Critical Care Rehabilitation and Follow up Team

Psychotherapy

Overview

• CCRAFT and how we work together . Integration

• Fast Track for patients , rapid access for staff .

• Presenting Problems

Overview

• Types of Psychological therapy offered .

• Overall Recovery Rate Data

• Feedback from Qualitative Data from 8 patients at 18 months follow up post discharge from therapy .

• Conclusions from Service Evaluation

Psychological Therapist Joined CCRAFT 2014

• 2013 :Bid made for funding for CBT Therapist with EMDR to be available for one day per week .

• Seconded from IAPT(Improving Access To Psychological Therapies) Mental Health Access Team which is Primary Care Mental Health .

• Based in outpatients.

• Can see patients in community clinics if necessary .

Patient Journey

• ICU • Rehab staff follow up on the ward . • IPAT tool • Discharged • Given information about ICU Support Group. • Reviewed in Follow up Clinic at 3 months post

discharge • Referred to Psychotherapy • Assessment appointment offered

Follow Up Clinic

• Dr Wenham.

• Jayne , rehab assistant.

• Physiotherapist, Catherine.

Patient attends with relative or partner. reviewed, ongoing problems identified, normalising length of time for recovery and referred to psychotherapy if needed. Summary letter to GP.

ICU Support Group

• Held in local community venue , away from hospital .

• Developed by nursing staff

• Peer support , normalises experience

• Shared understanding

• Many of the group members are frustrated by what they see as slow recovery .

• Questions answered

• Medical equipment session v helpful for some patients

• Specialist speakers arranged .

Referral process

Direct referral from Dr Wenham

Via the support Group

Referred via Jayne who is has followed patients onto the ward and is aware of those struggling with symptoms.

Relatives/carers

Bereaved Relatives

Staff can self refer and/ referred by senior clinician .

Assessment

• Comprehensive Clinical Assessment

• Checking that they are in the right part of the service . Patients with severe and enduring illness are referred to secondary care mh services .

• Risk

• Past Mental Health History

Presenting Problems .

Presentation/Problem No. of clients

Post-Traumatic Stress Disorder (PTSD) 31

Depression , fatigue, low motivation 31

Being distressed about not remembering anything “lost days or weeks “ 29

Feeling guilt for the impact the experience has had on family and friends 26

Anxiety ,fear of relapse 24

The experience of being in ICU ,seeing other critically ill patients , being next to someone who

died

22

Family and relationship problems , 17

Social stressors (including DWP) 8

Anticipatory anxiety related to further surgery 6

Panic attacks and agoraphobia 5

Bereavement 4

Coping in the night, fear of staff at night. 3

Adjustment to disability , immobility and having to depend on others 3

Not coping with a stoma 3

Relatives, both bereaved. 2

Word Cloud

Other factors affecting recovery

• Predisposing Mental Health Problem • Previous Trauma • Social deprivation. • Financial distress . • Environment. • Relationships. • Poor physical Health. • Further surgery or readmission . • Difficulty attending appointments due to poor mobility,

or illness • Avoidance .

CBT

• Cognitive Behavioural Psychotherapy • www.getselfhelp.co.uk/docs/5AspectsPrompts.pdf

• NICE Guidelines for Anxiety , Depression , PTSD , OCD, Phobia .

• www.nice.org.uk/guidance/cg26/evidence/full-guideline-including-

appedices-113-193442221

• Collaborative , agreed goals • Time Limited . • Clearly Defined Problem • Formulation , specific treatment models and protocols • .

EMDR

• Eye Movement Desensitisation and Reprocessing. • Evidence : NICE Guidance re PTSD . • Client handout

https://www.getselfhelp.co.uk/docs/EMDR.pdf

• Install safe place Imagery • Install resources, trusted family and friends , pets, can be superheroes ! • Undertake a Trauma Timeline • Cluster into themes • Ask for Image , Negative Cognition , Positive Cognition associated with the image . Ask for validity of

positive cognition eg how much do they believe …. Subjective Units of distress associated with negative image .

• Check out the emotion and any physical reaction associated with the image

• Using Bilateral Stimulation to reprocess traumatic memories , which might be related to the delirium .

