Older adults are nationally under-represented in IAPT with only 6.5% accessing IAPT and 6% within Sheffield IAPT. This highlights the proportion of people over 65 years old referred to IAPT services is lower than the proportion in the general population, however once referred data indicates that a greater proportion complete treatment and achieve better outcomes. We are currently developing Older Adult, Perinatal Mental Health, BAME referral pathways and groups, providing champion roles for staff within the service. We are committed to offering the right treatment at the right time whilst working in partnership with organisations and service users to enhance our interventions.
Co-Production
From start: No
During process: No
In evaluation: Yes
Evaluation
Peer: No
Academic: Yes
PP Collaborative: No
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Heather Stonebank - Lead Psychological Wellbeing Practitioner Sheffield IAPT South East Team
Sheffield is the 4th largest city in England with a population of 587,400. Sheffield Improving Access to Psychological Therapies (IAPT) exceeds over 12,000 people entering treatment each year, achieving our extended access standard of 18%. Sheffield IAPT was launched in 2008, a key strength of the service is our integration into primary care with PWPs, CBT therapists and Counsellors based in 85 GP practices across Sheffield, we also have a central self-referral team. Sheffield IAPT offer a wide range of NICE recommended evidence based treatments at Step 2 and Step 3 from one to one sessions, computerised Cognitive Behavioural Therapy, Psychoeducational groups such as Stress Control, Improving Wellbeing Sessions, Long-term condition and Pain management groups at Step 2 and also a Behavioural Activation group for depression, Mindfulness Based Cognitive Therapy and couples counselling for depression at Step 3. We offer Skype sessions and are currently developing our Step 2 group sessions for diverse patient populations and working towards offering online group sessions.
As a service we are constantly striving for continuous quality improvement and working in partnerships with other services to improve access, quality of care and patient experience. An objective of our service is to increase access to under-represented groups to ensure we are promoting equality and offering effective evidence-based interventions to meet the needs of diverse patient populations. Sheffield IAPT believes in supporting research to inform guidelines and improve clinical practice. We have strong links with the University of Sheffield and believe it is important we are providing opportunities to contribute to guidance to improve evidence-based interventions and quality of patient care.
Adapting our groups and interventions to meet the needs of diverse patient populations is a priority for the service in line with the Mental Health Five Year Forward View (MH5YFV). We are currently developing Older Adult, Perinatal Mental Health, BAME referral pathways and groups, providing champion roles for staff within the service. We are committed to offering the right treatment at the right time whilst working in partnership with organisations and service users to enhance our interventions.
The Challenge
Ten million people in the UK are over 65 years old. Older adults are nationally under-represented in IAPT with only 6.5% accessing IAPT and 6% within Sheffield IAPT. This highlights the proportion of people over 65 years old referred to IAPT services is lower than the proportion in the general population, however once referred data indicates that a greater proportion complete treatment and achieve better outcomes. It is a national priority for IAPT services to increase access for older adults to 12% and to offer more treatment choice.
The older adult population in Sheffield by 2020 is projected to rise to 97,000 and 8,349 are predicted to have depression and 26,029 people affected by long term conditions and illness which impact their day to day activities a little and also 27,910 people affected by long term conditions and illness which impact their day to day activities a lot. The MH5YFV suggests that people with long term conditions are more likely to suffer complications if they also develop mental health problems and those with long term conditions are more likely to experience a mental health problem. Therefore highlighting the importance of improving access and providing effective evidence-based treatments for older adults.
Generalised anxiety disorder (GAD) is also a common disorder in older adults. Prevalence rates of GAD in older adults are estimated to be between 3.4% and 6.3% (Allgulander, 2006; Golden et al., 2011; Wittchen et al., 2011). Older adults are found to prefer psychological therapy over medication for the treatment of anxiety conditions (Mohlman, 2012).
