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Evidence Based Mental Health Training Evidence Based Mental Health Training What is Evidence Based Practice? The Scope of Mental Health Training? Training For What? Learning EBP

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The Birth of CBT Ten Years Go By The Final Arbiter Can Being â&#x20AC;&#x2DC;Evidence-Based Work Against Us? Effective Therapies or Effective Therapists? Taking Evidence Direct from the Patient Evidence Based Training Does Training Work? Another Way

What is Evidence Based Practice?

John Hancock

A Different Approach Quality of Evidence and Evaluation Limitations of EBP

The Scope of Mental Health Training?

Camilla Slade, Staff Writer

Not Only Professionals A Broad Area of Work Evidence-Based Developments

Training For What?

Peter Dunwell, Medical Correspondent

Evidence-Based Training Evidence-based policy No Health Without Mental Health Better Outcomes

Learning EBP

John Hancock

A Changing World A Growing Role for Evidence Government and Professional Strategy Training Programs

References 15

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SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Foreword E

vidence-based practice (EBP) may seem to be

be at all the same. However, if evidence from

the new kid on the block in health care but stop

past cases is blended with the practitioner’s own

and think about it and it does seem very sensible.

experience and understanding of the patient, then

After all, what could be controversial about the idea

there is every chance that evidence-based practice

that you diagnose and treat disorders with a strong

will lead to improved patient outcomes and a less

reference to what has succeeded in the past?

costly treatment experience.

The opening article of this Special Report traces

In order to be able to bring those other factors

the history of Evidence Based Health Training,

into the process, those who use evidence-based

referring back to the 1970s when the concept of

practice in mental health care will need to be

Behavioural modification for dealing with a wide

properly trained in its capabilities but also its

range of conditions was beginning to question the

limitations and how they can be dealt with. They

then widely accepted Freudian approach. A new

need to understand how to judge what weight

term – cognitive therapy – was coined, based on

to put on evidence. Training needs to be broad

the notion of ‘evidence’ as being part and parcel

in every sense because there is a wide range of

of therapy. This transformed the thinking on the

mental health disorders that in turn afflict a broad

process of therapy. Following studies by the

spectrum of people.

National Institute for Mental Health published in

Also, training will ensure that evidence-based

1989, there was disagreement among supporters

practice retains its professional calibre and

of Cognitive Behavioural Therapy leading to the

capability and does not descend into one of many

teaching by the Association of Psychological

‘buzz-words’ that, while they sound good, are

Therapies (APT) of ‘five factor’ models of CBT. This

considered empty platitudes rather than serious

involved changing patient’s behaviour rather than

contributions to their disciplines. That would be

working directly on their emotions. This approach

sad because EBP as a system can provide the

was borne out by NICE, who are considered the

architecture to bring together all that is best in

ultimate arbiter of what the evidence has to say.

health care for people with mental disorders.

In truth, EBP does have its limitations, in areas where the case facing a healthcare practitioner today may not be easily matched with a superficially similar case in the past: habits change, ethnicity may be different, social circumstances may not

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Evidence Based Mental Health Training Dr William Davies, co-founder and Director of APT, The Association for Psychological Therapies

he story of Evidence Based Mental Health Training begins in the 1970s. The battle was between Psychodynamic (Freudian) approaches and behaviour modification (‘Skinnerian’) approaches. I was studying for my Doctorate in Clinical Psychology at Birmingham University, a hot bed in favour of the latter. The received wisdom for us was that “there is no evidence that Psychodynamic approaches work” whereas, for us, Behavioural approaches could cure everything from a little light dysphoria through to man’s inhumanity to man. No doubt there was a healthy dose of “allegiance bias” (supporting a particular therapeutic approach rather like football supporters support a particular football team) in our thinking at the time, and maybe this persists to this day. Lewinsohn said that “most people who are depressed are depressed because they lead depressing lives” which, nowadays might seem either a little harsh or somewhat over simplistic. At the time, when the prevailing wisdom amongst a lot of Psychotherapists was that it was all to do with “unconscious processes” this was like a breath of fresh air and led to a clear strategy for helping people lead more rewarding lives. To do this, we utilised behavioural strategies, and it is interesting to note that, just recently in 2012, the Beck Institute reminded us not to rush too hastily into Cognitive Interventions but, first, to check whether straightforward Behavioural Interventions had been applied.

The Birth of CBT It was Beck, previously a Psychodynamicallyorientated Psychiatrist, who wrote his first book on ‘Cognitive Behavioural Therapy’ in 1976, and his second, with others, in 1979. These added still more to the excitement of us young Behaviourists who felt we could now add ‘mental processes’ into the mix and, furthermore, to utilise everything we knew from our first degrees about Cognitive Psychology, into a therapeutic situation. To call a new therapy ‘Cognitive

Good programmes have built-in assessment, and can be run, for example, by a counsellor in a GP practice.

