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Client Selection for CCBT

Client Selection for CCBT. Steve Cottrell Updated 02-02-14. Quotes. Whatever exists at all, exists in some amount (Thorndike, 1918) Anything that exists in any amount can be measured (McCall, 1939) If you cannot measure it, you cannot improve it (William Thomson - Lord Kelvin, 1900)

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Client Selection for CCBT

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  1. Client Selection for CCBT Steve Cottrell Updated 02-02-14

  2. Quotes • Whatever exists at all, exists in some amount (Thorndike, 1918) • Anything that exists in any amount can be measured (McCall, 1939) • If you cannot measure it, you cannot improve it (William Thomson - Lord Kelvin, 1900) • Not everything that counts, can be counted,and not everything that can be counted, counts (Bruce Cameron, 1963)

  3. Contents 1 of 2 • Background • Drivers • The ‘YAVIS’ client • Positioning psychological therapies • IAPT Screening prompts • IAPT and NICE

  4. Contents 2 of 2 • Screening for anxiety and depression • Level of functioning • Transdiagnostic therapy • CCBT – anxiety and depression • Client selection and CCBT • Serenity Programme overview • PALS suicide risk assessment

  5. Contacts SERENE.ME.UK/HELPERS #SERENITYPROGRAM serene.me.uk/helpers/#SERENITYPROGRAM This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

  6. Background

  7. Mental Health Problems • Worldwide 151 million people suffer from depression at any one time and 844,000 people die by suicide every year (Funk et al, 2010) • One in four UK adults experiences at least one diagnosable mental health problem in any one year (ONS, 2001)

  8. 8 Why? (1 of 2) • About 13% of population of Britain suffer anxiety or depression or both at any one time (more than 7 million people) (Melzer et al, 1995)

  9. 9 Why? (2 of 2) • Of the 7 million people who may benefit from counselling or psychotherapy for anxiety or depression, 70,000 do so - about 1 in 100 (Melzer et al, 1995)

  10. Drivers - Clinical • The drive for cheaper & ‘better’ treatments • Evidence-based practice • Self-help books & guided self-help • The growth of the Internet • Clinical trials of Internet-based CBT & self-help • Increasing interest in high volume, low intensity manualised approaches to CBT

  11. Drivers - Contextual • Health promotion and public health • Changes to delivery (e.g. stepped care) • The move towards consumerism in the NHS • The ‘McDonaldisation’ of healthcare • Increasingly well-informed patients • The ascendancy of science and technology • Recognition of the economics of health issues

  12. Drivers - Financial • The financial cost of depression in the UK was estimated at approximately 150 billion pounds in 2009 / 2010, of which 30 billion is thought to be work related (Sainsbury Centre, 2010) • £7-10 billion of social security benefits payments are made to cover the unemployment costs of people with high prevalence mental health problems (CEP, 2006)

  13. The ‘YAVIS’ client • Young • Attractive • Verbal • Intelligent • Successful Coined by William Schofield in his 1964 book: ‘Psychotherapy: The Purchase of Friendship’

  14. The ‘Place’ of Psychological Therapies

  15. Tiered Service Structure High secure & residential highly specialist inpatient 4 Low and medium secure, specialist inpatient services specialist community teams 3 Assertive outreach, acute inpatient services, community mental health supported accommodation, early intervention & gateway crisis resolution and home treatment 2 Primary health & care team, third sector counselling & support, primary mental health support mainstream leisure, education & recreation, lower-level support & mainstream accommodation 1 Foundation Tier Self-help, mental health promotion and education 15

  16. Contribution of Factors to Disorders 0 20 40 60 80 100 Severity Diagnostic threshold Pre-morbid Acute Early Chronic Predisposing factors Precipitating factors Perpetuating factors

  17. Predisposing Factors Predisposing factors: social class, genetic vulnerability, inequity, parental health & wellbeing, cultural mores, economic factors Requires social & political interventions, policy level

  18. Precipitating Factors Precipitating factors: Stress, loss, social isolation, relationship conflict, acute health crisis, personal catastrophe Require workplace interventions, crisis intervention, individual and community focus

  19. Perpetuating Factors Perpetuating factors: Negative cognitions, entrenched behaviour patterns, gaps in knowledge, untested assumptions, unrecognised deficits, diet, exercise, social isolation, relationship conflict, stigma Requires personal therapeutic focus

  20. Protective Factors What are some mental health protective factors? How might CCBT contribute to these?

  21. The ‘Hype Cycle’

  22. IAPT Screening Prompts

  23. IAPT Screening Prompts For all clients ask questions one and two ... follow with questions three as required

  24. Depression Q1 • Review the PHQ-9 • score If symptoms of depression are present, ask about: Duration of current episode Number & recency of past depressive episode(s) Impact on personal, social and occupational functioning (including self-neglect) Where PHQ-9 score > 9 and depressive symptoms have lasted more than 2 weeks and impair functioning consider depression

  25. Are there times when you feel frightened or anxious and very uncomfortable? Q2 Yes

  26. Is it of sudden onset? Does it involve physical sensations such as palpitations, sweating, trembling, a sensation of shortness of breath, chest pain, dizziness, nausea, and / or thoughts such as fear of loss of control or dying? Does it usually peak within 10 minutes? Is this related to a specific situation(s) or object(s)? Q3 Q3(a) If not related to a specific situation(s) or objects – ask … No Yes If there are positive responses, considerpanic disorder.Also probe for agoraphobia and panic disorder with agoraphobia Q3(b) In what situation(s) or with what objects does intense anxiety arise?

