News: the power of evidence-based psychological therapies

Call for access to psychological therapies to double

Two of the key figures behind government reform in mental health care have spoken of the success of the Improving Access to Psychological Therapies (IAPT) initiative. Professor Lord Richard Layard, Emeritus Professor of Economics at the London School of Economics and Political Science (LSE), and clinical psychologist Professor David Clark (University of Oxford), were talking at the LSE to mark the launch of their new book Thrive: The Power of Evidence-Based Psychological Therapies.

In the special event, chaired by BBC journalist Andrew Marr, both authors referred to the pervasiveness of mental health problems. They argued, as in their book, that these problems have huge social impacts and huge economic costs yet they can be effectively treated by evidence-based psychological therapies: if only such treatments were more widely available. 

At the event, Professor Layard described mental illness as a ‘great hidden problem’ in our society, continuing: ‘Mental illness is a huge cause of misery and physical illness… The impact is huge, one of the things our research group has been doing is trying to identify the factors which cause the most misery in modern Western societies. We’ve been looking at evidence for Britain and many other countries. The story is always the same, that the single factor which explains the largest number of people who are in misery is mental illness.’

Professor Layard said mental illness was also a major cause of physical illness, adding that depression reduces life as much as smoking and that mental illness accounts for half of all disability in the UK, half of people on benefits and half of days taken off sick. He said that all of this adds up to around 8 per cent of the country’s GNP. Layard added: ‘David [Clark] and others have been developing effective psychological therapies which are evidence-based and which are achieving 50 per cent recovery rates and halving the risk of relapse… if you average from the mildest to the most severe, the average cost [of therapy] is £650. That’s a one-off cost. Against that, if someone is on benefits they are costing us £650 a month.

If we have more psychological therapy available what would we save? We would save as much on benefits and lost taxes as it would cost to expand psychological therapy.’

Layard said that since the programme began in 2008, 6000 new therapists have been trained in accordance with a national curriculum, services have been rolled out in every part of the country and this year IAPT was seeing three quarters of a million people, but he added that this was only a small fraction of the six million people in the UK with depression and anxiety problems. He asked all political parties to add into their manifestos a commitment to doubling the scale of the IAPT programme. He claimed there was no real, effective mental health lobby in the UK, and that this was understandable: ‘If you suffer from a mental health problem you’re not exactly going to go out demonstrating in favour of a better deal. It’s very much down to the general public who understand the importance of this issue to apply the pressure.’

Professor Clark spoke of the scope of evidence-based psychological therapies in their treatment of a range of disorders including depression, OCD and anxiety. He said it was a scandal that only 13 per cent of people with depression and anxiety have the chance to have such treatment. He pointed out that in the past, psychological therapy outcomes had not been well monitored and that therapists themselves had not always been kept abreast of new developments in therapies: ‘When keyhole surgery was developed surgeons were trained very systematically and quickly, but we don’t systematically train our staff.’

He continued: ‘We need to extend the benefits of IAPT to people with schizophrenia and bipolar disorder… The gap between availability and what you’d want is massive. One of the most effective interventions in schizophrenia is family therapy, which is very good for preventing people from having a relapse once they come out of hospital.’Professor Clark added that untreated mental health problems in childhood predict mental illness in adulthood and problems with conduct. He said: ‘For most children in this country with anxiety and depression you have to grow up before you get treatment. The government has created
a children and young person’s IAPT, but it’s very small. What we need is a clear and ambitious access target for children.’

The professors are now hoping that the scale of IAPT will be doubled by the next government throughout its time in power, including the training of another 6000 therapists.
- Ella Rhodes (ER)
- Watch the event at www.youtube.com/watch?v=a9eHyZmcLCk  

HCPC consult on standards of proficiency

The Health and Care Professions Council (HCPC) has launched a consultation asking stakeholders for their views on proposed changes to the standards of proficiency for practitioner psychologists.

The standards of proficiency are the threshold standards for safe and effective practice in the UK and play a key role in public protection. They are divided into generic standards (which apply to all of the 16 professions the HCPC regulate) and standards specific to each profession. They are used when an individual professional
applies for or renews their registration, or when concerns are raised about their competence. They are also used to approve education
and training programmes.