Therapy’ was a marketing masterstroke: all our learning about Cognitive Psychology was not to be wasted after all. One of the great things that Beck’s work did was to introduce the idea of ‘evidence’ as being part and parcel of therapy. Whereas previously many practitioners maintained that the process of therapy was so mystical that it was beyond the realms of measurement, Beck took the reverse approach. He said that ‘the way we think influences the way we feel’ was a hypothesis and, like any other hypothesis, needed testing. And that the best way of testing the hypothesis was to see if we could alter the way that depressed people thought, and measure whether this affected their level of depression. This contrasted with a rival hypothesis that depression was caused by, for example “a chemical imbalance in the brain” and once one is depressed then of course one thinks differently. In other words, the depression causes the changes in thinking rather than vice versa. So Beck tested his hypothesis and the rest, as they say, is history.

Ten Years Go By The next big event was the National Institute for Mental Health (NIMH) study published in 1989 by Elkin et al. This was a study that all of us who www.primarycarereports.co.uk | 3

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

To call a new therapy ‘Cognitive Therapy’ was a marketing masterstroke: all our learning about Cognitive Psychology was not to be wasted after all.

were ‘into’ CBT anticipated with the eagerness of a host of young puppies. A large scale study involving lots of clinicians across lots of treatment centres, Elkin et al compared the effectiveness of different treatments for depression. Not just Psychological treatments (including CBT of course) but Pharmacological ones too. So now at last there would be a definitive study showing how great CBT was and everybody would see the truth of what we had been saying for ten years. In the event, it was not quite like that. The most effective treatment for severe depression turned out to be … medication (Tricyclics in those days). And the most effective Psychological intervention turned out to be … Interpersonal Psychotherapy (IPT). The response from supporters of CBT was predictable. Some decided that the study was ‘fatally flawed’ after all. Some forgot all that they had ever known about ‘averages’ maintaining that “in some places CBT was shown to be really effective” forgetting that this implied that, in other places, CBT must have been really ineffective. But others took a more constructive view. Amongst these were Christine Padesky in the United States, and The Association for Psychological Therapies (APT) in the UK. Both responded by teaching ‘five factor’ models of CBT. The original model of CBT had just three factors: emotions, behaviour, and cognitions. The idea was simple, namely that while you didn’t usually get very far by working directly on patients’ emotions (“pull yourself together”) you could do so by changing their behaviour (showing them how to lead a more rewarding life) or their thoughts. Elkin’s 1989 study showed unequivocally that interpersonal factors should also be included in the mix, and there was equally unequivocal evidence that there were biological factors (e.g. taking exercise and learning how to relax) which were also highly relevant. Christine Padesky and The Association for Psychological Therapies (APT) responded by incorporating both of these into what they taught.

The Final Arbiter The National Institute for Health and Clinical Excellence (‘NICE’) arrived relatively late on the scene in 1999, but has nevertheless become ‘the ultimate arbiter’ of what the evidence has to say. NICE, like everybody else, does not view ‘mental health’ as a global entity but breaks it down into subsets of depression, anxiety etc. In psychological terms there are several approaches which feature, notably: • Cognitive Behavioural Therapy (CBT) • Interpersonal Psychotherapy (IPT) • Psychodynamic Approaches 4 | www.primarycarereports.co.uk

•B iological Factors, notably exercise, sleep etc. • Motivational Enhancement In fact, rather than recommending, say, “CBT” for a particular disorder, NICE usually advocates a particular ‘protocol’. So, for example, in Substance Misuse, NICE advocates (amongst other things) ‘Behavioural Couples Therapy’, which has been shown in the literature to produce positive effects. This is, as its title suggests, a mixture of CognitiveBehavioural Strategies and Interpersonal ones. Interestingly, it also includes the use of antabuse.

Can Being ‘EvidenceBased Work Against Us? This strategy of commending particular protocols (also evident in Roth and Pilling’s CBT Competences) is a controversial one. The logic behind it is to tighten up on what clinicians do, so that individual clinicians can’t simply ‘do their own thing’ and pass it off as ‘CBT’, ‘IPT’ or whatever is the evidence-based therapy of the time. It is controversial because good clinicians may well deviate markedly from specific protocols or even use no protocols at all. So on the one hand, advocates of protocol-based interventions maintain that they are the essence of ‘quality control’ and, on the other hand, objectors say that protocols may limit and stifle the effectiveness of talented clinicians.

Effective Therapies or Effective Therapists? Theorists such as Michael Lambert in the United States have suggested that it might be more fruitful to look at effective therapists rather than effective therapies. This radical approach accepts the idea that some therapeutic techniques may be more suitable to some therapists than others. For example, Beck presumably found CBT a more congenial approach than Psychodynamic Therapy. And it is an open question whether Carl Rogers, one of the founders of Counselling, would ever have made a good CBT Therapist. So maybe the question is not “what are the best therapeutic approaches” but rather “who are the best therapists?” It is this question that APT’s forthcoming Register of Patient Accredited Therapists addresses itself to, reasoning that what perspective patients are really interested in is how other patients viewed the therapist they are thinking of seeing.

