Transcript Client Selection for CCBT
CLIENT SELECTION FOR CCBT
Steve Cottrell Updated 02-02-14 1
Quotes
• • • • Whatever exists at all, exists in some amount (Thorndike, 1918) Anything that exists in any amount can be measured (McCall, 1939) If you cannot measure it, you cannot improve it (William Thomson - Lord Kelvin, 1900) Not everything that counts, can be counted, and not everything that can be counted, counts (Bruce Cameron, 1963) 2
Contents
1 of 2
Positioning psychological therapies
3
Contents
2 of 2
Screening for anxiety and depression
suicide risk assessment 4
Contacts
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License .
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Background
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Mental Health Problems
• Worldwide 151 million people suffer from depression at any one time and 844,000 people die by suicide every year (Funk et al, 2010) • One in four UK adults experiences at least one diagnosable mental health problem in any one year (ONS, 2001) 7
Why?
(1 of 2) • About 13% of population of Britain suffer anxiety or depression or both at any one time (more than 7 million people) (Melzer et al, 1995) 8 8
Why?
(2 of 2) • Of the 7 million people who may benefit from counselling or psychotherapy for anxiety or depression, 70,000 do so - about 1 in 100 (Melzer et al, 1995) 9 9
Drivers - Clinical
• • • • • • The drive for cheaper & ‘better’ treatments Evidence-based practice Self-help books & guided self-help The growth of the Internet Clinical trials of Internet-based CBT & self-help Increasing interest in high volume, low intensity manualised approaches to CBT 10
Drivers - Contextual
• • • • • • • Health promotion and public health Changes to delivery (e.g. stepped care) The move towards consumerism in the NHS The ‘McDonaldisation’ of healthcare Increasingly well-informed patients The ascendancy of science and technology Recognition of the economics of health issues 11
Drivers - Financial
• • The financial cost of depression in the UK was estimated at approximately 150 billion pounds in 2009 / 2010, of which 30 billion is thought to be work related (Sainsbury Centre, 2010) £7-10 billion of social security benefits payments are made to cover the unemployment costs of people with high prevalence mental health problems (CEP, 2006) 12
• • • • •
Y
oung
A
ttractive
V
erbal
I
ntelligent
S
uccessful
The ‘YAVIS’ client
Coined by William Schofield in his 1964 book: ‘Psychotherapy: The Purchase of Friendship’ 13
The ‘Place’ of Psychological Therapies
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Tiered Service Structure
4 High secure & residential highly specialist inpatient 1 3 Low and medium secure, specialist inpatient services specialist community teams 2 Assertive outreach, acute inpatient services, community mental health supported accommodation, early intervention & gateway crisis resolution and home treatment Primary health & care team, third sector counselling & support, primary mental health support mainstream leisure, education & recreation, lower-level support & mainstream accommodation Foundation Tier Self-help, mental health promotion and education 15
Contribution of Factors to Disorders
Diagnostic threshold Pre-morbid Predisposing factors Acute Early Precipitating factors Chronic Perpetuating factors
Predisposing Factors
• Predisposing factors: social class, genetic vulnerability, inequity, parental health & wellbeing, cultural mores, economic factors • Requires social & political interventions, policy level 17
Precipitating Factors
• Precipitating factors: Stress, loss, social isolation, relationship conflict, acute health crisis, personal catastrophe • Require workplace interventions, crisis intervention, individual and community focus 18
Perpetuating Factors
• Perpetuating factors: Negative cognitions, entrenched behaviour patterns, gaps in knowledge, untested assumptions, unrecognised deficits, diet, exercise, social isolation, relationship conflict, stigma • Requires personal therapeutic focus 19
Protective Factors
• What are some mental health protective factors?
• How might CCBT contribute to these?
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The ‘Hype Cycle’
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IAPT Screening Prompts
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IAPT Screening Prompts
For all clients ask questions
one
and
two
... follow with questions
three
as required 23
Depression
Q1 Review the PHQ-9 score If symptoms of depression are present, ask about: Duration of current episode Number & recency of past depressive episode(s) Impact on personal, social and occupational functioning (including self-neglect) Where PHQ-9 score > 9 and depressive symptoms have lasted more than 2 weeks and impair functioning consider depression 24
Q2 Are there times when you feel frightened or anxious and very uncomfortable?