  27. If limited to specific objects, activities or situations • Is your fear or anxiety associated with avoiding or doing an activity or being in contact with an object or animal or being in a particular environment (e.g. flights, heights)? • Do you think your fear is excessive or unreasonable in some way? • If there are positive responses consider … Specific Phobia

  28. If focused on social activities or situation(s) Is it associated with marked or persistent fears of social or performance situations and accompanied by thoughts of humiliation or embarrassment (and anxiety is present which may take the form of situation specific panic attacks)? Are you uncomfortable or embarrassed at being the centre of attention? Do you find it hard to interact with people? Do you avoid social or work situations where you feel you will be scrutinised or evaluated by others? Do you think your fear is excessive or unreasonable in some way? • If there are positive responses consider … Social Anxiety

  29. If focused on places or situations) e.g. being outside alone or in crowds • Are you afraid of going out of the house, being in crowds or taking public transport? • Do you need to be accompanied by someone to be able to undertake these activities? • If there are positive responses consider … Agoraphobia (or panic disorder with agoraphobia)

  30. If the fear is accompanied by recurrent thoughts, impulses or images or ritualistic behaviour (washing hands, switching off lights) or mental acts (e.g. counting, repeating words silently) • Do you have recurrent thoughts or images or impulses that you can’t easily stop (e.g. bad things happening to people, acting on impulses that you could harm others)? • Do you try and ignore or put these thoughts / images / impulses out of your mind? • Do you have recurrent rituals (behaviour or thoughts) that you can’t easily stop (e.g. washing hands, switching off lights, counting to yourself)? • Do you think that doing these rituals may make you feel better or stop something bad happening? • For obsessions and compulsions - Do you think your fear is excessive or unreasonable in some way? • If there are positive responses consider … Obsessive-compulsive disorder

  31. Q3(c) For all service users ask whether their current problems relate to any past traumatic event(s) • Have you ever had any experience that was so frightening, horrible or upsetting, that you have, in the past month: • Had thoughts or nightmares about it or thought about it when you did not want to? • Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? • Been constantly on guard, watchful or easily startled? • Been feeling numb or detached from others, activities or your surroundings? • If there are positive responses consider … Post-traumatic Stress Disorder

  32. Q3(d) • Are you overly concerned that you might have a serious illness or disease that doctors have not found? • What do you think you may have? For all service users enquire whether they are pre-occupied with the idea that they may have a serious disease(s) that have not been diagnosed, despite medical reassurance • If there are positive responses consider … Health Anxiety

  33. Q3(e) If none of the above anxiety disorders have been identified and the person reports anxiety symptoms • Do you worry most of the time about a variety of events and activities? • Do you find it difficult to control the worry? • Have the worries lasted at least six months? • If there are positive responses consider … Generalised Anxiety Disorder

  34. Q3(f ) • If some symptoms of both depression & anxiety are present, but … • Neither anxiety nor depression symptoms predominate and neither is sufficient for a provisional diagnosis of depression or any of the anxiety disorders • Consider … Mixed Anxiety and Depressive Disorder

  35. ‘Empirically Supported’ Treatments • Agoraphobia • Depression • Generalised Anxiety Disorder • Health Anxiety • Mixed Anxiety & Depressive Disorder • Obsessive-compulsive Disorder • Panic Disorder • Post-traumatic Stress Disorder • Social Anxiety • Specific Phobia

  36. IAPT and NICE NICE Indicated Treatments for Depression and Anxiety

  37. Source: IAPT Data Handbook Appendices, June 2011. Version 2.0.1

  38. IAPT Assessments

  39. Screening for Anxiety and Depression

  40. Depression – more than ‘in the mind’ Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.

  41. We may not know ... N = 1146 Primary care patients with major depression Simon GE, et al. N England J Med. 1999;341(18):1329-1335. In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms (MUS) as their chief compliant (n=1146)

  42. Sensitivity & Specificity (1 of 2) • Sensitivitymeasures the proportion of actual positives which are correctly identified as such (e.g. the percentage of sick people correctly identified as having the condition) • Specificity- the proportion of negatives correctly identified (e.g. the percentage of healthy people who are correctly identified as not having the condition)

  43. Sensitivity & Specificity (2 of 2) • A perfect predictor would be 100% sensitive (i.e. identifying all sick people as sick) and 100% specific (i.e. not identifying anyone healthy as sick) • As sensitivity goes up, specificity usually falls and vice versa

  44. Type I and Type II errors • A ‘type I’ error is a false positive. Usually a type I error leads one to conclude that a relationship exists when it doesn't. For example, that a patient has a disease being tested for, when the patient does not have the disease • A ‘type II’ error is a false negative. An example of a type II error would be a test failing to detect the disease in a patient who really has the disease

  45. ANDICREST http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479789/

  46. ‘And I See Rest’ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479789/

  47. ‘And I See Rest’ • In addition to all the ‘AND’ criteria, three or more of the ‘I C REST’ symptoms are also necessary to meet DSM-IV-TR criteria for GAD Failure to answer positively to all the first three questions makes a diagnosis of GAD unlikely, and proceeding with the remainder of the mnemonic unnecessary

  48. PHQ-9 • Nine questions about depression symptoms scored from 0 to 3 • Total score ranges from 0 to 27 • A score of 10 or above is a potential cut-point for a diagnosis of depression (Lowe et al, 2004) • Severity bands are: 0-4 not depressed, 5-9 mild, 10-14 moderate, 15-19 moderate / severe and 20-27 severe depression

  49. GAD-7 • The GAD-7 is a seven-item measure of the severity of anxiety symptoms (Spitzer et al, 2006) • The measure uses the same response options and item scores as the PHQ-9 • Total scores range from 0 to 21 • A score of 8 or more suggests a diagnosis of anxiety • Severity bands are: 0-4 not anxious, 5-9 mild, 10-14 moderate, 15-21 severe anxiety

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