Taking Evidence Direct from the Patient The evidence that most people think of is from published studies, ‘randomised control trials’. But once a therapeutic approach is taken out and used by clinicians there may be a whole different story. So good practice currently is to take

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

evaluation of the workshops by each and every delegate who attended them. Workshop topics were designed to keep up with the prevailing developments of CBT, IPT, and so on. 30 years on, in 2012, this has become very much established practice so that such workshops are integral to continuing professional development of mental health professionals. And there has been a proliferation of providers of such workshops, including not only those who have modelled themselves on APT, but also, some Universities. In parallel with this, and in an effort to be ever more cost-effective, some courses have migrated to the Internet and to ‘webinars’. ‘Prepared’ Programmes’ can short-circuit the training process. Sometimes it’s best to go out and buy a car, rather than learning how to build one yourself.

measures directly from the patient. Organisations such as CORE, IAPTUS and PC-MIS specialise in this, and some clinicians do something simpler but more direct, namely to ask their patients a question such as “considering the last week as a whole, how would you rate your mood out of 10, where 10 is good and 1 is bad?” If a patient’s scores progress over therapy from 2s and 3s to 6s and 7s then you can reasonably assume that you have done a fair job. If not, however, then it points you in the direction of doing something different. Regular measurements such as these, shared with the patient, have been shown to be good practice, for example by Michael Lambert. Even so, some clinicians are still apparently reluctant to implement them.

Evidence Based Training The attentive reader will have noticed that the story so far has covered evidence based practices but not the training in those practices. In fact there has been something of a revolution in training in the last 30 years. Up until 30 years ago, the training in a profession such as Psychiatry, Clinical Psychology, Occupational Therapy, Mental Health Nursing, Social Work, etc. was deemed to be sufficient training in and of itself. Supplementary training was provided very much on an ad hoc basis with workshops put together to cover topics of interest and a charge of a few pounds levied to cover the cost of tea and biscuits. If you were lucky you might also receive a barely legible photocopy, known as a ‘hand-out’. Then, in 1981, The Association for Psychological Therapies (APT) was established, aiming to transform the quality of those ‘workshops’ with tutors who had demonstrable knowledge of the subject in question, professionally produced workbooks, video materials to illustrate techniques and

Does Training Work? This is the latest chapter in the training story and it has to be split into two parts: 1. D o people learn anything when they attend training and, if so, 2. D oes what they learn benefit their patients in any way? The first of the two questions is much the easier one to answer and the concept of ‘demonstrable learning’ is an important one currently. Many web-based courses have a quiz/exam built into them so that the student can show that they have achieved a certain level by the end of the course. Some courses even have a comparable exam at the start of the input, so the students can demonstrate that they weren’t already at that level before sitting the course! Many live courses also have a similar module attached or as ‘an optional extra’. The concept of ‘pre and post’ evaluation is important because those people who are inherently suspicious of training need to know that students weren’t already at a high level on the topic before attending the course. The question of whether the training benefits patients is a much more difficult one. The nightmare scenario is where a naturally talented therapist has that natural talent diminished by training in specific techniques. To assess whether this happens is a much more difficult task than to assess whether any learning takes place on a course. So, although a few people are making commendable efforts to evaluate this, one generally has to rely on the expertise of the course author to avoid this danger.

Another Way One way is to find a technique such as CBT or IPT which has evidence to support it, attend a training course that teaches it, and work on applying that learning to a clinical situation. Although this sounds arduous, it is in fact what most people do, and with considerable success. However, there is another way of looking at it and that is to adopt prepared ‘programmes’ to tackle www.primarycarereports.co.uk | 5

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

The concept of ‘pre and post’ evaluation is important because those people who are inherently suspicious of training need to know that students weren’t already at a high level on the topic before attending the course.

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depression, anxiety, etc. Such programmes (MoodMaster Programmes from APT are one example) are usually run in groups. For instance, a Counsellor in a GP Practice may train to be a programme leader and so be able to run the Anti-depression Programme, the Anti-anxiety Programme and so on. Such programmes partially short-circuit the need for training, assimilation and application by providing a programme leader with prepared materials and script. Good programmes will also have an inbuilt measure of how the group members are progressing. So a typical group session might consist of group members coming in, settling themselves down, assessing their mood over the previous week, discussing notable incidents that have occurred, reporting back how any homework / project went, and then addressing ‘the topic for the week’, all under the guidance of the programme leader. Some of the earlier such programmes were devised for Forensic populations (in prisons for example) to tackle offending behaviour but their clear structure, built in evaluation, cost effectiveness and obvious validity has made their appeal much wider than that. In summary, the story of Evidence Based Mental Health Training is an interesting and convoluted one, dense with assumptions, prejudices and preferences. First about what should be trained, second about the extent to which patients benefit from their therapists attending such training, and third whether we are pursuing the right strategy: can one be trained in techniques of therapy in just the same way as one can be trained in surgical techniques for instance? But there is a lot of cause to be optimistic about the present and hopeful for the future partly because good providers are very thoughtful about these questions but also because of the alternative ‘higher order’ strategies emerging such as the work on assessing effective therapists rather than effective therapies and the provision of pre-written programmes that can be delivered direct to patients by programme-leaders.

