Increasing access to low intensity psychological intervention. (ICS-09)
Submitting Institution
University of ManchesterUnit of Assessment
Allied Health Professions, Dentistry, Nursing and PharmacySummary Impact Type
HealthResearch Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Depression and anxiety are common, cause significant disability and are
costly to the individual, the NHS and wider society. UK management of
depression and anxiety has been revolutionised as a result of our research
at the University of Manchester (UoM) on low intensity psychological
interventions (cognitive behaviour therapy (CBT) based Guided Self-Help
(GSH)) which is the primary form of care for hundreds of thousands of
people with depression and anxiety disorders (including generalised
anxiety disorder, post-traumatic stress disorder, obsessive-compulsive
disorder) through the "Improving Access to Psychological Therapies" (IAPT)
scheme. Between 2009 and 2012 more than one million people used the new
services, recovery rates are in excess of 45% and consequently 45,000
people have moved off benefits.
Underpinning research
See section 3 for references [1-6]; see section 5 for corroborating
sources (S1-S9); UoM researchers are given in bold. In REF3a and
REF5 this case study is referred to as ICS-09.
The impact is based on research that took place at the University of
Manchester from 1998-2013.
Key Researchers
-
Karina Lovell (Lecturer, 1998-2002; Senior Lecturer, 2002-2005;
Professor, 2005-date)
-
David Richards (Research Fellow, 1999-2002; Senior Lecturer,
2002-2004)
-
Penny Bee (Research Associate, 2002-2007; Research Fellow,
2007-2008; Lecturer 2008-2012; Senior Lecturer 2012-date)
-
Peter Bower (Research Fellow, 1995-2002; Senior Research
Fellow, 2002-2007; Reader, 2007-2012; Professor of Health Services
Research, 2012-date)
-
Judith Gellatly (Research Associate, 2004-date)
-
Anne Rogers (Senior Research Fellow, 1996-1999; Professorial
Fellow, 1999-2012)
-
Chris Roberts (Senior Research Fellow, 1997; Senior Lecturer,
1997-2004; Professor, 2004-date)
Our research showed that there was an urgent need, due to population
demand, to deliver psychological interventions in a more time efficient
and accessible manner [1]. In response to this we have developed and
evaluated low intensity psychological interventions, namely CBT based
Guided Self Help (GSH). We have also developed and evaluated delivery of
CBT by telephone, an approach implemented nationally by the "Improving
Access to Psychological Therapies" (IAPT) scheme.
We demonstrated that GSH is effective for both depression and anxiety
[2]. We developed GSH and demonstrated its benefit in anxiety and
depression via case studies, uncontrolled studies and RCTs [3] (Lovell
et al., BJGP 2003 53:133-5, Mead et al., Psychol Med
2005 35:1-11, Fletcher et al., Behav Cogn Psychoth 2005
33:319-31). We also showed that guided self-help is acceptable to service
users (Rogers et al., Patient Educ Couns 2004 53, 41-46,
MacDonald et al., Int J Soc Psychiat 2007 53:23-35). We
have developed culturally-sensitised GSH materials for the older person
and black and minority ethnic (BME) groups (Dowrick et al. Programme
Grants Appl Res 2013; 1(2)).
We demonstrated that the telephone can overcome many of the social,
physical and economic barriers which prevent access to mental health
services. Our research showed how remotely delivered therapy is effective
[4]. We then established the clinical and cost effectiveness of
telephone-delivered cognitive behaviour therapy (T-CBT) in a range of
service users including adults and young people with obsessive compulsive
disorder (OCD) [5] (Turner et al., Behav Cogn Psychoth 2012
37:469-74). We showed that T-CBT leads to medium-large effects on clinical
and work productivity outcomes (Bee et al., Gen Hosp Psychiat
2010 32:337-40). We demonstrated the clinical and cost effectiveness of
T-CBT with people with chronic pain [6].
References to the research
The research has developed as a result of a number of successful,
competitively awarded grants, including from the NIHR, MRC and ARC (now
AR-UK). The papers are published in leading journals in their respective
fields.
Key Publications
2. Gellatly J, Bower P, Hennessy S, Richards D, Lovell
K (2007). What Makes Self Help Interventions Effective in the
Management of Depressive Symptoms? Meta-analysis and Meta-regression. Psychological
Medicine 37, 1217-1228 DOI:
10.1017/S0033291707000062
3. Lovell K, Bower P, Richards D, Barkham M, Sibbald B, Roberts
C, Davies L, Rogers A, Gellatly J,
Hennessy S. (2008) Developing Guided Self Help for Depression using the
Medical Research Council Complex Interventions Framework: a description of
the modelling phase and results of an exploratory randomised controlled
trial: BMC Psychiatry, 2008, 8, 91 DOI: 10.1186/1471-244X-8-91
4. Bee P, Bower P, Lovell K, Gilbody S, Richards D,
Gask L, Roach P. (2008). Psychotherapy mediated by Remote
Communication Technologies: a meta-analytic review: BMC Psychiatry,
2008, 8, 60. DOI: 10.1186/1471-244X-8-60
5. Lovell K, Cox D, Haddock G, Raines D, Garvey R, Roberts
C, Hadley S. (2006). Telephone Administered Cognitive Behaviour
Therapy for Treatment of Obsessive Compulsive Disorder: A randomised
controlled non-inferiority trial: British Medical Journal, 333,
883 DOI: 10.1136/bmj.38940.355602.80
6. McBeth J, Prescott G, Scotland G, Lovell K, Keeley
P, Hannaford P, McNamee P, Symmons DPM, Woby S, Gkazinou C,
Beasley M, Macfarlane GJ (2012). Cognitive Behaviour Therapy,
Exercise or Both for Chronic Widespread Pain. Archives of Internal
Medicine, 2012; 172:48-57. DOI: http://dx.doi.org/10.1001/archinternmed.2011.555
Details of the impact
See section 5 for numbered corroborating sources (S1-S9).
