Different types of LI interventions + their role in the healthcare system Dr Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 23rd March 2023 Lecture plan (some of it might change) 1. Basic rationale of behavioural activation (BA) and other low intensity treatments (16/03/2023) 2. Different types of LI interventions and their role in the healthcare system 23/03/2023 3. The practical methodology of BA and other low-intensity skills (30/03/2023) 4. Discussion, Q&A with a Psychological Wellbeing Practitioner from the UK (06/04/2023) 5. Evaluating efficacy and areas of clinical application (13/04/2023) 6. Implementation and dissemination, challenges and solutions (20/04/2023) 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 Afternoon Morning What Where Who What Where Who What Where Who What Where Who Evening What Where Who What Where Who c S E E 3 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 teď hned udělat proti depresi? (Nevypusť duši) Jak* aUMij) m« r*ohly a&±M meten* /o/tvít od s+hsí/? RVTlNh/i I v 8 kxuy\ ohtéd\ c/césif, upr«i*f fiCMCíf se p«c+ dfit SÍ WUU4 $patA4»W___ • uklidit si v P0^*' Youtube: Co můžete teď hned udělat proti depresi? (Nevypusť duši) - VOAMLr p*W SpOAuV^ - rnsdii t*(£ /re/a* a UL 0% rVA'ROCÍV/OST VÍKOLU - uxvolafi porta - cist v - pro^rraymovavvA KSst9duSŮŽete t6ďhned Udě,at ■** *■>—> 4ai si bud/U idfkka Youtube: Co můžete teď hned udělat proti depresi? (Nevypusť duši) * př^btím, mí se »rv c/icí ! PO N 0€LÍ jř (xlmí^t c oko tídcv^ [j dai si v a iU4 pre<< sf»au/»i ČTVRTEK 0 podUW i<> ^ What activities help you feel better? Richards et al. (2016) study • Randomised controlled non-inferiority trial • Around 450 participants allocated to several weeks of BA or CBT (largest trial of BA to date) • BA administered by junior mental health workers (psychology graduates) with just a few days of training • No differences found in efficacy but BA much more cost-effective • This was driven by significantly lower cost of 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." Other low intensity interventions? • Problem solving - Sleep management • Worry time - Graded exposure • Motivational interviewing • Physical exercise interventions Problem solving First outlined by D'Zurilla and Goldfried (1971) • Step-by-step system to approach and solve problems • Aim to empower patients with skills * Excellent add-on to BA Evidence for treatment of depression and anxiety in older adults (Kirkham et al., 2016), veterans (Kasckow, et al, 2014), ethnic minorities (Unlu Ince et al., 2013), patients with chronic disease (Lee et al., 2015) and cancer (Hopko et al., 2011) Solving problems when we don't feel well Solving problems when we don't feel well Set up a new phone contract Decide what to do about my job that I hate Find a new doctor to get better treatment for eczema Organise mess in my house Figure out when I can visit my mum to help her care for my sick dad Find a new club where I could play volleyball Sort out my taxes for self-employment Solving problems when we don't feel well complex problems Solving problems when we don't feel well panic dispair avoidance complex _ fatigue problems self-hate frustration anger resignation Solving problems when we don't feel well + complex problems panic dispair avoidance fatigue self-hate frustration anger resignation Solving problems is often overwhelming LI problem solving intervention helps to: * break things down into smaller steps * create a helpful system that the client can use on Step 1: Write down all of your problems • Set up a new phone contract • Decide what to do about my job that I hate • Find a new doctor to get better treatment for eczema • Organise mess in my house • Sort out my taxes for self-employment Find a new club where I could play volleyball Figure out when I can visit my mum to help her care for my sick dad Step 2: Organise according to difficulty 1. Find a new club where I could play volleyball 2. Set up a new phone contract 3. Find a new doctor to get better treatment for eczema 4. Figure out when I can visit my mum to help her care for my sick dad 5. Organise mess in my house 6. Decide what to do about my job that I hate 7. Sort out my taxes for self-employment Step 3: Select one problem (because it's low in difficulty or high in importance) Set up a new phone contract Step 4: Write down any solution steps you can think of (no matter how crazy!) Step 4: Write down any solution steps you can think of (no matter how crazy!) • Ask a friend what contract they have • Ask a family member what contract they have • Spend 30min researching online and make a list of options • Go to a physical store and talk to a seller • Make a phone call to talk to a seller Step 5: Write pros and cons of each option Solution Pros Cons Ask a friend what contract they have Ask a family member what contract they have Spend 30min researching online and make a list of options Go to a physical store and talk to a seller Make a phone call to talk to a seller Step 5: Write pros and cons of each option Solution Pros Cons Ask a friend what contract they have Easier to choose when you have a personal recommendation Might take a while to get a response Ask a family member what contract they have Easier to choose when you have a personal recommendation Family relationships not great right now Spend 30min researching online and make a list of options Can examine all the major providers and find all the relevant information Might have to repeat this several times Hard to find motivation these days Go to a physical store and talk to a seller 1 can ask all the questions without having to read a lot on websites Can be hard to say no if they are pushy Make a phone call to talk to a seller 1 can ask all the questions without having to read a lot on websites Hate making phone calls Step 6: Select solution that seems best Ask a friend what contract they have Step 7: Make a plan for What/When/Where/How • Make sure the plan isn't too effortful or overwhelming for the client • If so, break it down into easier, measurable steps (e.g. 5min, 10min, just read one page) I Text friend Anna tonight to ask her about her phone contract Step 8: What could go wrong? What could get in the way? What could we do then? Anna might say that she doesn't like her phone contract Then I can... - choose the other phone provider than what Anna has - ask my other friend Mary - go to a physical store Step 9: Do the thing ree on accountability: When will the client report back? Step 10: Review, make another plan, rinse and repeat • Celebrate every step taken and each bit of progress achieved! • If the problem isn't solved, figure out the next step to take • If the problem is solved, move onto the next problem Try it yourself! 1. Write out all problems 2. Organise according to difficulty 3. Select a problem that's easy and/or important 4. Write out possible solutions 5. Evaluate pros and cons of each solutions 6. Choose a solution that seems best 7. Make a plan for what/when/where/how 8. What could go wrong? What could we do then? 9. Attempt the solution 10. Review & problem solve 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 problem solving • 30% recovered on placebo The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis John M. Malouff *, Einar B. Thorsteinsson, Nicola S. Schutte The meta- analysis, encompassing 2895 participants, showed that PST is significantly more effective than no treatment (d = 1.37), treatment as usual (d = 0.54), and attention placebo (d = 0.54), but not significantly more effective than other bona fide treatments offered as part of a study (d = 0.22). How many of you have struggled or know someone who has struggled with insomnia? 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 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 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 Espie et al. (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 - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently Podcasts, school workshops, media STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently Indiv Group therapy with specialist / Groups practitioners Single session counselling / Sjng|e contacts Books, phone calls, digital interventions Non face-to-face work GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Working with others Already existing services that could help signpost to or deliver LI treatment Podcasts, school workshops, media Population level Awareness raising; community STEPS system - intervene early - support prevention - distribute resources efficiently Individual therapy with specialist practitioners /lndivx Group therapy with specialist / Groups practitioners Single session counselling / Sjng|e contacts Books, phone calls, digital interventions / Non face-to-face work GPs, nurses, peer support, emergency SerViCwel^ '/ W0rking With °therS " /Already existing services that could help signpost to or deliver LI treatment Podcasts, school workshops, media ^ Population level Awareness raising; community Network Benefits Financial Legal Agencies David Clark & Richard Layard • In 2007, less than 5% of UK adults with anxiety and depression would access evidence-based psychotherapy • Waiting lists often over a year long • Survey showed public preferred psychological therapy to medication • Similar situation (or worse) all around the world |L| I ^ C National Institute for IN I LC Health and Care Excellence David Clark & Richard Layard Untreated depression and anxiety reduce GDP by 4% (absenteeism and presenteeism) •Increased access to psychological therapy will have a minimal net cost London School of Economics THE DEPRESSION REPORT A New Deal for Depression and Anxiety Disorders The Centre for Economic Performance's Mental Health Policy Group June 2006 = David Clark & Richard Layard 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 I •Between 2008 and 2011 investment in psychological therapies would rise to £173 million per annum above existing expenditure •The extra investment would be 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 pilot services in Doncaster and Newham during first 13 months • Patients seen within 21 days •Offering 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 TalkingSpace) _PI | C_/ NHS Foundation Trust • Trained 10 000 therapists • Treats over 1 000 000 patients annually now • Aims for 50% patients recovering and 75% improving • Collects outcome data on 98% patients • Similar services now implemented in Australia, Israel, Norway, Sweden • Recent evaluation: https://youtu.be/T1 r3ZqZK4iq Digital ft 89.9% of referrals accessing IAPT within 6 weeks 8.1 sessions of treatment on average per referral OPINION For better mental-health care in Canada, look to Britain DAVID CRATZER AND DAVID COLDBLOOM Stye $cUi Jlork Simcs England's Mental Health Experiment: No-Cost Talk Therapy LONDON — England is in the midst of a unique national experiment, the world's most ambitious effort to treat depression, anxiety and other common mental illnesses. Therapy deficit Nature 489, 473-474 (2012) "This programme represents a world-beating standard thanks to the scale of its implementation." Thank you! • Anonymous feedback forms: https ://t i ny u r I ■ com/s r79zyd k • Any questions, email me at ruzickova-te@gmaiLcom