Good practice,evidence base and implementation issues for psychological therapies for psychosis

Good practice,evidence base and implementation issues for psychological therapies for psychosis Professor Elizabeth Kuipers King s College London, Institute of Psychiatry Department of Psychology Chair of the NICE Guideline Development Group Schizophrenia update 2009 & 2011-13 IAPT Severe Mental Illness Stakeholder Event, Resource Centre for London, Holloway 23 rd November 2011

Overview - Evidence base for psychological therapies for psychosis - CBTp - FIp - CRT - The implementation challenges - The future E. Kuipers, KCL, IOP 23/11/11 2

NICE Guidelines for Schizophrenia Update (2009) 1. Better access & engagement for BME groups, staff training in equalities. 2. Medication tailored to people s individual responses & preferences. 3. Psychological therapies FI & CBT recommended, consider arts therapies. 4. Physical health checks GPs should monitor at least once a year. E. Kuipers, KCL, IOP 23/11/11 3

FI was described as discrete psychological interventions where:- Family sessions have a specific supportive, educational or treatment function and contain at least one other of the following components - problem solving/crisis management work - intervention with the identified service user E. Kuipers, KCL, IOP 23/11/11 4

CBT was defined as a discrete psychological intervention where service users: establish links between their thoughts, feelings or actions with respect to the current or past symptoms, and/or functioning, and re-evaluate their perceptions, beliefs or reasoning in relation to the target symptoms. In addition, a further component of the intervention should involve the following: service users monitoring their own thoughts, feelings or behaviours with respect to the symptom or recurrence of symptoms, and/or promotion of alternative ways of coping with the target symptom, and/or reduction of distress, and/or improvement of functioning. E. Kuipers, KCL, IOP 23/11/11 5

CRT (single modality intervention) defined as: an identified procedure that is specifically focused on basic cognitive processes, such as attention, working memory or executive functioning, and having the specific intention of bringing about an improvement in the level of performance on that specified cognitive function or other functions, including daily living, social or vocational skills (NICE 2009 update p. 276) E. Kuipers, KCL, IOP 23/11/11 6

Critical outcomes:- Mortality (suicide) Global state (relapse, rehospitalisation) Mental state (total symptoms, depression) Psychosocial functioning Family outcomes (including burden) Quality of life Leaving the study early for any reason Adverse events E. Kuipers, KCL, IOP 23/11/11 7

Psychological Therapies NICE Guidelines for Schizophrenia Update (2009) We now have good evidence that CBT and FI for psychosis works. CBT evidence: 31 RCTs reviewed, quality checks on methodology (N=3052). (22 new trials) Small but clear effect size on symptoms, including depression, but not on relapse rates. FI for psychosis evidence: 38 RCTs met quality checks (5 were follow ups) (N=3134). 32 studies (19 new trials) (N=2429) included in meta analysis. FI reduces relapse consistently. These are substantial gains, considering the fact that the effects of such psychological treatments add to medication. Pfammatter et al (2011) p.s1. (Schizophrenia Bulletin, 37 suppl 2, S1-S4) E. Kuipers, KCL, IOP 23/11/11 8

Cognitive Remediation Therapy (CRT) 25 trials (N=1,390) met quality criteria Overall no consistent evidence that CRT alone is effective in improving critical outcomes (p.282) such as: - cognitive improvement at follow-up, relapse rates, rehospitalisation, mental state or quality of life. E. Kuipers, KCL, IOP 23/11/11 9

NICE Guidelines for Schizophrenia Update (2009) Recommendations: - Offer CBT to people with schizophrenia which can be started in acute phase. Should be more than 16 sessions. - Offer Family Intervention to families of people with schizophrenia who are living with or in close contact with the service user, also can be started in acute phase. Should be 3-12 months, more than 10 sessions. - Consider offering arts therapies to people with schizophrenia, particularly for alleviation of negative symptoms (evidence base 7 RCTs). - CRT not recommended at this time. (Review of evidence planned 2011-2013.) E. Kuipers, KCL, IOP 23/11/11 10

Other evidence for CBTp for psychosis 14 studies, 1484 patients; effect size 0.37 (Zimmerman et al 2005). 19 studies Cochrane Review (Jones et al 2005). 17 studies consistent evidence for persistent positive symptoms (effect size 0.47) (Pfammatter et al 2006). 33 trials (N=1964); effect size 0.4 but linked to trial quality. Modest effects on positive symptoms (Wykes et al 2008).. PRP - N=301 (Garety et al 2008) CBT reduced depression (after 2 years) but not relapse. Those with carers had better outcome with CBT or FI. Dunn et al (2011) those who received full therapy improved on months in remission, positive and affective symptoms. Sarin et al (2011) Meta analysis, 22 studies (N=2469) - CBTp improved positive symptoms, negative symptoms and general symptoms. More than 20 sessions had better outcomes. Kingberg et al (abstract) POSITIVE trial (N=330). Improvements on positive symptoms at 18 months E. Kuipers, KCL, IOP 23/11/11 11

