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Improving therapeutic success rates: using UK IAPT data to assess how well we're doing therapeutically

I wrote a blog post in the autumn - "Improving therapeutic success rates: UK IAPT data gives us a clearer set of targets" - highlighting that, if we want to improve how effective we are at an activity, it's likely to be crucially important that we monitor how well we're actually doing and whether or not our outcomes are getting better.  For psychotherapists there are currently a number of quite widely used systems that we can use to assess ourselves including the "Clinical Outomes in Routine Evaluation (CORE)", the "Outcome Questionnaire-45 (OQ45)", the "Partners for Change Outcome Management System (PCOMS)", and the "Treatment Outcome Package (TOP)".  Disadvantages of these methods however include that most of them don't have results that are based on a similar patient population to the one that I work with ... and the CORE, which does, becomes expensive for a single-handed practitioner like me if it's used in its most modern incarnation.  Emerging research however suggests that I can now put together a self-monitoring, self-assessment approach (using freely accessible questionnaires) that bypasses the need for the 'subscription' systems that I've mentioned.  This recent research throws light on two helpful areas.  One involves making available a huge, developing database of therapeutic outcomes with UK adult psychotherapy patients, so I really can see how my results compare with relevant others.  The second helpful area that's being clarified is that, although monitoring clients for inadequate early progress continues to be a potentially extremely helpful way of reducing poor outcomes, standardised predicted improvement trajectories may be less one-size-fits-all than has sometimes been thought. 

In my autumn post, I pointed out that although early significant improvement (within the first 4 or 5 sessions) is an encouraging sign that's well worth striving for, recent research - "Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression" and "Shape of change in cognitive behavioral therapy for youth anxiety: Symptom trajectory and predictors of change" - highlights that eventually successful cases don't always follow similar improvement trajectories.  So the authors of the "Nomothetic and idiographic symptom change ... " paper, write "The current results present challenges to clinical tracking and prognostication. Because the three identified coherent change patterns predicted similar short-term outcomes, it may be difficult to gauge whether individual patients are “on track,” especially early in CT ... Although the odds of response decrease the longer patients maintain high symptom levels during CT, this may be due, at least in part, to use of a time-limited protocol, rather than an indication of highly stable causes of nonresponse."

My current take home message is that I want to try very hard to help clients achieve rapid improvements in their depression & anxiety (both because of the immediate symptomatic benefit & the likelihood of better longer term outcome), but I'm less convinced than some expert commentators that lack of such progress is fairly inevitably a sign of eventual treatment failure (although increased caution and problem-solving are sensible in this situation).  But ... let's see what further relevant research emerges in this area over the next year or two.  As is often quoted and I try to make true for myself (though it can be hard!) - "When the facts change, I change my mind.  What do you do, sir?"  This sense that not all successful cases follow the same improvement trajectories, means that I am less fixed on comparing an individual client's progress trajectory with predicted rates of change than I was (although I'm still highly vigilant to signs that a client's progress has stalled).  So I'm now more open to using progress assessments that aren't so tightly linked to pre-prepared graphs of expected rates of change.  Widely used free measures like the PHQ-9 and GAD-7 thus become more attractive and this is now even more the case since the publication of last year's paper "Enhancing recovery rates: Lessons from year one of IAPT" with its clear indication of what kinds of outcomes (using these scales) indicate low, standard or high rates of therapeutic success.  Still more fascinating comparative data is available with the Health & Social Care Information Centre's collection of linked documents from this January - see "Psychological therapies, annual report on the use of Improving Access to Psychological Therapies service - England 2012-13".

The "Enhancing recovery rates ... " paper is freely available in full text and its abstract reads: "Background: The English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines. Method: Data from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7). Results: Data completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff. Conclusions: Compliance with the IAPT clinical model is associated with enhanced rates of reliable recovery." 

These figures relate to 19,395 patients assessed over 2008/2009 - with 40.3% reliably recovered, 63.7% reliably improved and 6.6% reliably deriorated.  The most recent figures for 2012/2013 assessed 144,210 patients - with 41% reliably recovered and 57% reliably improved.  Note though that the 2012/2013 figures were calculated nationally whereas the 2008/2009 figures were calculated locally, so the varying percentages should be compared only cautiously.  Patients were seen across all four of the English NHS Commissioning Regions and data was reported separately for each of 25 Local Area Teams. Across the Local Area Teams recovery rates varied with 3 of the 25 achieving the target figure of more than 50% recovered (recovery is a marginally less stringent measure than "reliable recovery" - there's typically about a 2% difference between the rates), while at the bottom end of the scale the worst Local Team only managed to achieve 24% recovery.  For reliable improvement, two Teams managed to reach 65% benefitting, while the outlier worst Team only produced 31% reliable improvement.  

So here's a fascinating take home message and a clearly drawn challenge - if I can get 41% of my clients "reliably recovered" and 57% "reliably improved" it looks as though I'm doing a pretty good job.  However if I can get at least 50% of my clients "reliably recovered" and 65% "reliably improved" then I'm probably right up there with the most effective psychotherapists around.  Now this is interesting.  See tomorrow's blog post for how I can begin checking what recovery & improvement rates I'm actually achieving. 

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