3 LI interventions in healthcare &practical methodology of behavioural activation Dr Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 30th March 2023 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." Practical methodology of behavioural activation General factors - treating each client with respect and empathy (reflection, summarising, eye contact, nodding, facial expressions) - you are the expert on therapy, the client is the expert on their experience - treatment is decided collaboratively - BA practitioner's role is to validate, motivate and encourage (kind of like a coach) Initial assessment 1. Introduction 2. Confidentiality 3. Information gathering 4. Risk assessment ^ 5. Information giving 1. Introduction - introduce yourself and your role - describe agenda (length + purpose of meeting) - make it clear they can ask questions and express their own preference [2. Confidentiality] - record storage? - anonymised database? - supervision? - research? - conditions for breaking confidentiality? I will only break confidentiality if there are concerns about immediate or serious risk to, or from others, or to yourself. I would talk to you before taking action so we can come up with a plan of how best to do it. But it is important that you know that there are times when I would be legally bound to break confidentiality. 3. Information gathering The funnelling method 1. Open & general: four Ws • What is the problem? • Where does the problem occur? • With whom is the problem better or worse? • When does the problem happen? Typo* of Quo«Hons Open and General 1 Specific Open Closed (to clinch greater detail) Main proWem kJenOTcatton Check understanding at every level 3. Information gathering The funnelling method 1. Open & general: four Ws 2. Open & specific Can you tell me a bit more about... Can you say a bit more about... Typo* of Quo«Hons Open and General 1 Specific Open Closed (to cimcn greater detail) Check understanding at every level Main probtom WenWcatlon 3. Information gathering The funnelling method 1. Open & general: four Ws 2. Open & specific 3. Closed (frequency, intensity, duration, triggers) - How often do you feel depressed like this? - How long does it usually last? - On the scale from 0-10, how intense is the feeling (of depression/guilt/grief)? - What factors tend to trigger it? Typo* of Questions Open and General Closed (to clinch greater detail) Main proNem WentWcatton 3. Information gathering: specific example Describe the last time you felt depressed like this... - emotional symptoms - behavioural symptoms - cognitive symptoms - physical symptoms Environment Strang at home lying on sota when phone rings Thoughts What if ir$ wort calng rot? They think I'm shirking. They'll think I'm useless it I say that I am sil not well enough to come back to wort. Biology (Autonomlc/Physlcal) Sinking feeftng In stomach Heart racing Feeling sick Mood (Emotions) Anxious, sad. tearful Sen— of hcpilmnm Guilt Behaviour Puts bad cover over head Taking deep breaths to calm down [3. Information gathering: contextual information] - triggers, onset, progress, impact on daily life - other current mental health treatments - previous mental health treatments - other current physical health treatments - employment status - alcohol, drug, caffeine consumption + Routine Outcome Measures it 4 [Routine outcome measures] - completed at baseline and every week of intervention - checking whether our intervention is helping you - can always explain results - research support psychsurveys.com DeePsy.cz Problem Recommended measure Number of items Cut-off score Reference Depression PHQ-9 9 10 and above Kroenke et al. (2001) General anxiety GAD-7 7 8 and above Spitzeret al. (2006) Phobias Phobia scales 3 4 and above on any item Marks and Matthews (1979) Functioning Work and Social Adjustment Scale (WASAS) 5 N/A Mündt et al. (2002) Problem Recommended measure Number of items Cut-off score Reference Agoraphobia The Agoraphobia-Mobility Inventory (MI) 52 Above an item average of2.3 Chambless et al.(1985) Generalised anxiety disorder Penn State Worry Questionnaire - Short (PSWQ) 16 45 and above Behar et al. (2003) Health anxiety Health Anxiety Inventory - Short Week Version (SHAI) 18 15 and above Salkovskis et al. (2002) Obsessive compulsive disorder Obsessive Compulsive Inventory (OC1) 42 40 and above Foa et al. (1998) Panic disorder Panic Disorder Severity Scale (PDSS) 7 8 and above Shear et al. (2001) Post-traumatic stress disorder Impact of Events Scale (IES)- Revised 22 30 and above Creamer et al. (2003) Social anxiety disorder Social Phobia Inventory 19 19 and above Connor et al. (2000) [4. Risk assessment] - suicidal ideation - intent - plans - action - prevention - ideation: Do you ever have thoughts of taking your own life? Have you ever felt this way in the past? n-/\\ \ [4. Risk assessment] - intent: Have you ever thought about how you would take your own life? How often do you have thoughts of killing yourself? How easily can you put these thoughts out of your mind? How strongly do you believe that you would act on these thoughts on the scale 0-10? [4. Risk assessment] - plans Have you made any plans to act on these thoughts? Have you acted on these thoughts in the past? - actions Have you taken any steps towards taking your own life? What access do you have to things that you could use? What did you use when you attempted this in the past? [4. Risk assessment] - prevention What's keeping you going at the moment? Who do you turn to when you need someone to talk to? What stopped you from taking your own life in the past? 5. Start of behavioural activation - not like traditional talking therapy, more of a "doing therapy", where we will focus on how you spend your time - well supported by research evidence for people with low mood - try to approach it like an experiment The impact of low mood or depression BEHAVIOURAL Doing things differently or not doing the things you used to do, eating more or eating less Cycle of low mood and reducing activity r THOUGHTS Tend to be negative or unhelpful, such as feeling guilty, thinking you are useless, thinking the worst PHYSICAL Tiredness, problems sleeping, crying, losing or gaining weight, problems concentrating, being irritable r You feel worse You feel low and down, distressed, ill and have low motivation You do fewer activities You experience less fun and pleasure and have even less of a sense of achievement. Your energy levels begin to get even worse, you have poor sleep, difficulties concentrating and your general health worsens J What Do You Want to Get Out of Treatment? Today's Date Item 1 r Thoughts Write in here the specific types of unhelpful thoughts that go through your head Physical Write in here the physical changes you have noticed I can do this now (circle a number): 0 12 3 4 Not at all Occasionally Often I can do this now (circle a number): 0 1 2 Not at all Occasionally 4 Often Anytime 4 5 6 Often Anytime 6 Anytime 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. My Starting Point Diary 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' Monday Tuesday Wednesday What rning Where Who Mo What Where Who What rnoon Where Who Afte What Where Who What Where ling Who Ever What Where Who Comments Thursday Friday Saturday Sunday 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 (C 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 1 Worksheet B : Organising activities by how difficult they are Least difficult Medium difficult Most difficult Breaking tasks into smaller steps - what makes it hard to do? - time steps (5min, 10min, 1h) - component steps (read 1 page, tidy 5 items, write 2 sentences of email) - starter steps Oust put on running shoes, just open up laptop) - can somebody help you/do the task with you? - can somebody keep you accountable? Ability Chain STEP 4 : PLANNING There are a few additional helpful tips on planning your activities Planning activities for the week using My Next Steps Diary. If possible try to plan your activities on different days, spreading them over the week. Do not try to overload yourself on one particular day and have nothing on other days. Be as specific as possible when describing your chosen activities. As with the My Starting Point Diary try to include 'What' you are planning to do, 'Where' you are planning to do it and 'Who' you are planning to do it with. My Next Steps Diary Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning What Where Who What Where Who Afternoon What Where Who What Where Who Evening What Where Who What Where Who Comments