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

What is Evidence Based Practice? John Hancock

Although relatively new, the evidence-based approach to a number of disciplines is now the standard

efore we can understand evidencebased mental health training, it is probably as well to take a step back and understand evidence-based practice (EBP), an interdisciplinary approach across the healthcare sector that has developed since 19921. EBP originated as evidence-based medicine (EBM) and was then taken up in other fields – hence its application in mental health care and training. Other evidence-based templates include evidence-based guidelines, at an organisational or institutional level and also called evidence-based health care, and evidence based individual decision-making.

The article goes on to emphasise that people with severe mental illness are like any other people with long-term illnesses in the sense that they want to pursue normal, functional and satisfying lives and these aspirations need to be taken into account within the evidencebased practice model. Evidence-based practice is not the only legitimate model but it is one that, though it challenges practitioners, is more often than not best for patients. Blending evidence gained from scientific methods with the wants and needs of patients ought to provide the optimum balance of outcomes.

A Different Approach

Quality of Evidence and Evaluation

EBP moves away from the intuitive approach to diagnosis and treatment, to an approach where decisions are made based on evidence from past observations, experiments, studies or researches, along with the expertise and experience of the practitioner plus other environmental social and patient centred criteria. While drawing on research and experience, EBP also recognises that care is an individual matter, often changing and having to take account of uncertainties and probabilities. Specifically in the area of mental health, empirically supported treatments (ESTs) are defined as “clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population.” Taking this further, Psychiatry Online reported that the application of evidence-based practices rested on a series of research findings and philosophical commitments2 such as that reviews of research evidence has identified a core set of interventions that helped people with severe mental illness to attain better outcomes in terms of symptoms, functional status and quality of life. The journal went on to highlight, “that despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research also shows that routine mental health programs do not provide evidencebased practices to the great majority of clients with these illnesses.” At least one reason for improved training in evidence-based practice for professionals in the mental health field.

An important factor in supporting any evidencebased practice is in the quality of the evidence itself and the quality of the research on which it is based. Any training that seeks to inculcate evidence-based methods into students cannot ignore this reality. Neither should those who seek to practice in this way accept blindly the conclusions reported by other researchers but rather, training should include the reading of research reports and background information so that the student can also draw their own conclusions. Typical of the sort of training program that support this approach would be Oxford University’s part-time professional development course ‘Evidence – Based Diagnosis and Screening’ 3 which equips students with the intellectual tools needed to be able to evaluate material themselves and “critically appraise articles assessing the validity and repeatability [of] a screening or diagnostic test…” This allows those who practice evidencebased care of any sort to rate the sources of evidence. Various health services have tried to produce systems to assist this rating valuation process and, in the UK National Health Service, different levels of evidence are accorded labels A, B, C, and D for which, the Oxford Centre for Evidence-based Medicine4 suggests levels of evidence (LOE) according to the study designs and critical appraisal of prevention, diagnosis, prognosis, therapy, and harm studies: www.primarycarereports.co.uk | 7

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Few rigorous assessments of the effectiveness and cost effectiveness of interventions to promote mental well-being in people aged 65 and older have taken place in the UK.

•L evel A: Consistent Randomised Controlled Clinical Trial, cohort study, all or none, clinical decision rule validated in different populations. •L evel B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies. •L evel C: Case-series study or extrapolations from level B studies. • Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles. But sometimes it is simpler than that, such as when consistent scientific evidence shows that a particular practice improves patient outcomes. For instance, “research shows that using antipsychotic medications… and providing education and skills training for family caregivers… prevents or delays relapses of schizophrenia.” – Psychiatry Online again. Health Scotland in its evaluation guide ‘Mental Health Improvement: Evidence and Practice’5 produced a graphic that shows very clearly the evaluation process based on evidence from ‘Using Evidence to Informed Practice…’ to ‘Developing Indicators to Measure Success’, ‘Designing and Implementing an Evaluation’ and ‘Getting Results: Analysis and Interpretation’.