• Any abreactions go back to safe place imagery . • Aim to reduce SUDS and increase VOC • Install Future Template

EMDR

• Patient perspective :”Its tiring , I am

• CHECK DOCUMENT THAT IS ON THE LAPTOP.

EMDR Contraindications

• Epilepsy

• Benzodiazepine use

• Alcohol

• Dissociative Disorders : DES Dissociative Experiences Scale . Unable to continue if above cut off of ?40

Quantative Data

• The participants are 39 clients seen within the service. Of the 55 patients who were referred to the service, 6 people did not attend and were discharged back to the care of their GP. 6 have attended once and either dropped out or said they didn’t need the service. 4 people attended twice.

• The analysis is based on 39 patients who attended more than 2 sessions.

Patient feedback

• All patients are given IAPT Patient Experience Questionnaire . IAPT: Increasing Access To Psychological Therapy .

• Specific ICU Feedback Questionnaire .

Measures Used

• PHQ9 , Patient Health Questionnaire

• GAD7 Generalised Anxiety

• WSAS Work and Social Adjustment Disorder

• Phobia .Measures Avoidance

• IES-R Impact of Events Scale – Revised.

Measuring Recovery .

• For a referral to be recorded as 'moving to recovery’ at the end of treatment, it must have been at caseness at the beginning of treatment.

• To be at caseness, a referral must score above the clinical/non clinical cut off on either the assessment for depression (PHQ9), the assessment for anxiety (GAD7) or both.

• To move to recovery, a referral needs to move from caseness to below caseness on both sets of measures by the end of treatment.

• We can also measure how much a patient has improved throughout the course of treatment by looking at reliable change. A patient would reach reliable change if their assessment scores are 5 points lower, or more, on the assessments than they were at the start of treatment. for the GAD-7 and 6 points or more for the PHQ-9. Therefore, even if a referral hasn't moved to recovery, it's possible that the patient may have improved significantly.

• A feedback questionnaire was also developed to establish patient experiences of therapy. (See Appendix).

IES-R

• Impact of Events Scale – Revised/

• 44 questions

• Subscales identify hyperarousal , intrusion and avoidance

• Clinical cut off of 33

• Maximum score of 88

DES Dissociative Experiences Scale

• Measures level of dissociation . If someone is severely dissociative, not suitable for EMDR.

• More likely that they would be stepped up to secondary care.

Data re recovery of 39 patients during 2014-2016

PHQ-9 GAD-7 IES

Mean at Pre-treatment 17.7 15.2 55.7

Mean at End of Treatment 11 9.3 11.1

Mean Difference 6.7 5.9 44.6

End in Recovery 20

(51.3%)

20

(51.3%)

15 (x%)

Reliable Change x (x%) x (x%) n/a

Table 4: Mean client score pre and post treatment with difference, recovery and reliable change scores. n=111, meeting ‘caseness’ at start of intervention

Measuring Recovery Data

• The mean client score on the PHQ-9 before treatment was 17.7, indicating moderate – severe depression. At the end of treatment, the mean score had dropped to 11, indicating moderate depression. The difference between the scores was 6.7, indicating reliable change.

• The mean score on the GAD7 before treatment was 15.2, indicating severe anxiety. At the end of treatment, the mean score was 9.4, which is in the mild range. The difference between the scores was 5.9, again indicating reliable change.

• The mean score on the Impact of Events Scale before treatment was 55.7, which is well above the clinical threshold of 33. At the end of treatment, the mean score was 11.1 , a reduction of 44.6. Reliable change on this measure is a drop of 9 points, which was far exceeded in this study.

Data Analysis .

• The mean client score on the PHQ-9 before treatment was 17.7, indicating moderate – severe depression. At the end of treatment, the mean score had dropped to 11, indicating moderate depression. The difference between the scores was 6.7, indicating reliable change.

• The mean score on the GAD7 before treatment was 15.2, indicating severe anxiety. At the end of treatment, the mean score was 9.4, which is in the mild range. The difference between the scores was 5.9, again indicating reliable change.