A systematic review, meta-analysis and meta-regression titled ‘Efficacy of Cognitive Behavioural Therapy for Generalized Anxiety Disorder in Older Adults’ (Hall et al., 2016) found CBT was more helpful for GAD than having no treatment in later life. The study concluded that CBT should be routinely offered to older adults presenting with GAD, given that this level of evidence is not currently available for other psychotherapeutic approaches to the treatment of GAD in older adults. The meta-analysis suggested that there was no significant difference between group and 1-2-1 treatment outcomes for late life GAD, suggesting that group delivery may be a viable option. NICE currently recommends pharmacotherapy, Cognitive Behavioural Therapy (CBT), or applied relaxation to treat GAD in adults (NICE, 2011). However, no specific recommendations are made for older adult patients, due to lack of credible evidence.
Therefore, creating a group based intervention would be an ideal solution to increase access rates and treatment choice for older adults with GAD. Also other benefits of group therapy include reduced social isolation and shared empathy, which are particularly relevant for older adults given reductions in mental wellbeing associated with loneliness.
How It Worked
Sheffield IAPT were approached by the Sheffield Older Adult Community Mental Health Team (OACMHT) and University of Sheffield to work collaboratively in designing and evaluating a group treatment for GAD for older adults. This was termed the Older Adults Overcoming Worry Group (OWG) which designed to run for 12-weeks.
The Older Adults Overcoming Worry Group research study created an opportunity to work collaboratively with the OACMHT and to contribute to providing an evidence base for group treatments for older adults. The current study also created the opportunity to increase access and offer more treatment choice for older adults presenting with symptoms of GAD within Sheffield OACMHT and Sheffield IAPT.
Sheffield IAPT worked in collaboration with the OACMHT and University of Sheffield to also design the evaluation to assess the acceptability and effectiveness of the OWG to contribute to the evidence base concerning group treatment of older adult GAD.
The Older Adults Overcoming Worry Group
The OWG is a 12 week group for 2 hours each week. The group was designed and facilitated by Dr Shonagh Scott, Principal Clinical Psychologist and Dr Manreesh Bains, Senior Clinical Psychologist, Sheffield OACMHT. The group was based on the Dugas and Roubichaud (2007) adult protocol used in IAPT for the 1-2-1 treatment of GAD. The treatment protocol had encouraging results with working age adults in group and individual settings, and with older adults at an individual level in a small multiple baseline study (Dugas et al., 2010; Dugas et al., 2003; Ladouceur, Leger, Dugas, & Freeston, 2004). However, the protocol had not yet been tested with older adults in a group setting. The research was undertaken by Jo Hall DClinPsych student and Dr Steve Kellet HCPC Registered Practitioner Psychologist Consultant Clinical Psychologist and IAPT Programme Director.
Dugas and Roubichaud (2007) GAD treatment protocol is based on a cognitive model of GAD containing four main features:
Intolerance of uncertainty
Positive beliefs about worry
Poor problem orientation
Cognitive avoidance
Inclusion Criteria for the group:
Aged over 65 years, and already in contact with mental health services
GAD as the primary complaint, and to have scored >8 on the generalised anxiety disorder scale (GAD-7; Spitzer, Kroenke, William, & Löwe, 2006)
Willing, and able, to attend the 12-week group CBT intervention
Able to read, write, and understand English
The OACMHT opened up the referral pathway to the group to include IAPT and Dr Scott and Dr Bains attended IAPT forums and created a poster to advertise the group. IAPT older adult champions then continued to promote the OWG by discussing at profession specific forums and sending reminder emails. The OWG was routinely offered within IAPT to patients who matched the inclusion criteria above. The referrals would then be contacted by the OWG facilitators who screened for suitability to attend the group at an initial assessment appointment.
Impact
There were 3 OWGs in total. One pilot group was delivered where feedback was obtained and the protocol was adapted accordingly. The adaptations included increasing the number of older adult specific clinical examples within the manual, adaptations to the worksheets, and increasing the detail provided to facilitators in the delivery manual.
The results of the Older Adult Overcoming Worry group were as follows:
Referrals
Referrals for 37 potentially eligible patients were received (28 from IAPT and 9 from CMHTs), 87% opt-in rate for treatment and 65% opt-in rate for research.
This included 13 patients who agreed to partake in the research study – 2 dropouts at the end of treatment and 1 dropout at follow-up.
Design
Patients were asked to complete measures at three time points: at the beginning of the group, at the end of the group and 8 week follow up. Both patients and facilitators completed short interviews at the end of treatment.
