STEPS: Going beyond the tip of the iceberg. A multi‐level, multipurpose approach to common mental health problems

An evaluation of Access to Psychological Services Ireland: year one outcomes

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of Access to Psychological Services Ireland (APSI), a primary care adult psychology service.

METHODS

A repeated measures design was used to evaluate the clinical outcomes of service users who completed an intervention. Psychological distress, depressive symptomatology and anxiety symptomatology were measured using the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7), respectively. Self-reported health and economic outcomes were measured using the EQ-5D-3L and the Eco-Psy, respectively.

RESULTS

A total of 381 adults were assessed as suitable for an APSI intervention, with 198 (52%) of these completing at least one intervention. Significant reductions in psychological distress were observed for completers of guided self-help and brief cognitive behavioural therapy, with service users also showing significant reductions in anxiety and depressive symptomatology. Reliable and clinically significant change on the CORE-OM was observed for 67.9% of treatment completers. Service users reported significant improvements in their health status but did not show changes in their health service usage in the 3-month follow-up period.

CONCLUSIONS

APSI provided an accessible service model that was clinically effective in managing a range of mild to moderate mental health difficulties. The cost-effectiveness of the service model may be enhanced by offering a wider range of high-throughput interventions and by increasing the treatment completion rate.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care

BACKGROUND

Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.

METHODS

We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.

RESULTS

We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.

CONCLUSIONS

This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.

TRIAL REGISTRATION

Current controlled trials ISRCTN68572159.

‘Callback’: increasing access to, and improving choice in, a multi-level, multi-purpose low-intensity service

In a previous paper auditing individual therapy in the STEPS team, we demonstrated a significant problem with attrition for both CBT and person-centred therapy. We argued that a root-and-branch change to the referral process was needed. This paper looks at the system which replaced it. ‘Callback’ allows self-referral with service users able to leave a phone message at any time. Clinicians call back and carry out a protocol-driven assessment, arranging, where appropriate, services at the end of the call. Reporting on the first 2500 calls, 92% of callers were successfully called back. Individuals were, on average, called back in 8.4 hours. Eighty-six percent of callers were offered an intervention within the STEPS service. They entered these STEPS services, on average, 9.4 days after the initial phone call. Of all callers 15.6% were offered individual therapy. Of these, 93% attended the first appointment and 82% completed a course of treatment. The results suggest that Callback is a significant improvement on the GP-referral system it replaced and provide evidence supporting the utility of ‘multi-level, multi-purpose’ services in primary care.

Tackling inequalities in primary care mental health

Purpose

This paper aims to describe the development activity undertaken by a primary care mental team and public health specialists in Glasgow aimed at expanding the capacity of the primary care team to tackle health inequalities in the local area.

Design/methodology/approach

In association with the Glasgow Centre for Population Health (GCPH), a partnership between National Health Service Greater Glasgow and Clyde, Glasgow University, Glasgow City Council and the Scottish Government, work was undertaken to address inequalities within mental health in the context of service provision.

Findings

In an attempt to progress work on inequalities, a suitable model was required and the approach offered by the GCPH was a valuable starting point. Through a systematic consideration of available approaches, and the baseline position, it was possible to begin to reflect on potential interventions, and to consider ways in which outcomes could be measured and reviewed. This process, which evolved in discussion within the team and senior management, became an important starting point for longer term action. It provided a means of beginning to grapple with the impact of inequalities on service provision, and was an important first step in prioritizing possible approaches.

Originality/value

The team is considering further collaboration with GCPH to explore how they might assess the extent of mental health and well‐being concerns in their population and the implications for future service development.