IE SO INSIGHTS ISSUE 2 AUGUST 2020
The data science issue
A data revolution in telemedicine for mental health
The 7 subtypes of depression Delving into the demographics of Covid-19 therapy data Reaping the benefits of breaking with tradition
Constantly striving for better quality mental health We’re here to help as demand for mental healthcare surges Since the first issue of Ieso Insights we have slowly started to come out of lockdown in England. Pockets of continued rises in cases in the North suggest that this virus might take longer to control than most of us would have hoped. We take a look at some of the latest trends in the mental health world in relation to Covid-19 in this issue. We also take a look at some of Ieso’s broader findings from looking at the data. We share how we find the latest scientific discoveries in the field of mental health and how we put that insight back into therapy. Welcome to the second edition of Ieso Insights. The last page gives the chance to sign up to our free online Therapy Insights Festival. Please register to receive the next issue, which will be packed with content from experts lined James de Bathe, Director of Partnerships
up to speak at the event. James de Bathe, Director of Partnerships
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Contents 04
06
A data revolution in telemedicine
Covid-19: Delving into the
for mental health
demographics of the data
10
12
Reaping the benefits of breaking
The seven subtypes of depression
with tradition
08
The current status of mental health services
16
Lincolnshire’s Nick Harwood shares his
experience with Ieso
18
Deep learning: How psychotherapy
20
22
26
27
Day in the life of a clinical supervisor
How to quality assure Step 2
features relate to patient improvement
24
What patients say
Careers and subscription
Festival of Therapy Insights
Subscribe here to receive the next issue automatically
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NEWS
A data revolution in telemedicine for mental health “Now is the time to create smarter systems for mental healthcare delivery”
Ieso’s chief science officer, Andy Blackwell, explains how several extraordinary forces are colliding in mental health care.
variety of functions such as commissioning, clinical audit, service planning, regulation and policy development and performance management. But what about the in-session activity data captured during telehealthcare? These activity data include the most sensitive details of the events and utterances that take place during therapy. It goes without saying that this intimate personal information must be kept safe and protected via rigorous implementation of technical and operating protocols together Dr Andy Blackwell, Chief Science Officer
with managed consent. But we also believe that it is the study of complex activity-outcome association data that will unveil the crucial functional
A new model for data acquisition:
elements of effective treatment and fuel a new era in mental health science
telemedicine for mental health
and clinical innovation.
The COVID-19 pandemic has radically
A new model for knowledge and insight creation: AI and
accelerated patient, clinical and health system
other analytic approaches
adoption and acceptance of remote mental
High volumes of data alone will advance nothing. In the last 4 years advanced
healthcare delivery. This is generating vast
computational methods such as deep-learning have, for the first time,
amounts of structured and unstructured
enabled us to develop systems that can process and make sense of these
real-world data about the ‘in-session’ patient
clinical data at incredible speed. In August 2019 IESO published a landmark
and clinician activity. At the same time, health
paper in JAMA Psychiatry (Ewbank et al., JAMA Psychiatry. 2020;77(1):35-
systems such as the UK NHS IAPT programme
43) detailing an analysis of therapy content in over 90,000 hours of therapy,
have standardised the clinical pathways and
which Michael Ewbank explains in this magazine. In June 2020 Ieso
protocols for mental healthcare. Perhaps most
published a follow up paper using similar AI-driven analytic techniques to
importantly, integral to these systems is the
decode 180,000 hours of patient utterances (Ewbank et al., Psychotherapy
requirement to systematically measure and
Research, 2020). In June 2020 we also published an analysis using other
report the outcome of clinical care for
advanced statistical methods revealing new subtypes of depression in
every patient.
over 10,000 patients (Catarino et al., Psychological Medicine, 2020). Ana
But what should we do with these data? System-
genomics, we are coming to learn that the next era of knowledge creation in
wide availability of aggregated and highly
mental health science will require big datasets (such as those derived from
structured clinical outcomes data supports a
telehealthcare) ‘decoded’ by advanced and automated processing systems.
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Catarino has written a synopsis in this issue. As in the fast-evolving field of
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A new model for translation to impact: Clinical decision support and augmented intelligence Knowledge creation and peer-reviewed publication is important but for us it is not an end in itself. Almost every technology-enabled industry now uses data on previous activity and outcomes to enable smarter decision making. Mental healthcare can do this too. Through ubiquitous connectivity, established data models and practically unlimited computational power, it is now possible to embed clinical decision support technologies within telehealthcare systems that bring actionable insights to clinicians in the moment they are needed. Clinicians can and should be armed with insights from ‘augmented intelligence’ models continuously trained and updated on real-world clinical data. In the coming years these insight technologies will help clinicians to make more accurate diagnoses, to optimise treatment decisions for each individual and to eliminate unnecessary or ineffective practices. Such technologies will super-power the strengths of clinicians, empowering them with evidence of ‘what works best’ from high-scale real-world data, and enabling them to focus on the uniquely human elements of practice so vital to mental healthcare.
‘Telehealthcare can enable both knowledge creation and translation to impact’
Telemedicine for mental health is about so much more than convenient access Telemedicine for mental health offers a new model that can accelerate data capture that will fuel scientific knowledge creation. It offers new platforms through which we generate insights about how best to treat each individual according to their needs. It offers a new model for translating insight to impact via embedded clinical decision support and augmented intelligence technologies. These major advances will require openness to change, a willingness to shoulder some risks and a new partnership between science, clinical practice and technological innovation. As we emerge from the COVID-19 pandemic with a virtualised mental healthcare system we must recognise that telehealth not only offers a convenient way to deliver care but also an unprecedented opportunity to advance mental healthcare and clinical innovation.