Limitations of EBP As with any system, evidence-based practice also has its limitations and it is important that training programmes should not only specify that to students but also cover some of those limitations. Psychiatry Online (see reference above) considers how evidence gained in one dimension of assessment might become less clear when other dimensions are considered. The example given is where research clearly demonstrates that assertive community treatment effectively reduces hospital use for some patients with schizophrenia. However, the evidence is less clearly in favour of assertive community treatment if you include functional outcomes such as employment, ethnocultural grouping, and patients with other diagnoses. In her article for Health Affairs ‘Evidence – Based Practice as Mental Health Policy: Three Controversies and a Caveat6’ Sandra J Tanenbaum highlights ‘Defining Evidence’ (how restrictive should the definition of ‘evidence’ be; that is, does the dominant definition inappropriately privilege some kinds of treatment

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“Most people who are depressed are depressed because they lead depressing lives.” (Lewinsohn.) Beware of trying too eagerly to change people’s cognitions?

over others?); ‘Applying Research Evidence’ (can, and if so, should, practice consist of the faithful application of research evidence?); and ‘What is Effective?’ (to the extent that EBP is a means to effective healthcare, what is meant by ‘effective’ and who decides?) She closes with the caveat… “EBP in mental health may be more controversial than EBM [evidencebased medicine]…” A more simple limitation of evidence-based practice may be the quality of research itself from which evidence is drawn or gaps in the evidence. The UK National Institute for Health and Clinical Excellence (NICE) public health guidance 16 ‘Occupational therapy interventions and physical activity interventions to promote the mental well-being of older people in primary care and residential care’ states “Few rigorous assessments of the effectiveness and cost effectiveness of interventions to promote mental well-being in people aged 65 and older have taken place in the UK… PHIAC [the Public Health Interventions Advisory Committee] identified a number of gaps in the evidence relating to the interventions under examination, based on an assessment of the evidence.” The guidance goes on to identify 12 gaps in evidence in this field alone. The Health Scotland evaluation guide (see above for reference) nicely sums up the interpretation of evidence, “In evaluating mental health improvement, we need to ensure that the methods and indicators chosen are well thought out, in the light of what we know influences how people think and feel.”

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

The Scope of Mental Health Training? Camilla Slade, Staff Writer

The issues and people are as important as the evidence

vidence-based practice (EBP) is important, setting diagnoses, decisions and treatment plans on strong foundations of known outcomes. But any training that focused only on this scientific element of practice would produce inflexible and ill-equipped graduates because the other side of training in any area, but probably especially so in mental health, is people and the issues with which they have to deal.

Not Only Professionals In the National Institute for Health and Clinical Excellence (NICE) clinical guideline 72 ‘Attention deficit hyperactive disorder’7, it states that “Healthcare professionals should offer parents or carers of preschool children with ADHD [Attention Deficit Hyperactive Disorder] a referral to a parent–training/education program as the first line treatment… “ The guideline goes on to specify a number of elements that should be present in a parent–training/education programme and, while those elements refer to helping parents with ADHD children, any training program that is not for professionals must take account of the people it is seeking to improve – they may not be experienced learners or professionals. Sometimes, of course, training can be in a group-based program where, in addition to any evidence-based content, individuals on the program can also share experiences and add their own collective contributions to the evidence base. There are numerous mental health issues for which evidence-based practice may be appropriate and for which professionals will need training to ensure they are able to deliver the best outcome for each patient.

A Broad Area of Work Mental illness, unfortunately, often carries a stigma and it will be part of the professional’s task to help cope with and overcome this problem. Sometimes people with mental health issues also need to be helped to motivate themselves to even the most mundane tasks of daily life

including, for instance, management of their own health and medication, especially if, in addition to their mental health issues, they suffer from other health disorders. Evidence-based training can help students understand how to deal with these situations by highlighting real cases when the same issues have been tackled. In other cases, patients may have social skills difficulty or need supported employment opportunities. All of these issues are covered in ‘Strategies to Promote EBP/EBT (evidence-based training) in Social Work Education8 from the Institute for the Advancement of Social Work Research. Numerous issues fall into the Mental Health category. We’ve already touched upon Attention Deficit Hyperactive Disorder (ADHD) but there are other sources of poor mental health for which GPs need to be trained in applying the lessons learned from earlier evidence. Domestic abuse is an area in which a particularly sensitive approach is required. The Royal College of General Practitioners (RCGP) has recently issued a guidance9 which includes the need for training within the practice to cover, “The health markers of domestic abuse. For example, when patients present with depression, anxiety, tiredness, chronic pain or non-specific symptoms.” It is in situations like this where GPs have to gather their own evidence on which to base a decision for which training needs to ensure that they are able to ask questions sensitively and safely as well as to interpret answers and make what can be quite significant decisions. Mental health issues, while they may be caused by clinical conditions, are as likely to be caused by social, environmental, lifestyle, relationship or a whole host of other causes, to discover which GPs will need training in unearthing, interpretation of and acting on evidence. There are also several groups on both sides of the patient-professional relationship for whom an evidence-based approach to mental health is important. Although not strictly training programs, the guides issued by various healthcare bodies in the UK provide a very good source for the kind of continuing professional development that will www.primarycarereports.co.uk | 9

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Sometimes people with mental health issues also need to be helped to motivate themselves to even the most mundane tasks of daily life including, for instance, management of their own health and medication.

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help professionals and especially clinicians to ‘train’ themselves.