Grant et al (2011) Archives of General Psychiatry RCT of CBTp for low functioning patients with schizophrenia CBTp and TAU v. TAU 18 months recovery programme (N=60) CBTp successfully improved functional outcome, motivation and positive symptoms in low functioning patients with significant cognitive impairments E. Kuipers, KCL, IOP 23/11/11 12

Other evidence for FIp Cochrane Review - Pharoah et al (2006); another 15 trials (+ previous 13) confirm that FI reduces relapse and hospital admissions, encourages compliance with medication, and may improve social impairment and reduce EE. Pharoah et al (2010) Update. Another 21 studies (53 RCTs): FI may reduce relapse and re-admission (N=2981), improve social impairment and reduce EE. E. Kuipers, KCL, IOP 23/11/11 13

PORT (2009) Dixon, L.B. et al, Schizophrenia Bulletin PORT (2009) recommends FI & CBT for persistent symptoms. E. Kuipers, KCL, IOP 23/11/11 14

CRT evidence Wykes et al 2011 American Journal of Psychiatry CRT meta analysis (N=2104), 40 studies (RCT) 70% had diagnosis of schizophrenia Effects on global cognition (effect size 0.4) and functioning, at post treatment and at follow up CRT more effective when patients clinically stable Stronger effects found when CRT combined with adjunctive rehabilitation E. Kuipers, KCL, IOP 23/11/11 15

Predictions of responsiveness for CBTp Belief flexibility chink of insight predicts better outcomes (Garety et al 1997). Dorsolateral Prefrontal Cortex activity & its connectivity to the cerebellum predict responsiveness to CBT for psychosis. People probably do better with CBT if they have better planning & working memory. (Kumari et al 2009). Freeman et al (submitted) PRP sample. People with psychosis more likely to engage in full therapy if they have psychological view of their problems including potential to gain control over them (IPQ data). E. Kuipers, KCL, IOP 23/11/11 16

Neural changes in response to CBT for psychosis (Kumari et al 2011, Brain) 28 CBT+TAU vs 28 TAU (non-randomised but selection out of researcher control) Blind rating of symptoms CBT group improved, TAU did not (6-8 Mo FU) fmri during an affect processing task at baseline and FU (FU: 22 CBT, 16 TAU completers) E. Kuipers, KCL, IOP 23/11/11 17

Neural changes in response to CBT for psychosis At FU: CBT decreased activation of the inferior frontal, insula, thalamus, putamen and occipital areas to fearful and angry expressions Reduction of fmri response in inferior frontalinsular and occipital clusters during angry expressions correlated directly with symptom improvement E. Kuipers, KCL, IOP 23/11/11 18

Neural changes in response to CBT for psychosis (differences of the differences) CBTp may mediate symptom reduction by promoting processing threat in a less distressing way (Kumari et al 2011 p.2) E. Kuipers, KCL, IOP 18/07/11 E. Kuipers, KCL, IOP 23/11/11 19

Summary re effectiveness - CBTp Some evidence that depression and persistent positive symptoms of psychosis can be improved some patients more likely to respond (Garety et al 2008; Dunn et al 2011). New evidence that negative symptoms improve (Grant et al 2011). Emerging evidence from early intervention services that CBTp (&FIp) helpful (Bird et al 2010). Prodromal studies suggest CBT can be useful even without medication (but transition rates low) (French et al 2003; Morrison et al 2007; Addington et al 2011). New evidence for neural changes after CBT (Kumari et al 2011). Still controversial (Lynch, Laws & McKenna 2010). E. Kuipers, KCL, IOP 23/11/11 20

Carers and service users want more access to talking therapies. They improve outcomes evidence consistent over last 20 years (CBTp) and 30 years (FIp). We have evidence that these Psychological therapies do not do harm, or have unpleasant side effects, unlike many pharmacological treatments. E. Kuipers, KCL, IOP 23/11/11 21

BUT:- Psychological therapies: Evidence based but unavailable noted by Anderson and Adams talking about FI in 1996. Since 2002, NICE Guidelines have consistently recommended both CBT and FI. Availability is patchy, dependent on local initiatives. People not getting the treatments they need. E. Kuipers, KCL, IOP 23/11/11 22

What are the issues re implementation? E. Kuipers, KCL, IOP 23/11/11 23

Challenge of implementation in South London and Maudsley NHS Foundation Trust (Professor Philippa Garety & Dr Suzanne Jolley) Mental health, learning disabilities and addictions services; national specialist services; large R&D portfolio. Trust income 330M p.a.; 4,500 staff Core population - 4 South London Boroughs 1.1million; inner city, very high indices of social deprivation Substantially raised rates of psychosis, especially in ethnic minority populations (x4-9) E. Kuipers, KCL, IOP 23/11/11 24

Audit of provision in 16 teams, over 2 years (1900 clients) 100% 90% N=126 N=57 80% 70% Received Refused/Waiting Not Offered 60% 50% Community Teams Specialist Teams E. Kuipers, KCL, IOP 23/11/11 25

Conclusions (Prytys et al 2011) Audited provision remained low around 10% for CBTp and 5% for FIp. Barriers to implementation included pessimistic staff views (on recovery), misunderstanding of who was suitable for psychological therapy, heavy caseload, and pressure of other tasks. Need for highly trained and supervised staff. No funding for implementation E. Kuipers, KCL, IOP 23/11/11 26