Director of Policy and Standards Michael Guthrie commented: ‘We are reviewing the standards of proficiency for practitioner psychologists to ensure they continue to be set at an appropriate level for entry to the HCPC Register and are reflective of current practice. After incorporating initial feedback from the British Psychological Society we are now seeking the views of a wide range of stakeholders on the standards generally. In addition, we would welcome comments on the use of the terms ‘evidence-informed’ and ‘service user’ in the standards. We will then analyse the responses to decide if any further changes are needed. We will then publish the final standards as approved by our Council and will then work with education and training providers to implement the new standards.’

The consultation will run to Friday 17 October 2014; to respond, visit www.research.net/s/standardsofproficiencyforpractitionerpsychologists to complete the 10- to 20-minute questionnaire

 

Dementia and driving
A new clinical pathway, published in the International Journal of Geriatric Psychiatry, has been developed to provide clinicians and health professionals with guidelines on how to manage, and give support and advice to patients with a diagnosis of dementia who continue to drive.

Many patients who receive a diagnosis of dementia continue to drive, and although guidelines have been issued for dementia these have not addressed the issue of driving. The new pathway incorporates UK legislation and clinical practice and gives a structure for health professionals on how to deal with these patients. It was developed at Newcastle University by a team of clinicians from Northumberland Tyne and Wear NHS Foundation Trust, with input from the DVLA.
Alongside the pathway, a web resource has been developed
that offers a supporting pack to the pathway, along with links to information on where further help can be found for clinicians, patients and families (https://research.ncl.ac.uk/driving-and-dementia). er

 

An inspirational woman
Clinical psychologist Dr Melinda Rees has been named as one of the top 50 most inspirational women in healthcare by the Health Service Journal. As of September Dr Rees is Clinical Director for Beacon UK, which is working to change the way health services are purchased on a national scale in the UK. She was previously Consultant Clinical Psychologist and Clinical Lead and Manager for iCope, a large IAPT service in Camden & Islington NHS Foundation Trust.

Dr Rees said: ‘It is wonderful to have been recognised among these prestigious colleagues who are making such a real difference to the quality of people’s lives. I am privileged to lead a high-quality, dynamic team which continues to adapt in its endeavours to meet the needs of local communities within the borough of Islington. Being the Clinical Lead of this service has been an honour.’

Dr Rees will feature in our ‘One on one’ in the coming months. er

 

Self-managing diabetes

A team from NHS Grampian was one of only a small number to be successful in a UK-wide competition to identify innovative approaches to improving the quality of health care. The Health Foundation Shine programme is supporting them with £75,000 to run and test their quality improvement ideas. 

The initiative involves developing ACT Now!, a web-based guided self-help intervention. The intervention is based on the principles of acceptance and commitment therapy (ACT) and aims to improve the ability of adults with Type 2 diabetes to effectively self-manage their condition and improve their emotional well-being. The programme will include modules designed to help reduce levels of anxiety and promote the self-care behaviours that anxiety inhibits, to alleviate fear of hypoglycaemia, as well as to increase activity and promote healthy eating.

Project Manager for ACT Now!, Dr Kirsty MacLennan, said: ‘Over 23,000 people have Type 2 diabetes in NHS Grampian and approximately half of them understandably struggle to self-manage their condition. This project offers a person-centred approach to more effective self-management.’

Dr Andy Keen, Consultant Health Psychologist, welcomed the opportunity to try this novel approach. He explained: ‘We need innovative and flexible options for people trying to manage complex chronic conditions like Type 2 diabetes. Whilst a strong theoretical component is crucial, it is also imperative that interventions are accessible and make sense to people from all walks of life.’

ACT Now! is currently in the design and recruitment phase and will go live from December 2014. er

 

Human Brain Project – putting the cart before the horse?

An ambitious venture to simulate the brain’s networks using supercomputers could be under threat after scientists involved with the large-scale Human Brain Project, which more than 80 European and international institutions signed up to take part in, wrote an open letter threatening to boycott the project if reforms were not made.

