn't text back quickly he's a bad boyfriend" "I'm sure he wants to break up with me" Disqualifying^N the positive /" Over- >^ generalizing 'fvtrythtng is alwayt tuOOISn nothing ever •';<'<•; "He never texts me back quickly" "This always happens to me" f Labelling \ "I'm such an idiot" Personalization this is my fault "He is probably mad at me" cognitive distortions • monitoring automatic thoughts (journalling) • noting down thoughts that trigger intense feelings • evaluating evidence supporting the truth or helpfulness of the thought • practicing more positive interpretations Jacobson et al. (1996) background • Other components of cognitive behavioural therapy for depression • Monitoring daily activities (often the start) • Assessment of pleasure and mastery after activities • Gradually increasing difficulty of tasks • Imagining participation in activities • Preparing for obstacles • Assertiveness, communication skills Jacobson et al. (1996) study • Is full cognitive therapy necessary? Jacobson et al. (1996) study • Is full cognitive therapy necessary? • How important is activation? Jacobson et al. (1996) study • Is full cognitive therapy necessary? • How important is activation? • How important are coping skills? Jacobson et al. (1996) study • Is full cognitive therapy necessary? • How important is activation? • How important are coping skills? • How important is the work on negative "cognitive schemas"? Jacobson et al. (1996) study • Is full cognitive therapy necessary? • How important is activation? • How important are coping skills? • How important is the work on negative "cognitive schemas"? • Comparing full cognitive therapy (CBT), which included BA, AT and other techniques targeting deeper schemas vs Behavioural activation (BA) only vs Behavioural activation (BA) + Automatic thoughts intervention (AT) Jacobson et al. (1996) study * 152 participants • Scoring at least 20 on Beck Depression Inventory * Random allocation * Four experienced cognitive therapists • Three manuals created (CBT, AT, BA) • 12-20 sessions Jacobson et al. (1996) results • the 3 were groups (CBT, BA, BA+AT) equivalent in depression recovery after the intervention and at 6 month follow up THOUGHTS (What we think affects how we feel and act) ■ equivalent effects also found on measures of dysfunctional thinking • despite all therapists expecting full CBT to have the strongest effect (allegiance) BEHAVIOUR EMOTIONS (What we do affects (How we feel affects how we think and feel) what we think and do) So what is behavioural activation? Behaviourists & depression • Science and human behaviour (Skinner, 1957) • Functional analysis of depression (Ferster 1973) "A depressed person may sit silently for long periods, or perhaps even stay in bed all day " Driving forces of behaviour ... according to behaviourists * Reinforcement = leads to increase in behaviour • Positive reinforcement behaviour => something good happens • Negative reinforcement behaviour => something bad doesn't happen • Punishment = leads to decrease in behaviour behaviour => something bad happens or something good doesn't happen Driving forces of behaviour ... according to behaviourists What driving force would explain this? 1. Rat presses a lever and gets an electric shock. 2. Wife doesn't get coffee with a male friend so that husband doesn't shout at her. 3. Shop assistant wears a face mask during a pandemic. 4. Man spends all day watching pornography. 5. Scientist works hard on his publication. Behaviourists & depression • Depression is characterised by: • Decrease in positive reinforcement • Increase in negative reinforcement • Increase in punishment • Examples? Behaviourists & depression • Depression is characterised by: • Decrease in positive reinforcement: Less social connection, less work fulfilment, lower enjoyment from hobbies, exercise, sex, lower income... • Increase in negative reinforcement: Avoidant behaviour - increase in watching TV, sleeping, substance use, social media scrolling, ignoring contact from friends... • Increase in punishment: Loss of a job, loss of a relationship, grief, social rejection... The mechanism of depression onset & maintenance The mechanism of depression onset & maintenance Something difficult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4, Sadness, lack of energy Interrupted routine Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Anhedonia Lack of motivation The mechanism of depression onset & maintenance Something difficult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4, Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation The mechanism of depression onset & maintenance Something difficult happens Pnmary cause (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4> Secondary ^ cause Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation The mechanism of depression onset & maintenance increases punishment) Primary cause John has recently gone through a breakup. Secondary cause John has become a lot more inactive. John has recently gone through a breakup. The loss of pleasant experiences with his Primary cause girlfriend was a significant reduction in positive reinforcement (e.g. he cannot go on nice walks with her in the park). He started avoiding places that remind him of her as well as mutual friends (negative reinforcement). The grief he's experiencing makes him feel like his investment in the relationship has been wasted (punishment). Secondary cause John