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iBSC Health and Illness Across the Lifespan > Session Eleven (Psychological Interventions in Long-Term Conditions) > Flashcards

Session Eleven (Psychological Interventions in Long-Term Conditions) Flashcards

1
Q

What are the respective prevalences of long term conditions, mental health, and their overlap?

A
  • LTCs = 30% of UK
  • MH = 20% of UK
  • 30% of individuals with an LTC have a co-morbid MH problem
  • 46% of individuals with a MH issue have a concurrent LHC

Essentially: A staggering degree of overlap between the two

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2
Q

What impact does having a mental health condition have on an individual with an LTC?

A
  • Poorer clinical outcome, prognosis, mortality
  • Adverse health behaviours and poorer self care
  • Lower QoL
  • Monthly cost of care doubles
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3
Q

As an example, what impact has depression been shown to have on Renal patients?

A

Farrokhi et al (2013):
- Depression predicts 51% of increased risk of death in individuals with end stage renal disease

Bonnet et al (2005):

  • Depression causes a poorer lifestyle in individuals with renal disease
  • Linked to worse management and outcomes

Weisbord et al (2014):

  • Longitudinal study
  • Associated with increased rates of treatment non-adherance
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4
Q

Give an example of an especially dangerous LTC/psych co-morbidity?

A

Anxiety + respiratory condition.

Anxiety causes hyperventilation which can worsen resp symptoms and either have a direct effect on patient health OR can cause them to overuse rescue meds which is incredibly expensive

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5
Q

How disabling is depression

A
  • Extremely, 3rd leading cause worldwide

- Only made worse when you add on a LTC

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6
Q

How expensive is co-morbid mental health in LTCs?

A
  • Massively
  • Doubles the cost of treating the patient
  • About 1/8th of the money spent on treating LTCs goes specifically to mental health
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7
Q

What evidence is there to support the role of mental health care in LTCs?

A

Chiles et al (1999):

  • Meta-analysis of 91 studies into the effect of psych interventions on LTC treatment cost
  • Found an average reduction of about 20%

Moore et al (2007):

  • Studied the benefits of including a psych component to COPD clinics
  • Found they let to 1.2x fewer A&E presentations
  • 1.9x fewer bed days
  • And average savings of close to £850 per person per year
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8
Q

What is IAPT, and what is the reasoning behind it?

A

The Improving Access to Psych Therapies pathway for people with LT physical conditions (and MUS)

Reasoning:

  • Meeting MH needs means they are less likely to be distressed about physical health, less likely to visit GP
  • Meeting MH needs means patients are better able to self manage
  • Integrating care is cost effective

Essentially: its way cheaper on the NHS if LTC patients are mentally healthy

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9
Q

What are the important BioPsychoSocial factors involved in how a patient reacts to an LTC?

A

Bio:

  • The cause
  • The symptoms
  • The outcomes
  • The management (pharm/ surgical/ lifestyle)

Psycho:

  • Fight; information seeking, support seeking, adherence, self-assessment
  • Flight; denial, seek second opinion
  • Freeze; passive coping strategies

Social:

  • Availability of social support
  • Availability of financial resources
  • Access to resources
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10
Q

What are the various domains involved in Adjusting to a LTC?

A

1) Mastery over the illness itself
2) Preservation of functional status
- Sexual function
- Social function
- Physical function
- Cognitive function
3) Maintaining QoL
4) Absence of a psychological disorder
5) Low negative affect, high positive affect

Adjustment is a fluid process, changes over the course of the condition

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11
Q

What is the BPS model, and why is it important to health care professionals?

A

BPS factors = the three core mechanisms which can influence a person’s mental health outcomes

Important to understand these factors as they are what determines how well a patient adjusts to their condition, therefore can be used to identify areas they’ll need additional support in.

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12
Q

Outline the Moss-Morris model of LTC adjustment?

A

Background factors such as…

  • Illness specific factors
  • Personal factors
  • background social and environmental factors
  • Key critical events
  • Illness stressors

….lead to a Disruption in emotional equilibrium and current QoL. This emotional disruption will require adjustment, which can be either successful or not based on various…

  • Cognitive factors: +ve (e.g. self-efficacy, benefit finding, acceptance of illness, social support) vs -ve (e.g. stress, negative illness representations, helplessness, suppression of negative affect)
    AND
  • Behavioural factors: +ve (e.g. engagement with good health behaviours, adherence, maintaining activity, expressing emotions appropriately) vs -ve (e.g. avoidance, denial)

Together these processes lead to either Good or Poor adjustment

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13
Q

What is Illness Self-Management?

A

Any health related behaviour the patient engages in as a means of managing their LTC.