Many institutions refused to join the 10-year project at the outset because of its ‘fairly narrow approach’, the letter said. The neuroscientists added that after a Framework Partnership Agreement – for the second round of funding – was submitted this resulted in a further narrowing of goals for the project, including the deletion of 18 additional laboratories and the removal of a neuroscience subproject.

A formal review of the project has been scheduled to evaluate the success of the project’s so-called ramp-up phase. The letter, signed by more than 750 neuroscientists, said: ‘At stake is funding on the order of 50M€ per year European Commission for the “core project” and 50M€ in “partnering projects” provided largely by the European member states’ funding bodies. In this context we wish to express the view that the HBP is not  on course and that the European Commission must take a very careful look at both the science and the management of the HBP before it is renewed.

‘We strongly question whether the goals and implementation of the HBP are adequate to form the nucleus of the collaborative effort in Europe that will further our understanding of the brain.’

In a statement released by the project’s board of directors and executive committee, following the publication of the open letter, it said the project aimed to eventually move towards a multilevel reconstruction and simulation of the brain and attempted to address each of the concerns expressed in the letter.

Dr James Bednar, Director of the Doctoral Training Centre in Neuroinformatics and Computational Neuroscience (University of Edinburgh) was one of the original signatories of the letter and gave us his personal opinion on the project. He said the problem with the HBP was not its ambition but its focus and management. ‘The HBP is concentrating a huge amount of resources on one specific approach that the European neuroscience community simply doesn’t agree should be the priority. Moreover, it is being managed in a way that does not allow for meaningful external input, instead brushing aside serious criticism and concerns from numerous well-established researchers.’

Bednar said a particular issue was that the bulk of funding for the project was going towards developing a computing platform for simulating the human brain, but that there was little consensus on precisely how to go about simulating an entire brain and what type of simulations would be needed. He added: ‘It seems foolish to spend all our resources to develop specific hardware and software tools that the community does not agree are necessary or appropriate. Moreover, even if these were the right tools to build, we currently have only a tiny fraction of the biological data needed to constrain such a simulation so that it is modelling something meaningful. Thus there is very little point in investing in huge computing systems now, before such data is available, which will only be obsolete by the time we are ready to run detailed simulations grounded by data. The HBP is thus putting the cart before the horse, on a massive scale, without knowing what kind of cart we might eventually need. It is an ambitious, forceful step in the wrong direction.’ er

Scottish independence and academic research

Ahead of the Scottish independence referendum this month, the Presidents of the British Academy, the Royal Society and the Academy of Medical Sciences have written an open letter calling for a wider debate on the risks facing academic research if Scotland becomes an independent country.

The letter said that many people involved in research in Scotland were concerned about the issue but that some appeared to feel inhibited in expressing their views. They added: ‘We believe that if separation were to occur, research not only in Scotland but also in the rest of the UK would suffer. However, research in Scotland would be more vulnerable and there could be significant reductions in range, capability and critical mass. We have all gained much from integration and interaction in academic and research life, in which Scotland plays such a strong role.’ er

For a psychological discussion on the referendum see June’s issue of The Psychologist

 

‘Gamified’ neuroscience published

Initial findings from one of the largest cognitive science experiments ever conducted, involving tens of thousands of participants, have shown that mobile games can be used to address psychological questions, helping to form a better understanding of how cognitive functions differ across populations.

The Great Brain Experiment, a free mobile app run by neuroscientists at the Wellcome Trust Centre for Neuroimaging at UCL, uses ‘gamified’ neuroscience experiments to address scientific questions on a scale that would not be possible using traditional approaches. The app investigates memory, impulsivity, risk-taking and happiness. By playing the games, anyone can anonymously compare their abilities to the wider population and contribute to scientific research – More than 60,000 people have taken part so far.