has become a lot more inactive. Primary cause Secondary cause John has recently gone through a breakup. The loss of pleasant experiences with his girlfriend was a significant reduction in positive reinforcement (e.g. he cannot go on nice walks with her in the park). He started avoiding places that remind him of her as well as mutual friends (negative reinforcement). The grief he's experiencing makes him feel like his investment in the relationship has been wasted (punishment). John has become a lot more inactive. He stopped going to the gym and doesn't put as much effort into his work, because he doesn't feel motivated (loss of positive reinforcement - those behaviours could be rewarding). He started playing computer games and sleeping more (negative reinforcement). His boss is starting to get upset with him (punishment). The simple power of behavioural activation Behavioural activation • small, measurable steps towards increased activity just above current level • balance of routine, pleasurable and necessary activities • acting before feeling (outside in / action first) • avoiding boom and bust STEP 1 : RECORD WHAT YOU ARE CURRENTLY DOING Use the blank 'My Starting Point Diary' to record what you are currently doing during the week. Start today and record over the next 7 days. There are two boxes each for the morning, afternoon and evening so just try to include the main two things you have done for each. At the end of each day have a look at your diary and write any comments you have in the comments box. Think about what you have been up to, and try to note if there were times when you felt better or worse. This will help you and your PWP when you discuss your week at the next session. It can really help later on if you are able to provide some detail about: 'What' you are doing - i.e. 'watching television' 'Where' you are doing it - i.e. 'lounge' "Who' you were with - i.e. 'on my own' My Starting Point Diary Monday Tuesday Wednesday Thursday Friday Saturday Sunday < What Where Who What Where Who What Where Who What Where Who What Where Who What Where Who Worksheet A : Identifying activities Under each type of activity write down what you want to be able to achieve. Please include all activities you can think of here, regardless of whether you think you can do them or not. We will deal with that in Step 3. Again don't worry if you struggle with this step. Anything you get down will be a bonus as your PWP is always there to help. Routine e.g. cooking, walking the dog, food shopping Pleasurable e.g. going out with friends, reading Necessary e.g. paying bills, taking children to nursery I Worksheet B : Organising activities by how difficult they are Least difficult Medium difficult Youtube: Co můžete teďhned udělat proti depresi? Ja& ak4ivHjj ^ rr\oh(u mZ*ČA r«4cní / ufevit od s+h** RVTlNh/t 0o'$*s podle vidí**/ • ktzdjf de* n v*9* czvs-hrth*' vzdAtA* • ftctičíf se pec-f • čVsf ^pMijh je* ukliUíf Si v pokoji Youtube: Co můžete teďhned udělat proti depresi? Youtube: Co můžete tedhned udělat proti depresi? Z-3 ^tni tifof si bud/U dt&kff od pos-řtk. YtUft- hÄffťvf si f vf ď,»ut IctW i*viV\ cWv Youtube: Co můžete teď hned udělat proti depresi? * př^btím, mí se »rv c/icí ! PO N 0€LÍ D \Jk\\ v a iu4 pre<< spc^u/hn ST RE D A ČTVRTEK r o p*c*am Group 4 paper Richards et al. (2016) Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA) Richards et al. (2016) study • Randomised controlled non-inferiority trial • Around 450 participants allocated to either BA or CBT (largest trial of BA to date) • No differences found in efficacy but BA significantly more cost-effective • This was driven by lower costs of junior mental health workers who administered BA "Our results, offer hope to many societies, cultures, and communities worldwide, rich and poor, struggling with the effect of depression on the health of their people and economies." Group 3 paper Pinto-Meza et al. (2006) Behavioural inhibition and behavioural activation systems in current and recovered major depression Neuroscience of BA? BIS & BAS • Behavioural inhibition and activation (approach) systems •Gray (1987) two major neurobiological systems responding to reward and punishment y = -2 x = -4 Brainstem •Carver and White (1994) BIS/BAS scale development • Relate to personality factors like neuroticism and extraversion BIS & BAS Gray (1987) two major neurobehavioural systems responding to reward and punishment Carver and White (1994) BIS/BAS scale development 1. BIS Ifl think something unpleasant is going to happen I usually get pretty "worked up." I worry about making mistakes. Criticism or scolding hurts me quite a bit. I feel pretty worried or upset when I think or know somebody is angry at me. Even if something bad is about to happen to me, I rarely experience fear or nervousness. I feel worried when I think I have done poorly at something. •I have very few fears compared to my friends. 2. BAS Reward Responsiveness When I get something I want, I feel excited and energized. When I'm doing well at something, I love to keep at it. When good things happen to me, it affects me strongly. It would excite me to win a contest. When 1 see an opportunity for something I like, I get excited right away. 3. BAS Drive When I want something, I usually go all-out to get it. I go out of my way to get things I want. Ifl see a chance to get something I want, I move on it right away. When I go after something I use a "no holds barred" approach. 