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Covid-19: Delving into the demographics of the data Dr Ana Catarino, Principal Scientist at Ieso, investigates: Have different age groups benefitted or suffered with their mental health during Covid-19
Older adults have showed the greatest increase in anxiety incidence
Depression levels lessened for younger adults during lock-down
We have been looking at psychological trends in our patient
There are no major changes in disorder distribution either,
data in relation to coronavirus since the beginning of the
we are still seeing an increase in patients with hypochondria
year. The digital nature of internet-enabled CBT (cognitive
and OCD, which we would expect to see during a health crisis,
behavioural therapy) gives us a living, large-scale anonymous
while there’s still a dip in referrals for patients with depression.
dataset that can provide rapid insight into what is happening to our NHS psychological therapy patients. We have been sharing insights from this dataset to aid understanding of the mental health impact of Covid-19 and lockdown in the UK.
Dimensions and modulators of behavioural and mental-health changes during the Covid-19 pandemic A team of UK university researchers led by Dr Adam
In the previous issue of Ieso Insights we shared observations
Hampshire have also been studying the effects of lockdown
from our referrals about how suicidal thoughts have seen
over the past 6 months. The paper, “Dimensions and
a sustained reduction of up to 30% in patient assessment
modulators of behavioural and mental-health changes
scores on referral to adult psychological therapies. This trend
during the Covid-19 pandemic� reveals differences in
coincided with the start of lockdown.
sociodemographic distributions of mood and anxiety
We have repeated these analyses recently, up to calendar week 25, but no dramatic changes have been observed: the
for 233,268 people in January versus 109,749 in May 2020.
reduction of symptoms of tiredness, changes in appetite,
Dr Hampshire and his team observed that anxiety,
and low self-esteem are maintained. However, feelings of
depression and insomnia changed markedly across different
worry and anxiety seem to be back to normal levels, as do
demographics, with greater negative effects experienced
suicidal thoughts.
by older adults and positive benefits felt in younger adults.
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Frontline health workers, carers of vulnerable older adults, and disabled or
of loved ones, which was higher than concern
sheltered adults were disproportionately affected.
about one’s own health, and loss of leisure/health activities. The strongest disagreement was
“Older adults showed the greatest increase in anxiety incidence. Depression was lower for younger adults and higher for older adults. Females had
with statements regarding loss of employment, increased conflict at home, preoccupation with
a greater increase in anxiety than males. Increased anxiety incidence
infection and loss of access to basics. There
was greater for retired people, followed by homemakers and workers.
was strong agreement that technology/science/
These differences across sociodemographic axes indicated profound and
healthcare will advance more rapidly and
disproportionate pandemic effects on mental health for some people,
things will change but not necessarily for the
supporting the next step of fractionating the impact of the pandemic across
worse, and strong disagreement that economic
domains important in day-to-day life.” “Some of the strongest agreement (from participants) was with positive statements, improved natural environment, enjoying the simpler things in life, spending less, saving more and greater sense of community. Amongst the strongest agreement with negative statements was concern for health
impact will be temporary. People agreed that communication apps helped stay in touch with loved ones.”
Our own analyses on differences in age Inspired by Dr Hampshire and his team’s paper, we looked at our lockdown period patient data set broken down into different age groups. We observed an age effect for some of the symptoms of depression and anxiety - younger patients (age 18-25) do not see an increase in worry about something awful happening during lockdown, whereas older patients do. In terms of depressive symptoms, tiredness and suicidal thoughts, younger patients seem to see a greater relief in these symptoms, compared to older patients. Our GAD-7 patient referral questionnaires showed that there was a large age difference in patients reporting that they felt afraid, ‘as if something awful might happen’. The over 55 age group had a 55% higher mean score than previous years in week 14 (commencing 30th March) which coincides with the start of lockdown. Given that the over 55 age group was described at higher risk of death from Covid-19, it seems logical that the older generations would fear the virus the most. These findings are a result of analysis of the impact of the Covid-19 crisis on anonymised therapy data collected this year by Ieso Digital Health from over 8,000 patients. We will continue to monitor and explore this data in more detail during the next stages of this crisis in order to help therapists understand patient needs as they evolve.
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COMMENT
The current status of mental health services Sharon Harrison & Nii Lante Wallace-Davies provide an update on the UK’s mental health services through a digital lens.
Sharon Harrison, Ieso's head of accounts
Nii Lante Wallace-Davies, Ieso's head of business development
Where we started during in lockdown
With expectations of a looming mental health tsunami, which hasn’t hit
While we are now post lockdown and life is
yet, measures have been put in place to move patients through treatment,
resuming to some normality, our second update
using technology, time and budget to clear waiting lists in preparation for
in this IAPT service status series shows what
any future disruption to healthcare services.
we are hearing and seeing in terms of patient referrals and mental health service availability taking our own data discoveries from our online cognitive behavioural therapy (CBT) platform and analysing these alongside wider trends across the primary mental health care sector.
Where lockdown left us Over the past five months, continuity and quality of mental health services has never been more crucial. As the world around us changed
What else, if anything, has changed since May?
June & July: Referrals slowly picking up but not pre-COVID levels While mental health referrals seem to be slowly going back to pre-lockdown levels, we certainly aren’t seeing the surge in mental health referrals yet as some expected. All services are back to normal in terms of patient numbers they can see, but because referrals are still lower than normal levels we are seeing some NHS CCGs activate marketing campaigns to ensure people
overnight, the NHS, working with IAPT, made
know that services are up and running and, in turn, know where to go if they
sure mental health care remained a key priority
need help.
and worked hard to keep services running and available across the country. While many mental health care services turned to digital methods for delivery, and contingency plans were put in place to support people with
As during lockdown, the continuation of lower referral numbers could be for a number of reasons, including GP practices not being fully open for business and consultations taking place over video calls, which people aren’t always comfortable with. Many GP practices still warn of COVID restrictions
a ‘remain open’ directive, mental health referrals
on websites, and this could be putting people off requesting appointments,
to services appeared to experience a 30-60%
keeping referrals down, particularly in areas reliant on
drop off in April and May.
