Long term conditions within a Primary Care Psychology/IAPT service

Long term conditions (LTCs) are affecting increasing numbers, causing considerable

costs to the individual and the NHS. The benefits of psychological intervention have

been demonstrated, and the need to develop services is vital.

The department of health defines a Long Term Condition (LTC) as a ‘condition that cannot be cured but can be managed through medication and/or therapy’ (Department of Health, 2011). This term incorporates a range of diagnoses, such as diabetes, irritable bowel syndrome (IBS), chronic obstructive pulmonary disease (COPD), chronic fatigue syndrome (CFS), and chronic pain. With sufficient input at primary care level, many LTCs can be effectively managed within the community, reducing the overall cost to the NHS (Dr Foster Intelligence, 2006).

Over the last few decades, the role of psychology in the management of LTCs has become increasingly accepted. A recent large scale systematic review demonstrates that self management support improves clinical outcomes and quality of life, in addition to reducing health care usage (de Silva, 2011). There is a good evidence base for the use of Cognitive Behavioural Therapy (CBT) in managing numerous conditions, and as such is recommended in NICE guidelines (e.g. for managing Type 2 diabetes – NICE, 2008).

Least Intervention First Time (LIFT) Psychology in Swindon and Wiltshire is a community based primary care service and first wave IAPT site, offering psychological support in a stepped care way: it offers less intensive intervention initially (e.g. psycho-educational courses), and then more intensive intervention if required (e.g. individual CBT). The LIFT model enables the service to respond to the needs of large volumes of people whilst maintaining a person centred, accessible approach and ‘no wait’ policy.

Results

Four of the LTC courses were selected for preliminary analysis (Type 2 Diabetes, Fibromyalgia, Pain, and Chronic Fatigue) as these offered the largest sample sizes.

Analysis of condition specific questionnaires, using paired samples t-tests, reveals that the courses have produced statistically significant changes pre- and post-intervention. The clinical significance of these results could not be analysed, as, to the authors’ knowledge, the minimal clinical important difference has not yet been established for these measures.

Analysis of the Patient Health Questionnaire (PHQ-9; Kronke, Spitzer & Williams, 2001), using paired samples t-tests, reveals that the courses have also produced statistically significant changes in mood pre- and post-intervention.

LIFT Psychology run psycho-educational courses for LTCs, including chronic pain, chronic fatigue, fibromyalgia, irritable bowel syndrome, type 2 diabetes, asthma, and stroke. The service also provides input to three rehabilitation programmes (pulmonary, cardiac, and back pain) as well as individual CBT-based support, although this is beyond the scope of this poster. Regular training and supervision in LTCs is provided to all staff.

The courses focus on enhancing self management and self efficacy, increasing activity levels, and improving psychological wellbeing. Key interventions include behavioural management (such as prioritising, planning, and pacing), thought challenging and thought defusion, communication skills, sleep hygiene, stress management, SMART goals, mindfulness, and setback management.

Professionals from other disciplines (e.g. physiotherapy, nursing, dietetics) also provide input on some of the courses, disseminating their specialist knowledge.

To evaluate this type of intervention, standardised questionnaires are completed by individuals who access the service; these pertain to general emotional wellbeing and management of the specific LTC. Anonymous feedback questionnaires are also completed to provide qualitative feedback.

Future directions

LIFT are now involved with a Pathfinder Project, looking further into the role of psychology for LTCs. The project includes:

- Very low calorie diet project for type 2 diabetes

- Investigation of optimal pathways for LTCs

- Development of high intensity interventions for LTC, including for individuals who are exceptionally high users of services.

- An estimated 30% of people with a LTC also have a mental health difficulty

- Co-morbid mental health difficulties are a major cost driver in the care of long term conditions, accounting for a 45-75% increase in service costs

- Service models that address the full range of patient needs have been shown to improve patient outcomes and lead to cost savings that far outweigh the cost of the psychological interventions

Mental Health Network (2012)

Needs Welcome Clarity

Pain (n = 41) 6.6 7.8 7.8

Chronic Fatigue (n = 43) 6.1 7.6 7.3

Fibromyalgia (n = 21) 7 7.7 7.7

Diabetes (n = 9) 6.4 7 7.3

Reflections

Psycho-educational courses appear to be an effective and well received intervention to enhancing self-efficacy, self-management skills, and emotional wellbeing in people with LTCs.