Evidence-Based Developments Health Scotland has issued a guide entitled ‘Mental Health Improvement: Evidence and Practice’10 in which it is made clear that, “The guides are intended as a resource for colleagues across all sectors and settings [in the health service]. It is anticipated that they will be relevant to those working in a wide range of disciplines and services, both those with an explicit remit to mental health improvement and those to whom mental health improvement is an integral but implicit aspect of their work.” Further on, it lists what the guide covers, which also makes a useful reference. In Minnesota, USA the department responsible for children’s mental health has endeavoured to put in place a structure to support evidencebased practice11 with a database to guide decisions by parents and providers in planning for child and adolescent care. It is the first of its kind to be used in practice to address the question of what works for whom under what conditions? In the UK, the RCGP is promoting enhanced GP training including as a facilitator of improved care for people with mental health problems. The College’s paper on this subject, ‘Enhanced GP Training: The Educational Case’12 quotes from the Centre for Mental Health, “GP surgeries need to be welcoming places for people with mental health problems. All primary care staff have a key role in looking after the physical as well as mental health of people with mental illness.” NICE, again, in its public health guidance 16 ‘Occupational therapy interventions and physical activity interventions to promote the mental well-being of older people in primary care and residential care’13 is very heavily evidence-based to support the interventions or recommends and the training that will be needed to implement those interventions. Mental health training does need to be evidence-based but should not exclude the inclusion of specific mental health issues and individual patients from a GP’s view.

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Training For What? Peter Dunwell, Medical Correspondent

Evidence-based practice: policy, practice and programmes

lthough evidence-based practice in general can be dated back to 1992, 2003 was probably a more important date for evidence-based mental health practice. In that year EBMH (Evidence Based Mental Health) notebook and the BMJ (British Medical Journal) published details of the National Evidence-Based Practices Project 14 which aimed to implement effective mental health practices in diverse settings. The project ran in three phases including, in Phase 1 “developing structured resources (Toolkit) for consultation, training and implementation in six areas of evidence-based practice…”

Evidence-Based Training

Some theorists have suggested that it might be more fruitful to look at effective therapists rather than effective therapies.

Training to handle people who experienced serious mental health problems has always been an important part of the mental health care programme in the UK. As long ago as 1998 the Department of Health published ‘Modernising mental health services’, in which a vision was set out committing, “funding to a whole new raft of initiatives one of which [was] described as ‘more and better trained staff.’” The paper went on to say, “The programmes aim to teach mental health professionals the skills to work with people with serious mental health problems with curricular that are based upon research evidence about effective interventions.” Evidence-based practice in the treatment of people who experience serious mental health problems has featured in UK government policy for some while.

of the questions asked is “Do you support the twin themes of public mental health/prevention and mental health service development?” To this, Dr Maureen Baker for the Royal College of General Practitioners (RCGP) replied16, “We agree with this approach. However, there is a need to develop an evidence base about what interventions are effective, and base service design on that. There is also a particular need for evidence on the effectiveness of prevention as there is currently minimal evidence about these strategies.” Further on in the response, Dr Baker highlights a range of areas that would benefit from research due to evidence gaps.

Evidence-based policy

No Health Without Mental Health

More recently, in 2005, Health Scotland in its guide, ‘Mental Health Improvement: Evidence and Practice’, said in the first guide in the series, ‘Evidence-based practice’15,” … how can we use what we currently know to inform the design and delivery of interventions? This guide explores current debates about evidence of effectiveness and why they matter for mental health improvement. It also considers how the evidence base on mental health improvement can be used to inform the design of interventions and their evaluation.” More recently still, as part of the Department of Health 2009 consultation: ‘New Horizons – towards a shared vision for mental health’, one

Since then, the Department of Health has developed a strategy, ‘No Health Without Mental Health’, in which the aim is to treat mental health with the same weight as that already applied to physical health, and to improve the mental health and well-being of the nation through six shared objectives: • More people will have good mental health; •M ore people with mental health problems will recover; •M ore people with mental health problems will have good physical health; •M ore people will have a positive experience of care and support; • Fewer people will suffer avoidable harm; www.primarycarereports.co.uk | 11

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Apart from the fact that it is likely to lead to more favourable outcomes for patients with mental health problems, evidence-based practice is also more likely to lead to less interventions.

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•F ewer people will experience stigma and discrimination. This will, of course, entail significant levels of training to be delivered to those who deal with people who have serious mental health problems, as much of the above will need to be delivered through a program of evidencebased treatment. Evidence-based treatment (EBT) is an approach that tries to specify the way in which professionals or other decisionmakers should make decisions by identifying such evidence that there may be for a practice, and rating it according to how scientifically sound it may be. Its goal is to eliminate under sound or excessively risky practices in favour of those that have better outcomes17. All of this will, of course, require to be implemented and part of the training in evidencebased mental health will be to prepare students with strategies for implementing evidencebased practices. Again, going back to the EBMH notebook and BMJ publication about the National Evidence-Based Practices Project, at the same reference point will be found information on strategies for implementing evidence-based practices in routine mental health settings and implementing evidencebased mental health programmes. In the USA, Minnesota18 has developed an innovative model to implement evidence-based interventions to improve outcomes and transform the system of care. The model includes, among other things, training and clinical consultation

to mental health providers as a key pillar in delivering the strategy. In the UK, the RCGP in its response to the 2009 consultation, ‘New Horizons’ (see reference above) stated that “Identification of evidence about the cost effectiveness is vital to decision-making as such evidence should inform service redesign and commissioning of evidence-based services.” Of course none of this will be possible unless there is a significant element of training in evidence-based practice and treatment for mental health issues.