GPs to connect patients to mental health services.
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Widespread unemployment, job cuts around the country and people coming off furlough, could also contribute to spikes in mental health conditions in different UK geographies. This alone could increase localised mental health referrals by 20-30% over the next 2-3 years. As no one really knows what the real impact of Covid-19 will be and what the real fallout will be, it is very difficult to plan for ‘what might happen’ and the best any NHS CCG can do is be as prepared as possible, particularly in light of any further waves of Covid-19 cases. This surge could even be protracted over the coming years. With this in mind, many NHS services are now preparing for an unknown future. Many are planning to expand the current service models they have in place with digital methods as the main delivery mechanism. However, what they put in place is all based on assumptions and may be too much or not enough. This also means training more practitioners to deal with the possible surge in demand, while ensuring existing clinicians can address and treat issues that directly stem from Covid-19. While training more clinicians is a good solution, training Life has started to reflect some elements of pre-lockdown normality
can take up to two years, and the need for supervision from
NHS CCGs are now providing digital therapy by default, and
practicing clinicians means supervisors can be out
treatment over video, for example, isn’t always liked by people
of service themselves.
who prefer face to face sessions, so won’t move into treatment if this is what they are offered.
Essentially, we are still in a period of limbo where services are treating those that come forward digitally, while encouraging
NHS CCGs and services can’t predict when it will be
more people to seek help while waiting times are minimal, and
possible to fully return to face-to-face therapy. Many are
simultaneously preparing for an expected mental health crisis
looking at how they structure their services in terms of
that we don’t yet know how will play out. These are complex
types of treatment, capacity and how they can keep
challenges for service managers and decision makers.
patients engaged via digital methods.
We are now treating more patients through IAPT than ever
On top of this, with more people being at home more of the
before. As we transition through the next phase of this journey,
time, for some people lockdown has reduced anxiety and
we are prepared to flex to meet any surges in demand. We
stress levels because there is less social pressure to be out,
have been scaling up our online CBT service so that we can
commute, or be rushing around all of the time. Being at home
treat many more patients, regardless of geography, as soon
during the summer can also help general mental health and
as possible.
people are now managing their work life balance in different ways. This may mean less people may be seeking help for mental health at this time.
We have always delivered psychological therapy online and use technology to continually improve the quality of our care, by monitoring what is working in treatment, and by
There are, of course, many factors that play into this, but
making high-quality, training resources freely available to all
experts believe the surge could potentially come in the
therapists so they can learn and share knowledge during this
autumn when children go back to school, and we enter into
challenging time. Please reach out if you need flexible capacity
colder and darker months. With anticipated ups and downs of
or just some guidance. We are all in this together.
localised cases in Covid-19 continuing to affect people’s lives, the reality of ongoing difficulties may finally hit people.
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Reaping the benefits of breaking from tradition in psychotherapy Stephen Freer explains how Ieso embraces the non-traditional and harnesses the expertise of those who consistently deliver exceptional care for the benefit of every therapist
Ieso Digital Health
It sounds obvious to base a service on the preferences of a
provides remote digital
patient, but it’s actually the reverse of the traditional approach.
therapy services. While traditional therapy services can take somewhere between three and seven weeks Stephen Freer, Clinical Product Lead
from initial referral to the first telephone or face to face session, digital
While other industries have embraced operating more digitally, therapy has been clinging on to a traditional healthcare model: face to face appointments, with sometimes weeks in between each one, with no contact between patient and therapist. The success of digital therapy, forced into the mainstream as a result of the Covid-19 epidemic, is the antithesis of the traditional approach.
therapy can move much quicker. So much quicker that a
As a result of how we deliver therapy we can utilise clinical
patient can be talking and starting treatment in a few days.
science to predict the behaviour of some patients based on
On the surface this is what our NHS customer want from us; additional capacity that can be flexed at different points in time. We have therapists across the country ready to help serve the needs of any local service wherever they are.
their age, gender, ethnicity, and history and symptom information. Our therapy delivery platform has the capability to provide therapists with information on how severe and distressing the patient’s problem may be including the impact it is likely to having on their life. It is
Aside from the obvious benefits of not being bound by
also able to provide helpful indicators such as when the
physically seeing a therapist (when a patient can easily travel
patient may be likely to struggle to engage with treatment.
between work and other life commitments) the answer to why we see quicker turnaround times is quite simple:
When the therapist is armed with this information they can proactively act to counter the patterns we anticipate will
1.
A patient tells us when they want their appointments.
unfold without intervention. Some of these interventions
2.
We match them to a therapist that has the relevant
early on in treatment, an approach as un-traditional as
expertise with availability at that time.
they come, but one we have seen huge success with.
can be as simple as communication in-between sessions
As a result, we often see a much better engagement rate
The Ieso platform is a secure portal both therapist and
(50%) in a course of treatment in comparison to the IAPT
patient can access to communicate in confidence. Providing
national average (39%). Through the simple approach of
patients with the option for communication in-between
meeting patients on their terms, cancellations and no-shows
sessions amplifies the effect of therapy and can even reduce
are much less frequent.
the amount of sessions a patient needs thus expediating the individual’s therapeutic journey.