With the ever increased need to demonstrate cost savings, the service is currently evaluating the impact of course attendance on the use of NHS resources (e.g. GP consultations, emergency attendance).

Furthermore, follow-up data is being gathered and analysed to facilitate understanding of the longer term benefits of this intervention.

References

Bennett, R., Friend, R. & Jones, K. (2009). The Revised Fibromyalgia Impact Questionnaire (FIQR): Validation and psychometric properties. Arthritis Research and Therapy, 11, 415.

Chalder, T., Tong, J. & Deary, V. (1993). Development of a Fatigue Scale. Journal of Psychosomatic Research, 37, 147-153.

de Silva, D. (2011). Helping People Help Themselves. London: Health Foundation. Retrieved 22 September 2011 from www.health.org.uk/publications/evidence-helping-people-help-themselves

Department of Health (2011). Long Term Conditions. Retrieved 16 October 2012 from http://www.dh.gov.uk/health/category/policy-areas/nhs/long-term-conditions/

Dr Foster Intelligence (2006). Keeping People Out of Hospital: The Challenge of Reducing Emergency Admissions. London: Dr Foster Intelligence.

Kronke, K., Spitzer, R. L. & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.

Mental Health Network (2012) Long-term health gains: Investing in emotional and psychological wellbeing for patients with long-term conditions and medically unexplained symptoms. Briefings, 237. Retrieved 16 October 2012 from http://www.nhsconfed.org/publications/reports/Pages/InvestinginEmotionalandPsychologicalWellbeingLongTermPatients.aspx

National Institute for Health and Clinical Excellence (2008). Type 2 Diabetes: The Management of Type 2 Diabetes. London: Author.

Nicholas, M. K. (1989). Self efficacy and chronic pain. Paper presented at the annual conference of the British Psychological Society.

Polonsky, W. H., Anderson, B. J., Lohrer, P. A., Welch, G., Jacobson A. M., Aponte, J. E. & Schwartz, C. E. (1995). Problem Areas in Diabetes (PAID).

Lucy Hawkes, Georgina Ruddle, Madeline Harris & Jon Freeman

PAIN

Pain Self Efficacy Questionnaire

(Nicholas, 1989): t(36)=-2.292, p<0.05;

PHQ-9: t(38)=2.918, p<0.01

CHRONIC FATIGUE

Chalder Fatigue Scale (Chalder, 1993):

t(39)=4.844, p<0.001

PHQ-9: t(43)=5.227, p<0.001

Feedback

The courses are viewed very positively by attendees in terms of meeting their needs, feeling welcomed, and the clarity in which concepts were taught, as measured by an 0-8 Likert scale (see table opposite).

Analysis of feedback questionnaires demonstrate that, generally, the courses are well received, and help to normalise difficulties and reduce feelings of isolation:

‘I found it very helpful in the way things were explained, easy to understand’

‘[most helpful aspect of the course was] the realisation you are not alone’

TYPE 2 DIABETES

Problem Area In Diabetes

(PAIDS; Polonsky et al., 1995):

t(6)=3.328, p<0.05

PHQ-9:

t(6)=2.802, p<0.05Pre PAIDS Post PAIDS Pre PHQ-9 Post PHQ-9

0

5

10

15

20

25

30

Assessment Measure

Sco

re

FIBROMYALGIA

Fibromyalgia Impact Questionnaire Revised

(Bennett, Friend & Jones, 2009): t(18)=2.284 p<0.05

PHQ-9:

t(17)=3.369 p<0.005Pre FIQR Post FIQR Pre PHQ-9 Post PHQ-9

0

10

20

30

40

50

60

70

Assessment Measure

Sco

rePre CFS Post CFS Pre PHQ-9 Post PHQ-9

0

5

10

15

20

25

30

Assessment Measure

Sco

res

Pre PSEQ Post PSEQ Pre PHQ-9 Post PHQ-90

5

10

15

20

25

Assessment Measure

Sco

re