Includes:

  • Lifestyle changes (diet, exercise)
  • Adherence to pharm therapy
  • Attending health care appointments
  • Responding to symptoms appropriately
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14
Q

How important is patient knowledge in terms of adjustment/ changing their health care behaviour?

A
  • Knowledge = necessary but not sufficient for behavioural change
  • Knowledge + attitude around a behaviour explained only 10% of the variance in whether that behaviour is performed or not (McEachan, 2011)
  • However, education should always be the first part of an intervention
  • Need to explore and intervene on other factors that influence a person’s health related behaviours
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15
Q

Outline ‘empowerment’ interventions, aimed at improving a patient’s self-efficacy?

A
  • Determine skill level
  • Personal and vicarious experiences of success
  • Identifying and planning for barriers
  • Low and slow start to the process
  • Shaping and incorporating rewards
  • Bearing in mind that change is a process, not a single action

NICE 2014 recommendations centred around:

  • SMART goal setting
  • Action planning
  • Feedback + monitoring
  • Social support
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16
Q

What is a SMART goal?

A

Specific (define precisely what the goal is and how it’ll be achieved)
Measurable (give parameters to allow recognition of success)
Achievable (realistic to this patient)
Relevant (goal is in line with that patient wants)
Timely (set a time limit)

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17
Q

What is “If-then” planning in the context of aiding a patient in their adjustment to a condition?

A

IF a situation occurs, THEN I will do…..

A way of overcoming barriers a patient might experience in managing their condition. Useful at preventing relapse into a form of maladaptive coping.

e.g. if someone tries to persuade me to drink, then I will say I am planning for a holiday. good as can be highly personalised to the barriers a patient faces AND what coping mechanism might work for them

18
Q

What evidence is there to support the importance of empowerment interventions in the management of LTCs?

A

Adriaanse et al:

  • Meta-analysis of 23 studies investigating the effect of such implementations on eating behaviour
  • Effective both at increasing healthy eating and diminishing unhealthy eating patterns
19
Q

What are some examples of feedback which can be used to help patients adjust?

A
  • Monitoring and feedback by others
  • Self-monitoring of behaviour
  • Self-monitoring of outcomes
  • Biofeedback
20
Q

How vital is social support in aiding adjustment?

A

Generally very but important to note that not all individuals will benefit from their immediate social environment.

Social support may include:

  • Practical support
  • Emotional support
21
Q

What did Michie et al’s 2009 meta-regression study into intervention targeting exercise and lifestyle behaviours show?

A
  • 84 studies incorporated
  • Interventions overall were highly effective on outcomes
  • BUT average intervention actually used 6 techniques
  • Therefore suggests we could refine the way we use interventions, identify which ones actually work best
  • Self-Monitoring appears to be the most beneficial
22
Q

Define CBT?

A

Discrete, time-limited, structured psychological intervention.

23
Q

What is adjustment disorder?

A

DSM-5 Definition =

“The presence of emotional or behavioural symptoms in response to an identifiable stressor occurring within 3 months of the onset of said stressor (e.g. an illness)”

Also requires one of these criteria:

  • Distress out of proportion with stressor
  • Symptoms must be clinically significant

And all of these:

  • Distress and impairment isn’t just an escalation of Ann existing mental health disorder
  • Reaction isn’t part of normal bereavement
  • Symptoms must subside (within 6 months) when the stressor is removed
24
Q

How prevalent is adjustment disorder amongst patients dealing with an LTC?

A

Unclear as not enough data collection/screening occurs.

Palmer et al study into Renal patients:

  • 20-40% prevalence of AD
  • Numbers carried depending on whether patients self-assessed (20%) or were diagnosed in clinical interviews (40%)

Suggests it might be beneficial to screen more people

25
Q

Why has MS been a focus for CBT methods aimed at helping patients cope with LTCs?

A
  • MS = most common disabling condition affecting young adults in the UK
  • 23-41% experience anxiety
  • 10-41% experience depression
26
Q

How effective were early attempts at using CBT to help MS patients adjust?

A

Not very.

When attempting to recruit patients for computerised CBT methods (mood gym, beating the blues), researchers found them to be ineffective, largely because these methodologies were aimed at depressed patients, who experience very different issues than those with MS.

E.g. telling someone with MS to increase exercise isn’t massively beneficial.

27
Q

What factors specific to MS should be bared in mind when managing the condition with CBT?

A

Factors relating to the disease

  • Unpredictability of symptoms
  • Wide ranging nature of symptoms
  • Whether its relapsing/remitting or primary progressive
  • Effect on motor functions
  • Restriction of abilities
  • Treatment; disease modifying agents

Cognitive-Behavioural factors:

  • High levels of stress
  • Use of emotion focused coping
  • Managing uncertainty
  • Social support
  • Cognitive bias
  • Illness and symptom cognitions
28
Q

What processes are involved in CBT for MS?