Another model (in SLAM) a specialist psychology led, CBTp clinic (O/P) is PICuP (Psychological Interventions Clinic for outpatients with Psychosis) PICuP Team: Prof Kuipers (Founding Director) Dr Peters (Director) Dr Louise Johns (Consultant) Dr Juliana Onwumere (Consultant) Dr Elaine Hunter (band 8b) Dr Nadine Keen (band 8b) Psychology assistant Dorothy Abrahams (Administrator) CPD therapists (between 2-10 band 7-8c) DClinPsy trainees (between 2-5) 27 E. Kuipers, KCL, IOP 23/11/11

What does PICuP offer? For service-users: CBT for psychosis: CBT for psychosis booklet and other self-help literature (as recommended by NICE) weekly or fortnightly individual 1 hour sessions At least 6 months therapy (median = 16 sessions (range: 1-63)) Of those who engage (5+ sessions; 74%), 63% receive 16+ sessions (NICE recommendation) 100% are seen for assessment within 13 weeks 81% were seen for therapy within 18 weeks last year Suitability criteria: not inpatients distressing unusual experiences (positive psychotic symptoms; not diagnosis based) secondary emotional disturbances (in context of history of psychosis) not predominantly negative symptoms motivated to attend E. Kuipers, KCL, IOP 23/11/11 28

Who are our service-users? 53% are from ethnic minorities (N=304) 60.5% are male (N=351) Mean age of 38 (range 15-65) (N=351) 80% single (N=316), 50% have carer (N=30) Mean length of illness is 8 years (range 0-32) (N=74) Mean of 2.8 inpatient admissions (range 0-20) (N=74) 96% are on antipsychotic medication (N=74) E. Kuipers, KCL, IOP 23/11/11 29

Mean 9-month cost (2005/6 s) Randomised Controlled Trial (Peters et al, 10, Acta Psychiatrica Scandinavica) therapy costs are off-set by fewer inpatient costs at 3 months follow-up 14000 12000 10000 8000 6000 12,558 9018 6602 7236 Therapy Inpatient care Non-inpatient care (N = 74) 4000 2000 0 Therapy (baseline) Control (baseline) Therapy (follow-up) Control (follow-up) 30 E. Kuipers, KCL, IOP 23/11/11

Summary of what PICuP offers What we offer service-users: Individual CBT for psychosis with demonstrated improvements in psychotic symptoms, emotional disorders, and quality of life & functioning at the end of therapy, all of which are sustained at +6 months follow-up 90% are satisfied with therapy Access for ethnic minorities to specialist psychological therapies What we offer therapists: Free supervision to team therapists to develop and maintain skillbase in CBT for psychosis Access to PICuP supervision increases frequency of CBT for psychosis done in teams, and amount of supervision offered to colleagues in teams What we offer referrers: Help to implement NICE guidelines in boroughs for their complex patients Independent assessment reports and liaison with team throughout therapy 31 E. Kuipers, KCL, IOP 23/11/11

The future: (1) CBTp & FIp are not just add ons to medication. They should be part of a comprehensive service together with appropriate medication, vocational help and recovery plans. Unmet requirement for staff training and ongoing supervision needs to be solved. E. Kuipers, KCL, IOP 23/11/11 32

The future: (2) Early Intervention for psychosis services in UK (& elsewhere). They offer a model, are effective; Bird et al (2010). But we should be offering high quality, comprehensive needs led services at all stages of presentation (of psychosis) early, medium or later, including optimism and hope of recovery. (Kuipers 2008 p. 159) E. Kuipers, KCL, IOP 23/11/11 33

The future: (3) The usefulness of low intensity interventions: for CBTp offers specific goal directed help for anxiety and depression good outcomes in pilot (N=12) Walker et al (in preparation) E. Kuipers, KCL, IOP 23/11/11 34

The future: (4) Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse but is particularly difficult to implement. It is now time to consider theory-based interventions focused on improving carer outcomes. Kuipers, E. et al (2010) BJP, 196, 259-265. I am currently advocating that psychosis carers need their own service. Kuipers, E. (2010) E. Kuipers, KCL, IOP 23/11/11 35

Other groups are agreeing that stepped care might be particularly helpful to ensure more FIp implementation, with a focus on reducing distress. initial engagement No Yes still distressed? information No Yes still distressed? 4/5 crisis meetings No Yes still distressed? hi intensity FI (Cohen et al 2008) E. Kuipers, KCL, IOP 23/11/11 36

- Up to 40% of carers are clinically depressed (Kuipers et al 2010) could use this as a marker for hi intensity FI. - Low intensity interventions could include engagement information, and/or crisis meetings for 60% of families. - One model for low intensity FIp. Carers tell us they need information and their questions answered. - Need to show evidence for this model. E. Kuipers, KCL, IOP 23/11/11 37

www.mentalhealthcare.org.uk Funded by the Wellcome Trust Reliable and up-to-date information about psychosis for family members and friends 38 E. Kuipers, KCL, IOP 23/11/11