Yes 25
Q3 Is this related to a specific situation(s) or object(s)?
Yes Q3(b) In what situation(s) or with what objects does intense anxiety arise?
Q3(a) No If not related to a specific situation(s) or objects – ask … If there are positive responses, consider panic disorder. Also probe for agoraphobia and panic disorder with agoraphobia Is it of sudden onset?
Does it involve physical sensations such as palpitations, sweating, trembling, a sensation of shortness of breath, chest pain, dizziness, nausea, and / or thoughts such as fear of loss of control or dying?
Does it usually peak within 10 minutes?
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If limited to specific objects, activities or
situations
Is your fear or anxiety associated with avoiding or doing an activity or being in contact with an object or animal or being in a particular environment (e.g. flights, heights)?
Do you think your fear is excessive or unreasonable in some way?
If there are positive responses consider …
Specific Phobia
27
If focused on
social activities
or situation(s) Is it associated with marked or persistent fears of social or performance situations and accompanied by thoughts of humiliation or embarrassment (and anxiety is present which may take the form of situation specific panic attacks)?
Are you uncomfortable or embarrassed at being the centre of attention?
Do you find it hard to interact with people?
Do you avoid social or work situations where you feel you will be scrutinised or evaluated by others?
Do you think your fear is excessive or unreasonable in some way?
If there are positive responses consider …
Social Anxiety
28
If focused on places or situations) e.g. being outside alone or in crowds Are you afraid of going out of the house, being in crowds or taking public transport?
Do you need to be accompanied by someone to be able to undertake these activities?
If there are positive responses consider …
Agoraphobia (or panic disorder with agoraphobia)
29
If the fear is accompanied by
recurrent
thoughts, impulses or images or
ritualistic behaviour
(washing hands, switching off lights) or mental acts (e.g. counting, repeating words silently) Do you have recurrent thoughts or images or impulses that you can’t easily stop (e.g. bad things happening to people, acting on impulses that you could harm others)?
Do you try and ignore or put these thoughts / images / impulses out of your mind?
Do you have recurrent rituals (behaviour or thoughts) that you can’t easily stop (e.g. washing hands, switching off lights, counting to yourself)?
Do you think that doing these rituals may make you feel better or stop something bad happening?
For obsessions and compulsions - Do you think your fear is excessive or unreasonable in some way?
Obsessive-compulsive disorder
If there are positive responses consider … 30
Q3(c) For all service users ask whether their current problems relate to any past
traumatic event(s)
Have you ever had any experience that was so frightening, horrible or upsetting, that you have, in the past month: Had thoughts or nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Been constantly on guard, watchful or easily startled?
Been feeling numb or detached from others, activities or your surroundings?
Post-traumatic Stress Disorder
If there are positive responses consider … 31
Q3(d) For all service users enquire whether they are pre-
occupied with the idea that they may have a serious
disease(s) that have not been diagnosed, despite medical reassurance Are you overly concerned that you might have a serious illness or disease that doctors have not found? What do you think you may have?
Health Anxiety
If there are positive responses consider … 32
Q3(e) If none of the above anxiety disorders have been identified and the person reports anxiety symptoms Do you worry most of the time about a variety of events and activities?
Do you find it difficult to control the worry?
Have the worries lasted at least six months?
If there are positive responses consider …
Generalised Anxiety Disorder
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Q3(f ) If some symptoms of both depression & anxiety are present, but … Neither anxiety nor depression symptoms predominate and neither is sufficient for a provisional diagnosis of depression or any of the anxiety disorders Consider …
Mixed Anxiety and Depressive Disorder
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‘Empirically Supported’ Treatments
• • • • • • • • • • Agoraphobia Depression Generalised Anxiety Disorder Health Anxiety Mixed Anxiety & Depressive Disorder Obsessive-compulsive Disorder Panic Disorder Post-traumatic Stress Disorder Social Anxiety Specific Phobia 35
IAPT and NICE NICE Indicated Treatments for Depression and Anxiety
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Source: IAPT Data Handbook Appendices, June 2011. Version 2.0.1
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IAPT Assessments
Condition
Agoraphobia Depression Generalised Anxiety Disorder Health Anxiety Mixed Anxiety & Depressive Disorder Obsessive-compulsive Disorder Panic Disorder PTSD Social Anxiety Specific Phobia
IAPT Assessment
Mobility Inventory, IAPT Phobia Scale PHQ-9 GAD-7, PSWQ HAI PHQ-9 and GAD-7 OCI PDSS IES-R SPIN IAPT Phobia Scale 39
Screening for Anxiety and Depression
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Depression – more than ‘in the mind’
Emotional Symptoms Include
Sadness
Physical Symptoms Include
Vague aches and pains Loss of interest or pleasure Feeling overwhelmed Headache Sleep disturbances Anxiety Tiredness Diminished ability to think or concentrate, indecisiveness Back pain Excessive or inappropriate guilt Significant change in appetite resulting in weight loss or gain Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
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We may not know ...
• In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms (MUS) as their chief compliant (n=1146) 31% N = 1146 Primary care patients with major depression Simon GE, et al. N England J Med. 1999;341(18):1329-1335 .
69% MUS Other 42
Sensitivity & Specificity
(1 of 2) • • Sensitivity measures the proportion of actual positives which are correctly identified as such (e.g. the percentage of sick people correctly identified as having the condition) Specificity - the proportion of negatives correctly identified (e.g. the percentage of healthy people who are correctly identified as not having the condition) 43
Sensitivity & Specificity
(2 of 2) • • A perfect predictor would be 100% sensitive (i.e. identifying all sick people as sick) and 100% specific (i.e. not identifying anyone healthy as sick) As sensitivity goes up, specificity usually falls and vice versa 44
Type I and Type II errors
• • A ‘type I’ error is a false positive. Usually a type I error leads one to conclude that a relationship exists when it doesn't. For example, that a patient has a disease being tested for, when the patient does not have the disease A ‘type II’ error is a false negative. An example of a type II error would be a test failing to detect the disease in a patient who really has the disease 45
ANDICREST
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479789/ 46
‘And I See Rest’
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479789/ 47
‘And I See Rest’
• In addition to all the ‘AND’ criteria, three or more of the ‘I C REST’ symptoms are also necessary to meet DSM-IV-TR criteria for GAD Failure to answer positively to all the first three questions makes a diagnosis of GAD unlikely, and proceeding with the remainder of the mnemonic unnecessary 48
PHQ-9
• • • • Nine questions about depression symptoms scored from 0 to 3 Total score ranges from 0 to 27 A score of 10 or above is a potential cut-point for a diagnosis of depression (Lowe et al, 2004) Severity bands are: 0-4 not depressed, 5-9 mild, 10-14 moderate, 15-19 moderate / severe and 20-27 severe depression 49
GAD-7
• • • • • The GAD-7 is a seven-item measure of the severity of anxiety symptoms (Spitzer et al, 2006) The measure uses the same response options and item scores as the PHQ-9 Total scores range from 0 to 21 A score of 8 or more suggests a diagnosis of anxiety Severity bands are: 0-4 not anxious, 5-9 mild, 10 14 moderate, 15-21 severe anxiety 50
GAD-7 and PHQ-9
• • For the PHQ-9, reliable improvement requires an improvement of 6 points or more, clinically significant change requires a score of 9 or above pre-treatment and 8 or below post-treatment For the GAD-7, reliable improvement requires an improvement of 5 points or more, clinically significant change requires a score of 10 or above pre-treatment and 9 or below post treatment (Richards and Borglin, 2011) 51
IAPT Recovery Muralikrishnan Radhakrishnan et al 2011 Initial assessment Is PHQ-9 ≥ 10 and GAD-7 ≥ 8 ? Treatment Final session Is PHQ-9 < 10 and GAD-7 < 8 ? Yes Classify as ‘recovered’ No Classify as ‘non case’ No Classify as ‘not recovered’ 52
The Two-question Screen
Over the past 2 weeks, how often have you been bothered by any of the following problems …
Depression Anxiety
(1) Feeling down, depressed or hopeless?