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We look closely at our most effective therapists, those who are consistently achieving results well above the average. We look at therapists who are working with patients who traditionally might struggle with talking therapies but are actually engaging and improving to the point of recovery. We have started to analyse the practices of these “super shrinks” – those that are consistently over-performing – we look at what they’re doing to learn from it. We then provide training in those methods to our other therapists so that the entire practice of CBT levels up. Our system, for example, has uncovered that the presence of an agreed agenda with patients increases their likelihood of Ieso's CPD events share the latest in theory and best practice
recovering through CBT. This might not be surprising to learn if you understand CBT, however, what is game
It ensures that the patient is actively engaging in their
changing is the clinical tool we have was used. It looks for
treatment and isn’t just something they think about in their
the presence or absence of agendas in treatment sessions
60-minute session each week.
and where we find there are gaps we suggest relevant
Within the boundaries of an agreed therapeutic
content and learning development modules around how
relationship, an open line of communication allows the patient to call on the therapist when they need to. In regular therapy settings by the time lapse between appointments can mean the problem is brushed under
and why to introduce agendas into therapy. We can then go back and track the impact this training has and correlate with any improvements we see in patient outcomes. Our therapists find this feedback incredibly
the carpet, the patient struggles to remember exactly
helpful.
how they were feeling or, as is often the case with mental
Similarly, we have discovered that patients who are actively
health, the problem has become worse.
engaging in homework tasks between sessions are more likely
To better understand the effect of between session communication, we analysed the outcomes and journeys of 256 patients, where therapists were trained in asynchronous messaging techniques. We discovered interactions didn’t need to be lengthy, or even complex. Even just a few supportive sentences to help patient understanding that someone was there with them increased the speed of engagement in the therapy process and resulted in faster recovery in depressed patients. This provided us with the inspiration to take our analysis further and deconstruct the success of the top therapists, to see what we could all learn from them.
to get better than those who don’t. We’re developing future innovations to include automated reminders to encourage the use of homework and potentially deploy clinical therapy assistance in our platform to work through homework tasks with, providing prompts on how to approach some CBT tasks and mirroring those things that therapists might be doing with them, but in between sessions. It seems odd that it’s considered controversial to suggest therapy outcomes could be improved by providing more opportunities for a patient to communicate with a therapist more frequently, but it has taken some time for this to be accepted. The system itself is complex but the
Modelling the super-shrinks The continuous professional development infrastructure we have built for our therapist networks is another nontraditional approach we’re proud of. We have a model that
principles of our innovation are always straightforward. We seek more opportunities for clinical treatment to be delivered based on patient needs in order to improve people's lives.
analyses the performance of each therapist to discover whether they achieved the outcomes we might expect for certain patient profiles. Harnessing this learning allows us to then direct that therapist towards bespoke and tailored CPD to help them become the best they can be. Ieso Digital Health
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The seven subtypes of depression Dr Ana Catarino discusses how better understanding of depression presentations can affect clinical outcomes.
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Dr Ana Catarino
Just half of those who
effectively online, particularly as referrals increase. Many
suffer with depression
providers and associations, including Ieso, the NHS and
recover, despite decades
BABCP, are offering training and support to enable clinicians
of research and the
to transition to digital methods. Advice is also being provided
development of effective
on what to be aware of during the COVID-19 pandemic in
medication. Depression is a
terms of how patients are presenting, what to think about in
complex and multi-faceted
terms of consent and patient contact, what trends are being
condition, and one we
seen 8+ weeks into the lockdown, as well as more specific
understand deeper with
training on conditions we expect to see more of during
each patient we support.
this time.
Our understanding grows over time, but our clinical approach doesn’t always reflect the evolution of that understanding or the rich complexity of mental health disorders. We need to update our approach while providing a flexible structure to guide clinicians. We challenged ourselves to investigate why do some patients suffering from depression respond better to CBT than others. What we found is that depression is not the same for everyone.
Clinicians and patients are getting used to these new ways of working. We will continue to closely monitor the situation, and share what we are seeing and hearing, so that we can all benefit from this learning experience.
Summary of findings Our analysis revealed seven depressive states, varying in symptoms and severity. Some states show mild to minimal
The status quo In the early stages of referral, patients are asked a range of questions to determine their state of mind – have they little interest or pleasure in things, do they feel down, do they have trouble falling asleep; staying asleep; or sleeping too much? Do they feel tired or have little energy, are they over or under-eating? How is their concentration? Do they struggle to concentrate at work or even while watching TV programmes? Do they feel worthless? Do they speak slowly or are they overly restless? Have they thought about harming themselves? A diagnosis of depression is made when a patient displays five
symptoms, while others are characterized by higher severity of specific symptoms. For example, patients in some states may show more intense feelings around low mood, tiredness and low self-esteem (cognitive/affective, or mood-based depression), while others may show difficulty with sleep and loss of appetite (somatic, or physical-based depression). Some patients in more severe states may show a combination of both mood and physical symptoms of depression. Importantly, this research shows how patients with different types of symptoms move through the various states over a course of therapy.
symptoms, one of which must be linked to low mood or loss of interest or pleasure in most activities. This means that there are more than a hundred combinations of symptoms that can lead to a single diagnosis of depression. Usually, a ‘one size fits all’ approach to treatment is taken, which could be to blame for the low recovery rate in depressed patients. It is time to recognise the diversity of symptoms, in order to formulate better tactics to support patients through their therapy journeys. We analysed real-world clinical data from almost 10,000
We analysed and compared clinical outcomes for those
patients with depression to understand how patients with
who begin their treatment in cognitive/affective states,
different combinations of depressive symptoms respond to
experiencing low mood and a negative mindset, and those
cognitive behavioural therapy.
who begin in somatic states. Our results show that somatic
The aim of this research was to improve our understanding of different depression sub-types, and to provide the basis for strategic treatment plans that will improve clinical outcomes
patients who suffer from physical symptoms including fatigue and loss of energy are far less likely to engage with treatment, or show often small areas of improvement.
and speed up the patients’ road to recovery.
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While patients transition from one state to another, almost all will settle in one state after their sixth therapy session, having learned to trust the CBT process.