A
  • Introduction to MS
  • Adapting to living with MS
  • Setting goals and problem solving
  • Managing symptoms
  • Tackling unhelpful thoughts
  • Improving sleep
  • Managing stress
  • Managing social relationships
  • Preparing for the future
29
Q

How effective has CBT for MS been shown to be?

A

Very.

Moss-Morris et al, 2012:

  • Reduction in distress immediately post therapy (sustained at 12 months)
  • Improvement in work and social life adjustment scale (sustained at 12 months)
  • While results were sustained after 12 months, there was an amount of drop off
  • Found to be more effective than SL for adjustment, especially in the post-therapy period
  • Patients with relapsing-remitting illness and lower levels of perceives support benefit more
  • However there were theoretical issues, revised models need to pay more attention to emotional processing and acceptance.
  • Requires more booster sessions post therapy, to prevent drop off in adjustment observed

Provides evidence for the role of specifically targeted interventions in LTCs&raquo_space; generic ones.

30
Q

What is collaborative care?

A

Health service delivery framework which supports the implementation of depression intervention.

Four components:

  • Proactive screening (for emotional issues and adjustment issues)
  • 2+ health care professionals collaboratively working to manage a person’s health
  • Regular interviews and monitoring
  • Use of evidence based treatment protocols
31
Q

How effective is Collaborative Care?

A

Cochrane review of 79 CC trials (25,000 patients):

  • More effective than usual care for both depression and anxiety
  • Both immediately after treatment and up to 2 years after
  • Associated with greater use of anti-depressant medication
  • More effective than just medication alone
32
Q

Collaborative Care has been shown to be effective, but requires a massive amount of health care professional time. What solution to this problem has been suggested?

A

Telephone delivered case management within collaborative care.

  • Proven to have equivalent effectiveness to face-to-face treatments.
  • Better for scale and reach of interventions.
33
Q

How effective has CC been shown to be, specifically in the treatment of LTCs?

A

Katon et al (2010):

  • Studied effectiveness of CC for LTCs in US
  • Found moderate to large treatment effects for a range of physical and mental health outcomes (e.g. depression, diabetes, cholesterol, systolic BP)

However unclear if this is relevant to us in the UK:

  • US medical system fundamentally so different to ours
  • Heavy reliant on elite academic input (the people they used were super high flying researchers, not average people)
  • Highly selective, affluent populations were studied
34
Q

What did the COINCIDE study look into?

A

Effectiveness of CC in a UK setting, for Depression:

  • Improved depression outcomes over 4 months
  • Improved anxiety outcomes over 4 months
  • Better self-management on 5/8 domains on self-reported measure
  • Felt their care was more patient centred
  • More satisfied with their care

However some issues were flagged, mainly around patient engagement:

  • Patients attended a mean of 4.4 sessions, only 12% went to the full 8
  • Only about a quarter went to the joint sessions
35
Q

What is Stepped-Care?

A

Bower and Gilbody, 2006:

  • Framework for designing roll-out of psych therapies
  • Stepped in order to provide most effective yet least resource intensive treatment according to degree of clinical need
  • Brought out because demand greatly outweighs supply for NHS mental health services
36
Q

Outline Step 1 of Stepped Care?

A

Step 1 =

  • For all known suspected presentations of depression
  • Involves assessment, education, support, active monitoring, referral for further assessment and intervention
37
Q

Outline Step 2 of Stepped Care?

A

Step 2 =

  • For mild to moderate depression
  • Involves low-intensity psychosocial interventions, medications, referrals for further assessment
38
Q

Outline Step 3 of Stepped Care?

A

Step 3 =

  • For mild-moderate with inadequate response to 1+2, moderate-severe
  • Involves medication, high-intensity psychosocial interventions, combo therapy, CC, referral
39
Q

Outline Step 4 of Stepped Care?

A

Step 4 =

  • For severe and complex depression, risk to self or risk of neglect
  • Involves medication, high-intensity interventions, ECT, crisis services, combo therapy, multi-profesional and inpatient care
40
Q

Give some support evidence for stepped care?

A

Kontopantelis et al, 2013:

  • Those with mod-severe depression benefited most from step 2 interventions
  • Supports notion that steps to care is a good idea
41
Q

What is an issue with Stepped Care when it comes to the management of individuals with LTCs?

A

It is unclear whether presence of LTCs should influence where a person goes into the pyramid.

In its current formulation the SC programme ignores LTCs, which we know from evidence is foolish.

iBSC Health and Illness Across the Lifespan (12 decks)

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