Update on the Improving Access to Psychological Therapies programme in England: Commentary on … Children and Young People's Improving Access to Psychological Therapies.

Professor Sami Timimi recently expressed concerns about the Improving Access to Psychological Therapies (IAPT) programme. We argue that the concerns are largely unfounded and provide readers with an update on the programme

Improving access to psychological therapies : a review of the progress made by sites in the first rollout year

Improving Access to Psychological Therapies (IAPT) is a programme designed to make psychological therapies for common mental health problems widely available. Following pilot work in Doncaster and Newham, the first wave of roll‐out sites started operation in 2008. We report a study of their work in the year from October 2008 to September 2009. Allowing for varying start times, this was roughly their first full year of operation

Factorial invariance of the Patient Health Questionnaire and Generalized Anxiety Disorder Questionnaire.

The UK's Improving Access to Psychological Therapies (IAPT) programme uses the Patient Health Questionnaire Depression Scale (PHQ-9; Kroenke, Spitzer, & Williams, , J. Gen. Intern. Med., 16, 606) and Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., , Arch. Intern. Med., 166, 1092) to assess patients' symptoms of depression and anxiety respectively. Data are typically collected via telephone or face-to-face; however, no study has statistically investigated whether the questionnaires' items operate equivalently across these modes of data collection. This study aimed to address this omission

Social context and distress : environment, power, distress and IAPT, a discourse analysis

There is a consistent research base that shows that class and inequality is associated with poorer mental health and experiences of distress. Various explanations for this link have been proposed, including psychological, social, structural, material and political factors. Experiences of powerlessness and oppression have also been implicated. Nevertheless psychology focuses predominately on explanations and interventions at the individual level. To explore this incongruence, a Foucauldian Discourse Analysis was completed of texts produced by Improving Access to Psychological Therapies (IAPT), related to the development and practice within IAPT and supervision sessions of high-intensity therapists practicing in IAPT. The emerging discourses are discussed

The relationship between competence and patient outcome with low-intensity cognitive behavioural interventions

Little is understood about the relationship between therapist competence and the outcomes of patients treated for common mental health disorders. Furthermore, the evidence is yet to extend to competence in the delivery of low-intensity cognitive behavioural interventions. Understanding this relationship is essential to the dissemination and implementation of low-intensity cognitive behavioural interventions. The aim of this study was to explore the relationship between Psychological Well-being Practitioner (PWP) competence and patient outcome within the framework of the British government's Improving Access to Psychological Therapies (IAPT) initiative. Forty-seven PWPs treating 3688 patients participated. Relationships between PWP scores on three observed standardized clinical examinations and reliable change in patients' symptoms of anxiety and depression were explored at two time points: during the year-long training phase, and over a 12-month follow-up. Results indicated that patients treated by qualified PWPs achieved superior outcomes than those treated by trainees. Little support was found for a general association between practitioner competence in delivering low-intensity cognitive behavioural interventions and patient outcome, either during or post-training; however, significantly more patients of the most competent PWPs demonstrated reliable improvement in their symptoms of anxiety and depression than would be expected by chance alone and fewer deteriorated compared with those treated by the least competent PWPs. Results were indicative of a complex, non-linear relationship, with patient outcome affected by PWP status (trainee or qualified) and by competence at its extremes. The implications of these results for the dissemination and implementation of low-intensity cognitive behavioural interventions are discussed

Key Factors to Maintaining Treatment Fidelity in an Improving Access to Psychological Therapies (IAPT) Model of CBT