Recovery
Reliable and clinically significant improvement is an accepted measure of recovery:
Measures were taken pre, post and follow-up.
Penn State Worry Questionnaire (PSWQ: Myer, Miller, Metzger & Borkovec, 1990); Generalised Anxiety Disorder Scale (GAD-7: Spitzer, Kroenke, Williams & Lowe, 2006); Patient Health Questionnaire (PHQ-9: Spitzer, Kroenke & Williams, 1999); Intolerance of Uncertainty Scale (IUS: Freeston et al, 1994); Elliott’s Change Interview (Elliott, Slatick & Urman, 2001).
Recovery rates at the end of treatment: GAD = 46%, depression = 0%.
Recovery rates at follow-up: GAD = 70%, depression = 33%.
No patients made reliable and clinically significant deterioration in GAD during the study, or at follow-up.
Results from the qualitative interviews with patients identified five themes: (1) Enjoyable, (2) Better in a group than expected, (3) Supportive facilitators, (4) Not as expected, and (5) Why invent worries! A couple of examples of quotes for the themes are outlined below:
g. Theme 1: Enjoyable. Many of the patients (10/11) described treatment as an enjoyable and social experience: “I’ve enjoyed it, I think some of the time it was just meeting people as well” (Participant 8).
g. Theme 2: Better in a group than expected. Almost half of the patients (5/11) described coping better with group-based treatment than expected: “I thought I might not be able to do that and yet I did do that, and went to all 12 of them” (Participant 5).
Again, a number of themes were extracted from the facilitator feedback interviews, with example quotes below: (1) OK together, (2) drop the diary, (3) too much paperwork, (4) familiar co-facilitator helps, (5) structure helps, (6) invisible research, (7) doing helps, (8) positive feedback.
g. Theme 7: Doing helped. Facilitators described the behavioural experiments as a helpful element of treatment: “I think the behavioural experiments are really key. Really good at keeping that consistency of doing things differently” (Psychologist 1, OWG2).
g. Theme 8: Positive feedback. Facilitators shared positive feedback from patients, and their networks: “He’d [participant’s husband] got his wife back and he was very positive about the group and that it should continue. Generally people were very positive” (Psychologist 2, OWG2).
Findings
The study’s mixed method findings converged to suggest that the Overcoming Worry Group was an acceptable and feasible treatment option.
The opt-in rate (87%) was comparable to rates reported in trials of individual CBT for older adults with GAD (91%: Stanley et al., 2009; 93%: Stanley et al., 2014).
The dropout rate (15%) was lower than previous studies of group CBT for older adults with GAD (26-39%: Stanley et al., 1996; Stanley et al., 2003; Wetherell et al., 2003).
Facilitator feedback was confirmatory and also suggested that feasibility had been enhanced in two ways: delivery with a familiar co-facilitator and the structure of the protocol.
Group delivery of the Dugas and Roubichaud (2007) worry protocol is an acceptable, feasible treatment option, which shows initial efficacy, for older adults with GAD.
The protocol shows real promise as a treatment for GAD in older age.
OA Perspective
‘The group has highlighted the importance for clients of having a group facilitator who has knowledge and expertise in the specific challenges of later life and who are able to draw on a wealth of clinical experience to illustrate concepts within the model with older adult specific examples. It has been a great opportunity to work more closely with our IAPT colleagues.’
IAPT Perspective
An older adult champion for the Sheffield IAPT and Lead Psychological Wellbeing Practitioner, Heather Stonebank, shadowed the group several times to assess the facilitators using a treatment integrity scale, to feedback on the group and facilitation skills as part of the research study. This opportunity and joint working opened up a dialogue regarding how to adapt groups to meet the needs of older adults regarding content, pace and delivery.
Sheffield IAPT – older adult champion feedback:
‘The older adult overcoming worry group was absolutely fantastic, it was a really good opportunity to shadow and learn ways of adapting groups to meet the needs of older adults. I realised the importance of ensuring materials and case examples were specific to this patient group. Facilitators were warm and empathic, the group was delivered at a good pace, which facilitated conversations and learning. The group formed quickly in comparison to other groups I have facilitated and group members seemed to have an almost instant rapport which was lovely to see. I am looking forward to working more closely with the older adult team to improve access and treatment choice for older adults.’