The seven subtypes of depression Our analysis, based on the Hidden Markov Model of PHQ-9 data, revealed 7 depressive states varying in symptom profile and overall severity. •
States 1 and 2 represent states of minimal to mild overall severity
•
State 3 shows peak symptom intensity around feelings of depression, tiredness and low selfesteem (cognitive/affective state)
•
State 4 shows a relatively even spread in symptom intensity across items (hybrid state)
•
State 5 shows peak symptom intensity around difficulties sleeping, feelings of tiredness and changes in appetite (somatic state)
•
States 6 and 7 represent moderately severe and severe states respectively
Figure 1
Our research shows that patients starting in each of these states transition between states over a course of therapy. Analysis revealed that patients in cognitive/affective states do not typically transition towards somatic states and vice-versa.
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Transitions seem to stabilize at around treatment
One assumption that can be made is that women who suffer from long-
session 6. This is likely a reflection of the mean
term physical conditions may be predisposed to develop depression
treatment duration across all starting states (i.e.
characterised by similarly physical symptoms. The contrary argument is
approximately 5 treatment sessions), but also that
that anyone suffering with difficult and long-term physical issues may be
in CBT the greatest clinical benefit is likely to be
worn down by this, and more likely to develop depression and the physical
achieved in the first half of treatment.
symptoms associated with it, including fatigue and changes in appetite.
We also observed that patients in the cognitive/ affective and somatic states (State 3 and 5 respectively) do not transition to hybrid State 4, despite this being lower in overall severity. Similarly, about a quarter of patients starting in hybrid State 6 transition to hybrid State 4, with a small chance of transitioning to less severe States 3 or 5.
Equally, patients who are prescribed antidepressants may be more likely to suffer from somatic symptoms (which can include fatigue, insomnia and changes in appetite) as a consequence of medication side-effects.
What does this mean for patients? We believe the model developed presents remarkable clinical potential. If implemented as part of a digital triage tool, it could allow clinicians
A similar pattern is observed for symptom
to identify patients in depressive states which are most responsive to
deterioration, where patients starting in hybrid
therapy. This would then enable clinicians to select treatment interventions
State 4 deteriorate with low probability to hybrid
(medication and/or talking therapies) tailored to each patient. The more
State 6, but not to cognitive/affective and somatic
personalised we can make treatment, the more we can aim to increase
States 3 and 5. Patients in cognitive/affective
a patient’s engagement with treatment, and the likelihood of them
State 3 and somatic State 5 also do not seem to
responding to treatment.
deteriorate to hybrid states 6 or 7. We evaluated differences in clinical outcomes and patient demographics across cognitive/affective and somatic states. Despite similar overall severity, patients starting treatment in cognitive/affective and somatic states (State 3 and 5) show significant differences in outcomes, with somatic patients less likely to engage with treatment, improve or show percent improvement. We also found that patients starting in hybrid State 6 sometimes transition to somatic State 5, but not to cognitive/affective State 3. Together, this may suggest that CBT may be more effective at targeting cognitive/affective symptoms, with somatic symptoms appearing to be more resistant to treatment.
The link between physical health, depression and gender
What’s next? To take this further, we need further research into targeted interventions on the basis of these subtypes of depression. Targeted treatments could bring the dual advantage of improving clinical outcomes, as well as improving the cost-effectiveness of psychological therapies by shortening overall treatment periods. Finally, future research should also investigate how effective these models could be in treating wider patients groups receiving other types of therapy. The model could also be used to support patients presenting to their GPs with other issues, where depression is a secondary factor. The study has deepened our knowledge of depression as a mental health disorder. What is most exciting, is the questions it has raised which can be answered through future research. By exploring the dynamic response to therapy in different depression types, it increases the likelihood of pushing past that 50% success rate. Ultimately, it will help us make a meaningful difference to patients who are suffering.
Our analyses showed that patients who start in a somatic depressive state are less likely to engage
This is an extract of a peer reviewed paper which
with or improve with therapy. These patients
can be read in full here.
are also more likely to be female and suffer from comorbid long-term physical conditions. These patients are also more likely to be taking medication to manage their mental health issues.
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COMMENT
Lincolnshire: an Ieso case study
I
eso has had four contracts with
term so it was important to use the money as
steps2change since first partnering in
efficiently and rapidly as possible to reduce
2016. The main driver for steps2change
waiting times for our patients. We were aware of
commissioning Ieso was to provide urgent
Ieso offering online CBT and were interested in
additional capacity to relieve waiting lists
using the service as an alternative to the usual
over the vast geographical area the service
agency staff approach to this short-term fix.
spans. This is in addition to patient choice, out of hours provision and digital innovation
“The flexibility that could be offered was
drivers. Steps2change is the lead provider of
something that we hadn’t considered. We had
Psychological therapies (IAPT) for Lincolnshire
a reason for wanting to use Ieso but through
Partnership NHS Foundation Trust.