The results, published in PLoS ONE, demonstrate that mobile games can be used to conduct research in psychology and neuroscience, reproducing previous findings. Writing in the journal, the researchers explained: ‘Smartphone users represent a participant pool far larger and more diverse than could ever be studied in the laboratory. By 2015, there will be an estimated two billion smartphone users worldwide. In time, data from simple apps could be combined with medical, genetic or lifestyle information to provide a novel tool for risk prediction and health monitoring.

’Rick Adams, a developer of the Great Brain Experiment based at the Wellcome Trust Centre for Neuroimaging at UCL, said: ‘The initial aim was simply to make the public more aware of cognitive neuroscience experiments, and how they are conducted. However, with such large numbers of people downloading the app and submitting their results, it rapidly became clear that there was the potential for studying task performance at an unprecedented scale.’ er

‘We should bring death back to life, into the open’

The prospect of having a law in place that would allow people to get help to end their own lives has caused UK-wide debate in recent months after House of Lords peers backed Lord Falconer’s Assisted Dying Bill at its second reading following a nine-hour debate of its proposals. More than 130 peers spoke at the debate on the Private Members’ Bill, which would make it legal for terminally ill adults to be given assistance to end their own lives – it would apply to people with less than six months to live.

There are obvious ethical and religious concerns that this bill would bring to light, were it to become law, but what would it mean from a psychological perspective? We spoke to specialists in pain, disability and palliative care for their views.

Pain
Pain specialist Professor Owen Hughes, Consultant Counselling Psychologist and Head of Pain and Fatigue Management, Powys Teaching Health Board, does not back the Assisted Dying Bill, despite living with a chronic pain condition himself and spending his life helping people to accept their own chronic pain.

He said that after being told that they are going to have to live with pain for the rest of their lives many believe that they are going to be miserable for the rest of their lives. He said it is important that people are shown that relying on themselves is a better way forward
than relying on health professionals.

He added: ‘There is a metaphor which is often used in acceptance and commitment therapy of the tramp at the party: A man is about to hold a huge party to celebrate his birthday. He has decorated the house, completed the catering and ordered the entertainment; just as the party is about to start he discovers that a tramp has moved into the shed in the garden. He now has a choice; he can focus his attentions and energies on trying to get the tramp to leave or he can accept that the tramp is there and is doing no harm and enjoy the company of his friends. Chronic (non-malignant) pain is like the tramp, and people can be helped to accept it and focus their energies on enjoying the rest of their life.’

He told The Psychologist: ‘Unfortunately, people can feel that they have lost control of their life and that ending their life (or at least thinking about it) can give them a sense that they do have one option open to them. As someone who has a chronic pain problem myself I have firsthand experience of how it can take over your conscious mind if you let it. I was lucky in that I had 15 years of practising the techniques beforehand. I certainly wouldn’t support assisted dying for people who have pain – I would support the greater availability of pain management. Once pain management is available to all in a timely and effective manner, if there is still a problem then I may reconsider my position, but I doubt it.’

Disability
Dr Brett Smith (Loughborough University), who has worked with disabled athletes in his research, said the Assisted Dying Bill had sparked debate throughout the disabled community. Dr Smith carried out research last year with spinal cord injury charity Aspire, and found that young men aged 18 to 26 often go straight from rehab care into care homes. He said: ‘These young men are thrown into a care home with 80-year-old people with dementia, so we wanted to look at the effects of this on their mental health and well-being.

‘Psychologically, unsurprisingly many experienced depression, it was very, very common amongst them and many reported low quality of life. Also, 25 per cent of them had attempted suicide, none of them had told the staff because they were worried their next port of call would be in a mental health institution. So they kept these attempts to themselves. This wasn’t their fault, the problem is that society doesn’t offer appropriate housing. If that was available it could benefit the ageing population as well.’

Dr Smith has been lobbying Parliament to change housing law, and
he said the Assisted Dying Bill could be glossing over the roots of some of the problems people with disabilities face:
‘If we take a leap straight into the Assisted Dying Bill people will feel under pressure and it may feel that it’s their only option. It’s not about disability per se but it’s a societal issue.