Pathways to impact
Our work on developing accessible, acceptable and evidence-based low
intensity interventions began in 1998, prior to IAPT, through strong
collaborations with researchers at the National Primary Care Research and
Development Centre at UoM. We have conducted systematic reviews,
uncontrolled studies, RCTs and qualitative work to establish the evidence
base and acceptability to both users and those delivering services. We
established the first Guided Self Help Clinics across 36 GP practices in a
then Primary Care Trust. Lovell has trained in excess of 2,000 UK
Psychological Well-being Practitioners, Cognitive Behaviour Therapists and
other mental health practitioners to deliver GSH both face to face and via
the telephone. Once we had shown that low intensity interventions are
effective and acceptable to service users we adapted these interventions
for `hard to reach' groups, e.g., BME and older people.
One of our guided self-help books, based on our research, `A Recovery
Programme for Depression' (Lovell and Richards, London:
Rethink Mental Illness 2012) was used as the principal self-help material
for the national IAPT NHS demonstration site (Doncaster) and was used by
more than 6,000 patients. Lovell has led the development of a range
of other GSH books for specific difficulties including agoraphobia, OCD,
chronic pain, chronic oro-facial pain, irritable bowel syndrome. Our more
recent work has focussed on developing and delivering low intensity
interventions for people with depression and long term conditions
including diabetes, coronary heart disease, chronic widespread pain and
chronic oro-facial pain.
Reach and significance of the impact
Impact on practice
The findings of our research on low intensity interventions have been
widely implemented and have led to significant benefits for people with
common mental health problems. Telephone-delivered psychological
interventions have proved a significant benefit for those who are unable
(or who prefer not to) attend scheduled face-to-face appointments and we
have shown that it is highly cost effective. Our work with BT plc tested
the use of telephone-CBT and GSH (Bee et al., Gen Hosp Psychiat
2010 32:337-40), demonstrating effects on clinical and work productivity
outcomes. Based on these findings telephone-CBT and GSH have been
implemented across the company (approx. 73,500 employees). Since the
inception of the service there have been 1530 referrals, as confirmed by
the BT Group Wellbeing Adviser (S1).
Our recovery book `A Recovery Programme for Depression' is used in IAPT
services across the UK and has been endorsed by Rethink (a large national
user charity), which has the licence to publish the book on a
not-for-profit basis (S2). Between 11,000 and 13,000 manuals are sold each
year.
We have recently released the licence for our self-help manual for
chronic widespread pain and we have received requests to use the manual
from St Bartholomew's Hospital (UK) and the Mayo clinic (US). We have
recently given `beyondblue' (an Australian national initiative to
create a community response to depression) permission to print the
materials in Australia for clinical, research and teaching purposes.
A large naturalistic observational study, not involving us but based on
our work, of 7 IAPT services which included more than 7,000 patients in
the East of England evaluated face-to-face and telephone-based
psychological interventions (S3). This evaluation found that the clinical
effectiveness of low intensity CBT-based interventions delivered by
telephone was as good as face-to-face CBT except for people with more
severe illness and cost 36% less per session than face to face CBT.
(Hammond GC et al., PLoS ONE 2012 7(9): e42916)
In 2002, in partnership with Anxiety UK, a large national user charity
which has supported more than a million people with anxiety, we developed
and implemented a T-CBT and more recently Skype service for people unable
to access face to face therapy. The service has seen a year on year
increase in referrals for telephone-CBT and currently receives in excess
of 400 referrals per year (S4). Lovell has provided written
guidelines for telephone-CBT and provided regular training to volunteers
and therapists. Anxiety UK also distributes Lovell's
self-help manuals on agoraphobia and obsessive compulsive disorder freely
to their members. Feedback from users has found that these self-help
manuals are regularly downloaded from their website and acceptable to
members (S5).
Impact on policy
National (UK) policy increasingly advocates the use of the telephone to
deliver psychological interventions, based on our work. Our work is cited
in the national IAPT National Programme Educator Materials to Support the
Delivery of Training for Psychological Wellbeing Practitioners Delivering
Low Intensity Interventions (S6). Lovell has also contributed to
the national IAPT `Good practice guidance on the use of self-help
materials within IAPT services' (S6).
Lovell and Bower were co-investigators in the national
external evaluation of IAPT implementation at demonstrator sites, funded
by the NIHR Service Delivery and Organisation programme (S7).
Our research has contributed to treatment recommendations influencing
current clinical practice in the following NICE guidelines: Post-Traumatic
Stress Disorder (CG26); Depression (CG23, update CG90); OCD (CG31) and OCD
Evidence Update (2013) (S8).
Lovell has been a member of the NICE guideline development group
for both OCD (CG31), which recommend telephone delivered low intensity
interventions for OCD, and the updated Anxiety guidelines (CG113) (S9).
She developed implementation tools for the clinical case scenarios, the
evidence update for generalised anxiety and the NICE pathway for OCD (S9).
Sources to corroborate the impact
S1. Corroborating email from BT Group Wellbeing Adviser.
S2. http://www.rethink.org
S3. Corroborating email from Professor of Psychiatry, University of
Cambridge.
S4. http://www.anxietyuk.org.uk
S5. Letter from CEO, Anxiety UK.
S6.http://www.iapt.nhs.uk/silo/files/reach-out-educator-manual.pdf
http://www.iapt.nhs.uk/silo/files/good-practice-guidance-on-the-use-of-selfhelp-materials-within-iapt-services.pdf
S7. www.nets.nihr.ac.uk/projects/hsdr/081610154
S8. See:
S9. See: