Long Term Conditions and Talking Therapies

1. Long Term Conditions and Talking Therapies John Manley, HielkjeVerbruggeClinical Lead, LTC LeadLambeth Talking Therapies Lambeth CCG

2. Agenda • Background – 5 Year Forward View (5YFV) • The patient journey • Mind Body Integration • What we are doing • Access to Talking / Psychological Therapies

3. Context: 5YFV: Increasing Access…..!

4. Challenges – 5YFV • Focus on LTC • MH interventions can improve health, quality of life, care and health service costs overall • Need for CCG / provider vision, strategic plan, and engagement of health services in the role of Mental Health interventions in LTC

5. 5YFV • Physical health improvements for people with long term conditions when co-morbid mental health problems treated. • Reduced healthcare utilisation in A&E attendances, short stay admissions and prescribing. • New integrated services will deliver savings

6. 5YFV • The strongest evidence is for: • Diabetes • COPD • Cardiovascular • Chronic pain • Medically unexplained symptoms.

7. Patient journey and issues At risk- education / behaviour change Diagnosis /impact– struggle with Lifestyle– behaviour changes Impact –Anxiety / Depression Complexity –physical/ mental

8. A range of emotional reactions • Most patients will not meet criteria for a disorder • May show ‘diabetes distress’ • difficulty coping /coping with other social stressors/ stigma about seeing it as a mental health issue Impact on: • Motivation Engagement Quality of life with care

9. Diabetes distress • Struggle to adhere to medications • ‘I can’t be bothered’ / let it slip • Difficulty making link between own behaviour change and outcomes • Avoidance

10. Further emotional reactions • Adjustment difficulties • Sadness - loss • Depression • Can be associated with not getting / engaging with the right treatment and poorer care / survival • Anxiety • Sleep problems, nausea, tension • Can lead to avoidance of following treatment

11. What can be done? Evidence base: • ‘Low Intensity’ group • Diabetes and anxiety / depression • Adapt CBT to include diabetes • Very difficult to recruit patients, needed active Health Professional promotion • Improved physical (reduction in HbA1c)and MH outcomes

12. What can be done? Evidence base: 2. ‘High Intensity’ Cognitive Behaviour Therapy- CBT • Diabetes and anxiety / depression • Adapt CBT to include diabetes • E.g. Lustman ‘98 RCT - Education group plus CBT improved depression and may help glycaemic control – improved at FU

13. What we are doingStepped care: Anxiety / depression Diabetes distress Early intervention Diagnosis At risk

14. Some initial feedback • General IAPT service - 70 people with diabetes and anxiety / depression • Diabetes Follow Up - Wellbeing Workshop – few have ‘anxiety or depression’ but are interested in wellbeing • General IAPT service groups hard to fill eg chronic pain

15. Mind / Body • How do we treat the whole person? • How does the service user see the head and body / problems as connected?

16. Achieving a culture and practice shift • We will fail on our own…. • Our focus will be on Diabetes • Large population, but low uptake • Loss of part of Lambeth’s diabetes MH pathway

17. What you can do - Ask • Screen with PHQ 2 and GAD 2 questions • Over last 2 weeks - • Little interest or pleasure in doing things? • Feeling down, depressed or hopeless? GAD 2 • Feeling nervous, anxious or on edge • Not being able to stop or control • worrying

18. What you can do - Ask • Screen with DD2: • If score 3, discuss referral?

19. What we offer We are Lambeth Talking Therapies Service - part of SLaM NHS Foundation Trust Our role is to improve psychological wellbeing by directly providing psychological therapies and encouraging good psychological wellbeing

20. What we offer • Guided self help for common psychological problems, online and face to face • Cognitive Behaviour Therapy Treatment based on understanding • what keeps your problem going • and then practical strategies for putting it right • Here and now based – not talking about the past.

21. How to get to us • Self referral – via website slam-iapt.nhs.uk- and then ring in • Read leaflet – then ring in. • GP/ HCP referral– via website or paper form • SU still needs to ring in.

22. Websitewww.slam-iapt.nhs.uk

23. What can you expect • When you ring in we will ask you a series of questions about your problem – this will take about 25 minutes. • If our service is suitable for you we will then offer you online programme, a workshop, group or face to face assessment followed by a brief number of sessions. • This will be by phone or face to face.

24. What can you expect • If the right service for you is a workshop, or online guided self help - no wait • For guided self help - about six weeks. • If you need a more intensive service (CBT) the wait is longer – around 12 weeks.

25. Where we are • Team bases in • Brixton, Edmondsbury Estate, Ferndale Road • Streatham, Palace Road Surgery • Landor Road • GP surgeries • Some community centres

26. Key points • 5YFV – need to change how we see physical and mental health treatment • How do we achieve integration from the start of the patient journey?

27. Questions

28. How to get to this?- Integration • What would an integrated physical/ mental health service look like for diabetes? • In primary care? • In LCNs? • In secondary care?

29. Integration? • Co location? • Shared clinic / shared learning? • Liaison?

30. What can be done?Case vignettes • 34 year old, Spanish speaking South-American woman, married with a young child. • Chronic pain, diabetes, depression • Suicidal • Treatment – 9 sessions of guided self help – pacing, behavioural activation, finding value and direction, relaxation, thought challenging and distancing. • Moved into recovery (PHQ9 from 24 to 3, GAD7 from 17 to 1).

31. What is being offered already • Preventative: • Healthier YOU • STEPS • Dietician • Diagnosed: • DESMOND • Insulin group • Diabetes and food group • Diabetes nurses • Complex • Diabetes clinic SLaM (health psychology)? • Diabetes nurses • Care coordination (future)