4. BAS Fun Seeking I will often do things for no other reason than that they might be fun. I crave excitement and new sensations. I'm always willing to try something new ifl think it will be fun. I often act on the spur of the moment. Behavioural inhibition system * punishment (innate & learnt) * absence of expected reward (= disappointment, frustration) * novelty * inhibits behaviour that may lead to negative outcomes * hyperactive in depression Sensitivity to punishment scale Reward predicted Reward occurs cs A P Reward predicted No reward occurs M 0 CS 1 2s (NoR) Schultz, Dayan, Montague Science, 1997 Behavioural activation (approach) system * reward * absence of punishment (= relief) * hypoactive in depression -decreased approach towards rewarding behaviour Sensitivity to reward scale Pinto-Meza et al. (2006) • Participants with current MD, participants recovered from MD and healthy controls • Current and recovered MD showed hyperactive BIS and hypoactive BAS • Possible personality / physiological vulnerability marker that can be objectively measured • May explain the mechanism of BA treatment Other low intensity interventions? • Problem solving • Worry management - Graded exposure • Sleep management • Motivational interviewing • Physical exercise interventions Problem solving • First outlined by D'Zurilla and Goldfried (1971) • Step-by-stem system to approach and solve problems • Aim to empower patients with skills adopted for the treatment of depression and anxiety across a variety of populations: older adults (Kirkham etal., 2016), veterans (Kasckow, etal., 2014), ethnic minorities (Unlu Ince et al., 2013) and patients with chronic-obstructive pulmonary disease (Lee et al., 2015) and cancer (Hopko et al., 2011) Problem statement: Over the last few months I have been feeling stressed and overwhelmed due to lots of pressures in everyday life. I have been working long hours to try to help this, but this has meant that I am constantly tired and irritable and I have been seeing much less of my family and spending less quality time with my children. I have also been avoiding addressing problems elsewhere. As a result, I have thoughts of 'I can't cope' and 'I'm a bad parent'. This is impacting on my relationships with others. Problem solving Explain problem solving Identify main problems Worksheet 16.2 Jamie's problem list Problem list Main problem area Main problem area Work Financial Specific problems Not getting on with colleagues Having to cover for two colleagues who are off on long-term sick leave Current project is behind Getting to work Specific problems Credit card payment is overdue Always running out of money towards the end of the month Car MOT Least difficult to solve Least difficult to solve Getting to work Having to cover for two colleagues who are off on long-term sick leave Most difficult to solve Most difficult to solve Current project is behind Not getting on with colleagues Always running out of money towards the end of the month Selected problem Having to cover for two colleagues who are off on long-term sick leave Medium difficulty solving Medium difficulty solving Credit card payment is overdue Car MOT Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions Problem-solving worksheet Identify the problem Having to cover for two colleagues who are off with long-term sickness Potential solutions (Generate as many as possible) Quit my job Continue as I am currently - do nothing Speak to manager and discuss difficulties managing workload Refuse to do the extra work Delegate more responsibilities Ask colleagues for help Organise a team night out to boost morale Book some annual leave Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons Solution: Quit my job Advantages Disadvantages Would no longer have the stress Would have lots of spare time Don't have another job to go to Would be more stressed due to financial issues Could lose house if we can't pay the mortgage Would miss my job as its something I am good at Solution: Speak to manager and discuss difficulties managing workload Advantages Disadvantages They may not know how much work I currently have to do They may be able to take some of the responsibilities from me They could help with some of the tasks themselves They may just expect me to continue working as I am I may be seen as less capable than colleagues Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom 7. Attempt the solution Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve Group 6 paper Mynors-Wallis et al. (1995). Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. Mynors-Wallis et al. (1995) • 90 patients with major depression • Randomised to 1) problem solving (6 short sessions over 12 weeks), 2) antidepressant or 3) placebo • No significant difference found between problem solving (60% recovered) and antidepressant (50% recovered) •High patient satisfaction after PS • 30% recovered on placebo Digital LI treatment for insomnia CBT model of insomnia Arousal • Emotional (fear, sadness) • Cognitive (thoughts, images) • Physiologic (pain, muscular tension) ft v \ \ \ \ \ \ N Beliefs and Attitudes • Worry over sleep loss • Rumination over consequences • Unrealistic expectations • Misattributions and amplifications Consequences • Fatigue • Performance impairments • Mood disturbances • Social discomfort Maladaptive Habits • Excessive time spent in bed • Irregular sleep schedule • Daytime napping • Sleep-incompatible activities • Inappropriate use of hypnotics CBT tools Examining sleep-related thoughts Correcting distortions Setting up realistic expectations Sleep restriction Sleep hygiene Arousal • Emotional (fear, sadness) • Cognitive (thoughts, images) • Physiologic (pain, muscular tension) ft v \ \ \ \ \ \ N Beliefs and Attitudes • Worry over sleep toss • Rumination over consequences • Unrealistic expectations • Misattnbutions and amplifications Consequences • Fatigue • Performance impairments • Mood disturbances • Social discomfort Maladaptive Habits • Excessive time spent in bed • Irregular sleep schedule • Daytime napping • Sleep-incompatible activities • Inappropriate use of hypnotics Sleepio is a 6 week online program designed by sleep experts and based on cognitive and behavioral techniques. Sleep Restriction The most powerful way to increase your sleep drive and reset your sleep schedule. lorzil Stimulus Control Rebuild a healthy association between your bed and sleep. Cognitive Tools Manage the worries and thoughts that make it difficult to sleep. Sleep Hygiene Review Optimize your environment and habits for better sleep. • Fully automated • Algorithms for personalised recommendations How would you like to improve your sleep? Select all that apply Get to sleep more easily Sleep right through the night without waking up Stop waking up too early Wake up feeling refreshed None of the above o Your lifestyle e Your bedroom o The truth about sleep o Challenging negative thoughts o The Weekly Quiz Group 5 paper Espie et al. (2019) Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. Espie etal. (2019) • Over 1700 participants • Randomised 12 weeks of Sleepio programme vs sleep hygiene education website (superiority trial) Espieetal. (2019) Over 1700 participants Randomised 12 weeks of Sleepio programme vs sleep hygiene education website (superiority trial) Significantly improved sleep, physical health, wellbeing Assessment3 Unadjusted, Mean (SD) Adjusted Difference (95% CI) Cohen d P Value SHE + TAU dCBT + TAU PROMIS-10 Week 4 32.52 (6.05) 33.84 (6.49) 0.90 (0.40 to 1.40) 0.16 <.001 Week 8 32.92(6.18) 35.08 (6.65) 1.76 (1.24 to 2.28) 0.31 <.001 Week 24 33.10(6.10) 35.24 (6.88) 1.76 (1.22 to 2.30) 0.31 <.001 WEMWBS Week 4 44.72 (8.21) 46.03 (8.55) 1.04 (0.28 to 1.80) 0.13 .007 Week 8 45.16(8.77) 48.12(8.82) 2.68 (1.89 to 3.47) 0.35 <.001 Week 24 45.31 (8.89) 48.62 (9.02) 2.95 (2.13 to 3.76) 0.38 <.001 GSIIb Week 4 69.80 (23.64) 60.69 (26.20) -8.76 (-11.83 to-5.69) -0.69 <.001 Week 8 65.68 (25.86) 46.78 (29.90) -17.60 (-20.81 to-14.39) -1.38 <.001 Week 24 63.33 (27.26) 43.78 (31.25) -18.72 (-22.04 to-15.41) -1.46 <.001 Abbreviations: dCBT, digital cognitive behavioral therapy; GSII, Glasgow Sleep Impact Index; PROMIS-10, 10-item Patient-Reported Outcomes Measure; SHE, sleep hygiene education; TAU, treatment as usual; WEMWBS, Warwick-Edinburgh Mental Well-being Scale. Integrating LI interventions into the healthcare system STEPS system STEPS system Podcasts, school workshops, media Indiv Groups STEPS system Single contacts GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Non face-to-face work Working with others Podcasts, school workshops, media Population level Awareness raising; community Indiv Groups STEPS system Books, phone calls, digital interventions GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Single contacts Non face-to-face work Working with others Podcasts, school workshops, media Population level Awareness raising; community Specialist practitioners STEPS system Books, phone calls, digital interventions GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Podcasts, school workshops, media Network Benefits Financial Legal Agencies Group 2 paper Clark et al. (2009) Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Clark et al. (2009) •On World Mental Health Day in October 2007 the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders within the English National Health Service •Between 2008 and 2011 investment in psychological therapies for these conditions will rise to £173 million per annum above existing expenditure •The extra investment is being used to train and employ at least 3600 new psychological therapists who will work in new IAPT clinical services offering evidence-based psychological therapies Clark et al. (2009) • Two new services in Doncaster and Newham during first 13 months • Patients seen within 21 days •HI specialist therapy or LI (most commonly guided self-help) • Self-referral or GP-referral • Careful outcome monitoring •50-60% recovery if at least two or more sessions, compared with 20% spontaneous recovery • 4-10% increase in employment Clark et al. (2009) • Two new services in Doncaster and Newham during first 13 months • Patients seen within 21 days •HI specialist therapy or LI (most commonly guided self-help) • Self-referral or GP-referral • Careful outcome monitoring •50-60% recovery if at least two or more sessions, compared with 20% spontaneous recovery • 4-10% increase in employment IAPT successes • Trained 10 000 therapists • Treats over 500 000 patients every year • Average waiting time is 20 days • Around 50% patients recover and 75% improve • Collects outcome data on 98% patients TalkingSpace -PLUS- Oxford Health NHS Foundation Trust Similar services now implemented in Australia, Israel, Norway, Sweden Thank you! • Please fill in feedback forms • Any questions, email me at ruzickova-te@gmaiLcom