conversations we discovered an added benefit
Nick Harwood, steps2change Service Manager, shares his experience of working with Ieso “We initially invited Ieso to join a tender process
to using it. Having the service running remotely online became an empowering advantage in giving our patients flexibility around times they could choose to access therapy. Generally, our service is 9-5, Monday to Friday. Ieso is
for a waiting list initiative. We had some waiting
accessible in the evenings, middle of the night,
lists that had become longer than we’d like for
weekends. This offered added, unexpected
CBT in some areas due to growing numbers of
benefits for people who couldn’t get to our
patients. The challenge with having long wait
bases for whatever reason, be it transport, work
lists and some newly allocated budgets with spend deadlines attached is how to turn the money into seeing patients, with recruitment being a process that doesn’t happen overnight. Budgets are often non-recurrent and short-
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commitments, childcare commitments or comorbid conditions limiting mobility. “Around that time digital was a relatively new option to mental health services. We had many
Ieso Insights
clinicians with the attitude that therapy is best delivered face to face in the same physical location. The evidence was suggesting that online, text-based CBT is just as effective but our therapists didn’t agree at that point in time, they hadn’t seen the results for themselves. The idea that a patient would never actually go and see their therapist and only have a conversation online and only through a text-based service was novel. We were all a little cynical and sceptical but overriding that was an interest in how this could really work as effectively as face to face so we allocated the budget to online CBT and the long waiting times disappeared with results exactly as we had hoped. “Now that we have been working with Ieso for a while we don’t have any second thoughts about using them when we have budget available to reduce waiting lists. We don’t have any hesitation from clinicians either. Digital solutions are becoming more important as they offer patient choice about access. “We’ve used Ieso for the past 5 years now to reduce waiting lists. It’s reassuring to know that we’ve got the backup from Ieso as an extra resource that we can pull in. In terms of being able to mobilise quickly versus internal recruitment processes or taking on agency staff, it can take weeks or months. Whereas with an Ieso contract in place I can say “Can we have Ieso access tomorrow please” and Ieso can mobilise quickly and with a recognised framework. Within a day of mobilising with Ieso we can start making referrals and patients get into treatment as soon as possible. “Feedback from patients is good. It doesn’t appeal to everybody but patients who do engage with Ieso are positive. People are increasingly accessing their world through smartphones and tablets so why not therapy? We don’t discriminate with who we offer Ieso to, but we take personal preferences into consideration. In terms of who accepts it, it would be easy to assume it would be all young people, but in reality, it is quite cross sectional. With our own computerised CBT we have had patients as old as 86. Longer term we’d like to be able to offer all suitable patients online CBT through Ieso or similar, all year-round.”
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Ieso’s deep learning study reveals features of psychotherapy that are related to patient improvement
M
ichael Ewbank, a senior scientist at
transcripts from our Internet-enabled cognitive behavioural therapy
Ieso and lead author on Ieso’s paper
(ieCBT) platform, the Ieso team and I trained a deep learning model (a
‘Quantifying the association between
type of machine learning), to automatically recognise the content of the
psychotherapy content and clinical outcomes
language used by therapists during online patient CBT sessions. We then
using deep learning’, discusses the research
used this model to measure the treatment delivered to determine which
findings and what this means for monitoring
features are associated with improvement in patient symptoms.
therapy to improve clinical practice in CBT. Our research has provided valuable insights into the relationship With unique access to hundreds of thousands
between therapy content and clinical outcomes that have previously
of hours of anonymised recorded therapy
been unavailable. Our findings showed that when treatment contained a greater quantity of CBT change methods, patients are more likely to show an improvement in symptoms. Patients were less likely to improve when sessions had increased quantity of ‘non-therapy’ content (i.e. conversations not related to treatment).
Why is this important? Compared with the treatment of physical conditions, the quality of care of mental health disorders has largely remained static and the rate of improvement in treatment is slow. A primary reason for this is the lack of objective and systematic methods for measuring the delivery of psychotherapy. However, with ie-CBT, a patient communicates with a therapist using realtime instant messaging, which means conversations can be captured as transcripts. Using deep learning, we can identify the content of therapist language during a psychotherapy session, and provide previously unavailable insights into what aspects of psychotherapy are most effective. Our deep learning model means we can extract knowledge accumulated across thousands of hours of CBT in a way that would be impossible for a human to do. What is exciting about this study is that it demonstrates the potential of Ieso’s data set, where we can understand more about what the active ingredients of therapy are, what works for whom, and develop new and more effective treatments for mental health disorders.
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Ieso Insights
Our work represents a first step towards a practicable
Conclusions and relevance:
approach for quality controlled behavioural health care with
Our work demonstrates an association between clinical
the goal of improving the efficacy of psychotherapy.
outcomes in psychotherapy and the content of therapist
What were the main outcomes and measures? We measured clinical outcomes in terms of reliable improvement in patient symptoms and treatment engagement. Reliable improvement was calculated based on 2 severity measures: Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder 7-item scale
utterances. These findings support the principle that CBT change methods help produce improvements in patients’ presenting symptoms, indicating that it is not simply communicating with a therapist, but rather the content of the therapy delivered that underlies clinical improvement. The application of deep learning to large clinical data sets can provide valuable insights into psychotherapy, informing
This example is the fith session in a treatment of Generalized Anxiety Disorder. A long block of non-CBT discussion by the therapist starts the session. The therapist then reviews homework and pivots the subject through cognitive reattribution, conceptualisatoion and some socrativ questioning starting a piece of teaching of cognitive reattribution.
(GAD-7), corresponding to depressive and anxiety symptoms
the development of new treatments and helping standardise
respectively, completed by the patient at initial assessment
clinical practice. We are working hard to learn more from this
and before every therapy session.
data and taking new insights to help improve how we deliver
What did Ieso find? Having trained a deep learning model to automatically
digital therapy to patients, which we hope in turn improves patient experience and recovery rates.
categorise therapist utterances into 1 or more of 24 feature
Ieso’s research design, setting and participants:
categories, the model was applied to Ieso’s data set to obtain
All our data was obtained from patients receiving ie-CBT for
quantifiable measures of each feature of treatment delivered.
the treatment of a mental health disorder between June 2012
A logistic regression revealed that increased quantities of
and March 2018 in England. Cognitive behavioral therapy
a number of session features, including change methods
was delivered in a secure online therapy room via instant
(cognitive and behavioral techniques used in CBT), were
synchronous messaging. The initial sample comprised a
associated with greater odds of reliable improvement in
total of 17 572 patients (90 934 therapy session transcripts).
patient symptoms (odds ratio, 1.11; 95% CI, 1.06-1.17) and patient
Patients self-referred or were referred by a primary health
engagement (odds ratio, 1.20, 95% CI, 1.12-1.27).
care worker directly to the service.
