Understanding causes of and developing effective interventions for schizophrenia and other psychoses

• NIHR RP PG 0606 1335
• This study developed our understanding of the social epidemiology of psychosis, which will help people at high risk of developing first-episode psychosis (FEP) receive appropriate services focused on their current mental state.

Views on identification and treatment of common mental disorder (CMD) including PE in NHS Talking Therapies (formely, IAPT)

• • Qualitative study of service user, NHS Talking Therapies therapists and managers views on the identification and treatment of PE in NHS Talking Therapies services.
  • With the purpose to inform the development of TYPPEX training package, interviews sought to understand the priorities, preferences and views of staff and patients prior to developing the TYPPEX model.
  • Outcome: Not finished, TBC. 

Conference on Transdiagnostic Approaches to Mental Health Challenges

• Our lovely Research Associate, Debra Russo, present the poster entitled: “Managing complexity as indexed by psychotic experiences in UK Improving Access to Psychological Therapies (IAPT) services“.

Brainworks, Cambridge

• The lovely Freya Stuart (Study team/PPI), Annie Walsh (LEAP), Anjie Chhapia (LEAP)and  present the poster entitled: “Embedding lived experience to enhance the development, pilot and trial of a psychological therapy“.

Developing the TYPPEX model into a deliverable training course for CBT therapists in NHS Talking Therapies services

• The TYPPEX model was specifically designed for qualified CBT therapists in Talking therapies services.
• The training focuses on enhancing existing skills to address PE co-occurring with depression and/or anxiety, whilst maintaining fidelity to the fundamentals of CBT. In consultation with senior managers, we designed a 3-day, three-module course delivering face-to-face including lecture-based learning, role play sessions and access to TYPPEX therapy resources.
• The core training package was tested ahead of the TYPPEX feasibility study (described as the ‘sense check’) with a team of Talking therapies’ therapists independent from the feasibility study and c-RCT.
• The TYPPEX team observed the training in situ and collected feedback of participating therapists. In parallel, our co-applicant Paul French who leads the Early Detection and Intervention Team in Manchester, a centre of excellence for the psychological treatment of PE in specialist mental health care settings, observed and appraised the training.
• Outcome: This formative feedback informed modifications to optimise the TYPPEX curriculum and delivery, which was discussed with the TDG and TYPPEX PPI group ahead of the TYPPEX feasibility study.

Impact of PE on recovery rates in NHS Talking Therapies services

• The impact that the presence of PE had on recovery from depression and/or anxiety in the NHS Talking Therapies population was assessed through patient-reported measures of depression (PHQ-9) and anxiety (GAD-7), routinely collected from all service users receiving treatment. This occurs before, during and after therapy and these scores define and assess recovery standards in NHS Talking Therapies services.
• All NHS Talking Therapies services routinely monitor and report recovery data which is compared with the national standard that at least 50% of NHS Talking Therapies service users should achieve recovery.
• Our primary interest for this trial is recovery as defined by NHS Talking Therapies, as it is this metric that drives uptake and implementation, and the impact of the programme.
• Outcome: We demonstrated that PE at both CAPEP15 thresholds are associated with lower NHS Talking Therapies-defined recovery.

TYPPEX feasibility study

• This study to assess the practicality of proposed methodology for the TYPPEX c-RCT, recruitment and retention of the NHS Talking Therapies therapists to receive TYPPEX training, the acceptability of the TYPPEX concept, techniques, course materials and training activities.
• Between April and December 2019, a total of 36 therapists (from across 3 trusts) went through the 3 days of “TYPPEX” training.
• When back to practice, CAPE P-15 scores were collected as well as anonymised routine clinical data on recovery rates for CAPE+ patients.
• For successful recruitment to this stage, all new patients beginning a new course of CBT treatment received a CAPEP15 during their first treatment session as part of a battery of routinely collected clinical measures
• Total recruitment closed at 129 for participants with a CAPE P-15 threshold score of 1.47+ and 153 for participants with a CAPE P15 threshold score of 1.30+. Recruitment to health economics data collect, cost-effectiveness of trial, closed at 69 participants.
• From September 2019 to February 2020, there was a process evaluation. A total of 30 service users, 15 trained therapists and 6 managers were interviewed.
• Outcome: Therapists initially struggled to normalise and formulate PEs, but developed in confidence after supervision. Patients that received TYPPEX resources or had TYPPEX strategies integrated into their main frame CBT were able to perceive their PEs more positively, and understand how they link to their primary presenting problem.

TYPPEX trial in NHS Talking Therapies

Intervention

• December 2020: site 1 opening (CPFT)
• January/February 2021: site 2/3 opening (NSFT and SPFT)
• The trial offically opened on 11th March 2021 in Control phase.
• A total of 73 therapists were recruited prior to randomisation, meeting our minimum target of seven therapists per cluster.
• Withdrawal of therapists during the trial was an anticipated risk but to mitigate this, recruitment of therapists was re-opened prior to each CBT-ts training course to increase cluster sizes going into training.
• June 2023: site 4 opening (HHFT).
• A total of 56 therapists have been recruited post-randomisation, and therapist recruitment was closed in June.
• Six cohorts of therapists (10 clusters) have now received CBT-ts training, with courses running in September 2021, May 2022, and January, June and September 2023.
• Therapists who have received CBT-ts training received specialist clinical supervision from the team until the end of April 2024 and ad-hoc supervision will continue until the end of the trial.

Cost effectiveness

• Our overall recruitment figures exceeded target making a total of 335 participants in the UK:
  • 139 in Cambridgeshire and Peterborough;
  • 140 in Norfolk and Suffolk;
  • 54 in Sussex;
  • 2 in Homerton.
• Patient recruitment ended at the end of April 2024 and the follow-ups are due to end at the end of October 2024.
• Then, all the data collected will be cleaned and prepared to be passed on to our collaborating Health Economics team at King’s College London for final analysis.
• Outcomes are due at the end of January 2025.

TYPPEX trial in NHS Talking Therapies

Process Evaluation

There is often a lack of clarity on how an intervention leads to, or fails to lead to, the expected outcomes. To illustrate, consider the start of a study as similar to following a cake recipe. We begin with a protocol, which acts as a recipe for how the trial will be conducted, and we have an expected outcome. However, as many of us know from cooking, the final product can sometimes look very different from what was anticipated, even if the same recipe was used. This variability can also occur in scientific trials, such as TYPPEX, where the outcome may not align with expectations, and the reasons for this discrepancy are unclear.

This is where a process evaluation becomes important. A process evaluation helps to illuminate what is actually happening in practice. It allows us to answer questions such as what was implemented and how, how the intervention brought about change, and how the context influenced the outcomes.

For TYPPEX, a team led by THIS Institute conducted a process evaluation. This involved interviewing people involved in TYPPEX, including therapists, service users who received CBT-ts, line managers working in Talking Therapies, and study team members, to gather their experiences in the trial. The process evaluation team then analysed the interviews, looking for common themes in what people said to provide a more comprehensive overview of how TYPPEX worked in practice.

Process evaluation and PPI

Throughout TYPPEX, the LEAP and the process evaluation team collaborated closely. The LEAP provided feedback on study findings and advised on wording. For example, they recommended using the term “service users assessed as CAPE positive” instead of “CAPE positive service users” in any outputs.

The LEAP also assisted in interpreting interview transcripts. In one session, they participated in a workshop to learn how to apply research methods for organising and analysing interviews. Following this workshop, the LEAP analysed a subset of interview transcripts from service users previously interviewed by the process evaluation team. This collaboration offered researchers new interpretations of the interviews, as the LEAP provided insights from their lived experiences that the researchers could not.