(2) Having little interest or pleasure in doing things?
(1) Feeling nervous, anxious, or on edge (2) Not being able to stop or control worrying 53
Physical Problems
• Some physical problems increase the likelihood of depression by 2 – 3 times (NICE, 2009) – Cancer – Heart disease – Neurological disorders – Musculoskeletal problems – Respiratory disorders – Diabetes 54
Diagnosing Depression
• • Severity is determined by the number and severity of symptoms, as well as impairment. A diagnosis using DSM-IV requires at least 5 out of 9 symptoms for a diagnosis of major depression. Symptoms should be present for at least 2 weeks and each symptom should be present at sufficient severity for most of every day Low mood, loss of interest and pleasure, or loss of energy must be present 55
Depression Symptoms
(1 of 2) • • • • • Depressed mood (sad, hopeless or empty) Markedly diminished pleasure in all (or almost all) activities Insomnia or hypersomnia Increase or decrease in appetite or significant weight loss Fatigue or loss of energy 56
Depression Symptoms
(2 of 2) • • • • Feelings of worthlessness Excessive or unwarranted guilt Diminished ability to think, concentrate or take decisions Recurrent thoughts of death, suicidal ideation, having a suicide plan or making a suicide attempt 57
GAD-2
• • GAD-2 scores range from 0-6 A GAD-2 score of three or more has a sensitivity of 86% and a specificity of 83% for generalised anxiety disorder 58
PHQ-2
• • • PHQ-2 scores range from 0-6 A PHQ-2 score of three or more has a sensitivity of 83% and a specificity of 92% for major depression A PHQ-2 score of 3 is the optimal threshold for screening, a threshold of 2 would enhance sensitivity, 4 would improve specificity 59
GAD-2
Over the past 2 weeks, how often have you been bothered by any of the following problems … Feeling nervous, anxious, or on edge Not being able to stop or control worrying
Not at all
0 0
Several days
1
More than half the days
2
Nearly every day
3 1 2 3 60
PHQ-2
Over the past 2 weeks, how often have you been bothered by any of the following problems … Little interest or pleasure in doing things Feeling down, depressed or hopeless
Not at all
0 0
Several days
1
More than half the days
2
Nearly every day
3 1 2 3 61
IAPT in England
• • • Doncaster and Newham - 2007 By 2016, 6000 new psychological therapists will have been trained and employed in new IAPT services offering NICE based treatments IAPT activity and costs 62
IAPT Activity
01-04-09 to 31-03-10 • • 10,789 patients completed or ended IAPT treatment between 1 April 2009 and 31 March 2010 Table 1 presents baseline demographic and clinical characteristics of the 8464 patients who attended 2 or more sessions 63
IAPT Activity
• 21.2% attended only 1 session • Of those attending 2 or more sessions, 4844 (44.9%) completed the treatment • 1961 (23%) dropped out after 2 or more sessions • 861 (8%) were ‘unsuitable for IAPT’ after 2 or more sessions Muralikrishnan Radhakrishnan et al 2011 65
Level of Functioning
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The mGAF
(1 of 5) 40 - 50 • Pete is a 54 year-old white British male with a diagnosis of Post Traumatic Stress Disorder with paranoid features. His onset of symptoms coincided with his service in the Falklands conflict. Pete was married when he was 27 years old and was divorced just over a year later. He has dated sporadically, but has not had a relationship in 8 years. He now lives in a caravan on his parent's farm. His parents are supportive and set clear boundaries. They are also supporting his 92 year-old grandmother and are having a difficult time with Pete’s level of stress and anxiety. Pete is reluctant to attend mental health services. He recently lost the factory job he found six weeks ago. He has a meeting with the DSS next week.
