This is the IAPT Minimum Data Set (MDS) and should be routinely collected by all sites to support IAPT Key Performance Indicators. The. MDS includes patient. Map of positive practice examples for IAPT. . Useful resources on IAPT background and context. .. measures (minimum data set [MDS] and. ADSMs). The IAPT Programme is a Department of Health initiative to improve access to the IAPT Routine Outcome Measuring Tool (Minimum Data Set) should.
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This paper aims to evaluate accessibility, waiting times and clinical outcomes of IAPT for older adults.
Waiting times, type of referrals and reliable recovery rates were investigated. Waiting times for both IAPT assessment and treatment were slightly lower for older adult. The IAPT services were shown to be beneficial to older patients, however, access to these services in later life has been lower than expected. The service pathway for older populations needs to be better researched in order to eliminate possible obstacles in accessing services. Anxiety and depression are two highly prevalent mental conditions in adults.
Anxiety and depression remain common throughout the lifetime with estimates among older people varying from The type of treatment offered for common mental disorders is similar for both younger and older adults, with pharmacological and psychological interventions being the most common.
Partly based on the effectiveness of psychological therapies for the treatment of common mental disorders, a large-scale scheme for Improving Access to Psychological Therapies IAPT for people suffering with mild or moderate anxiety and depression was announced within the English National Health Service in October and piloted in Doncaster and Newham in Greater London.
Low intensity interventions are delivered during Step 2 by a mix of workers with a wide range of backgrounds who have trained as Psychological Wellbeing Practitioners PWPs.
The types of therapies available in Step 2 can be delivered by either face-to-face contact or telephone support and include bibliotherapy, mdss activation, guided cognitive behavioural self-help, guided self-directed exposure therapy, and computerised CBT. Step 3 is used mostly for moderate to severe depression and is generally delivered by CBT competent professionals.
A specific aim of the IAPT programme was to relieve the stress and financial costs associated with mood disorders. The cost-benefit assumption that was made at the inception of IAPT is probably more applicable to working-age adults rather than to older adults, a group of people unlikely to re-enter the work market.
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However, under the Equality Actpublic bodies are not allowed to discriminate access to services on the basis of age. IAPT services are no exception. The economic argument however may also be valid for older adults. Indirect cost savings related to hospitals and carers could be used to argue for better recognition and treatment of common mental disorders in older age. Moreover, many older adults are also involved in other ways besides paid employment, for example in voluntary roles or in supporting family members e.
It is therefore important that older adults are able to access services, not only on moral grounds, but also on quality of life grounds and potential cost savings to health services, and more broadly to society. Clinical outcomes and differences in clinical recoveries are also explored. Five of the 12 Primary Care Trusts PCTs had been commissioning the service for less than 12 months, so data were used only from the remaining seven PCTs with stable services by September One further PCT was removed from the analyses as it did not include any adults over the age of The remaining six PCTs were: The information captured at each session contributed to the IAPT minimum data set.
This included information on socio-demographics, attendance, source and date of referral, date of appointment, primary diagnosis and treatment outcomes. Symptom severity was assessed using two different scales.
The cumulative score on this scale can range from 0 to The item scoring for this scale is similar to the GAD-7, with responses ranging from zero to three. The sum score can range from 0 to Information on socio-demographic data was also included in the IAPT minimum data set and included gender, age and ethnicity. For this study, we subdivided the sample in two age groups: We compared and contrasted clinical indicator scores PHQ-9 and GAD-7 and outcomes waiting times, source of referrals, recovery.
Source of referrals and waiting times compared between the two groups using Chi-Square tests of independence. Both time to first assessment and time to first treatment were calculated using the referral date as time zero.
Mean and median times were calculated with their respective standard deviations SDs and interquartile ranges IRQs. Mann—Whitney U tests were used to compare median times between the two different populations. The sources of referrals were grouped in the following categories: Because the sampling criteria of two or more completed sessions may have distorted true dropout rates, we included all the individuals who had their referrals accepted, regardless of whether or not they had completed two sessions.
The improvement was considered reliable if the change in scores between the initial and the last assessment was above 5. Finally, to investigate the role of confounding variables, we modelled potential factors associated with recovery using logistic regression. The treatment step corresponds to NICE steps 2 and 3 for the treatment as described in the previous section. Of these, 0. Referrals were declined for individuals Of all the people who had their referrals accepted Fig.
This difference may have been due to variations in treatment dropout rates, with only The characteristics of the different populations have also been compared and highlighted in Appendix 1. Asian and Asian British were the second largest ethnic group, followed by Black and other groups.