The quantity of non-therapy-related content was associated with reduced odds of symptom improvement (odds ratio, 0.89; 95% CI, 0.85-0.92) and patient engagement (odds ratio, 0.88, 95% CI, 0.84-0.92).
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The paper was peer reviewed and published in JAMA Psychiatry. It can be read in full here.
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Day in the life of a clinical supervisor Emily Marshall is a 33-year-old cognitive behaviour therapist and clinical supervisor based in Warrington. She has her own patients via a private practice, but also manages a team of other therapists for Ieso Digital Health, the largest provider of digital therapy services to the NHS.
We switch between our work and caring for him every two hours. I’m on autopilot at the moment and haven’t got the luxury to think about how I’m feeling - something that I think a lot of us are going through. I’m very lucky to have an office that I can work from home in, and I know when I close the door - I can get my head down and work. As chaotic as it sounds to switch between work mode and parent mode as swiftly as every two hours, I’ve become very adept at switching to play with him and then back to my professional life. Today, the sun is shining and that makes a big difference. It means I can go outside and enjoy the outside space with my little boy. I’ve learned that if I connect my senses and be in the moment as soon as I can with him, the time we spend together is better. Emily Marshall, Clinical Supervisor
I’m acutely aware that I’ve put myself on the back-burner at the moment. I no longer get up and have a five-minute break, I don’t take time for myself. Again, this is something I
6.30am
am hearing from so many people. Our basic needs takeover;
During the pandemic, I’ve had to flex how I work, and I spread
employment, juggling childcare, furlough stress, financial
my hours out, working every day. On Tuesdays, Thursdays and
stress. Self-care isn’t featuring in our priorities right now and
Fridays, I wake up at 6.30am and I’m at my desk and working
that’s going to have a huge impact on our collective mental
almost immediately. On the other days, I’m up at the same
health as a nation, further down the line.
time, but I’m looking after my little boy - he’s four years old.
7am
My husband and I share the responsibility so we both have the chance to be able to work uninterrupted when we can,
I turn on my laptop and check my emails. I then check what’s called a supervisor dashboard, where the therapists I support
while also spending time with our son. He had a birthday in
log issues they need help with. Depending on the cases, from
lockdown, we had a party with his teddies with some balloons -
here I might have to refer people to secondary care if they’ve
it was different, but it was lovely.
become a risk to themselves or others, or help therapists
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Ieso Insights
make decisions on what approach will get the
7pm
best outcomes for a patient. A part of what I do
I’m clocking off for the day quite early today,
is also caretaking our therapists, it’s a difficult
although the latest I usually finish is 9pm. I’m
time for everyone, you’re not immune to anxiety just because you support other people to overcome theirs.
back on mummy duty and it’s straight to bath time, followed by a bedtime story and I lie in bed with him until he goes to sleep. I head back downstairs and watch Netflix with my husband.
1pm Sometimes I have a working lunch break and
We’re binge-watching Stranger Things right now,
make myself a sandwich. When I have more
but we’ve just finished a Belgian crime thriller
time, I love making homemade ramen noodles
series which was brilliant escapism.
with heaps of green veg, but that’s very much gone out of the window. Today’s lunch was leftover pizza which I ate on my knee watching a programme about a monkey with my son.
10.30pm I try and head to bed at this time every night. I sometimes go earlier because I’ve found that my new routine makes switching off harder. I get
3pm
into my pyjamas, wash my face, brush my teeth
Today I spent the afternoon in a sandpit in the
and listen to a podcast or an audiobook on a
sunshine - which actually feels like it was really
sleep timer. I like to take a bit of time to reflect on
good for my own mental health. I’m tying up a
what’s happening.
few loose ends with a colleague this afternoon I’m working with a therapist to refer a patient to
I remind myself to follow my own advice about
a specialist who deals with PTSD. I sit down to
what I’ve found most helpful during this crisis
eat food with my son and husband around 5pm,
and hope elsewhere people are doing the same:
we try to spend time together like this every
take it one day at a time, let tomorrow come
evening, and then I get back to work from 6-7pm.
to you.
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iesohealth.com
Quality assurance at step 2 Jack Southward, Ieso Service Lead
The expansion and development of IAPT
While it is increasingly challenging to keep up with the demand for services,
services is an integral element to meeting
key targets remain in place in relation to recovery, waiting times and
the aims of the Five Year Forward View for
prevalence. It is the plate spinning act that services throughout the UK
mental health. Specifically, this states that
will be all too familiar with. Often, as one target is addressed, focus is lost
evidence based psychological therapies
from the others. Covid-19 has added another rather unpredictable factor
should reach 25% of those who are in
for services to be keeping an eye on. The key question remains, how do you
need of it, meaning that at least 1.5 million
ensure a level of clinical excellence as prevalence targets continue to rise?
adults experiencing anxiety and depression
Effective and efficient patient care is the key.
should be able to access care by 2020/21. By 2023/24 IAPT aims to provide 1.9 million
The National Institute for Health and Clinical Excellence (NICE) guidance
adults with access to mental health care.