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The mGAF
(2 of 5) 60 - 70 • Rebecca is a 23 year-old Welsh woman. She is diagnosed with Bipolar Disorder. Between the ages of 11-17 years she was admitted to psychiatric hospitals on five occasions due to suicide attempts. She is currently employed at the local supermarket. She is returning to University next term and has been dating her current boyfriend for over six months. Rebecca reports this is the most stable her life has been since she can remember. She currently has a low level of anxiety and depression.
http://depts.washington.edu/washinst/Resources/CGAS/GAF%20VIGNS/GAFAlice.htm
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The mGAF
(3 of 5) 20 - 40 • Kim is a 31 year old woman with Major Depression. She has a history of heavy alcohol abuse and has been in inpatient alcohol treatment units. Her family of origin has a long history of mental illness and drug and alcohol dependency on both sides. She is currently in a co-dependent relationship with an abusive boyfriend. Kim's mother tries to support her, but is regularly involved in heavy alcohol use. Kim is on the verge of losing another job and is expressing suicidal ideation, but has agreed to a ‘no suicide’ contract. 69
The mGAF
(4 of 5) 65 - 85 • Sheri is a 47 year old African American female with Borderline Personality Disorder. She has a history of substance abuse. She has a long history of crisis contacts, mostly around her depression and relationship issues. She entered a Dialectical Behavioural Therapy Programme about a year ago. Since that time, she has had one crisis contact and no self-injurious behaviours. Sheri broke up with her boyfriend about six months ago and has been single ever since. She has been in a women's support group for the past five months. She has maintained a job for the past 18 months and is seen as an ‘excellent waitress.’ She says that, apart from some minor conflicts with her sister, her life is going well.
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The mGAF
(5 of 5) 50 • Sam is a 42 year old male with Paranoid Schizophrenia. He has a history of disappearing for months at a time since his late teens. He has several assault charges for domestic violence with a series of girlfriends. He was on probation but was released 2 months ago after completing all of the court requirements. Sam is currently in recovery and is actively participating in AA meetings. Sam is stabilising and is now concordant with his medication. He maintains contact with his ex-probation officer and several staff at the psychiatric hospital. He is trying to get a job but has not had any replies to his applications. 71
The Case for a Transdiagnostic Approach
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Anxiety and depression
In recent times have been viewed as: (a) Different points along the same continuum (b) Alternate manifestations of a common underlying tendency (c) Separate phenomena, each of which may develop into the other (d) Conceptually distinct phenomena 73
Common Factors
• Mixed anxiety and depression is the most common mental health problem (Meltzer et al, 1994) • Anxiety has unique components (high physiological arousal) • Depression has unique components (low positive affect or anhedonia) • There’s a common component to both anxiety and depression (‘negative affectivity’) 74
Serotonin and Norepinephrine
• Serotonergic (5HT)-related symptoms include tachycardia, diaphoresis (sweating), tachypnea, (rapid shallow breaths), gastrointestinal upset, agitation & chest discomfort - they are seen in anxious depressed patients (‘agitated depression’) and people with anxiety disorders (poor modulation of affect and impulsivity) 75
Serotonin and Norepinephrine
• Catecholaminergic (norepinephrine) symptoms include poor concentration, low energy, low motivation, social withdrawal and apathy (general reduced activation) • General distress, including fatigue, tension, restlessness, worry, and hopelessness can be related to either 76
Serotonin and Norepinephrine
Serotonin (5-HT) Norepinephrine (NE) Sex Appetite Aggression Low Mood Anxiety Hopelessness Aches & Pains Irritability Interest Motivation Concentration Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 3
rd
ed. Cambridge University Press 2008.
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Transdiagnostic therapy
Many people with depression experience: (1) Poor modulation of arousal associated with relative serotonin deficiency or ...