Better Outcomes Apart from the fact that it is likely to lead to more favourable outcomes for patients with mental health problems, evidence-based practice is also more likely to lead to less interventions because interventions will be based on what has already demonstrably succeeded. As a result, the practice will also be cost-effective and, in this day and age, that is, unfortunately, something that must be taken into account. One other part of the rationale for and importance of high-quality training in evidencebased treatment for mental health is to ensure that the term itself is protected. Unfortunately the term ‘evidence-based…’ may sometimes be used because it sounds up-to-date even when the person using it may not really be practising the evidence-based methods. If the term is to continue to be associated with high quality mental health care, then high-quality training is a must.

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Learning EBP John Hancock

Evidence-based practice in mental health education and training

he reforms of the NHS which will be putting general practitioners (GPs) at the heart of the commissioning process will add considerably to the demands on a GP with increasing numbers of patients being treated not in hospital but in their homes and communities. The Royal College of General Practitioners (RCGP) recognises that this will have ramifications beyond the day-to-day running of the practice and, especially, in the area of training GPs. In its paper, ‘Future of speciality training for general practice19’ the RCGP recommends an extension of GP training from 3 to 4 years with more specialist placements including mental health placements. This is, as the paper says, “ensuring that future GP training keeps up with the demands of an increasingly challenging and complex environment.” That referred to the need to treat an ageing population with complex, multiple comorbidities and where loneliness can itself create mental health issues.

A Changing World But even more than that, modern lifestyles have driven a growing need for mental health care. The demise of the nuclear family and associated support system, the rise of less formal family structures and a growing propensity to resort to alcohol and drugs for recreational purposes have all contributed to the growth of mental health issues and GPs will need to be trained to deal with them. In its paper, ‘Enhanced GP training: the educational case20’, the RCGP again highlights the need for GPs to be trained in, “Improved academic skills for evidence-based practice, innovation, quality improvement, education and research.” Good though GPs are in many things, as the world changes and new results and realities come to light to support evidence-based practice, they will need to be trained to leverage the best value from this.

A Growing Role for Evidence Evidence-based practice is a theme that runs strongly through much of the U.K.’s healthcare practice these days. The Nursing Times carried

30 years after APT was established, high quality workshops are now integral to continuing professional development of mental health professionals.

an article, ‘Evidence-based psychological interventions in mental health nursing 21’ referring to a National Service Framework (NSF) which, “attempts to be evidence-based wherever possible and specifically mentions that the effectiveness of some therapies is supported by empirical evidence.” Further on, the same article goes on to suggest that, “the most competently administered forms of counselling provided by mental health nurses could be seen as being evidence-based…” And as long ago as 2001, Psychiatry Online reported that, “An important focus of psychiatric services in 2001 is on the implementation of evidence-based interventions in mental health care.” Southampton University in the UK conducted research into ‘Evidence-based programs for promotion and prevention in mental health22’ in which it is revealed that “Mental disorders account for 20% of European ill-health and premature death. Social and economic costs [of these disorders] (between 3%-4% of GDP) include reduced productivity and increased levels of crime. The social capital of Europe can be increased and the burden of mental ill-health reduced by implementing evidence-based mental health promotion (MHP) and mental disorder prevention (MDP) programmes.” There is clearly www.primarycarereports.co.uk | 13

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

Also, we mustn’t imagine that only professionals require training. Many carers, especially of children with mental health problems but also of other people with mental health issues, also need training.

a very strong case for evidence-based training in the mental health field.

Government and Professional Strategy Most of those concerned with caring for people who face mental health problems, arising from whatever causes, would agree that evidencebased practice is the most effective and, the current UK government strategy ‘No Health Without Mental Health23’ is supported by an additional £400 million, made available over the four years from 2011, “to ensure that choice of evidence-based psychological therapies is available to all those who need.” Not only is the evidence base prevalent now in mental health practice, but also, it has become the principle on which training courses for professionals are based. As the Association for Psychological Therapies (APT) explains24, it is not simply a principle but also, “the approaches that published evidence suggests are likely to be the most effective.” And training in the field need not always be through courses: publications such as Evidence-Based Mental Health (EBMH) Magazine25 serves a range of international medical journals to present readers with the latest evidence-based practice information.