Overall, mixed anxiety and depression There were differences between older and younger adults with respect to source of referral.
Self-referrals were higher among older adults 8. In order to calculate the expected rate of access in people aged over 65, we estimated the differences in the age structure in the Eastern region based on census data. Given the differences in the prevalence of CMDs and the age profile of the population in the Eastern Region, the expected rate of access to the IAPT service in older people should be In order to assess waiting times, two definitions were used: Mean and median times to assessment were The mean time to treatment in the sample was Experiencing a longer waiting time to either assessment or treatment was not associated with an increased likelihood of dropping out, with ORs of 1.
Recovery here is defined as being below the clinical cut-off for each scale, and showing reliable improvement during treatment.
Improving access to psychological therapies and older people: Findings from the Eastern Region
When recovery was assessed across both scales i. Recovery varied between different PCTs. Overall reliable recovery ranged from In order to investigate factors associated with recovery, multivariate logistic regression models were run. Odds ratios of recovery adjusted for gender, age, primary care trust, max number of sessions and ethnicity. People aged over 65 were less likely to be referred to IAPT from their GPs, compared with adults of working age, and they were more likely to refer themselves.
Dropouts from treatment and waiting times were also reported to be lower in this age group. Recovery rates varied across PCTs but they were generally better among older patients. One of the major strengths of this study lies in its large sample size that included over 16, individuals and data from almostsessions over a two-year period. Six PCTs were represented covering a major mes of this region. Although it is difficult to generalise the findings to other locations across the United Kingdom, fixing the site effects did not impact the mdx of the recovery for older adults.
This suggests that similar outcomes may be found in other areas outside this region.
The relatively high percentage of missing data in this sample is a major limitation of the study. Routinely collected data are often subject to incompleteness, and are very unlikely to reach the low percentages of missing data seen in some research studies. A large proportion of missing data were present for the ethnic categories. This hindered any further analysis based on this information. Completeness of this variable is important and should be achieved by the therapists who record the data during the assessment, if important questions relating to access and outcomes of ethnic minorities are to be addressed.
The largest limitation of this outcome analysis is intrinsic to the study design itself and relates to the use of symptom severity measures as proxies for diagnoses. Another problem aipt short symptom rating scales is that they are not often able to incorporate the md spectrum of symptoms seen in older adults Baldwin, Interestingly, an optimum cut-off point of nine was found, compared with ten that was used in this study.
This could explain why older adults were less likely to have lower baseline scores than younger adults. It is possible the improvements in symptoms may not be genuine effects. These changes could represent regression to the mean or natural resolution of symptoms.
However, the efficacy of psychological interventions has been shown in randomised controlled trails, therefore suggesting that these changes could denote real treatment effects. Finally, a large number of patients ended treatment after only one session, which certainly raises some questions as to why there are so many dropouts who do not complete treatment. The large number of dropouts could have also affected the generalisability of our analysis. Given the close proximity and the high number dms sessions, a problem with test-retest bias, where scales are administered on multiple occasions in a short time period, mdd also arise.
This expected rate is however likely to be an underestimate, as the calculations are based on the assumptions that the prevalence of CMDs in these age groups is accurate. This survey only included households, and excluded hospitalised and institutionalised subjects, suggesting that the true-estimate of CMDs in overs may be higher.
Translated Outcome Measures – UEA
Referrals made by general practitioners were lower for older people. This is probably due to the fact that GPs are generally less attuned to identifying mental health problems and needs in older patients.
One of the potential sources of referrals in the IAPT programme is via self-referral. mdd
This was introduced to provide another route into services and to target individuals or minorities who would not otherwise access traditional services. In this regard, the results from this study are somewhat encouraging, showing that groups who would not traditionally be captured can be targeted by increasing the type and sources of referrals.
One of the PCTs included in our evaluation did not allow for self-referrals, and it is likely that similar exclusions are present across the country. This needs to be addressed. A recent paper by Brown, Boardman, Whittinger, and Ashworth has highlighted the positives and negatives of a self-referral system in IAPT, concluding that this system is mostly advantageous, bolstering access to harder to reach communities, and to those who never thought of consulting a GP, because of stigma, pre-conceived attitudes towards doctors, or health beliefs.
Differences in waiting times for both treatment and assessment were also found between various age groups.
The shorter waiting times for older adults could potentially be attributed to lower depression and anxiety scores at baseline, however this is unlikely to be the case. Unfortunately, we were not able to test this in the database. Waiting times were reduced not only for treatment but also for assessment, and differences kds still seen when the maximum step of treatment, which relates to the severity of the condition, was taken into account.