(2) Diminished activation / arousal relating to norepinephrine / dopamine deficiency, or a combination of both The common factors, negative affectivity, are amenable to a transdiagnostic approach 78
Transdiagnostic therapy
• Affect regulation skills • Distress tolerance, resilience, radical acceptance • Confusion, conflict and deficits - learning • Mind management – mindfulness skills • Wellbeing approaches – giving, relationships, positive psychology, sleep hygiene, exercise (behavioural activation), • Existential approaches – belonging, purpose, connectedness, awe 79
CCBT for the treatment of anxiety and depression
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CCBT - Pros and Cons
Pros Cons
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Advantages
• • • • Accessibility & convenience - no waiting (maybe …) Users have more ownership Egalitarian Transcript record • • • • • Increased choice Advantages for practitioners & the service Stepped care approach Mastery and agency Cost benefits 82
Disadvantages
• • • • What’s the model?
– Bibliotherapy?
– Psychoeducation?
– CBT?
– Something else?
How does the therapy ‘test’ the client?
Are there boundaries in the traditional sense?
What about acting out?
• • • • • • • • Disinhibition (+ / -) Cue reduction Differences in information processing Ethics - who is the client?
How can you assess?
How can you formulate?
How can you plan?
Do you need to?
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Who for?
• • • • • • • • • Social phobia Shame / fear of humiliation / stigma Fear of judgement (race, sexuality, socio-economics) A way to avoid authority / dependence Disability Life patterns (work routines, mobility) Rural issues Desire for anonymity Choice and curiosity!
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CCBT – Client Selection
(1 of 5)
Criteria for a Successful Psychological Approach 1
Desire for a psychological approach
2
Previous positive experience of talking therapy
3
Psychological mindedness
4
Introspective ability
5
Ability to form a trusting relationship Table 1 85
CCBT – Client Selection
(2 of 5)
Criteria for a Successful CCBT Approach 1
Familiarity with computers
2
Desire to work with CCBT
3
Desire and ability to work independently
4
Symptoms make F2F distressing or unfeasible
5
Pressing need (isolation, mobility or access issues) Table 2 86
CCBT – Client Selection
(3 of 5)
Factors Mitigating Against Effective CCBT Treatment 1
Reduced concentration or cognitive impairment
2
Severe or intrusive symptoms affecting functioning
3
Suicidal intent (especially if plans made to act)
4
Severe depression with incapacitating symptoms
5
Pessimism or skepticism which inhibits working Table 3 87
CCBT – Client Selection
(4 of 5)
Factors Mitigating Against Effective CCBT Treatment 6
Dangerously impulsive or risky behaviour
7
Active, intrusive psychotic symptoms
8
Intrusive current or repeated ongoing crises
9
No accessible ‘problem thoughts’ or behaviours
10
Severe personality problems Table 3 88
CCBT – Client Selection
(5 of 5)
Factors Mitigating Against Effective CCBT Treatment 11
Hearing loss making telephone work impractical
12
Inability to read English (w/o interpreter available)
13
Primary problem is neither anxiety nor depression
14
Lack of access to either computer or telephone
15
Therapy-interfering behaviour e.g. low participation Table 3 89
Decision Making
A score of 15 in the PHQ-9 signifies a depression score in the ‘moderately severe’ range, a score of 15 or above signifies symptoms in the ‘severe anxiety’ range of the GAD-7. For the Hospital Anxiety and Depression Scale (HADS), a score of 16 or above is in the ‘severe’ range for either anxiety or depression symptoms.
PHQ-9 & GAD-7 < 15 & GAF > 50 >= ⅗ from table 1 and >= ⅗ from table 2 PHQ-9 or GAD-7 > 15 < ⅗ from table 1 or < ⅗ from table 2 GAF <50 or other impairment One or more from table 3 (exclusion criteria) CCBT recommended CCBT with extra support CCBT not applicable 90
What is it?
A theoretically integrative blended learning approach to treatment of anxiety Human contact, interactive Internet programme and telephone support Telephone Support Human Contact Self Assessment Interactive Programme 91
A hierarchy of engagement
• • • • • • • Specific software e.g. Fear Fighter, Beating the Blues, LLTTF Moodgym, Blues Begone etc.