The research study and working in collaboration has provided older adults in both Sheffield IAPT and the OACMHT with an opportunity to participate in an effective treatment for GAD and contribute to the evidence based for the effectiveness of GAD group based treatments for older adults. This development is very important for improving access and contributing to an evidence base and also providing a group therapy option for older adults, which we know has many other benefits for this patient population such as the reduction in social isolation.
Results were shared with IAPT staff and the impact of the research study and working in collaboration has also facilitated communication between Sheffield IAPT and the OACMHT. Discussions have begun around how we can continue to work collaboratively and improve access and provide high quality interventions for older adults.
What Next?
The Older Adult Overcoming Worry group will continue to be delivered by the OACMHT and IAPT staff will attend and shadow the group to develop group facilitation skills with older adults.
We will create supervision structures and case consultations between the OACMHT and IAPT to learn from each other to share best practice and inform clinical decisions.
We now have a bi-monthly meeting with the OACMHT to discuss and consult on developments and working collaboratively to continue to improve access for older adults offering a stepped care approach.
In Sheffield IAPT we have created an older adults strategy group within the senior team to dedicate time and resources to continuous quality improvement to implement strategies relating to improving access and quality of care.
Sheffield IAPT have established an older adult working group for PWPs, CBT therapists and Counsellors to share best practice and generate innovative ideas to contribute towards improving access and treatment choice for this patient population.
We plan to deliver a masterclass collaboratively with the OACMHT to enhance the skills of our workforce and improve referral pathways.
We also plan to deliver yearly skills refresher training for staff as part of continued professional development in areas such as older adults and long terms conditions. To ensure fidelity to the model and promote sharing best practice.
One of our challenges when thinking about how we could take this group forward was ensuring we were able to offer a stepped care approach, increased access into treatment and offer treatment options for older adults with depression. To overcome this challenge we will create a Step 2 older adults overcoming depression/anxiety group. Generating referrals for both groups in line with the stepped care model, matching the patient to the most appropriate treatment and offering a therapeutic dose of treatment. To develop this group we will work jointly and consult with the OACMHT to seek expertise and link up with an older adults service user group to inform materials and session content.
In summary, as a result of our collaboration and good relationships we are continuing to work collaboratively with the OACMHT. We will continue working together to improve access and treatment choice for older adults in Sheffield. This will enable us to enhance referral pathways and supervision structures for staff from both services to access advice and case consultations contributing to better quality care and patient experience. We will continue to work in partnership with the OACMHT and other organisations to achieve objectives set out in the MH5YFV.
References
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Elliott, R., Slatick, E., and Urman, M. (2001). Qualitative change process research on psychotherapy: Alternative strategies. In J. Frommer & D. L. Rennie (Eds.), Qualitative psychotherapy research: Methods and methodology (pp 69–111). Lengerich, Germany: Pabst Science.
Dugas, M. J. and Roubichaud, M. (2007). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. London: Routledge.
Freeston, M. H., Ladouceur, R., Rheaume, J., Letarte, H., Gagnon, F., and
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Hall, J. (2016). Cognitive behavioural therapy for older adults with generalised anxiety disorder (Unpublished doctoral dissertation). University of Sheffield, UK
Hall, J., Kellett, S., Berrios, R., Bains, M. K., and Scott, S. (2016). The efficacy of cognitive behavioural therapy for generalized anxiety disorder in older adults: Systematic review, meta-analysis and meta-regression. American Journal of Geriatric Psychiatry, 24, 1063 – 1073. doi: 10.1016/j.jagp.2016.06.006
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Mohlman, J. (2012). A community based survey of older adults’ preferences for treatment of anxiety. Psychology and Aging, 27, 1182–1190. doi:10.1037/a0023126
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Spitzer, R. L., Kroenke, K., and Williams, J. B. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. The Journal of the American Medical Association, 282, 1737–1744. doi:10.1001/jama.282.18.1737
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Stanley, M. A., Beck, J. G., and Glassco, J. D. (1996). Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches. Behaviour Therapy, 27, 565–581. doi:10.1016/S0005-7894(96)80044-X
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