‘My own personal view is that we could be rushing into this, we need a more informed dialogue. It raises  a number of interesting questions, who is doing the campaigning? When it’s placed in the media often they ask celebrities with disabilities for their opinion or people in high positions in the Church, but where are the voices of the “ordinary” disabled people in this discourse?’

Dr Smith said it was important to remember that disability is not a homogeneous construct, and that people with varied disabilities and impairments need to join in the discussion, as well as people such as disability lawyers and psychologists. He added: ‘The other issue to me is that the bill may give the impression that disability equates simply to a tragedy or that becoming disabled equates to having a poor quality of life.

As a consequence, rather than ignoring why this can be the case or tracing such ideas to individuals, we need to trace disability and how people are perceived to broader issues in society.’

Palliative care
Professor Scott Murray (University of Edinburgh) St Columba’s Hospice Chair of Primary Palliative Care, has studied the trajectory of psychological distress in terminally ill lung cancer patients, as well as the effects of dealing with a terminal illness on family carers. His work has involved interviewing inoperable lung cancer patients from the point of diagnosis until death, a process of around six months. He said: ‘We’ve shown that people are typically most psychologically distressed four times throughout their disease progression. The first time, as you’d imagine, is when they’re told they have cancer. Then they go into hospital and it’s very reassuring so they start to
feel a bit better. Once they go home more questions come up and they dip again. As the disease progresses they dip back into anxiety and then at the very end of life they may be anxious again.’

Professor Murray said that if a clinician is able to talk through these various stages of distress at the point of diagnosis it can be useful for patients, as they will then be aware of what to expect. He told us: ‘Psychological help often occurs at the very end of life, but it would be better given at diagnosis. There are also existential issues which follow a similar trajectory, people often wonder about the meaning and purpose of life.’ 

Qualitative research by Professor Murray and his team has suggested that people should be given support at diagnosis. ‘That’s a huge issue. Just sitting and listening to someone can be helpful, you’re confirming their identity as a person. Also people with cancer get more psychological help than people who die in other ways; in people with a longer prognosis like in MS, frailty, heart failure or dementia, it’s hard to know when to give them this advice.’

Professor Murray said he is against the Assisted Dying Bill for a number of reasons: ‘I had an older lady whose husband had died and at that stage her house passed on to their children. The children threw her out of the house and I helped her to find a council house. It illustrates how nasty mankind can be. If we have this bill a lot of people would feel useless. It would turn into a duty for some people to die.

‘The fluctuations in psychological distress show that at some points, patients might want to die, but then they’ll feel better later. One or two people have bad pain that’s hard to treat, but if we don’t just think about painkillers but think about a person holistically, it’s pain that you don’t understand that’s unbearable, if you understand why you’re suffering it can be very therapeutic.’

He said that many of the advocates for assisted dying had illnesses with greater prognostic uncertainty and where palliative care and end-of-life issues had not been raised. If such people had been given the chance to discuss what might happen, they would feel more in control and able to seek other support rather than taking their own life. He said: ‘If you’re told what the progression will be like, psychologically, physically and existentially, and what various people will be able to do for you at those times, it can be a great support. It is a more uncertain prognosis, and it’s harder to know when it would be useful to have that conversation with people, but most patients do value such a conversation to understand what the future might hold, and to anticipate what they might do to stay on top of the situation.

‘We should give people an assessment and cover psychological and existential issues and then people may not feel like they need to have this choice to die. The euthanasia debate is helpfully bringing up the fact that we should have better psychological support from the point of diagnosis with life-threatening illness, it would help everyone, the 90 per cent of the population who don’t die suddenly. When people learn they might die, they have existential and psychological problems, and they should be allowed to speak to someone about how they feel. We should bring death back to life, into the open, and promote a greater public understanding of what it will hold for us all… even before we need to know.’

Where are the supporters?According to figures from Dignity in Dying, 80 per cent of the general public support assisted dying. So why were we unable to find psychologists to speak in favour of the bill? Perhaps there is a desire in the community to address and resolve issues rather than using this quicker means to an end. To add your voice to  the discussion, send your letters for consideration to [email protected].

The Assisted Dying Bill now goes forward to a Committee of the whole House for scrutiny. ER