No visual or auditory information - asynchronous (e.g. email) No visual or auditory information - synchronous (e.g. ‘chat’) Auditory information only (e.g. ‘phone) Visual and auditory at a distance (e.g. Skype) Blended methods e.g. Serenity Programme Immediacy, contextual richness and sense of presence increase with each step 92
A Continuum, not ‘either - or’
The ‘blend’ can be adjusted to suit the client ...
Computer use Practitioner contact time 93
The Serenity Programme
94
What’s in the Programme?
• • • • • • A series of assessment measures A series of information pages A resource page for helpers A brief self-help programme, open to anyone A series of interactive workbooks ‘Microsites’ 95
Site Structure
http: // serene.me.uk
Free Programme Helpers Resources Microsites Members Area Information Pages Tests and Assessments Cwm Taf Mind Welsh Information Health Information Local Resources 96
Assessment meeting Module 3
The Programme
Modules 1 and 2 Goal setting meeting Support call Module 4 Support call Module 5 Support call Module 6 Support call Module 9 Support call Module 8 Final meeting Module 7 Support call 97
Referral received Contact client & arrange to meet Meet with client – baseline measures, login given, ask to read Modules 1 & 2, make appointment to ‘phone in 2 weeks 98 Helper telephones client at agreed time
Serenity Programme Helper’s Guide
v.1.2
Yes Client wants to continue?
Yes Client keeps appointment?
No Ask client to read Module 3 - make appointment for 2 – 4 weeks to meet face-to-face Face-to-face session – goal setting using Module 3 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time Module 4 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time Module 5 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time Module 6 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time Module 7 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time No Two more contact attempts, discharge if no further contact Module 8 - make appointment to ‘phone in 2 - 4 weeks Helper telephones client at agreed time Module 9 - arrange follow up meeting if required, post-measures Follow-up meeting (if required) Discharge or re-assess and refer to step-up service if required
Thanks for Listening!
Questions?
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References
• • • • • • • • • • • • • • Cameron, B. (1963) Informal Sociology: A Casual Introduction to Sociological Thinking. New York, Random House.
Centre for Economic Performance (2006), The depression report: A new deal for depression and anxiety disorders. London: London School of Economics and Political Science Centre for Economic Performance.
Funk, M., et al., eds. Mental health and development: targeting people with mental health conditions as a vulnerable group. 2010, WHO: Geneva.
Kroenke, K., Spitzer, R.L., Williams, J.B., et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity and detection. Ann Intern Med 2007 146: 317–25.
Kroenke, K., Spitzer, R.L., Williams, J.B. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003 Nov 41(11): 1284-92.
Lowe, B., Kroenke, K., Herzog, W., Grafe, K.,(2004). Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). Journal of Affective Disorders; 81: 61-66.
McCall, W. A. (1939). Measurement. New York: Macmillan.
Meltzer, H., Gill, B. & Petticrew, M. (1994) OPCS Surveys of Psychiatric Morbidity in Great Britain. Bulletin No. 1: The Prevalence of Psychiatric Morbidity among Adults Aged 16-64, Living in Private Households, in Great Britain. London: OPCS.
Radhakrishnan, M., Hammond, G., Jones, P.B., Watson, A., McMillan-Shields, F., Lafortune, L. Cost of Improving Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region. Behaviour Research and Therapy 51 (2013) 37-45.
NICE (2009) CG-91 Depression in Adults with a Chronic Physical Health Problem: treatment and management. NICE, London.
ONS (2001) available from: http://www.ons.gov.uk/ons/guide-method/census/census-2001/index.html Accessed 30-03-13.
Richards, D.A., Borglin, G. Implementation of psychological therapies for anxiety and depression in routine practice: Two year prospective cohort study. Journal of Affective Disorders 133 (2011) 51–60.
Sainsbury Centre, (2010), The Economic and Social Costs of Mental Health Problems in 2009/10. London: Sainsbury Centre for Mental Health.
Thorndike, E. L. (1918). The nature, purposes, and general methods of measurement of educational products. In S. A. Courtis (Ed.), The Measurement of Educational Products (17th Yearbook of the National Society for the Study of Education, Pt. 2. pp. 16–24). Bloomington, IL: Public School.