• The mean score on the Impact of Events Scale before treatment was 55.7, which is well above the clinical threshold of 33. At the end of treatment, the mean score was 11.1 , a reduction of 44.6. Reliable change on this measure is a drop of 9 points, which was far exceeded in this study.

Data Analysis

• The mean client score on the PHQ-9 before treatment was 17.7, indicating moderate – severe depression. At the end of treatment, the mean score had dropped to 11, indicating moderate depression. The difference between the scores was 6.7, indicating reliable change.

• The mean score on the GAD7 before treatment was 15.2, indicating severe anxiety. At the end of treatment, the mean score was 9.4, which is in the mild range. The difference between the scores was 5.9, again indicating reliable change.

• The mean score on the Impact of Events Scale before treatment was 55.7, which is well above the clinical threshold of 33. At the end of treatment, the mean score was 11.1 , a reduction of 44.6. Reliable change on this measure is a drop of 9 points, which was far exceeded in this study.

Findings from service evaluation

• Patients are seen quickly after referral .There is no waiting list. • Staff have also used the service and recovered. Data from staff was not

included in this evaluation .This is for the purpose of confidentiality • The recovery rate is good. • In particular the recovery rate using the IES-R (Impact of Events Scale –

revised) • What is really interesting is that PTSD is really impacted, but experience

residual depression. Patients may have lasting disability which they are adapting to and their socioeconomic environment remains the same or worse,if they are unable to work.

• 20 patients reached recovery and 15 reached reliable clinical change • There was a 50 % response rate for the questionnaire developed to look at

outcome at 18months post therapy and qualitative data shows an improvement in mental wellbeing and patients were able to resume their normal way of life.

Post 18/12 Q1. How are you feeling

now in terms of your

physical wellbeing?

Very well Well Okay Poorly Very poorly

No. of responses 4

Q2. How are you feeling

now in terms of your

mental wellbeing?

Very well Well Okay Poorly Very poorly

No. of responses 1 3

Q4. Do you feel you have

been able to resume your

normal way of life?

Completely Almost

completely

Almost Somewhat Not at all

No. of responses 2 2

Q6. Were you aware that

there is individual support

available for your

relatives and friends

provided by the ICU

Psychotherapist and that

there is a monthly

support group?

Yes No No response

No. of responses 3 1

Qualitative Data .

• Q3: What do you think was the hardest thing to cope with during your recovery? • • “Nightmares were a big problem , enclosed spaces /panic attacks .Talking about my experiences with

family .Not knowing whether my experiences were real or imaginary .Returning to hospital was sometimes necessary for therapy and that was difficult “

• • My “mental wellbeing” is much as before .I have not and never will come to terms with the tragedy that affected me so much“.

• • Trying to come to terms with illness and not being able to remember things leading up to ICU admission .Lack of energy

• • Hallucinations which still trouble me at times even now. Flashbacks to when I felt in fear for my life during the hallucinations

• Q5: What other kinds of support do you think would have been helpful to you ? • • Nothing! I thought the service was fine for my needs • • No response. • • Can’t think of anything else. • • If there had been more understanding and communication coming out of ICU onto the general ward .I

found no understanding of my hallucinations on the ward I was put on .It was as if they blamed me and my family for what I was going through.

Case Examples.

• One patient has attended three times but ongoing illness and deteriorating mobility affected engagement . Has now engaged and working on PTSD, making good progress towards recovery .

• Bowel surgery , horrific nightmares of hallucinations during psychosis, also disclosed childhood sexual assault, did not want to work on that and focused on current symptoms.Distress resolved very quickly following EMDR .

Future Development

• Bereavement group , in partnership with a patient ,Nursing Staff and Recovery College .

• Further learning and sharing of the experiences of other services is likely through the attendance of a recently developed special interest group of psychological therapists working in critical care

• Consider how best to support staff , currently individually following referral to the service .

Areas for Development

• ?Administering the HADS to get a more

accurate representation of level of depression .

• Further qualitative study to find out what was most helpful in recovery.

• Confidential /anonymous Feedback for staff who have used the service

• How do we promote the service to staff ?

Any Questions?