The aim of this contribution is to provide evidence and greater theoretical understanding of the relationship between key factors that maintain treatment fidelity in CBT, outside of research settings. This spans decades in CBT training, supervision and practice, contributing new terms, concepts, models and clinical recommendations. The series culminates by focusing on Improving Access to Psychological Therapies (IAPT). A coherent body of work emerges, when an ‘empirically-grounded clinically interventions’ approach is applied. This uses practice-based research, pilot data and preliminary studies, combined with original empirical evidence. Aims are achieved by defining and appraising five topics - Treatment Fidelity, Service-Model Fidelity, Training, Clinical Supervision and Service Framework. Once their key functions are established, their inter-relatedness emerges. The rationale has a basis in findings that clinical outcomes in research do not always translate into services, despite insignificant demographic differences and more experienced practitioners in services. This hypothesises, services with more variables that increase treatment fidelity to known interventions, will be linked to superior clinical outcome. Whilst drilling deeper into key concepts at one level, the overarching theme remains the tension between outcome research in CBT and its failure to translate into standard clinical services. This historical lack of replication was a factor in the modernisation agenda of IAPT. Three broad recommendations and implications for future research are concluded from the series. First, adhering to a High Dose Narrow/Bandwidth (HD/NB) model (Cromarty 2016), increasing the dose of the primary intervention allows IAPT practitioners to closer match treatment fidelity and clinical outcomes of research trials. The Australian IAPT contributions explicitly showcase this, supporting the hypothesis that services with increased treatment fidelity yield superior clinical outcomes. Secondly, HD/NB interventions must be supported by Service-Model Fidelity (Cromarty 2016). The delivery system in which HD/NB principles operate is equally important. This recommendation for integrating clinical improvement and service-redesign models, notes Treatment Fidelity is not guaranteed in clinical services with training, supervision and best-practice alone. Placed within an optimised service model such as IAPT, the joint strengths of key variables are amplified. Further research on service model being a possible factor of improved clinical outcome is recommended. Thirdly, if known problems translating research into clinical practice persist, additional research closing the gap, can originate from the clinical practice! CBT has an actual empirical basis in clinical observation with additional theoretical aspects, researching and treating numerous variables, including psychosocial and psychological processes. CBT clinical practice possesses several overlapping features with single-case methodology. Small scale, service-based studies allow convenient samples, with high inference and low numbers. They have high clinical and face validity with the ability to study individual change processes. The advent of IAPT services allows a more robust two-way process to augment controlled research. They are ideal grounds for translating research findings into services due to inexorably linked variables, combining to improve treatment fidelity. This constitutes a continual two-way process by recipient IAPT services increasing the empirical basis of practice-based research. This can contribute back into the wider evidence base to inform future large-scale research

Determinants of patient-reported outcome trajectories and symptomatic recovery in Improving Access to Psychological Therapies (IAPT) services.

BACKGROUND: Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting. METHODS: Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery. RESULTS: Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria). CONCLUSIONS: We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients' needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.NIHR, Gates Cambridge Trus

Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience

The Improving Access to Psychological Therapies (IAPT) programme is a large-scale initiative that aims to greatly increase the availability of NICE recommended psychological treatment for depression and anxiety disorders within the National Health Service in England. This article describes the background to the programme, the arguments on which it is based, the therapist training scheme, the clinical service model, and a summary of progress to date. At mid-point in a national roll-out of the programme progress is generally in line with expectation, and a large number of people who would not otherwise have had the opportunity to receive evidence-based psychological treatment have accessed, and benefited from, the new IAPT services. Planned future developments and challenges for the programme are briefly described

Stress and burnout in Improving Access to Psychological Therapies (IAPT) trainees: a Systematic Review

For more than a decade, Improving Access to Psychological Therapies (IAPT) has been training a new workforce of psychological therapists. Despite evidence of stress and burnout both in trainee mental health professionals, and qualified IAPT clinicians, little is known about these topics in IAPT trainees. Consequently, this systematic review sought to establish the current state of the literature regarding stress and burnout in IAPT trainees. Electronic databases were searched to identify all published and available unpublished work relating to the topic. On the basis of pre-established eligibility criteria, 8 studies (including 6 unpublished doctoral theses) were identified and assessed for quality. This review identifies that research into the experience of IAPT trainees is under-developed. Existing evidence tentatively suggests that IAPT trainees may experience levels of stress and burnout that are higher than their qualified peers and among the higher end of healthcare professionals more generally. The experience of fulfilling dual roles as mental health professionals and university students concurrently appears to be a significant source of stress for IAPT trainees. More research regarding the levels and sources of stress and burnout in IAPT trainees is urgently needed to confirm and extend these findings. Recommendations for future research in the area are given