recommends that any psychological treatment should always have the best chance of delivering positive conclusions whilst placing as little burden as possible on the patient. With pressures on services, services sometimes have little choice but to start patients at step 2, regardless of presentation. At Ieso, we are able to follow the stepped care model, treating only those cases of mild to moderate depression and anxiety at step 2. Regular review through supervision, aided by our data informed supervision tools, allows us to detect non-improvement in patients earlier in treatment and as such we are able to consider the effectiveness of step 2 treatment and seamlessly ‘step up’ patients for more intensive CBT treatment in a timely manner, without any additional wait. Within the Ieso step 2 team, we have a particular focus on ensuring that clinical supervision is not simply case management. Instead it is a place to reflect on clinical practice, Psychological Wellbeing Practitioners (PWP’s) wellbeing and patients’ needs and how best to meet these. The burnout rate of PWP’s is well documented, and as such regular and supportive
Jack Southward
supervision is an absolute essential. Clear and concise information gathering at assessment is fundamental to the success of any step 2 service. It is a skill that runs through the PWP training. To further aid this, owing to our platform and triage process, we
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Ieso Insights
are able to identify which Anxiety Disorder Specific Measures
From my time in IAPT I am acutely aware of the difficulties
(ADSM’s) will most likely be clinically significant and can
of engaging hard to reach groups using traditional methods
request that our patients complete these prior to the initial
of delivering therapy. By providing treatment through our
appointment. I have found that this early identification
platform, we are reducing barriers to accessing psychological
significantly aids the patient centred initial assessment and as
treatment by allowing our patients to choose appointments
such we are able to have a clear idea of a treatment pathway earlier, which in turn allows for a more focused episode of treatment for our patients. Routine outcome monitoring, using the right ADSM’s, and basing clinical decision making on these,
that are convenient for them, outside of a typical weekday 9-5, including evenings and weekends. We also encourage our PWPs to communicate in between sessions which Stephen Freer talks more about in this magazine.
helps to assure safety, clinical effectiveness and
The answer to my earlier posed question of maintaining
patient satisfaction.
quality whilst meeting targets may seem really quite simple;
An often overlooked aspect of low intensity CBT is that
using our data informed approach to getting our patients into the right modality of treatment as early as possible whilst
steps towards recovery do not end with the final session of
ensuring NICE recommended and evidence based treatment.
treatment. Fundamental to step 2 work is the notion that we
I feel that this is something that we achieve, and perhaps
are able to provide our patients with tools and techniques to
because of this our recovery rate at step 2 is currently 74%. It
see improvement. Hence another key issue in IAPT; once we
is through our pursuit of effective and efficient patient care
have seen improvement in patients, how do we maintain this?
that we continue to push and improve our clinical recovery
Vitally, a unique aspect of our platform is that our patients
rates and aim to increase the quality of care across not just
can revisit the transcripts from their sessions to remind
step 2, but our whole service.
themselves of what they have learned. This is another way in which momentum in treatment can be maintained and proves to be extremely useful in relapse prevention work.
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What patients say about digital therapy Ieso Digital Health
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Ieso Insights
“Is Ieso worth trying?” “When I was first referred to Ieso I did not like the idea very much. At the time I was suffering mentally and feeling very negative about myself, and my history, to the extent that suicide was a very real consideration. The thought of trying to express myself on a computer was just far too stressful and I could not see it helping me. “Although my first session was difficult I quickly found that writing online is in fact a great way to put your feelings thoughts and fears down, spelling and expressing yourself well are not important and you very soon establish a very real relationship with your therapist that is there all day every day. “It is hard to explain how this happens but the therapy that Ieso provide is tailored exactly to you and your needs and although you will never meet your therapist they will become a real part of your daily life and your approach to it, the skills and tools that your therapist equips you with mean that working with an Ieso therapist is your life 24 hrs a day, not just an hour a week, and there is a very real sense that they are there for you. “I had wrestled and failed for 45 years but now after working with Ieso I feel a different person with a very different approach to life; a happier, more wholesome, and safe person. In truth though I think I can hear my therapist saying “you are not a new person, you are the person you always were rising up and above the turmoil of life and seeing things in a different perspective” and perhaps that gives you an idea of how therapy teaches you to find new ways of doing things that honestly can be a real and lasting liberation. “I feel happier now than I have for a very long time and far more positive about the future. I have energy and enthusiasm for life that I thought I had lost forever and I honestly believe, no matter what your situation, Ieso can give you that too if you talk, listen and work with them.” Allan
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At Ieso we are committed to delivering world-class mental healthcare
Some of the Ieso team in the office on a charity fund-raising day (before lock-down)
We have one overriding mission here at Ieso that rings true with all of our people. We are truly passionate about making people better; driving improvements and breakthroughs in mental healthcare for everyone. Our patients are at the centre of everything we do.
Our cutting-edge technology Imagine for a moment capturing the collective knowledge of the world’s leading and most effective therapists. Then imagine taking that collective knowledge, and by using deep learning techniques, natural language processing engines and sophisticated artificial intelligence practices, being able to make every therapist better. Imagine those learnings translated into clinical practice guidance tools that provide patient-personalised guidance to therapists, to improve the therapy being delivered and as a result, get patients better, faster.
How you can be a part of it We are entering an exciting stage of growth and looking for likeminded, enthusiastic and positive people to join our expanding team. Find out more at https://www.iesohealth.com/en-gb/careers The next issue will be a special focus providing coverage of the Therapy Insights Festival. Register to attend this free online event on the next page, or subscribe to read highlighted content. Subscribe here to receive the next issue automatically
This magazine was produced by Huuha Ltd. If you have any feedback, or would like to contribute to the next issue, please email hello@huuha.co.uk
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Ieso Insights
Join us at this exclusive online event! 21st - 25th September The Therapy Insights Festival will bring together the digital mental healthcare industry at a time when restrictions are in place to meet face to face. Join expert speakers every day, covering a multitude of hot topics, including:
•
Key learnings from treatment during lockdown
•
Experience, engagement and recovery
•
How to deliver high-quality therapy using
•
The future of digital care delivery
•
What great therapists do
•
And much more…
digital methods •
Improving therapeutic skills and understanding patient variables
This is an opportunity to for clinicians, service providers and NHS leaders to network in a virtual social environment. We hope you can join us for what is our first ever virtual festival.
Registration is free but places are limited.
Reserve your spot here!
Contact us today envelope info@iesohealth.com phone-alt 0800 074 5560 map-marker-alt
Ieso Digital Health The Jeffreys Building Cowley Road Cambridge Cambridgeshire CB4 0DS