Training Programs Considering that mental health is an important and growing element in the overall healthcare sector, it is surprising what gaps there remain in training for some of the more important areas of the discipline. For instance 2006 research26 in

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the United States found that psychology and social work training programs were the least likely to include training in evidence-based treatment (EBT). Of course, there are training programs in evidence-based practice but often these are specific to particular areas of practice in mental health. For instance the REsource for Advancing Children’s Health (REACH) runs a number of psychotherapy training programmes for child mental health, behavioural and emotional disorders which are aimed to equip clinicians with evidence-based treatment techniques that work for children, adolescents and their families. In this area of child mental health, evidence-based practice will help practitioners sort the schemes that have some record of success from the 500 odd therapies that have been used to treat children and adolescents with emotional and behavioural challenges in recent years. Also, we mustn’t imagine that only professionals require training. Many carers, especially of children with mental health problems but also of other people with mental health issues, also need training and most health services in the developed world offer some level of training for families and carers of such patients. There is plenty of evidence available to support treatment for young children who have disruptive behaviour problems or who have experienced traumatic events. Just as an evidence basis can strengthen a practice model, so it can also strengthen the quality of training, based on what has happened rather than what we think.

SPECIAL REPORT: EVIDENCE BASED MENTAL HEALTH TRAINING

References: 1

Wikipedia http://en.wikipedia.org/wiki/Evidence-based_practice

Psychiatry Online, ‘Implementing Evidence-Based practices in Routing Mental Health Service Settings’ http://ps.psychiatryonline.org/article.aspx?Volume=52&page=179&journalID=18

‘Evidence – Based Diagnosis and Screening’ http://www.conted.ox.ac.uk/courses/details.php?id=B900-30

Oxford Centre for Evidence-based Medicine http://www.cebm.net/index.aspx?o=1025

NHS Health Scotland in its evaluation guide ‘Mental Health Improvement: Evidence and Practice’ Page 4 http://www.evaluationsupportscotland.org.uk/downloads/Guide2Measuringsuccess.pdf

Health Affairs ‘Evidence – Based Practice as Mental Health Policy: Three Controversies and a Caveat’ Sandra J Tanenbaum http://content.healthaffairs.org/content/24/1/163.full?sid=9f265768-7180-4d5c-b1e1-43390d37602f

NICE clinical guideline 72 ‘Attention deficit hyperactive disorder’ http://www.nice.org.uk/nicemedia/live/12061/42059/42059.pdf

Institute for the Advancement of Social Work Research, Evidence-based Practice http://www.socialworkpolicy.org/documents/EvidenceBasedPracticeFinal.pdf

RCGP ‘Responding to Domestic Abuse’ http://www.rcgp.org.uk/pdf/DV_practice_guidance_June_2012.pdf

Health Scotland, ‘Mental Health Improvement: Evidence and Practice’ http://www.evaluationsupportscotland.org.uk/downloads/Guide2Measuringsuccess.pdf

DHS Children’s Mental Health Division, ‘Evidence-Based Practices’ http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144791

RCGP, ‘Enhanced GP Training: The Educational Case’ http://www.rcgp.org.uk/pdf/Case_for_enhanced_GP_training.pdf

NICE, ‘Occupational therapy interventions and physical activity interventions to promote the mental well-being of older people in primary care and residential care’ http://www.nice.org.uk/nicemedia/live/11999/42395/42395.pdf

EBMH notebook and the BMJ, National Evidence-Based Practices Project http://ebmh.bmj.com/content/6/1/6.full

Health Scotland, ‘Mental Health Improvement: Evidence and Practice: 1 Evidence-based practice’ http://www.healthscotland.com/uploads/documents/Guide1Evidencebased.pdf RCGP response to ‘New Horizons… ‘ https://www.rcgp.org.uk/pdf/RCGP_Responses_Oct%2009%20DH%20New%20Horizons%20consultation.pdf

Wikipedia http://en.wikipedia.org/wiki/Evidence-based_practice

Minnesota Evidence-Based Practices http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144791

RCGP, ‘Future of speciality training for general practice9’ http://www.rcgp.org.uk/gp_training/reviewing_specialty_training.aspx

RCGP, ‘Enhanced GP training: the educational case http://www.rcgp.org.uk/pdf/Case_for_enhanced_GP_training.pdf

Nursing Times, Evidence-based psychological interventions in mental health nursing http://www.nursingtimes.net/nursing-practice-clinical-research/evidence-based-psychological-interventions-in-mental-health-nursing/206109.article

Southampton University, ‘Evidence-based programs for promotion and prevention in mental health’ http://www.southampton.ac.uk/education/research/projects/evidence_based_programmes_for_promotion_and_prevention_in_mental_health.page#publications

UK Department of Health (DH),’No Health Without Mental Health’ http://socialcarebulletin.dh.gov.uk/2011/03/15/equality-of-care/

The Association for Psychological Therapies http://www.apt.ac/aboutapt.html

Evidence-Based Mental Health Magazine http://ebmh.bmj.com/site/about/

National Institute of Mental Health, Partnerships to Integrate Evidence‐Based Mental Health Practices into Social Work Education and Research http://www.socialworkpolicy.org/documents/EvidenceBasedPracticeFinal.pdf

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