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PALS - Proximity to others
‘P’ = Proximity to Others • • • How isolated is the client? Are there any significant others around who might be potential rescuers and interfere or otherwise foil the client’s plan?
Can others be encouraged to actively defuse the client’s plan - e.g. hide guns or confiscate pills?
Clients with few significant relationships are at higher risk 101
PALS - Proximity to others
Which plan below is most likely to be foiled by others?
• • • A. I am going to go into the girls toilets at school and take an overdose B. I am going to wait till my parents have left for work and then go into the basement and slash my wrists C. I am going to go to my boyfriend's house during his birthday party and hang myself in his backyard 102
PALS - Proximity to others
Which plan below is most likely to be foiled by others?
• • • A. I am going to go into the girls toilets at school and take an overdose (possible answer – toilets are public places) B. I am going to wait till my parents have left for work and then go into the basement and slash my wrists C. I am going to go to my boyfriend's house during his birthday party and hang myself in his backyard (very high likelihood of intervention by others) 103
PALS - Availability of means
‘A’ = How accessible is weapon or means of self harm?
• • • • Does the client have a gun, knife, pills etc. in his or her possession?
Do they have to steal, borrow or purchase them?
How easily can means of self harm be obtained?
Means of self harm already in client’s possession are most risky 104
PALS - Availability of means
Which of the means below is most accessible?
• • • A. I have got a large carving knife stashed in the back of my bottom drawer B. I am going to get my psychiatrist to write me a large prescription for barbiturates C. I am going to go out on the street and find a drug dealer who will sell me a large dose of heroin 105
PALS - Availability of means
Which of the means below is most accessible?
• • • A. I have got a large carving knife stashed in the back of my bottom drawer (readily available nearby) B. I am going to get my psychiatrist to write me a large prescription for barbiturates C. I am going to go out on the street and find a drug dealer who will sell me a large dose of heroin (Both ‘B’ & ‘C’ rely on the cooperation of others to obtain the means) 106
PALS - Lethality of means
‘L’ = Lethality of Means • • • • How precipitous is the method of self harm? Once started can the method be reversed?
Guns, jumping from great heights and jumping in front of moving vehicles are highly lethal Cutting and overdoses may be relatively less lethal because people might be able to can change their minds … Precipitous methods in a plan are more serious and more lethal 107
PALS - Lethality of means
Which of the means below is least likely to be harmful?
• • • A. I am going to get my husband's loaded revolver and blow my brains out B. I am going to jump off a the bridge over the A55 at 5 o’clock C. I am going to take a whole bottle of antibiotics left over from my last urinary track infection 108
PALS - Lethality of means
Which of the means below is least likely to be harmful?
• • • A. I am going to get my husband's loaded revolver and blow my brains out (very precipitous and lethal) B. I am going to jump off a the bridge over the A55 at 5 o’clock (highly lethal) C. I am going to take a whole bottle of antibiotics left over from my last urinary track infection (antibiotics are not usually lethal in overdose) 109
PALS - specificity of plan
‘S’ = Specificity of Plan • • • How detailed is the client’s plan?
Have they thought of a place, time or deadline for the act?
Have they made special arrangements to make the plan work?
110
PALS - specificity of plan
Which plan below is most specific and therefore most risky?
• • • A. I am going to hurt myself so my partner will appreciate me more B. I am going to drive my father's new car off a bridge on my parent's anniversary next week!
C. I am going to get a prescription of pills and take them when no one is around 111
PALS - specificity of plan
Which plan below is most specific and therefore most risky?
• • • A. I am going to hurt myself so my partner will appreciate me more (neither method, time nor place specified) B. I am going to drive my father's new car off a bridge on my parent's anniversary next week (method, time and deadline specified) C. I am going to get a prescription of pills and take them when no one is around (what kind of drug, how will they get it and when will it be taken?) 112
Care …
• • PALS Scale is not predictive when PSYCHOSIS and / or SUBSTANCE ABUSE are present Alcohol, drugs and severe mental illness may distort judgement such that the risk of suicide, intentional or otherwise, increases significantly 113